Abstract
This chapter presents the adaptation of transference-focused psychotherapy for personality disorders in adolescents (TFP-A). This treatment is based on contemporary psychoanalytic object relations theory as developed by Kernberg (1984, 1992) and supported by findings from current evidence-based and neurobiological research (Clarkin, Levy, Lenzenweger, & Kernberg, 2004; Clarkin & Posner, 2005; Doering et al., 2010; Levy et al., 2006). The specificity of the treatment involves assessing dominant pathological object relations activated in the here-and-now interaction with the therapist, as well as engaging the adolescent in a contract that helps him prioritize mentalization and thinking about his motivations rather than acting out. In addition there is a specific approach to dealing with parents in order to create a mental space for the adolescent where he can exercise both autonomy and responsability for his difficulties. Furthermore, the consistent emphasis on intrepreting transference and countertransference reactions is a defining feature of this treatment. The therapist uses these reactions to identify split self- and other-respresentations that prevent integration of the personality and without which the adolescents is not able to use his mentalization capacities in order to deal with the challenges of adolescence. Finally a clinical vignette is presented that illustrates how these principles are applied in the context of the treatment of an adolescent.
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Appendix: Clinical Vignette
Appendix: Clinical Vignette
Case of Jacob
Jacob, aged 13½, was brought to the clinic by his parents after his school threatened to expel him because he physically assaulted another student. In spite of above average intellectual ability, he was failing at school and had a long history of oppositional behavior at school and at home. At home, his parents were at a loss as to how to deal with his swings from being oppositional, provocative, and argumentative to being stubbornly silent and passive aggressive, or overly dependent, infantile, and submissive at other times. They were also concerned about the extent to which he was bullying his younger brother. In addition he was eating uncontrollably and never seemed satisfied, and as a result was becoming increasingly overweight. In terms of his early history, his mother described him as a demanding and hypersensitive baby. Her first impression of him at birth was that there was something in the way that he looked at her that evoked a fear in her that he would suck her dry.
In therapy, Jacob habitually slouched in his chair and seemed to cut off and became morosely silent and exaggeratedly tired and sleepy the moment he entered the therapy room. This contrasted sharply with how he behaved when the therapist fetched him in the waiting room when he seemed evidently happy to see her, talking on the way to the therapy room about computer games, card collections, and television series and being obviously pleased when he could see that she new what he was talking about. The main difficulty however was his extreme and prolonged silences during the sessions. While it is common for adolescents to be silent especially during the beginning phase of treatment, in Jacob’s case his silence went far beyond this. An intense paranoid reaction was apparent and he acts like someone who has been dropped behind enemy lines. Jacob used his silence so that he could feel in control of the relationship, and while this defended him from revealing and facing a much more sensitive dependent side, it also left him with a very restricted inadequate range of interpersonal responses, and evoked frustration and rejection in others, who felt devalued and treated as if they were trying to control him. His peers did not tolerate his superiority and haughtiness and humiliated and rejected him when he responded like that, something he was highly sensitive to and unable to defend himself from, except through aggressive retaliation.
The following extract is from a session after a humiliating experience at a summer camp where his characteristic stubbornness and refusal to participate in any activity provoked mockery and rejection from the other boys. For example, he refused to prepare for a 3-days survival excursion, something that could potentially place the other members of the group at risk. He found the rejection by his peers extremely humiliating and difficult to tolerate, but had no other strategy to repair and reinsert himself socially and consequently remained rejected and isolated. When he was no longer able to tolerate this situation, he phoned his father and asked him to come and fetch him.
In this session the therapist uses clarification, confrontation, and interpretation to address the dyad that Jacob sets up with the therapist where he induces her to become the controlling object.
Th: Do you have any further thoughts about the meeting we had with your parents?
Pt: No, but I guess we are obligated to talk about it. (The therapist had the impression here that this was said without hostility, and that Jacob actually wanted to speak about it, but that he would only do this in the context of an interrogation where he set up a dyad, where he was the victim and the therapist the torturer).
Th: Does it mean that you don’t want to share your thoughts because you have the impression that I am forcing you?
Pt: Let’s say, just as a question, what is your point in asking me. If YOU want to, we will end up talking about the meeting, about what you have seen (He has successfully reestablished the victim–torturer dyad, even though the family session had ended up with a feeling of cooperation).
Th: If I understand you correctly, you seem to think that I have something in mind and you will have to hear it no matter if you like it or not, no matter if you want it or not… It may be important to try to understand why you see it like that; either you are right but then we have a problem because I am certain that you know that therapy is not about a therapist imposing on a person in need; or there is something in you right now that need to see me as imposing my own point of view on you.
Pt: (Interrupting the therapist) I have nothing to say!
Th: Wait a minute Jacob, are you answering my first question or commenting on what I just said? Right now, I was questioning the fact that you stay with the impression that I am forcing you to talk, that you have no choice and this situation leaves us with two options; either you are right or this way of seeing me help you in someway.
Pt: I have the choice to leave if I want… I also have the right to remain silent and sleep for an hour (said in a somewhat haughty tone).
Th: (smiling) Yes, this is right…. and by doing that you can be freed from having to decide between the two ways of seeing the situation.
Pt: (Nodding his head with a triumphant smile). Yes!
Th: You smile…. As if now you are the one who is in control of the situation, and of me.
Pt: Yes!
Th: What I am wondering now is that during the session with your parents you were able to share what you have been experiencing at the camp and seemed to be able to participate in the discussion actively and honestly. I am wondering if anything has happened since then to explain why you seem now to behave as if I am against you.
Pt: I don’t know; nothing has changed.
Th: This is interesting… do you remember how you were able to talk during that session?
Pt: No, I am the same.
Th: Right now could you say that there is a part of you that is convinced that I am controlling you so much so that you feel justified to not respond…. I understand that.
Pt: (looking more vulnerable) But I have the right to stay silent, you just said so, what is the problem?
Th: Right now we are stuck because you are so convinced that I want to control you or force you that you don’t see any other possibilities but to oppose. This thought seems so strong that you even forgot how it was during that session and specially at the end of that session. It looks as if something terrible is going to happen between you and me. Do you have any idea?
Pt: I am sure that you will want to dig, and dig, and dig, and find another fault…
Th: Hah! Hah! Again this is quite interesting and I think we have to try to understand what is going on right now. What I understood at that meeting was that you had a good reason for not wanting to stay at the camp anymore, and that your parents didn’t understand that. They were not able to understand the reason it was so difficult for you to stay at the camp. ………What I understood from what you were saying is that it was difficult for you to stay there because you could not bear to be humiliated for being French and being treated as different from Quebecers and put aside. You found it difficult to protect yourself and defend yourself. I don’t think your parents knew that side of you at least it is not a side of you that you show to them. Most of the time, they see quite a different side of you. It seems that there is a side of you that feels easily hurt, easily humiliated, and you are not able to protect yourself and then there is that other side that acts as if nothing happened.
Pt: (silent but listening).
Th: When we look at what is happening between you and me right now, you seem to be engaged in a similar struggle with me. Because you are deeply convinced that I will find faults, that I will humiliate you, you don’t have any other choice but to start a battle and being really decided to win that battle. But do you see how this side clashes with the one side at the camp who could not tolerate being joke at and humiliated. So, there is that part of you that is very “defiant,” very “arrogant” as your parents would say, and that other part of you that is very very sensitive, easily hurt, and defenseless. What do you think?…. Is it possible?
Pt: (mumbling) It is possible!…… I don’t know….. Anyway, what is the problem?
Th: I guess we have a problem. I say “we” because I think that what happened at the camp is serious because it shows a part of you that needs help to learn to protect yourself. But when I offer my help you don’t see it like help, you have the conviction that I will humiliate you even more, that I won’t let you say what you want to say… that I will do whatever I want with you, that I will force you to talk, that I will torture you… So we have a problem because it seems like the only way you think you can protect yourself from me is to stand up against me. It is okay in a way because I think you get some sort of a reassurance from that. It is like saying to yourself: “So it is me who is in control here, nothing will happen to me! ……. It is OK…. in the sense that you communicate something important there, but deep down, there is a problem…And the problem is that it is your only card. When you get into a situation like that, let’s say with your parents for example, … they react quite strongly when you enact this role because you don’t have any other card in your pocket. With your classmates, or with the other boys at the camp, you couldn’t use that card, or maybe you used it, I don’t know. But, am I right if I say that if you were inflexible with them, they will go away or they will continue to provoke you and hurt you.”
Pt: That is true. They were laughing at me.
Th: Your card, the only card you have in your game, which is to be opposed… to stand up… was not working there and it left you exposed.
Pt: Hum, hum… yes.
Th: Yes!… I find you quite courageous for saying “yes” like during the meeting with your parents, I also found you courageous for tolerating being there with them while they were obviously angry and depreciative of you. Courageous for staying there. You didn’t subside into your chair, you didn’t fall asleep. You did not provoke your parents too much. You were able to tell me enough about what happened with the boys at the camp and the issue around your French accent so much so that I could understand how difficult it must have been for you at camp. I found you courageous because you, in a way, admitted that it had nothing to do with finding the camp boring, that it had nothing to do with the fact that it was not what you were expecting.
Pt: (looking engaged and interested).
Th: And I don’t know if you had noticed something then, but your father changed his attitude towards you just before the end of the meeting. He mentioned that you have expressed remorse for having him to drive all the way to the camp to fetch you and that you were searching somehow for ways to repair it by offering to pay for the expenses.
Pt: I know, I remember.
Later in the session:
Th: I wonder if we can understand that famous incident where you assault one of your classmates last fall. I wonder if there is a link between being unable to protect yourself when you feel humiliated and exploding?… You know between the fact that this person had probably provoked you by humiliating you and that the only way you could find at that moment, to stop the torture, to protect yourself was by hitting him….
Pt: Yes, he did not want to stop. The girl too, was provoking me (revealing by the same token that he had been assaulting at least one other classmate).
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Normandin, L., Ensink, K., Yeomans, F.E., Kernberg, O.F. (2014). Transference-Focused Psychotherapy for Personality Disorders in Adolescence. In: Sharp, C., Tackett, J. (eds) Handbook of Borderline Personality Disorder in Children and Adolescents. Springer, New York, NY. https://doi.org/10.1007/978-1-4939-0591-1_22
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