Considering Transference-Focused Psychotherapy for BPD

Personal Perspective: Transference-focused psychotherapy saved my life.

Reviewed by Gary Drevitch

I’ve always maintained that it was transference-focused psychotherapy (TFP) with my former psychiatrist, Dr. Lev, which saved my life and gave me a life worth living. I’ve recently been looking at posts on Instagram and TikTok about borderline personality disorder (BPD) and some mention dialectical behavior therapy (DBT) as the gold standard treatment. None mention TFP.

Before managed care, I spent 10 months in a long-term inpatient unit that treated patients diagnosed with BPD with dialectical behavior therapy. Then I was discharged to that hospital's day program for patients with BPD. We were treated with DBT by many of the same staffers. I stayed in that program for 18 months.

TFP is a psychodynamic treatment, as opposed to DBT, which is a skills-based treatment. DBT is based in the here and now, while TFP treats BPD by focusing on the relationship — or the "transference" — between the therapist and the patient.

Transference-focused psychotherapy most often takes place twice weekly, and treatment lasts between one and three years. I worked with Dr. Lev for 11 years, with twice-weekly sessions. Before Dr. Lev and I started working together, we created a contract the purpose of which was to identify any behaviors that might interfere with treatment. The three items on my contract were:

• If I fell below a certain weight, I had to enter inpatient eating disorder treatment.
• If I cut myself, even a scratch, I had to seek medical treatment.
• If I attempted suicide, Dr. Lev would do everything she could to save me, then she would end treatment.

During the first years, just keeping me alive, not cutting, and out of the hospital was progress. At one point during a particularly rough stretch, I saw Dr. Lev three times a week. Our work had stalled. She recorded our sessions and showed them to her colleagues (with my permission).

When we first started working together, I was on Spcial Security disability due to electroconvulsive therapy (ECT) treatments I received for an intractable and suicidal depression. After two years, Dr. Lev told me it was time to go back to work. She told me it could be part-time, any job, even a volunteer job. She told me in no uncertain terms that she did not work with patients who were content to remain stagnant. If that was what I wanted to do, she would be happy to refer me to a therapist who could provide me with good psychiatric management. I was terrified of losing Dr. Lev. I went out and got a part-time job in a women’s clothing store that week.

According to researchers Frank Yeomans, John Clarkin, and Otto Kernberg, who authored A Primer of Transference-Focused Psychotherapy For The Borderline Patient, TFP is defined by its roots in the object relations model and the ensuing emphasis on the transference as the key to understanding and change, since it is believed that the patient’s internal world of object representations unfolds and is “lived” in the transference. The goal of treatment is "symptom improvement and substantial change in personality organization.”

I developed an intense attachment to Dr. Lev almost immediately. Unlike most people with BPD, I never devalued her; I was afraid to. My mother had passed away three years prior and while I don’t believe I saw Dr. Lev as a mother figure, I clung to our therapeutic relationship as I still felt adrift and lonely as a result of my mother’s passing. I couldn’t imagine risking losing her by devaluing her, even in my mind.

That attachment wouldn’t break until my fourth suicide attempt in 2014 (the only one I had while working with Dr. Lev). I was still in the psychiatric hospital when I received word that Dr. Lev was willing to talk to me instead of ending therapy per our original contract. I felt intense relief, and I knew I needed to be honest with her about how angry I’d been feeling with her regardless of how difficult that was for me.

In their discussion of signs of progress in TFP, Yeomans, Clarkin, andf Kernberg include: "[T]he patient can begin to tolerate some awareness of the patient’s hatred, and of the patient’s love.”

It took me nine years of working with Dr. Lev to get to this point. I was finally able to express my anger toward her without fear of abandonment or rejection. Those last two years of work were our most productive and intense.

In the first nine years, I had difficulty speaking spontaneously. One of Dr. Lev’s favorite phrases was “What comes to mind?” I’d stare at her, look around her office, and gaze out the window. I was timid, afraid of saying the wrong thing. Intellectually, I knew that in therapy there was no right or wrong thing to say.

Looking back, this was part of the transference as I lived in fear of saying the wrong thing to my father, for fear of unleashing a torrent of drunken cruelty. That fear had a long-lived and far-reaching effect.

In the last two years that we worked together, it was still an effort for me to speak extemporaneously, but I did. I tried to talk without censoring myself, knowing that Dr. Lev wasn’t judging me. She was the first therapist with whom I felt comfortable talking about sex and sexuality. By then we’d concluded I was asexual, through my experimentation with BDSM.

In their primer, Yeomans, Clarkin, andf Kernberg write of "terminating with a patient who has resolved the major borderline issue of integrating a split internal world.” At the end of 2015, I told Dr. Lev I wanted to spend the next year terminating. She agreed a year was an appropriate amount of time after the 10 years we’d been working together. I couldn’t believe I was initiating ending therapy. Just a year prior, I’d firmly believed I’d never be able to survive without paying someone to talk to each week. About six months into the year, we cut down to one session a week. In the fall of 2016, Dr. Lev’s father became ill and she was flying to Europe often to be with him. She was gone for several weeks at a time. Her frequent and prolonged absences were good practice for me.

Sometime during that last year, I asked her: If she had known what she was getting into, would she have made the decision to work with me? She didn’t answer, she just smiled. I took that as a no.

Dr. Lev continues to manage my medication, so I still see her a couple of times a year. We have a full session, not just a 15-minute med management session and I try to catch her up on all that has been going on in my life. Fifty minutes never seems like enough.

I no longer need to thank Dr. Lev for saving my life and giving me a life worth living. She is well aware.