A Primer of Transference-Focused Psychotherapy for the Borderline Patient

FRANK E. YEOMANS, JOHN F. CLARKIN, AND OTTO F. KERNBERG: A Primer of Transference-Focused Psychotherapy for the Borderline Patient. Jason Aronson, Northvale, NJ, 2000, 283 pp. $50.00, ISBN: 0-7657-0355-6. The authors offer a treatment guide for, what they call, transference-focused psychotherapy for borderline patients. In the format of 79 questions and answers they provide details about all aspects of this type of psychotherapy. Background information regarding diagnostic issues is included, and illuminating clinical examples are continually provided. The book is succinct, clearly written, and quite easy to understand. The content is similar to a previously published book by Kernberg, Seltzer, and Koenigsberg (Psycho-dynamic Psychotherapy of Borderline Patients. Basic Books, New York, 1989). Transference-focused psychotherapy is a form of analytically oriented psycho-therapy, centrally focused on the transference, and based on an underlying object relations model, written about previously by Kernberg (Object Relations Theory and Clinical Psychoanalysis. Jason Aronson, New York, 1976). It emphasizes the frame of psychotherapy, contract setting, and a somewhat "classical" psychoanalytic model. Transference-focused psychotherapy is advocated for only certain borderline patients, basically those that are higher functioning, although this is not explicitly stated. More supportive techniques are advocated for the more difficult borderline individuals. The format is twice- (and occasionally three-times) a-week psychotherapy, sitting up, for several years. There is an introductory phase in which two to three sessions are used to establish an accurate diagnostic impression, followed by two or more sessions for discussion of the treatment contract. The rigorous contract emphasizes the patient's responsibilities, including the need for honest communication and for keeping the therapist informed about life events. Emphasis on the contract is thought to help protect the therapist's ability to think and reflect, and to provide a safe therapeutic environment. It allows for a baseline, to return to whenever there is any deviation. The contract is individualized in accordance with the particular patient's problems, especially those related to potential destructive acting out. Recommendations about how to deal with a variety of potential problems are detailed. Regarding the therapy itself, therapists are advised to focus their attention first on the material that carries the most affect. They should work from surface to depth, addressing defense before that which is defended against, but not neglecting to address the latter. Attention should be paid to both verbal and nonverbal content, in addition to the countertransference. A hierarchy of priorities is presented, with overt threats to the individual and to the therapy having priority over other issues. Regarding technique, the interpretive process, including clarification, confrontation, and interpretation per se, is emphasized. There should be a systematic analysis of primitive defenses, as they enter the transference. Technical neutrality is maintained as much as possible, and countertransference is continually monitored and used to help with the interpretive process. Interpretations should be made in detail and with conviction. Relevance, clarity, depth, and speed of the interpretations must always be considered. One of the core problems in the borderline patient is the difficulty in integrating good and bad self representations and object representations. Thus the patient uses splitting and other related primitive defenses, has not attained libidinal object constancy, and does not have a consolidated integrated identity. One of the goals of transference-focused psychotherapy is to convert splitting and related primitive defenses to higher-level defenses, thus enhancing patients' ability to experience themselves and others as coherent, integrated, and realistically perceived individuals. …