TFP in Forensic Psychiatry (TFFP)

This approach started to develop following an initiative by Viennese forensic psychotherapists. In the late 1990s a traditionally psychodynamically oriented institution, the Forensic-Therapeutic Center of Vienna (FTZW), was challenged by the psychopharmacological and cognitive-behavioral change of course of the new supervisory board chairman. As a consequence, the therapists of the FTZW adopted TFP as an up-to-date and evidence-based psychotherapy for personality disorders.

A few years later forensic institutions both in Vienna and Marsberg (Germany) began to employ TFP for some of their delinquent patients. Since 2005 two international meetings were held by these German and Austrian institutions with the inspiring participation of Gerhard Dammann from Münsterlingen (Switzerland).

We had the opportunity to discuss this approach at some international forensic meetings, not least at the International Association of Forensic Psychiatry (IAFP) meetings in Oxford (2007) and Konstanz (2009). From the clinical work with our patients on the one hand, and the debates with our international colleagues on the other hand, a new approach emerged that was based on TFP-principles, but included some important modifications reflecting the specific patient population as well (TFFP).

In 2008 a German language book was published by Fritz Lackinger, Gerhard Dammann and Bernhard Wittmann: Psychodynamische Psychotherapie bei Delinquenz [Psychodynamic Psychotherapy with Delinquents]. This book is a summary of our international debate but also includes a number of guest contributions and positions of alternative therapeutic approaches. The authors engage in a serious but friendly debate. E.g., the differences between TFFP and the Hamburg Model of group therapy for sexual offenders by Wilhem Preuss and Wolfgang Berner are discussed as well MBT as a forensic-therapeutic method in relation to TFP.

The work to develop TFP into a forensic-therapeutic approach is far from finished. The question of differential indication is not finally solved and we still need more clinical experience and theoretical discussion to prepare a treatment manual for TFFP.

The ability to mentalize as assessed by the Reflective Function Scale (Fonagy et al. 1998) might help to differentiate between different groups of delinquent patients and, thus, facilitate indication for different types of treatment. Levinson & Fonagy (2004) reported a RF of college students of 5.3 (on the scale from -1 to +9), an RF of clinical borderline patients of 3.7 (similar to Levy et al. 2006), and a RF of a prisoner population of 2.5. An average RF of 1.4 was found in violent offenders. In the prisoner group 73% had low Reflective Function (RF) in a deficit range (below 3) compared to 32% in psychiatric patients with personality disorders. In violent offenders 93% were in a deficit range. These data suggest that prisoners are more severely disturbed than clinical populations, and that among prisoners there are probably different groups with regard to the severity of their mentalization deficit.

TFP has been modified in a number of ways for the application in criminal offenders.

In the diagnostic realm it is of special importance to focus on the quantity and quality of the antisocial traits in terms of super-ego fragmentation, extent of ego weakness and malignancy of perverse sexuality. We have subdivided the lower level of borderline pathology into three sub-levels following Otto Kernberg´s differentiation between

1. chronic antisocial features in the context of lower level borderline personality but with a residual capacity to experience guilt feelings,
2. the syndrome of malignant narcissism with a lack of guilt feelings even in relation to the own manifest sadism but with apparent incidences of masochistic features, and
3. the psychopathic personality in the narrower sense with a lack of both, guilt feelings and masochistic features, which precludes psychotherapy.

The treatment contract focuses – in addition to its usual content – on

1. the limited confidentiality of the therapist in the context of the danger the patient represents for other people,
2. the use of juridical documents and records as separate source of information of the therapist,
3. the problem of missing therapy sessions as a habitual form of resistance, and
4. the analysis and working through of the offence because of which the patient is in forensic treatment.

The characteristic transference patterns observed in TFFP are shown in a prototypical case of a pedophile offender:

1. In a psychopathic transference patients try to give the impression to agree genuinely or even imitate the therapist, but in fact, they lie about their lives and hide important information.
2. Frequently a prolonged phase of alternating psychopathic and paranoid transferences occurs, where patients blame the therapist as useless and dishonest, patients are distrustful and cynical about the therapist, and their mistrust might lead to withdrawal into submission.
3. After the early psychopathic and paranoid transference phases have been overcome to a certain degree, a pronounced (characterological) sadomasochistic transference is often observed. The patient repeatedly violates the treatment contract, reactively squirms and winds in the face of the therapist´s confrontation, and perverse themes tend to be enacted in a prevailing manner.
4. The repeated analysis of the sadomasochistic transference reveals an underlying primitive idealizing attitude towards the therapist which sometimes includes wishful phantasies of fusion with him or her.
5. Dealing with these idealizations might bring anxieties and phantasies to the surface that are related to sexual sadism and masochism. These sadistic and abusive sexual phantasies (as they are experienced in a clearly sexualized transference) represent the core of the paedophile perversion.
6. Potentially the sexualized transference paves the way to phantasies of loneliness and dependency on the therapist, which may be the starting point of a phase of a more mature depressive transference.

The techniques, tactics, and strategies of dealing with these transferences are in line with the standard TFP. It has to be expected that the treatment processes take more time, that the initial stage might sometimes demand explicit mentalizing techniques, and that the final phase of a depressive transference is less likely to be reached than in usual borderline therapies.

References

Fonagy P, Target M, Steele H, Steele M (1998). Reflecting Functioning Manual, Version 5, for Application to Adult Attachment Interviews. Unpublished manuscript.

Frottier P (2008). TFP als Baustein eines stationären Therapiekonzeptes für zurechnungsfähige, gefährliche und geistig abnorme Rechtsbrecher. In: Lackinger F, Dammann F, Wittmann B (2008). Psychodynamische Psychotherapie bei Delinquenz. Praxis der Übertragungsfokussierten Psychotherapie. Stuttgart: Schattauer.

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

Levinson A, Fonagy P (2004). Offending and attachment. The relationship between interpersonal awareness and offending in a prison population with psychiatric disorder. Can J Psychoanal 12:225–251.

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.

Contact

Vienna/Austria
Fritz Lackinger, Ph.D., Vienna Psychoanalytic Academy, flackinger (at) utanet.at