Videoconferencing psychotherapy from a psychodynamic point of view. A qualitative analysis.

There is a growing interest in delivering videoconferencing psychotherapy (VCP) due to the enormous impact of the COVID-19 pandemic on our lives since the beginning of severe restrictions worldwide in March 2020. Scientific literature has provided interesting results about the transition to remote sessions and its implications, considering different psychotherapy orientations. Less is known about whether and how VCP affects psychodynamic psychotherapeutic approaches and reports on remote work with severe and complex mental health problems such as severe personality disorders are still scarce. The aim of the study was to examine the experiences of psychodynamic psychotherapists, mainly delivering Transference-Focused Psychotherapy (TFP), with the transition and delivery of VCP during the first wave of the COVID-19 pandemic. Four hundred seventy-nine licensed psychotherapists completed an online survey during the peak of the pandemic. Survey data were analyzed using qualitative analysis. Results are presented and discussed concerning advantages and disadvantages regarding the access to psychotherapy, the specificity of the online video setting, bodily aspects, the quality of the therapeutic relationship, the therapeutic process including technical aspects and therapist's experience. Furthermore, we analyzed and discussed the statements concerning transference and countertransference reactions differentiating between high-level borderline and neurotic patients and low-level borderline patients. Our results support the importance to identify patients who potentially benefit from VCP. Further research including more prospective randomized controlled trials are needed to investigate the therapeutic implications of the findings.

Developments in Group Transference-Focused Psychotherapy.

Several evidence-based psychotherapies for personality disorders have been developed in recent decades, including transference-focused psychotherapy (TFP), a contemporary model of psychodynamic psychotherapy developed by Otto Kernberg. Kernberg established Group TFP (TFP-G) as an alternative or adjunct treatment to individual TFP. Although not yet manualized, TFP-G is used in publicly and privately funded mental health services, including outpatient clinics, subacute hospitals, therapeutic inpatient units, partial hospitalization services, and rehabilitation services serving people with borderline personality. Kernberg's model of TFP-G psychotherapy, its application in clinical settings, and what differentiates it from other group psychotherapy models is described as well as illustrated with some examples useful to practitioners.

The Development of Transference-Focused Psychotherapy and Its Model of Supervision.

Transference-focused psychotherapy (TFP) is an empirically based, manualized psychodynamic psychotherapy that emerged as an adaptation of psychoanalytic techniques to meet the needs of patients with personality pathology. As it became more clearly defined through a series of treatment manuals and empirical research, TFP has also come to be considered a conceptual and technical model of therapy that can be used to introduce therapists in training to the principles of psychodynamic psychotherapy in a systematic way. Advanced levels of TFP training and practice involve an emphasis on supervision that is applied in a more structured way than traditional psychodynamic supervision, while respecting the depth and subtlety of psychoanalytic exploration. This article reviews the development of the treatment model and the supervisory process that guides the therapist to carry out TFP in accordance with its proposed mechanism of change.

Functions of the Treatment Contract in TFP.

The use of a verbal or written contract has been employed in many different modalities of treatment as a means of establishing the expectations and parameters of treatment. Traditionally, the contract is seen as serving a somewhat utilitarian purpose: setting up the practical conditions of treatment and providing a containing frame for the patient. Contracts, however, can extend to establishing agreed-upon goals of treatment, anticipating obstacles that may arise in the treatment and clarifying how they will be dealt with should they arise, and clearly defining the roles of the patient and therapist in a way that aids the exploratory process once the treatment has begun. Importantly, the mutually agreed-upon contract serves as a useful roadmap to keep the treatment focused and on track. In this article we will emphasize how the treatment contract can facilitate in-depth understanding of the patient's internal world, particularly when challenges to the contract are enacted by the patient. We will begin by briefly summarizing the functions of the contract and then focus on the key role of the treatment contract in furthering the exploratory process of the patient's dynamics as expressed in the transference/countertransference matrix.

Transference-Focused Psychotherapy for Pathological Narcissism and Narcissistic Personality Disorder (TFP-N).

In this article, we provide an overview of transference-focused psychotherapy for patients with pathological narcissism and narcissistic personality disorder (TFP-N). In TFP-N we have modified and refined the tactics and techniques of TFP, an evidence-based treatment for borderline personality disorder, to meet the specific challenges of working with patients with narcissistic personality pathology whose retreat from reality into an illusory grandiosity makes them particularly difficult to engage in treatment. We first describe a model of narcissistic pathology based on considerations of psychological structure stemming from object relations theory. This model provides a unifying understanding of the core structure of narcissistic pathology, the pathological grandiose self, that underlies the impairments in self and interpersonal functioning of those with narcissistic pathology across the levels of personality organization (from high functioning to borderline to malignant). We then delineate the clinical process of working with patients with pathological narcissism and narcissistic personality disorder. Starting with the assessment process, using a detailed clinical example, we guide the reader through the progression of TFP-N as it helps the patient move from the distorted, unintegrated sense of self underlying the narcissistic presentation to the more integrated, realistic sense of self that characterizes healthier personality functioning. In TFP-N the focus on the disturbed interpersonal patterns of relating in the here and now of the therapeutic interaction is the vehicle to diminish grandiosity and improve relatedness, thereby effecting enduring changes in mental representation and real-world functioning.

Borderline Personality Disorder: Barriers to Borderline Personality Disorder Treatment and Opportunities for Advocacy.

Patients experience difficulty in accessing the evidence-based treatments that exist for borderline personality disorder. This article identifies barriers to treatment within the US structural, economic, and political landscape and how families have created an advocacy movement to address this problem. It explores how the United States has addressed such barriers, in comparison to other countries. Finally, it offers recommendations for future advocacy to increase access to treatment for borderline personality disorder.

Clinical Necessity Guidelines for Psychotherapy, Insurance Medical Necessity and Utilization Review Protocols, and Mental Health Parity.

The founding members of the Coalition for Psychotherapy Parity present Clinical Necessity Guidelines for Psychotherapy, Insurance Medical Necessity and Utilization Review Protocols, and Mental Health Parity. These guidelines support access to psychotherapy as prescribed by the clinician without arbitrary limitations on duration or frequency. The authors of the guidelines first review the evidence that psychotherapy is effective, cost-effective, and often provides a cost-offset in decreased overall medical expenses, morbidity, mortality, and disability. They highlight the disparity between clinicians' knowledge of generally accepted standards of care for mental health and substance use disorders and the much more limited "crisis stabilization" focus of many insurance companies. The clinical trials that health insurers cite as justification for authorizing only brief treatment for all patients involve highly selected, atypical populations that are not representative of the general population of patients in need of mental health care, who typically have complex conditions and chronic, recurring symptoms requiring ongoing availability of treatment. The standard for other medical conditions reimbursed by insurance is continuation of effective treatment until meaningful recovery, which is therefore the standard required by the Mental Health Parity and Addiction Equity Act for mental health care. However, insurance companies frequently evade the legal requirement to cover treatment of mental illness at parity with other medical conditions. They do this by applying inaccurate proprietary definitions of medical necessity and imposing utilization review procedures much more restrictively for mental health treatment than for other medical care to block access to ongoing care, thus containing insurance company costs in the short term without consideration of the adverse sequelae of undertreated illness (eg, increased costs of other medical services and increased morbidity, mortality, and costs to society in increased disability). The authors of the guidelines conclude that, given appropriate medical necessity guidelines at parity with other medical care, consistent with provider expertise and a broad range of psychotherapy research, there would be no need or place for utilization review protocols. Individuals and psychotherapy organizations are invited to visit the website psychotherapyparity.org to sign on to the guidelines to indicate agreement and support.

The Psychodynamic Treatment of Borderline Personality Disorder: An Introduction to Transference-Focused Psychotherapy.

The authors describe the application of a twice-weekly exploratory psychotherapy, transference-focused psychotherapy (TFP), to patients with borderline personality disorder. The article describes the pathology of internal object relations that provides a framework for understanding borderline personality and how TFP establishes a treatment framework to address such pathology and set the stage for working at the level of internal psychological structure. An outline of the assessment and treatment protocol is described along with a case example to illustrate the same.

Behavioral activation in TFP: The role of the treatment contract in transference-focused psychotherapy.

Transference-focused psychotherapy (TFP) is a manualized evidence-based treatment for borderline and other severe personality disorders that is based on psychoanalytic object relations theory. Similar to other psychodynamic psychotherapies, TFP focuses on changing psychological structures, but also focuses on symptom and behavioral change, particularly the importance of being active (e.g., obtaining a job or involvement in similar activities). In TFP, the establishment of the treatment contract, also known as the treatment frame, is where goals such as work and other activities are agreed upon. The focus on such activities is particularly relevant to the concept of behavioral activation. We provide a clinical vignette to illustrate how TFP utilizes behavioral activation in facilitating treatment outcome both at the behavioral level and at the psychological level. (PsycINFO Database Record

Qualitative Analysis of Resources and Barriers Related to Treatment of Borderline Personality Disorder in the United States.

OBJECTIVE: Resources and treatment for individuals with borderline personality disorder (BPD) are limited and often difficult to obtain. This article aimed to identify key resources for and barriers to obtaining supportive and treatment services for BPD from the perspective of individuals seeking information or services related to BPD ("BPD care seekers"). METHODS: Data came from transcripts of resource requests to the Borderline Personality Disorder Resource Center from January 2008 to December 2015 (N=6,253). Basic statistics, including the type of service requested, demographic information for the BPD care seeker, and national distribution of requests, were generated for all eligible transcripts. Qualitative analysis of a random subset of 500 transcripts was used to identify themes, challenges, and common experiences reported by BPD care seekers. RESULTS: The greatest number of requests for primary services or resources among the random subset of transcripts was for outpatient services (51%), informational materials (13%), and day programs (9%). Family services, crisis intervention, and mental health literacy were identified as areas where available resources did not meet current demand and that could be improved or expanded. Factors identified as potential barriers to finding and obtaining appropriate treatment for BPD included stigmatization and marginalization within mental health care systems, financial concerns, and comorbidity with psychiatric or medical disorders. CONCLUSIONS: BPD care seekers face numerous barriers to obtaining appropriate care. Expanded services and resources to connect individuals with treatment are needed to meet the current demands and preferences of those seeking care.

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.

The efficacy of psychotherapy: focus on psychodynamic psychotherapy as an example.

The growing number of individuals seeking treatment for mental disorders calls for intelligent and responsible decisions in health care politics. However, the current relative decrease in reimbursement of effective psychotherapy approaches occurring in the context of an increase in prescription of psychotropic medication lacks a scientific base. Using psychodynamic psychotherapy as an example, we review the literature on meta-analyses and recent outcome studies of effective treatment approaches. Psychodynamic psychotherapy is an effective treatment for a wide variety of mental disorders. Adding to the known effectiveness of other shorter treatments, the results indicate lasting change in many cases, especially for complex and difficult to treat patients, ultimately reducing health-care utilization. Research-informed health care decisions that take into account the solid evidence for the effectiveness of psychotherapy, including psychodynamic psychotherapy, have the potential to promote choice, increase mental health, and reduce society's burden of disease in the long run.

Approaches to psychotherapy for borderline personality: demonstrations by four master clinicians.

Several efficacious therapies for borderline personality disorder (BPD) now exist despite longstanding skepticism in the field regarding amenability to treatment. In this article, 4 master clinicians describe a brief interaction with an actress playing the part of a patient with BPD that occurred at the First Annual Meeting of the North American Society for the Study of Personality Disorders in Boston, April 2013. The approaches include dialectical behavior therapy, transference focused psychotherapy, mentalization based therapy, and good psychiatric management. The paper concludes with a discussion of what these approaches have in common, how they differ, and future directions for the treatment of BPD.

Psychotherapy for suicidal patients with borderline personality disorder: an expert consensus review of common factors across five therapies.

The objective was to review established literature on approaches to the psychotherapy of borderline personality disorder with specfic reference to suicide in order to determine if there were common factors across these efforts that would guide future teaching, practice and research. The publications from the proponents of five therapies for the treatment of suicidal behavior in individuals with borderline personality disorder (BPD), were reviewed and discussed by the members of the Group for the Advanced of Psychiatry, Psychotherapy Committee (GAPPC). Twenty nine published research and summary reports were reviewed of the specific treatments noted above along with two other reviews of common factors for this group of treatments. We used expert consensus as to the salient articles for review and the appropriate level of abstraction for the common factor definition. We formulated a definition of effectiveness and identified six common factors: 1) negotiation of a specific frame for treatment, 2) recognition and insistence on the patient's responsibilities within the therapy, 3) provision to the therapist of a conceptual framework for understanding and intervening, 4) use of the therapeutic relationship to engage and address suicide, 5) prioritization of suicide as a topic to be actively addressed whenever it emerges, and 6) provision of support for the therapist in the form of supervision, consultation or peer support. We discuss common factors, their formulation, and implications for development and teaching of psychotherapeutic approaches specific to suicide in patients with borderline personality disorder and note that there should be greater attention in practice and education to these issues.

Transference-focused psychotherapy.

Transference-Focused Psychotherapy (TFP) is a manualized evidence-based treatment for borderline and other severe personality disorders that is based on psychoanalytic object relations theory. The treatment contracting/setting the frame, managing countertransference, and the interpretative process are three critical components of TFP. We provide vignettes to illustrate these techniques and data that support their role in facilitating treatment outcome.

Borderline personality disorder, bipolar disorder, depression, attention deficit/hyperactivity disorder, and narcissistic personality disorder: Practical differential diagnosis.

The challenge of accurate diagnosis remains at the heart of good psychiatric treatment. In the current state of psychiatry, a confluence of forces has increased this challenge for the clinician. These include practical pressures-such as limited time for diagnostic evaluation, the question of what is reimbursed by insurance, and the issue of directing patients to acute treatments-and also trends in nosology, such as the descriptive focus on signs and symptoms in the current official diagnostic system. The authors offer observations that we hope will help clinicians who have to make difficult diagnostic differentiations often under pressured circumstances. The paper is motivated both by the high frequency of diagnostic errors observed under such conditions and also by the belief that considering symptoms in the context of the patient's sense of self, quality of interpersonal relations, and level of functioning over time will help guide the diagnostic process.