Correspondence

RESPONSE TO ‘THE FUTURE OF THETRANSFERENCE-BASED THERAPIES’bjp_1159 122..124

Dear EditorsLesley Murdin’s article in the August issue (BJP 25(3): 331–42) and the

responses to it in the same issue raise important points about the place oftransference-based therapies today.

There are clearly well-grounded concerns amongst those of us practisingpsychoanalytic psychotherapy as there are two aspects of the current therapyclimate in the UK that appear to be quite threatening. As Lesley Murdin’sarticle points out, we have to think about NICE and the guidance it produces,which is drawn from evidence and RCTs which are seen as the gold standard.Then there is the whole ImprovingAccess to PsychologicalTherapies (IAPT)project which is largely about providing CBT interventions.

There is one area in which there are grounds for optimism about thefuture of transference-based therapies. For many years now in the UnitedStates John Clarkin, Otto Kernberg, Frank Yeomans and colleagues fromthe Personality Disorders Institute, New York Presbyterian Hospital, havebeen working with and researching a form of psychodynamic psychotherapythey term Transference-Focused Psychotherapy (TFP). This is a treatmentthat has shown good results in treating borderline patients and others withsevere personality disorders, in particular narcissistic patients.

What is important about Clarkin et al. is they have grasped the nettle ofconducting clinical research without compromising their approach. Theyhave produced a book (Clarkin et al., 2006) which outlines the approach. Atthe heart of the treatment is attention, always, to what is happening in thetransference as well as the therapist’s countertransference. There is anemphasis on the use of transference interpretations although there is adevelopmental aspect to this as therapy moves from emphasis on the treat-ment frame (especially necessary with patients who tend to act out) toclarification of the patient’s affect states and confrontation–reflection oncontradictory aspects of the material they bring to the session and thenfinally to interpretation itself.

In using interpretation the TFP therapist will work within the transferencerelation in the room but will also make references to relationships thepatient has with others. What is consistent is a focus on the present, inattempt to help the patient move, in Kleinian terms, from the paranoid–schizoid to the depressive position.

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When NICE published their draft guidelines on working with patientswith borderline personality disorder I submitted a response through theUKCP. I drew attention to the Multiwave Study (Clarkin et al., 2007) inwhich a Randomized Control Trial looked at the effectiveness of TFP, Dia-lectical Behaviour Therapy and Supportive Psychotherapy (specifically thisis psychotherapy that does not use transference interpretations). NICEeventually included TFP in their final guidelines as a treatment worthy offurther research. Interestingly TFP is normally a twice-weekly therapy for atleast a year. NICE did recommend considering therapy that is more frequentthan once a week and were cautious about any therapy for borderlinepersonality disorder of less than three months.

Clearly, using any model that has been ‘manualized’ can feel like giving uppart of the therapist’s autonomy. For me the reverse has been true in that Ihave found it extremely helpful, in working with patients with complexpersonality disorders, to think about things like a treatment contract and theneed to prioritize the management of risk. And actually the TFP manual isless a ‘How to do it’ book than it is a practical and theoretical tool that givesvaluable pointers as to what to consider and how to make sense of whatmight be happening in the room.

TFP is taught and used in Germany, Austria, Holland, Denmark, Spain,Italy, Canada, Mexico, and Chile as well as the USA. I attended a two-daytraining in Amsterdam. Working as an Adult Psychotherapist in the NHS Ihave had support within my service in the use of this model and I’ve also hadvery generous, invaluable help from Frank Yeomans and Monica Carsky inthe USA.

There are papers about TFP (Kernberg et al., 2008; Yeomans et al., 2008)as well as an interesting study regarding the use of transference interpreta-tions (Hoglend et al., 2008). The website address of the Personality Dis-orders Institute is at [www.borderlinedisorders.com]

This letter was written in collaboration with Frank Yeomans.

Yours sincerelyFrank I. Denning

Psychoanalytic Psychotherapist (UKCP Registered)Principal Adult Psychotherapist, Manchester Mental Health and

Social Care Trust, Manchester[frank.denning@mhsc.nhs.uk]

References

Clarkin, J.F., Levy, K.N., Lenzenweger, M.F. & Kernberg, O.F. (2007) Evaluatingthree treatments for borderline personality disorder:A multiwave study. AmericanJournal of Psychiatry 164: 922–8.

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Clarkin, J.F., Yeomans, F.E. & Kernberg, O.F. (2006) Psychotherapy for BorderlinePersonality Disorder: Focusing on Object Relations. Washington, DC: AmericanPsychiatric Publishing.

Hoglend , P., Bogwald, K.-P., Amlo, S. et al. (2008) Transference interpretations indynamic psychotherapy: Do they really yield sustained results. American Journalof Psychiatry 165: 763–71.

Kernberg, O.F., Yeomans, F.E., Clarkin, J.F. & Levy, K.N. (2008) Transferencefocused psychotherapy: Overview and update. International Journal of Psycho-analysis 89: 601–20.

Yeomans, F.E., Clarkin, J.F., Diamond, D. & Levy, K.N. (2008) An object relationstreatment of borderline patients with reflective functioning as a mechanism ofchange. In: F.N. Busch (ed.), Mentalization: Theoretical Considerations ResearchFindings, and Clinical Implications, pp. 159–81. Hillsdale NJ: Analytic Press.

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