A Primer of Transference-Focused Psychotherapy for the Borderline Patient (Book Review)

Title:  A Primer of Transference-Focused Psychotherapy for the Borderline Patient
Author:  Yeomans, Frank E., John F. Clarkin and Otto F. Kernberg
Publisher:  Northvale, NJ: Jason Aronson, 2002
Reviewed By:  Louis Rothschild, Winter 2004, pp. 49-50

In the fall issue of Psychologist-Psychoanalyst, Ronald Levant (2003) provides an adaptation from his forthcoming book in which he suggests that so called evidence based practice is in danger of eclipsing clinical judgment within psychology by virtue of its tendency to devalue subjectivity. Although he did not use this description, while reading him I conjured that in the extreme, the treatment manuals of research protocols prescribe a method of intervention similar to a paint by numbers book in which the clinician becomes a technician, not a scientist-practitioner. Levant illustrates that despite this trend within clinical psychology, most medical doctors appear to be able to function while affirming a subjectivity of clinical judgment that is informed by empiricism and other domains of knowledge such as in vivo experience. Levant closes by recommending the Institute of Medicine guidelines that assert that research evidence, clinical expertise, and patient values can co-exist without one of these components having privilege over the other. That subjectivity is under attack within psychology in the twenty-first century, might lead Tolman and Hull to stir in their respective graves, aghast by the apparent tendency for those inclined towards a cognitive behaviorist approach to diminish the cognitive yet again.

In a climate that views a psychotherapist’s subjectivity as error variance, a psychoanalytically-informed clinician might consider simply not adding or eliminating treatment manuals from their diet. However, the psychotherapy treatment manual universe is not monolithic, and it is a pleasure to review a manual that falls within the group of treatment manuals that view the subjectivity of the therapist as a central ingredient for the soup that is psychotherapy. As one would expect, the latest offering from Otto Kernberg’s group at the Personality Disorders Institute of the Weill Cornell School of Medicine affords a significant amount of space to the topic of countertransference, and provides specific examples illustrating the therapist’s use of their own emotional state in order to guide intervention with borderline patients. This primer of Transference Focused Psychotherapy (TFP) co-written with Frank Yeomans and John Clarkin further reveals that psychodynamic psychotherapy is alive and well, supported by both theory and empirical data.

The format of the manual itself is interesting in its own right. First, the text is laid out in strict outline form. Each of the twelve parts that cover diagnosis, contract, and treatment techniques are composed of numbered subparts, many of which contain increasingly discrete, additionally numbered subparts. To flip through the pages of the manual is to conjure up the specter of a thick PowerPoint presentation. However, unlike my soon-to-be-sleepy experience during many PowerPoint presentations, this works. The format is accessible and easy to negotiate. For example, the reference list is followed by nine pages of recommended readings in which a concise paragraph is devoted to each entry. Further, towards the end of the manual, an Internet address (Borderlinedisorders.com) is found in reference to the question of consultation and the setting up of a TFP supervision group. As is mentioned in the forward, the primer is appropriate for many different levels of training, from the student in a formalized training situation to the licensed therapist utilizing peer supervision.

One would hope that internet access is a constant across these groups as a visit to the website provides not only useful information (some in PowerPoint form), links to helpful resources, but commentary concerning this and other books by Kernberg and his team. In reference to the manual under review, Peter Fonagy is quoted: “In an era of empirically supported therapies… it can be done superbly, and that it can be done without violating a single one of our cherished ideals as psychoanalytic clinicians.” Enrico Jones stated that “It is the best example yet of a manual for psychodynamic psychotherapy.” Additionally, Lester Luborsky adds “This new book is a treat to read!”

Such praise is not limited to the authors internet presence. It may not be an overstatement to say that to pick up any work concerning the treatment of borderlines is to find mention of Kernberg’s work. However, the frequency of such an occurrence is notable. Three relatively recent primer level texts come to mind. Nancy McWilliams (1994, 1999) draws on Kernberg’s research regarding the borderline ability to utilize reality testing in order to make differential diagnosis regarding psychotic/borderline levels of functioning and the experience of totalistic ego states lacking a sense of tension. Another example may be found in Messer and Warren’s (1995) work on comparative approaches to therapy, as they cite Kernberg, among others, to state that although signs of a separate self may begin to emerge in therapy with borderline patients, there is no time in brief therapy to enable the development of a more cohesive experience of self and other. Each of these points and more are addressed within the primer under review—a primer that provides both an excellent introduction for anyone unfamiliar with Kernberg’s work as well as a good update for those who are familiar with the body of work that has preceded this manual.

TFP is considered to be a long-term treatment that recommends twice weekly meetings for over a year. The manual provides comments on working in less than ideal conditions, in addition to inclusion and exclusion criteria, prognostic factors, alternative treatments, tactics and strategies, and over 30 pages on diagnostic issues.

The manual is aimed at the treatment of the borderline level of functioning and, in terms of the Diagnostic and Statistical Manual–IV, it is pertinent to borderline, schizoid, schizotypal, paranoid, histrionic, narcissistic, antisocial, and dependent personality disorders. Additionally, sadomasochistic, hypochondriasis, and malignant narcissism are added to the category of borderline personality organization. I am aware of no empirical work suggesting that these disorders constitute an aggregate. So, here one is left with theory, albeit a theory which many find valid. To those who might think theory and validity cannot co-occur, I recommend a visit to physics where terra firma is found with such a stance (i.e., theory matters). To critique on these grounds is again to set the bar higher than it is found in other fields.

Ninety-one pages focus on the contract-setting portion of the treatment. Here topics such as secondary gain and deciding which phone calls are appropriate or not are treated with care. By itself the decision tree regarding the contract and suicidal behavior makes this book worth having. Interestingly, although TFP separates the contract setting phase from the work of therapy itself, Kernberg et al., state that a psychoanalytically-based therapy does not make a strict separation between the two, since working with the resistance is considered to provide information as to how to proceed in the therapy.

Further, the text addresses therapist vacation, supervision, and basic skills required to deliver such a therapy. Techniques such as clarification, confrontation, and interpretation are discussed. The vignettes included are engaging by virtue of being clear, direct, and illuminating. Particular situations such as patients who attempt to control therapy, those with split-off aggression, dropping out of treatment, termination, hospitalization, and medication are all given ample focus. For example, three algorithms are provided regarding the use of medication with particular patients. Which should be helpful to any therapist who is not responsible for psychopharmacology but is sharing treatment with another. Each algorithm addresses the medication of a different profile of patient, and provides an order in which a regimen might work. As one might expect, the manual also addresses the difficulty found when two clinicians are providing treatment.

My only critique of this excellent manual is minimal: depending on who uses the manual, the particular point of view found here may be taken as the point of view of a unified psychoanalytic theory. The treatment of object relations illustrates this quite well. A solid developmental perspective is found here in a manner that is accessible for a novice in need of a primer and a more advanced audience. However, the description runs the danger of leaving a novice reader with the impression that object relations is a unified theory. Such a description would do well to incorporate the work of others (e.g., Tronick, 2003).

That said, the manual is indeed excellent, and it is without reservation that this reviewer recommends it to both those well seasoned in the art and science of psychotherapy and to those just beginning to soak in the marinade. In conclusion, lest one think the manual is enough on its own, the authors wisely include A Final Note to the book. Here one finds that TFP is simply a tool, and that decisions regarding its use must be made clinically. The therapist is not a technician. Additionally, the authors state that the manual is a flexible guideline as we treat individuals not diagnosis. The surgeons know this. As therapists it will behoove us to remember it well.

Levant, R. F. (2003). The Empirically-validated treatments movement: A practitioner perspective. Psychologist-Psychoanalyst, 23, 4-6 &16.
Messer S.B., Warren C. S. (1995). Models of brief psychodynamic therapy: A comparative approach. New York: Guilford Press.
McWilliams, N. (1994). Psychoanalytic diagnosis: Understanding personality structure in the clinical process. New York: Guilford Press.
McWilliams, N. (1999). Psychoanalytic case formulation. New York: Guilford Press
Tronick, E. Z. (2003). “Of course all relationships are unique”: How co-creative processes generate unique mother-infant and patient-therapist relationships and change other relationships. Psychoanalytic Inquiry, 23, 473-491.

Louis Rothschild is in independent practice in Providence, RI, and is a member of the local chapter, Rhode Island Association for Psychoanalytic Psychotherapy.

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