Dustin Ezequiel Amador Jimenez
Master in Clinical Psychology
dustin.amador@keiseruniversity.edu
Borderline Personality Disorder (BPD)
Borderline Personality Disorder (BPD) presents a “generalized pattern of instability and dysregulation in all domains of functioning” (Barlow 2021, p. 382), and is characterized by a high sensitivity to perceived interpersonal conflicts, a sense of unstable self-esteem, intense emotions and impulsivity (Gunderson et al., 2018), with a high suicidal risk (Barlow, 2021).
Patients with BPD present a characteristic pattern of deficits in ego functioning, such as difficulty in planning realistically, inability to regulate impulses, and the predominance of the primary process (Videler et al., 2019). Grinker et al. (1968, cited in Gabbard, 2017) identified the predominance of anger as the main affect, the presence of problems in social relationships, identity diffusion and depressive symptoms along with affective instability, impulsive behaviors, aggressiveness and suicidal behaviors, including Self-injury without suicidal intent that they carry out to avoid intense emotional pain (Behn and Fischer, 2021), is characterized by the concern of establishing exclusive relationships without risk of abandonment, which overwhelms others (Gabbard, 2017; APA, 2013).
Borderline Personality Disorder from the perspective of Otto Kernberg
Kernberg (1987) proposes a descriptive, structural and dynamic analysis for patients with BPD from the perspective of the Borderline Personality Organization (BPO). In the descriptive analysis (Labbé et al., 2020), BPO contains general clinical characteristics such as an unstable mood, disproportionate emotional responses, and impulsive behaviors; difficulties in the ability to establish intimate interpersonal relationships; Furthermore, the diffusion of identity; Finally, there are failures in the integration of the superego.
In structural analysis (Labbé et al., 2020), the BPO is characterized as a preserved reality test, vulnerable in intense affective states; the predominance of low-level defenses around the split; in addition to moderate to severe identity diffusion that would develop in adolescence (Foelsch et al., 2015).
In the dynamic description (Labbé et al., 2020), the predominance of defenses around the split would result in alterations and subjectivation of the perception of reality in moments of distress, the lack of integration of mental representations internal aspects of the self and others, and the consequent diffusion of identity and problems in object relationships, with a predominance of paranoid-schizoid conflicts that make it difficult to establish intimate and deep relationships.
Transference Focused Therapy (TFP)
In structural terms, TFP has the general objective of the patient being able to function at a neurotic level of personality organization (NPO), which implies a preserved reality test, the predominance of high-level defensive operations around the repression and an integrated identity, developing coherent and three-dimensional representations of oneself and others, which would manifest itself in the reduction of symptoms; identity integration, reintegration into intimate relationships, work and leisure (Clarkin et al., 2006).
Generally, therapy sessions are conducted in an individual format and occur twice a week, with a structured treatment framework based on an initial treatment contract and clear treatment priorities (Gabbard, 2014). This model takes into account general priorities that must be addressed immediately, which include: suicidal or homicidal behavior; threats to discontinue treatment; severe performance in the session, which threatens the patient’s life or the treatment; dishonesty; trivialization of the content of the hour; and narcissistic resistances, which must be resolved through a coherent analysis of the transference implications of the pathological grandiose self (Clarkin et al., 2006).
Once the conditions for initiating treatment are established, the main strategy in TFP consists of “facilitating the (re)activation in the treatment of the patient’s internalized and split object relations that are then observed and interpreted in the transference” (Kernberg et al., 2008, p. 603). Therefore, TFP “encourages change by reactivating primitive object relations under controlled circumstances without the vicious cycle of provoking the feared reaction from the environment when the patient engages in emotion dysregulated behavior” (Clarkin et al. ., 2006, p. 40), in this way, the patient is encouraged to experience their internal representations in a controlled environment, this would be the essence of the transference. The mechanism of change would be “the facilitation of the reactivation of dissociated, repressed or projected internalized object relations under controlled circumstances” (Clarkin et al., 2006, p. 41), and together with the development of the capacity for self-observation and reflection of the patient, are essential mechanisms of change.
As a general procedure, the patient is asked to make a free association based on the problems that brought him to the treatment, and the therapist observes the activation of split regressive dyadic relationships (positive and negative) in the transference, which reflect a dyadic unity of a self-representation, an object representation and a dominant affect that links them, helping to identify and interpret them (Kernberg et al., 2008).
Psychotherapeutic techniques in TFP
The main technical instruments of TFP are the basic techniques of psychoanalysis: interpretation, transference analysis and technical neutrality, including countertransference analysis as an additional technique (Kernberg et al., 2008).
In the early phases of the interpretation process, clarification and confrontation of the patient’s subjective experience are used. Clarification consists of asking the patient to explore and explain unclear or contradictory information, and seeks to facilitate the development of the patient’s awareness of their own experience, while allowing them to identify and tolerate the affects that emerge from the awareness of the experience. and the associated meanings (Foelsch et al., 2015). Confrontation seeks to draw attention to any inconsistency or contradiction in the patient’s communication, awareness of repetitive and conflictive patterns increases through confrontation, gradual integration, greater tolerance of affects and impulses, and improved interpersonal functioning are sought (Foelsch et al., 2015).
These techniques allow for the implementation of interpretation, which consists of providing hypotheses for the patient to consider and helping to organize and develop meaning for her own thoughts and actions. It focuses on intra-psychic functioning based on material that presents conflicts and the goal is to articulate the relationship between conscious material and connect it with the inferred unconscious, which influences its motivation and functioning, seeking to integrate contradictory aspects (Foelsch et al., 2015).
Regarding technical neutrality, due to the instability of the patient with BPD, it is sometimes necessary to interrupt it due to the urgency of establishing limits to make a non-neutral intervention by the therapist, for example, in the case of suicidal risk. After an intervention that involves a temporary deviation from neutrality, an analysis of the transference consequences of this is carried out, until it can be resolved and then continue with the analysis of the transfer of the reasons that forced neutrality to be interrupted.
On the other hand, the analysis of transference is closely linked to the analysis of the patient’s problems in external reality, in order to avoid the dissociation of psychotherapy sessions from the patient’s external life. The use of countertransference is an important therapeutic tool and source of information on dominant themes at the moment, “it allows an analysis in terms of the nature of the self-representation or the representation of the object that is being projected onto the therapist at that point, facilitating the complete interpretation of the dyadic relationship in the transference” (Kernberg et al., 2008, p 610), in this way, the analysis of the countertransference is used by the therapist to clarify the transference, incorporating them in the interpretations of the latter.
Empirical evidence
It is important to review the existing empirical evidence on this therapeutic model for the treatment of BPD. The results reported by Clarkin et al. (2007) from an RCT and meta-analysis conducted by Stoffers-Winterling et al. (2012) suggest that TFP contributed to the improvement of depression, anxiety, global functioning and interpersonal adjustment in the participants. TFP was also associated with significant reductions in suicidality and anger; according to Clarkin and colleagues, irritability, physical and verbal aggression, and impulsivity only changed in TFP, compared to other therapeutic models such as Dialectical Therapy. Behavioral (DBT).
In conclusion, TFP is a contemporary psychodynamic therapy designed to support people with personality disorders, including BPD; has a robust and consistent theoretical framework that describes and explains the psychopathology of the disorder; The methodology focuses on the analysis of the transference in the psychotherapeutic relationship and has as its general objective, achieving the structural change of personality that implies the integration of identity, an improvement in acute symptoms, the strengthening of I and its functions such as the reduction of impulsivity and decreased emotional dysregulation.
