Could Knowledge of Borderline Personality Disorder Benefit College Campus Mental Health?

Borderline personality disorder is a common, treatable condition that usually presents in late adolescence or early adulthood. Patients with borderline personality disorder are disproportionately represented in many clinical settings. Early identification and intervention of borderline personality disorder could help address the current mental health affecting young adults. College and university mental health settings have an opportunity to identify borderline personality disorder and to help guide students and families to appropriate treatment. College-based clinicians also have a role in educating campus administrators who may have little or no familiarity with standard borderline personality disorder symptoms or the trajectory of the disorder.

Treating Narcissistic Disorders in General Psychiatry: Practical Application of Transference-Focused Psychotherapy Principles.

Patients with primary or co-occurring narcissistic disorders are seen routinely in general psychiatry settings. Contemporary trends in training and practice have impacted psychiatrists' skills and confidence in identifying and treating these disorders, which can range from relatively benign to high-acuity presentations. The goal of this article is to introduce key principles derived from transference-focused psychotherapy (TFP) for use by clinicians in general practice in their work with patients with narcissistic disorders, even when those clinicians do not routinely provide individual psychotherapy. Practical application of TFP principles in work with patients with narcissistic disorders in general psychiatry are proposed, including in diagnostic evaluation, family engagement, prescribing, and safety assessment and risk management calculus. Many psychiatrists whose practices are focused primarily on psychopharmacology, or a "medical model," may not appreciate fully the impact of pathological narcissism in their work. Clinicians who may benefit from familiarity with TFP principles in work with patients with narcissistic disorders include the approximately one-half of U.S. psychiatrists who do not offer psychotherapy in their practice.

Review of Contemporary Risk Management Challenges in the Treatment of Patients With Borderline Personality Disorder.

Standard psychiatric risk management challenges are routinely amplified in the treatment of patients with primary or co-occurring borderline personality disorder diagnosis. Most psychiatrists receive limited guidance during training or as part of continuing medical education about specific risk management concerns in work with this patient population; nevertheless, these concerns can occupy a disproportionate amount of time and energy in clinical practice. The goal of this article is to review the frequently observed risk management quandaries encountered in work with this patient population. The more familiar risk management dilemmas related to management of suicidality, potential boundary violations, and patient abandonment, are considered. In addition, salient contemporary trends in prescribing, hospitalization, training, diagnostic classification, models of psychotherapeutic treatment, and use of emerging technologies in provision of care, are explored in terms of their impact on risk management.

Applied Transference-Focused Psychotherapy: An Overview and Update.

Transference-focused psychotherapy (TFP), developed and studied as an extended individual psychotherapy for patients with borderline personality disorder (BPD), rests on a rich theoretical foundation informed by psychoanalytic object relations theory. "Applied TFP" is a developing initiative using TFP principles in multiple clinical situations other than the standard extended individual psychotherapy, which has been empirically validated and is detailed in the TFP treatment manual. The growing application of TFP principles in innovative, overlapping ways has been focused primarily in three spheres: (1) the integration of TFP principles in pluralistic theoretical approaches to treatment of patients with personality disorder pathology; (2) the use of TFP elements in multiple teaching situations as part of curricula for trainees and practicing clinicians, and (3) the employment of TFP theory and interventions in settings across a continuum of patient acuity, tailored for patients with varying diagnoses. The use of TFP principles in the situations described directly addresses needs emerging in particular contexts that reflect specific requirements of clinician practice and training and of broader public health missions.

A Novel Approach to Supervision of Transference-Focused Psychotherapy (TFP): Examining the First Three Minutes of the TFP Session.

Transference focused psychotherapy (TFP), an empirically validated, manualized treatment for patients with borderline personality disorder (BPD), is arguably the most challenging to learn of the evidence-based treatments for BPD. Following an introduction to the TFP manual and the treatment's central tenets, ongoing individual, group, or peer supervision of case material, ideally with recorded video sessions, would be expected when the clinician's goal is fidelity to the prescribed approach. Our proposal for a novel supervision intervention emerges directly from the basic theoretical foundations of TFP, the process of research investigation, which has evolved over the years, with its goal of assessing both measurable patient outcomes and research clinician adherence to the model, and collective clinical experience. A deliberate assessment of the initial minutes of TFP as a supervision or self-assessment method is not meant as a substitute for more comprehensive supervision, nor is it offered as an exclusive path to mastering TFP. This approach to TFP supervision aims to distill and focus in a common-sense, accessible way the process of practicing TFP, thereby facilitating therapist consistency. Our proposed, more limited and concise tactic for TFP training can be used as an instruction building block, incrementally extending the access for practicing and mastering this intervention to a broader group of motivated providers.

Transference-Focused Psychotherapy for Narcissistic Personality Disorder: An Object Relations Approach.

Transference-focused psychotherapy (TFP) is an empirically validated psychodynamic psychotherapy for borderline personality disorder (BPD), based on object relations theory, that has clinical utility for individuals with narcissistic personality disorder (NPD). Given the effectiveness of TFP for patients with BPD, including a number of patients with comorbid NPD, we have adapted the tactics and techniques of TFP with specific modifications for patients with NPD or narcissistic traits. TFP for NPD (TFP-N) retains core elements of the treatment, including a contracting phase and an interpretive process designed to identify and modify maladaptive mental representations of self and others that underlie the affect and behavioral dysregulation in those with personality disorders including NPD. The major goal of TFP-N is the focus on disturbed interpersonal patterns of relating in the here-and-now of the therapeutic interaction as a vehicle to effect enduring changes in personality organization and real-world changes in the areas of love and work.

Money Questions and the Structural Interview.

Kernberg's structural interview integrates exploration of elements of personality organization into the standard initial psychiatric evaluation. The structural interview approach, while essential to transference-focused psychotherapy for patients with borderline personality disorder, is not limited to use in that context. Following the model of the structural interview, clinicians ask a series of questions, which elucidate elements of personality pathology, thereby facilitating comprehensive diagnosis, guiding treatment, and informing prognosis. Direct questioning about finances and the clinician's general curiosity about issues related to money, in the context of the structural interview, can be high-yield lines of inquiry. Patients' history with their finances, attitudes about money, and ways questions about finance emerge in the transference around fees and related concerns, can add an important, often overlooked, dimension to the assessment of personality organization and personality disorder pathology. This article proposes the utility of prioritizing questions regarding money, as might be integrated into the structural interview, as a template for a broader recognition of the value of this line of inquiry in a diagnostic assessment process.

A Psychodynamic Approach for the General Psychiatrist: Using Transference-Focused Psychotherapy Principles in Acute Care Settings.

Transference-focused psychotherapy (TFP) is one of the empirically validated treatments for patients with borderline personality disorder. TFP has roots in psychoanalytically informed psychotherapy, although important elements of the treatment have been adapted and refined for patients with significant personality disorder pathology. TFP's assessment process is informed by the structural interview, an approach that synthesizes standard DSM-5 nosology with the psychodynamic concept of the personality organization. TFP principles can be integrated into practice in general psychiatry settings in the care of patients with primary or co-occurring personality disorder pathology.

Using transference-focused psychotherapy principles in the pharmacotherapy of patients with severe personality disorders.

Transference-focused psychotherapy (TFP) is an evidence-based, manualized treatment for severe personality disorders. TFP provides clinicians with a comprehensive diagnostic approach, overarching theoretical orientation, and specific clinical techniques. While TFP was developed as a long-term psychodynamic psychotherapy for patients with personality disorders, the approach, orientation, and techniques used in psychotherapy treatment may be of use in pharmacotherapy with the same patients. Patients with borderline personality disorder, in particular, are high utilizers of all subtypes of psychotropic medication despite limited evidence for their effectiveness, creating multiple challenges for the prescribing clinician. The author suggests specific ways the TFP model can assist prescribers, including those who do not practice TFP psychotherapy.

Disclosure of a diagnosis of borderline personality disorder.

OBJECTIVE: Borderline personality disorder (BPD) is a common psychiatric disorder with a prevalence of 1%-2% in the general population. BPD also has the potential to cause significant distress in the lives of patients with BPD and their families. The diagnosis of BPD, however, is often withheld from patients. The purpose of this article is to explore the history of diagnostic disclosure in medicine and psychiatry and then discuss reasons why clinicians may or may not disclose the diagnosis of BPD. METHODS: The authors review medical literature about diagnostic disclosure and other issues that may affect the decision to disclose a diagnosis of BPD. RESULTS: The authors discuss the historical precedents for diagnostic disclosure and reasons a clinician may not disclose the diagnosis of BPD to a patient: questions regarding the validity of BPD as a diagnosis, worries about the stigma of the diagnosis being harmful to the patient, and transference/countertransference issues common in the treatment of patients with BPD. The authors cite factors promoting disclosure, such as the ideal of patient autonomy, possibilities for psychoeducation and collaboration with the patient toward more specific and effective therapies, and the increasing availability of diagnostic information available to patients from sources other than their clinicians. CONCLUSIONS: There are compelling reasons to make the diagnosis the subject of open examination and discussion between clinician and patient, and reasons to believe that disclosure would serve to advance the patient in his or her recovery.