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Research on TFP

Many groups of researchers all over the world are investigating different aspects of Transference-Focused Psychotherapy (TFP). This research can be grouped into (1) theoretical and conceptual work on borderline personality disorder (BPD) and TFP, (2) conceptual and empirical work on diagnostic instruments for the assessment of different aspects of BPD, and (3) empirical research on the outcome of TFP. Recently empirical research on the neurobiological foundations of BPD and its treatment has been begun in New York as well as Germany and Austria. A comprehensive list of publications on TFP can be found on the “publications” page of this website.

Theoretical and conceptual research

The major theoretical work on BPD and TFP origins from Otto F. Kernberg. Modern concepts of BPD go back to his perennial work on “Borderline Conditions and Pathological Narcissim” (1975) and “Severe Personality Disorders” (1984). Until today these books have shaped the diagnostic criteria for BPD in psychiatry and its classification systems ICD-10 and DSM-IV. In his recent work, Kernberg kept refining his concepts and applying it to different clinical conditions related to BPD, e.g., narcissistic personality disorder (Kernberg 1992, 2007, 2008, 2011).

From his theoretical and clinical work emerged the description of a specific treatment for patients with BPD (e.g., Kernberg 1975, 1976) that led to the first treatment manual in 1989 (Kernberg et al. 1989). Together with his co-workers, particularly John F. Clarkin and Frank E. Yeomans, to name only two of them, he refined this treatment, which is now called TFP and validly described in a comprehensive treatment manual (Clarkin et al. 2006).

Based on Kernberg´s concepts a number of modifications of TFP have been developed. Paulina Kernberg was the first to describe personality disorders in children and adolescents and their treatment (Kernberg et al. 2000). Her approach has been developed further by a number of researchers, particularly Pamela Foelsch and Lina Normandin, a treatment manual will soon be published.

An adaptation of TFP for forensic patients was developed in the German speaking countries (Lackinger et al. 2008), TFP for higher level (neurotic) personality disorders was conceptualized by Eve Caligor and colleagues (Caligor et al. 2007). Moreover, TFP applications for narcissistic patients, elderly patients, and groups, respectively, as well as inpatient TFP are currently in preparation.

Diagnostic instruments and assessment

In 1981 Kernberg published his first paper on Structural interviewing. His clinically oriented Structural Interview aims at the assessment of personality organization, a concept that is now incorporated into modern psychiatric diagnosis: The DSM-5 classification will contain a Levels of Personality Functioning Scale that is derived from Kernberg´s dimensions of personality organization. Clarkin and colleagues (2003) transformed the Structural Interview into a structured interview, the Structured Interview for Personality Organization (STIPO) that allows for quantification of different dimensions of personality organization. A self-rating instrument that is closely related to the STIPO is the Inventory of Personality Organization (IPO; Clarkin et al. 2001a). Stimulated by Kernberg´s diagnostic approach a number of observer-rated and self-rating instruments occurred during the last decade (for review see Doering & Hörz 2012). The assessment of personality organization (synonym: personality structure, personality functioning) nowadays receives increasing attention in psychiatry and clinical psychology. A number of empirical studies have investigated the relationship of personality disorders and personality organization (e.g., Fischer-Kern et al. 2010; Hörz et al. 2009) and the effect of TFP on personality organization (Doering et al. 2010).

Empirical outcome research

Transference-Focused Psychotherapy (TFP) is an empirically-validated treatment for personality disorder that has proven its efficacy in three uncontrolled studies (Clarkin et al. 2001b, Cuevas et al. 2000, Lopez et al. 2004). These three investigations demonstrated significant improvements in psychopathology, self-mutilizing behaviour, and psychiatric hospitalizations after one year of TFP.

Three randomized controlled trials (RCT) evaluated the efficacy of TFP. In the study of Giesen-Bloo et al. (2006) TFP was comparator for Schema Therapy. Both treatments improved psycho- and personality pathology significantly, but Schema Therapy was superior after three years of treatment. These results have been criticised for methodological reasons (Yeomans 2007). A second RCT compared TFP with Diallectic Behavioral Treatment (DBT) and Psychodynamic Supportive Therapy (SPT) (Clarkin et al. 2007). Ninety borderline patients were included into the study and received psychotherapy for one year. All three groups showed significant positive change in depression, anxiety, global functioning, and social adjustment in a multiwave design. TFP and DBT were associated with a significant improvement of suicidality, TFP and SPT improved facets of impulsivity, and only TFP yielded a significant improvement in anger, irritability, and verbal and direct assault. Moreover, only patients that received TFP improved significantly in their reflective function and their attachment style; 28.6% of the TFP patients changed from an insecure to a secure attachment style, whereas none of the DBT and SPT patients did (Levy et al. 2006). In a third RCT TFP was compared to treatment by experienced psychotherapists in the field (Doering et al. 2010). One hundred and four patients were treated for one year in Munich and Vienna, respectively. TFP resulted in a significantly higher remission rate, fewer drop-outs, fewer suicide attempts, fewer psychiatric in-patient admissions, higher improvement of personality structure and psychosocial functioning. A RCT on TFP for adolescents is about to be finalized and reveals encouraging results so far.

Taken together, three uncontrolled studies and two randomized controlled trials from independent groups demonstrated the efficacy of TFP for the treatment of borderline personality disorder. A recent Cochrane review on psychotherapy for BPD counts TFP among the “beneficial” borderline treatments together with Dialectc behaviour Therapy (DBT), Mentalization-based Therapy (MBT), Schema Therapy, and STEPPS (Stoffers et al. 2012).

References

Caligor E, Kernberg OF, Clarkin JF (2007). Handbook of Dynamic Psychotherapy for Higher Level Personality Pathology. Washington, DC: American Psychiatric Publishing.

Clarkin JF, Caligor E, Stern BL, Kernberg OF (2003). Structured Interview of Personality Organization (STIPO). New York: Personality Disorders Institute, Weill Medical College of Cornell University. [Free download at http://psinstitute.org/pdf/Structured-Interview-of-Personality-Organization.pdf]

Clarkin JF, Foelsch PA, Kernberg OF (2001a). The Inventory of Personality Organization. White Plains, NY, The Personality Disorders Institute, Weill Cornell Medical College.

Clarkin JF, Foelsch PA, Levy KN, Hull JW, Delaney JC, Kernberg OF (2001b). The development of a psychodynamic treatment for patients with borderline personality disorder: a preliminary study of behavioural change. J Personal Disord 15:487-95.

Clarkin JF, Levy KN, Lenzenweger MF, Kernberg OF (2007). Evaluating three treatments for borderline personality disorder: a multiwave study. Am J Psychiatry 164:1-8.

Clarkin JF, Yeomans FE, Kernberg OF (2006). Psychotherapy for Borderline Personality. Focusing on Object Relations. Arlington: American Psychiatric Publishing.

Cuevas P, Camacho J, Mejia R, Rosario I, Parres R, Mendoza J, Lopez D (2000). Cambios en la psicopatologia del trastorno limitrofe de la personalidad, en los pacientes trtados con la psicoterapia psicodinamica. Salud Mental 23(6):1-11.

Doering S, Hörz S, Rentrop M, Fischer-Kern M, Schuster P, Benecke C, Buchheim A, Martius P, Buchheim P (2010). Transference-focused psychotherapy v. treatment by community psychotherapists for borderline personality disorder: randomised controlled trial. Br J Psychiatry 196:389-395.

Doering S, Hörz S (2012). Handbuch der Strukturdiagnostik. Konzepte, Instrumente, Praxis. Stuttgart: Schattauer.

Fischer-Kern M, Schuster P, Kapusta ND, Tmej A, Buchheim A, Rentrop M, Buchheim P, Hörz S, Doering S, Taubner S, Fonagy P (2010). The Relationship between personality organization, reflective functioning, and psychiatric classification in borderline personality disorder. Psychoanal Psychol 27(4):325-409.

Giesen-Bloo J, van Dyck R, Spinhoven P, van Tilburg W, Dirksen C, van Asselt T, Kermers I, Nadort M, Arntz A (2006). Outpatient psychotherapy for borderline personality disorder. Arch Gen Psychiatry 63:649-58.

Hörz S, Stern B, Caligor E, Critchfield K, Kernberg OF, Mertens W, Clarkin JF (2009). A prototypical profile of borderline personality organization using the Structured Interview of Personality Organization (STIPO). J Am Psychoanal Assoc 57(6):1464-8.

Kernberg OF (1970). Factors in the psychoanalytic treatment of narcissistic personalities. J Am Psychoanal Assoc 18(1):51-85.

Kernberg OF (1975). Borderline Conditions and Pathological Narcissim. New York: Janson Aronson.

Kernberg OF (1976). Technical considerations in the treatment of borderline personality organization. J Am Psychoanal Assoc 24(4):795-829.

Kernberg OF (1981). Structural Interviewing. Psychiatr Clin North Am 4(1):169-95.

Kernberg OF (1984). Severe Personality Disorders. New Haven: Yale University Press.

Kernberg OF (1992). Aggression in Personality Disorders and Perversions. New Haven: Yale University Press.

Kernberg OF (2007). The almost untreatable narcissistic patient. J Am Psychoanal Assoc 55:503-539.

Kernberg OF (2008). The Destruction of Time in Pathological Narcissism. Int J Psychoanal 89:299-312.

Kernberg OF (2011). The Inseparable Nature of Love and Aggression: Clinical and Theoretical Perspectives. Washington, DC: American Psychiatric Publishing.

Kernberg OF, Selzer MA, Koenigsberg HW, Carr AC, Appelbaum AH (1989). Psychodynamic Psychotherapy of Borderline Patients. New York: Basic Books.

Kernberg PF, Weiner A, Bardenstein K (2000). Personality Disorders in Children and Adolescents. New York: Basic Books.

Lackinger F, Dammann G, Wittmann B (2008). Psychodynamische Psychotherapie bei Delinquenz. Praxis der Übertragungsfokussierten Psychotherapie. Stuttgart: Schattauer.

Levy KN, Meehan KB, Kelly KM, Reynoso JS, Weber M, Clarkin JF, Kernberg OF (2006). Change in attachment patterns and reflective function in a randomized control trial of transference-focused psychotherapy for borderline personality disorder. J Consult Clin Psychol 74:1027-1040.

Lieb K, Stoffers J (2012). Comparative efficacy of evidence based psychotherapies in the treatment of borderline personality disorder. Oral presentation at the 20th European Congress of Psychiatry, Prague, Czech Republic, 3-6 March 2012.

López D, Cuevas P, Gomez A, Mendoza J (2004). Psicoterapia focalizada en la transferencia para el trastorno limite de la personalidad.Un estudio per el pacientes femininas. Salud Mental 27(4):44-54.

Stoffers JM, Völlm BA, Rücker G, Timmer A, Huband N, Lieb K (2012). Psychological therapies for people with borderline personality disorder. Cochrane Database Syst Rev 2012 Aug 15;8: DOI:10.1002/14651858.CD005652.pub2

Yeomans F (2007). Questions concerning the randomized trial of schema-focused therapy vs transference-focused psychotherapy. Arch Gen Psychiatry 64:609-10.