Determining the Effectiveness of Transference-Focused Psychotherapy on Personality Structure in Patients with Borderline Personality Disorder

Fakhraei Nejad , Siamak; Bahrainian , Seyed Abdulmajid; Shahabizadeh , Fatemeh; Mohseni , Mina; Ghanifar , Hassan

Volume 15 - Articles-1404 MEJDS (2025) 15: 76 | Back to browse issues page

Research code: 162350878

Ethics code: IR.SIRUMS.REC.1400.011

Clinical trials code: IR.SIRUMS.REC.1400.011

Mendeley

Zotero

RefWorks

Fakhraei Nejad S, Bahrainian S A, Shahabizadeh F, Mohseni M, Ghanifar H. Determining the Effectiveness of Transference-Focused Psychotherapy on Personality Structure in Patients with Borderline Personality Disorder. MEJDS 2025; 15 (0) :76-76
URL: http://jdisabilstud.org/article-1-3153-en.html

Determining the Effectiveness of Transference-Focused Psychotherapy on Personality Structure in Patients with Borderline Personality Disorder

Siamak Fakhraei Nejad¹

, Seyed Abdulmajid Bahrainian ^*²

, Fatemeh Shahabizadeh³

, Mina Mohseni⁴

, Hassan Ghanifar⁵

1- PhD Student in Clinical Psychology, Department of Psychology, Islamic Azad University of Birjand, Birjand, Iran
2- Full Professor, Department of Clinical Psychology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
3- Associate Professor, Department of Psychology, Islamic Azad University of Birjand, Birjand, Iran
4- Assistant Professor in Psychiatry, Sirjan School of Medical Sciences, Sirjan, Iran
5- Assistant Professor, Department of Psychology, Islamic Azad University of Birjand, Birjand, Iran

Abstract: (2154 Views)

Abstract
Background & Objectives: Borderline personality disorder (BPD) is one of the most common personality disorders in psychiatric situations. Beginning in early adulthood and present in a variety of contexts, one of the remarkable characteristics of BPD is identity diffusion. According to Kernberg's theory, the main problem of borderline personality disorder is the defect in the object and the integrated self. Integrated identity is defined as a person experiencing a deep and stable sense of self and others. It indicates identity diffusion —a lack of coherence between the self and significant others in life —manifested by mental emptiness, inconsistent perceptions of self and others, contradictory behaviors, and a superficial understanding of others. Another dimension that affects the behavior of borderline patients is the use of defense mechanisms that act to protect a person from anxiety–producing thoughts and feelings related to internal conflicts and external stressors. Borderline personality disorder is chronic and debilitating, with individuals with this disorder showing high rates of use of medical and psychiatric services. So, the present study aims to determine the effectiveness of transference–focused psychotherapy (TFP) on personality structure in patients with borderline personality disorder.
Methods: This quasi–experimental study used a single–subject design with an A–B–A approach. Among the clients with borderline personality disorder (BPD) who were referred to the psychotherapy and counseling clinic (Hadi) in Sirjan City, Iran In the second half of 2020, 3 persons (qualified volunteers) were selected by available sampling through a clinical interview, the Millon Clinical Multiaxial Inventory–III (MCMI–III) (Millon, 1994), and the Personality Organization Questionnaire (Kernberg, 2002). They were subjected to transference–focused psychotherapy for 12 months. The inclusion criteria for subjects in the study were as follows: having diagnostic criteria for borderline personality disorder; willingness to cooperate in receiving counseling intervention and agreeing to the goals and conditions of treatment; obtaining written consent from the subject to participate in the study; having at least education in third grade of middle school; being between 18 and 50 years old; having cognitive ability appropriate for treatment; not receiving psychotherapy services for at least the past two months; not using psychiatric medications; and lacking substance abuse or dependence for at least three months before entering the study. To implement ethical considerations, the following points were observed in the present study. The clients had complete freedom to participate in the research and were assured of the principles of confidentiality and privacy of the information. To convince and prepare for sustained participation in the research, the purpose of the study was explained to them, and written consent to participate in the treatment period was obtained. The participants were assured that the researcher would keep the data and that, to maintain confidentiality, all names and characteristics mentioned for the subjects would be pseudonyms. Data were collected using the Personality Organization Questionnaire (Kernberg et al., 2002) across three stages: baseline, treatment, and follow–up at 16 months, with an interval of 4 months. To analyze the results, indices of visual analysis, recovery percentage, effect size, and reliable change were used.
Results: In the treatment and follow–up stages, Cohen's effect size index for the total scores of personality organization, primitive defense mechanisms, identity diffusion, and reality testing in clients was higher than the average of 1.15. Also, the recovery percentage index for the mentioned variables among clients increased significantly. All results of the reliable change index were greater than 1.96, indicating the treatment's effectiveness and maintenance.
Conclusion: Transference–focused psychotherapy over 12 months causes significant changes in the personality structure of borderline personality disorder patients. To significantly reduce the use of primitive defense mechanisms and increase integrated identity and reality testing in patients with borderline personality disorder. Future research is needed to deepen the understanding of the treatment dimensions.

Keywords: Transference–focused psychotherapy, Borderline personality disorder, Personality structure, Borderline personality organization, Identity diffusion, Primitive defense mechanisms, Reality testing

Full-Text [PDF 591 kb] (126 Downloads)

Type of Study: Original Research Article | Subject: Psychology

References

1. Battle DE. Diagnostic and Statistical Manual of Mental Disorders (DSM). Codas. 2013;25(2):191–2. [DOI]

2. Swartz M, Blazer D, George L, Winfield I. Estimating the prevalence of borderline personality disorder in the community. Journal of Personality Disorders. 1990;4(3):257–72. [DOI]

3. Torgersen S, Kringlen E, Cramer V. The prevalence of personality disorders in a community sample. Arch Gen Psychiatry. 2001;58(6):590–6. [DOI]

4. Gunderson JG. Borderline personality disorder: a clinical guide. Washington, DC: American Psychiatric Publ; 2001.

5. Black DW, Blum N, Pfohl B, Hale N. Suicidal behavior in borderline personality disorder: prevalence, risk factors, prediction, and prevention. Journal of Personality Disorders. 2004;18(3):226–39. [DOI]

6. Sadock BJ, Sadock VA, MD DPR. Kaplan and Sadock's synopsis of psychiatry: behavioral sciences/clinical psychiatry. 11th ed. Philadelphia, Pa.: LWW; 2014.

7. Berman ME. Abnormalities of personality: within and beyond the realm of treatment: By M.H. Stone. New York: W.W. Norton & Co., 1993. 546 pp. Clinical Psychology Review. 1994;14(6):607–8. [DOI]

8. Zanarini MC, Frankenburg FR, Hennen J, Reich DB, Silk KR. Prediction of the 10–year course of borderline personality disorder. Am J Psychiatry. 2006;163(5):827–32. [DOI]

9. Barlow DH, Durand VM, Hofmann SG. Abnormal psychology: an integrative approach. Eighth edition. Boston, MA: Cengage Learning; 2015.

10. Zimmerman M, Mattia JI. Axis I diagnostic comorbidity and borderline personality disorder. Compr Psychiatry. 1999;40(4):245–52. [DOI]

11. Gabbard GO. An overview of countertransference with borderline patients. J Psychother Pract Res. 1993;2(1):7–18.

12. Kernberg OF. A psychoanalytic theory of personality disorders. In: Kernberg OF, editor. Aggressivity, narcissism, and self–destructiveness in the psychotherapeutic rela: new developments in the psychopathology and psychotherapy of severe personality disorders. Yale University Press; 2004. [DOI]

13. Sandler J, Dare C, Holder A, Dreher AU. The patient and the analyst: the basis of the psychoanalytic process. 2nd ed. Madison, CT, US: International Universities Press, Inc; 1992. [DOI]

14. Fox RP. Book review: psychopathology and treatment handbook of dynamic psychotherapy for higher level personality pathology. By Eve Caligor, Otto F. Kernberg, and John F. Clarkin. Washington, DC: American Psychiatric Publishing, 2007, 284 pp., $65.00. J Am Psychoanal Assoc. 2008;56(3):1053–6. [DOI]

15. Pines M. Borderline conditions and pathological narcissism. By Otto Kernberg. New York: Jason Aronson. 1975. Pp 361. Price $15.00. Br J Psychiatry. 1977;131(2):212–3. [DOI]

16. Millon T, Millon T, editors. Personality disorders in modern life. 2nd ed. Hoboken, N.J: Wiley; 2004.

17. Hébert É, Diguer L, Descôteaux J, Daoust JP, Rousseau JP, Normandin L, et al. The Personality Organization Diagnostic Form (PODF): a preliminary report on its validity and interrater reliability. Psychotherapy Research. 2003;13(2):243–54. [DOI]

18. Di Giuseppe M, Perry JC, Conversano C, Gelo OCG, Gennaro A. Defense mechanisms, gender, and adaptiveness in emerging personality disorders in adolescent outpatients. J Nerv Ment Dis. 2020;208(12):933–41. [DOI]

19. Clarkin JF, Yeomans FE, Kernberg OF. Psychotherapy for borderline personality: focusing on object relations. American Psychiatric Publishing, Inc.; 2006.

20. Kernberg OF. Omnipotence in the transference and in the countertransference. The Scandinavian Psychoanalytic Review. 1995;18(1):2–21. [DOI]

21. Eurelings–Bontekoe EHM, Luyten P, IJssennagger M, van Vreeswijk M, Koelen J. Relationship between personality organization and Young's cognitive model of personality pathology. Personality and Individual Differences. 2010;49(3):198–203. [DOI]

22. Clarkin JF, Levy KN, Lenzenweger MF, Kernberg OF. Evaluating three treatments for borderline personality disorder: a multiwave study. Am J Psychiatry. 2007;164(6):922–8. [DOI]

23. Clarkin JF, Cain NM, Lenzenweger MF. Advances in transference–focused psychotherapy derived from the study of borderline personality disorder: clinical insights with a focus on mechanism. Curr Opin Psychol. 2018;21:80–5. [DOI]

24. Zanarini MC, Frankenburg FR, Hennen J, Silk KR. Mental health service utilization by borderline personality disorder patients and Axis II comparison subjects followed prospectively for 6 years. J Clin Psychiatry. 2004;65(1):28–36. [DOI]

25. Paris J. The treatment of borderline personality disorder: implications of research on diagnosis, etiology, and outcome. Annu Rev Clin Psychol. 2009;5:277–90. [DOI]

26. Millon T. MCMI-III Manual: Millon Clinical Multiaxial Inventory–II. Minneapolis, MN: National Computer Systems; 1994.

27. Lenzenweger MF, Clarkin JF, Kernberg OF, Foelsch PA. The Inventory of Personality Organization: psychometric properties, factorial composition, and criterion relations with affect, aggressive dyscontrol, psychosis proneness, and self–domains in a nonclinical sample. Psychol Assess. 2001;13(4):577–91.

28. Millon T, Davis R, Millon C. MCMI–III mannual (2nd ed). Minneapolis, MN: National Computer Systems; 1997.

29. Dadfar M, Lester D. Prevalence of personality disorders and clinical syndromes using the Millon Clinical Multiaxial Inventory III (MCMI-III) in an Iranian clinical sample. Int J Biomed Eng Clin Sci. 2017;3(4):36–47. [DOI]

30. Chegini M, Delavar A, Garrayi B. Psychometric characteristics of Millon Clinical Multiaxial Inventory–III. Journal of Modern Psychological Researches. 2013;8(29):135–62. [Persian] [Article]

31. Kernberg OF, Clarkin JF. The Inventory of Personality Organization. White Plains, NY: The New York Hospital Cornell Medical Center; 1995.

32. Al Behbahani M, Mohammadi N. Investigating the psychometric properties of Kernberg's Personality Organization Questionnaire. Journal of Psychology. 2007;11(2):185–97. [Persian]

33. Clarkin JF, Foelsch PA, Levy KN, Hull JW, Delaney JC, Kernberg OF. The development of a psychodynamic treatment for patients with borderline personality disorder: a preliminary study of behavioral change. J Pers Disord. 2001;15(6):487–95. [DOI]

34. Evans VA, Axelrod S. Kazdin, AE. Single–case research designs, Second edition. Child & Family Behavior Therapy. 2012;34(1):76–9. [DOI]

35. Nazari MA, Dadkhah M, Hashemi T. Effectiveness of cognitive rehabilitation on dictation errors of students with dysgraphia. Journal of Research in Rehabilitation Sciences. 2015;11(1):32–41. [Persian] [Article]

36. Zahra D, Hedge C. The reliable change index: why isn't it more popular in academic psychology? Psychology Postgraduate Affairs Group Quarterly. 2010;76:14–9. [DOI]

37. Hayee H, Raana T, Haider II, Sajid MR. Association between predictors of borderline personality disorder and quality of life of undergraduate students of Lahore, Pakistan. Nurture. 2022;15(1):26–35. [DOI]

38. Sollberger D, Gremaud-Heitz D, Riemenschneider A, Agarwalla P, Benecke C, Schwald O, et al. Change in identity diffusion and psychopathology in a specialized inpatient treatment for borderline personality disorder. Clin Psychol Psychother. 2015;22(6):559–69. [DOI]

39. Neacsiu AD, Herr NR, Fang CM, Rodriguez MA, Rosenthal MZ. Identity disturbance and problems with emotion regulation are related constructs across diagnoses. J Clin Psychol. 2015;71(4):346–61. [DOI]

40. Carpenter RW, Trull TJ. Components of emotion dysregulation in borderline personality disorder: a review. Curr Psychiatry Rep. 2013;15(1):335. [DOI]

41. Jahn C, Wieacker E, Bender S, Krischer M. reduction of non–suicidal self–injury (NSSI) in adolescents with borderline personality organization treated with TF–PA. Prax Kinderpsychol Kinderpsychiatr. 2021;70(8):728–47. [German] [DOI]

42. Krischer M, Ponton–Rodriguez T, Gooran GR, Bender S. Transference focused psychotherapy for borderline–adolescents in a day clinic treatment program. Prax Kinderpsychol Kinderpsychiatr. 2017;66(6):445–63. [German] [DOI]

43. Giesen–Bloo J, van Dyck R, Spinhoven P, van Tilburg W, Dirksen C, van Asselt T, et al. Outpatient psychotherapy for borderline personality disorder: randomized trial of schema-focused therapy vs transference-focused psychotherapy. Arch Gen Psychiatry. 2006;63(6):649–58. [DOI]

44. van Asselt ADI, Dirksen CD, Arntz A, Giesen–Bloo JH, van Dyck R, Spinhoven P, et al. Out–patient psychotherapy for borderline personality disorder: cost–effectiveness of schema–focused therapy v. transference–focused psychotherapy. Br J Psychiatry. 2008;192(6):450–7. [DOI]

45. Kivity Y, Levy KN, Kelly KM, Clarkin JF. In–session reflective functioning in psychotherapies for borderline personality disorder: the emotion regulatory role of reflective functioning. J Consult Clin Psychol. 2021;89(9):751–61. [DOI]

46. Lee YJ, Keum MS, Kim HG, Cheon EJ, Cho YC, Koo BH. Defense mechanisms and psychological characteristics according to suicide attempts in patients with borderline personality disorder. Psychiatry Investig. 2020;17(8):840–9. [DOI]

47. Levy KN, Clarkin JF, Yeomans FE, Scott LN, Wasserman RH, Kernberg OF. The mechanisms of change in the treatment of borderline personality disorder with transference focused psychotherapy. J Clin Psychol. 2006;62(4):481–501. [DOI]

48. In–Albon T, Bürli M, Ruf C, Schmid M. Non–suicidal self–injury and emotion regulation: a review on facial emotion recognition and facial mimicry. Child Adolesc Psychiatry Ment Health. 2013;7(1):5. [DOI]

49. Doering S, Hörz S, Rentrop M, Fischer–Kern M, Schuster P, Benecke C, et al. Transference–focused psychotherapy v. treatment by community psychotherapists for borderline personality disorder: randomised controlled trial. Br J Psychiatry. 2010;196(5):389–95. [DOI]