BOOK FORUM

Book Forum

Transference-Focused personality disorder (while also discussing the biological sub-

Psychotherapy for strates) as an inability to integrate the multitude of positive and
negative representations. Patients with borderline personality
Borderline Personality
disorder and other DSM-5 personality disorders (e.g., paranoid,
Disorder: A Clinical Guide narcissistic, antisocial, and histrionic) all suffer with a borderline
by Frank E. Yeomans, M.D., Ph.D., John F. personality organization. Borderline personality organization is
Clarkin, Ph.D., and Otto F. Kernberg, M.D. characterized by 1) problems/distortions in realty testing (e.g.,
Washington, DC, American Psychiatric
disturbances in the sense of realty, such as derealization, de-
Publishing, 2015, 427 pp., $75.00.
personalization, and déjà vu or transient psychotic experiences);
Transference-Focused Psychotherapy 2) identity diffusion (e.g., unstable, rapidly changing, and black
for Borderline Personality Disorder: A and white perceptions of self and others); and 3) use of primitive
Clinical Guide is the fourth book in the defenses (e.g., splitting, idealization, devaluation, and projective
ongoing evolution of the original work of Otto Kernberg, identification).
M.D., John Clarkin, Ph.D., and Frank Yeomans, M.D., Ph.D. The book describes how, because of these pathological object
Frank Yeomans, the first author and a master clinician, leads relations, patients with borderline personality disorder develop
this group to clearly and simply describe the theory behind symptoms of disturbed interpersonal relations, emotional
the treatment of borderline personality organization and the storms, distorted thinking, and self-destructive behaviors. The
use of transference-focused psychotherapy. Transference- ambitious goal of transference-focused psychotherapy is not
focused psychotherapy is one of four evidenced-based to treat personality traits but rather to help patients with
treatments (the others include dialectical-behavioral therapy, borderline personality disorder to “integrate all aspects of their
schema-focused psychotherapy, and mentalization-based internal world … in order to experience themselves and others
treatment) that were all designed specifically to treat borderline in a coherent and balanced way” (p. 42).
personality disorder but have been developed into broader This clinical part of this book, which seamlessly and prac-
clinical approaches for the treatment of the wider scope of tically integrates object-relations with transference-focused
personality disorders. Transference-focused psychotherapy is psychotherapy, begins in chapter 4 with a discussion of the
a clinical form of dynamic psychotherapy, which is accessible to assessment of patients with borderline personality disorder.
psychotherapists with a wide variety of orientations. The book The structural interview (demonstrated in a helpful and accom-
also has accompanying online videos, which demonstrate how panying video), developed by Otto Kernberg, begins with the
to perform a structural diagnostic interview for borderline following questions and domains: 1) What brings you here? 2)
personality disorder patients, some of the techniques of treat- What is the overall extent of your problems and difficulties? 3)
ment, and how to deal with affective storms. How do you understand your problems? 4) What do you expect
The transference-focused psychotherapy clinical approach from treatment? 5) Fully describe yourself and someone im-
is grounded in object-relations theory originally developed by portant to you. 6) Exploration of the past as it relates to current
Melanie Klein, Michael Fairburn, Edith Jacobson, Margaret difficulty. This assessment determines the personality organi-
Mahler, and Otto Kernberg. The authors describe how “object” zation (e.g., whether the patient has neurotic, borderline, or
refers to the internal representation of a person who is the psychotic personality organization), which then helps clinicians
“object” of our attention, interest, or wishes. We internalize (and have some indication of how the treatment will unfold.
invariably distort) our interpersonal relationships, forming Chapter 5 describes how to develop the therapeutic con-
mental representations of self and others, which are connected tract, lays out the responsibilities of the patient and the ther-
by an emotion. These object-relations dyads (self-other repre- apist, and describes a hierarchy of acting out issues, which can
sentations) are linked by the originally experienced affect. In- threaten a treatment. It also recommends the use of medication
ternalized self and other representations are incorporated and adjunctive-behavioral treatments and self-help.
during many different stages of development. These object- Chapters 6 and 7 discuss the transference-focused psy-
relations form the building blocks of our internal lives. In normal chotherapy strategies, tactics, and techniques. The authors
or healthy development, positive and negative representation of describe and demonstrate, with accompanying videos, the uses
self and others combine into stable self and balanced identity, of confrontation, clarification, and interpretations; the need
along with stable and complex perceptions of others. This for ongoing focus and use of deep interpretations of both the
clinical guide describes the psychological origins of borderline positive and negative transferences; analysis of the primitive

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BOOK FORUM

splitting defenses as they are activated in the transference; the intense separation anxiety, fears of total abandonment,
importance of technical neutrality and the occasional need for paranoid/persecutory responses, regressions, and splitting,
using parameters; how transference-countertransference expe- with much less (if any) depressive themes. This general re-
riences and patterns lead to the clinical understanding of the action is often the initial borderline personality disorder
dominant object-relations dyads; how these dyads can be used reaction to impending termination. If these reactions occur, it
defensively; and ultimately how these dyads are recreated in the is important to deal with persecutory themes, splitting, and
present and their links to the past. Using case examples, the regression before working on depressive themes. Insofar as
authors discuss and illustrate the tactics of treatment. The tactics patients with borderline personality disorder have transitioned
used include eliminating secondary gain and choosing the the- to a neurotic level of personality organization, they may move
matic focus of each session, giving first priority to suicidal/ from anxiety and persecutory themes to more appropriate
homicidal threats, followed by threats to the treatments (e.g., depressive themes of feeling sad, mourning for someone who
arriving late, not paying bills, etc.), prioritizing a focus on dis- is loved, and internalization of the therapist.
honesty or the withholding of important information, as well as The final chapter discusses measures of structural change
contract breeches, and then to a focus on affects and the trans- that are overtly manifest at the end of a fully successful
ference. This discussion and video are especially useful when treatment of a patient with borderline personality disorder.
dealing with any patients who act out. These measures include a progression from antisocial to
Chapters 8, 9, and 10 focus on issues that emerge in the narcissistic to paranoid to depressive transferences; reduction
early, middle, and advance phases and termination of treat- in acting out and symptoms; integrations of split-off affects and
ment. Case examples are effective in bringing the technical increasingly stable and balanced object relations and aware-
aspects of the treatment to life. ness of ambivalence; movement from preoedipal to oedipal
Early phases of the treatment involve borderline personality issues; and improvement in the capacity to relate meaningfully
disorder patients testing the boundaries and the frame of the to others, with a growing ability to work, play, and love.
treatment, containment of the patient’s impulses, dealing with This book is a synthesis of more than 25 years of original
affective storms (video 3), and the identification of the oper- work from the founders of the Personality Disorder Institute
ative object-relations dyads, which emerge in the transference- of New York. This book is a wonderful blend of theory and
countertransference experiences. techniques offering clinical examples and high-quality useful
Midphase of treatment focuses on a deepening under- videos. It is a treasure of wisdom immensely useful to all those
standing of self and others (as expressed in the transference who are interested in treating patients with severe person-
and countertransference) as multiple object-relations dyads. ality disorders.
During this phase, the interpretation of primitive defenses
Robert E. Feinstein, M.D.
leads to integration of split-off affective extremes, which leads
to more balanced emotional responses. In addition, the bor- Dr. Feinstein is Professor of Psychiatry, University of Colorado Denver; Vice
Chair of Clinical Education & Quality & Safety; Practice Director, University of
derline personality disorder patient begins to integrate and
Colorado Hospital.
coalesce disparate images of self and others and develops new
The author reports no financial relationships with commercial interests.
ways of behaving, leading to improved interpersonal relations.
Book review accepted February 2015.
During the advanced phases of therapy, the interpretive
Am J Psychiatry 2015; 172:589–590; doi: 10.1176/appi.ajp.2015.15020158
processes in the here and now and genetic interpretations (e.g.,
about the connection between the present and the past) help
the patient improve his or her reflective ability. Patients begin
Serving the Amish:
to accurately perceive themselves and others. Reality testing is
less disturbed and more accurate. There is growing openness
A Cultural Guide for
and freedom to discuss all experiences with the therapist. Professionals
Identity becomes stable, since object relations are more in- by James A. Cates. Baltimore, Johns
tegrated and balanced. Patients who progress to this phase are Hopkins University Press, 2014, 256 pp.,
more curious about the therapist’s comments and are less $34.95.
symptomatic because they can better contain anxious, de- The Amish church is a branch of the
pressive, angry affect, and impulsive behaviors. Their per- Mennonites that emerged in Germany
sonality structure is morphing from a borderline personality and Switzerland in 1525, “on the
organization to the neurotic personality organization. coattails of the Protestant reforma-
Successful termination with borderline personality disorder tion” (p. 5). Persecuted for their strict
patients often brings up paranoid and depressive themes and religious beliefs, they accepted William Penn’s offer of re-
periods of regression. ligious tolerance in Pennsylvania. The last European Amish
Separations during treatment are an indication of early died in 1936. In the United States, there are about 300,000
responses to termination. In the earlier stages of treatment, Amish living in 40 communities.
patients with borderline personality disorder, in response to Amish are one of the Plain people, a description given to
a therapist’s vacation or temporary illness, will experience religious groups whose plain dress symbolizes their rejection

590 ajp.psychiatryonline.org Am J Psychiatry 172:6, June 2015