A case report of the treatment of narcissistic personality disorder with transference focused psychotherapy.

The following case study provides a description of the transference-focused psychotherapy (TFP) treatment of a young man diagnosed with narcissistic personality disorder (NPD). TFP is an individual, psychodynamic therapy developed to treat a range of personality disorders. TFP is evidence-based for the treatment of borderline personality disorder and has been adapted for the treatment of NPD. This case illustrates the application of the strategies and techniques of TFP to treatment of NPD as well as challenges clinicians may face in arriving at timely diagnosis of the disorder. Although no specific treatment for NPD has been empirically validated, TFP utilizes the therapeutic techniques identified across modalities for successful treatment of pathological narcissism. This report describes how treatment interventions such as goal setting, developing a therapeutic alliance, using a treatment contract and addressing treatment interfering behaviors contributed to this patient's improvement in self-reflection, formation of healthier and more flexible ideas about self and other, increased self-agency, tolerance of normative disillusionments and increase in empathy.

Changes in Attachment Representation and Personality Organization in Transference-Focused Psychotherapy.

OBJECTIVE: The aim of this article was to construct an empirical bridge between object relations theory and attachment theory by investigating how researchers in both traditions have contributed to understanding and assessing identity diffusion (a keystone of personality pathology) and object relations in patients with borderline personality disorder during 1 year of transference-focused psychotherapy (TFP). METHODS: The Adult Attachment Interview (AAI) and the Structured Interview of Personality Organization (STIPO) were administered to patients (N=104, all women) before and after 1 year of treatment. This study was part of a randomized controlled trial in which 104 patients with borderline personality disorder were randomly assigned to receive either TFP (a manualized, structured psychodynamic treatment approach) or treatment by experienced community psychotherapists. Changes on the AAI in attachment representations, narrative coherence, and reflective function were examined for their associations with changes on the STIPO in identity, object relations, and aggression. RESULTS: Patients who shifted from disorganized (unresolved) to organized attachment on the AAI after 1 year of TFP (but not treatment by experienced community psychotherapists) showed hypothesized improvements in domains of personality organization on the STIPO, including identity, object relations, and aggression. Those who did not change from disorganized (unresolved) to organized attachment improved only in the domain of aggression. CONCLUSIONS: These findings highlight the centrality of identity diffusion to borderline personality disorder pathology and the importance of targeting it in treatment. Furthermore, the results suggest that identity may be indexed by measures of attachment security, narrative coherence, and personality organization.

Empirical Developments in Transference-Focused Psychotherapy.

OBJECTIVE: Transference-focused psychotherapy (TFP) is an empirically supported individualized psychotherapy for patients with borderline personality disorder. This review highlights its development and current status. METHODS: A review of the theoretical background underpinning TFP and empirical advances in the development of TFP provide perspective. RESULTS: Otto Kernberg's object relations model of personality and its implications for assessment and diagnosis of personality disorders are described. The authors review the programmatic research that has been developed and has demonstrated the efficacy of TFP. In view of the empirical studies that have demonstrated the successful outcomes and processes of TFP for patients with borderline personality disorder, compared with other approaches, TFP has been applied to a broader range of difficulties related to patients' self-functioning and interpersonal functioning across the range of severities in personality pathology, consistent with the Alternative DSM-5 Model for Personality Disorders. The authors discuss borderline personality organization in the context of interpersonal, neurocognitive, and self-regulatory dysfunction, including preliminary findings. CONCLUSIONS: The theoretical and empirical advances in TFP lead to future directions for research evaluating personality disorder and its treatment.

Complex depression: The treatment of major depression and severe personality pathology.

The intensive treatment of a patient presenting with major depression, chronic suicidal ideation, and a borderline personality disorder with narcissistic features is described as it developed over an 18-month treatment. The treatment approach is a transdiagnostic one with an emphasis on change in the patient's representation of self and others, identity and interpersonal functioning. The intended change is not only in the reduction of depression and suicidal ideation but also an improvement in interactions with others at work and intimate relations. The combination of rich clinical information from the therapist and independent research ratings of patient progress provide a complex picture of the treatment.

[Transference Focused Psychotherapy for Borderline-Adolescents in a Day Clinic Treatment Program]. / Übertragungsfokussierte Psychotherapie von Borderline-Jugendlichen im tagesklinischen Setting.

Transference Focused Psychotherapy for Borderline-Adolescents in a Day Clinic Treatment Program This paper focuses on the concept of transference focused psychotherapy (TFP) modified for juvenile borderline patients. Adolescents with borderline developmental personality disorder (bpd) have an essential deficit in their personality structure that leads to oscillations in their self-esteem and in a "split" perception of the world. They suffer from a variety of symptoms and severe impairments on their own and their families' quality of life. Their fragmented perception of themselves and others make relationships almost unbearable for them. Relationships are mostly marked by severe anxiety of resentment and rejection. For these patients this causes intolerable trouble at school where every day conflicts take place. Self-mutilation and suicidal thoughts often seem the only way out. By now, there is an agreement that an early specialized assessment and treatment is necessary in order to stop the typical consequences of their self-mutilative and dysfunctional behavior. Still, in contrast to adult age, empirical evidence is missing which proves the effectiveness of treating adolescent borderline patients. In this paper we present a research project on the effectiveness of transference focused psychotherapy with adolescent borderline patients (TFP-A) in a day clinic setting, combining TFP with group skills training as known from dialectic behavior therapy (DBT). Furthermore, we give first results on analyzing the effectiveness of our day clinic treatment program based on TFP-A, focusing on improving core symptoms such as affective problems, aggressive behavior against self and others and interpersonal problems.

Frontolimbic neural circuit changes in emotional processing and inhibitory control associated with clinical improvement following transference-focused psychotherapy in borderline personality disorder.

AIMS: Borderline personality disorder (BPD) is characterized by self-regulation deficits, including impulsivity and affective lability. Transference-focused psychotherapy (TFP) is an evidence-based treatment proven to reduce symptoms across multiple cognitive-emotional domains in BPD. This pilot study aimed to investigate neural activation associated with, and predictive of, clinical improvement in emotional and behavioral regulation in BPD following TFP. METHODS: BPD subjects (n = 10) were scanned pre- and post-TFP treatment using a within-subjects design. A disorder-specific emotional-linguistic go/no-go functional magnetic resonance imaging paradigm was used to probe the interaction between negative emotional processing and inhibitory control. RESULTS: Analyses demonstrated significant treatment-related effects with relative increased dorsal prefrontal (dorsal anterior cingulate, dorsolateral prefrontal, and frontopolar cortices) activation, and relative decreased ventrolateral prefrontal cortex and hippocampal activation following treatment. Clinical improvement in constraint correlated positively with relative increased left dorsal anterior cingulate cortex activation. Clinical improvement in affective lability correlated positively with left posterior-medial orbitofrontal cortex/ventral striatum activation, and negatively with right amygdala/parahippocampal activation. Post-treatment improvements in constraint were predicted by pre-treatment right dorsal anterior cingulate cortex hypoactivation, and pre-treatment left posterior-medial orbitofrontal cortex/ventral striatum hypoactivation predicted improvements in affective lability. CONCLUSIONS: These preliminary findings demonstrate potential TFP-associated alterations in frontolimbic circuitry and begin to identify neural mechanisms associated with a psychodynamically oriented psychotherapy.

Change in Identity Diffusion and Psychopathology in a Specialized Inpatient Treatment for Borderline Personality Disorder.

OBJECTIVES: Patients with borderline personality disorder (BPD) show various psychopathological symptoms and suffer especially from disturbance in their identity. The purpose of the study was to investigate changes-particularly in affective BPD symptoms and identity diffusion-during a structured, disorder-specific inpatient treatment (DST) that combined a psychodynamic transference-focused psychotherapy approach with modules of dialectical behavioural skills training. METHOD: In a prospective, two-group comparison trial, 44 patients with BPD were assessed with questionnaires addressing identity diffusion and state, as well as trait affective psychopathology, before and after 12 weeks of inpatient treatment. Thirty-two patients received DST, whereas 12 patients were given inpatient treatment-as-usual (TAU). The patients were allocated in a non-random procedure for two groups, in order of admission and availability of treatment options in the DST unit. RESULTS: In the pre-post-comparison, the DST group showed a significant decrease in identity diffusion (p < 0.001) and improvements in instability of the image of self and others (p < 0.008), as well as in pathological (trait and state) symptoms. However, there was no significant improvement in the TAU group. CONCLUSIONS: After a 12-week inpatient treatment, the findings indicate significant improvements in the DST group in typical affective borderline symptomatology and in the personality structure feature of identity diffusion. This highlights the significance of a short-term specific inpatient therapy for BPD. KEY PRACTITIONER MESSAGE: A structured, disorder-specific inpatient treatment of patients diagnosed with borderline personality disorder (BPD) combined a psychodynamic transference-focused psychotherapy treatment approach (focusing on pathological features in personality organization, particularly on non-integrated images of self and others) with modules of dialectical behavioural skills training. This treatment is associated with a decrease in identity diffusion of these patients after 12 weeks of treatment. The treatment is also related to a significant decrease in borderline typical psychopathological symptoms such as depressive symptoms, as well as an improvement in state anger. The outcomes of this structured, disorder-specific inpatient treatment of severely ill BPD patients indicated the relevance of intensive short-term inpatient psychotherapy in terms of psychopathological improvements as well as initial changes in structural personality organization.

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.

Attachment and object relations in patients with narcissistic personality disorder: implications for therapeutic process and outcome.

This article presents a therapeutic approach for patients with severe personality disorders, transference-focused psychotherapy (TFP), a manualized evidence-based treatment, which integrates contemporary object relations theory with attachment theory and research. Case material is presented from a narcissistic personality disorder (NPD) patient in TFP whose primary presenting problems were in the arena of sexuality and love relations, and whose attachment state of mind showed evidence of oscillation between dismissing and preoccupied mechanisms. Clinical process material is presented to illustrate the tactics and techniques of TFP and how they have been refined for treatment of individuals with NPD. The ways in which conflicts around sexuality and love relations were lived out in the transference is delineated with a focus on the interpretation of devalued and idealized representations of self and others, both of which are key components of the compensatory grandiose self that defensively protects the individual from an underlying sense of vulnerability and imperfection.

Trust in Therapeutic Work With Adolescents With and Without Personality Disorders: A Transference-Focused Therapy Perspective.

Trust is central to successful therapeutic work with adolescents, but establishing trust can be challenging, especially with adolescents with personality disorders. We present our understanding of trust in working with adolescents with and without personality disorders. We draw on complementary and overlapping perspectives, namely the attachment model, Kernberg's object relations model, and Fonagy's mentalization model. In Kernberg's object relations conceptualization, difficulties in trust experienced by patients with borderline personality disorders result from paranoia associated with splitting and identity diffusion. In Fonagy's mentalization model, epistemic trust is rooted in early experiences of being responded to and understood. We outline how techniques used in transference-focused psychotherapy for adolescents promote the development of the adolescent's capacity to trust by facilitating identity integration, thus reducing paranoia. Finally, we use two clinical case illustrations to demonstrate how trust unfolds in working with adolescents with and without personality disorders.

Transference-Focused Psychotherapy and Trust Processing in BPD: Exploring Possible Mechanisms of Change.

Individuals with borderline personality disorder (BPD) struggle to identify whom they can safely trust, and this struggle contributes to profound emotional turmoil in their close relationships. Transference-focused psychotherapy (TFP) is an application of object relations theory (ORT) that posits that polarized mental representations of self and other define the personality organization of BPD. TFP aims to utilize a clear treatment frame coupled with an analysis of the therapeutic relationship (i.e., the transference) to help individuals with BPD integrate their polarized mental representations. Improvement in the capacity to trust others is inherent in the mechanisms of change in TFP. In this article, a social cognitive model of trust processing provides a new lens through which we formulate how TFP may enhance trust processing in BPD. Recent evidence from randomized clinical trials supports the argument that TFP may intervene with BPD in a way that is concordant with uniquely improved trust processing.

The Sound of Silence: Engaging the Quiet Adolescent.

Engaging the silent adolescent is a major psychotherapeutic challenge. This article presents a comprehensive approach to this problem, illustrated with clinical material. This approach emphasizes a careful diagnostic assessment, including an assessment of the patient's level of personality organization and capacities to participate in psychodynamic psychotherapy. Three approaches to the silent teenager are explored in depth: a mostly supportive approach focused on containment of maladaptive behaviors; a psychodynamic approach with supportive elements focused on demonstrating safety through humor, play, normalization, and self-disclosure while exploring the patient's automatic relationship patterns; and a psychodynamic approach using transference-focused psychotherapy for adolescents (TFP-A), aimed at effecting long-lasting changes in the patient's views of self and others and their characteristic ways of managing conflict and stress, with gradual movement from a tendency for controlling, protective silence to vulnerable, cooperative sharing.

Transference-focused psychotherapy as an aid to learning psychodynamic psychotherapy: qualitative analysis of UK psychiatry trainees' views.

AIMS & METHOD: Learning psychotherapy can be difficult and stressful. We explore core trainees' (n = 5) views on undertaking a psychodynamic psychotherapy training case using transference-focused psychotherapy (TFP), in an East London NHS Foundation Trust supervision group. We used framework analysis of focus group interviews to examine trainees' concerns, their views about this experience and its impact on general psychiatric practice. RESULTS: Trainees described various concerns on starting: providing an effective intervention, insufficient experience and training-related pressures. However, they found that TFP addressed some of them and was helpful for learning psychodynamic psychotherapy. Difficulties around the countertransference remained at end-point. Trainees suggested that introductory teaching and learning through observation might be worthwhile. CLINICAL IMPLICATIONS: Trainees' experience suggests that an evidence-based operationalised approach such as TFP can be integrated into the core psychiatry curriculum as a psychodynamic psychotherapy learning method. Trainees report benefits extending to other areas of their practice.

Conversion to Transference-Focused Psychotherapy from Other Treatments by the Same Therapist: Pitfalls and Benefits.

Borderline personality disorder and broadly speaking, borderline personality organization, including narcissistic personality disorder, can be effectively treated by transference-focused psychotherapy (TFP), which is a modern object relations-based structured psychoanalytic psychotherapy. TFP can be taught successfully to therapists from a wide array of backgrounds, not only to psychoanalysts, provided they have a basic grasp of psychodynamic concepts, including object relations theory. We initially thought that starting with a new patient would always be easier than conversion to TFP from a different method. Our supervisory experience supported this only partially. To learn more, we distributed a survey among therapists who completed formal TFP training or participated in supervision for at least 1 year. Only four of the 36 respondents felt that starting with a new case was easier. Conversion was a lot more common than we had expected (in fact, it seemed to be an almost inevitable part of training), and it often took place without appropriate supervision of the process. Moving from supportive therapy to TFP was the most difficult for the therapist, and often for the patient. All respondents felt that they would treat all new patients with borderline personality organization with TFP from the outset or, if indicated or necessary, begin with a preliminary treatment using TFP elements. Our findings strongly suggest that conversion needs to be taught in training seminars, and should not be left to be dealt with entirely in supervision.

Trading Patients: Applying the Alternative Model for Personality Disorders to Two Cases of DSM-5 Borderline Personality Disorder Over Time and Across Therapists.

The DSM-5 Alternative Model for Personality Disorders (AMPD) dimensionally defines personality pathology using severity of dysfunction and maladaptive style. As the empirical literature on the clinical utility of the AMPD grows, there is a need to examine changes in diagnostic profiles and personality expression in treatment over time. Assessing these changes in individuals diagnosed with borderline personality disorder (BPD) is complicated by the tendency for patients to cycle through multiple therapists over the course of treatment leaving the potential for muddled diagnostic clarity and disjointed case conceptualizations. Following patient trajectories across therapists offers a unique opportunity to examine the AMPD's sensitivity to and utility for capturing personality stability and change over time for patients with BPD. This article demonstrates the utility of the AMPD for two clinical cases in three distinct ways: (i) highlighting heterogeneity in BPD between patients, (ii) comparing improvements in personality severity and style over time, and (iii) elucidating profile change across therapist ratings. We present two patients diagnosed with DSM-5 Section II BPD, crossing between two therapists over the course of 3 years of psychodynamic psychotherapy. Treating clinicians rated patients for their respective treatment phases using the Level of Personality Functioning Scale (LPFS), capturing severity, and the Personality Inventory for the DSM-5 (PID-5), capturing style. AMPD diagnostic profiles differentiated patients with BPD in both severity and style, and captured within-patient change beyond within-therapist response bias. Results indicated greater improvements in personality severity while personality style remained more stable. Implications for the patients' treatment progress and associated challenges are discussed, as are considerations for the utility of the AMPD in therapy.

Transference-Focused Psychotherapy for Adolescents With Personality Disorders.

This article presents a conceptualization of personality disorders in adolescence and the adaptation of transference-focused psychotherapy (TFP) for personality disordered adolescents (TFP-A). The model of assessment and treatment presented is based on contemporary psychoanalytic object relations theory developed by Otto F. Kernberg and supported by findings from current evidence-based outcome research. We present a method of assessing personality disorders in adolescents that addresses the variability of personality disorder symptoms and traits among adolescents and their instability over time. We then present the goal of TFP-A and its major phases of implementation. A major focus is therapist interventions.

Managing Countertransference in the Treatment of Personality Disorders.

The clinical and technical difficulties presented by patients with personality disorders are well documented. This article focuses on the challenges faced by therapists when managing their emotional reactions, that is, their countertransferences, to patients with personality disorders. While leaving room for therapists' unique and idiosyncratic countertransferences to the patient with personality pathology, Kernberg emphasized the role of a more general form of countertransference, one reflective largely of the patient's conflicts and defenses, in the treatments of personality disordered individuals. Here, the nature of the patient's internal and external functioning can be seen to lead to similar reactions among different therapists, opening the possibility of utilizing countertransference to better understand the patient's difficulties. In transference-focused psychotherapy (TFP), countertransferences arising in the patient-therapist interaction are first identified and contained by the therapist and then utilized to clarify and explore how the patient's internal object relations are being enacted in the clinical process. This article describes this process and how TFP therapists work with their countertransference to help illuminate the patient's split representational world, paving the way for interpretation and integration.

Thoughts on Transference Analysis in Transference-Focused Psychotherapy.

Transference-focused psychotherapy (TFP) represents a specific extension of psychoanalytic therapy for treatment of individuals with personality disorders, who may be helped without the more significant time investment required of a standard psychoanalysis. The treatment represents a contemporary formulation of psychoanalytic psychotherapy, updated in light of both empirical research and scientific developments in boundary fields close to the psychodynamic endeavor, particularly affective neuroscience and the psychology of couples and small groups. In TFP, the transference signifies the enactment in the here and now of a specific affective relationship between patient and therapist that reflects one aspect, defensive or impulsive, of a pathogenic dynamic unconscious conflict. This conflict needs to be analyzed, interpreted, and resolved. Various elements of transference analysis in TFP are discussed in this article.