ISTFP.ORG

International Society of Transference-Focused Psychotherapy

Advancing Treatment of Borderline Personality Disorder

The ISTFP’s Training and Education Committee

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Dear Colleagues,

When it was formed, the ISTFP established the Training & Education Committee to uphold quality standards for international TFP training and supervision, to promote the development of standardized teaching tools, and to work on ways we can improve how we educate our students and supervise both our students and each other. The T&E Committee also plays a crucial role in shaping the educational policy of the ISTFP, preparing certification regulations, and establishing guidelines and documents for examinations.

The T&E Committee currently comprises 15 members, including two co-chairs (Luis Valenciano and myself), from various countries: Marion Braun (GR); Peter Bucheim (GR); Eve Caligor (USA); Sergio Dazzi (IT); Stephan Doering (AU); Diana Diamond (USA); Frank Denning (UK); Nel Draijer (NL); Katarzyna Gwozdz (PL); Otto Kernberg (USA); Judit Lendvay (USA); Mathias Lohmer (GR); Philipp Martius (GR); Verónica Steiner (CL); Frank E. Yeomans (USA).

I became involved with the T&E Committee in 2018 during the 5th Biennial ISTFP Conference in Barcelona, taking on the role of secretary to the then-chair, Nel Draijer. In this capacity, I began assisting with the various committee tasks, and as of 2022, I have become a co-chair with Luis Valenciano.

The Committee meets regularly every about three months and addresses various issues, particularly in light of the increasing number of TFP therapists and TFP Teacher and Supervisors. Our objectives for this year include:

  • Organizing therapist exams for countries without a local TFP organization, as well as organizing Trainer-Supervisor exams.
  • Arranging the Bi-Annual ISTFP Supervisors’ Meeting on October 6-7, 2023, in Milan.
  • Promoting pedagogical methods that facilitate the learning of our therapy.
  • Fostering the exchange and discussion of technical challenges among members.

To effectively tackle these objectives, given the volume of issues we wish to address, we have formed sub-committees focusing on specific topics, such as:

  • Subcommittee on Supervision, which is preparing a paper on TFP supervision, a curriculum for supervision, a reading list on TFP supervision, and developing a training tool for teaching and supervising microprocess.
  • Subcommittee on Video Initiative, aiming to collect videos made by our members that can assist in teaching the basic aspects of TFP: techniques, tactics, and strategies.
  • Subcommittee on a Blog on Technical Challenges, which will be incorporated into our ISTFP Newsletter, addressing clinical situations that TFP therapists encounter in therapy and supervision.

As you can see, one of our 2023 objectives was to organize the Bi-Annual ISTFP Supervisors’ Meeting, which took place on October 6 and 7 in Milan, my hometown. I had the honor and responsibility of actively participating in the organization of this conference, which welcomed 70 supervisors from around the world, with both in-person attendees from Mexico, Austria, Germany, Switzerland, the Netherlands, Hungary, Poland, the USA, Chile, Italy, Spain, the UK, Canada, and Belgium, and remote viewers as we live-streamed the event for those who couldn’t join us in Milan. The event featured prominent speakers who aimed to address central questions related to the role of supervisors, such as major difficulties in learning TFP and how we can provide support as supervisors, the role of treatment goals in TFP training and supervision, detecting and teaching to detect affects and affective dominance in supervisions, using the contribution from group members in a TFP supervision session, dilemmas of the supervisor, and working with and supervising concrete thinkers-low reflective patients. The conference provided a special and emotional opportunity to meet in person after a long period of exclusively online meetings, offering us a chance to engage in more intimate and fruitful exchanges, both professionally and personally, especially during the very congenial social moments.

Best regards,

Irene

Irene Sarno

Irene Sarno Ph.D. is a psychotherapist and a psychoanalyst of the International Psychoanalytic Association (IPA). In her clinical practice she works mainly with adolescents, young adults, and adults. She trained between USA and Italy with Otto Kernberg and coll. on Transference-Focused Psychotherapy for adults and adolescents, and she is a certified TFP teacher and supervisor for both adults and adolescents. She is a founding member of the Personality Disorders Lab (PdLab), branch society of the International Society of Transference-Focused Psychotherapy (ISTFP). With the PdLab she has organized a number of training programs on TFP in Italy.
She is Adjunct Professor of Psychotherapy and Counselling at the University of Milan-Bicocca, where she is also consultant at the Psychological Counselling Centre for University Students.
She is author of national and international scientific articles, books and book chapters on Non Suicidal Self-Injury, diagnosis and assessment, and personality disorders.

PD lab website

Let’s meet Mariana del Hoyo from Mexico

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Last June, I had the pleasure of conducting an enlightening interview with Mariana del Hoyo, a dedicated and passionate psychiatrist who recently completed her residency. Our conversation focused on Mariana’s journey and her profound interest in Transference-Focused Psychotherapy. I am excited to share this experience with all of you.

Her educational background is diverse. Not only does she have a Bachelor’s degree in Medicine from UNAM but she as also completed a postgraduate degree in Rural Development from UAM Xochimilco, a postgraduate program in Competencies for Managing BPD from UIC Barcelona, and a specialization in Psychiatry at the National Institute of Psychiatry “Ramón de la Fuente” in Mexico.

Her fascination with TFP began during her psychiatric residency, where she was deeply intrigued by the wide-ranging symptomatology of personality disorders. It stood out as a powerful technique that empowers individuals who have experienced invalidation in the past, helping them recognize their capacity for self-reflection. She was particularly impressed by how TFP integrates the therapist’s introspection and tackles not only the complexities of borderline personality disorder, but also fundamental human concerns.

Throughout her journey, Mariana has actively sought additional training and education. She has completed theoretical courses offered by TFP-Group Mexico, the TFP course provided by the TLP group in Barcelona, and has attended seminars led by Dr. Otto Kernberg. These experiences have enriched her understanding of TFP and facilitated valuable connections with experts in the field.

Currently, Mariana’s professional activities include private psychiatric consultations, supportive psychodynamic therapy at the Fray Bernardino Psychiatric Hospital and collaborative research projects. She actively participates in research focused on studying behaviors and risk factors in young people with HIV, as well as research projects related to Borderline Personality Disorder and its clinical features.

One of the most profound impacts of TFP on Mariana’s practice has been the development of a holistic understanding of her patients’ symptoms and the cultivation of stronger therapeutic relationships. TFP allows her to use transference as a valuable source of information, providing insights into relational dynamics. She considers it vital to the success of psychiatric management and psychotherapeutic interventions when working with patients with significant psychopathology, such as Borderline Personality Disorder. It has transformed Mariana’s overall therapeutic practice by fostering deeper reflection in her interactions with patients.

Mariana’s dedication to TFP goes beyond her clinical practice. She aspires to conduct research that demonstrates the effectiveness of TFP in the Mexican population, recognizing the need for its wider adoption. Currently, the studies focus on gender differences in clinical presentation and symptoms among individuals with Borderline Personality Disorder in Mexico City.

Regarding the advantages and disadvantages of TFP, she emphasized its reflective and introspective nature, which allows for deeper engagement with patients and addresses the chronic sense of emptiness and identity diffusion. However, she acknowledged that TFP requires a longer training period and comes with a certain level of complexity.

That is why she actively participates in supervision, recognizing its pivotal role in her professional development. She is convinced that supervision has been invaluable in guiding her through challenging cases, providing diverse perspectives, and offering emotional support. It has also contributed to her understanding of significant moments in a therapist’s life and their influence on countertransference and transference dynamics.

Practicing TFP in Mexico presents unique challenges due to the complex social and economic context of the country. However, Mariana remains steadfast in her commitment to promote the use of TFP, conduct research, and provide high-quality care to her patients. She is truly an inspiration to all of us as we strive to provide the best possible care in less than ideal situations. Mariana’s story shows us how important it is to include some teaching about TFP in psychiatry residency programs. From that initial contact with TFP, Mariana has gone on to practice both standard and applied TFP and to begin important research.

I hope you had as much pleasure to meet her as I did.

Warm regards,

Diana

Diana Tellez

Diana Téllez Quiroz, PhD

Diana Téllez has been working as a psychodynamic psychotherapist in Mexico since 2005. In 2009, she successfully completed a master’s degree program in psychotherapy for children, adolescents, and adults. She went on to earn a PhD in Psychoanalytic Psychotherapy from the Mexican Psychoanalytic Association in 2012.

She’s a certified TFP Teacher-Supervisor and has clinical practice in TFP since 2011.  Since 2016, she is responsible for the Psychology department at a public hospital part of the Mexican Social Security Institute (IMSS) in Mexico City. She is also an active member of the Academic Committee of Mexico involved in the organization of multiple trainings and supervisions in TFP.

Author’s website

Empirical support for Kernberg’s concept of Temperament

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Scientific fondations of TFP series

As a member of the ISTFP Public Relations and Communication committee, I have the privilege of connecting with professionals from diverse backgrounds who share their experiences and challenges in implementing Transference Focused Psychotherapy (TFP) in various therapeutic settings worldwide. One recurring challenge that has emerged is the persistent misconception that TFP lacks scientific validity. In this series of articles, my objective is to provide fellow members with the necessary tools to debunk this myth.

Thank you for randomized control trials

In my experience, one of the most effective strategies to address the challenge of perceived lack of scientific validity in Transference Focused Psychotherapy (TFP) is to begin communications by highlighting TFP as a psychodynamic treatment for personality disorders that has been validated by randomized control trials (RCTs). This approach tends to engage the interest of a wide range of audiences.

I hold great respect and gratitude for fellow members who have dedicated themselves to the development of these RCT’s and who continue to plan new RCT’s. Conducting such trial, which play an indispensable role in establishing the credibility of TFP requires a great deal of effort. Especially when pretigious entities like the Cochrane database of systematic reviews use those RCT’s to determine which treatments have the most empirical support. I was happy to see that in 2012 Transference Focused Psychotherapy was considered a promising treatment for BPD along with Dialectic Behavioral Therapy, Schema Therapy, and Mentalisation Based Therapy. Unfortunately, in Cochrane’s new iteration of the review (2020), only DBT and MBT are mentioned as promising treatments. For this reason, the ISTFP is actively pursuing new RCT’s. To ensure that all members have easy access to the existing data, I have included links to all the RCTs at the end of this article.

However, even after presenting evidence of the treatment’s effectiveness, we often encounter a recurring weakness, which is the questioning of our theoretical foundation. I understand that some of you may disagree, emphasizing that our capacity to draw from the extensive psychoanalytic literature is indeed one of our greatest strengths. I completely agree , but we also have to recognize that in an evidence-based world, this reliance on psychoanalytic literature can sometimes undermine our credibility in the eyes of many.

Kernberg’s theory of personality

We are fortunate that Dr. Kernberg, the founding father of Transference Focused Psychotherapy (TFP), has successfully expanded the roots of psychoanalysis to create a psychodynamic treatment that integrates contemporary advancements in neurology with core concepts of psychoanalysis. In this series of articles, we will delve into the scientific evidence that substantiates the fundamental principles of Transference Focused Psychotherapy. Moreover, my aim is to present this information in a manner that is accessible to everyone, so it can be used in many contexts. To facilitate this, I will include links not only to scientific papers but also to the relevant images I have utilized.

Given the extensive nature of the topic, I will employ the following papers as guiding lights to navigate our exploration:

Kernberg, Otto. F (2016): What is personality?, Journal of Personality Disorders, Volume 30(2), 145-156

Otto F. Kernberg M.D. (2001) Object Relations, Affects, and Drives: Toward a New Synthesis, Psychoanalytic Inquiry, 21:5, 604-619

In the first paper, Kernberg provides a clear depiction of personality as a dynamic “umbrella” organization comprising various major component systems.

  1. Temperament
  2. Object relations
  3. Character
  4. Identity
  5. Ethical value system
  6. Cognitive capability (More precisely, attention and effortful control)

When I read the article, I was captivated by the elegant simplicity of the description, which not only established a connection with neurology but also provided bridges with other sciences.

For the time being, our exploration will focus on examining the temperamental components of this organization, deferring the investigation of its dynamic to a later point.

Temperament

I consider temperament as the fundamental constitutive structure of the
personality, represented by the general psychological reactivity of the or-
ganism, particularly psychomotor, cognitive, and affective reactivity. Affective reactivity Is the fundamental aspect of the organism’s psychic operation, in terms of constituting the primary motivational system, relating the individual to the environment in terms of positive, rewarding, or negative, aversive affective states reflected, particularly, in peak affect state activation.

Otto Kernberg, 2016

This is, in a nutshell, Kernberg’s theory of temperament and his psychodynamic conception of the the deep layers of the unconscious. A significant advance in supporting his theory of temperament came through the integration of data from Panksepp’s experiments in affective neurology. This integration has provided us with a robust scientific foundation to anchor our psychodynamic thinking.

Panksepp’s Affective Neuroscience

Scientific investigation of the brain is a formidable endeavor, as neurons intricately form vast and complex networks throughout an individual’s lifetime. Panksepp’s work stands out due to its unique focus on the sub-cortical networks of the brain. These networks exhibit minimal changes after birth and are present in all mammals, including humans like us.

Panksepp’s scientific protocol involves stimulating the sub-cortical networks of various animals through the application of small electric shocks or specific chemicals, followed by the observation of their resulting behaviors.

Reminder

  • The cortex is the seat of many high level functions like language and decision making
  • Subcortical structures are located under the cortex and are the seat of primitive fonctions like emotions processing
  • They represent networks of neurons that change very little during an individuals lifetime.

Through his research, Panksepp identified seven networks of neurons that, when stimulated in mammals, elicit the following responses:

  1. Specific behaviors, such as facial expressions.
  2. Specific cognitive activities, including distinct attention states and states of effortful control.
  3. Specific subjective experiences of positive or negative valence.

It is important to note that Panksepp aimed to differentiate affect from its subjective experience, which he denoted by writing the affect in capital letters and the associated subjective experience in lowercase. This distinction emphasizes that AFFECTS encompass a range of phenomena that include subjective experiences but are not limited to them.

SEEKING-expectancy

The primary function of the affect is to prompt individuals to actively engage with their environment in order to acquire the necessary resources to fulfill basic needs such as hunger, thirst, security, or sexual arousal.

FEAR-anxiety

The primary function of this affect is to safeguard against existential threats, such as heights, fire, or predators, by employing either a freezing or escaping mechanism.

RAGE-anger

The primary function of this affect is to remove obstacles that hinder access to essential resources or the satisfaction of basic needs, often accomplished through acts of biting or killing.

LUST-sexual arousal

The primary function of this affect is to facilitate reproduction by eliciting seductive behaviors, such as ear wiggles in rats or assuming a position that prominently displays sexual organs in female dogs.

CARE-love

The primary function of this affect is to promote parental care and nurturing of the young by eliciting behaviors such as huddling or grooming. These behaviors help create a nurturing and protective environment that supports the well-being and development of the offspring.

PANIC-sadness

The primary function of this affect is to prevent the risks associated with separation from primary caretakers by eliciting a sequence of behaviors that typically begins with crying, grasping, and other distress signals. If the caretaker does not return, this sequence may culminate in a decline of motor activity and drive.

PLAY-social joy

The primary function of this affect is to foster attachment and establish dominance structures within social groups by engaging in a behavior commonly known as “rough and tumble play.”

This neurological data provides support for the existence of primary motivational systems, aligning with Kernberg’s theory of affects. The findings indicate that specific neural mechanisms underlie the functions and expressions of these affects, reinforcing their role as fundamental drivers of behaviour.

Now we have to find empirical validation that they relate the individual to the environment in terms of positive or negative affects states.

Unveiling the Neural Mechanisms of Relating

Having mapped out the networks of each core affect, Panksepp devised an experiment to ascertain their subjective valence. To conduct this experiment, he placed rats within a maze, allowing them to freely explore their surroundings. Within a specific section of the maze, Panksepp stimulated one of the seven pre-identified affects using electric stimulation. Subsequently, he closely observed the rats’ behavior, aiming to discern the impact of the activated affect on their responses.

The affective precursors of ideal object relations

Through numerous trials, a consistent pattern emerged in Panksepp’s research, revealing that rats exhibited a distinct preference for the areas where specific affective states were triggered. Notably, the affects of SEEKING/expectancy, CARE/nurturing, PLAY/social joy, and LUST/sexual arousal. Based on their behavior and responses, it can be inferred that these affective states evoked a sense of positive subjective experience, prompting the rats to seek the repetition of such experiences.

  • Gallery Image
    SEEKING-Expectancy
  • Gallery Image
    PLAY-Social joy
  • Gallery Image
    LUST-Sexual arousal
  • Gallery Image
    CARE-love

The affective precursors of persecutory object relations

Through an extensive series of trials, a notable pattern emerged, revealing that rats consistently avoided the areas where specific affective states were triggered, namely RAGE/anger, FEAR/anxiety, and PANIC/sadness. The observed avoidance of these affective states strongly indicates that the rats experienced negative subjective experiences when exposed to the corresponding affective stimulation, leading them to actively seek to avoid repeating such experiences.

  • Gallery Image
    FEAR-Anxiety
  • Gallery Image
    RAGE-Anger
  • Gallery Image
    Panic-Sadness
  • Gallery Image
    Panic-Sadness

The preceding experiments not only confirms that affects are biologically encoded as either positive or negative experiences, but also shed light on the immediate contextualization that occurs when these affects are activated. This contextualization process leaves a lasting memory trace that takes the form of a dyadic relation. From the rat’s perspective, the memory of the experience encompasses the representation of their own body (self representation) being in a specific part of the maze (object representation) while experiencing a particular affect.

Because of Panksepp’s work, we now have compelling evidence that, as defined in Kernberg’s theory of temperament, affect are primary motivational systems that relate the individual to the environment in terms of positive or negative affects states.

What’s next?

At this time, it is pertinent to acknowledge that the seven affect systems discussed thus far might not represent all core affects. Others, like surprise, have yet to undergo neurologic exploration.

Furthermore, they do not encompass the entirety of our vast emotional life. Rather, they represent core affects, akin to primary colors in the realm of emotions. Analogous to how a combination of just three primary colors can produce an extensive range of hues, it is conceivable that these seven core affects can give rise to a diverse array of subjective experiences, spanning from admiration to contempt, compassion to indifference, and love to hate.

To understand the process of how the integration of basic affects give rise to novel emotional experiences, it is imperative to turn our attention to the second article mentioned earlier “Object Relations, Affects, and Drives: Toward a New Synthesis”. But it would mean that we tackle the concept of character, another important component of personality.

In adherence to the framework of our discussion (we TFP therapists always strive to maintain frame adherence), I will refrain from diving into this new subject. However, I invite you to read the aforementioned paper and contemplate the significance of temperament and the fresh perspectives that emerge from Jaak Panksepp’s affective neurology within the context of your daily practice of TFP.

I hope that through the assimilation of these insights, you can highlight the unique strengths and advantages of our model, making a persuasive case for its implementation and widespread acceptance.

Looking forward to your feedbacks,

Mathieu Norton-Poulin

TFP Randomized Controlled Trials

Clarkin, J. F., Foelsch, P. A., Levy, K. N., Hull, J. W., Delaney, J. C., & Kernberg, O. F. (2001). The development of a psychodynamic treatment for patients with borderline personality disorder: A preliminary study of behavioral change. Journal of Personality Disorders, 15, 487–495.

Clarkin, J. F., Levy, K. N., Lenzenweger, M. F., & Kernberg, O. F. (2007). Evaluating three treatments for borderline personality disorder: A multiwave study. American Journal of Psychiatry, 164, 922–928.

Doering, S., Hörz, S., Rentrop, M., Fischer-Kern, M., Schuster, P., Benecke, C., Buchheim, P. (2010). Transference-focused psychotherapy v. treatment by community psychotherapists for borderline personality disorder: Randomized controlled trial. British Journal of Psy- chiatry, 196, 389–395.

Fischer-Kern, M., Doering, S., Taubner, S., Hörz, S., Zimmermann, J., Rentrop, M., Buchheim, A. (2015). Transference-focused psychotherapy for borderline personality dis- order: Change in reflective function. British Journal of Psychiatry, 207, 173–174.

Levy, K. N., Kelly, K. M., Meehan, K. B., Reynoso, J. S., & Weber, M. (2006). Change in attachment patterns and reflective function in a randomized control trial of transference focused psychotherapy for borderline personality disorder. Journal of Consulting and Clinical Psychology, 74, 1027–1040.

Stoffers-Winterling JM, Völlm BA, Rücker G, Timmer A, Huband N, Lieb K. Psychological therapies for people with borderline personality disorder. Cochrane Database of Systematic Reviews 2012, Issue 8.

Bibliography

Antonio Alcaro, Stefano Carta and Jaak Panksepp, The Affective Core of the Self: A Neuro-Archetypical Perspective on the Foundations of Human (and Animal) Subjectivity, Frontiers in Psychology, www.frontiersin.org, September 2017, Volume 8, Article 1424.

Christian Montag and Jaak Panksepp (2017), Primary Emotional Systems and Personality: An Evolutionary Perspective, Frontiers in Psychology, www.frontiersin.org April 2017, Volume 8, Article 464.

Douglas F. Watt (2017) Reflections on the neuroscientific legacy of Jaak Panksepp (1943–2017), Neuropsychoanalysis, 19:2, 183-198, DOI: 10.1080/15294145.2017.1376549.

Jaak Panksepp (2004). Affective consciousness: Core emotional feelings in animals and humans. Consciousness and Cognition 14, 30–80.

Jaak Panksepp (2011). Cross-Species Affective Neuroscience Decoding of the Primal Affective Experiences of Humans and Related Animals, PLoS ONE, www.plosone.org.

Jaak Panksepp, Andrea Clarici, Marie Vandekerckhove & Yoram Yovell (2019) Neuro-Evolutionary Foundations of Infant Minds: From Psychoanalytic Visions of How Primal Emotions Guide Constructions of Human Minds toward Affective Neuroscientific Understanding of Emotions and Their Disorders, Psychoanalytic Inquiry, 39:1, 36-51.

Jason S. Wright and Jaak Panksepp (2012), An evolutionary Framework to understand Foraging, Wanting, and Desire: The Neuropsychology of the SEEKiNG system, Neuropsychoanalysis, 2012, 14 (1).

Kenneth L. Davis and Christian Montag (2019), Selected Principles of Pankseppian Affective Neuroscience, Frontiers in Neuroscience, www.frontiersin.org, January 2019 Volume 12, Article 1025.

Mark Solms and Jaak Panksepp (2012), The “Id” Knows More than the “Ego” Admits: Neuropsychoanalytic and Primal Consciousness Perspectives on the Interface Between Affective and Cognitive, NeuroscienceBrain Sci. 2012, 2, 147-175; doi:10.3390/brainsci2020147

Otto F. Kernberg M.D. (2001) Object Relations, Affects, and Drives: Toward a New Synthesis, Psychoanalytic Inquiry, 21:5, 604-619.

Otto F. Kernberg, M.D. (2016) What is Personality?, Journal of Personality Disorders, Volume 30(2), 145-156, © 2016 The Guilford Press.

Mathieu Norton-Poulin

Mathieu Norton-Poulin, M.Ps.

Mathieu Norton-Poulin is a psychologist in private practice in Gatineau, Québec. He graduated from Laval University in 1995 and started his training in transference focused psychotherapy in 2005. Member of the TFP-Québec group he as been practicing as a certified TFP therapist for the last 11 years. Since 2009 he organized several training events and has given lectures on TFP for medical doctors and college students. He maintains a blog where he write, in plain words, articles to explain TFP to the general public.

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Word from the president – July 2023

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Dear fellow members of the ISTFP,

My thought after reading the excellent newsletter that our Public Relations Committee has put together is: “Never Bored!”

Why are we never bored? The articles included in the newsletter remind us of:

  1. The increasing need for our services.
  2. The never-ending efforts of our members to meet the need.
  3. The challenge of sharing our knowledge and skills with colleagues from different parts of the world and from different cultures, and the opportunity to learn from them.

In addition, the newsletter, in its informal poll of what others think of TFP, tells us that we should reflect on some internal representations people outside our community have of TFP… and how to modify those representations when they contain inaccuracies. I found this poll very helpful since it contained information that I have been, to some extent, in denial of (like everyone, I have my defenses).

In Theophilus Kok’s interview with Xumei Wang, we read a first-person account of what may be the most common challenge in learning TFP: the shift from supportive psychodynamic to deep work that offers profound change but that usually requires a period of induction into an exploratory therapy in which the patient, and therapist, must tolerate levels of anxiety as the patient’s earlier maladaptive adjustment to life is questioned.

Xumei Wang’s reflection on her experience also reminds us that what we learn when we learn TFP can help us understand the systems and networks within which we work, and the individuals who compose those networks. This kind of reflection requires the utmost tact since we are seeking an understanding that will help us negotiate challenging situations, with the possible goal of making changes in a system, while having to understand how best to deal with individuals who may be challenging.

Finally, Xumei Wang’s thoughts introduce a topic that we, at the Personality Disorders Institute, have deferred for a long time: should the student of TFP have the opportunity to participate in TFP as a patient? I propose that the ISTFP address this question more directly.

The articles on TFP for adolescents and on applied TFP in this newsletter speak to how members of our Society are expanding the application of our basic model of treatment to help more people in more circumstances. The need for good treatment for adolescents with personality difficulties is reaching crisis proportions and our Society as a whole will do what it can to support our growing initiatives for adolescents.

In the introduction to Mathieu Norton-Poulin’s excellent first article about empirical support for concepts at the heart of TFP, he reminds us of the need for additional RCT’s to add to the evidence base for TFP itself. I can reassure all members of our Society the ISTFP Executive Board is working very actively to initiate more RCT’s on TFP.

Please also take note of the excellent work done by Diana Tellez who has organized the listings of TFP trainings in a very clear and user-friendly way. This way of presenting the trainings will help guide potential students to the training that best suits them. It is a very important development as interest in TFP training continues to grow throughout the world.

A very special announcement before ending my letter is to welcome TFP-Puerto Rico to the ISTFP as a group in formation. TFP-Puerto Rico is an important addition to our community and will provide much-needed help to people on the island. Congratulations to Francisco Ramos-Rivera for taking the initiative to organize this group and to Mónica Eidlin for providing guidance and mentoring.

So, to get back to my initial comment, we all have chosen to devote ourselves to a kind of work in which we will be NEVER BORED! The need for our help presents us with challenges that would be daunting if we faced them alone but, together in this Society, we can turn those challenges into opportunities to work creatively together to advance our skills and understanding.

In the spirit of advancing our knowledge, I remind you to please save the date for our next ISTFP Biennial meeting, September 27 to 29, 2024 in New York.

Wishing you some rest and relaxation in the second half or the summer as we prepare to resume our full-speed efforts in September. 

With best wishes,

Frank

Frank E. Yeomans, MD, PhD

Frank E. Yeomans, MD, PhD, is a Clinical Professor of Psychiatry at the Joan and Sanford I. Weill Medical College and Graduate School of Medical Sciences of Cornell University. He is a Senior Consultant in and teaches internationally for the Personality Disorders Institute, and is in private practice in White Plains and New York City.

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The public image of TFP – What are people saying about us?

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Dear members of ISTFP,

It’s already been a year since the ISTFP’s Public Relation and Communications Committee has been working at bringing our community closer and finding ways to disseminate the model more efficiently. This is why I feel that, before introducing the main subject, I should give you a summary of what as been done so far. I the past year we have:

  • Successfully orchestrated and coordinated the promotion of the highly anticipated 7th ISTFP conference, ensuring a wide reach and strong attendance from professionals in the field.
  • Developed and curated engaging newsletters, including the ISTFP members Newsletter and the Mental Health Professionals Newsletter, providing valuable insights, updates, and resources on TFP to a diverse audience.
  • Established a comprehensive and GDPR-compliant database of mental health professionals, facilitating effective promotion of TFP events while respecting European regulations on personal data protection.
  • Implemented a standardized system for event organizers to submit new training events, streamlining the process and ensuring consistency and efficiency in event management.
  • Enhanced the ISTFP website by creating a dedicated TRAINING section, offering a comprehensive repository of seminars, courses and events related to TFP, catering to the needs of professionals and students alike.
  • Enriched the ISTFP website with a NEWS section, featuring the latest updates, research findings, and noteworthy developments in the field of TFP, keeping the community informed and engaged.

Reaching and maintaining these achievements take a lot of time and energy. Veronica and I would like to express our gratitude to our team, Diana Tellez, Theophilus Kok, Silvia Bernardi and Glauco Valdivieso for their involvement in these different projects. We would also like to thank Darlene McCormick, ISTFP website webmaster, for her counsel, and Frank Yeomans who has shown tremendous support and guidance for our ambitious initiatives.

That being said, let’s go to our main subject: What are people saying about us?

The public image of TFP

During my first meeting with Veronica Steiner, as co-chair of the Public Relations and Communication’s committee, she presented me with a homemade poll she conducted with general mental health professionals from Chile about their perception of Transference Focused Psychotherapy. I thought it was a great idea for assessing the strengths and weaknesses of our current dissemination strategy. So, a year later, I decided to mobilize the whole team to use social media to ask mental health professionals from their country simple question. While it is an informal and unscientific poll, it provides information for us to think about. The question is the poll was:

What are your thoughts or impressions on Transference Focused Psychotherapy (TFP)? Please provide any ideas, opinions, or experiences you may have regarding this treatment for personality disorders.

This is what they answered:

I know nothing about TFP

No tengo mucha información sobre este enfoque

I don’t have much information about this treatment. (Peru)

Connaissance limitée, outre le nom des auteurs, (…) je ne connais pas l’approche.

Limited knowledge, aside from the names of the authors, (…) I am not familiar with the treatment (Canada) .

TFP is violent

No sé qué es eso, y si se deriva de la teoría de Kernberg, debe ser violento. Es una técnica distante de los pacientes, el terapeuta es muy frío y sigue su técnica como si fuera la biblia.

I don’t know what it is, and if it derives from Kernberg’s theory it must be violent. It is a technique distant from patients, the therapist is very cold and follows his technique like the bible. (Chile)

(…) trouver cette approche comme inutilement violente pour les client(es)  axée sur une confrontation hâtive à leurs défenses et enjeux et dans un cadre inutilement rigide

(…) find this approach unnecessarily violent towards clients, focused on prematurely confronting their defenses and issues within an unnecessarily rigid framework. (Canada)

J’ai jamais pratiqué cette approche mais j’ai souvent eu vent que c’était une approche plus cassante et carrée que les approches psychodynamiques comme l’intersubjectivité.

I have never practiced this approach, but I have often heard that it is a more abrasive and rigid approach compared to psychodynamic approaches such as intersubjectivity. (Canada)

TFP is the same as Psychoanalysis

Pensé que era una forma de psicoanálisis, más enfocada en el pasado y poco estructurada.

I thought it was a form of psychoanalysis, more focused on the past and poorly structured. (Chile)

Muchos piensan que es igual al psicoanálisis clásico

Many people think it is the same as classical psychoanalysis. (Peru)

Я не повністю розумію унікальність цього методу; інші психоаналітичні школи також вважають контртрансференцію основним інструментом роботи з людьми, що мають розлад межової особистості.

I do not fully understand the uniqueness of the method; other psychoanalytic schools also consider countertransference to be the main tool for working with people with a borderline. (Ukraine)

TFP is not an evidence-based treatment

Es una técnica sin evidencia real y útil para un grupo muy pequeño de pacientes.

It is a technique without real evidence and useful for a very small group of patients. (Chile)

C’est de la psychanalyse et plusieurs études on démontré que c’est une pseudoscience sans fondements scientifiques.


It is psychoanalysis, and several studies have shown that it is a pseudoscience without scientific foundations. (Canada)

TFP is for a closed group of elitist

每週兩次，在實際層面上，每次前往的財務壓力並不小，而我希望每週都能夠實踐這種工作方法。

Twice a week, at the practical level, the financial pressure of visiting is not small, and I want to practice this working method twice a week (China)

Es un grupo muy cerrado, imposible acceder a ellos.

It is a very closed group, impossible to access them. (Chile)

la tfp a la mauvaise réputation d’être réservée a « l’élite » privilégiée par ses contacts.

TFP has the reputation of being reserved for the privileged “elite” favored by its connections. (Canada)

TFP is a empirically supported treatment

Tengo una impresión positiva de este enfoque terapéutico respaldado empíricamente. Esta aproximación me parece interesante porque reconoce la importancia de las relaciones y las representaciones internas en el desarrollo y mantenimiento de los trastornos de personalidad.

I have a positive impression of this empirically supported therapeutic approach. This approach seems interesting to me because it recognizes the importance of relationships and internal representations in the development and maintenance of personality disorders. (Mexico)

尤其是在循证医疗的大背景下，能站得住脚，有实证检验真的很不容易，其实这一块还是能让患者在接受这种疗法上更有信心。

Especially in the context of evidence-based healthcare, it’s not easy to stand up to empirical testing, and this piece actually gives patients more confidence in accepting this therapy. (China)

TFP is a treatment with a clear clinical rationale and structured interventions

Personnellement, la TFP demeure une de mes approches privilégiées pour sa conception du cadre thérapeutique, ses rationnels cliniques clairs et logiques, le psychodiagnostic structurel et les pistes d’interprétation qu’elle offre, notamment dans la compréhension et l’identification des dyades relationnelles.

Personally, the TFP (Transference-Focused Psychotherapy) remains one of my preferred approaches due to its conception of the therapeutic framework, clear and logical clinical rationales, structural psychodiagnostic, and the interpretative pathways it offers, particularly in understanding and identifying relational dyads. (Canada)

En la formación descubres que se trata de una terapia centrada en el presente y en la visualización de las representaciones actuales de las relaciones objetales, con una estructura sólida y técnicas que te permiten discernir los conflictos afectivos y las diadas dominantes en la relación a través del transferencia como laboratorio para la observación del paciente.

In the training, you discover that it is a therapy focused on the present and on observing the current representation of object relationships, with a solid structure and techniques that allow you to discern affective conflicts and dominant dyads in the relationship through transference as a laboratory for patient observation. (Chile)

Переклад українською: ефективний психотерапевтичний інструмент у роботі з повним спектром психопатології. Здається логічним та послідовним.

An effective psychotherapeutic tool in working with the full spectrum of psychopathology. It seems logical and consistent. (Ukraine)

Kernberg is a genius

Переклад українською: Добрий метод для клієнтів з низькою функціональністю межового розладу. Кернберг – геній.

good method for low functioning borderline clients. Kernberg is a genius. (Ukraine)

Переклад українською: Модель терапії Отто Кернберга є дуже цінною, якісною та зрозумілою лише тоді, коли її представляє сам Отто Кернберг.

Otto Kernberg’s model of therapy is very valuable, qualitative and understandable only when presented by Otto Kernberg himself. (Ukraine)

Переклад українською: Я вважаю, що ТФП повинен бути ефективним психотерапевтичним інструментом у роботі з повним спектром психопатології. Це здається логічним та послідовним. Г-н Кернберг не “винаходить колесо”, шукаючи нові теорії або відкриття.

I think TFP should be an effective psychotherapeutic tool in working with the full spectrum of psychopathology. It seems logical and consistent. Mr Kernberg does not “reinvent the wheel” by looking for new theories or revelations. (Ukraine)

When we read all of these quotes at once, it might seen a little discouraging especially because of all the energy the we put on perfecting, validating, and disseminating the model. But I am sure my fellow members have a stable identity and will see these perceptions as internal objects from the those who participated in the survey that have to be clarified and tactfully confronted.

From a positive perspective, feedback from mental health professionals who do not regularly utilize TFP but have attended TFP conferences or new TFP trainees (like the members of the Ukraine cohort) reaffirms that dedicated time spent with them can significantly challenge and correct misconceptions surrounding Transference Focused Psychotherapy.

As you can see, these findings tell us the there is hope but still a lot to do so let’s get back to work!

Mathieu Norton-Poulin
On behalf of the PR committee

Mathieu Norton-Poulin

Mathieu Norton-Poulin, M.Ps.

Mathieu Norton-Poulin is a psychologist in private practice in Gatineau, Québec. He graduated from Laval University in 1995 and started his training in transference focused psychotherapy in 2005. Member of the TFP-Québec group he as been practicing as a certified TFP therapist for the last 11 years. Since 2009 he organized several training events and has given lectures on TFP for medical doctors and college students. He maintains a blog where he write, in plain words, articles to explain TFP to the general public.

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Mathieu Norton-Poulin, M.Ps.
Mathieu Norton-Poulin, M.Ps.

Mathieu Norton-Poulin is a psychologist in private practice in Gatineau, Québec. He graduated from Laval University in 1995 and started his training in transference focused psychotherapy in 2005. Member of the TFP-Québec group he as been practicing has a certified TFP therapist for the last 9 years. Since 2009 he organized several training events and has given lectures on TFP for medical doctors and college students. He maintains a blog where he write, in plain words, articles to explain TFP to the general public.

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Applied Transference Focused Psychotherapy

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Applied Transference Focused Psychotherapy in psychiatric settings

We often wonder about the future of Transference Focused Psychotherapy (TFP) and the challenges that lie ahead, as well as the directions we would like to pursue. The paper featured this month examines the recent developments of our technique, observing how specific principles of TFP have naturally met the needs of the broader community of mental health providers.

Over the past four decades, there has been a gradual increase in attention given to the personality component of various pathologies and pathological or quasi-pathological circumstances. For instance, the study of pathological dynamics in large groups.

The author of the paper, Richard Hersh MD, is a psychiatrist, psychoanalyst, certified TFP supervisor, and a well-known figure for his contributions in expanding the applications of TFP to different clinical settings. This includes settings that do not primarily focus on psychotherapy-based interventions. You can find more information about Dr. Richard Hersh at this link: https://www.columbiapsychiatry.org/profile/richard-g-hersh-md

Indeed, as Dr. Hersh points out, certain core principles of TFP lend themselves to a variety of practical applications that may differ significantly from the traditional psychoanalytic foundations from which TFP originated. TFP principles are characterized by hierarchy of importance, common sense, pragmatism, and reproducibility.

Some of the most valuable, yet perhaps most distinctive and challenging, principles to learn include openness to consider and share a diagnosis of personality disorder, early involvement of significant others in treatment, clear definition of roles and responsibilities for both the patient and therapist, and continuous, dynamic attention to the therapeutic alliance that allows for adjustment and analysis as the relationship between patient and therapist evolves.

These core principles make TFP a labor-intensive modality for both the patient and therapist. It requires constant observation of countertransference, best achieved through continuous supervision or contact with peers and, when possible, the use of video recordings. Not all clinical cases are motivated enough to adhere to long-term individual TFP treatment. In addition, practical circumstances may not all for long-term individual treatment. Due to its labor-intensive nature and the constant need for supervision and attention to the therapeutic relationship, therapists are limited in the number of patients they can effectively treat in long-term individual therapy compared to other modalities. However, as Dr. Hersh notes, the core principles mentioned above can easily be translated to different settings, such as psychopharmacology or supervision of different treatment modalities, providing significant benefits (Carsky and Yeomans, 2012).

Dr. Hersh’s contribution, “Fundamentals of Transference Focused Psychotherapy: Applications in Psychiatric and Medical Settings” was published in 2016 and written for a broad audience. In addition, TFP diagnostic tools have been applied and taught in a weekly curriculum for internal medicine residents (Petrini, 2017) who often encounter patients with personality disorders but lack training in how to handle these patients and their own emotions in response to these patients. As Gunderson has pointed out, overprescribing in response to patients with Borderline Personality Disorder (BPD) is a common countertransferential response, one that physicians in medicine and other sub-specialties are often unaware of and likely to fall into. TFP principles are also beneficial for psychopharmacologists who frequently treat patients with personality disorders. By understanding how medications can serve as a vehicle for expressing transference feelings, these providers can contextualize treatment non-compliance, possible side effects, and acting out between visits. Most importantly, they can discern the genuine needs and benefits of medications.

Another important aspect highlighted by Dr. Hersh is the evolution of TFP with regards to the incorporation of its basic concepts in different clinical contexts. TFP has been applied to geriatric patients, users of psychoactive substances, trauma patients, adolescents in day hospital units, liaison psychiatric services, forensic patients, and minority communities. Many of these initiatives have been adapted by various authors to contexts where they have had to accommodate case management and other evidence-based therapies, such as dialectical behavior therapy and mentalization-based therapy. The experiences have been promising, facilitating access to therapy, minimizing psychosocial impact, and establishing achievable goals.

Undoubtedly, TFP, as applied in our time, has garnered interest from clinicians who approach the principles of modern psychoanalytic approaches with flexibility and respect. This contributes to dispelling the stigma associated with this therapy and opens it up to the scientific community.

Silvia Bernardi and Glauco Valdivieso

Silvia Bernardi

Silvia Bernardi

Silvia Bernardi, MD, is an Assistant Professor of Psychiatry at Columbia University. After graduating from medical school in Florence Italy in 2006, Silvia emigrated to the USA to work intensively in neuroscience research, studying the bases of the interaction between emotions and cognition. Silvia completed her residency in Psychiatry at Columbia and has since practiced privately in New York. She trained in Transference Focused Psychotherapy and continues to see patients for medication management and psychotherapy while conducting her research to unlock further knowledge to support the biological underpinnings of TFP and borderline personality disorder.

Author’s website
Glauco Valdivieso

Glauco Valdivieso

Glauco Valdivieso is a Peruvian psychiatrist, psychotherapist, and researcher based in Lima, Peru. He completed his medical degree at the Universidad Nacional Mayor de San Marcos and specialized in psychiatry at the Hospital Nacional Víctor Larco Herrera, becoming a board-certified psychiatrist in 2018.

He is a certified psychotherapist in Transference-Focused Psychotherapy (TFP), trained by the International Society of Transference-Focused Psychotherapy (ISTFP). In addition, he has completed formal training in Cognitive Psychotherapy, Dialectical Behavior Therapy (DBT), and Mentalization-Based Treatment (MBT).

More information

Dr. Valdivieso is the co-founder and medical director of the Instituto Peruano para el Estudio y Abordaje Integral de la Personalidad (IPEP), where he also coordinates the TFP Peru division. He founded and currently leads the Chapter on Personality Disorders within the Peruvian Psychiatric Association (APP), and works at the Mental Health Unit of Hospital de Villa El Salvador in Lima.

He is also a co-founder and editorial board member of the Latin American Journal of Personality, a collaborative initiative with the Instituto Argentino para el Estudio de la Personalidad y sus Trastornos (IAEPD). Additionally, he serves on the editorial board of the Peruvian Journal of Psychiatry. Internationally, he is a Board Member of the International Society for the Study of Personality Disorders (ISSPD), where he chairs the Communications Committee and leads the Latin American Regional Group.

His main clinical and research interests include the treatment of personality and mood disorders, with a particular focus on advancing research in Transference-Focused Psychotherapy (TFP).

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The ISTFP adolescent committee

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Dear Colleagues,

The ISTFP established the Adolescent Committee to develop a treatment for adolescents with various personality pathologies. Since the DSM diagnostic system officially recognized the diagnosis of BPD in adolescence and considering the unique developmental challenges of this stage (puberty, peer and love relationships, sexuality, aggression, and narcissism), a group of ISTFP members (L. Normandin, K. Ensink, A. Weiner, and Otto F. Kernberg) published the first edition of a TFP-A manual (Normandin et al., 2021). The manual preserves the core techniques and strategies of TFP for adults but includes specific adaptations for working with parents and addressing developmental issues.

I have chaired the TFP-A Committee since its foundation. It was essential for me to structure a working group with representatives from each country interested in pursuing the development of TFP-A. Committee members include Alan Weiner (New York, USA), Karin Ensink (Quebec, Canada), Maya Krischer (Cologne, Germany), Gabrielle Kehr (Berlin, Germany), Teressa Ribalta (Barcelona, Spain), Brenda Tarragona Medina (Barcelona, Spain), Emanueli Preti (Milano, Italy), Irene Sarno (Milano, Italy), , Clarissa Laczkovics (Vienna, Austria), and Marko Biberdzic (Wollongong, Australia), who serves as the assistant chair. I am consistently impressed by their expertise and dedication to adolescent treatment and the ISTFP.

So far, the Committee has been meeting twice a year. It has statute on requirements to become TFP-A therapist as well as trainer-supervisor. It has supported several research efforts such as on PD diagnosis in adolescence, implementation of TFP-A in an inpatient unit in Cologne, and the validation of outcome instruments namely the STIPO-A and the LPOD-q. One or two members of the Committee have been entrusted to join the main ISTFP committees for instance the Training and Supervision Committee, the Research Committee and the Ethics Committee.

Our goals for the coming years include:

  • Advancing the development of TFP-A
  • Implementing a group approach from Spain
  • Incorporating parental involvement strategies from Germany and the USA
  • Publishing an edited book on TFP-A
  • Expanding the training of TFP-A therapists and supervisors to promote wider dissemination of this new treatment
  • Collaborating with multiple sites to gather scientific evidence of its efficacy
  • Developing research instruments such as STIPO-A and LPODq
  • Aspiring to conduct a randomized controlled trial (RCT) at one of our sites.

Through our combined efforts, we will improve treatment for this group of adolescents, provide specialized training for clinicians and move towards collecting outcome data at our sites. 

Yours truly,

Lina Normandin

Lina Normandin, Ph.D.

Dr. Lina Normandin is a professor of psychology at Laval University in Quebec City, Canada and clinical psychologist working with children, adolescents and adults. Her main research themes are in child abuse, adolescent personality disorders and psychotherapy processes such as countertransference. She is an accredited trainer and supervisor in Transference-Focused Psychotherapy (TFP and TFP-A) for personality disorders at the New York Personality Disorders Institute of Weill-Cornell University.

Laval University profile

8th ISTFP Biennial Conference in New York

Africa, Asia, Conferences, Europe, ISTFP Conference, Latin America, North America, Seminars

ISTFP

Biennial Conference

September 27, 28 and 29, 2024

8th ISTFP Biennial Conference in New York

English – Hybrid Event – Online and In person (New York)
Take note that REGISTRATION CLOSED FOR IN PERSON ATTENDANCE.
Registrations for the virtual ISTFP conference are still open.
Otto Kernberg, Frank Yeomans, Eve Caligor, John Clarkin, Jill Delaney, Stephan Doering,
Lina Normandin, Emanuele Preti, Vero Steiner, Luis Valenciano

INFORMATION | REGISTRATION

[Read more…] about 8th ISTFP Biennial Conference in New York

TFP in Wartime

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In February 2022, Ukraine was invaded by its powerful neighbor. Since then, the whole world has been witnessing with horror and sadness the struggle of the Ukrainian people to protect their lives, land, culture, and identity.

In this article, I invite you to meet the leader of TFP-Ukraine, Oleksii Lemeshchuk. With his openness, wit, and generosity, he helps us understand his people and reflect on the challenges of applying TFP in a country at war.

Meeting Oleksii and his people

My first contact with Oleksii was through an email I sent him during the holidays. I decided to contact him when I discovered, through the warm holiday wishes that many of you sent, that we had a Ukrainian TFP group in our society. It seemed to me that they would have a unique perspective on human nature and on the application of transference focused psychotherapy in a difficult context.

He answered quickly and showed enthusiasm for the project. We arranged a zoom meeting with an interpreter so that communication of his ideas would not be limited by language. 

On the given day, I connected with Oleksii and his interpreter and was pleasantly surprised by the brightness of his office. Looking back, I wonder if I was expecting darkness and despair. The short time I spent with Oleksii showed me light and hope for a better future.

Perhaps that resilience comes from spending his childhood in a communist country. Oleksii remembers how it was dangerous to exist outside of Marx and Lenin’s thinking: 

That was the time when everybody had to be obedient and do what is told.

Olexeii Lemeshchuk, Leader of TFP-Ukraine

Because of that, having personal discussions to talk about one’s problems was not allowed. Original thinking that could foster a deep understanding of oneself was considered dangerous. You could be arrested or killed for thinking the wrong things. Furthermore, since psychiatric facilities were used to enforce control of dissidents who would not comply with the policies of the communist party, seeking help would make you suspicious to neighbors and friends. That is why many people turned to drugs and alcohol as the only means of relief from their suffering.

Despite the context, Oleksii’s independent thinking led him to be interested in people’s emotions and behaviors. Unfortunately, the political context did not permit the study of psychology until the dissolution of the Soviet Union in 1991. This led to more freedom of thought and action and gradually paved the way for him to undergo different psychology studies. But it was really in 2010 that psychology became very popular in Ukraine.

Before the war

Oleksii has been a clinical psychologist for 15 years. Although the study and practice of psychology have developed rapidly since 2010, the public system in Ukraine does not offer psychotherapy services. As a result, psychologists like Oleksii work in private offices, and patients pay for their own treatment since there is no insurance for psychological services. Those who cannot afford psychotherapy are treated with medication in the state psychiatric system. Although Ukrainian society has seen significant positive changes, it is still difficult for older people to seek help. Fortunately, the younger generation is more emotionally open and does not see seeking psychological help as a big problem.

Oleksii’s first contact with TFP was through his teachers who used Kernberg and Kohut to talk about narcissism. He immediately fell in love with Kernberg’s theories, which he found very reasonable. At that time, he never dreamed he would be able to attend seminars with him. Starting in 2015, he attended all of his seminars that took place in Ukraine and Russia.

It was finally in 2017 that he joined a Russian TFP study program under the direction of Frank Yeomans. Out of the 400 people who completed the course, 15 were from Ukraine. He was one of the 5 participants who joined a regular supervision group composed of Russians and Ukrainians.

While he was studying TFP, he fostered the project to start a TFP group in Ukraine, but he always postponed its inception because he was waiting for certification. 

Then the war began.

Being a TFP therapist in wartime

The first impact of the war was felt by Oleksii’s supervision group on the evening of February 24, 2022. Earlier that day, Russia had invaded Ukrainian territory. The group consisted of three Ukrainian and three Russian supervisees, as well as several Russian observers and a supervisor from the USA. That evening, the Ukrainians were supposed to present cases, but they were too overwhelmed by the shock and frustration of what was happening. They felt the danger of splitting and falling into a black and white vision of the situation. However, Monica Carsky, the group supervisor, and the Russian colleagues present showed tremendous support, with some of them crying,  appalled by what was happening.

Oleksii emphasized the importance of these spontaneous reactions from their Russian counterparts, as they had a profound emotional impact on him. It helped them maintain a nuanced view of the world, where not all Russians are bad and not all Ukrainians are good. The experience highlights how external reality has a great influence on the capacity to maintain technical neutrality. It shows us how important it is for TFP therapists to cultivate this stance in their personal life by surrounding themselves with people who support it. It also highlights how a supervision group can serve as an emotional support group and treating colleagues with honesty and compassion matters.

According to Oleksii, the group led by supervisor Monica Carsky has become essential to each of its participants. Recently, the group discussed the significance of their collective experience. For Oleksii, it represents the idea that psychological well-being, love, and friendship can help individuals overcome even the most challenging times. It’s not surprising that this group, composed of both Ukrainians and Russians, continues to meet regularly.

However, the emotional strain can sometimes be too much. Oleksii and other Ukrainian TFP therapists had a hard time continuing to develop within the Russian TFP community while Putin’s regime continued to bomb Ukrainian cities and kill Ukrainians.

Oleksii had to quickly develop a project of founding a TFP group in Ukraine. TFP-Ukraine is made up of 14 members, with four in Odessa, three in Kiev, two in Kharkov, one in Dnipro, and one in Lugansk. Three have left the country. The situation in Kharkov is the worst, as the city is located 50 km from the Russian border and experiences shelling and artillery fires every day. Dnipro is also in a tough situation as it is a city closer to the front line and is quite often shelled. Odessa, where Oleksii lives, is now 200 km from the front lines.

Despite the war, TFP-Ukraine was able to arrange for over 200 Ukrainian therapists to participate in a seminar on personality disorders by Dr. Kernberg and to conduct a seminar with Dr. Kernberg on narcissistic disorder. They also have further plans to develop TFP in the country. For many people, it might be a bit surreal to study in a time of war, but that is the Ukrainian reality – war is not a hindrance to life.

Wartime TFP

Even in a relatively safe city, events happening anywhere in the country can have a profound impact on all citizens. For example, when a missile hits a residential building in cities like Dnipro, Kharkov, or even Odessa, people throughout the country share in feelings of sadness and anger. Despite the destruction caused by the ongoing conflict, the people of Kharkov and other affected cities demonstrate remarkable resilience and work tirelessly to rebuild after each attack.

I asked Oleksii about his experience working with patients during this challenging time. He explained that at the beginning of the war, many patients sought help for emotional trauma, which prompted Ukraine’s psychotherapists to volunteer to form a few crisis centers that continue to work.

However, as the conflict persisted, patients began seeking help for long-lasting emotional difficulties that had been exacerbated by the ongoing conflict. Interestingly, some patients who had previously been reluctant to engage in psychotherapy were now motivated to address longstanding issues.

Before our interview, I had wondered how challenging it must be for a TFP therapist practicing in Ukraine to apply basic principles of transference focused psychotherapy in the midst of such extreme circumstances. 

My primary concern pertained to the assessment process, specifically how one could differentiate between symptoms of post-traumatic stress disorder and personality disorders.

According to Oleksii, a key factor in differentiating between post-traumatic disorders and personality disorder symptoms is to observe for signs of persistent identity diffusion. In order to make an accurate diagnosis, it is crucial to inquire about the patient’s emotions, behavior, and interpersonal relationships prior to the onset of war. This information can provide valuable insight into their baseline personality and help to differentiate between the two disorders.

I also asked Oleksii how the extreme circumstances in Ukraine have impacted the treatment process, and he acknowledged that maintaining a treatment contract can be a challenge. To overcome this, he frequently evaluates the treatment frame by asking himself “what” and “why” questions. This allows him to determine whether a patient is attacking the treatment frame or reacting to real-life situations.

I was intrigued to learn from Oleksii that even patients with dysfunctional personality structures tend to behave in adaptive ways in the current situation. However, he also noted that these patients differ from those with functional personality structures by displaying a significant denial of the emotional impact of the war. For instance, they may describe actions such as packing their belongings or leaving their homes, but they do not discuss their emotional responses to the conflict.

Interestingly, narcissistic patients, in particular, were noted to be less distressed by the war. This may be because their worst fear – the collapse of their grandiose self – had already occurred due to bankruptcy or other reasons. As a result, they may prioritize defending their grandiosity over reacting to the destruction of cities and loss of lives. In this way, it appears that even in extreme situations, structural anxiety and psychic defense mechanisms continue to override reality, and having a personality disorder may paradoxically protect individuals from the suffering of wartime.

However, it is important to note that patients with personality disorders are not immune to the traumatic effects of an armed conflict. Such extreme situations can challenge one’s character and allow for structural changes, especially when working with a skilled therapist. Oleksii has observed that the collapse of the grandiose self can expose narcissistic patients to emotional experiences they have never felt before, providing an opportunity for meaningful therapeutic work. Nonetheless, therapists must exercise caution in their interventions, as interpretations and confrontations that are too intense can cause dissociation or regression instead of integration.

I was also surprised to learn from Oleksii that he doesn’t consider paranoid object relations as an adaptive response to war, except perhaps for soldiers on the front line engaged in military action. For civilians and patients seeking therapy, such dynamics are not a healthy response. Instead, he has observed a prevalence of narcissistic dynamics that center around Ukrainian identity, including culture and traditions.

This suggests that individuals are seeking a sense of safety and stability in their cultural identity during a time of crisis. According to Oleksii, the emergence of two distinct groups reflects the underlying narcissistic dynamics at play. The first group is seeking a sense of superiority and validation of their Ukrainian identity by demonizing Russians. The second group, on the other hand, acknowledges the complexities of the situation and recognizes that not all Russians are to blame for the actions of their government. By not idealizing their own identity and not demonizing others, they demonstrate a healthier approach to their identity and relationships. Oleksii emphasizes the importance of acknowledging these dynamics in therapy and in society.

According to him, both groups have their roles to play in society. The more radical group promotes a deeper understanding and appreciation of Ukrainian culture, which can be valuable for preserving and promoting the country’s identity. However, he also believes that the second, more integrated and democratic group has an important role to play in preventing radicalization and promoting cooperation and understanding between different groups. He suggests that the two groups should work together and learn from each other’s strengths and convictions to build a stronger, more united society.

How can we help?

When preparing for the interview, I consulted with fellow committee members to gather questions they had for Oleksii. The most common question was how they could offer help. This is Oleksii’s answer, in his own word: 

For us, it’s very important to know that there are people in the world we can count on.  It was very important to know that we can speak to somebody, we can share with somebody that will understand us. I want to thank Monica Carsky and Frank Yeomans who are constantly in touch with us  for professional help and emotional support they give us. We are truly grateful for the excellent TFP supervisors Jos von Mosel from the Netherlands and Katarzyna Gwozdz from Poland who work with us on our difficult cases in supervision groups. I would also like to say that the knowledge that I gained in TFP, the knowledge of how the psychic of the person is working, helps me going through the situation right now. So, I am very grateful to everybody involved in the creation and development of the ISTFP.

Oleksii Lemeshchuk, Leader of TFP-Ukraine

Well, Oleksii, as we discussed during our interview, you have the unwavering emotional support of all the members of the ISTFP. We are deeply saddened by the situation you are facing, and we are committed to standing with you until you are finally safe. 

We eagerly await the day when we can meet you in person, shake hands in friendship, and listen and learn about your people. 

Mathieu Norton-Poulin

Mathieu Norton-Poulin

Mathieu Norton-Poulin, M.Ps.

Mathieu Norton-Poulin is a psychologist in private practice in Gatineau, Québec. He graduated from Laval University in 1995 and started his training in transference focused psychotherapy in 2005. Member of the TFP-Québec group he as been practicing as a certified TFP therapist for the last 11 years. Since 2009 he organized several training events and has given lectures on TFP for medical doctors and college students. He maintains a blog where he write, in plain words, articles to explain TFP to the general public.

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Word of the president – April 2023

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Peace

Dear Colleagues,

In this period of troubles in the world, I am particularly aware of how much I take for granted. An example is taking for granted that my life is not directly disrupted by a war. Oleksii Lemeshchuk’s interview in this newsletter reminds me of how quickly life can become a struggle for life itself. In that context, I tend to wonder about the importance of my contributions to society as a psychotherapist. It is encouraging to read that psychotherapy has an important role in helping both individuals and society in a time of war. In keeping with that theme, Silvia Bernardi and Glauco Valdivieso have written an important commentary in this newsletter on “The role of psychodynamically informed therapy in complex socio-political realities” in which they elaborate on Otto Kernberg’s reflections on malignant narcissism and group processes. I encourage you all to read it.

Another area of grave concern these days is the increasing level of mental health problems in our adolescents. The TFP-Adolescent (TFP-A) committee is a very important part of our Society and the members of the Committee are highly aware of the current crisis in the adolescent mental health. The path to becoming a certified TFP-A therapist involves a major investment in training. While we are pleased to see increased interest in obtaining full certification in working with adolescents, we are aware that many of our therapists who are certified in TFP for adults are asked to see adolescent patients. I have asked Lina Normandin, the chair of the TFP-A Committee to begin to conceptualize a training workshop that would provide the community of TFP therapists with the major concepts and tools that are necessary in treating adolescent patients. This plan for Adolescent Workshops would not replace the full specialization in TFP-A but would allow our general TFP therapists to be better equipped to help this population of patients.

Looking to the future, it is my pleasure to announce that the next ISTFP Biennial Conference will take place in New York City on September 27, 28, and 29, 2024. We are planning to have the conference in-person for the first time in six years. As we look forward to this event, I would like to again thank Anna Buchheim and her Innsbruck and Munich colleagues for the excellent job they did in organizing the past two conferences and to empathize with the disappointment we all shared that those conferences could not bring us together in person in Innsbruck.

In ending this message, I extend my gratitude to our Public Relations Committee for the energy, creativity, and wisdom that they put into producing the ISTFP newsletters.

With best wishes,

Frank

Frank E. Yeomans, MD, PhD

Frank E. Yeomans, MD, PhD, is a Clinical Professor of Psychiatry at the Joan and Sanford I. Weill Medical College and Graduate School of Medical Sciences of Cornell University. He is a Senior Consultant in and teaches internationally for the Personality Disorders Institute, and is in private practice in White Plains and New York City.

Promoting and submitting TFP training events

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In the previous newsletter, I introduced the ISTFP mailing list project as the initial step in a comprehensive global strategy to support TFP-Groups worldwide in promoting their training activities. The primary objective of this project is to facilitate the dissemination of information about TFP training opportunities in a convenient and efficient manner.

We are pleased to report that a significant number of you have subscribed to the ISTFP members list. For those who have not yet subscribed, we strongly encourage you to do so promptly to continue receiving our newsletter.

Additionally, we have observed a consistent flow of subscriptions to the ISTFP mental health professionals newsletter. As this mailing list serves as our primary means of recruiting new trainees, I will provide you with ways to contribute to its growth. 

Furthermore, I will outline the process for submitting your upcoming training events to ensure that they are featured on our website and newsletter. We are striving to establish guidelines that will enhance our effectiveness and the success of your events.

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Mathieu Norton-Poulin, M.Ps.
Mathieu Norton-Poulin, M.Ps.

Mathieu Norton-Poulin is a psychologist in private practice in Gatineau, Québec. He graduated from Laval University in 1995 and started his training in transference focused psychotherapy in 2005. Member of the TFP-Québec group he as been practicing has a certified TFP therapist for the last 9 years. Since 2009 he organized several training events and has given lectures on TFP for medical doctors and college students. He maintains a blog where he write, in plain words, articles to explain TFP to the general public.

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The role of psychodynamically informed therapists in complex socio-political realities

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In this issue of our newsletter, we focused on the role of psychodynamically informed therapists in current sociopolitical conflicts. That is why we have chosen to review Otto Kernberg’s paper: Malignant Narcissism and Large Group Regression.” Psychoanalytic Quarterly 89(1):1-24, 2020.

This article gains in appropriateness by the minutes, as we see conflicts, natural catastrophes and new regimes come to exist all over the world. In the first section of the manuscript, Dr. Kernberg reviews the major contributions of Freud, Bion, Turquet and Volkan on group psychology, highlighting how, at all different levels of grouping, from individual to large groups, when regression develops and the normal social structure that assures the individual of his status in the society disappears, a search for a “second skin”, a second identity that returns individual security begins. In reviewing these masterful contributions.

Social instability and the defensive behaviours of large groups

Otto depicts how, during threats, groups adopt defensive behaviors similar to the paranoid-schizoid position described by Melanie Klein, splitting, denial, omnipotent control, projective identification. In the headline section of this newsletter, Oleksii references his attention and awareness to these feelings and phenomena as his own population goes through massive destruction during the war (Read the article).

In such conditions of crisis, the search for a leader to provide the large group with a new senses of identification to a new society, becomes critical. Under condition of weakening of traditional social structures, the emergence of extremist political groups and parties with narcissistic and paranoid traits tends to become more likely, given their natural propensity to satisfy the “anxiety” of the mass, left without a strong sense of identity.

Malignant narcissism leadership: a desperate defence of identity

Leadership characterized by malignant narcissism (defined by Dr. Kernberg in 1984 and 2018 as a pathological grandiose self characterized by a sense of superiority, envy, devaluation, chronic emptiness, significant paranoid features, strong, ego-syntonic aggression and antisocial behavior), becomes particularly adept at fulfilling the large group needs for a “second skin” by providing an easy, strong identification with the leader (which in turn, Dr. Kernberg says, spares the need for the mass to envy the leader) and with an ideology that allows to identify the self against the other, aggressively othering a victim minority of choice.

The emergence of this malignant narcissistic leadership through mutual identification with mass crises can lead to devastating consequences. Dr. Kernberg quotes three major examples that led to genocides: Hitler’s Germany attempting to recover from WW1, the economic crisis of Rwanda after decolonization, and the aftermath of the decomposition of the communist system in Yugoslavia. But independent social structures, such as the media, the financial elites, and the armed forces, may have an impact on the regressive processes and set limits to the antisocial behaviors adopted by the leader, for example by not allowing dishonesty.

Preventing large group regression

Given the psychological processes underlying political catastrophes, and given the need for an integrated personality and healthy narcissism to evaluate self and others properly, Dr. Kernberg concludes that psychodynamically-informed therapists can contribute in several ways to the evaluation of political leaders. That should not be done not by labeling leaders with diagnostic names, but by pointing out their nature and the nature of the consequences of their actions and behaviors within complex social realities as divisive, or paranoia-inducing. Inspired by the contribution of historian Snyder (2017 “On Tyranny: twenty lessons from the twentieth century”), Dr. Kernberg writes.

We must remember professional ethics, believe in truth, investigate and listen for dangerous words. [Snyder] explains the importance of establishing a private life, contributing to good causes, learning from peers of other countries. He outlines a profile of individual courage, responsibility independence of thinking and public action. I think these are eminently reasonable and, in fact, essential qualities that permit the individual to stand up to the dangerous imprisonment in regressive group formations and confront dishonest, corrupting and corrupted leadership.

Otto Kernberg, M.D.

Silvia Bernardi and Glauco Valdivieso

Silvia Bernardi

Silvia Bernardi

Silvia Bernardi, MD, is an Assistant Professor of Psychiatry at Columbia University. After graduating from medical school in Florence Italy in 2006, Silvia emigrated to the USA to work intensively in neuroscience research, studying the bases of the interaction between emotions and cognition. Silvia completed her residency in Psychiatry at Columbia and has since practiced privately in New York. She trained in Transference Focused Psychotherapy and continues to see patients for medication management and psychotherapy while conducting her research to unlock further knowledge to support the biological underpinnings of TFP and borderline personality disorder.

Author’s website
Glauco Valdivieso

Glauco Valdivieso

Glauco Valdivieso is a Peruvian psychiatrist, psychotherapist, and researcher based in Lima, Peru. He completed his medical degree at the Universidad Nacional Mayor de San Marcos and specialized in psychiatry at the Hospital Nacional Víctor Larco Herrera, becoming a board-certified psychiatrist in 2018.

He is a certified psychotherapist in Transference-Focused Psychotherapy (TFP), trained by the International Society of Transference-Focused Psychotherapy (ISTFP). In addition, he has completed formal training in Cognitive Psychotherapy, Dialectical Behavior Therapy (DBT), and Mentalization-Based Treatment (MBT).

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Dr. Valdivieso is the co-founder and medical director of the Instituto Peruano para el Estudio y Abordaje Integral de la Personalidad (IPEP), where he also coordinates the TFP Peru division. He founded and currently leads the Chapter on Personality Disorders within the Peruvian Psychiatric Association (APP), and works at the Mental Health Unit of Hospital de Villa El Salvador in Lima.

He is also a co-founder and editorial board member of the Latin American Journal of Personality, a collaborative initiative with the Instituto Argentino para el Estudio de la Personalidad y sus Trastornos (IAEPD). Additionally, he serves on the editorial board of the Peruvian Journal of Psychiatry. Internationally, he is a Board Member of the International Society for the Study of Personality Disorders (ISSPD), where he chairs the Communications Committee and leads the Latin American Regional Group.

His main clinical and research interests include the treatment of personality and mood disorders, with a particular focus on advancing research in Transference-Focused Psychotherapy (TFP).

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The ISTFP research committee

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The Research and Publication Committee was established within the ISTFP to promote attention toward research relevant to the field of TFP. John Clarkin has guided the Research Committee since the foundation of the ISTFP. During the past decade, I had the opportunity to assist Dr. Clarkin in the initiatives of the Committee. In particular, we had regular open meetings of the Committee during the biennial ISTFP conferences, and the stimuli from those meetings fostered the initiatives of the Committee. In 2022 I was given the exciting opportunity to chair the Research and Publication Committee and was honored to accept this role. The first task was to establish a group of members. With the precious consultation of John Clarkin and Stephan Doering, a list of highly competent and motivated colleagues emerged:

Marko Biberdzic, Victor Blüml, Anna Buchheim, John Clarkin, Chiara De Panfilis, Rossella Di Pierro, Stephan Doering, Karin Ensink, Eric Fertuck, Andrea Fontana, Susanne Hörz-Sagstetter, Maya Krischer, Maria Jesus Rufat

I could list several qualities when thinking about these esteemed colleagues mentioned above. I want to underline how this roster of members is representative of different sites and countries, different research backgrounds, and different areas of expertise. What all these members have in common, however, is an evident enthusiasm for fostering the empirical basis of object relations and TFP.

During the first inaugural meeting at the last ISTFP conference, the Committee discussed its mission and mid- and long-term goals. We agreed that the Committee would serve as a nexus of communication among clinical researchers in the ISTFP. The initiatives and actions that we are developing aim to stimulate and assist in generating research among members of the ISTFP. Areas of research interest include:

  1. Psychopathology research, primarily as related to object relations theory
  2. Adolescence and developmental research
  3. Research on clinical assessment, e.g., STIPO-R, IPO-A, LPOq
  4. TFP process and outcome research

After the inaugural meeting, the Committee has scheduled a periodic follow-up meeting to translate the ideal mission into practical operations. In particular, we identified some initiatives as priorities for our joint work:

  1. Generation of a general research plan for conducting randomized clinical trials (RCT) of TFP.
    We all know how crucial it is to continue accumulating empirical evidence on the efficacy of TFP. New RCTs are paramount to continue being on the map of Evidence-Based Treatments for personality disorders. At the same time, such research efforts are hard to implement and pursue. Thus the Research Committee is supporting sites undergoing such efforts.
  2. Consultation with potential sites for the conduction of RCTs of TFP.
    Along the same line, as some RCT plans are almost ready to start, we need to prepare new sites for (near) future efforts.
  3. Mapping research expertise within the ISTFP
    The ISTFP community is unique in how clinical, theoretical, and research experiences are shared among many valuable members. We will soon circulate a brief survey for those members of ISTFP who are involved in research. We aim to get a clear map of such diffused expertise to create and foster collaboration networks.
  4. Reviewing empirical evidence on TFP and the object relations model of personality pathology.
    The TFP model is unique compared to other treatment models in that therapeutic techniques derive from a specific well developed clinical and theoretical model of the mind. We thus think that, besides RCTs, we can foster the empirical foundations of TFP, stimulating research in other areas. In particular, we came up with some research areas, and we are now in the process of reviewing existing contributions in the following domains:
    • Developmental research and adolescence
    • Assessment
    • Social cognitive processes and neurobiological underpinnings
    • Psychotherapy research (outcome, process, mediators/moderators)

We have set an exciting and challenging roadmap, and we look forward to conducting this journey!

 Emanuele Preti

 Emanuele Preti, Ph.D.

Emanuele Preti, PhD is an Associate Professor of Clinical Psychology in the Department of Psychology at the University of Milano-Bicocca in Milan, Italy, where he teaches and conducts research on personality pathology, clinical assessment, and psychotherapy. He serves on the Executive Committee of the International Society of Transference-Focused Psychotherapy and is a Fellow of the European Society of Personality Disorders. Preti also contributes to several international editorial boards and collaborates on research projects exploring dimensional models of personality disorders and related social-cognitive processes.

Research gate profile