We are pleased to present a review of the scientific article:
TRANSFERENCE-FOCUSED PSYCHOTHERAPY:
CLINICAL OUTCOMES IN PATIENTS WITH
BORDERLINE PERSONALITY DISORDER
Authors: Oleksii Lemeshchuk and Kateryna Miliutina
The article was published in the Kyiv Journal of Modern Psychology and Psychotherapy (Issue No. 2 (10), 2025), Kyiv.
The full text of the article (in Ukrainian) is available free of charge at the following link:
https://mpp-journal.com/index.php/journal/article/view/92
The article addresses one of the most complex and, at the same time, highly relevant problems in contemporary psychiatry and clinical psychology — the treatment of Borderline Personality Disorder (BPD), which is characterized by high prevalence, severe functional impairment, and significant therapeutic challenges.
The primary aim of the article is to introduce Transference-Focused Psychotherapy (TFP) to Ukrainian professionals as a therapeutic model specifically developed for the treatment of patients with borderline pathology. The authors outline the core features of the model, its theoretical foundations, clinical goals, and methods of intervention. The article also presents empirical evidence supporting the validity and effectiveness of this therapeutic approach.
The authors emphasize that these factors create a clear need for treatment methods capable of influencing not only symptoms, but the deep structure of the patient’s personality itself.
This article review was prepared for the TFP-Group Ukraine and Ukrainian Institute for Personality Disorders Studies.
Transference-Focused Psychotherapy:
Theoretical Foundations and Mechanisms of Action
Transference-Focused Psychotherapy (TFP) was developed by Otto Kernberg as a specific psychodynamic intervention for patients with borderline personality organization. Grounded in object relations theory, TFP places the analysis of transference at the center of the therapeutic process, viewing it as the expression of the patient’s internal object relations.
Importantly, in TFP transference is not considered a secondary by-product of therapy, but rather the central clinical tool through which the patient’s internal world and their way of experiencing self and others become accessible.
The fundamental hypothesis of TFP is that within the therapeutic relationship, patients inevitably reenact their split representations of self and object, allowing these internal structures to be addressed directly in treatment.
The primary goal of TFP is the integration of split self- and object-representations. This is achieved through the systematic interpretation of dominant affective states and primitive defense mechanisms as they emerge in the transference.
The therapeutic process in TFP begins with the establishment of a clear therapeutic contract that defines the basic conditions of treatment and the patient’s responsibilities.
Such an approach creates the necessary sense of safety and stability, without which work with intense affects would not be possible.
Subsequently, the therapist adheres to the principle of technical neutrality, understood as empathic engagement, careful observation of the patient’s entire psychic world, and the therapist’s avoidance of identification with any particular side of the patient’s internal conflicts.
In clinical practice, TFP relies on classical psychodynamic techniques applied in a clearly defined sequence. The therapist begins with clarification, helping the patient articulate their experiences more precisely. This is followed by confrontation, which draws attention to contradictions or aspects of experience that remain outside awareness. At a deeper level, interpretation is used to reveal the unconscious meanings of the patient’s experiences, particularly the links between different self- and object-representations.
All of these interventions are applied sequentially, in accordance with the principle of moving from surface to depth.
The mechanisms of therapeutic change in TFP are primarily associated with the awareness and integration of conflicting self-states, the development of reflective functioning—the capacity to understand oneself and others in terms of mental states—and the transformation of primitive defense mechanisms into more mature ones. Over the course of therapy, a more secure attachment style gradually develops, along with improved affect regulation, which directly impacts patients’ everyday functioning.
Neurobiological Changes Associated with TFP
Special attention in the article is given to neurobiological changes associated with participation in a course of Transference-Focused Psychotherapy (TFP) (Perez et al., 2016).
The article presents findings from a study that, for the first time, demonstrated neurobiological correlates of therapeutic change in patients with borderline personality disorder following the completion of treatment.
The average duration of TFP treatment was 12.1 months.
Using functional magnetic resonance imaging (fMRI), the researchers examined neural activation during an emotional–linguistic go/no-go task, which made it possible to investigate the interaction between negative emotional processing and inhibitory behavioral control.
Detailed results of the study are presented in the full text of the article; here we summarize the key conclusions.
The findings, including observed neurobiological changes, support the hypothesis that TFP enhances regulatory control of the prefrontal cortex over limbic structures responsible for emotional reactivity.
Notably, baseline (pre-treatment) patterns of neural activation were found to predict therapeutic outcomes. Hypoactivation of the right dorsal anterior cingulate cortex prior to treatment predicted greater improvement in impulse control, while hypoactivation of the left posterior medial orbitofrontal cortex/ventral striatum predicted a greater reduction in affective lability.
These data suggest that TFP may contribute to the normalization of neural networks involved in emotion regulation and behavioral control, and provide objective biological markers of the effectiveness of psychodynamic treatment in patients with borderline personality disorder.
Empirical Evidence for the Effectiveness of Transference-Focused Psychotherapy
The empirical data presented in the article demonstrate that TFP has a robust and consistent evidence base. Its effectiveness has been examined in six uncontrolled studies and three randomized controlled trials (RCTs), ranging from early clinical case series to large-scale comparative studies.
Early research conducted by a Mexican group led by Pablo Cuevas showed that TFP leads to significant reductions in affective instability and substantial improvements in overall functioning, while changes in identity integration required longer treatment duration. Importantly, treatment effectiveness did not depend on the therapist’s level of experience, provided that the manual was followed and regular supervision was maintained.
Subsequent studies by the same group, conducted with samples of women diagnosed with BPD, confirmed significant improvements in impulsivity, affective instability, and identity disturbance.
Randomized controlled trials provided even stronger evidence.
Clarkin and colleagues conducted the first RCT comparing three treatments for BPD: Transference-Focused Psychotherapy (TFP), Dialectical Behavior Therapy (DBT), and Supportive Psychodynamic Therapy (SPT).
All approaches resulted in overall improvement; however, TFP demonstrated specific effects, including reductions in anger and aggression, and—alongside DBT—reductions in suicidal behavior.
The most distinctive outcomes for TFP were observed in reflective functioning and attachment style: nearly one-third of patients shifted from an insecure to a secure attachment style, a change not observed in the other treatment groups. This finding is particularly significant, as attachment style is considered a stable characteristic formed in early childhood and traditionally viewed as resistant to change. Improvements in reflective functioning also align with theoretical assumptions regarding the mechanisms of therapeutic action in TFP.
Further large RCTs, including studies by Doering and colleagues, demonstrated lower dropout rates, fewer suicide attempts, and large effect sizes for TFP across key domains, including borderline symptoms, psychosocial functioning, and the number of psychiatric hospitalizations.
Additional comparative studies confirmed that TFP is as effective as other structured treatment approaches, and systematic reviews have included it among recommended treatments for BPD.
More recent research extends these conclusions by demonstrating the effectiveness of TFP in inpatient settings, as well as its impact on patients’ daily affective and interpersonal functioning.
Overall, empirical evidence indicates that TFP produces not only symptom reduction but also deep, structural changes in emotional regulation, reflective functioning, and attachment. This makes it one of the most theoretically grounded and empirically supported treatments for Borderline Personality Disorder.
Detailed research findings are available in the full article at the following link:
https://mpp-journal.com/index.php/journal/article/view/92
In summary, the reviewed article presents Transference-Focused Psychotherapy as a method that combines theoretical coherence, empirical validation, and the capacity to influence the core mechanisms underlying Borderline Personality Disorder pathology.
(c) Yuliia Holopiorova,
Ukrainian Association of Transference-Focused Psychotherapy