Dr Sean Fernandez. Consultant Psychiatrist in Psychotherapy Mid and East Surrey Psychotherapy Service Shaws Corner, Blackborough Road, Reigate

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1 Dr Sean Fernandez Consultant Psychiatrist in Psychotherapy Mid and East Surrey Psychotherapy Service Shaws Corner, Blackborough Road, Reigate

2 Understanding of borderline personality disorder from TFP perspective Introduce TFP approach to the treatment of borderline personality disorder

3 TFP developed out of the work of Prof. Otto Kernberg and his team based at The Personality Disorders Institute, Weill Medical school, New York Influences on his thinking ego psychology, british object relations theory especially Klein, Fairbairn and attachment theory Manualised evidence based treatment TFP is not just for the treatment BPD but personality disorders in general

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5 Frantic efforts to avoid real or imagined abandonment Pattern of unstable and intense interpersonal relationships Identity disturbance Impulsivity- at least 2 areas sex, substance misuse, gambling, reckless driving, binge eating Recurrent suicidal behaviour and self harm Affective instability Chronic feelings of emptiness Inappropriate intense anger Transient stress related paranoid ideation and severe dissociation 5 out 9 criteria / vast variety of presentations

6 Non-specific ego weakness Disturbed interpersonal relationships Difficulty with work and love Some degree of pathology in sexual relations Superego pathology

7 Identity integration Habitual level of defence mechanism Reality testing Aggression Internalised values Object relatedness

8 Neurotic personality organisation Borderline personality organisation Psychotic personality organisation

9 Integrated and stable sense of self Intermediate and mature defence mechanisms Rigidity Repression based, rationalisation, humour, sublimation, isolation of affect, undoing, reaction formation etc. Reality testing is intact Aggression inhibited, angry outburst followed by guilt Internalized values excessive guilt some inflexibility in dealing with self Object relations, some degree of sexual inhibition or difficulty integrating sex with love, deep relations with others with specific focused conflicts with selected others.

10 Identity diffusion Habitual use of primitive defence mechanisms Splitting, idealization, denigration, projection,projective identification, primitive denial, omnipotence, somatisation Reality testing - generally intact but can break down under stress Aggression -tends to be self -directed sometimes externally directed, hatred in severe cases Internalised values-contradictory value system, incapacity to live up to own values significant absence of certain values Object relations-troubled interpersonal relationships, confused internal working models of relationships, severe interruption with love relations

11 NPO Introversion Extroversion Obsessive- Compulsive Depressive- Masochistic hysterical dependent High BPO Sadomasochistic cyclothymic histrionic narcissistic paranoid Low BPO hypomanic Malignant Narcissism Hypochond -riacal schizoid borderline Antisocial schizotypal PPO

12 Very fragmented sense of self Reliance on primitive defence mechanisms Reality testing - absent /unable to distinguish external and internal reality. Aggression severe fragmentation can be self and other directed.

13 In TFP the core difficulty is Identity diffusion Early experiences with care givers are internalised, some experiences will be extremely pleasurable, others extremely painful. If the care provided is good enough both these extreme sets of experience are integrated such that neither predominates and self and others seen as flawed but good enough. If extremely negative experiences predominate marked by significant levels of hostility the two sets of experience are kept apart. Splitting Identity diffusion - the experience of self and others which derives from a split and polarised internal world in which others likely to be experienced as all good or all bad,persecutors or idealized rescuers and the self in a similar way as either worthless, helpless and despised victim or cherished recipient of perfect care. Object relational dyad-internalized relationship between self and other based on early experiences with care giver.

14 Splitting divides the world into all good or all bad. Predominance of splitting in personality disorders gives rise to identity diffusion Projective identification is a way of splitting off and projecting into others unwanted aspects of the self. Countertransference Omnipotent control, idealization, denigration, denial, somatization

15 In TFP the core difficulty is Identity diffusion Identity diffusion - the experience of self and others which derives from a split and polarised internal world in which others likely to be experienced as persecutors or idealized rescuers Object relational dyad

16 Self affect Object Object relational dyad basic structural unit consisting of aspect of self in relationship with aspect of other and affect that connects them

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19 Unwanted, deprived child Absent, neglectful parent Defective, worthless child Contemptuous parent Valued, competent child Admiring, loving parent Threatened, abused victim Sadistic attacker / persecutor

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22 Oscillation of roles Persecutor Perfect carer Cared for child Persecutor

23 O+/O- O+/O- S+/S- O+/O-

24 Ambitious aim of TFP is integration of the self. Move from very split view of self and others to a more integrated, realistic and nuanced view of oneself and others Paranoid/schizoid to depressive position functioning Mastery and sublimation of aggressive feelings

25 TFP is a manualised form of psychodynamic therapy specifically adapted to treat borderline pathology. Based on the work of Otto Kernberg Treatment is involves a minimum twice weekly individual therapy for at least a year. Transference interpretation is central to therapeutic change. Evidence Based-4 major studies

26 Assessment-structural interview Contract setting- tactic #1 Treatment-Strategies/Tactics/Techniques

27 Pre-therapy Evaluation Sessions Contracting Sessions Family sessions Therapy

28 Focus on current life, relationships and activities To get a sense of the patient's personalities structure the focus is on the patient's present relationships and on how they are with the therapist in the interview procedure. The past is explored, but later in the interview

29 Ask about current problem in considerable depth Ask patient view of him/herself Ask who the most important person is in his/her life and to give a picture of them More fragmented and incoherent more likely to be suitable for TFP Check reality testing

30 Start with 3 Questions What brings you here? What is the overall extent of your problems? How do you understand your problems and what do you expect from treatment? At some point ask person to describe Themselves Someone close to them Ask about previous therapy/ contact previous therapists

31 Three channels of communication. Verbal Non-verbal Countertransference Neutrality/concerned objectivity Clarification Confrontation Trial interpretation

32 Active substance misuse or eating disorder Antisocial PD more psychopathy than just ASPD Secondary gain as motivation for treatment no real desire for change

33 Pervasiveness of aggression Quality of interpersonal relationships Physical attractiveness Intelligence Negative therapeutic reaction

34 Best to look at contract setting and treatment in terms of ; Strategies-Long term aims Tactics-aims within session Techniques-moment to moment interventions

35 Define therapists and patients responsibilities-general and particular responsibilities. Protects the therapist ability to think clearly and reflect. Allow patients dynamics to unfold in a safe place. Set stage for interpreting the meaning of deviations from the contract as they occur. Providing an organizing therapeutic frame that permits therapy to become an anchor in the patient s life.

36 Patient s responsibilities Attend all sessions on time, leave on time Limit contact to session times except in cases for practical reasons and true emergency. (Pay fee on time) Report all thoughts feelings that come to mind without censoring them Therapist responsibilities Provide regularly scheduled sessions/ provide adequate notice of breaks or changes to schedule To be attentive and open to patients communications and help understand the patients internal world and promote change. Maintain confidentiality unless patient at risk to self or others Provide clearly defined treatment geared to character change

37 Suicide and self-harm Homicidal ideation Lying and withholding information Substance abuse Uncontrolled eating disorder Excessive intrusion into therapist life Problems created in external relationships that interfere with therapy (Not paying fee or putting self in situation unable to pay fee) Chronically passive lifestyle fosters secondary gain of illness

38 Define dominant object relationships Observe and interpret role reversals of predominant object relational dyads Observe and interpret linkages between object relational dyads that defend against each other and maintain internal conflict and lack of integration Elaborate and work through more mature integrated affective experience that begins in the transference and review patients major relationships in relation to this. Roughly parallels the phases of treatment

39 Contract setting maintaining treatment frame Choosing priority themes to address in the material Expanding incompatible views of reality between patient and therapist in preparation for interpretation Analysis of positive and negative aspects of the transference Regulating intensity of affective intensity

40 The interpretative process Transference analysis Managing technical neutrality Use of countertransference

41 Contract setting Address sessional material in particular order Obstacles to treatment / re-addressing the frame Transference manifestations Non transferential material Follow the affect

42 Interpretive process-clarification/confrontation/interpretation Transference analysis Technical neutrality Integrating countertransference into interpretive process

43 This requesting information from patient Provides information for interpretation by getting patient to express in greater detail patients perception of themselves Also patients perception of the therapist /other Helps to shed light on patients internal world and helps bring out distortions. Enhances mentalization

44 Not a hostile challenge Contradiction via same channel Contradiction via different channels

45 Interpretation uses information gained from clarification and confrontation to link the material the patient is conscious of with inferred unconscious material believed to be influencing the patients experience Proposes a hypothesis about why it aspect is being kept out of consciousness Insight into unconscious conflict between un-integrated parts of patient s internal world makes apparent contradiction and maladaptive behaviours understandable

46 Interpret how acting out or primitive defences serve to avoid internal experience Interpret current active object relational dyad describe self and object representations and any role reversals Interpret how one dyad defends against another and explore what that might be Move from 1 to 3

47 Neutrality - position of an observer (observing ego) in relation to patients difficulty. Therapeutic Stance. Help the patient understand all the forces giving rise to the conflict within themselves Try to help patient to make as fully informed decision on basis of this understanding Deviation from neutrality to control dangerous acting out that cannot be contained by confrontation and interpretation

48 Unnecessary deviations from neutrality often due to countertransference Therapist issues being transferred onto patient Patients transference to therapist In borderline patients the latter is more important Projective identification

49 Concordant countertransference -akin to empathy Complementary countertransference Harder to empathise with patient more likely to leave neutrality and act out. Essential- Consultation and peer supervision

50 4 studies Study 1 Non RCT, patients were own controls 17 patients completed 1 year of TFP cf 1 year before treatment. Clarkin, Foelsch, Levy, Hull, Delaney and Kernberg. The development of a psychodynamic treatment of patients with borderline personality disorder: A preliminary study of behaviour change. Journal of Personality Disorders. 2001;15, Study 2 Non RCT. TFP c.f. TAU 26 patients having received 1 year TFP compared with 17 subject evaluated for but who did not enter treatment Levy, Clarkin and Kernberg, in review.

51 Study 3 Randomised controlled trial Looked at 90 patients in three manualised treatments TFP, DBT and Supportive therapy Clarkin, Levy, Lensweger and Kernberg. Evaluating three treatments for borderline personality disorder: a multiwave study. American Journal of Psychiatry , Study 4 TFP compared with experienced community psychotherapists Doering S et al. TFP vs treatment by community therapists for BPD. British Journal of Psychiatry. 2010; 196 (5)

52 They found substantial reductions in symptoms and suicidal behaviour compared with the previous year. Though the frequency of non-suicidal self injury did not reduce,the severity and level of medical risk did. Marked reduction in hospitalizations from 1.24 to 0.35 With the average length of stay reducing from to 4.5 Approached statistical significance P=0.06 Drop out rate was 19% which is low for this population No suicides None of the patients who completed treatment deteriorated or were adversely affected

53 Patients were not randomised but the groups had no significant differences between the two groups in regard to symptoms and functioning. TFP group showed reductions in visits to casualty, hospitalisations, and number of days in hospital they also improved in global functioning. Both within group and between group changes were large and significant and no less than with DBT and MBT

54 90 BPD patients were randomised to three types of manualised treatment TFP, DBT and Supportive psychotherapy All groups 1 years treatment plus medication as required. 92% female, mean age 31, mean GAF 50 indicates substantial degree of symptoms and impaired functioning. Other Axis I and II disorders 57% prior suicidal behaviour 64% prior Para suicidal behaviour 17% history of neither

55 Results were all three treatments were effective Few major differences No differences in domains of anxiety, depression and GAF In suicidality only TFP and DBT made significant differences supportive therapy did not Another important outcome was they looked at Reflective Functioning, measure of ability to mentalize and marker of secure attachment. Only TFP lead to a significant change in this.

56 TFP had fewer drop outs Fewer patients attempted suicide Greater improvement in Borderline symptomatology Greater improvement in psychosocial functioning Greater improvement in level of personality organisation Reduction in number of inpatient admissions Reduction in general psychopathology ( trend) Both reduced anxiety and depression But neither group had reduction in non lethal self harming

57 Re-focusing case load Using experienced honoraries Special interest sessions

58 TFP is an evidence based treatment for personality disorders The goal of TFP is personality integration.

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