Transference-focused psychotherapy training during residency: an aide to learning psychodynamic psychotherapy

Transference-focused psychotherapy as an aid to learning psychodynamic psychotherapy: qualitative analysis of UK psychiatry trainees' views

AIMS & METHOD

Learning psychotherapy can be difficult and stressful. We explore core trainees' (n = 5) views on undertaking a psychodynamic psychotherapy training case using transference-focused psychotherapy (TFP), in an East London NHS Foundation Trust supervision group. We used framework analysis of focus group interviews to examine trainees' concerns, their views about this experience and its impact on general psychiatric practice.

RESULTS

Trainees described various concerns on starting: providing an effective intervention, insufficient experience and training-related pressures. However, they found that TFP addressed some of them and was helpful for learning psychodynamic psychotherapy. Difficulties around the countertransference remained at end-point. Trainees suggested that introductory teaching and learning through observation might be worthwhile.

CLINICAL IMPLICATIONS

Trainees' experience suggests that an evidence-based operationalised approach such as TFP can be integrated into the core psychiatry curriculum as a psychodynamic psychotherapy learning method. Trainees report benefits extending to other areas of their practice.

Applied Transference-Focused Psychotherapy: An Overview and Update

Transference-focused psychotherapy (TFP), developed and studied as an extended individual psychotherapy for patients with borderline personality disorder (BPD), rests on a rich theoretical foundation informed by psychoanalytic object relations theory. "Applied TFP" is a developing initiative using TFP principles in multiple clinical situations other than the standard extended individual psychotherapy, which has been empirically validated and is detailed in the TFP treatment manual. The growing application of TFP principles in innovative, overlapping ways has been focused primarily in three spheres: (1) the integration of TFP principles in pluralistic theoretical approaches to treatment of patients with personality disorder pathology; (2) the use of TFP elements in multiple teaching situations as part of curricula for trainees and practicing clinicians, and (3) the employment of TFP theory and interventions in settings across a continuum of patient acuity, tailored for patients with varying diagnoses. The use of TFP principles in the situations described directly addresses needs emerging in particular contexts that reflect specific requirements of clinician practice and training and of broader public health missions.

A Novel Approach to Supervision of Transference-Focused Psychotherapy (TFP): Examining the First Three Minutes of the TFP Session

Transference focused psychotherapy (TFP), an empirically validated, manualized treatment for patients with borderline personality disorder (BPD), is arguably the most challenging to learn of the evidence-based treatments for BPD. Following an introduction to the TFP manual and the treatment's central tenets, ongoing individual, group, or peer supervision of case material, ideally with recorded video sessions, would be expected when the clinician's goal is fidelity to the prescribed approach. Our proposal for a novel supervision intervention emerges directly from the basic theoretical foundations of TFP, the process of research investigation, which has evolved over the years, with its goal of assessing both measurable patient outcomes and research clinician adherence to the model, and collective clinical experience. A deliberate assessment of the initial minutes of TFP as a supervision or self-assessment method is not meant as a substitute for more comprehensive supervision, nor is it offered as an exclusive path to mastering TFP. This approach to TFP supervision aims to distill and focus in a common-sense, accessible way the process of practicing TFP, thereby facilitating therapist consistency. Our proposed, more limited and concise tactic for TFP training can be used as an instruction building block, incrementally extending the access for practicing and mastering this intervention to a broader group of motivated providers.

Augmenting Psychiatric Risk Management: Practical Applications of Transference- Focused Psychotherapy (TFP) Principles

Risk management challenges in psychiatry are made more complicated when they involve the treatment of patients with primary or co-occurring personality disorder pathology. Principles of transference-focused psychotherapy (TFP), a treatment empirically validated for borderline personality disorder (BPD) and with utility for patients with varying personality disorder presentations, are practical, commonsense measures that can guide clinicians in these difficult matters. Applied TFP principles are useful in this area even when clinicians are not engaged in an extended individual psychotherapy. Central to the TFP approach are: (1) an openness to identifying personality disorder pathology; (2) a deliberate process to assess personality disorder diagnoses with attention to severity of illness; (3) an emphasis on the informed consent process, which includes sharing fully with the patient the clinician's diagnostic impression with germane psychoeducation; (4) an expectation for timely contacts at the outset of treatment with prior practitioners and with family members, when indicated; and (5) the development and maintenance of a treatment frame. TFP stresses the active monitoring of three channels of communication (what the patient says, how the patient behaves, and the clinician's countertransference) as a guiding precept that informs clinical decision-making. TFP principles can serve as a useful risk management "checklist" by organizing a clinician's approach to inherently confounding material.

How can transference-focused psychotherapy (TFP) help general psychiatrists working with patients with borderline personality disorder?

Transference-focused psychotherapy concepts and techniques have much to offer experienced psychiatrists and psychiatrists in training in their work with patients with borderline personality disorder and, as a consequence, help address the stigmatisation of this group of patients and improve their clinical care.

DECLARATION OF INTEREST

W.B.-J. is chair of the Specialty Advisory Committee of the Faculty of Medical Psychotherapy, RCPsych, with governance for the content and delivery of the curriculum for psychotherapy training of trainee psychiatrists in the UK.

A Psychodynamic Approach for the General Psychiatrist: Using Transference-Focused Psychotherapy Principles in Acute Care Settings

Transference-focused psychotherapy (TFP) is one of the empirically validated treatments for patients with borderline personality disorder. TFP has roots in psychoanalytically informed psychotherapy, although important elements of the treatment have been adapted and refined for patients with significant personality disorder pathology. TFP's assessment process is informed by the structural interview, an approach that synthesizes standard DSM-5 nosology with the psychodynamic concept of the personality organization. TFP principles can be integrated into practice in general psychiatry settings in the care of patients with primary or co-occurring personality disorder pathology.

Training in Good Psychiatric Management for Borderline Personality Disorder in Residency: An Aide to Learning Supportive Psychotherapy for Challenging-to-Treat Patients

Given many competing demands, psychotherapy training to competency is difficult during psychiatric residency. Good Psychiatric Management for borderline personality disorder (GPM) offers an evidence-based, simplified, psychodynamically informed framework for the outpatient management of patients with borderline personality disorder, one of the most challenging disorders psychiatric residents must learn to treat. In this article, we provide an overview of GPM, and show that training in GPM meets a requirement for training in supportive psychotherapy; builds on psychodynamic psychotherapy training; and applies to other severe personality disorders, especially narcissistic personality disorder. We describe the interpersonal hypersensitivity model used in GPM as a straightforward way for clinicians to collaborate with patients in organizing approaches to psychoeducation, treatment goals, case management, use of multiple treatment modalities, and safety. A modification of the interpersonal hypersensitivity model that includes intra-personal hypersensitivity can be used to address narcissistic problems often present in borderline personality disorder. We argue that these features make GPM ideally suited for psychiatry residents in treating their most challenging patients, provide clinical examples to illustrate these points, and report the key lessons learned by a psychiatry resident after a year of GPM supervision.

Transference-Focused Psychotherapy in Australian psychiatric training and practice

OBJECTIVE

This article discusses Transference-Focused Psychotherapy, a contemporary evidence-based and manualised form of psychoanalytic psychotherapy for borderline personality disorder. Transference focused psychotherapy has evolved from decades of research in the object-relations approach developed by Professor Otto Kernberg and his collaborators. It is being adopted increasingly throughout North and South America and Europe, and this article explores the role its adoption might play in psychiatric training as well as public and private service provision contexts in Australia.

CONCLUSIONS

Transference focused psychotherapy is readily applicable in a range of training, research and public and private service provision contexts in Australia. A numbers of aspects of current Australian psychiatric training and practice, such as the Royal Australian and New Zealand College of Psychiatrists advanced training certificate, and the Australian medicare schedule, make it especially relevant for this purpose.

Evidence-Based Treatments for Borderline Personality Disorder: Implementation, Integration, and Stepped Care

LEARNING OBJECTIVE

After participating in this activity, learners should be better able to:• Evaluate evidence-based therapies for borderline personality disorder

ABSTRACT

Several manualized psychotherapies for treating borderline personality disorder (BPD) have been validated in randomized, controlled trials. Most of these approaches are highly specialized, offering different formulation of BPD and different mechanisms by which recovery is made possible. Mental health clinicians are challenged by the degree of specialization and clinical resources that these approaches require in their empirically validated adherent forms. While these effective treatments have renewed optimism for the treatment of BPD, clinicians may feel limited in their ability to offer any of them or may integrate an eclectic assortment of features from the different treatments. This article will evaluate four major evidence-based treatments for BPD-dialectical behavioral therapy, mentalization-based treatment, transference-focused psychotherapy, and General Psychiatric Management-and possible modes of implementation in adherent and integrative forms. Models of implementing these diverse treatment approaches will be evaluated, and the potential advantages of combining evidence-based treatments will be discussed, along with some cautionary notes. A proposal for providing stepwise care through assessment of clinical severity will be presented as a means of achieving system-wide changes and greater access to care.

"Good Enough" Psychiatric Residency Training in Borderline Personality Disorder: Challenges, Choice Points, and a Model Generalist Curriculum

While the public health burden posed by borderline personality disorder (BPD) rivals that associated with other major mental illnesses, the prevailing disposition of psychiatrists toward the disorder remains characterized by misinformation, stigma, aversive attitudes, and insufficient familiarity with effective generalist treatments that can be delivered in nonspecialized health care settings. Residency training programs are well positioned to better equip the next generation of psychiatrists to address these issues, but no consensus or guidelines currently exist for what and how residents should be taught about managing BPD. Instead, disproportionately limited curricular time, teaching of non-evidence-based approaches, and modeling of conceptually confused combinations of techniques drawn from specialty BPD treatments are offered. In this article, we (1) explain why training in a generalist model is sensible and why alternative approaches are not appropriate for residents, (2) propose a plan for giving residents adequate training via a generalist model, highlighting minimal didactic and clinical-training objectives (dubbed "core competencies" and "milestones") and a model curriculum developed at the Massachusetts General Hospital/McLean Hospital residency program, and (3) describe obstacles to implementation of effective generalist training posed by infrastructural, faculty-centered, and resident-centered variables.