I'm Dr. David Stifler on behalf of the American Academy of Addiction Psychiatry, just want to welcome you to today's webinar in our series titled Advanced Addiction Psychotherapy, which is our monthly series focused on evidence-based intensive psychotherapy training for not only addiction psychiatry fellows, but faculty or any of our members of AAAP. This is hosted in partnership with the Oregon Health and Science University and New York University. We are excited that you could join today, and we offer these live trainings that will be held the second Wednesday of the month, although December was an exception, from 5.30 to 7 p.m. Eastern Time. Today's presentation is titled Transference-Focused Psychotherapy. Our next presentation will be in January. Dr. Robert Gregory will talk about the dynamic deconstruction of challenging interactions when working with difficult patients. Please check the AAAP website for updates on our other upcoming speakers for the next academic year. Well, thanks everybody, and thanks for joining us. We're lucky to have Dr. Richard Hirsch present to us today, and he's a special lecturer in the Department of Psychiatry at Columbia University. He's trained at Stanford, George Washington, Northwestern, and earned his certificate of psychoanalytic training from Columbia. He was an attending psychiatrist at Mass General and McLean Hospitals before returning to Columbia University, where he was a psychiatrist on the inpatient service and serving for 15 years as the associate director of the Department of Psychiatry's Intensive Outpatient Program. He's a teacher and supervisor for transference-focused psychotherapy, which is what we're talking about today, as well as good psychiatric management for borderline personality disorder at Columbia. He's also the co-author of the textbook, Fundamentals of Transference-Focused Psychotherapy Applications in Psychiatric and Medical Settings, and he's the co-editor of the forthcoming Implementing Transference-Focused Psychotherapy General Psychiatric Care for Personality Disorders. So welcome, Dr. Hirsch, and thank you for participating in our conference. Great. Well, thanks so much, Dr. Blaisdell and Dr. Stifler. Pleasure to be here. So my talk this evening will have two parts. The first part will be an overview of transference-focused psychotherapy. The second part will have a focus on applied transference-focused psychotherapy, which is the use of these principles in different psychiatric and medical settings. So we'll start with, and together I have about 60 minutes of slides. I think I'm happy to answer questions whenever, but I'll just get going. So nothing to disclose. So the goals of today's presentation are to place transference-focused psychotherapy in the continuum of treatments that include psychoanalysis and psychoanalytic psychotherapy, and the evidence-based treatments for borderline personality disorder, and to review the key principles of TFP. So transference-focused psychotherapy was developed for patients with borderline personality disorder. Over time, transference-focused psychotherapy has been used to treat patients along the continuum of personality disorder pathology. It's been used to treat adolescent patients with borderline personality disorder. More recently, volume on the use of transference-focused psychotherapy for patients with pathologic narcissism has been authored. And then finally, the applied transference-focused psychotherapy, which we'll talk about more in the second half. So these are some of the key books. This is what we think of as the manual for TFP. Frank Yeomans is the first author. This book is Dr. Calagour's Handbook of Dynamic Psychotherapy for Higher-Level Personality Pathology. This uses TFP principles with patients, as I said, along the continuum of personality disorder severity of illness. Dr. Calagour's Psychodynamic Therapy for Personality Pathology maps closely to the emerging alternative model of personality disorders from the DSM-5 appendix, the hybrid categorical and dimensional model. This is the volume on transference-focused psychotherapy for work with adolescents. This is the volume on work with patients with narcissistic disorders. And this is our volume on applied TFP. This just gives you a sense of the scope of the focus of TFP and how it's evolved since it was first developed for patients with borderline personality disorder. So an overview of TFP. It's a psychoanalytic psychotherapy. It's informed by object relations theory. It's a reworking of standard psychoanalytic psychotherapy to treat more impaired patients. It's an evidence base for patients with BPD. It's manualized. It's a twice-weekly, one-to-three-year treatment. And it's anchored by two key elements, the structural interview developed by Otto Kernberg, which is a diagnostic assessment process, and the negotiation and maintenance of a treatment contract or frame. So these two elements I'll refer to repeatedly, the structural interview and the treatment contract. They're the cornerstones of TFP. So TFP and psychoanalysis are very different. TFP retains key elements of psychoanalytic psychotherapy, but with major adjustments made. So for example, transference analysis is a key element of psychoanalysis and psychoanalytic psychotherapy. With patients with BPD, the transference analysis is likely to be more immediate and more intense. Interpretation or offering a hypothesis about unconscious motivation is part of TFP, but it's used more judiciously and usually following extensive clarification and confrontation. It's done very often well into the treatment, sometimes not for many weeks or months after the treatment has started. Monitoring of countertransference in TFP is likely to be more intense and unambiguous. Because the patients have borderline personality disorder, the countertransference experience is positive or negative, as I said, likely to be more intense. And technical neutrality, the goal of not endorsing one particular side of a patient's conflict, in TFP we're probably more likely to deviate from technical neutrality because this is often required in work with patients with impulsivity and prominent denial. So these four elements are considered by Kernberg the cornerstones of psychoanalysis and psychoanalytic psychotherapy. But in TFP, we think about these four elements in a somewhat different way. So when we think about psychoanalytic psychotherapy, it's often framed as bringing into a patient's awareness material that is preconscious or unconscious. And this is what I associate with traditional orthodox psychoanalytic approach. In TFP, because of the nature of the patient's defenses, we don't think about only making unconscious material conscious. We think of this particular building block and exploration of this building block as central to the therapy. And this is what we call an object relations dyad. So we're talking about how a patient experiences him or herself, a self-representation, the experience of another key figure, either the therapist or someone else in the patient's life, and an associated affect. And again, we think of this as the building block of TFP. We don't conceptualize what we're doing as making what is unconscious conscious only, but also looking at the patient's experience of self and others and the associated affect. So I'm going to try to explain a little bit about how TFP unfolds. It starts with a structural interview. We'll talk a little bit more about this. But this is an assessment process that aims to integrate both examination of standard DSM-5 nosology, but also exploration of personality organization. I'll talk more about that. That would be step one. Step two is sharing the diagnosis. All of the evidence-based treatments for BPD recommend talking to patients about the borderline personality diagnosis. There's not the same consensus about talking to patients about other personality disorder diagnoses, but in TFP, we expect that clinicians will talk to patients about, for example, narcissistic disorders, even if they don't necessarily use that term. Obtaining parallel information from prior treaters, considered standard of care in psychiatry. This is a key element because it's central to putting together the treatment contractor frame. Conducting a family meeting when indicated in TFP, we will recommend a meeting with spouse, parents, children of a patient at the outset of treatment in any situation where the patient is fundamentally dependent on a family member. That can be emotionally or financially dependent. As you can imagine, that would be a lot of patients. There are multiple goals for the family meeting, but as with obtaining information from prior treaters, it's considered key in developing the treatment contract. Then all this is done before the treatment even begins. In TFP, the structural interview and assessment process, these other steps sometimes can take a few weeks, but we don't go forward until we've done all of this, even when a patient presents with relative urgency. This is a complicated slide that attempts to just give you a sense of the difference between a standard decision tree format, as we would do when looking at DSM-5 diagnostic criteria, and on the right, the structural interview. I don't want to get too caught up in those details, but the goal is, as is sometimes said, that we wear three hats in succession, physician, psychiatrist, and psychodynamic psychotherapist. We're looking to clarify that they're not organic disorders, memory problems, et cetera, then a full investigation of a psychiatric diagnosis, and then investigation of personality organization. The takeaway from this graphic is that it is a circular process. It tries to capture the use of the clinician's counter-transference in exploring any particular material that the patient presents. It's unclear, somehow confusing, discrepant. Again, the goal is just to get the sense that it's a circular versus a decision tree assessment process. This is a very complicated slide, but a very useful slide, because it maps onto the DSM-5 personality disorders, also includes certain personality disorder diagnoses that are no longer in the DSM, and certain descriptions of personality disorders that come from the psychoanalytic literature. The key takeaway from this slide is the north and south, meaning it tries to capture how the different personality disorder diagnoses fall along a continuum of severity of illness. Assessing severity of illness, not just the personality disorder diagnosis, but the level of impairment is considered essential in the TFP, in this structural interview. It's also considered one of the best ways of assessing prognosis. As you can see, the higher level personality disorders are at the top, obsessive, compulsive, depressive, masochistic. Borderline personality disorder is considered middle to low. We use the term borderline personality organization to capture a large group of patients with personality disorder diagnoses that include borderline personality disorder. If you look just slightly to the right of the midsection, you can see the range of narcissistic presentations from on the cusp of neurotically organized, relatively healthy, to all the way to extreme severity, and particularly the subgroup of malignant narcissism. Again, this tries to capture the focus in the structural interview and in the assessment process in TFP of severity of illness. So sharing the diagnosis. As I mentioned, this is expected in all evidence-based treatments for BPD. It allows for a genuine informed consent process. It helps guide families and patients to evidence-based treatments. It addresses in advance unrealistic expectations for pharmacotherapy. Sorry about this. Sorry about that. It allows clinicians to document honestly and therefore protect themselves. And there are familiar challenges in making and sharing a personality disorder diagnosis. Clinicians, some clinicians may not believe in making a diagnosis. Clinicians may conflate the patient's chief complaint, what the patient believes sheer he may have, and the diagnosis, what the clinician believes the patient has. Clinicians may feel that personality disorder diagnoses are stigmatizing, and clinicians may feel that a personality disorder conveys that the patient is untreatable. And in real life, and in many parts of the United States and around the world, there are challenges in accessing treatment specific for patients with a personality disorder diagnosis. That said, communicating to patients about a personality disorder diagnosis when that is reliably done is considered a key step in transference-focused psychotherapy. So obtaining parallel information from prior treaters. Again, this is considered the standard of care in psychiatry. It guides the TFP therapist in including specific details in the treatment contract. So if you reach out to a prior treater, the prior treater tells you the patient was often using marijuana and wasn't open about it, that's something that you would include in the treatment contracting process. If you don't reach out and get that information, you may not know that, and the treatment contract may not be as thorough as it needs to be. Obtaining, asking for permission to obtain parallel information may be an early activation of expectable splitting. A patient may say something like, that therapist wasn't helpful, I can already tell that you understand me. And insisting that you get permission to speak to a prior treater addresses that splitting, which is very familiar in work with BPD patients in advance. And it may be an early activation of paranoia in the transference. A patient may say, why do you need to speak to her? Don't you trust my account? In TFP, we would then focus on that emerging element of the transference, distrust or paranoia, and try to understand or to begin to understand how the patient imagines, what the patient imagines our motivation to be. So conducting a family meeting when indicated, as I said in TFP, that means when a patient is fundamentally dependent on a family member, again, financially or emotionally. It obviously captures many, maybe even most patients with these diagnoses. So some of the goals of the family meeting are as follows, to obtain parallel information that the patient may not be forthcoming about, to provide psychoeducation about the disorder. It's really familiar for all of us that many patients with primary personality disorder diagnoses have never been told of that diagnosis. And families are very confused as to why standard interventions for a mood disorder or an anxiety disorder don't seem to be working. Part of the goal of the family meeting is for the TFP therapist to start a psychoeducation process that can continue during the course of the treatment, to explain certain counterintuitive elements of the treatment. For example, in TFP, we have limits on intercession contact. It's not like DBT with phone coaching. And for many family members, that's counterintuitive, maybe even alarming if patients can't reach out to the primary therapist whenever they're in a crisis. In TFP, part of the contract will be that we will defer to an emergency department and inpatient psychiatry staff about certain clinical decisions, like admission, discharge from the inpatient unit. And we'll always plan to work in concert with an ER staff or inpatient staff. But we would explain to the family in advance that we would not be in a position to make decisions unilaterally, for example, about a patient's admission or discharge. The goal of the family meeting, again, is to address in advance expectable splitting. The patient may paint a picture of us to the family, positive or negative. Similarly, the patient may describe the family in caricatured terms. Our goal is to address that by having a meeting in advance. And finally, another goal is to describe the range of family interventions. And there's a whole continuum of family interventions for families of patients with BPD. It can be psychoeducation only. It can involve coaching, which would be different from family therapy. In general, we tend to put more of an emphasis on psychoeducation and coaching, certainly at the beginning of treatment. So, clarifying the patient's goals. The patient's personal goals will organize the treatment. We consider the patient's goals, and we spend a lot of time at the outset of the treatment in an effort to elucidate those goals. We'll add a dimension to the assessment and contracting part of the treatment. So, for many patients with BPD with prominent identity diffusion, they'll have great difficulty talking about goals that they might have for work, for their social lives, for their romantic lives. This will, again, help us understand more about their severity of illness. Identity diffusion is a key element in assessing a patient's severity of illness, as I mentioned, and also will inform the contracting part of the treatment. A focus of goals aims to help avoid intellectualized, aimless treatment. Again, TFP was developed in part because of the limitations of standard psychoanalytic interventions with BPD patients. Very often, treatments that were extended but remained on the surface without clear changes in the patient's life. A focus on goals also helps us to measure progress in the treatment. Again, we want the goals to be as concrete as possible. So, in TFP, when we mean concrete goals, we're going to ask specifically about categories such as work or studies, dating, romance, sexual intimacy, friendships, and hobbies and avocations. On the left are goals people often come with but we would not think of as a TFP goal. I want to be happy. I want to know myself better. I want to have better self-esteem. I want to accept my impaired functioning. Those would not be goals that we would accept. We might explain to patients that we hope that they'll have better self-esteem as they pursue these more concrete goals. But we'll work hard to clarify at the outset what the patient's actual goals are. We try to avoid imposing our goals on the patient. But again, as I said, try to clarify what their goals for themselves would be. So, establishing a treatment contract. The treatment contract in TFP is personalized and detailed. The treatment contract goes beyond the standard office policies that we would share with every patient. The reason we obtain parallel information from other clinicians, as I mentioned, is that it should add a dimension to the treatment contracting phase. Was the patient honest? Was the patient timely? That kind of information that we would learn from another treater we would incorporate in the contracting phase. The treatment contract should facilitate the emergence of negative or paranoid transfer elements. That means we don't expect patients to be particularly agreeable to the treatment contract. We often say that our goal is a grudging acceptance rather than an ambivalent agreement. So, patients very often come to treatment expecting that treatment is something that's done by the therapist to the patient. And talking about a treatment contract at the outset addresses that. It's our hope. So, these are details of a treatment contract, and they vary. Some of these points would be part of standard office policies, like a cancellation policy or fee and payment. But we're going to make an effort to have as detailed a treatment contract ironed out in advance. But the key element in TFP is what we call the meaningful activity requirement. So, in TFP, we expect that patients will engage in paid work, volunteer work, or meaningful studies at least 20 hours a week. So, as you can imagine, for many patients, this might feel overwhelming. They may not accept this part of the activity, a part of the treatment contract. But we would attempt to explore why this feels overwhelming. I think our general attitude in TFP is that many borderline patients are more capable than they think they might be, and that doing some kind of paid work, volunteer work, or meaningful studies is possible for many patients who think it's not. And of course, it's key in generating useful content for the treatment once it starts. So, these are the elements of the treatment contract, including management of suicidal behavior, adherence to medication, starting and stopping sessions on time. Again, all things that we're familiar with as being areas of difficulty with some patients with BPD. OK. So, once we've touched all those bases, the treatment begins. Patients are instructed to speak freely, but with a particular focus on material that relates to their goals. This is not free association, as in psychoanalysis, where we would tolerate patients talking about things that are not directly related to the goals that are established at the start. The TFP therapist doesn't organize the session, as is often the case in supportive psychotherapy or cognitive behavioral therapy. This change in format may present a challenge for some patients, requiring that the therapist acknowledge that it is difficult to free associate, to speak freely, and to explore with patients the barriers that emerge once the treatment starts. Our job as therapists start with monitoring the three channels of communication. In psychoanalysis, there's a great focus on what the patient says. We're interested in what the patient says, but given the patient population that we're working with, we're equally interested in how the patient behaves, nonverbal communications of all kinds, facial expressions, patient's appearance, patient's conduct, as well as how the therapist feels with the countertransference. So we're going to constantly monitor these three channels of communication in sessions with the patient. One of the phenomenon that we often see in patients with BPD is that the material they present can be very confusing. We have observed that personality disorder patients may not likely present material in an orderly and coherent way. A higher functioning patient with a circumscribed problem might be able to present a coherent story to you so that you can understand it. With BPD patients, that's often not the case. We're aware of our countertransference impulse to organize the material for the patient. We try to avoid that. And one of the first aspects of a TFP treatment is to tolerate the confusion and allow the therapist to listen for what we call the emerging dominant object relations dyad. So the object relations dyad, I showed you a graphic earlier, is about the patient's self-representation, how he or she sees himself, an experience of another, could be the therapist, could be someone else in the patient's life, and the dominant affect. So there's that graphic again. We're going to tolerate the confusion and try to observe what is emerging as a patient is speaking freely. In this process, we try to put that into words. We sometimes call this naming the actors. It's really just an exercise in putting into words the patient's experience of him or herself, the therapist very often, as I mentioned, the associated affect. The goal would be for this to contribute to the patient feeling understood. You're working hard to put into words what you're observing. But the goal isn't so much for the therapist to name the dyad with precision, but to rather offer a conjecture that leads to a dialogue. So you could say, well, it sounds like you feel oppressed and that you see me as a therapist, as indifferent, but also oppressing, and that you're angry about that. So we might offer that in naming the actors. The patient may agree with that, or the patient may say, no, it's not that, and might adjust some aspect of that. But it's really an opening gambit in TFP. So TFP, as in other psychodynamic psychotherapies, we're going to use a combination of clarification, confrontation, and interpretation. And when we say clarification, we're talking about asking for additional information about anything the patient offers that is vague, confusing, or contradictory. Confrontation means bringing to the patient's attention any material that is somehow discrepant. Could be discrepant, the patient says things over time that are discrepant, or if the discrepancy is between, the patient says, and a nonverbal communication like a facial expression. And finally, interpretation is offering a hypothesis about motivation that may not be entirely in the patient's awareness. In TFP, the use of interpretation is judicious and often delayed. So I'm getting into the part about TFP that emerges over time. This might be a little complicated. I'll try to make it as clear as I can. We're interested in TFP in identifying role reversals that emerge over time. And identifying role reversals is central to the effort to bring into the patient's awareness aspect of his or her aggression that is denied or disavowed. So the aggression can be self-directed or other directed. In doing so, identifying role reversals requires tact and timing. It usually works best when the therapist has established some kind of working alliance with the patient. So this is a graphic of identifying role reversals. On the top is the dyad of a patient experiencing him or herself as victim, the therapist, for example, as persecutor, and an affect of fear or suspicion or hate. The bottom part is the role reversal where the patient is the persecutor and, for example, the therapist is in the role of the victim. This might be, for example, of a patient who comes in and says, this meaningful activity requirement that you made, you have no idea how awful it's making me feel. It's making things worse. You're the persecutor. I'm very angry about this. Then the bottom part might be the patient who says at the end of the session, you know, I feel so terrible. I don't know if I'm going to be here on Monday. I may be. I may not be. But I'm not sure I'm going to come back. I'm not sure if you're ever going to see me again. We would describe that as a role reversal where the therapist in this context now experiences himself or herself as a victim and the patient as a persecutor. Now, again, bringing this to a patient's awareness requires a great deal of tact and timing, but it's considered an important step in TFP in the patient beginning to integrate aggression that has been disavowed or denied. So as the treatment goes on, we start to look at how diads impact other diads. Again, this is more like an interpretation of unconscious material, often emerges more in the mid-phase of treatment. It's bringing into patient's awareness something that might be partially or not at all in awareness. A familiar pattern might be the patient who on the surface is mistrusting or rejecting, but whose behavior suggests some kind of emerging dependence or vulnerability. And this would be the graphic here, the patient on the surface feels victimized or abused, the therapist as rejecting or malevolent, but in the patient's behavior, in the patient's attendance, devotion to the treatment, coming early. For example, even though the patient superficially conveys negativity about the treatment and about the relationship with the therapist, there's material that suggests something that more along the lines of a dependent or needy patient and a caring, nurturing therapist. And again, this is like an interpretation we would make later in the treatment. So technical neutrality I referenced earlier. We're not technically neutral about the patient's pursuit of goals. We are going to be supportive of that. But in general, we attempt to avoid taking one or other side of a patient's conflicts as they are presented to us. We will deviate from technical neutrality in any situation that involves a patient's safety or clearly destructive acts. This is different, for example, from psychoanalytic therapy where the therapist might avoid being directive with a patient. But if we observe something that we feel is threatening to the treatment, threatening to the patient's safety, we will come down on one side or the other of a patient's conflict. We'll say, we don't think it's a good idea for you to quit this job abruptly, something like that. Again, exploration is a goal, but there are certain situations when we would feel the need to be more directive. And again, in general, in other exploratory therapies that don't have the same clarity about goals and treatment contracts, there may be less likelihood that the therapist would intercede. So in summary, TFP straddles the worlds of psychoanalysis and psychoanalytic psychotherapy and the evidence-based treatments for BPD. TFP is highly structured treatment. The keen focus on diagnosis, goals, and patient responsibilities. It's not the best fit for every patient. It can be used in sequence with other interventions. And TFP principles are likely useful for clinicians even if they do not offer extended individual psychotherapy. So this fourth point will be the subject of the next part, which is about applied TFP using these principles for clinicians who aren't doing a twice-weekly, one-to-three-year treatment, but are treating patients with personality disorder, pathology, in different psychiatric settings. So you'll need to let me know if we should take a break to answer some questions now or go to the second part. There are some questions, but I think we're on a roll, and I don't know, I think we should... Agree. I think we should just keep going. Yeah, this is going great. Okay. So. So transference-focused psychotherapy applied applications in acute and shorter-term settings. So the goals of this presentation are to introduce the concept of applied TFP, to trace the evolution of TFP principles used in clinical settings other than in an extended individual psychotherapy, to describe the benefits of applied TFP for clinicians in different settings, and to use a vignette about prescribing to convey the application of TFP principles for general psychiatrists. So the overview, just to repeat, TFP was developed for patients with borderline personality disorder. It's been extended across the continuum, but it's also been used in general psychiatry settings. So this book from 2017 is a bottom-up initiative where clinicians familiar with TFP started using TFP principles outside of the standard twice-weekly psychotherapy setting. This is our fundamentals of TF people. So those settings included in the inpatient unit, medical settings, in prescribing pharmacotherapy, in crisis management, in family involvement, and in psychiatry residency training. So TFP has been used around, applied TFP has been used around the world, and this just gives you some sense, particularly in Western Europe, the use of TFP principles in general psychiatry settings has grown much more than it has, for example, in the United States. So there are developments in Spain, Italy, Germany, the Netherlands, UK. And together, the clinicians interested in this have gotten together and we're publishing at the end of this month, a new book on implementing transference-focused psychotherapy principles. Again, mostly contributions from Western Europe, but on a variety of subjects, as I said, like inpatient units, day treatment settings, for example. So applied TFP, some key points. Clinicians in acute care and shorter-term settings, both psychiatric and medical, routinely see a significant number of patients with personality disorder pathology. Failure to recognize primary or co-occurring personality disorder pathology can be problematic and complicated. TFP provides an overarching theoretical approach, even when the clinician is not offering an extended individual psychotherapy, and TFP principles can help manage outcomes and serve as an effective risk management strategy. Okay. Applied TFP versus extended, TFP extended. It's not the same goals. We don't expect a sustained integration of a patient's split internal world with applied TFP. But the assessment process should help clinicians recognize pathology that's often minimized or ignored in situations where doing so is not a priority. Clinicians can borrow TFP elements for use on an ad hoc basis when they're helpful. So why TFP principles in general psychiatry? Again, high rates, high rates of comorbidity. Limited training in most residency programs in the assessment and management of patients with personality disorders. The effects of personality disorder pathology on the success of treatment of other diagnostic categories. So for example, the treatment of major depression for patients with co-occurring major depression and borderline personality disorder will be nowhere near as robust as for patients with major depression alone. And it helps manage, as I mentioned before, expectable risk management concerns. It seems, it makes sense that a lot of the avoidance of working with patients with moderate to severe personality disorder pathology has to do with clinicians' concern about risk. So having an organized way to approach work with these patients that can address risk management concerns might help lower the stigma over time. So what's so special about TFP principles? It's coherent and organizing and it's an overarching approach. It flows naturally from a psychiatric orientation. It has sensitivity to comorbidities and a focus on diagnosis. It allows psychiatrists to address personality disorder pathology and avoid reflexive referrals to costly or unavailable adjunctive treatments. It confers skills to manage difficult patients and it can help avoid familiar pitfalls of treating patients with personality disorder pathology, all of which I assume you're familiar with, including polypharmacy, unnecessary hospitalizations, and unfocused and aimless psychotherapies. And TFP maps very closely onto the emerging hybrid dimensional categorical model of the alternative model of personality disorders in DSM-5 section 3. So in general, the field is moving from a pure categorical approach to approach that looks at both dimension and category with a focus, as I mentioned earlier, on severity of illness because that's among the best prognostic indicators. Okay, so we like to think of apply TFP as a toolbox of interventions. Number one is an openness to considering a personality disorder even with incomplete information. Tolerating the confusion, as I mentioned, often encountered with personality disorder patients. Actively monitoring the three channels of communication and appreciating the dominant affect expressed with words or actions. That's the affect I noted in the object relations dyad graphic. So in the assessment process, it's helpful to think about the mnemonic radios. In the structural interview, the questioning should get at these elements. The patient's reality testing. Aggression, self-directed and other directed. The patient's defenses, and in particular, we're interested in the admixture of repression-based defenses and splitting-based defenses. In moderate to severe personality disorder pathology, splitting-based defenses, including splitting, omnipotent control, denial, will predominate. As I mentioned earlier, identity consolidation versus diffusion. How consolidated are the elements of the patient's identity? Interest, friend group, work identity, object relations. Who are the people in the patient's life? What is the nature of the relationships? Clarifying whether a patient has an impoverished life or a populated life. And finally, superego functioning. And in particular, in TFP, in the structural interview, we're interested in antisocial traits and secondary gain of illness and parasitism, because those are all, again, would suggest a guarded prognosis. So learning the structural interview and integrating the radios mnemonic can be helpful, even if a clinician isn't planning to offer an individual psychotherapy. Other tools are establishing and maintaining a treatment contract, which, as I've said, move beyond policies and underscores the responsibility of both parties. An assumption from the outset that other parties will be involved, like family members, active co-treaters, reaching out to prior treaters. As I said, involvement of the family as an integral part and sometimes ongoing, not the same as family therapy, naming the actors we talked about. And using what we call therapist-centered interpretations in periods of heightened affect or affect storms. Working with patients with personality pathology very often is stormy. It can be very frustrating if you're trying to use logic or become defensive with patients. And one of the interventions in TFP is what we call a therapist-centered interpretation, where you really just attempt to put into words the patient's experience, usually negative, often paranoid, of the therapist at a given point in time. So now I'm going to go over a case vignette. This is for applied TFP in prescribing or pharmacotherapy. Mr. B is a 25-year-old unemployed man. He recently moved back home to live with his parents after failing out of college. He's been evaluated and given diagnoses of major depression and social anxiety disorders. He's treated with venlafaxine. He's failed to respond to a number of antidepressant medications and lorazepam, used by his previous psychiatrist as an adjunct to the antidepressant. He's only intermittently adherent to the medication regimen. When he meets his new psychiatrist, he insists he needs a higher dose of lorazepam, even though he complains at times of excessive sedation and a second antidepressant because of, quote, the stress of moving home, unquote. He sees a therapist on and off and reports that the therapist feels, quote, unquote, the meds are not working, exclamation point. He describes marked and persistent affective instability and mood reactivity, almost all interpersonally mediated, often in the context of routine requests of accountability by teachers and family members. So you might think, do any of the patients I treat have any of the elements that are described here in Mr. B? So some of the challenges of pharmacotherapy with patients with personality disorder pathology. They may not be aware of their diagnosis. Clinicians may have been reluctant first to make the diagnosis. They may have been reluctant to share the diagnosis, even when reliably made. They may not respond robustly to pharmacotherapy for co-occurring conditions. They may engender splitting between prescribers and other members of the team, as in this vignette. Patients with personality disorders may present for adjustment of medications in crises, leading to frequent changes in medication or eventually polypharmacy, and threats of suicide may compromise the prescriber's steadiness and consistency in pharmacotherapeutic practice. So the extended evaluation focuses both on the DSM diagnostic criteria and questions informed by the structural interview. It aims to clarify the patient's functioning and impairment in different spheres, like work, relationships, and self-care. Again, integrating the questions captured by the radio's mnemonic. So Dr. H distinguishes between Mr. B's chief complaint, depression, and his own diagnostic impression, uses elements of the structural interview, uses the radio's mnemonic. Dr. H expands the standard social history to gather information about work and relationships to assess Mr. B's level of functioning. Part two, a straightforward sharing with the patient of the clinician's tentative diagnostic impression. This might include a discussion of clinical disorders such as depression or anxiety, as well as a technical or layman's discussion of personality disorder pathology, if that's in evidence. Dr. H feels he can share with Mr. B his diagnostic impression. He describes ways Mr. B's history is consistent with mood and anxiety disorder diagnoses, and he initiates a discussion about personality disorder traits. He uses layman's language, a variable self-esteem, sensitivity to perceived criticism, to convey elements of narcissistic personality disorder. Next, a deliberate discussion of the patient's personal goals, treatment goals, and target symptoms for medication. Dr. H requires Mr. B to engage in detailed discussion of the goals for himself and his goals for treatment. He also engages in an explicit conversation about medication target symptoms. Next part, contract with a prior treater. Mr. B is reluctant to give Dr. H permission to speak to his prior psychiatrist. He feels the psychiatrist, quote unquote, never understood his challenges, and he wouldn't be comfortable allowing Dr. H contact with him. Dr. H feels he could not feel sufficiently safe without this contact with the prior treater. He makes doing so an unconditional part of his work with Mr. B, who grudgingly accepts this. A family meeting, if the clinician feels the patient is dependent as Mr. B is. Mr. B had not allowed his family contact with his prior psychiatrist or his social worker therapist, claiming concerns about confidentiality. Dr. H insists that Mr. B and his family meet with him at the outset of the treatment. He airs Mr. B's concerns, but does not feel there is evidence of any kind, like history of trauma or abuse, that should preclude this meeting. A treatment contract outlining the respective responsibilities of both parties. This process should automatically address a patient's unconscious wish or expectation that medication alone will solve their problem, and this is a common feature we see in work with patients with borderline or other severe personality disorder presentations. Dr. H raises with Mr. B the issue of a required contract between them as they consider beginning their work together. This comes as a surprise to Mr. B, who says, I quote, I thought your job was to make me feel better. Dr. H outlines their respective responsibilities, including Mr. B's adherence to medication, his medication regimen as prescribed. Once the treatment has begun, Dr. H utilizes TFP principles and is prescribed, tolerating the confusion, naming the actors, monitoring the three channels of communication, and identifying the dominant object relations paradigm as it emerges and its reversal. TFP principles as a risk management tool. It's useful as a checklist. That includes openness to identifying personality disorder pathology, a focus on severity of illness. Again, that's a theme in this presentation, that that is key both. In assessing prognosis and also as a risk management tool, an emphasis on contact with prior treaters, the family meeting done early to counter the possibility of festering anger and resentment, and also to educate families about the risk of suicide. We work with patients with BPD. It's approximately a 10% completed suicide rate. Talking about that early in the treatment before a crisis arises is a useful risk management intervention, and to, as I said, proactively address that. Having these tools informed by TFP of maintaining a frame and monitoring of countertransference can help manage boundary concerns, which are often an area including over-involvement, but also a risk of patient abandonment, which is often described in work with patients with significant personality pathology. This is just a review of TFP principles. That's good risk management tool. In summary about applied TFP, it offers a coherent package of knowledge, attitude, and skills. Knowledge is a working application of contemporary object relations theory, helps clinicians identify extreme positions and rapid state shifting of patients with BPD and other moderate to severe personality disorder presentations. The attitude includes the acceptance of the expectable confusion seen with PD patients, conveying the therapist having comfort in conveying what the patient can realistically expect from the treatment by way of establishment of a treatment frame, and skills, monitoring three channels of communication, identifying dominant object relations dyads as they emerge, identifying reversal in those dyads, and managing periods of heightened affect with what I've described as therapist-centered interpretations. So thank you for your interest, and I am happy to answer any questions I can. Appreciate it. Thank you, Dr. Hirsch. Just to remind everybody, you can place your questions in the Q&A box, or we'll also be monitoring the chat box for questions. I'm just going to start off with my own question first, which is, how has the widespread use of cannabis affected psychotherapy from your perspective? That is a really great question, and a really important one. I think in TFP as an individual psychotherapy, part of what we try to do at the outset is to determine whether the patient's use of cannabis will in some way interfere with the patient-deriving benefit from the treatment. So I would say that we don't have a consensus. It's something we talk about in our group supervision often, but we're trying to get at some of the affects, the feelings that a patient may not be available, a patient may be using cannabis to manage, and that would be one particular problem in this particular treatment for patients who use more than just occasionally. But it's really our thinking about it as a group. It's a work in progress, but as a role with all substance use, co-occurring substance use and personality disorder in patients is whether the pattern is likely to preclude the patient from benefiting from the treatment. I hope that's clear. I don't know, what are your thoughts? Yeah, it's really challenging. The cannabis industry and the widespread use has has made psychiatry in general really challenging. It's hard to make diagnoses. I found that both pharmacological and psychotherapeutic modalities are much less effective, you know, anecdotally from my experience. So it's a bit of a conundrum, and that's why I just keep asking the question because it's really challenging. Right. Yeah, Chris, I'll start going through the list. First question that came in, can you please explain coaching in the context of the family meeting? Sure. So the focus on coaching comes even more from good psychiatric management for borderline personality disorder than it comes from TFP. And basically what the good psychiatric management attitude is that many, maybe even most patients with BPD early in treatment really can't use family therapy in a traditional sense. And so coaching is a very different kind of intervention. It's basically giving advice, guidance, direction, psychoeducation to family members about how they manage difficult situations. It's not the more familiar family psychotherapy model. That's really, in good psychiatric management, something that in a way patients will earn over time. But coaching is helping the family members with what they say, how they manage things, how they manage patients' outbursts, their suicidality, things like that. And there are, for those of you who aren't familiar with the Family Connections Program, I don't know if people are familiar with that, but that's a program of peer coaching for families, individuals with borderline personality disorder. And that was started as part of an organization called the National Education Alliance for Borderline Personality Disorder. It's both in-person and virtual, and it's worldwide. And that is, again, a peer coaching. So that idea of coaching before family therapy is as much from GPM as it is from Transference-Focused Psychotherapy. All right, next question. I appreciate that the treatment contracts are quite personalized, but if you were to objectively review a typical one and ask this question, would an individual with a mildly neurotic or healthy level of personality organization likely accept it for their own treatment without much ambivalence? Or would a less impaired individual also find its elements to constitute a fair degree of imposition or intrusion that would generate significant discomfort that would be stressful and or mobilize major psychological defenses? I think I understand that question. So it underscores a really good point, which is the difference from how a healthier, neurotically organized, the term we use, neurotically organized patient might present for help with a circumscribed problem. Do I have this anxiety? I have this phobia, versus a patient organized in a mid to low borderline level where there's more comprehensive pathology, where it affects multiple spheres. So I think that the, if I understand the question is, wouldn't that cause a negative reaction even to a healthier patient? But I think that the point is that the area of focus, the goals of the treatment would be different. I hope that answers your question. Next. Go ahead, Dave. Oh, yeah. I'll just get to the next one. It's a book recommendation. You've mentioned several in the beginning, and then also in the middle of the talk. Of the books you showcased at the beginning, which would be the first choice for PGY1 or 2 residents who are psychodynamic curious, though limited to short-term acute treatment settings? Right. So I'll just get to the next one. It's a book recommendation. You've mentioned several in the beginning, and then also in the middle of the talk. Of the books you showcased at the beginning, which would be the first choice for PGY1 or 2 residents who are psychodynamic curious, though limited to short-term acute treatment settings? Right. So I'll just get to the next one. the first choice for PGY1 or 2 residents who are psychodynamic curious, though limited to short-term acute treatment settings? Right. So I think that the first two chapters of the Fundamentals book is a very straightforward synopsis of TFP. The manual is the definitive book, but the Fundamentals book, particularly the first two chapters, is 3D accessible. And I think that might also answer another question, which is, how should primary care and emergency medicine providers learn more about these principles? Is that probably a good place for them to start? Yeah. So we have a chapter in the Fundamentals book on the interface of medical issues and personality disorder pathology. It's a complicated chapter, but that would be a place to start. Yeah. Next one, does child care count as meaningful work? I'm thinking of parents who are taking care of small children full time. Also, how do you explain meaningful work to patients to ensure that you do not inadvertently reinforce power differentials between the patient and the therapist, especially if it is reminiscent of things like requiring work for government benefits, et cetera? OK. So the first part is a really good question, and I think that we're still debating this. But what I'd like to say is that what is the best scenario for many patients is a job with a boss. We like the meaningful activity to involve socialization. So meaningful activity would not be, I'm going to write a novel on my own. We would not accept that. It involves socialization and, ideally, having a supervisor, having colleagues. But there are patient populations, individuals with large families, where it's just not feasible. So we're familiar with the question, and we debate it. What was the second part of the question? The second one, yeah. I guess, simply, how do you explain meaningful work to patients, but ensuring that you're not inadvertently reinforcing power differentials between the patient and the therapist, especially if it's reminiscent of something like requiring work for government benefits? Sure. So I have found the work by a colleague of ours at the New School here in New York, who has written about the adaptation of TFP in disadvantaged communities and the benefit of stressing work for many patients who are deemed that there's not an expectation that they can or should work. And his work really has focused on the benefit of integrating the meaningful activity requirement in economically marginalized communities. So I understand your question, but I've been very influenced by that particular work and the potential benefits of doing that, versus communicating that a certain group of patients is kind of beyond work, or that's not a realistic expectation. Oftentimes when I'm kind of quantifying patient stressors, sometimes I'll include a lack of purposeful activity as a stressor. So it's interesting to see this integrated into a psychotherapeutic modality. All right, next question. What cross-cultural training do you recommend to ensure that the therapist is not inadvertently invalidating when treating patients of color when the therapist is not a person of color? For example, the person of color has experienced very real impacts of structural racism, and the therapist might indeed be demonstrating microaggressions even if it's not conscious. I'm asking this as a person of color who is a physician. So again, I would invoke the work that I just described by Daniel Gastambide at the New School, where he... It's both an essay and a chapter in a book called Psychoanalysis in the Barrio, where he looks at this and kind of teases these questions apart, but comes down on a modification of TFP principles, including the meaningful activity requirement with the patient population he's working with. Anyway, I hope that's helpful. I'm happy to supply that reference to anyone who's interested. At what age can TFP principles generally be applied? I think you mentioned that on one of your initial slides, but yeah. There's a TFP for adolescents manual, and so it's in use with patients younger than age 18, yeah. This is kind of a statement, but also a question. It sounds as if identifying enactments in the treatment will be especially important. So I'm not exactly sure what the questioner means by enactment, but I would say that we're going to focus on nonverbal communication, how the patient behaves, as much as we focus on what the patient says. And if what's meant is enactments, meaning communication through nonverbal, a patient comes late, or the patient has a certain facial expression, that will be very much a focus of our work. I hope I understand what that questioner was asking, yeah. Next one, can you offer any thoughts about working with incarcerated people where antisocial traits are often present, along with other, quote, cluster B features in substance use disorders? Right. So in our new book, we have an extended chapter on TFP principles in forensic populations. This comes from Germany. It's a very detailed, very scholarly approach to using TFP with incarcerated patients. So the book should be out by the end of the year, and I can, again, if someone wants to email me, I can give you the name and some citations, but it's all done, as I said, it's in Germany and Switzerland, not in this country. Can TFP be integrated concurrently with other modalities, such as DBT? So the answer is yes. So there is definitely a place for certain patients in DBT skills. I wouldn't say a full DBT, I wouldn't recommend both TFP and a full DBT program. As you can imagine, right, for example, well, we would want two primary therapists anyway, but phone coaching wouldn't be, would undermine aspects of that TFP contract, but accessing DBT skills groups would be perfectly okay. As other adjunctive interventions, 12-step, that kind of thing, yeah. Some of these are comments I'm just kind of looking through. All right, I'll ask one then while we're going to the next one. So the structured interview, how long does that take? Is it in your book that it's structured enough that you can take it directly from the book? So there is an operationalized structural interview called the STIPO, like the SCID, it's the structural interview operationalized. So there's the STIPO intervention for a clinician doing the structural interview. I would say it's usually two or three sessions. But again, clinicians can use the STIPO as well, which gets at all these questions that I described, yeah. Do you think TS, transverse focus psychotherapy is useful in patients who don't have personality disorders, or is it really just for personality disorder patients? So Dr. Calagour's book really extends the use of the TFP model to patients what we call higher level, including, again, they use the term neurotically organized, but it's not a treatment for mood disorder, anxiety disorder, phobia, would not be appropriate for those patients, yeah. I have a follow-up question since we've been talking about the contract and meaningful work or employment. And so you have this contract, assuming they've agreed to it, and then you were explaining that the sessions are usually, like the frame is open-ended. So let's, okay, you mentioned the assessment could take several sessions, and then you have the contract, they agree, and you're moving forward a couple of sessions, and then they're not bringing up their employment. So I don't know if you have to change the frame then, and you have to kind of jump in and review that, and then do you have to keep bringing it up or kind of how, an example of how that might play out? Yes, so part of the contract isn't just that the patient's speaking freely, but speaking freely in a way that addresses the patient's goals that were clarified at the outset. So really soon, five minutes, 10 minutes into a session, the therapist would say, I'm confused about how, in what way, what you're just talking about relates to the goals that you have. So very much the therapist's intervention to keep the focus on the goals. There's a term used in the TFP, which is trivialization, where patients fill sessions with material that's just not centrally related to the goal. So we're very mindful of trivialization, of the risk of trivialization, and we'll address that in a very proactive way. Next question, could you comment on how to incorporate trauma-informed care principles with TFP? So this is also an ongoing debate in the TFP world. So in general, as related to, for example, questions about substance abuse, there are going to be certain patients with diagnoses of trauma or active post-traumatic stress disorder where we would determine that treatments need to be sequenced. A patient should have a treatment specific for post-traumatic stress disorder first before TFP. But for patients who have trauma in their history, but not post-traumatic stress disorder, that would be a patient that we would see as appropriate for TFP. And again, the focus is going to be mostly on the here and now, at least in the initial stages of the treatment. Very often, some patients might not feel that that's the treatment that they want, but it's going to be very much focused, again, on the patient's goals and on the here and now, even those patients with a trauma history. So again, there's some patients with trauma diagnoses where we would not offer TFP, and there are some patients I think we would offer who might not be interested in it because they want to focus on the trauma in the treatment. Hope that's clear. So maybe we'll have time for one last question, David. Yeah, a new one came in. Can you explain a little more or give a scenario of how a family physician might use this in a family practice in a typical patient with high blood pressure, diabetes, etc., in addition to their personality disorder? We do contrive to avoid these patients because we don't know what to do. The staff complains, we get a headache, etc. Right. So in our forthcoming volume, one of my colleagues who was trained in internal medicine and then trained in psychiatry and is a TFP therapist, outlines a course that he gives to Colombian medicine residents in their clinic about how to use TFP principles. So I would say some of the cornerstones would be a treatment contract. At the beginning, I'm going to talk a little bit about putting together a treatment contract and referring to that contract throughout the patient's care. And also exploring role reversals, like for example, patients who feel maybe mistreated by the clinician's staff or by the clinician who is then mistreating the staff, you know, raising his or her voice or storming around. So we would use some of these basic interventions, including in a medical setting. But in particular, we would focus on, at the outset, establishing a treatment contract. And that's outlined in the chapter on TFP in general medicine. Part of it's about TFP, using TFP on the CL service, and part of it is using TFP in general medicine. Well, thank you very much, Dr. Hurst, for presenting to us in the advanced addiction psychotherapy curriculum. I definitely feel smarter for having participated in this. And David, who do we have up next month? I think it's Dr. Gregory looking at the dynamic deconstruction of challenging patient interactions with difficult patients, I think. All right. Well, again, thank you, Dr. Hurst, and thank you, everybody, for joining us. We'll see you next month. Thanks, everyone. Thank you again, Dr. Hurst. Appreciate the opportunity.

Transference-Focused Psychotherapy

Borderline Personality Disorder

Personality Pathology

Structured Approach

Transference Analysis

Countertransference

Risk Management

Pharmacotherapy

Cultural Sensitivity

Clinical Outcomes

Diagnosis Sharing

Personality Disorders