Transference-Focused Psychotherapy (TFP) is a highly structured, modified, manualized psychodynamic treatment, typically conducted twice per week. It is grounded in the object relations model developed by Otto F. Kernberg [1]. Initially, the TFP model was designed for the treatment of borderline personality disorder (BPD), but it has since been expanded to address the broader spectrum of borderline personality organization, including pathological narcissism.
[1] Clarkin, J. F., Yeomans, F., Kernberg, O. F. (2006). Psychotherapy for borderline personality: Focusing on object relations. New York: Wiley.
The model conceptualizes individuals with borderline personality organization (BPO) as exhibiting identity diffusion – namely, incoherent and contradictory internalized representations of the self and significant others that are affectively charged. Defensive operations aimed at managing these conflicting internalized object relations lead to splitting and distortion of perceptions of self and others, thereby impairing real interpersonal relationships as well as distorted self-image.
The treatment focuses on the distorted self-image, distorted perception of others, and the associated affects emerging within the therapeutic relationship (transference). The treatment focuses on the integration of split-off parts of the self and object representations, with the consistent interpretation of these distorted internal images viewed as the primary mechanism of change.
TFP has been recognized as an effective treatment for personality disorders [2, 3]. Several studies, including randomized controlled trials, have demonstrated its efficacy in treating borderline personality disorder. In one study comparing TFP, Dialectical Behaviour Therapy (DBT), and a modified psychodynamic supportive psychotherapy for borderline personality disorder, only TFP was found to change how patients think about themselves in relationships [4], which is considered an indicator of identity integration.
[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] 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 randomized controlled trial. British Journal of Psychiatry, 196, 389–395.
[4] 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.
Borderline Personality Disorder (BPD)
TFP is an effective treatment for Borderline Personality Disorder (BPD). Individuals with BPD are characterized by intense affects, tumultuous interpersonal relationships, and impulsive behaviours. Due to heightened sensitivity to environmental stimuli, patients with BPD often experience abrupt and short-lived mood shifts, alternating between states of euphoria, depression, anxiety, and nervousness. They frequently report an unbearable sense of emptiness, which they attempt to alleviate through self-damaging impulsive behaviours, such as substance abuse, risky sexual activity, uncontrolled spending, or binge eating. Additionally, BPD patients often exhibit recurrent suicidal behaviours, suicidal ideation, or threats. Under conditions of acute stress, they may present with transient dissociative or paranoid symptoms. [5]
[5] Leichsenring, F., Heim, N., Leweke, F., Spitzer, C., Steinert, C., & Kernberg, O. F. (2023). Borderline Personality Disorder: A Review. JAMA, 329(8), 670–679.
Theoretical Model of Borderline Personality Organization
According to the object relations theory, in normative psychological development, mental representations of the self in relation to others – also known as object representations – become increasingly differentiated and integrated over time. [6] An infant’s early experience, initially organized around moments of discomfort ("I am in pain and need someone to care of me") and satisfaction ("Someone is soothing me, and I feel loved"), gradually develops into a more complex and differentiated mental model of the self in relation to others. These increasingly mature representations make it possible to realistically reconcile positive and negative aspects of people, forming a nuanced, multifaceted view (e.g., "Although she is not caring of me right now, I know she loves me and will continue to love me"). Such integrated representations allow for tolerance of ambivalence, differences, and contradictions within both the self and others.
[6] Yeomans, F., Clarkin, J. F., & Kernberg, O. F. (2015). Transference-Focused Psychotherapy for Borderline Personality Disorder: A Clinical Guide. American Psychiatric Publishing, Inc.
According to Kernberg [7], the degree of differentiation and integration of these self and object representations – along with their affective valence – constitutes personality organization. In normal personality organization, the individual possesses an integrated model of self and others, which ensures stability and coherence in identity and interpersonal perception, as well as the capacity to engage in intimate relationships while maintaining a sense of self. For example, such an individual can tolerate feelings of hate within the context of a loving relationship without experiencing inner conflict or fragmentation in their perception of the other person.
In contrast, in borderline personality organization (BPO), the lack of integration in representations of self and others leads to the use of primitive defence mechanisms (e.g., splitting, projective identification, dissociation), identity diffusion (incoherent and inconsistent views of self and others), and impaired reality testing (inconsistent differentiation between internal and external experiences). Under stress, individuals with BPO are unable to perceive situations holistically and tend to interpret events in catastrophic or excessively personalized ways. They are unable to distinguish the intentions and motivations of others and perceive primarily threat or rejection. As a result, thoughts and feelings about the self and others are split into dichotomous experiences – good or bad, black or white, all or nothing.
[7] Kernberg, O. F. (1975). Borderline Conditions and Pathological Narcissism. New Haven, CT: Yale University Press.
We assume that the psyche is composed of multiple dynamic forces, often in conflict with one another, and that mental life involves constant efforts to achieve balance between these competing forces. This implies that symptoms and functional difficulties may be rooted in deep structural dynamics within the psyche and in how these internal structures relate to one another.
Narcissistic Personality Disorder (NPD)
Clinical experience in treating patients with severe narcissistic pathology suggests that this group is among the most treatment-resistant within the spectrum of personality disorders. Recent studies indicate that individuals with Narcissistic Personality Disorder (NPD) constitute approximately 6.2% of community samples [8] (Dhawan et al., 2010) and up to 35.7% in clinical populations [9] (Zimmerman et al., 2005). Furthermore, multiple studies have identified high rates of comorbidity between NPD and other personality disorders – particularly borderline, antisocial, and histrionic disorders – as well as mood disorders (unipolar and bipolar depression), substance use disorders, anxiety disorders, and eating disorders.
[8]Dhawan N, Kunik ME, Oldham J, Coverdale J (2010). Prevalence and treatment of narcissistic personality disorder in the community: a systematic review. Compr Psychiatry 51 (4) :333-339.
[9]Zimmerman M, Rothschild L, Chelminski I (2005). Prevalence of DSM-IV personality disorders in psychiatric outpatients. Am J Psychiatry 162:1911-1918.
The diagnostic picture is complicated by the fact that pathological narcissism spans a spectrum from neurotic to severe borderline levels of personality organization.
Narcissistic disorders are thought to involve:
- Identity disturbances, which manifest in unrealistic self-experiences, particularly in exaggerated self-evaluations; grandiosity, which may be overt or covert (characterized by inflated or deflated self-worth, superiority, or inferiority, and fluctuations between these states); and, in some patients, excessive dependence on others for identity formation and self-definition.
- Impairments in interpersonal functioning, including the instrumental use of others to regulate self-esteem; superficial and shallow relationships lacking empathy, serving primarily to satisfy the patient’s need for admiration, attention, and affirmation; and interpersonal antagonism.
Difficulties with aggression regulation, along with other impairments in self and interpersonal functioning, arise from a specific configuration of self and object representations—namely, a pathological grandiose self, which is a condensation of ideal self-representations, idealized object representations, and actual self-representations. This structure excludes the possibility of deep relationships, resulting in a dismantling of connections with others through chronic devaluation of the external world. Negative affects including devalued aspects of the self are repressed, denied, and projected onto others, leading to antagonism toward others and an internal sense of emptiness.
Overall, individuals with NPD are characterized by attachment representations marked by detached devaluation of attachment relationships and unresolved anger toward early attachment experiences – often oscillating between these two conflicting states. This dynamic helps explain the fluctuations in narcissistic defences and transference patterns that complicate the treatment process.
Transference-Focused Psychotherapy (TFP) is a psychodynamic treatment approach developed for patients with a range of personality disorders of varying severity, including individuals with NPD. Both borderline and narcissistic personalities share structural features, particularly identity diffusion, supported by the operation of primitive defence strategies aimed at unconsciously managing intolerable self-states and affects.
The central focus of TFP is the identification and articulation of maladaptive, distorted internal representations of the self and complementary distorted object representations, with the goal of interpreting and eventually overcoming the defence of splitting and other primitive defensive operations that obstruct a more realistic, integrated, and differentiated experience of self and others. Tracking these object-relational dyads in the patient’s internal world, identifying the defensive processes that sustain them, and working through negative affects (such as antagonism) and the object relations that fuel them allows TFP to be an effective treatment for a wide spectrum of narcissistic pathology – from low-functioning to high-functioning patients (including grandiose, vulnerable, and even malignant narcissism).
Additionally, because TFP emphasizes identification with both the self and object poles of the internal object-relational dyads (e.g., grandiose self – devalued other; vulnerable self – idealized other), it is particularly effective in addressing the varied phenotypic expressions of narcissistic personality disorder, including differing modes of expression and/or fluctuating internal states – ranging from grandiose to vulnerable, from entitled/arrogant to depressed/depleted. [10]
[10] Diamond, D., Yeomans, F. E., Stern, B. L., & Kernberg, O. F. (2023). Treating Pathological Narcissism with Transference-Focused Psychotherapy. Guilford Press.
Based on clinical experience and empirical data, modifications of TFP have been developed to address narcissistic pathology across different levels of severity. These adaptations focus on the central role of the grandiose self, its defensive function within the psychological structure of patients with NPD, and how to most effectively engage with this rigid defensive system.
Treatment Goals for All Types of Borderline and Neurotic Patients
The main goals of Transference-Focused Psychotherapy (TFP) are to foster better understanding and control of behaviour, including serious forms of acting out (such as substance abuse, promiscuity, eating disorders, and other types of self-destructive behaviour), improved affect regulation, the establishment of satisfying relationships – including romantic and sexual ones –and the ability to pursue professional and life goals. For severely borderline patients exhibiting self-destructive behaviours, the goal is to reduce suicidality and self-harming behaviour.
These outcomes are believed to be achieved through the development of integrated representations of self and others, the modification of primitive defensive operations, and the resolution of identity diffusion, which maintains the fragmentation of the patient’s inner representational world.
The goals of TFP go beyond symptom reduction to include:
- Changes in personality functioning – improving self-functioning and interpersonal functioning.
- Achieving a cohesive sense of self, characterized by stability, depth, self-awareness, and positive affect, as well as the capacity for empathic and caring relationships with others.
- Ultimately, finding satisfaction in work, love, friendships, and leisure.
Treatment Procedure
Diagnosis
TFP begins with a diagnostic assessment of the patient. One of the diagnostic models used is either the Structural Interview (Kernberg) or the STIPO-R (Structured Interview of Personality Organization–Revised). After the diagnostic phase, the therapist discusses the diagnostic impressions with the patient. This discussion serves as the foundation for a conscious therapeutic alliance, as the therapist links the patient's reported problems to the underlying psychological dynamics identified during the assessment.
It is essential for the diagnostician to determine the level of personality organization: lower, mid, or higher borderline level, or neurotic level; and in the case of serious impairments in reality testing, psychotic level (in which case TFP is not recommended). The therapist also identifies the predominant personality disorder types to be addressed during therapy. [11]
[11] Yeomans, F., Clarkin, J. F., Kernberg, O. F. (2015) Transference-focused psychotherapy for borderline personality disorder: A clinical guide. American Psychiatric Publishing, Inc.
Therapeutic contract
Treatment begins with the establishment of a therapeutic contract, consisting of general recommendations applicable to all patients and specific provisions tailored to the problematic areas of the individual patient that might hinder therapeutic progress. Treatment does not begin without a mutually agreed-upon contract.
The contract serves to limit the patient’s enactment of unbearable parts of the self so that all unconscious and preconscious psychological conflicts – and the defences against them – can become accessible for exploration and processing in therapy.[12]
[12] Carsky M (2020) How Treatment Arrangements Enhance Transference Analysis in Transference Focused Psychotherapy. Psychoanalytic Psychology, 37(4): 335-343.
Therapeutic Process
The TFP model of treatment includes strategies (long-term guidelines that organize therapy into a cohesive whole), tactics (intermediate-level directives that guide the therapist on where, when, and how to intervene), and techniques (moment-to-moment interventions made by the therapist).
Strategies:
- Identifying and exploring dominant object relations dyads.
- Observing and interpreting role reversals.
- Identifying and interpreting splitting and the defensive function of splitting.
Main tactics:
- Establishing and maintaining the therapeutic contract.
- Maintaining the treatment frame.
- Using a hierarchy of priorities when choosing the focus of interventions.
- Transforming enactments into understanding of the object relations emerging in the transference.
- Exploring beliefs that are incompatible with reality.
- Regulating the intensity of affective involvement.
Core Techniques:
- Technical neutrality.
- Use of countertransference.
- Interpretative process.
- Transference analysis.
TFP is organized into distinct phases of treatment: the initial phase, middle phase, advanced phase, and termination phase. The therapist monitors which phase the treatment is currently in and adjusts the focus of the sessions accordingly.
Transference analysis is the primary tool for transforming primitive (split, polarized) object relations into more advanced (complex, differentiated, and integrated) object relations. Unlike therapies that focus on short-term symptom relief, TFP has the ambitious goal of changing the personality organization itself – the context in which the symptoms arise.
To achieve this, affect-laden representations of the patient's internal object relations are gradually interpreted as they emerge in the therapeutic relationship i.e., in the transference. The techniques of clarification, confrontation, and interpretation (the interpretative process) are used within the transference relationship that unfolds between the patient and the therapist.
[13]
[13]Yeomans, F., Clarkin, J. F., Kernberg, O. F. (2015) Transference-focused psychotherapy for borderline personality disorder: A clinical guide. American Psychiatric Publishing, Inc.
The information that surfaces through the transference provides direct access to the patient’s inner world for two main reasons. First, it is observed by both the therapist and the patient simultaneously, allowing discrepancies in perception of shared reality to be immediately explored. Second, this shared reality is imbued with affect, whereas discussion of historical material may be more intellectualized and thus less integrative.
TFP emphasizes the role of interpretation during sessions. As split representations of self and others are re-enacted in the course of treatment, the therapist helps the patient understand the underlying causes (fears or anxieties) that maintain this persistent fragmentation. This insight occurs in the context of intense affective experiences within the therapeutic relationship.
The integration of these split and polarized representations of self and others leads to a more complex, differentiated, and realistic sense of self and others. This, in turn, enables better affect modulation, clearer thinking, and ultimately:
- greater coherence of identity;
- more balanced and stable relationships over time that are less vulnerable to disruption by aggressive affect;
- increased capacity for intimacy;
- reduction in self-destructive behaviours;
- overall improvement in functioning;
- ability to set and pursue professional and life goals.
Mechanisms of change
In Transference-Focused Psychotherapy (TFP), the mechanisms of change are derived from Kernberg’s theory, which is based on the concept of borderline personality organization, conceptualized in terms of non-integrated and undifferentiated affects and representations of the self and others. Partial representations of self and others are linked by affect into mental units called object-relation dyads, which constitute elements of psychological structure.
In borderline pathology, the lack of integration of internal object-relation dyads corresponds to a split psychological structure, in which entirely negative representations are separated from idealized positive representations of self and others (seeing people as all good or all bad). The core mechanism of change in patients undergoing TFP is the integration of these polarized affective states and representations of self and others into a more coherent whole. [14] [15]
[14] 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.
[15] 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.
Empirical support
Early Studies
In early studies assessing the effectiveness of a one-year TFP course, suicidal behaviour significantly decreased during treatment. Additionally, patients’ physical health improved markedly. Comparing the year of treatment to the year prior, researchers observed a significant reduction in psychiatric hospitalizations and inpatient days. [16]
[16] 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 behavioural change. Journal of Personality Disorders, 15, 487-495.
TFP vs. Standard Treatment
Results showed that the TFP group experienced fewer emergency room visits and hospitalizations during the treatment year and had significantly improved global functioning compared to the standard treatment group. [17]
[17] 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.
TFP vs. Community Expert Treatment
In a randomized clinical trial comparing TFP and treatment by community psychotherapists in 104 patients with borderline personality disorder, dropout rates were significantly higher in the community expert group. The TFP group showed notable improvements in personality organization, psychosocial functioning, and a reduction in suicide attempts. [18]
[18] 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.
TFP, DBT, and Supportive Psychodynamic Therapy (SPT)
Patients were assessed before treatment and every four months during therapy on the following dimensions: suicidal behaviour, aggression, impulsivity, anxiety, depression, and social adaptation. Results demonstrated that all three treatments led to improvements in many areas after one year. However, only DBT and TFP were significantly associated with reductions in suicidal behaviour, and TFP outperformed DBT in improving anger and impulsivity.
Overall, TFP showed significant improvements in 10 out of 12 variables across 6 domains, compared to 5/12 for DBT and 6/12 for SPT. [19]
[19] 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.
