TCPR: Dr. Levy, there are so many different “brands” of therapy for personality disorders. Can you start by giving us a little background on how and when transference-focused psychotherapy (TFP) was developed, and the evidence that it’s helpful for patients?
Dr. Levy: Sure. TFP is a modified psychodynamic psychotherapy developed by psychoanalyst Otto Kernberg, MD, specifically for severe personality disorders such as borderline and narcissistic personality disorders. To date, three randomized controlled trials (RCTs) have examined TFP and show that it is an effective treatment for borderline personality disorder (BPD), including one RCT showing it to be as effective as dialectic behavior therapy (DBT). TFP is now considered an evidence-based therapy by Division 12 (Society of Clinical Psychology) of the American Psychological Association, as well as by the National Institute for Health and Care Excellence (NICE) guidelines in the United Kingdom, and the Cochrane Collaboration.
TCPR: Now please describe the technique. How is it administered?
Dr. Levy: TFP is a face-to-face individual therapy that takes place twice weekly in 45 to 50 minute sessions. The focus is on reducing symptomatology that is associated with personality disorders (PD), particularly parasuicidality, suicidality, and self-destructive behaviors. Treatment begins with a thorough assessment of the person’s difficulties, which leads into a very specific discussion of the treatment frame.
TCPR: Please tell us more about that. What do you mean by “treatment frame?”
Dr. Levy: When a patient starts psychotherapy, the therapist usually begins by setting a treatment frame that lays out how often you meet, when you meet, etc.—basic things. But with patients with severe personality disorder, such as borderline personality disorder or narcissistic personality disorder, it is even more important to come to an explicit agreement with the patient about the roles and responsibilities of the patient and therapist in the treatment. You want to discuss what the treatment looks like, the rationale for working this way, and what to expect. This includes the structure of the treatment, such as the number of sessions, how often we meet, and what happens in and even between sessions, as well as what kinds of behaviors/events we might expect to arise during the course of treatment. And we will talk very explicitly with patients about what has transpired in past therapies, feelings and difficulties that the patients may have had, and how best to safeguard against, and be prepared for, what happens when they come up in the current treatment.
TCPR: Do you discuss with the patient why past therapies did not work?
Dr. Levy: Yes. For instance, if you have a patient who has dropped out of lots of different treatments, which is often the case with patients with BPD, we can predict that he or she may have impulses to drop out again. We examine with the patient what kind of things might have led to their dropping out before, and we’re very clear that not only might these thoughts and feeling re-occur, but we expect that they would occur in this treatment, too. And then we discuss how we will handle those feelings or impulses in a collaborative way.
TCPR: And what would you say to a patient?
Dr. Levy: I might say, “I realize that right now you are feeling very good about the treatment, and you are feeling hopeful and want to continue in this treatment. But it is possible that as treatment goes on, there may be times you may feel differently about treatment. I am suggesting that may occur here too, and rather than drop out, I suggest you talk very directly to me in session about those feelings, even if you are afraid that I may not like what you have to say.” So essentially we try to get the patient to recognize that there are these patterns, and these patterns are somewhat independent of the specific people involved, and that rather than behave the way they may have behaved in the past, they should be open to reflection and discussion.
TCPR: And this therapy also involves psychoeducation?
Dr. Levy: Yes, most explicitly during the setting of the treatment frame. One component of TFP is providing psychoeducation about how we understand a patient’s difficulty and how the psychotherapy will unfold as a result of their difficulties. This is a core aspect of setting the treatment frame because frequently patients come in for treatment never having been diagnosed with or told they have a personality disorder. It is very common, for instance, for people with borderline personality disorder to have been diagnosed with bipolar disorder or some other disorder instead. Sometimes therapists believe their patient has BPD but are scared to tell him or her or feel it will be hurtful to tell them. We feel it is important to share our understanding of the patients’ difficulty with them, albeit in a tactful and sensitive manner. When a patient is diagnosed with a non-BPD disorder, bipolar for instance, they can become quite invested in the diagnosis. However, often I find patients are ambivalent about having a bipolar disorder diagnosis—there may be a part of them that does not like the diagnosis, but often another part of them actually likes it because it absolves them from some of their behaviors: “It’s not me, it’s my bipolar disorder.” And so we spend a lot of time educating them about how we understand what they have told us.
TCPR: Can you give us an example of how you do that?
Dr. Levy: I might say, “It sounds like you were diagnosed with bipolar disorder because of the way people might have understood the shifts in mood that you describe, which is a key symptom of bipolar disorder. But the swings between moods in bipolar disorder tend to be between extreme elation and depression, and tend not to occur moment-to- moment, but actually over periods of days or weeks. The kinds of changes in mood you have described, particularly between anger and feeling very depressed, are more moment-to-moment. These changes are actually more characteristic of personality difficulties, what the Diagnostic and Statistical Manual used by therapists calls a personality disorder, specifically what is called borderline personality disorder.” And I explain that there are pros and cons to being diagnosed with BPD rather than bipolar disorder, including the fact that it is important to have an accurate diagnosis in order to best treat their difficulties. In addition, we know how to treat personality disorders and therefore the prognosis can be quite good.