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Wise Counsel Interview Transcript: An Interview with John Clarkin, Ph.D. on Transference-Focused Therapy

David Van Nuys, Ph.D.

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Dr. David Van Nuys

Welcome to Wise Counsel, a podcast interview series sponsored by MentalHelp.net, covering topics in mental health, wellness and psychotherapy. My name is Dr. David Van Nuys. I'm a clinical psychologist and your host.

On today's show, we will be talking about an approach known as transference-focused therapy with John F. Clarkin, Ph.D., who is co-director of the Personality Disorder Institute at New York Presbyterian Hospital, Westchester Division, and Clinical Professor of Psychology and Psychiatry at the Weill Medical College and Graduate School of Medical Sciences of Cornell University in New York City.

He is past-president of the International Society for Psychotherapy Research. He's an expert on the treatment of borderline personality, and among his many publications, he's co-author of Psychotherapy for Borderline Personality

Focusing on Object Relations. Now, here's the interview.

David

Dr. John F. Clarkin, welcome to the Wise Counsel podcast.

Dr. John F. Clarkin

Thank you very much. I'm happy to be here.

David

Great. I gather that a lot of your work is with borderline personality so maybe that's a good place for us to start. Perhaps you can tell us, what does borderline personality refer to?

John

I think the main thing that should be noted is that we're talking about a personality disorder. That is, if you can think of what is personality, and then what might go wrong in the development of the person that you'd have a personality disorder. We're talking about people, young adults, often they appear for psychiatric or psychological help around ages 18 to 35.

David

OK.

John

These particular people meet the diagnostic criteria for borderline personality disorder. It's a particular type of personality disorder. The term "borderline" is not a good term. Historically, it comes from the idea of being on the border between psychotic and not psychotic, and we know that that's totally inappropriate.

David

So really the thinking about it changed because I think when I was in school way back when, that was the meaning that was given then. It's always strikes me as very pejorative and sounds like name-calling.

John

Yes, I think that's absolutely true. When we talk to people that we assess, and we think that these people have this disorder, we talk to them about the symptoms or the behaviors involved. We don't emphasize the name itself. In fact, there's a whole discussion in the field about trying to find a different name that isn't so pejorative.

David

What's being considered?

John

I'm sorry, what names?

David

Yes.

John

One name that's used in Europe, in the diagnostic system there, is impulsive disorder.

David

That would make sense.

John

People with borderline personality disorder - let me go down to some of the symptoms. I think it'll put some flesh on the bones, so to speak.

David

Excellent.

John

In terms of personal behaviors, people with this disorder often feel empty. They often have frantic efforts to be attached to other people. They fear abandonment from other people. Along with this, when they relate to other people, they can have very unstable, intense relationships with others. These intense relationships can alternate between idealizing the other person or, in fact, attacking and devaluing the other person.

People with this disorder do tend to be impulsive, as the name that's used in Europe would imply, so sometimes there are self-damaging acts, there's self-damaging spending, central behavior out of control, sometimes reckless driving, and so forth. Then of course, the criterion that is most manifest, although not all people have all of these criteria, is suicidal behavior.

David

OK.

John

These are people that usually appear for help in outpatient clinics or hospitals, like the one I work at, where they've had, often, an upset in their love life, or in work and there's been some suicide attempts or self-destructive behavior, like cutting of the skin, and a lot of affective or emotional turmoil.

David

OK. What's the role of medication in treating these people? Does that play any role?

John

Yes, it can. It's clear from some of the best psychopharmacologists that you don't treat a borderline personality per se with medications, but you can treat some of the symptoms of this disorder. For example, some of the mood disorders, some of the depression, some of the volatile moods can be helped with the modern SSRIs, for example.

David

I know that your name is associated with a particular psychotherapeutic treatment approach called transference-focused therapy. Are you the originator of that approach?

John

No, the originator is a psychoanalyst and psychiatrist named Otto Kernberg, a man that came to this country from South America, actually. He's a man well-known, more known in Europe than here.

It's a psychoanalytically-oriented treatment, although you should not think of the stereotypes of psychoanalysis when you think of this treatment, because it's modified greatly to try to focus upon the pathology that I just described, in terms of the criterion. The patient doesn't lie on a couch four days a week, and the therapist is not passive and states very little. Rather, it's a very active treatment.

David

OK.

John

I'm the person who helped Dr. Kernberg to formulate the treatment in a way that others could understand it in a manual form and then we've gathered data on the effectiveness of this treatment over the last 25 years.

David

Yes, and as a matter of fact, one of the reasons I contacted you, was you've been in the press recently for a fairly large-scale study that you conducted where you compare transference-focused therapy with two other approaches. Perhaps you can kind of give us a lay person's summary of that research study and the findings.

John

Sure. First all, I'd like to say that the study is a large study. We randomized 90 borderline patients here in the New York area who would not have gotten treatment because often they can't afford treatment. They would not have gotten treatment if this study hadn't been run. The study was funded by a wealthy family from Europe, actually, who lost several members to suicide, suffering from this disorder.

David

Interesting.

John

We suggested that the field needed a study in which we compared three of the best treatments for this disorder in the community. One of the distinctive features of our study was that while it was conducted out of Cornell Medical School, the therapists used their own private offices in the New York City area, and the patients went to those offices for treatment.

We compared three treatments

the transference-focused treatment that I described; a second treatment was dialectical behavior therapy, which is a very well-known and well-researched cognitive behavior approach to the disorder; and then finally a supportive treatment, which is a very typical treatment used in private practice.

We compared the efficacy of these three treatments across a treatment expanse - over one year time. We found, to our delight, that all three treatments are helpful, and in fact, help these patients improve significantly in the areas of depression, anxiety, global functioning and social adjustment.

That's very good news that these patients do respond to an out-patient treatment of a one year duration. In addition to that, we also looked at other domains of change. We did find some differences. For example, suicidality was reduced in the dialectical behavior therapy and in the transference-focused treatment of ours, but not in the supportive treatment. Those kinds of differences did emerge.

David

So the general finding was that, I gather, was that all three treatments were helpful to some extent, is that right?

John

That's correct. That's absolutely correct.

David

And then you found a specific effectiveness, a somewhat differential specific effectiveness, and overall I got the impression that transference-focused therapy was the one that was effective on the most dimensions that were measured.

John

That's correct. Transference-focused psychotherapy seemed to have the widest effect.

David

OK. Maybe you could give us a little more of a concrete understanding of that approach. If I were a fly on the wall in the treatment room, what would I see a transference-focused psychotherapist doing that, say, would be different from another kind of therapist?

John

The reason that it's called "transference-focused" is just jargon for focusing on the relationship that evolves between the therapist and the borderline patient. There's no doubt that these patients have difficulty in their relationships with other people; that would be in love relationships, in friendships, in relating to their family members, and also if they work, in their work relationships.

We, of transference-focused orientation, think that the best place to capture that difficulty is in the here and now relationship that the patient forms with the therapist. We frame the treatment as to what's expected of the patient - to be there on time, and so forth - and to talk about what difficulties they're having.

What evolves in the treatment is that the patient begins to relate to the therapist in certain conflicted and distorted ways. In this structured setting, we invite the patient to begin to understand what they're doing in the relationship that is actually destructive to them and that causes them difficulties.

David

This sounds very familiar. This sounds like basic psychoanalytic theory going way back. Many therapists, from quite a wide variety of schools, have learned to use the relationship with the client as kind of a laboratory to say, "OK, the problems that we're having in this relationship are like the problems you're having out in your life, so let's look at those and see if we can resolve those."

You mentioned that you've developed a manual approach. I'm aware that the American Psychological Association has been pushing towards the ideas of manualized therapies, which I understand to mean that the procedures are spelled out in a certain kind of detail. Maybe you can elaborate on that a little bit.

John

Sure. In terms of the manual, yes, it's true that we have a book that describes this treatment. But I would quickly add, it doesn't describe the treatment session by session in a kind of cook book fashion.

David

OK.

John

Rather, it describes the principles of treatment and how these principles can be applied to the individual case. You're absolutely right; these ideas are not entirely new. In fact, I think the strength of our approach is to take old ideas that have some proven wisdom to them over the years, and apply it in its modified form to borderline personality disorder. How is it modified?

David

Yes.

John

First of all, it's very here and now focused. It's focused on the present.

David

Uh-huh.

John

It's not focused on the past, as it's kind of typically assumed in psychodynamic therapy. We're not sitting there asking the patient asking them what happened to them when they were three or four.

David

OK.

John

We, in fact, make a contract with the patient at the beginning of the treatment. We focus on the here and now. In fact, we ask them in this contract to get either volunteer work or work. Because we feel if.

The patient is just sitting at home, or on public assistance, that they're really not utilizing their own talents and skills. In fact, they're going to be symptomatic and depressed because they are so inactive. It's an active treatment, but it does focus in the here and now, not in the past, on how the patient is relating to other people, including the therapist.

David

OK. That's all very interesting. I'm particularly struck by the urging of the person to get involved either in work or volunteer work. That could feel like they're caught in a paradox. I wonder if they might not say, "Well, of course I'd love to work but I can't work because I'm too depressed, or I'm too upset, or I'm too dysfunctional." [laughs] Does that come up?

John

Of course, it does. I would say in almost every case, the person is, in fact, saying that to us.

David

Uh-huh.

John

We say back that we're concerned about that attitude in their lives, and that we want them to begin to change that and change it even minimally with some volunteer work at the beginning. Then we'll pursue what problems they have in that work.

I guess what I'm trying to emphasize, is that while it's transference-focused psychotherapy - that is it's focused on the relationship between the patient and the psychotherapist in the therapy room - we also think that therapy can't just be an internal experience between the therapist and the patient only; that we have to have one foot in the relationship with the patient and one foot in real everyday life.

These are people that are really quite symptomatic and yet not utilizing the talent they have. One thing comes to my mind. In our large sample of borderline patients we treated here in New York, the average borderline patient in our study, overwhelmingly female, had a college degree.

Yet the college degree was matched by a very minimal functioning on jobs, or if they did have something, it was very much beneath their talent. These are, in many ways, talented people who are not utilizing their own resources.

David

Interesting. Has this category been historically challenging to treat - the borderline personality?

John

Absolutely. As you know - you and I are both old enough - this diagnosis was introduced in 1980 in the DSM-III for the first time. Since then, we've gathered data on the disorder. We've begun to realize that, first of all, the name is inappropriate.

David

Yes.

John

Secondly, from the beginning, a lot of people thought these people were not treatable. They could not change; that it was ingrained and that it would not respond to treatment. I think our study, and the work of others, like Marshall Linehan and DBT, is clearly showing that many of these people can change and can change, in some instances, rather dramatically.

David

How are transference-focused therapists getting trained? Is there a training program somewhere that's turning people of this persuasion out? How is this getting diffused into the world so that people who suffer from this disorder can be helped?

John

First of all, we're here at Cornell's medical school in New York City. So we train our residents in psychiatry, and our psychology interns, and our post-doctoral fellows in this treatment. Then these people go out, and they have their influence in terms of other training programs.

Secondly, this treatment is being taught at one of the prestigious psychoanalytic institutes here in the city. And thirdly, we do offer training in terms of seminars and supervised experience to people in the New York City area.

In addition to that, we have several sites in Canada and in Europe where there are groups of people who are using this treatment, like in Vienna, in Munich, several place in Switzerland, and in Holland for example. These groups of people receive live supervision via videotape with our supervisors here in New York City.

We've also sponsored conferences that are open to people across the United States. It's also diffusing through the manual, which is written to describe the treatment for practicing people who can take the principles and begin to apply them.

David

Where do you see...

John

So that's what's being diffused at the moment.

David

What do you see as the future of transference-focused therapy?

John

I'm sorry, I misunderstood.

David

Where do you see it going in the future?

John

That's a very good question. Let me try to answer it in this fashion. I would compare transference-focused psychotherapy to dialectical behavior therapy which is in many ways more wide-spread.

One of the differences is the goals of the two treatments. Dialectical behavior therapy, or DBT, has focused on the impulsive, suicidal and self-destructive behaviors. They use skill training to stop the cycle of impulsive and destructive behaviors. That treatment has been shown to be very effective in achieving that goal.

David

OK.

John

We think that that goal is (A) very necessary for borderline patients who have those kinds of behaviors, but then (B), after that, there are other goals that these people need to achieve. Certainly the first goal is to keep these people alive and to keep them from self-destructive behavior. We think our treatment really takes the patient further into improving their relationships with other people, both in friendships and in love relations and in work. I think that as the field progresses, I think we'll see a progression of the goals of these treatments and what the different treatments can provide for people.

I think also in the future, what's exciting to me, is that we've also done some neurobiological studies with these patients. We've gathered genetic material, for example; we've also gathered fMRIs, that is functional magnetic resonance images, comparing borderline patients to normal people in terms of how they process affective stimuli.

David

What have you found?

John

We have found that borderline patients are indeed different from normal individuals, matched for sex and age, in terms of how they process negative emotions. To be somewhat more concrete about it, it would appear that the systematic relationship between different parts of the brain, as the brain is functioning, is different in borderline patients than in normals.

That the borderline patients, when hit with affective stimuli, they over-respond at the amygdala level - at the level of emotional response - and they under-respond in the frontal cortex, where there's usually modulation of affect by the cortex. It's almost like their information system is overly charged to see things as dangerous. So they're very hypervigilant and they have trouble putting those affective stimuli into a larger context.

In the prefrontal cortex, it says, "Wait a minute, there's nothing to be afraid of here." I think where things will go in the future is

can psychotherapy, or a more targeted medication or some combination, can that combination begin to change both the psychological behavior at a psychological level of functioning, and the neurobiological behavior, at the level of the brain?

To me, that's quite exciting; that we can begin to, in some ways, better understand the mechanisms of how this disorder operates.

David

Yes, it sounds like you've just described some research for the future, if it hasn't already been done. Has there been research where they've done the fMRI after treatment to see if the brain is handling these... if the brain processing has changed?

John

That's a good question. Unfortunately, all these research studies take an awful lot of funding. Funding, these days, is difficult to come by.

David

Uh-huh.

John

We were able to get fMRIs prior to treatment, but didn't have the resources to continue that after treatment. We're seeking monies to try to do that now. As I understand it, there is a group in Germany who is beginning to gather such data before and after treatment. I think they're beginning to see some changes in these biological systems.

David

Yes, I think I've heard of research in other domains that would tend to support that idea.

John

Yeah.

David

I think a picture is beginning to emerge that it's not surprising that the brain drives the various kinds of behavior that we see, whether normal, or in the case of pathological behavior, that there would be some kind of brain processes that would be reflective of that pathology.

I think we're also beginning to understand - to be able to verify - that it's a two-way street, and that the experience of being in therapy, for example, can, if you will, rewrite or rewire the brain in some corrective ways.

John

Absolutely. I think that we were raised on the notion that your brain is your brain is your brain.

David

Yes.

John

That it's rather hardwired, so to speak. It's becoming clearer that there's a great deal of plasticity or flexibility in the brain. So the brain responds to experience, and experiences, of course, are shaped by the brain. So it's an iterative process.

David

Uh-huh.

John

I'm not trying to imply that borderline patients were born with this brain mechanism of over-response to the amygdala and under-response to the prefrontal cortex. It's very plausible that there may have been proclivities at birth, but that these differences we see in 25 year olds have accrued and been shaped with experience; sometimes very negative experiences that some of these patients have had in growing up.

David

You open up a very interesting area there that we haven't explored, which is the development of the symptomatology or the problems that people have. Are there certain early childhood patterns of trauma or abuse that underlie these conditions? Or does it just vary widely from case to case?

John

I think that for a while, the last 10 or 15 years, there was a lot of excitement about the idea that borderline pathology was intimately related to childhood physical, sexual and emotional abuse.

What's become clear, I think, is that indeed there are some borderline patients who have experienced childhood physical and sexual abuse. On the other hand, there are other adults who are not borderline who have also experienced such physical and sexual abuse. And of course, as I've implied, there are other borderlines who have not.

The correlation is certainly less than perfect on this. In fact, it's somewhat mysterious. I don't want to give the impression that any time you find a borderline young adult that the parents must have been abusive and neglectful, and so forth. Our clinical experience is not that.

Some of these individuals seem to have very normal, nurturing parents, and the parents experience these individuals slightly different from birth. On the other hand there are other situations where clearly the borderline individual has suffered at the hands of caregivers or others, where there was abuse and neglect. We tend to think, although there needs to be much more research on this. We tend to think that probably there are early childhood experiences, but they're probably primed by biological temperamental dispositions that are also contributory.

It's probably a mixture of nature and nurture that results in these patterns. But it's not a one-to-one correlation, so we don't know that certain kinds of childhood events are going to definitely predict borderline.

David

Un-huh.

John

What happens is that these childhood events tend to predict adult problems, some of which appear borderline-like and others don't.

David

Your recent study certainly does suggest the effectiveness of transference-focused therapy for people who are dealing with this disorder. By the way, I definitely cast my vote for a change in the name away from borderline personality...

John

Yes.

David

...to some better name. If a listener, either for themselves or for a family member, were to be impressed by this research finding and this approach that you've described, how might they go about looking for a transference-focused psychotherapist in their local area?

John

That's a good question. Probably the best way they could do that would be to email me, and I would hand that on to my colleagues. We have a service here that provides information for referral to people. I don't have that website at my fingertips, but they could email me, which is jclarkin@med.cornell.edu.

David

OK, well that's good. Just to close here on a personal note, what's your own background educational training?

John

I'm trained as a clinical psychologist. I went to university here in New York City, and then I spent my professional career here at Columbia Medical School and then Cornell. I was raised in a cognitive behavioral tradition...

David

Ah-hah!

John

...but then met this Dr. Otto Kernberg, who influenced me to go, I think, beyond just a behavioral orientation to really focus on the internal representations of, at least for borderlines, for self and other people. That was, I think, neglected a great deal in the very behavioral periods that psychology has been through in the last 25 or 30 years.

That's, in some ways for me, where neurobiology fits in. With neurobiology imaging, it's becoming more academically fashionable now to go beyond behavior and to think about what's going on inside the individual- at the brain and cognitive and emotional levels. I hope I've gone beyond my own early training in trying to pursue these things at level of organization.

David

It certainly sounds like you have. What if your life had taken a different a different turn and you had not become a therapist or psychological academic? What other career, do you think, would have drawn you in?

John

That's an interesting question. In undergraduate work, I was a biology and a psychology major. Certainly, the biology of these things has often very much attracted me. I think that I would have ended up in some kind of human service delivery system because I have a keen interest in personality and how people function. I don't know what it would have been, but some other service area to people.

I suppose family practice medicine, something along those lines. I think that family physicians see many of these psychological disorders, and they have a keen perception. They follow some of these families and patients across time in a way that I think is quite therapeutic, not just medically but psychologically.

David

Thanks for sharing that personal glimpse with us. Dr. John Clarkin, I want to thank you so much for being our guest today.

John

You're very welcome. It was my pleasure.

[music]

David

I hope you enjoyed this interview with my guest, Dr. John F. Clarkin of the Cornell University Medical School. Personally, I was intrigued to learn that transference-focused therapy is pretty much what it sounds like.

It sounds very much like the approach I was trained in many years ago, however, it also sounds as if it's been streamlined and standardized a bit, as a result of the efforts of Dr. Clarkin and others. It's very reassuring to know that has been proven effective in the treatment of borderline personality, a disorder which I sincerely hope will get a new name in the coming years.

You've been listening to Wise Counsel, a podcast interview series sponsored by MentalHelp.net. If you found today's show interesting, we encourage you to visit MentalHelp.net where you can add a comment or question to the show's web page, view other shows of the series, or simply page through the site which is full of interesting mental health and wellness content.

Access this show's page and show archive information via the podcast box on the MentalHelp.net home page. If you like Wise Counsel, you might also like Shrink Rap Radio, my other interview podcast series which is available online at www.shrinkrapradio.com. Until next time, this is Dr. David Van Nuys and you've been listening to Wise Counsel.