A
special issue on Transference-focused psychotherapy
André Renaud
Santé mentale au Québec is pleased to offer its readership
a special issue on Transference-focused psychotherapy (TFP). Published
in two parts (the first in the current issue; the second, this Fall),
this dossier examines the model of psychotherapy for the treatment
of personality disorders as elaborated by Dr Otto F. Kernberg and his
collaborators at the Personality Disorders Institute at the New York
Presbyterian Hospital and Weill School of Medicine of Cornell University,
West¬chester Division. This publication has been made possible
thanks to the collaboration of the Personality Disorders Institute,
the Transference-focused psychotherapy group of the École de
psychologie of Université Laval in Québec City, and Santé mentale
au Québec.
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Transference focused
psychotherapy
Frank Yeomans, Jill C. Delaney, André Renaud
Transference focused psychotherapy is a version of psycho¬dynamic
psychotherapy that is modified and specialized for patients with borderline
personality disorder. It is based on psychoanalytic prin¬ciples
with an emphasis on object relations theory. A fundamental concept
in this model is that the organization of an individual’s psyche
is structured around internalized versions of interpersonal relations.
The relationship experiences that are internalized involve a specific
representation of the self, a specific representation of the other
(the object of the libidinal or aggressive drive) and an intense affect
that links them. However, this movement toward integration of the internal
representational world does not take place in individuals with borderline
personality, who continue to experience life in a way that is based
on rigid and extreme views of self and others. The goal of transference
focused psychotherapy is to help individuals advance to an integrated
internal world through the analysis of the patient’s ongoing
experience of his or her relationship with the therapist. It is assumed
that the analysis of this relationship will bring to light the internal
repre¬sen¬tations of self and other, and the corresponding
affects, that are related to unconscious desires and motivations, and
that underlie the individual’s extreme and discontinuous experience
in life. The therapy begins with a specific diagnostic interview and
the establishment of a treatment contract with the patient before the
psychotherapeutic work begins. The first goal of the therapy is to
engage the patient in the process of observing and gaining awareness
of the representations of self and other that guide his or her perceptions
of the world. The therapy then helps the patient to understand the
internal forces that have kept theses representations segregated from
each other and to integrate them into a more mature and coherent sense
of self and others.
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The empirical development
of Transference-Focused Psychotherapy
John F. Clarkin
The author describes the stages of elaboration of Transference Focused
Psychotherapy (TFP) : choice of theoretical model, observation and
analyses of several sessions of psychotherapy led by experienced therapists,
team discussions on problems encountered that rise both from the pathology
itself and from the therapeutic approach applied, a quest of empirical
data to explain as much the personality disorder as its neurological
and psychological roots, etc. The author reviews the efforts made to
arrive at the description in writing of a manual on TFP, a manual that
meets the criteria of a treatment method. Finally, the author sum¬marizes
studies conducted to measure the psychotherapeutic efficacy of the
method and the possibilities of generalizability.
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The Countertransference
Rating System (CRS): a tool to analyse contertransference in the treatment
of severe personality disordersde
Lina Normandin, Karin Ensink
This paper introduces the central role of countertransference reactions
in the treatment of borderline patients in transference focused psychotherapy
developed by Otto F. Kernberg. The Countertransference Rating System
is presented to illustrate the diversity of the therapist’s mental
activities involved in his attempts to process and use reactions call
to mind by borderline patient. A clinical example is presented as such
as empirical evidence in support of the usefulness of the CRS and of
the importance of processing countertransference reactions.
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Transference focused
psychotherapy and reflective functioning
Karin Ensink, Lina Normandin
Reflective functioning is a relatively new concept which broadly
speaking, refers to the capacity to interpret human behaviours and
interpersonal reactions in terms of underlying intentions and mental
state motivations. This capacity is particularly important in the regulation
of affects and the management of challenging interpersonal relations.
In comparison to dialectical behavioural therapy (DBT) and supportive
therapies, transference focused psychotherapy (TFP) has been shown
to have unique advantages in terms of producing im¬prove¬ments
in RF of borderline patients. In the present article, we propose a
developmental perspective for understanding how TFP produces these
changes in RF. Using this perspective, we identify a number of thera¬peutic
mechanisms through which TFP facilitate the development of RF and specifically
transference interpretations.
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The author examines the impact of depression in borderline personality
and attempts to explain its profound reasons from a psychoanalytical
perspective. The psychic organization of the borderline personality
predisposes to intense depressive affects. Being unable to come to
a sufficiently harmonious psychic integration of life experiences and
emotions, the individual conserves a divided and rigid organization
of his internal world. The self is thus weakened and vulnerable, confused
and defensive, what constitutes grounds for depressive affects. The
diagnosis commands meticulous attention, because the borderline personality
has tendency to project his difficult affects on people around him.
It is often the therapist who first experiences the depression. The
borderline personality’s recourse to primitive defences renders
him even more vulnerable and fragile in his interpersonal relationships
and the failures are multiplied in his adaptation to the real world,
education, work, personal relationship, etc. The author explains how
the borderline personality has a particular way of entering in relation
with people and situations. The borderline personality has a diffuse
identity and does not distinguish well the borders between himself
and the other. Thus, the borderline personality perceives the other
more like an instrument to satisfy his own desires and needs. The other
does not appear as similar and equal. His relational mode remains essentially
narcissistic and his choices of objects as much as his identifications
remain of narcissistic nature. This creates a confusion between a more
or less important part of his Self and the other. Relational instability
of the borderline personality entails breakups, losses that easily
become sources of depression. The individual thus becomes lost, empty,
depressed as if he was in fact losing an important part of himself.
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This study examines if the timing of disclosure (early or late) of
a sexual assault and if the romantic partner’s participation
in the study have an impact on relational and affective aspects of
the victims at Time 1 (initial interview) and Time 2 (4 months later).
The sexual assault occurred to victims (N = 27) between 1 month to
7 years prior to the first assessment interview. Twenty-six percent
of victims were diagnosed with posttraumatic stress disorder (PTSD).
Descriptive analyses indicate a difference between timing of disclosure
and romantic partner’s participation in the assessment process
of the study. All victims indicate that they have received more emotional
support at the second assessment in the study, whether they have disclosed
the aggression early or lately. Victims have disclosed the assault
early reported more depressive symptoms.
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This exploratory study examines relations between socio-demographic,
social, psychological, cognitive, variables and stressors, coping strategies
and adaptation of individuals with schizophrenia. The study’s
design is correlational with two repeated measures (cross-sectional)
with 153 subjects at a six-month interval. The variables of the model
explain 49,3 % of adaptation at time 1, and 54,6 % of adaptation at
time 2. Data show that five predictors are simultaneously significant
at both times : work, social integration, long term memory, positive
and negative symptoms. At time 2, variables of self-esteem and « changing
the situation » are also significant.
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In this exploratory study, the authors examine the various occupational
and neuropsychological assessments used to analyze deficits qualitatively
and quantitatively in patients with schizophrenia. Considering that
it is necessary to further explore their repercussion on the performance
of activity of daily living (ADL) and domestic activities (DA), they
thus attempt to verify if the distinction between two levels of functional
autonomy could translate at the cognitive and clinical levels in (25)
23 patients included in a program destined to young adults (schizophrenia
spectrum DSM-IV criteria) in Montréal. These patients had the
opportunity, within the clinical program, to submit to neuropsychological
evaluations as well as evaluations offered by the occupational therapy
service thanks to a tool frequently used by occu¬pational therapists
entitled Assessment of Motor and Process Skills (AMPS). The objective
of this article is to conjugate two possible perspectives, drawn from
two different disciplines, on a very current human activity such as « preparing
meals » in people suffering from schizophrenia and which functioning
of daily life is disturbed.
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There are at least six psychotherapeutic treatments of personality
disorders having received empirical and clinical validation in terms
of their efficacy. These treatments are based on different theoretical
models, namely the cognitive-behavioural, psychodynamic and interpersonal
models. This article briefly presents these treatments, focusing on
the process of therapeutic change. It is assumed that the process of
emotional activation is one of the most interesting theoretical psychotherapy
ingredient in treatments of these patients. The treatments are discussed
regarding this hypothesis and its clinical implications.
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This article analyses an intercultural clinical practice in a legal
setting from an anthropological and psychoanalytical perspective, demonstrating
necessary reorganizations inherent to the framework. The culture of
the new country and its founding myth being implicit to the judicial
framework, the professional intervening introduces psycho¬analytical
references particularly totemic principles and the symbolic father
by making genealogy, a universal object of transmission as guarantee
of fundamental taboos of humanity. The metacultural pers¬pective
in this approach integrates ethnopsychoanalytical principles put forth
by Devereux as well as the method although this latter has been adapted
to the framework. This approach allows to re-question Devereux’s
ethnopsychoanalytical principles by opening the debate on the perspective
of a psychoanalytical as well as psychiatric.
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Adolescence is the specific stage during which psychological changes
and identity searching are at the forefront of preoccupations. The
identity construction proves to be particularly complex in a transcultural
context. Starting from their clinical questioning, the authors propose
a literature review of the process of identity construction in a population
of adolescent children of migrant parents. This theoretical reflection
is based on conceptualisations of this process in intercultural psychology,
transcultural psychology and in the theory of dialogical self. Putting
into perspective these different approaches and their interconnections
will help better understand the reality of hybrid or half-breed identity
during adolescence.
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Being part of the psychiatric practice, civil detention of patients
in hospitals against their will remains difficult to assess clinically
in regards to the role of social protection desired by our society.
In this paper, the authors promote a broader understanding of the concept
of danger that grounds the application of this civil commitment regime
in order to fulfill both duty of intervention and promotion of values
of beneficence and protection of patients.
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With the publication of Quebec’s Plan d’Action en Santé Mentale
2005-2010 the province announced an intent to develop a recovery-oriented
mental health system. This article provides planners in Quebec, and
elsewhere, with an overview of issues pertinent to recovery imple¬men¬tation.
It reviews examples of system-level guidelines, program models, practitioner
competencies, and measurement tools designed to promote a recovery
orientation and suggests how these tools might be used by those charged
with implementing recovery in their own jurisdictions. Finally, it
raises some of the hard questions about meaning and power that must
be addressed during the implementation process.
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Context: General practitioners (GP) play a preponderant role in the
treatment of patients suffering of schizophrenia. Objectives: Discovering
the number of patients with schizophrenia who are treated by GPs ;
the needs and attitudes of GPs, their knowledge concerning diagnosis,
and the treatment they provide. Methodology: A postal survey was conducted
with Quebec GPs who were randomly chosen. Results: A total of 1 003
GPs have participated in the survey. Among them, a small percentage
have to treat an early onset schizophrenia and the GPs have expressed
their wish to be more informed on the accessibility of specialized
services. Results pertaining to questions on diagnoses and knowledge
on treatments are inconsistent. The majority of GPs treat the first
psychotic episodes with antipsychotic medication. Only a third of GPs
surveyed propose maintaining the treatment after a first psychotic
episode, in accordance with international recommen¬dations and
the recent Canadian guidelines on practices that recom¬mends at
least 6 to 12 months of treatment after a partial or complete clinical
response. Time given by male GPs to a first contact varies between
10 and 20 minutes, while 80 % of female GPs spend at least 20 minutes.
The adverse effects of antipsychotic medication that raise most concern
is weight gain before neurological signs. Conclusion: some of this
survey’s data should be considered by various professional and
governmental associations, in order to improve the place of GPs in
a health plan destined to treat schizophrenia.
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June 2004: the Quebec association of early psychosis programs, AQPPEP
(Association québécoise des programmes pour premiers épisodes
psychotiques), was created. The Association’s objectives is to
promote clinical and scientific discussions between health care professionals
and researchers sharing an interest for people suffering from an early
psychosis, and to improve earlier detection of psychosis. It also aims
at increasing awareness of the problem in the general population and
governments. To reach these goals, AQPPEP has organized the first early
psychosis awareness day in Quebec and developed one of the rare French
language web sites in this area. Finally, the Association is a tool
to better face, in a concerted approach, some difficulties that many
first episode clinics have to deal with, in order to share or develop
common solutions.
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In this article, the authors examine specialized programs and services
in the treatment and rehabilitation of people with an early psychosis.
The authors realized that various programs have multiplied in the course
of the last decade and many have shown benefits in comparison with
the usual treatments delivered in general psychiatry. Thus these programs
are composed of the following elements : family intervention, intensive
community treatment, employment support, cognitive behavioural therapy
and social skills training.
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In this essay, the author states that the first onset psychoses clinics
described in many articles of this special issue of Santé mentale
au Québec are not as evidence-based than the enthusiasm of its
promoters would lend to believe. Using three stories based on observations
made recently in Quebec where the argument of evidence-based support
was brought, it will be illustrated how groups, their interventions
and programs positioned themselves to their advantage.. These promoters
in the health care system aim at better care, but they are also motivated
by their own professional, departmental and research agendas ; they
are supported by other logics and stakeholders like pharmaceutical
firms, consumers and relatives; but can be slowed down by decision-makers
and planners querying the ressources required, the efficiency, the
accessibility, the training and the impact on other programs in a balanced
mental health care system. This essay also briefly review the definitions,
the limits of an evidence-based approach, and its origins from clinical
epidemiology and public health. It does not consist solely of evidence
drawn from randomised clinical trials and quantitative research designs,
but also from qualitative and mixed designs, that have been developed
by human sciences. The practice and application of evidence is not
mastered in mental health systems, but the author hopes that with increased
training by all stakeholders in its use, it will introduce a continuous
evaluation at the individual clinical level, at the program and system
levels. A continuous questioning that signals quality in clinical practices
and services.
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Recent neuroanatomical studies imply a reversal of normal sexual
dimorphism in schizophrenia in several corticolimbic structures, including
the anterior cingulate, orbitofrontal cortex and amygdala. Prompted
by these reports we have analyzed data of fifteen men and ten women
with the diagnosis of schizophrenia who underwent functional magnetic
resonance imaging (fMRI) during exposure to two emotion processing
tasks. Overall both tests evoked much more extensive and intense cerebral
activations in men than in women with schizophrenia. The pattern of
obtained results differs significantly from what has been observed
in the general population, thus giving support for the recent suggestion
of “masculinization” of females and “feminization” of
males with schizophrenia. More thorough investigation of a larger number
of patients and healthy participants is currently on its way to substantiate
this hypothesis.
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Individuals with Asperger syndrome may, when exposed to hostility
(e.g. bullying at school or at work), develop hostile ideas against
their social environment, sometimes leading to aggression. These ideas
and acts may be confounded with those arising from a persecutory state
in schizoid or schizotypal personality, or even schizophrenia. These
entities can be confounded with Asperger syndrome due to their permanent
nature, and the presence of atypical social and emotional behaviours.
This paper proposes cognitive (Wechsler profile), developmental (course
of hostile behaviours), discursive (qualitative features of discourse
reporting hostile thoughts), which may contribute to differential diagnosis
in the presence of hostile thoughts and behaviours. Consequences for
case management are also reported.
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