What Is Transference-Focused Psychotherapy?
Transference-focused psychotherapy (TFP) is a treatment that was developed to treat patients with borderline personality disorder (BPD) and other personality disorders. This modality aims to help clients understand how their emotional responses to relationships and present experiences impact their connection with their therapist, the people in their lives, and themselves. This therapeutic modality uses techniques like parts work, integration, and observations to change behaviors and beliefs.
What is the goal of transference-focused therapy?
The definition of psychotherapy transference is, according to a report from 2022, “dysfunctional patterns, beliefs, and assumptions that affect a patient’s perception of other people often affect their perceptions and behaviors towards the therapist.” We’ll detail this more later, but for now, it’s enough to know that transference-focused psychotherapy (TFP) often aims to help clients understand how they externalize or transfer their emotions and behaviors in a therapeutic setting. The therapist can observe how the individual's dialogue, expressions, or tone changes during sessions to prompt conversations about these changes and why they might occur.
As TFP was developed to treat personality disorders – and more specifically, borderline personality disorder (BPD) – it explicitly explores "splitting behaviors," defined as the fragmentation of a conscious experience, often directed at one's self, environment, or relationships. This is what makes the treatment transference-centered; it is aimed at analyzing how emotions transfer from one part of the conscious experience to another or from situation to situation. For example, feeling connected to a person in one moment and hateful toward them several minutes after due to a disappointment or emotional change may be an example of splitting, a symptom of borderline personality disorder.
In therapy, splitting may occur toward the therapist, and the client may reflect their experiences with others or themselves onto the therapist. The therapist may be able to observe the client's patterns in their outside relationships by noting how they act in session. The phenomenon of a client reflecting labels, roles, behaviors, or ideas onto their therapist is called transference, which is why transference-based therapy is named this way.
The goal of TFP is often to create a healthy relationship in session between the therapist and the client while addressing boundaries, interpersonal concerns, and splitting behaviors.
What are personality disorders?
Personality disorders are mental illnesses classified under the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). These conditions fall under several clusters and fundamentally alter or impact an individual's personality and perception of personality. Transference-focused psychotherapy is often used in the treatment of those with cluster B personality disorders, including the following:
Antisocial personality disorder (ASPD)
Borderline personality disorder (BPD)
Narcissistic personality disorder (NPD)
Histrionic personality disorder (HPD)
Personality disorders are marked by a pervasive pattern of inner experiences and behaviors that deviate from culture's expectations in cognitive and emotional responses, interpersonal relationships, and impulse control. These impacts are seen through apparent deficits in functioning for the individual. Although each personality disorder has different symptoms, many are identified by challenges in identity, personality, and relationships. For this reason, transference-focused psychotherapy can be beneficial for more than one.
The effectiveness of TFP for personality disorder treatment
In treating borderline personality (BPD), TFP has been found highly effective in reducing symptoms of depression, anxiety, and social challenges. It also improved global functioning and social adjustment by reducing client anger, impulsivity, and splitting behaviors.
One 2001 study examined TFP for BPD for one year. Twenty-three women diagnosed with BPD attended sessions two times a week and were assessed before and after treatment. After the therapy had ended, the number of clients who attempted suicide in a specific period significantly decreased, as well as the risk of self-harm. This study showcases that TFP can be a crisis intervention support.
2020 and 2021 studies have also looked at adapting transference-focused psychotherapy (TFP) for the treatment of narcissistic personality disorder (NPD). Although further studies are required, methods appear favorable and promising for the future.
Can you see a transference-focused therapist for other reasons?
Anyone can see a transference-centered psychotherapist, including those with other mental health diagnoses or no diagnosis of borderline or any other personality disorder. However, due to the nature of the sessions, the therapy may not be as effective for those who do not experience transference, splitting, or reflective behaviors. Other forms of therapy that may be effective for those looking to address interpersonal connections and behaviors can include:
Cognitive-behavioral therapy (CBT)
Interpersonal psychotherapy (IPT)
Dialectical behavior therapy (DBT)
Emotionally focused therapy (EFT)
Acceptance and commitment therapy (ACT)
Marriage and family therapy
Internal family systems therapy (IFS)
Several techniques these therapists may use to support clients in therapy, TFP or otherwise, including the following. Keep in mind that this type of psychotherapy for borderline personality disorder and other conditions will look different for everyone.
Parts work is a therapeutic technique inspired by internal family systems therapy (IFS). It involves identifying different parts of the self or various aspects of the personality that care for various responsibilities for the individual. Parts are not "multiple personalities." They are parts of the self that make up an individual's whole personality.
In BPD, the parts of an individual's personality may be more pronounced or apparent to others. One part may be considered more angry and confrontational, whereas another may be passionate, kind, and empathetic. These parts are aspects of the same person, but they help an individual cope with various situations. Parts are often said to have developed due to a past adverse event, traumatic experience, or challenging childhood.
Identifying and understanding these parts may help clients form a clear picture of their identity, which can benefit those with a personality disorder who struggle with self-image and identity. In this therapy, the focus is given to accepting, loving, and opening space to these parts to give each one a voice.
Note that parts in this context are different from dissociative identity disorder (DID), a rare condition in the DSM-5 separate from BPD or any other mental illness.
Integration is connected to parts work. In integration techniques, the psychotherapist helps the client take the identified parts and bring them together to see them as a whole and to solidify the client's understanding of who they are and what they can do. TFP is about developing an embodied self, feeling compassion for the parts that may cause shame, and identifying how certain parts of the personality may reflect dynamics onto others.
Therapist-client relationship work
Through the transference treatment theme, TFP psychotherapists work with clients on their therapeutic relationship and the client's outside concerns. For example, if a client frequently raises their voice at the psychotherapist when the psychotherapist suggests a particular topic, they can explore where the defensive mechanism came from and how to change it. The client can learn to identify that their psychotherapist is not the source of their anger.
For the therapist-client relationship to be healthy, the first couple of sessions may be dedicated to setting boundaries for therapy and clearly outlining what will occur and what can be accepted. For example, the therapist may let the client know that they are using the treatment to treat symptoms of borderline personality disorder and ask the client if they want any clarification on what that means for them.
Afterward, the therapist can let the client know if there are any behaviors they cannot accept as part of the professional alliance. For example, clients may be expected to attend therapy sessions consistently. Frequently missed sessions or no payment of the missed session fee might end the therapeutic relationship. Receiving these boundaries upfront may help those with personality disorders cope with a fear of abandonment, as they know their actions can have direct results. Often, TFP requires structure and frequent attendance. Clients may be asked to come in once or twice a week for therapy when they begin the program.
As personality disorders often involve symptoms of self-harm and suicidal ideation, the therapist can help the client develop a safety plan early in the intervention. The safety plan may include a list of crisis support hotlines, social support systems, local resources, and a plan for how to act if a crisis occurs. Some therapists may also offer their clients an on-call number for crises they can call anytime.
If you are experiencing suicidal thoughts or urges, call the National Suicide Prevention Lifeline at 1-800-273-TALK (8255) or text 988 to talk to someone over SMS. They are available 24/7 to offer support.
Transference-focused psychotherapy can be practiced in various environments, including in person at a therapist's office or online. Many clients may find online TFP preferable due to its lower cost, availability, and flexibility in scheduling. On days when it is difficult to leave home due to symptoms, you can still have therapy from your bed or couch, as long as you have an internet connection.
A 2022 review of 11 studies about internet-delivered interventions for personality disorders found that online therapy is more available than in-person therapy and shows promise for the future. The effectiveness of these treatments was on par with in-person options, and client satisfaction was high.
If you're interested in trying an online therapy format, consider signing up with a platform like BetterHelp, which offers a vast network of therapists providing various types of support. With multiple specialties and modalities offered, you can request a transference-focused therapist upon signing up to get matched with a provider within 48 hours.
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