Overview
TFP is a treatment for borderline and other severe personality
disorders. It was developed in the USA by Dr Otto Kernberg and
colleagues. The model is based on object relations theory. The idea
is that people relate to one another and to themselves in terms of
object relations dyads. An example of such a dyad might be a person
views themselves as weak the other as powerful and the linking
affect is one of fear.
A person's internal world is made up of a number of these dyads
and their linking affects. In most people we see a healthy mix of
positive dyads alongside more negative ones.
The theory of borderline personality disorder is that patients
with this condition are in a position where negative and positive
dyads are kept apart and not integrated into the personality as a
whole. There is a split in the patient's internal world that is
played out in relationships with others who are experienced as 'all
good' or 'all bad'. This split leads to 'identity diffusion', a
sense of self that is lacking coherence and is often accompanied by
chronic feelings of internal emptiness.
All of this can have a disturbing effect on the patient who may
experience periods when it is difficult to make sense of their own
feelings and those of others.
Dyads can be unconscious but also conscious. They are addressed
as the therapy progresses rather than identified and named at the
beginning.
Who can benefit?
Patients with a diagnosis of borderline personality disorder can
benefit from TFP. It can also be a helpful treatment for patients
who have a more Narcissistic Personality Disorder.
Patients need to have a willingness to engage in treatment and a
wish to change.
General exclusions
It is not possible to work with patients who have a severe
alcohol or substance misuse problem. This would need to be
addressed first. The service will work with people over the age of
sixteen years.
Patients who present a serious risk of harm to the therapist
cannot be worked with as the therapist needs to feel safe.
It is useful for the patient to have had a previous experience
of therapy. However this is not essential as it is recognised that
short term interventions are not helpful for patients with a
borderline personality disorder.
How does it work?
TFP involves a contract between the therapist and patient. This
helps create a safe treatment frame in which the therapy can take
place. The contract includes things like what to do in a crisis,
how to get help, as well as specific aspects such as conditions
around alcohol or treatment for self harm.
In TFP patients are expected to do something that involves
contact with others. This might be a training course, voluntary
work, or a job. The key thing is the opportunity to mix with others
means this can be discussed in the sessions.
TFP emphasises the use of transference and transference
interpretation. This is the idea that the patient's internal world
is expressed in the relationship with the therapist within the
boundaries of the treatment contract. Interpretation draws
attention to aspects of the patient's experience that might not be
accessible to current awareness. In TFP interpretation is a gradual
process beginning with clarification and moving through
confrontation which is the process of pointing out to the patient
contradictory statements in a way that is meant to stimulate
curiosity rather than catch the patient out.
The relationship with the therapist is the key aspect of TFP and
the therapist tolerates often very powerfully experienced emotions
in a wish to help the patient understand themselves better.
Length of Therapy
In the USA TFP consists of twice weekly sessions for a minimum
of a couple of years or so. We have adapted this model and offer
TFP as a once-weekly therapy for 12 months.
Ending Therapy
Like all psychodynamic therapies the fact the treatment will end
is present from the beginning and is thought about and discussed as
the treatment progresses. Ending can be a difficult experience and
patients may feel anxious and for a time it may appear that some of
their earlier difficulties have re-emerged. The therapist will help
the patient think about the ending of the relationship and reflect
on the work they have done together. Follow-up review sessions are
sometimes offered as these may help the patient deal with the
ending as they have the opportunity to come back and let the
therapist know how they are getting on.