The available epidemiological studies suggest that the prevalence of BPD in the general population of adolescents is around 3% (Zanarini, et al., 2008; Chanen & McCutcheon, 2008). Although the clinical samples are heterogeneous, one observes an increase in the prevalence of BPD according to the severity of the clinical picture and the type of psychiatric care received in adolescent services. Indeed, 11% in outpatient adolescents have received a diagnostic of BPD (Chanen, et al., 2004), between 19% and 53% in hospitalized adolescents (Sharp et al., 2012; Ha, Balderas, Zanarini, Oldham, & Sharp, 2014), 62% in hospitalized suicidal adolescents (Knafo, Guilé, Breton, et al., 2015), and up to 78% in adolescents attending the emergency department for suicidal behaviors (Greenfield, Henry, Lis, et al., 2015). Within other personality disorder categories (PDs), the prevalence rates range from 10 to 15% within this age group (Feenstra, Busschbach, Verheul, & Hutsebaut, 2011; Johnson & al., 2005). Longitudinal data show a normative increase in BPD traits after puberty and reach peak prevalence in early adulthood and subsequently declining over subsequent decades (Chanen, 2012; Shiner, 2009; Tackett, Balsis, Oltmanns, & Krueger, 2009; Cohen, Crawford, Johnson, & Kasen, 2005). Its manifestations are mostly marked mood swings, affective instability, aggression and impulsivity, including self-harm, suicide attempts, and substance abuse. There is irrefutable evidence that personality disorder diagnoses in adolescents have validity and stability over time (Chanen & Kaess, 2012; Cohen, Crawford, Johnson, & Kasen, 2005; Sharp & Fonagy, 2015).
Despite converging evidence that personality disorders emerge in childhood and are clearly evident in adolescence, clinicians have remained reluctant to diagnose PD before age 18. This was partly due to concerns that behaviors that might be normative in children and adolescents, and part of normal adolescent “sturm und drang”, might be misdiagnosed as signs of BPD and that diagnosis may lead to unnecessary stigmatization. The advocacy work of pioneers like P. Kernberg (1997; Kernberg, Weiner & Bardenstein, 2000) and research over the past decade (Miller, Muehlenkamp, & Jacobson, 2008; Chanen & McCutcheon, 2008; Chanen & Kaess, 2012) have done much to dispel these concerns and it is evident that a constellation of PD type symptoms can be observed in children and adolescents. Furthermore, it is evident that personality difficulties are unlikely to resolve without specific interventions that are developed explicitly to treat adolescents with personality disorders. Stigmatization of adolescents with PD remains a real concern, and much remains to be done to address this through education and training of mental health staff to understand and respond to adolescents with PD, as well as through making available treatments designed to address the challenges adolescents and young people afflicted with personality difficulties pose to others and experience themselves. The hesitation of clinicians to diagnose PDs may have delay the development of treatment models for this age group. Currently, there is relatively little research on effective treatments for adolescents with PDs. Therefore, we are trying to take up this imperative need for treatment models focusing on adolescent personality disorders that would have both strong theoretical foundations and manualised interventions.
This Transference-Focused Psychotherapy for Adolescents manual (TFP-A) presents a treatment for adolescents and young people who suffer from severe personality disorders. It is an adaptation of Transference Focused Psychotherapy (TFP) for adults suffering from borderline personality disorders (Yeomans, Clarkin & Kernberg, 2015; Clarkin, Yeomans, & Kernberg, 2006). It is grounded in a psychoanalytic object relations approach developed by Kernberg (1985,1993), as well as developmental theory and empirical research (Clarkin, Levy, Lenzenweger, & Kernberg, 2004; Clarkin & Posner, 2005; Doering et al., 2010; Levy et al., 2006). In this treatment, PDs is seen as a disturbance in the process of identity formation. Adolescence, which is the pivotal developmental period for identity formation and personality consolidation (Erikson, 1968), is therefore seen as a sensitive period to intervene.
The TFP-A treatment is inspired by Paulina F. Kernberg’s exceptional work with children and adolescents. She was the director of the Residency Program in Child and Adolescent Psychiatry at the New York Presbyterian Hospital, Payne Whitney Westchester-Weill Cornell Medical Center since 1978, until she died in 2006. She was also a teacher, supervisor and training analyst at the Columbia University Center for Psychoanalytic Training and Research. She was probably the first to draw attention to and write about early manifestations and development of personality disorders including borderline and narcissistic personality disorders in children. She elucidated assessment criteria and treatment approaches for a wide spectrum of personality disorders observed in children and adolescent and she developed assessment interviews to measure the level of personality integration in adolescents. Several aspects of her thinking are reflected in this manual.
Features and Goals of TFP-A
The specificity of transference-focused psychotherapy for personality disorders in adolescents (TFP-A) includes a focus on facilitating identity integration and personality consolidation through: 1) addressing dominant pathological object relations as they are activated and manifested in the here-and-now interactions with the therapist; 2) elaboration of a contract with adolescents to help them reduce, contain and ultimately control acting out while stimulating curiosity about their motivations and prioritizing mentalizing about self and others as well as about the consequences of their actions and their future; 3) a specific approach to supporting parents, facilitating their collaboration and reducing their interference as well as creating a mental space for the adolescent where they can develop autonomy and gradually assume responsibility for their difficulties. In essence, the work with parents supports parents to use their authority where appropriate and when adolescents are potentially in danger, but also supports the parents to step back to facilitate separation and individuation and to decrease conflict, overt aggression, battles over power and control that can derail therapeutic work and progress; and 4) an emphasis on interpreting transference and countertransference reactions in order to identify split self- and other-representations that are viewed as an impediment to the flow of the developmental processes and undermine personality consolidation as well as the adaptive use of acquired mentalization capacities in order to deal with the challenges of adolescence and the future.
TFP-A is also grounded in an understanding of the major structural changes and developmental tasks that the adolescent is facing. Therefore, the aim of TFP-A is to scaffold structural changes and oversee developmental challenges central to adolescence while at the same time addressing pathology in object relations and identity integration that disrupt these developments. The major structural changes concern constituents of personality (self-image, ideal self and self-esteem as well as moral and ethics, sexuality and eroticism, concern and reparation wishes) that have to be consolidated. The developmental challenges include becoming more independent from family, establishing their own social networks, negotiating sexual relationships and forming romantic and couple relationships, while at the same time, clarifying future life and career goals and pursuing this purposefully. In contexts of family dysfunction or disorganization, parental mental illness, substance abuse and violence or where there is little family support, adolescents without personality pathology may also have difficulties successfully engaging with the challenges of adolescence but are generally receptive and responsive to help when this is offered. To distinguish and identify personality pathology, it is important for clinicians to consider the developmental history of adolescent patients as well as their current functioning with family and peers, at school or work, while also being well informed regarding developmental issues and structural changes specific to adolescence. This provides a framework that facilitates understanding the adolescent’s developing sense of self and others – the process of identity formation – as it unfolds during separation from family and entry into the adult world. Radical failures in engaging with the normative challenges of adolescence and the manifestation of immature internal structures are features of adolescent personality disorders.
Normandin, L., Ensink, K., Weiner, A., & Kernberg, O. (2021). Transference-Focused Psychotherapy for Severe Personality Disorders in Adolescents. Washington: American Psychiatric Press.
Biberdzic, M., Ensink, K., Normandin, L., & Clarkin, J.F. (2018). Empirical Typology of Adolescent Personality Organization. Journal of Adolescence. 66, 31-48.
Biberdzic, M., Ensink, K., Normandin, L., & Clarkin, J.F. (2017). Psychometric Properties of the Inventory of Personality Organization for Adolescents. Adolescent Psychiatry, 7(2), 127-151.
Chretien, S., Ensink, K., Descôteaux, J., & Normandin, L. (2018). Measuring Grandiose and Vulnerable Narcissism in Adolescents. Mediterranean Journal of Clinical Psychology, 6(2), 1-23.
Duval, J., Ensink, K., Normandin, L., & Fonagy, P. (2018). Mentalizing mediates the relationship between childhood maltreatment and adolescent borderline and narcissistic personality traits. Adolescent Psychiatry, 8(3), 156-173.
Normandin, L., Ensink, K., Yeomans, F. E., & Kernberg, O. F. (2014). Transference-focused Psychotherapy for Personality Disorders in Adolescence. In C. Sharp & J. Tackett (Eds.), Handbook of Borderline Personality Disorder in Children and Adolescents (Chapter 25). New York: Springer Press.
Wiener, A., Ensink, K., & Normandin, L. (2018) Psychotherapy for Borderline Personality Disorder in Adolescents. Psychiatric Clinics of North America, 41, 729-746.
New York, USA
Otto F. Kernberg, MD., Weill Medical College of Cornell University ([email protected]);
Alan Weiner, Ph.D. ([email protected])
This page updated 2019-11-26.