Transference Focused Psychotherapy Works and Psychoanalysis Is Not Dead
Our field has seen decades of debate over which type of therapy is the best and which theoretical orientation is superior to any other. In fact, the gap between the proponents of Cognitive Behavior Therapy and proponents of Psychoanalysis often appears larger than the age difference between Justin Bieber and Betty White.
In the spirit of continuing the rat-race, the British Journal of Psychiatry just published a study on the effectiveness of Transference Focused Psychotherapy (TFP) compared to “plain old treatment as usual”. For those of you new to my blog, Transference Focused Psychotherapy was developed by Dr. Otto Kernberg and his team at Weill Cornell Medical College in New York, and a paper published last year compared the effectiveness of TFP to other types of therapy. I’ve written about this in a previous blog. Over the last two decades, TFP has received a great deal of attention from many other parts of the world besides the US, such as Canada, Chile, Mexico, Germany, Austria, or the Netherlands, and clinicians and researchers from those parts of the world have been trained in its methods and techniques.
The British Journal of Psychiatry study was conducted by Dr. Stephan Doering, who is Professor of Psychiatry at the University of Munster in Germany, and his colleagues in Europe. The study was conducted collecting data at different sites, namely in Munich, Vienna and Innsbruck. The goal of the study was to compare Transference Focused Psychotherapy, which is a highly structured type of therapy and has been written up in a manual, with treatment as it is typically administered by experienced clinicians in the community (which we refer to as “Treatment As Usual (TAU)”). The TAU therapists were of varying different theoretical orientations, such as psychoanalysis, behavior therapy, client-centered therapy, or systemic therapy. Participants in the study were 104 women with Borderline Personality Disorder between the ages of 18 to 45. The study period was one year, and since the health insurance situation in Germany and Austria is quite different from the United States, all treatments were covered entirely by insurance.
Of the 104 participants, only 49 completed the entire year of therapy. What’s really striking, though, 42% of participants receiving TFP did not meet the DSM IV criteria for Borderline Personality Disorder anymore after the treatment year was completed. That number was significantly higher than in the TAU group. The group receiving TFP also showed significant improvement with regards to their suicidality and were doing much better in their interpersonal relationships and at work.
There are a few things that I find particularly interesting about the study:
-Drop out: For one, the drop out rate is higher than in other studies. Doering believes that this is because of a crucial difference in the healthcare system between Austria and Germany and other countries, such as Britain and the US. Health insurances in the former countries cover psychotherapy, including TFP, for as long as it’s needed. I am not sure that this is necessarily the explanation, but I also don’t know what else it could be.
-Dosage: TFP therapists met with their patients approximately twice as often as the TAU therapists. Interestingly, when the researchers controlled for this significant difference in dosage, TFP was still superior to treatment as usual in most variables.
-Supervision: Aside from the very specific techniques, strategies, and tactics, the twice a week setting, and the establishment of a treatment contract with a client (as outlined in the TFP manual), there is another important characteristic of TFP that is worth mentioning: Supervision is extremely important for the TFP therapist. All TFP sessions in this study were videotaped and supervision groups met on a regular basis. The videotapes were used to give feedback to the therapist, and they were also used in order to make sure the TFP therapists were adherent to the therapy model. Every TFP case was supervised at least every 4-6 weeks. This is consistent with the belief of many experts on BPD who recommend that a therapist treating someone with BPD should work with the support of a team. In contrast, the community therapists attended supervisions according to their usual routines and their sessions were not recorded. The study does not mention whether they controlled for the difference in supervision. It would be interesting to know if there was an effect.
“Many believe Psychoanalysis is dead,” says Dr. Doering, “Transference Focused Psychotherapy is really a modification of psychoanalysis. The DSM IV classification of BPD is heavily based on the idea that people with BPD have a specific way in which their personality is organized. TFP offers a method of addressing that: Our goal in treating Borderline Personality Disorder is to change the way someone’s personality is organized. Our study shows that TFP is doing just that. The take-home message here is that TFP is effective in treating Borderline Personality Disorder.“