Businesswoman looking at herself in a mirrorPrimarily developed for people with a borderline personality (BPD) diagnosis, transference-focused psychotherapy (TFP) works to help people develop positive self-regard and more constructive behaviors. TFP helps identify problematic patterns of interaction or self-destructive ideas as they arise during a therapy session, rather than focusing only on scenarios that arise outside of psychotherapy.

What Is Transference-Focused Therapy?

Transference is the phenomenon in which an individual projects emotions or expectations onto another person, especially their therapist. This often happens unconsciously and may be overlooked unless it interferes with therapeutic progress. TFP, however, assumes transference is a normal or expected part of psychotherapy, and uses it to break down destructive behavioral patterns. 

For example, a transference-focused therapist would verbally identify, or ask the person in therapy to identify, examples of their behavior that are happening immediately in the course of a therapy session. By shining a light on those problematic interactions when they occur, both therapist and client can better recognize and develop positive alternatives to destructive or potentially unhealthy behavior as it happens.

What TFP Can Help With

Most research related to TFP has evaluated its effect on individuals who have a borderline personality diagnosis. In several studies, TFP has successfully:

  • Reduced common symptoms of BPD, such as impulsivity, irritability, anger, and self-harm
  • Improved emotional regulation
  • Lowered anxiety and depressive symptoms
  • Improved social interactions
  • Reduced suicidal ideation

Some preliminary research also supports the use of TFP for other mental health considerations such as narcissism. Because narcissism and borderline can share some traits related to social interactions, TFP may be easily applied to identifying similar patterns in individuals with narcissism. Therapists using TFP with people who have narcissistic personality traits may need to be more mindful of a resistance to treatment and a tendency toward attrition in these populations.

How Does TFP Work?

TFP is based on a twice-weekly treatment approach that uses object relations theory to shift and improve ingrained behavioral patterns that may be destructive or unhealthy. Object relations theory is the belief that humans are motivated by social interaction and relationships with other humans than by sex or aggression. By addressing behaviors from the standpoint that all people fundamentally want to improve relations with others, therapists focus on the way someone can make lasting change, rather than on their perceived pathologies.

The International Society for Transference-Focused Psychotherapy articulates two beliefs that guide the practice of TFP:

  1. Treatment relies on the recognition of symptoms as internal factors and emotional states, not as manifestations visible to the naked eye.
  2. Both client and therapist continually develop and hone their awareness of the client’s symptoms or problematic behaviors throughout the course of treatment, not just during assessment or the initial phase of therapy.

TFP encourages the person in therapy to take responsibility for their actions and behaviors through the understanding that while the diagnosis of a personality disorder may be lifelong, the way a person copes with related symptoms and interacts with others can change and improve. This happens when a person identifies or is shown, in real time, shifts in their emotional state or interactive approach and is given the opportunity to make other choices that better serve them.

As a very specific approach designed to address issues related to personality and interpersonal relationships, TFP assumes one these are the sole or primary concerns for which an individual is seeking therapy. For example, TFP might not be the appropriate first step in psychotherapy for someone who also has mental health considerations around drug or alcohol abuse, eating disorders, or severe suicidal ideation. Someone with any of these diagnoses or concerns may try a complementary therapy before beginning TFP or in correlation with TFP.

What Happens in a Typical TFP Session?

In the very beginning stages of TFP, the therapist will work with the individual to establish informed consent. Because TFP is a unique therapeutic method which generally uses a more active approach from the psychotherapist than other forms of talk therapy, it is especially important an individual beginning TFP is thoroughly comfortable with their therapist. 

There are two phases of TFP which sometimes overlap or continue to weave together through the course of treatment:

  1. Establishing trust, a treatment structure that will guide future sessions, and boundaries that may be specific to a person’s individual destructive behaviors
  2. Exploring and revisiting the individual’s mind, sense of identity, emotions, and recurring behavioral patterns

As the individual and therapist begin to work through identity issues and behavioral patterns, instances of emotional instability, aggression, defensiveness, or other reactions may emerge. Each of these occurrences is an opportunity for the psychotherapist to draw attention to the emotional shift or change in behavior. 

This process of coming to terms with one’s own harmful thought patterns or emotional reactions can be extremely raw or uncomfortable—but most research results related to TFP point to the efficacy of this type of treatment. Clinical trials show TFP is most effective when used regularly for at least one year to establish a trusting therapeutic relationship and ample time to work on core objectives outlined early in therapy.

Concerns and Limitations

The Society of Clinical Psychology rates TFP as “strong/controversial” because of mixed findings from studies. Most research pointed to great success associated with prolonged TFP treatment. Trials with questionable results did not demonstrate TFP was ineffective—they only raised further questions about how long results would last or whether TFP was a clear choice over another therapy, such as schema-focused therapy. 

As TFP seems to be exclusively applied to individuals with borderline personality disorder, it is unclear whether this modality would be effective for populations without a BPD diagnosis. More research is needed to demonstrate the success of TFP, both for individuals with borderline and people with other mental health issues.

References:

  1. Clarkin, J. F., Levy, K. N., Lenzenweger, M. F., & Kernberg, O. F. (2007). Evaluating three treatments for borderline personality disorder: A multiwave study. American Journal of Psychiatry, 164(6), 922-928. Retrieved from https://ajp.psychiatryonline.org/doi/abs/10.1176/ajp.2007.164.6.922 
  2. Doering, S., Hörz, S., Rentrop, M., Fischer-Kern, M., Schuster, P., Benecke, C., ... & Buchheim, P. (2010). Transference-focused psychotherapy v. treatment by community psychotherapists for borderline personality disorder: randomised controlled trial. The British Journal of Psychiatry, 196(5), 389-395. Retrieved from https://www.cambridge.org/core/journals/the-british-journal-of-psychiatry/article/transferencefocused-psychotherapy-v-treatment-by-community-psychotherapists-for-borderline-personality-disorder-randomised-controlled-trial/0F703220DA3A6669FC6B3C5B0433FA4B 
  3. Fischer-Kern, M., Doering, S., Taubner, S., Hörz, S., Zimmermann, J., Rentrop, M., ... & Buchheim, A. (2015). Transference-focused psychotherapy for borderline personality disorder: change in reflective function. The British Journal of Psychiatry, 207(2), 173-174. doi: 10.1192/bjp.bp.113.143842
  4. Giesen-Bloo, J., Van Dyck, R., Spinhoven, P., Van Tilburg, W., Dirksen, C., Van Asselt, T., ... & Arntz, A. (2006). Outpatient psychotherapy for borderline personality disorder: randomized trial of schema-focused therapy vs transference-focused psychotherapy. Archives of General Psychiatry, 63(6), 649-658. doi:10.1001/archpsyc.63.6.649
  5. Stern, B. L., Diamond, D., & Yeomans, F. E. (2017). Transference-focused psychotherapy (TFP) for narcissistic personality: Engaging patients in the early treatment process. Psychoanalytic Psychology, 34(4), 381. Retrieved from http://psycnet.apa.org/record/2017-27043-001 
  6. Stern, B. L., Yeomans, F., Diamond, D., & Kernberg, O. F. (2013). Transference-focused psychotherapy for narcissistic personality. American Psychological Association. Retrieved from http://psycnet.apa.org/record/2012-22247-014 
  7. Transference-focused therapy for borderline personality disorder. (2016). Society of Clinical Psychology. Retrieved from https://www.div12.org/treatment/transference-focused-therapy-for-borderline-personality-disorder
  8. Yeomans, F. E., Levy, K. N., & Caligor, E. (2013). Transference-focused psychotherapy. Psychotherapy, 50(3), 449. Retrieved from http://psycnet.apa.org/record/2013-30487-038 
  9. Yeomans, F. E., & Stern, B. L. (n.d.). About transference-focused psychotherapy (TFP). International Society of Transference-Focused Psychotherapy. Retrieved from http://istfp.org/about-tfp/about-transference-focused-psychotherapy-tfp