News

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:

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

TFP is violent

TFP is the same as Psychoanalysis

TFP is not an evidence-based treatment

TFP is for a closed group of elitist

TFP is a empirically supported treatment

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

Kernberg is a genius

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, 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 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.

READ THE AUTHOR’S BLOG

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, 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 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).

Author’s facebook page

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

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, 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.

Read author’s Blog

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

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.

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.

READ THE AUTHOR’S BLOG

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

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

Daniela Saralegui is a young member of the ISTFP since 2020. She is a member of Grupo TFP Chile. She is a clinical psychologist, has a master’s degree in Adolescents from the University of Valencia, and has TFP training from TFP Latin America. Upon meeting her, we discovered an inquisitive girl who was involved in various activities. She is a university professor, attends to patients, and devotes much of her time to research, particularly in the field of TFP supervision.

Her first contact with the structural approach was during her undergraduate training at the university.

I learned Otto’s theory at the university, and from the beginning, it seemed orderly and made sense to me. Although they only taught me the structural theory and nothing about TFP, I came to that a little later. Once I was out of university, I started working at a psychiatric hospital in my country. I had no approach, and I really did not know where to start; it was somewhat chaotic. I thought the appropriate thing was to be eclectic and put a little bit of everything together… so sometimes it was cognitive-behavioral, other times it was psychodynamic, and sometimes I did a third-generation therapy.

It was a mess, and what was impressive was that my supervisor at that time was not concerned, and it bothered me a bit, but not enough. The breaking point came when I had around 20 patients, and one of them was getting worse and worse, going from crisis to crisis, and no matter how much I took the case to supervise, nothing changed.

This led me to a personal crisis, feeling that this was very difficult or not for me… that’s how I came to a supervisor who did TFP, and little by little, the situation became more organized, and so did my internal feelings. I discovered an approach that worked with the type of patient that I was treating. This was my start, and since then, I have trained in various seminars, congresses, and in TFP Latin America, and of course in supervisions, essential to be able to do it well.

Daniela Saralegui

Daniela tells us that this initial “chaos” gave way to a more orderly and structured way of working with clear objectives and easy-to-follow stages. For her, the challenge had not been simple, “being a manualized therapy is a double-edged sword for me. On the one hand, it organizes me, but on the other, I must be careful, given my way of being, I can become a bit rigid, I must always be alert not to lose my spontaneity and closeness, luckily always looking at myself in the session, and in supervision helps me with this.”

This professional start of Daniela marked and fixed her particular interests and challenges. A doubt arose in her about what helped novice therapists like herself. This, coupled with her passion for research, especially qualitative research, embarked on a major project: Investigating Supervision. She is leading the development of a line in this area, focused on researching therapist training, along with Luis Valenciano from Murcia and Verónica Steiner from Chile. “My interest is in conducting empirical research on training, and at the moment, I am starting with supervisions. It is not simple; I would say that this line is divided into three sections.

First, we carried out an exploratory review of what is written in this field; the truth is that quite little, and what there is more from the experiential point of view of the supervisee or from a theoretical point of view. This review examines supervision within the psychoanalytic world. We realized that since the 1980s, different authors have suggested empirical research, but it has remained there, as suggestions

We have decided to take this step and are currently conducting an analysis that will allow us to systematize the dynamics or patterns that occur in a supervision between the supervisee and supervisor. Specifically, we are developing a microanalysis of a supervision session using qualitative methodology and conducting discourse analysis. It has been quite a bit of work, as we are triangulating our analysis with that conducted by research assistants who are working with us. We are also training an artificial intelligence model for emotion recognition, which we hope will contribute to analyzing psychotherapy sessions as well.

Daniela’s project aims to develop a tool that can help therapists better identify and understand the emotions of the supervisee and supervisor during supervision sessions. By collecting and analyzing data from facial expressions, tone of voice, and other nonverbal indicators, the goal was to create an accurate and efficient model of emotion recognition. The objective is that this model can be used to help therapists adapt their interventions to the emotional needs of each supervisee, thus improving therapeutic outcomes.

In addition, Daniela is working on the concept of “intangibles,” which refers to the skills and knowledge that are not easily measurable but are fundamental to the success of supervision in clinical practice. Daniela believed that these “intangibles” are an important part of supervision and are directly related to the quality of care provided to patients. Therefore, she is developing an innovative approach to supervision that includes the evaluation of these “intangibles, ” along with other, more measurable skills and knowledge.

“All of the innovative research I have developed has been driven by my supervisors, Verónica and Luis, with whom we now work in a research laboratory where we jointly develop studies that seek to support our teaching models with empirical evidence.”

Undoubtedly, Daniela’s work is much more than a simple career. She has a passion to help therapists improve the quality of care they provide to their patients, especially in her country, where psychotherapy focused on transfer is still unknown. Daniela hopes to make a real contribution to clinical practice and the training of new therapists, so that they can avoid the mistakes she made when she began as a therapist.

In summary, Daniela is committed to the development of new tools and approaches to improve the clinical practice and training of therapists. Her work on emotion recognition and “intangibles” in supervision is an example of her innovative approach to and dedication to the constant improvement of patient care. Undoubtedly, Daniela is a therapist with a great future, and will be a true leader in her field. Daniela hopes to make a real contribution to Transference Focused Psychotherapy.

I hope that this helps therapists who are starting out, so that hopefully no one goes through the disorder I went through, and I hope that it also helps to spread awareness of this technique in my country, which is still unknown. Although in recent years this has been slowly changing, and more and more people are seeking us out, consulting with us, and wishing to refer patients, however, it is a vicious circle, there are people who are trained, but this is complemented with supervision, and there are few supervisors, meaning we are in a moment of being trapped, I hope this will be resolved so that with more people trained we can begin to develop the technique in other contexts, and who knows, perhaps someday have a presence in the public system of my country.

Daniela Saralegui

Ps. Veronica Steiner

Veronica Steiner Segal is a Chilean clinical psychologist who graduated in 1998. Since her beginnings she has been working with patients with Severe Personality Disorders in different health institutions in her country, and since 2018 she is a certified TFP therapist. In 2019 she obtained her accreditation as a teacher and supervisor. Since the same year she is coordinator of Grupo TFP Chile. She is the Executive Officer for the Board and she collaborates with the T&E Committee. She also teaches at the University of Valparaiso, in the Department of Psychiatry, where she also teaches in the Diploma of Severe Personality Disorders.
She collaborates in different courses looking for the diffusion of TFP. Together with Luis Valenciano and Pepa Gonzalez she directs an important training in TFP for Spanish speaking students, Instituto TFP Hispanoamerica.

TFP Chile WebsitE

On May 13, an event an oral “Festschrift” was held, in which the part of the ISTFP community connected to Cornell and special guests gathered with Otto Kernberg to celebrate his retirement as Director of the Personality Disorder Institute of New York Presbyterian-Weill Cornell Medical College.

More than 90 colleagues and members of his family paid heartfelt tribute through special words dedicated by Nancy Mc Williams, John Oldham, Salman Akhtar, Mark Solms, and Stephan Doering.

Undoubtedly, it was a moment of many mixed emotions.

Many voices honouring the same man

A lot can be said about Otto, his versatility and his skills in different fields make it difficult to choose how to pay tribute to him. Not surprisingly, everyone who spoke at the Festchrift chose a similar path, by addressing not only his long career and inspiration for many mental health professionals and therapists, but also his human qualities.

The Festschrift turned out to be an event full of emotions and memories. Inevitably, everyone present started to recall how and when they met Otto and what an important part of our professional development and work he has been.

Otto is a master in building bridges between different worlds.

John Oldham

John Oldham highlighted Otto’s mastery in building bridges between different worlds, between the world of psychoanalytic theory, the world of the clinic, the world of medicine, last but not least the world of research. This is only possible through particular traits that characterize his persona, such as his determination, and the ability to visualize a clear goal to guide his work. Nancy Mc Williams mentioned how difficult it is to summarize the contributions of someone who has dedicated himself to the study of so many phenomena associated with mental health, art, politics, neuroscience, supervision, education, love and aggression. She decided to show us who Otto through a personal anecdote. 

When I needed help, Otto treated me with a perfect combination of respect, consideration and honest criticism

Nancy McWilliams

It was 1991 and Nancy was writing a book as an introduction to psychoanalytic thinking. With this goal, she decided to ask Otto Kernberg, whom she had not met in person yet, for help. We all know how generous Otto is, so he did not hesitate to dedicate an hour of lunch, several pieces of advice and text recommendations to her. From there, a close relationship was forged that lasts to this day. Nancy recalls that day with various emotions such as “that lunch was the perfect combination of respect, consideration and honest criticism”.

Otto is an example of generosity of knowledge, kindness and a great capacity to forgive

Salman Akhtar

Similarly, Dr. Salman Akhtar took us back to 1978, when he met Otto for the first time at a lecture. Dr. Akhtar recalls “I did not understand a single word he said”. Hearing that, several Festschrift attendees smiled in complicity, as they surely identified with Dr Akhtar’s experience. In 1978, although he did not understand much of what Otto was talking about, he could tell that Dr. Kernberg was an eminence, and that his thinking was enticing. He decided to start reading his books. However, it was not until 5 or 6 years later that he was able to meet Otto in person, Dr. Akhtar defines the following 40 years of his career as “constant dedication”, highlighting Otto’s great generosity, referring to him as “generosity of knowledge, kindness, great capacity to forgive”. 

Dr. Akhtar, with an unmatched skill of language, highlighted above all Dr. Kernberg’s ability to delicately and precisely use irony, as well as his great capacity to unite and synthesize. He said, “What could someone born Jewish in Vienna, raised in Chile, a Catholic country, living in Topeka, Kansas do? Well, he could dedicate himself to synthesizing”. And yes, Otto is a synthesizer of different thoughts, a unifier of theories, a builder, but above all a noble, generous, and very respectful man.

Not an ideal, but surely an inspiration

And so one by one they spoke and paid tribute to Otto, all agreeing on his refusal to be idealized and his attachment to reality, because the reality is that on that Friday, May 13, everyone spoke of a dedicated Otto Kernberg, humble, generous with his knowledge, able to support and make us feel that we can all go far, and ahead of his time, trusting and supporting women long before others. So much knowledge transmitted with unmatched simplicity.

Many of us are fortunate to live in times where Otto is still a great teacher giving the best he has, to witness some of his qualities and employ them in life, and why not say it, it is because of him that many of us are today in this great family that is the ISTFP.

Thank you Otto!

Dear Colleagues,

First, I hope everyone has had the opportunity to have a good holiday break and a good start to the new year.

My understanding is that the classical Greeks taught us to “observe moderation in all things” (it sounds like a different way to say “avoid splitting”).

In that spirit, I would like to direct your attention to the post from Mathieu Norton Poulin, our Co-Chair of the ISTFP Public Relations Committee.

Mathieu outlines a system of email communication that is designed to keep you from the annoyance of getting too many ISTFP communications but to assure that you get important news, information, and resources from our organization. His letter is of particular interest to those who have a leadership role in their local TFP group. I would like to thank Mathieu and the rest of the PR Committee for their hard and successful work.

A second thought is the power of the discussion that took place last week between Otto Kernberg and Thomas Kohut, PhD. It was the first part of a series of meetings sponsored by the Austen Riggs Center, entitled “Refugees and Immigrants: Their Experience and Contribution to Psychoanalysis in North America”. The discussion, moderated by Nancy McWilliams, was both very moving and very wise. It is reminder of our great good fortune in having Otto Kernberg as the inspiration of our group.

While this Austen Riggs meeting was not an ISTFP event, our new communications system sent notification of the discussion to our members, and I noticed many of your names among the 750 people who attended virtually. If you missed the event and would like to see it, the recorded version will be available from Austen Riggs in a month.

My final theme in this letter will be to encourage as broad participation as possible from the different TFP groups. All of our component parts have talented and creative members. At the beginning of TFP, the PDI in New York was the source of most TFP publications. Since then, the TFP literature has been enriched by contributions from many of you. I would like to encourage an increase in contributions from our different members. My contacts with you provide ample evidence of the richness of clinical, theoretical, and research thinking. There are papers to be written (I have in mind the example of an impressive case of treating a DID patient with TFP, among many others). So please do not hesitate to put your ideas on paper. If you need someone to work with or to offer you some mentorship, we can try to provide that.

In the spirit of maximizing the involvement of the different groups, Verónica Steiner, our new Executive Officer, has been meeting with leaders of the different TFP communities throughout the world in an effort to better co-ordinate our international community. In welcoming Verónica into this position, I would like to take this opportunity to thank Luis Valenciano for his years of excellent service as Executive Officer as he transitions to the role of Director of Training and Education.

My gratitude also goes out to Nel Draijer for her excellent work and the important changes she made as Director of Training and Education for many years.

Another transition to note is John Clarkin’s stepping down as ISTFP Director of Research, after having created that role and providing essential leadership in the research necessary both to establish TFP as an evidence-base treatment and to provide evidence of its mechanisms of change.

I welcome Emanuele Preti as the new Director of Research and am excited about his vision for future research directions for the ISTFP.

Well, that sums it up: a combination of change and continuity as we strive to meet the needs of those suffering from serious personality disorders.

I thank you all for your commitment to that goal.

Best wishes,
Frank

Frank E. Yeomans, MD, PhD
President ISTFP

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.

Dear ISTFP members,

The 7th ISTFP conference ended just over two months ago, and I am still reflecting on how stimulating it was, both intellectually and emotionally. Like me, those of you who attended were able to witness our strong sense of community that prevails despite the challenges to group cohesion wonderfully described during the conference by Miguel Angel Gonzalez Torres.

Our sense of community strengthens each of us in numerous ways, so it is important that we nurture this sense of community on an ongoing basis. One way to accomplish this is to enhance our ability to share different skills and resources.

To formalize this ability to share and communicate, the ISTFP’s Public Relations and Communications Committee is creating a complimentary service that will be provided to all TFP groups. We call this service “The ISTFP Mailing List Project”. This will be especially relevant to those of you who plan lectures, trainings, and other academic events.

What is a mailing list?

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.

READ THE AUTHOR’S BLOG

In this issue of our research digest, we focus on a very recent article from Eric Fertuck, Ph.D. and colleagues entitled:

Rejection Distress Suppresses Medial Prefrontal Cortex in Borderline Personality Disorder.

Dr. Fertuck is an Associate Professor of Psychology at CUNY, NY, a certified TFP supervisor and therapist, a psychoanalyst, as well as a member of ISTFP. The article investigates the neurobiological underpinning of distress related to social exclusion, often a core symptom of borderline personality disorder (BPD). We chose to feature this article not simply because its result shed light on the biological underpinning of BPD, which is of course of interest for our community, but also because its methods are driven by the profound understanding of emotional processes that TFP, and psychoanalytic approaches, allow. By applying a deeper conceptual understanding of social rejection, Fertuck et al. help elucidate a biological mechanism that in the past has been investigated as a categorical, insular, function, leading to mixed results that have been difficult to replicate. We see this contribution as one of the first compelling papers utilizing awareness gained from the psychotherapy setting and psychoanalytic theory to deepen biological knowledge. This type of studies and approaches breaks the stigma of the absence of foundations in psychotherapy and psychoanalytic theory, likewise contributing to the scientific knowledge of clinical effectiveness through its different neurobiological mechanisms.

First, we will quickly review the results of Fertuck et al., to then focus on the creativity of their methodological strategy.

Prior studies have investigated rejection sensitivity by employing a paradigm called the Cyberball game, which is a computer-driven algorithm in which a human subject and two additional virtual players toss a ball to each other in a virtual environment. In one phase of the game, a ball is tossed with equal probability to the subject and to the additional players. In a second phase, the human subject is consistently excluded from receiving the ball. Prior studies have used fMRI to measure brain activity in human subjects while they play Cyberball during inclusion and exclusion phases.

Fertuck et al. studied rejection sensitivity in two groups of subjects, patients with BPD and a control group. Subjects played a modified version of the Cyberball game, and were asked to report their degree of rejection distress after each run. The authors found an inverse correlation between stress related to rejection and the rostro-medial prefrontal cortex (rmPFC) response to exclusion events. Both groups showed similar levels of rmPFC activity in relation to exclusion events, but not surprisingly BPD patients reported higher rejection distress. Strikingly, as more rejection distress was reported, rmPFC responses to rejection events decreased in BPD patients but not in controls. Stronger modulation of the rmPFC response by rejection distress was associated with higher trait rejection expectation.

The authors conclude that rmPFC may normally play an important role in mentalization processes that regulate emotional responses to social rejection. BPD patients may therefore fail to maintain or upregulate rmPFC activity to regulate emotional responses to social rejection, with concomitant inverse coupling between rmPFC activity and social rejection distress contributing to heightened rejection expectation in patients with BPD. This result is of particular interest for the TFP community. More and more studies, several of which are contributions from members of the ISTFP community, have been pointing at an improvement in mentalization as a key therapeutic mechanism for the treatment of personality disorders, as well as a key mediator of TFP efficacy (for example see Keefe et al., 2022; Kivity et al., 2021; Fisher-Kern et al., 2015 and many others).

Fertuck et al., uses their knowledge of psychological functions not only to lead the goals of their study, but also their methodology. Prior studies exploring mechanisms of social rejection in clinical and non-clinical population have led to mixed results, a testament to both the power of fMRI studies to investigate cognitive and emotional processes, as well as the limitation of interpreting those findings given the complexity of human psychology and behavior. The paper by Fertuck et al. strives to overcome this limitation by using a more in depth understanding of interpersonal sensitivity – understanding built both on psychoanalytic theory and on experience gained in the psychotherapy setting – to inform experimental design and data analyses. In making important modifications to the approach taken in prior work, Fertuck et al. obtain data that is likely more applicable to social rejection in real life.

One key example of the modifications made by Fertuck et al. was built on the insight that social inclusion and social exclusion may not simply be two different states of the same underlying affective process, but instead they may be two completely separate processes. When examining the activity of brain areas, prior studies had typically simply subtracted the activity in each brain area in the social exclusion condition from activity observed during the social inclusion condition. If social inclusion and social exclusion are best viewed as distinct processes, then simply subtracting activity across the two conditions may not elucidate how the brain mediates each distinct process. The best approach may therefore be to understand brain activity that underlies each process separately and in each of their own contexts, a key insight taken to heart in the Fertuck et al. paper.

A second key modification made by Fertuck et al. recognized the critical importance of considering the context of rejection events during social exclusion. For example, a social rejection in the context of several recently experienced social inclusions may be perceived differently than if a social rejection is experienced in the context of repeated social exclusion. And indeed this may be the key difference between BPD patients and the rest of the population.

This insight may be critically important for understanding psychopathology and treatment. In everyday life, everyone experiences social exclusion from time to time. However, the development of issues with interpersonal sensitivity for an individual may arise in part from the fact that there was a pattern of social exclusion during her or his psychological development.

Clearly, these results must be replicated and the study extended. But the thoughtfulness of the methodological approach in this paper is striking. Over the last 20 years, a plethora of fMRI studies have been published investigating both clinical and non-clinical human populations, often reporting conflicting results, arguably because of difficulties interpreting the complexity of human behavior. Another limitation has been the number of participants, which has often been insufficient, and the follow-up time to ensure accurate conclusions regarding neural functioning and social cognition.

One way of overcoming the ambiguity of this large body of research is to resort to reductionist behaviors, that is less equivocal in terms of underlying cognitive processes. This is typically obtained in animal studies such as non- human primates experiments. Another way is to approach complex behavior thoughtfully, without preconceived assumptions about cognitive processes underlying it, and this is what Fertuck et al, are doing. This approach is likely to be critical if significant headway is to be made in understanding the neurobiology underlying complex disorders like BPD that are difficult if not impossible to study in animal models.

Silvia Bernardi