Transference focused psychotherapy

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Transference focused psychotherapy (TFP) is a highly structured, twice-weekly modified psychodynamic treatment based on Otto F. Kernberg's object relations model of borderline personality disorder. [1] It views the individual with borderline personality organization (BPO) as holding unreconciled and contradictory internalized representations of self and significant others that are affectively charged. The defense against these contradictory internalized object relations leads to disturbed relationships with others and with self. The distorted perceptions of self, others, and associated affects are the focus of treatment as they emerge in the relationship with the therapist (transference). The treatment focuses on the integration of split off parts of self and object representations, and the consistent interpretation of these distorted perceptions is considered the mechanism of change.


TFP has been validated as an efficacious treatment for borderline personality disorder (BPD), [2] [3] though too few studies have been conducted to allow firm conclusions about its value. [4] TFP is one of a number of treatments that may be useful in the treatment of BPD; however, in a study which compared TFP, dialectical behavior therapy, and modified psychodynamic supportive psychotherapy, only TFP was shown to change how patients think about themselves in relationships. [5]

Borderline personality disorder

TFP is a treatment for borderline personality disorder (BPD). Patients with BPD are often characterized by intense affects, stormy relationships, and impulsive behaviors. Due to their high reactivity to environmental stimuli, patients with BPD often experience dramatic and short-lived shifts in their mood, alternating between experiences of euphoria, depression, anxiety, and nervousness. Patients with BPD often experience intolerable feelings of emptiness that they attempt to fill with impulsive and self-damaging behaviors, such as substance abuse, risky sexual behavior, uncontrolled spending, or binge eating. Further, patients with BPD often exhibit recurrent suicidal behaviors, gestures, or threats. Under intense stress patients with BPD may exhibit transient dissociative or paranoid symptoms. [6]

Theoretical model of borderline personality

According to an object relations model, in normal psychological development mental templates of oneself in relation to others, or object representations, become increasingly more differentiated and integrated. [7] The infant's experience, initially organized around moments of pain ("I am uncomfortable and in need of someone to care for me") and pleasure ("I am now being soothed by someone and feel loved"), become increasingly integrated and differentiated mental templates of oneself in relation to others. These increasingly mature representations allow for the realistic blending of good and bad, such that positive and negative qualities can be integrated into a complex, multifaceted representation of an individual ("Although she is not caring for me at this moment, I know she loves me and will do so in the future"). Such integrated representations allow for the tolerance of ambivalence, difference, and contradiction in oneself and others.

For Kernberg [8] the degree of differentiation and integration of these representations of self and other, along with their affective valence, constitutes personality organization. In a normal personality organization the individual has an integrated model of self and others, allowing for stability and consistency within one's identity and in the perception of others, as well as a capacity for becoming intimate with others while maintaining one's sense of self. For example, such an individual would be able to tolerate hateful feelings in the context of a loving relationship without internal conflict or a sense of discontinuity in the perception of the other. In contrast, in Borderline Personality Organization (BPO), the lack of integration in representations of self and other leads to the use of primitive defense mechanisms (e.g., splitting, projective identification, dissociation), identity diffusion (inconsistent view of self and others), and unstable reality testing (inconsistent differentiation between internal and external experience). Under conditions of high stress, borderline patients may fail to appreciate the "whole" of the situation and interpret events in catastrophic and intensely personal ways. They fail to discriminate the intentions and motivations of the other and thus, perceive only threat or rejection. Thus thoughts and feelings about self and others are split into dichotomous experiences of good or bad, black or white, all or nothing.


The major goals of TFP are to reduce suicidality and self-injurious behaviors, and to facilitate better behavioral control, increased affect regulation, more gratifying relationships, and the ability to pursue life goals. This is believed to be accomplished through the development of integrated representations of self and others, the modification of primitive defensive operations, and the resolution of identity diffusion that perpetuate the fragmentation of the patient's internal representational world. [1]

Treatment procedure


The treatment begins with the development of the treatment contract, which consists of general guidelines that apply for all clients and of specific items developed from problem areas of the individual client that could interfere with the therapy progress. The contract also contains therapist responsibilities. The client and the therapist must agree to the content of the treatment contract before the therapy can proceed.

Therapeutic process

TFP consists of the following three steps:

During the first year of treatment, TFP focuses on a hierarchy of issues:

In this treatment, the analysis of the transference is the primary vehicle for the transformation of primitive (e.g., split, polarized) to advanced (e.g., complex, differentiated and integrated) object relations. Thus, in contrast to therapies that focus on the short-term treatment of symptoms, TFP has the ambitious goal of not just changing symptoms, but changing the personality organization, which is the context of the symptoms. To do this, the client's affectively charged internal representations of previous relationships are consistently interpreted as the therapist becomes aware of them in the therapeutic relationship, that is, the transference. [9] Techniques of clarification, confrontation, and interpretation are used within the evolving transference relationship between the patient and the therapist.

In the psychotherapeutic relationship, self and object representations are activated in the transference. In the course of the therapy, projection and identification are operating, i.e., devalued self-representations are projected onto the therapist whilst the client identifies with a critical object representation. These processes are usually connected to affective experiences such as anger or fear.

The information that emerges within the transference provides direct access to the individual's internal world for two reasons. First, it is observable by both therapist and patient simultaneously so that inconsistent perceptions of the shared reality can be discussed immediately. Second, the perceptions of shared reality are accompanied by affect whereas the discussion of historical material can have an intellectualized quality and be thus less informative.

TFP emphasizes the role of interpretation within psychotherapy sessions. [10] As the split-off representations of self and other get played out in the course of the treatment, the therapist helps the patient to understand the reasons (the fears or the anxieties) that support the continued separation of these fragmented senses of self and other. This understanding is accompanied by the experience of strong affects within the therapeutic relationship. The integration of the split and polarized concepts of self and others leads to a more complex, differentiated, and realistic sense of self and others that allows for better modulation of affects and in turn clearer thinking. Therefore, as split-off representations become integrated, patients tend to experience an increased coherence of identity, relationships that are balanced and constant over time and therefore not at risk of being overwhelmed by aggressive affect, a greater capacity for intimacy, a reduction in self-destructive behaviors, and general improvement in functioning.

Mechanisms of change

In TFP, hypothesized mechanisms of change derive from Kernberg's [10] developmentally based theory of Borderline Personality Organization, conceptualized in terms of unintegrated and undifferentiated affects and representations of self and other. Partial representations of self and other are paired and linked by an affect in mental units called object relation dyads. These dyads are elements of psychological structure. In borderline pathology, the lack of integration of the internal object relations dyads corresponds to a 'split' psychological structure in which totally negative representations are split off/segregated from idealized positive representations of self and other (seeing people as all good or all bad). The putative global mechanism of change in patients treated with TFP is the integration of these polarized affect states and representations of self and other into a more coherent whole. [11] [12]

Empirical support

Preliminary research

In early research studying the efficacy of a year-long TFP, suicide attempts were significantly reduced during treatment. Additionally, the physical condition of the patients was significantly improved. When the researchers compared the treatment year to the year prior, it was found that there was a significant reduction in psychiatric hospitalizations and days spent as inpatients in psychiatric hospitals. The dropout rate for the 1-year study was 19.1%, which the authors state as comparable to dropout rates in previous studies assessing the treatment of borderline individuals, including DBT research. [13]

TFP vs. treatment-as-usual (TAU)

Results indicated that the TFP group experienced significant decreases in ER visits and hospitalizations during treatment year, as well as significant increases in global functioning when compared to TAU. [14]

TFP vs. treatment by community experts

A randomized clinical trial compared the outcomes of TFP or treatment by community experts for 104 borderline patients. The dropout rate was significantly higher in the community psychotherapy condition; however, the dropout rate for TFP was 38.5%, which the authors acknowledge as somewhat higher than dropout rates associated with dialectical behavior therapy (DBT) and schema-focused therapy (SFT). The TFP group experienced significant improvement in personality organization, psychosocial functioning, and number of suicide attempts. In this study neither group was associated with a significant change in self-harming behaviors. [3]

TFP vs. DBT vs. supportive treatment

Prior to treatment and at four-month intervals during treatment, patients were assessed in the following domains: suicidal behavior, aggression, impulsivity, anxiety, depression, and social adjustment. Results indicate that patients in all three conditions showed improvement in multiple domains at the one-year mark. Only DBT and TFP were significantly associated with improvement in suicidal behaviors; however, TFP outperformed DBT in anger and impulsivity improvement. Overall, participation in TFP predicted significant improvement in 10 of the 12 variables across the 6 domains, DBT in 5 of 12, and ST in 6 of the 12 variables. [2]

TFP vs. schema focused therapy

Significant improvements were found in both treatment groups on DSM-IV BPD criteria and on all four of the study's outcome measures (borderline psychopathology, general psychopathology, quality of life, and TFP/SFT personality concepts) after 1-, 2-, and 3-years. Schema focused therapy (SFT, or schema therapy as it is now commonly known) was associated with a significantly higher retention rate. After three years of treatment, schema therapy patients showed greater increases in quality of life, and significantly more schema therapy patients recovered or showed clinical improvement on the BPD Severity Index, fourth version. However, the TFP cell contained more suicidal patients and showed less adherence casting doubt on a direct comparison between treatments. [15] The schema therapy group improved significantly more than the TFP group with respect to relationships, impulsivity, and parasuicidal/suicidal behaviour although many of the alliance ratings were made after dropout. It was concluded that schema therapy was significantly more effective than TFP on all outcome measures assessed during the study. A follow-up of this study concluded that both clients and therapists rated therapeutic alliance higher in schema therapy than in TFP. [16] [17]

Related Research Articles

Borderline personality disorder Personality disorder characterized by unstable relationships, impulsivity, and strong emotional reactions

Borderline personality disorder (BPD), also known as emotionally unstable personality disorder (EUPD), is a mental illness characterized by a long-term pattern of unstable relationships, distorted sense of self, and strong emotional reactions. Those affected often engage in self-harm and other dangerous behavior. They may also struggle with a feeling of emptiness, fear of abandonment, and detachment from reality. Symptoms of BPD may be triggered by events considered normal to others. BPD typically begins by early adulthood and occurs across a variety of situations. Substance abuse, depression, and eating disorders are commonly associated with BPD. Approximately 10% of people affected with the disorder die by suicide. The disorder is often stigmatized in both the media and the psychiatric field.

Schizoid personality disorder Personality disorder involving social isolation and emotional coldness

Schizoid personality disorder is a personality disorder characterized by a lack of interest in social relationships, a tendency toward a solitary or sheltered lifestyle, secretiveness, emotional coldness, detachment and apathy. Affected individuals may be unable to form intimate attachments to others and simultaneously possess a rich and elaborate but exclusively internal fantasy world. Other associated features include stilted speech, a lack of deriving enjoyment from most activities, feeling as though one is an "observer" rather than a participant in life, an inability to tolerate emotional expectations of others, apparent indifference when praised or criticized, a degree of asexuality, and idiosyncratic moral or political beliefs. Symptoms typically start in late childhood or adolescence.

Dialectical behavior therapy to treat borderline personality disorder

Dialectical behavior therapy (DBT) is an evidence-based psychotherapy that began with efforts to treat borderline personality disorder. There is evidence that DBT can be useful in treating mood disorders, suicidal ideation, and for change in behavioral patterns such as self-harm, and substance abuse. DBT evolved into a process in which the therapist and client work with acceptance and change-oriented strategies, and ultimately balance and synthesize them, in a manner comparable to the philosophical dialectical process of hypothesis and antithesis, followed by synthesis.

Otto F. Kernberg

Otto Friedmann Kernberg is a psychoanalyst and professor of psychiatry at Weill Cornell Medical College. He is most widely known for his psychoanalytic theories on borderline personality organization and narcissistic pathology. In addition, his work has been central in integrating postwar ego psychology with Kleinian and other object relations perspectives. His integrative writings were central to the development of modern object relations, a theory of mind that is perhaps the theory most widely accepted among modern psychoanalysts.

Transference phenomenon within psychotherapy

Transference is a phenomenon within psychotherapy in which the feelings a person had about their parents, as one example, are unconsciously redirected or transferred to the present situation. It usually concerns feelings from a primary relationship during childhood. At times, this transference can be considered inappropriate. Transference was first described by Sigmund Freud, the founder of psychoanalysis, who considered it an important part of psychoanalytic treatment.

Psychodynamic psychotherapy or psychoanalytic psychotherapy is a form of depth psychology, the primary focus of which is to reveal the unconscious content of a client's psyche in an effort to alleviate psychic tension.

Multimodal therapy (MMT) is an approach to psychotherapy devised by psychologist Arnold Lazarus, who originated the term behavior therapy in psychotherapy. It is based on the idea that humans are biological beings that think, feel, act, sense, imagine, and interact—and that psychological treatment should address each of these modalities. Multimodal assessment and treatment follows seven reciprocally influential dimensions of personality known by their acronym BASIC I.D.: behavior, affect, sensation, imagery, cognition, interpersonal relationships, and drugs/biology.

Complex post-traumatic stress disorder is a psychological disorder that can develop in response to prolonged, repeated experience of interpersonal trauma in a context in which the individual has little or no chance of escape. C-PTSD relates to the trauma model of mental disorders and is associated with chronic sexual, psychological, and physical abuse or neglect, chronic intimate partner violence, victims of prolonged workplace or school bullying, victims of kidnapping and hostage situations, indentured servants, victims of slavery and human trafficking, sweatshop workers, prisoners of war, concentration camp survivors, residential school survivors, prisoners kept in solitary confinement for a long period of time, and defectors from authoritarian religions. It is most often directed at children and emotionally vulnerable adults, and whilst motivations behind such abuse vary and it’s predominantly malicious, it’s been shown it can be well-intentioned. Situations involving captivity/entrapment can lead to C-PTSD-like symptoms, which can include prolonged feelings of terror, worthlessness, helplessness, and deformation of one's identity and sense of self.

Malignant narcissism is a psychological syndrome comprising an extreme mix of narcissism, antisocial behavior, aggression, and sadism. Grandiose, and always ready to raise hostility levels, the malignant narcissist undermines families and organizations in which they are involved, and dehumanizes the people with whom they associate.

Splitting is the failure in a person's thinking to bring together the dichotomy of both positive and negative qualities of the self and others into a cohesive, realistic whole. It is a common defense mechanism. The individual tends to think in extremes.

James F. Masterson was a prominent American psychiatrist.

Mentalization-based treatment (MBT) is an integrative form of psychotherapy, bringing together aspects of psychodynamic, cognitive-behavioral, systemic and ecological approaches. MBT was developed and manualised by Peter Fonagy and Anthony Bateman, designed for individuals with borderline personality disorder (BPD). Some of these individuals suffer from disorganized attachment and failed to develop a robust mentalization capacity. Fonagy and Bateman define mentalization as the process by which we implicitly and explicitly interpret the actions of oneself and others as meaningful on the basis of intentional mental states. The object of treatment is that patients with BPD increase their mentalization capacity, which should improve affect regulation, thereby reducing suicidality and self-harm, as well as strengthening interpersonal relationships.

Peter Fonagy

Peter Fonagy, is a Hungarian-born British psychoanalyst and clinical psychologist. He studied clinical psychology at University College London. He is Professor of Contemporary Psychoanalysis and Developmental Science and Head of the Division of Psychology and Language Sciences at University College London, Chief Executive of the Anna Freud Centre, a training and supervising analyst in the British Psycho-Analytical Society in child and adult analysis, a Fellow of the British Academy, the Faculty of Medical Sciences, the Academy of Social Sciences and a registrant of the BPC. His clinical interests centre on issues of borderline psychopathology, violence and early attachment relationships. His work attempts to integrate empirical research with psychoanalytic theory. He has published over 500 papers, 270 chapters and has authored 19 and edited 17 books.

The mainstay of management of borderline personality disorder is various forms of psychotherapy with medications being found to be of little use.

Schema therapy was developed by Jeffrey E. Young for use in treatment of personality disorders and chronic DSM Axis I disorders, such as when patients fail to respond or relapse after having been through other therapies. Schema therapy is an integrative psychotherapy combining theory and techniques from previously existing therapies, including cognitive behavioral therapy, psychoanalytic object relations theory, attachment theory, and Gestalt therapy.

Narcissistic abuse is a hypernym for the psychological, financial, sexual, and physical abuse of others by someone with narcissistic traits or suffering from narcissistic personality disorder (NPD). Narcissistic Personality Disorder has been referred to as a mental health condition by several medical research and journal organisations, such as, for example, the United States National Library of Medicine, Mayo Clinic, and Cochrane medical journals.

David P. Bernstein

David Philip Bernstein was professor of forensic psychotherapy at Maastricht University in the Netherlands, an endowed chair jointly sponsored by Forensic Psychiatric Center "de Rooyse Wissel". His work is also supported by the Expertise Center for Forensic Psychiatry (EFP). At Maastricht University, Bernstein leads the forensic psychology section, which is embedded within the department of clinical psychological science. Bernstein has served as President of the Association for Research on Personality Disorders, Vice President of the International Society for the Study of Personality Disorders and Vice President of the International Society for Schema Therapy.

Dynamic deconstructive psychotherapy (DDP) is a manual-based treatment for borderline personality disorder.

Sidney J. Blatt was a professor emeritus of psychiatry and psychology at Yale University's Department of psychiatry. Blatt was a psychoanalyst and clinical psychologist, empirical researcher and personality theoretician, who made enormous contributions to the understanding of personality development and psychopathology. His wide-ranging areas of scholarship and expertise included clinical assessment, psychoanalysis, cognitive schemas, mental representation, psychopathology, depression, schizophrenia, and the therapeutic process, as well as the history of art. During a long and productive academic career, Blatt published 16 books and nearly 250 articles and developed several extensively used assessment procedures. Blatt died on May 11, 2014, in Hamden, Conn. He was 85.

Borderline personality disorder (BPD) is a psychological disorder characterized by chronic instability of relationships, self-image, moods, and affect, which is frequently misdiagnosed. This misdiagnosis can come in the form of providing a BPD diagnosis to a person who does not actually meet criteria or providing an incorrect alternative diagnosis in the place of a BPD diagnosis.


  1. 1 2 3 Clarkin, J. F., Yeomans, F., Kernberg, O. F. (2006). Psychotherapy for borderline personality: Focusing on object relations. New York: Wiley.
  2. 1 2 Clarkin, J. F., Levy, K. N., Lenzenweger, M. F., & Kernberg, O. F. (2007). A multiwave RCT evaluating three treatments for borderline personality disorder. American Journal of Psychiatry, 164, 922-928.
  3. 1 2 Doering, S., Hörz, S., Rentrop, M., Fischer-Kern, M., Schuster, P., Benecke, C., Buchheim, A., Martius, P., Buchheim, P. (2010). Transference-Focused Psychotherapy vs. treatment by community psychotherapists for borderline personality disorder: A randomised controlled trial. British Journal of Psychiatry, 196, 389-395.
  4. Stoffers, J.M., Vollm, B.A., Rücker, G., Timmer, A., Huband, N., & Lieb K. (2012). Psychological therapies for people with borderline personality disorder. The Cochrane Collaboration. Published online: 15 Aug 2012
  5. Levy, K.N., Meehan, K.B., Kelly, K.M., Reynoso, J.S., Weber, M., Clarkin, J.F., & Kernberg, O.F. (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.
  6. American Psychiatric Association (2000). Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition-Text Revision. Washington DC: Author.
  7. Kernberg, O.F. (1975). Borderline conditions and pathological narcissism. New Haven, CT: Yale University Press.
  8. Kernberg, O. F. (1984). Severe personality disorders. New Haven, CT: Yale University Press.
  9. Foelsch, P.A.,& Kernberg, O.F. (1998). Transference-Focused Psychotherapy for Borderline Personality Disorders. Psychotherapy in Practice, 4(2), 67-90.
  10. 1 2 Kernberg, O.F., & Caligor, E. (2005). A psychoanalytic theory of personality disorders . In Major Theories of Personality Disorder, ed. M.F. Lenzenweger & J.F. Clarkin. 2nd ed. New York : Guilford Press, pp. 114-156.
  11. Levy, K. N., Clarkin, J. F., Yeomans, F. E., Scott, L. N., Wasserman, R. H., & Kernberg, O. F. (2006). The mechanisms of change in the treatment of transference focused psychotherapy. Journal of Clinical Psychology, 62, 481-501.
  12. Clarkin, J.F. & Levy, L.N. (2006). Psychotherapy for patients with borderline personality disorder: Focusing on the mechanisms of change. Journal of Clinical Psychology, 62(4), 405-410.
  13. Clarkin, J. F., Foelsch, P. A., Levy, K. N., Hull, J. W., Delany, J. C., Kernbery, 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.
  14. Clarkin, J., Levy, K., & Schiavi, J. (2005). Transference focused psychotherapy: Development of a psychodynamic treatment for severe personality disorders. Clinical Neuroscience Research, 4, 379-386.
  15. Levy, K.N., McMain, S., Bateman, A., Clouthier, T. (2020)
  16. Giesen-Bloo, J., van Dyck, R., Spinhoven, P., van Tilburg, W., Dirksen, C., van Asselt, T., et al. (2006). Outpatient psychotherapy for borderline personality disorder - randomized trial of schema-focused therapy vs transference-focused psychotherapy. Archives of General Psychiatry, 63, 649-658.
  17. Spinhoven, P., Giesen-Bloo, J., van Dyck, R., Kooirnan, K., & Arntz, A. (2007). The therapeutic alliance in schema-focused therapy and transference-focused psychotherapy for borderline personality disorder. Journal of Consulting and Clinical Psychology, 75, 104-115.