Developments in Group Transference-Focused Psychotherapy.

Several evidence-based psychotherapies for personality disorders have been developed in recent decades, including transference-focused psychotherapy (TFP), a contemporary model of psychodynamic psychotherapy developed by Otto Kernberg. Kernberg established Group TFP (TFP-G) as an alternative or adjunct treatment to individual TFP. Although not yet manualized, TFP-G is used in publicly and privately funded mental health services, including outpatient clinics, subacute hospitals, therapeutic inpatient units, partial hospitalization services, and rehabilitation services serving people with borderline personality. Kernberg's model of TFP-G psychotherapy, its application in clinical settings, and what differentiates it from other group psychotherapy models is described as well as illustrated with some examples useful to practitioners.

The interpretive process in the psychoanalytic psychotherapy of borderline personality pathology.

While all patients become more concrete in their psychological functioning in areas of conflict, especially in the setting of transference regression, in the treatment of patients with severe personality pathology this process poses a particular clinical challenge. In the psychoanalytic psychotherapy of patients with severe personality pathology in general, and borderline personality disorder in particular, the interpretive process serves multiple functions. This process comprises a series of steps or phases that can be viewed as moving the patient further away from a single, poorly elaborated, and concrete experience in the transference, which dominates and floods subjectivity, and toward more fully elaborated, complex, stable, and integrated representations of the analyst and of what he or she evokes in the patient's internal world.

Refining the borderline personality disorder phenotype through finite mixture modeling: implications for classification.

Borderline personality disorder (BPD) is characterized by considerable heterogeneity. Prior approaches to resolving heterogeneity in BPD pathology have used factor and cluster analytic as well as latent class analysis strategies. These prior studies have been atheoretical in nature, but provide an initial empirical corpus for further sub-typing efforts in BPD. A model-based taxonomy for BPD that is supported by evidence from an advanced statistical methodology would enhance investigations of BPD etiology, pathophysiology, and treatment. This study applied finite mixture modeling analysis, in a model-guided fashion, to selected dimensions of pathology within a group of well-characterized BPD patients to determine if latent groups are harbored within the disorder. Subjects with BPD (N = 90) were examined on a variety of model-relevant psychopathology dimensions. We applied finite mixture modeling to these dimensions. We then evaluated the validity of the obtained solution by reference to a variety of external measures not included in the initial mixture modeling. Three phenotypically distinct groups reside within the overall BPD category. Group-1 is characterized by low levels of antisocial, paranoid, and aggressive features. Group-2 is characterized by elevated paranoid features, whereas Group-3 is characterized by elevated antisocial and aggressive features. External correlates reveal a pattern of differences consistent with the validity of this proposed grouping structure. A theory-guided finite mixture modeling analysis supports a parsing of the BPD category into three subgroups. This proposed BPD taxonomy represents an approach to reducing heterogeneity observed among BPD patients and it may prove useful in studies seeking to understand etiologic and pathophysiologic factors as well as treatment response in BPD.

Transference focused psychotherapy: overview and update.

This paper describes a specific psychoanalytic psychotherapy for patients with severe personality disorders, its technical approach and specific research projects establishing empirical evidence supporting its efficacy. This treatment derives from the findings of the Menninger Foundation Psychotherapy Research project, and applies a model of contemporary psychoanalytic object relations theory as its theoretical foundation. The paper differentiates this treatment from alternative psychoanalytic approaches, including other types of psychoanalytic psychotherapy as well as standard psychoanalysis, and from three alternative non-analytical treatments prevalent in the treatment of borderline patients, namely, dialectic behavior therapy, supportive psychotherapy based on psychoanalytic theory, and schema focused therapy. It concludes with indications and contraindications to this particular therapeutic approach derived from the clinical experience that evolved in the course of the sequence of research projects leading to the empirical establishment of its efficacy.

Behavioral activation in TFP: The role of the treatment contract in transference-focused psychotherapy.

Transference-focused psychotherapy (TFP) is a manualized evidence-based treatment for borderline and other severe personality disorders that is based on psychoanalytic object relations theory. Similar to other psychodynamic psychotherapies, TFP focuses on changing psychological structures, but also focuses on symptom and behavioral change, particularly the importance of being active (e.g., obtaining a job or involvement in similar activities). In TFP, the establishment of the treatment contract, also known as the treatment frame, is where goals such as work and other activities are agreed upon. The focus on such activities is particularly relevant to the concept of behavioral activation. We provide a clinical vignette to illustrate how TFP utilizes behavioral activation in facilitating treatment outcome both at the behavioral level and at the psychological level. (PsycINFO Database Record

Qualitative Analysis of Resources and Barriers Related to Treatment of Borderline Personality Disorder in the United States.

OBJECTIVE: Resources and treatment for individuals with borderline personality disorder (BPD) are limited and often difficult to obtain. This article aimed to identify key resources for and barriers to obtaining supportive and treatment services for BPD from the perspective of individuals seeking information or services related to BPD ("BPD care seekers"). METHODS: Data came from transcripts of resource requests to the Borderline Personality Disorder Resource Center from January 2008 to December 2015 (N=6,253). Basic statistics, including the type of service requested, demographic information for the BPD care seeker, and national distribution of requests, were generated for all eligible transcripts. Qualitative analysis of a random subset of 500 transcripts was used to identify themes, challenges, and common experiences reported by BPD care seekers. RESULTS: The greatest number of requests for primary services or resources among the random subset of transcripts was for outpatient services (51%), informational materials (13%), and day programs (9%). Family services, crisis intervention, and mental health literacy were identified as areas where available resources did not meet current demand and that could be improved or expanded. Factors identified as potential barriers to finding and obtaining appropriate treatment for BPD included stigmatization and marginalization within mental health care systems, financial concerns, and comorbidity with psychiatric or medical disorders. CONCLUSIONS: BPD care seekers face numerous barriers to obtaining appropriate care. Expanded services and resources to connect individuals with treatment are needed to meet the current demands and preferences of those seeking care.

The efficacy of psychotherapy: focus on psychodynamic psychotherapy as an example.

The growing number of individuals seeking treatment for mental disorders calls for intelligent and responsible decisions in health care politics. However, the current relative decrease in reimbursement of effective psychotherapy approaches occurring in the context of an increase in prescription of psychotropic medication lacks a scientific base. Using psychodynamic psychotherapy as an example, we review the literature on meta-analyses and recent outcome studies of effective treatment approaches. Psychodynamic psychotherapy is an effective treatment for a wide variety of mental disorders. Adding to the known effectiveness of other shorter treatments, the results indicate lasting change in many cases, especially for complex and difficult to treat patients, ultimately reducing health-care utilization. Research-informed health care decisions that take into account the solid evidence for the effectiveness of psychotherapy, including psychodynamic psychotherapy, have the potential to promote choice, increase mental health, and reduce society's burden of disease in the long run.

Approaches to psychotherapy for borderline personality: demonstrations by four master clinicians.

Several efficacious therapies for borderline personality disorder (BPD) now exist despite longstanding skepticism in the field regarding amenability to treatment. In this article, 4 master clinicians describe a brief interaction with an actress playing the part of a patient with BPD that occurred at the First Annual Meeting of the North American Society for the Study of Personality Disorders in Boston, April 2013. The approaches include dialectical behavior therapy, transference focused psychotherapy, mentalization based therapy, and good psychiatric management. The paper concludes with a discussion of what these approaches have in common, how they differ, and future directions for the treatment of BPD.

Borderline personality disorder, bipolar disorder, depression, attention deficit/hyperactivity disorder, and narcissistic personality disorder: Practical differential diagnosis.

The challenge of accurate diagnosis remains at the heart of good psychiatric treatment. In the current state of psychiatry, a confluence of forces has increased this challenge for the clinician. These include practical pressures-such as limited time for diagnostic evaluation, the question of what is reimbursed by insurance, and the issue of directing patients to acute treatments-and also trends in nosology, such as the descriptive focus on signs and symptoms in the current official diagnostic system. The authors offer observations that we hope will help clinicians who have to make difficult diagnostic differentiations often under pressured circumstances. The paper is motivated both by the high frequency of diagnostic errors observed under such conditions and also by the belief that considering symptoms in the context of the patient's sense of self, quality of interpersonal relations, and level of functioning over time will help guide the diagnostic process.

Transference-focused psychotherapy.

Transference-Focused Psychotherapy (TFP) is a manualized evidence-based treatment for borderline and other severe personality disorders that is based on psychoanalytic object relations theory. The treatment contracting/setting the frame, managing countertransference, and the interpretative process are three critical components of TFP. We provide vignettes to illustrate these techniques and data that support their role in facilitating treatment outcome.

Predicting domains and rates of change in borderline personality disorder.

What changes and how quickly these changes occur as a result of therapy in borderline personality disorder (BPD) is an important ongoing question. The features of BPD patients that are most predictive of rates of change in such patients remain largely unknown. Using the Cornell Personality Disorders Institute (CPDI) randomized controlled trial data, we sought to determine (a) the number and nature of broad domains underlying a large number of rate of change (slope) measures across many psychological, psychiatric, and psychosocial indexes, and (b) which baseline individual difference psychological features of the BPD patients correlated with these rate of change domains. We examined the latent structure of slope (rate of change) measures gleaned from individual growth curves for each subject, studied in multiwave perspective, on separate measures of anger, aggression, impulsivity, depression, global functioning, and social adjustment. Three broad domains of change rate could be discerned. These domains were reflected in factors that are described as (a) anger/aggression change ("aggressive dyscontrol"), (b) global functioning/social adjustment change ("social adjustment/self-acceptance"), and (c) anxiety/depression/impulsivity change ("conflict tolerance/behavioral control"). Factor scores were computed for each change domain and baseline measures of personality and psychodynamic features, selected a priori, were correlated with these factor scores. Multiple regression analyses revealed (a) baseline negative affectivity and aggression predicted the aggressive dyscontrol change domain, (b) baseline identity diffusion predicted the social adjustment/self-acceptance change domain, and (c) baseline social potency predicted the conflict tolerance/behavioral control change domain. These baseline predictors suggest potential research foci for understanding those aspects of BPD that change at comparable rates over time.

Psychodynamic treatments of self-injury.

The authors address psychodynamic therapies, particularly transference-focused psychotherapy (TFP), in the treatment of patients who present with non-suicidal self-injury. In doing so, they briefly discuss various psychodynamic approaches with empirical evidence for their effectiveness. They describe TFP, including its treatment rationale, putative change mechanisms, and outcome research. They then present a case illustration of a patient with borderline personality disorder who engages in non-suicidal self-injury to demonstrate how TFP can be applied to such cases.

The mechanisms of change in the treatment of borderline personality disorder with transference focused psychotherapy.

We address how Transference Focused Psychotherapy (TFP) conceptualizes mechanisms in the cause and maintenance of borderline personality disorder (BPD) as well as change mechanisms both within the patient and in terms of specific therapists' interventions that engender patient change. Mechanisms of change at the level of the patient involve the integration of polarized representations of self and others; mechanisms of change at the level of the therapist's interventions include the structured treatment approach and the use of clarification, confrontation, and "transference" interpretations in the here and now of the therapeutic relationship. In addition, we briefly review evidence from our group regarding the following hypothesized mechanisms of change: contract setting, integration of representations, and changes in reflective functioning (RF) and affect regulation.