APA Citation
Clarkin, J., Yeomans, F., & Kernberg, O. (2006). Psychotherapy for Borderline Personality: Focusing on Object Relations. American Psychiatric Publishing.
Summary
This treatment manual presents Transference-Focused Psychotherapy (TFP), developed by Otto Kernberg and colleagues for borderline personality disorder. TFP is a psychodynamic approach that uses the therapeutic relationship to address the fragmented, polarized internal world characteristic of severe personality pathology. The treatment helps patients integrate split-off parts of themselves and develop more stable, nuanced views of self and others. While focused on BPD, the principles apply to other severe personality disorders including narcissistic personality disorder.
Why This Matters for Survivors
Understanding how personality disorders are treated helps survivors grasp both the possibility of change and why it's so difficult. TFP addresses the internal fragmentation underlying personality pathology—the black-and-white thinking, the idealization and devaluation cycles you experienced. Knowing that treatment exists, but requires sustained commitment the narcissist probably won't make, helps calibrate realistic expectations.
What This Work Establishes
Severe personality disorders can be treated. TFP provides a structured, evidence-based approach for conditions once considered untreatable. Meaningful change in personality organization is possible.
The therapeutic relationship is the treatment tool. Patients enact their patterns in therapy; working through these enactments produces change. This is different from just talking about problems.
Integration is the goal. Treatment aims to integrate split representations—moving from black-and-white to nuanced views of self and others. This addresses the idealization-devaluation cycles characteristic of these disorders.
Treatment requires sustained commitment. Deep personality change takes years of twice-weekly therapy. There are no shortcuts for restructuring how someone relates to themselves and others.
Why This Matters for Survivors
Change is possible but demanding. The narcissist could potentially change—but it would require acknowledging problems and committing to years of difficult therapy. Most narcissists won’t do this.
Understanding what treatment involves. Knowing that effective treatment requires sustained self-examination helps explain why the narcissist hasn’t changed despite promises. The work required is exactly what narcissistic defenses avoid.
The patterns you experienced are treatable. The splitting, idealization-devaluation, and identity confusion you witnessed are recognized clinical patterns with established treatments. What you experienced wasn’t random.
Calibrating expectations. Understanding treatment realities helps you decide based on facts. Hoping for change that requires commitment the narcissist hasn’t shown isn’t realistic.
Clinical Implications
Consider TFP for severe personality pathology. This evidence-based approach may be indicated for patients with identity diffusion, splitting, and chaotic relationships.
Assess treatment readiness. Not all patients can engage in TFP’s demands. Assess capacity for reflection and tolerance of uncomfortable insights.
Educate about treatment realities. Help family members understand what effective treatment requires—this may help them calibrate expectations about the personality-disordered individual.
Use TFP principles in understanding. Even when treating survivors rather than the personality-disordered individual, TFP concepts help explain what the survivor experienced.
How This Work Is Used in the Book
Kernberg’s treatment approach appears in chapters on treatment possibilities:
“Otto Kernberg and colleagues developed Transference-Focused Psychotherapy—an evidence-based treatment for severe personality disorders. The treatment works, but requires years of twice-weekly therapy with sustained self-examination. The narcissist must acknowledge their patterns, tolerate painful insights, and persist through difficult phases. Most narcissists won’t do this—their defenses exist precisely to avoid such self-examination. Knowing treatment exists but demands what narcissists typically refuse helps you make decisions based on reality rather than hope.”
Historical Context
This 2006 manual codified Kernberg’s decades of clinical development. His object relations approach to personality disorders had been influential since the 1960s, but lacked standardized treatment protocol. This manual made TFP teachable, testable, and exportable.
Subsequent research demonstrated TFP’s effectiveness—not just symptom reduction but actual changes in personality organization. This established TFP alongside DBT and mentalization-based treatment as evidence-based approaches for severe personality pathology.
Further Reading
- Kernberg, O.F. (1975). Borderline Conditions and Pathological Narcissism. Jason Aronson.
- Yeomans, F.E., et al. (2015). Transference-Focused Psychotherapy for Borderline Personality Disorder: A Clinical Guide. American Psychiatric Publishing.
- Clarkin, J.F., et al. (2007). Evaluating three treatments for borderline personality disorder: A multiwave study. American Journal of Psychiatry, 164(6), 922-928.
- Levy, K.N., et al. (2006). Change in attachment patterns and reflective function in a randomized control trial of transference-focused psychotherapy. Journal of Consulting and Clinical Psychology, 74(6), 1027-1040.
About the Author
Otto F. Kernberg, MD is one of the most influential figures in personality disorder theory and treatment. His object relations approach has shaped understanding of borderline and narcissistic pathology for decades.
John F. Clarkin, PhD and Frank E. Yeomans, MD, PhD have collaborated with Kernberg to develop and test TFP, establishing it as an evidence-based treatment for severe personality disorders.
Historical Context
This 2006 manual codified decades of clinical development. Kernberg's object relations approach to personality disorders, developed since the 1960s, had been influential but lacked a standardized treatment protocol. This manual made TFP teachable and testable, leading to research demonstrating its effectiveness.
Frequently Asked Questions
TFP is a psychodynamic treatment that uses the patient-therapist relationship to address personality pathology. As patients enact their characteristic patterns in therapy, the therapist helps them observe, understand, and ultimately integrate these patterns.
Object relations refers to internalized representations of self and others, formed from early relationships. In personality disorders, these representations are often fragmented and polarized—all-good or all-bad. TFP helps integrate these split representations.
Splitting is the tendency to see things in black-and-white terms—people are either all-good or all-bad, with no middle ground. This explains the idealization-devaluation cycles characteristic of personality disorders. TFP helps patients develop more nuanced, integrated views.
Yes. While developed for BPD, TFP applies to other severe personality disorders including NPD. The underlying processes—splitting, identity diffusion, primitive defenses—occur across Cluster B disorders, though with different manifestations.
TFP is typically long-term treatment—often two or more years of twice-weekly sessions. This reflects the depth of change required for severe personality pathology. Quick fixes aren't possible for restructuring personality organization.
TFP requires acknowledging psychological difficulties, tolerating uncomfortable insights, and staying in treatment through painful phases. Narcissists' defenses are designed to avoid exactly this kind of self-examination. Most won't seek or persist in such treatment.
Knowing that treatment exists but requires sustained commitment helps calibrate expectations. The narcissist could potentially change—but would need to acknowledge problems and commit to years of difficult therapy. Understanding this helps you make decisions based on reality.
Research shows TFP produces lasting changes in personality organization, not just symptoms. Studies demonstrate improvement in identity integration, relationships, and functioning. It's one of the evidence-based treatments for severe personality disorders.