Dr. Frank Yeomans is an Adjunct Associate Clinical Professor of Psychiatry at Columbia University Vagelos College of Physicians and Surgeons. He is one of the developers of Transference-Focused Psychotherapy (TFP). In this episode, he offers a deep dive into the theory and clinical practice of TFP as a treatment for Borderline Personality Disorder. Drawing on object relations theory, Dr. Yeomans explains how BPD is understood through the lens of identity integration and split internal representations, and walks clinicians through the full arc of TFP treatment — from thorough assessment and diagnostic feedback, through contracting and frame-setting, to active intervention using clarification, confrontation, and interpretation. He also addresses the clinical use of countertransference as a window into the patient's internal world, signs of therapeutic progress, and how object relations principles can be applied even outside a formal TFP frame.

Published On: 4/16/2026

Duration: 40 minutes, 21 seconds

Topics covered in this interview:

• Conceptualizing personality and personality disorders through a TFP lens
• The object relations model and the role of splitting
• Assessment process and identity integration
• Transitioning from assessment to active treatment
• Introducing the TFP model to patients and contracting
• Setting the treatment frame
• What active TFP treatment looks like in session
• What the therapist tracks: verbal content, nonverbal cues, and countertransference
• Core interventions: clarification, confrontation, and interpretation
• Understanding and using countertransference clinically
• Deciding when and what to intervene on
• Signs of progress in TFP
• Applying TFP principles in general practice
• Termination and readiness to end treatment

Abigail Rasol: Hi everyone, and welcome back to the Carlat Psychotherapy Report podcast series. This is the second episode on Borderline Personality Disorder, where we're exploring the range of evidence-based treatments for BPD to help clinicians better understand the interventions available.

I'm your host, Abigail Rasol, and today I'm joined by Dr. Frank Yeomans to discuss Transference-Focused Psychotherapy. Dr. Yeomans is an Adjunct Associate Clinical Professor of Psychiatry at Columbia University Vagelos College of Physicians and Surgeons, a frequent contributor to the Carlat Psychiatry Report, and one of the original developers of TFP alongside Otto Kernberg and John Clarkin. He has co-authored the primary TFP treatment manuals, trains and supervises clinicians internationally through the International Society for Transference-Focused Psychotherapy, and has been a principal investigator on key studies examining TFP's efficacy for BPD.

Welcome, Dr. Yeomans. Thank you so much for joining us.

Frank Yeomans, MD: Thank you. And I do want to thank people for listening because, along with everything else, I'm a big advocate for people who suffer from BPD, and there just aren't enough clinicians. So anybody who's interested in helping this patient population is doing a great service.

Conceptualizing Personality: A TFP Perspective

Abigail Rasol: So I'd like to start off by just speaking a little bit about how transference-focused psychotherapists conceptualize personality, personality disorders, and how that understanding sets the stage for the model of transference-focused psychotherapy.

Frank Yeomans, MD: It used to be that personality was defined as categories that were determined by traits, but personality disorders have a core common factor, which is the experience of self in relation to others.

So personality is the way we experience ourselves and the way we experience the world around us, and that can be either successful and adaptive or maladaptive and frustrating. And people with personality disorders are unfortunately not able to adjust well because of their difficulty accurately perceiving what's going on in them and around them.

Object Relations Model

Abigail Rasol: So, if I'm not mistaken, it sounds like what you're starting to touch on here is this idea of the object relations model. Could you speak a little bit to how that informs the conceptualization that you're talking about here and Transference-Focused Psychotherapy in general?

Frank Yeomans, MD: Essentially, an object is another person. So we talk about emotional states not only in terms of what emotion is being experienced, but what is the object of the emotion and how that all computes in the patient's mind.

The idea is that in the course of early development, inevitably there are moments of satisfaction and there are moments when needs are not satisfied. When the caretaker is satisfying the baby's needs, we're in heaven. But in those inevitable moments when the desired care is not available, there is no idea of, "I just have to wait." The idea is "I'm being made to suffer."

It's too scary to hate your caretaker, so you project everything that's aggressive onto the outside world. Now, when we reach the integrated state, we realize we have anger and aggression as well as love and affection, and so do others. And this is essentially the path we want to help our patients achieve—to go from splitting extreme experiences to a much fuller and richer experience of self and others.

Clinical Example of Splitting

Abigail Rasol: Do you have a clinical example of what that split organization can look like in practice and how it can show up in the patient's life and in the treatment room?

Frank Yeomans, MD: A patient of mine started therapy with quite a history of acting in an aggressive way toward her husband. So after about two years of therapy, she said in a session, "You know, you've helped me, and my husband and I can get along now and have a good time. But you've also taken something away from me. I used to think I could find the perfect other. And now I realize that's not possible, and that's sad."

So she was describing in her own words what we see as the evolution that we try to help people with.

The interesting thing was that in the very next session, she said, "It was hard for me to come here today. I feel so guilty now about things I did to my husband that at the time I thought I was justified in doing. I realize now I was acting in an aggressive way, and it's painful to think about that."

So that's the change we try to affect in our patients, but that's also why it's hard, because they have to come to these sometimes painful awarenesses.

So if we have the idea that in the mind of every individual we have internal representations of who we are and who others are, the question is how well do those internal representations approximate external reality, or how different are they?

And in patients with borderline or other severe personality disorders, the internal representations don't fit well with external reality.

Assessment Process

Abigail Rasol: For a clinician that doesn't have formal psychoanalytic or TFP training, or an outside observer that's sitting in and watching a session, what does that session look like for those 45 minutes?

Frank Yeomans, MD: That's a great question, and there's a misconception in the minds of many therapists that therapy consists of two people sitting in a room, the patient talking, and the therapist just listening and suggesting things to understand as they proceed.

First of all, we need to do a very thorough assessment, and I want to emphasize this because I think modern psychiatry has become a little bit simplistic in its way of assessing patients.

Too often the chief complaint is accepted as the accurate diagnosis. Simple example: a patient comes in, you say, "Why have you come here for therapy?" "I'm depressed." You write that—diagnosis: depression. Well, what if the diagnosis is really an underlying narcissistic personality disorder, perhaps of a covert type?

So you've got the person there. Why are you here? I'm depressed, they say. Okay. Can you tell me more about your life experience? Can you tell me who you are? Can you describe yourself to me?

If we go back to the basic concept of personality disorder as not having a full-bodied and complex sense of self, you find that the descriptions people give tell you a lot about what we call their identity integration, or lack thereof.

Sense of Self and Identity Integration

Abigail Rasol: And what would a strong versus weak, or less complex, sense of self look like?

Frank Yeomans, MD: Clinical example: a man who came in because his girlfriend abruptly left him, and he's blaming outside people for having talked her out of the relationship. I said, "Tell me about yourself. Explain who you are." "I'm a very loving man." That was his self-definition.

Now, when I went in and got more details about what led up to the breakup, we found out that he had been physically aggressive with her, but he split that off, couldn't think about it because it was too distressing, and came in seeing himself as the excessively loving victim of mean people who talked the girlfriend out of the relationship.

So what I'm trying to say here is that in your evaluation, try to go deeper. We want to know if the person's sense of identity is superficial, as in the case of the man I just described, or does it have complexity and depth?

Somebody else might have said, "Well, I really love this woman. I have problems with anger and sometimes I can't contain myself." That's a more complex version, but the version my patient gave was a split, superficial version.

Then you want to get to know the person's experience of others in a symmetric way to their experience of self. Is it complex and rich, or is it superficial?

So when I asked this man, "Describe your girlfriend to me"—they'd been together for years—and he said, "She's really beautiful, she dresses well, she's kind and she's sweet," which is nice, but it's almost like, who is she in any depth?

We also want to know if there's evidence of what we call characteristic defense mechanisms. Do they seem to externalize all responsibility for things onto others, or can they see their role in things?

We want to get a sense of the quality of interpersonal relationships. We want to get a sense of their functioning in life. Are they engaged in a meaningful way in the world because they have a sense of productive activity that gives some gratification?

It's important to know if there are any antisocial features, dishonesty, or what have you, and if aggression is a major part of their personality.

From Assessment to Treatment

Abigail Rasol: So once you're done with the assessment, what are the next steps in terms of transitioning into the active treatment?

Frank Yeomans, MD: Once we do the thorough assessment and determine it's a personality disorder, first we have to discuss that diagnostic impression with the patient in a tactful way, then we have to describe the model of treatment we're recommending, and then a third thing is to describe the conditions that the treatment requires.

So here's how we would discuss BPD. We'd start by saying, "I think the best way to understand your problems and to begin to think about how to treat them is to think about what we call a personality disorder. I know that term might be a little uncomfortable, but we all have a personality. What is a personality? How we experience ourselves and others. It's automatic, it's instinctive. We don't really think about it, but sometimes it's maladaptive.

I'd say, I think we can look at four domains in life that are problematic:

First of all, emotions. You tend to experience emotions in the extreme, probably more often extremely negative, sometimes very positive, but it's like an emotional rollercoaster in your life.

Then, after the emotional difficulties, there are the relational difficulties. Relationships tend to have conflict and difficulty—it's hard to find peace and harmony.

Then the third area of difficulty—and this is an area that is the most dramatic and so it gets the most attention and in the minds of many people it defines the illness—has to do with the behaviors and actions.

Now, in my mind, these behaviors do not define the condition. They are a surface manifestation. So there might be instances of self-harm, a history of cutting, or substance abuse or an eating disorder.

A lot of treatments just say, "Let's focus on the behaviors," which is important to focus on. But I think the core of the disorder is a sort of lack of a cohesive, solid, clear sense of self.

So I'd like to consider those four areas of difficulty with the understanding that it's the last one that is probably at the root of everything.

Introducing the Treatment Model

Abigail Rasol: So say that the client accepts the diagnosis, accepts the model, and would like to move forward. What does that next stage of contracting and setting the frame look like?

Frank Yeomans, MD: So if the person is willing to consider what you've said about personality disorder, then you say there are different treatments for this kind of condition.

I say something along the lines of, "I'm going to recommend what we call an exploratory psychotherapy. It's based on the idea that there are parts of your mind that you're not aware of, and these parts of your mind have a big impact on how you feel, what you think, and what you do.

And your lack of awareness of these parts of your mind is based on the fact that it's uncomfortable to think about these things within oneself.

So if you're interested in this kind of therapy, I can describe the conditions that would be necessary, but that's the gist of the model and an understanding of how to proceed."

And then you see if that appeals to the patient or not.

Contracting and Setting the Frame

Frank Yeomans, MD: So if it does appeal to them, this is where TFP differs a great deal from a lot of psychoanalytic therapy and maybe from other therapies in general.

We emphasize the contract and the frame more than a lot of therapies do. We think it's essential to have a clear definition of the conditions of treatment in order for the work to proceed. It's not just about behavioral control—it's about a frame to further understanding.

So we say, "If you're interested in this kind of therapy, these are the conditions that are necessary."

And then we describe what the patient's role is and what the therapist's role is.

We say, "Your role is to come here regularly and to speak as freely as you can with some connection to the topics and the problems that brought you here. My role is to help you understand things about yourself. I listen, I think, and if I have a question or comment that I think might advance our understanding, I introduce it. I do not provide direct supportive interventions. I do not give my opinion about problems you're having unless I think there's a real risk issue."

Now, the second stage of contract setting has to do with the particular interferences with treatment that might be represented in the patient's form of acting out.

For instance, a patient who has made suicide attempts—that can derail the person's life, but it can also derail the therapy because there's nothing that makes a therapist more anxious than suicide risk.

So we have to have an understanding. We say, "I know when you're feeling suicidal, it's very intense, but in my experience, people still have a little bit of their mind that they can work with. So if you're feeling suicidal and feel you can't contain it, in this therapy it would be your responsibility to seek emergency services."

The patient often says, "Don't you know when I'm feeling suicidal, I have no ability to act or to function?" I say, "A lot of people think that, but I think there's still a part of you that you could try to muster up that could remind you of this discussion and guide you in this circumstance."

So we have parameters about suicidality, parameters around substance abuse. We might have to recommend, as an adjunctive treatment, a 12-step program. We might have to have drug screening. These are behavioral interventions that are relatively unfamiliar to most analytically inclined therapists, but we feel that without the containment of acting out, you can't do a deep exploration.

So once the contract is in place and the patient agrees to it, we say, "Okay, now we can do the therapy."

Beginning Active Treatment

Abigail Rasol: So now we're going into an active TFP treatment. I'm curious if you can take us through what that looks like for you as a clinician in that room. What are you doing as the treatment begins? 

Frank Yeomans, MD: So after we have an adequate agreement to the contract, now we can start therapy. And that's a real shift from one perspective to another—from setting up the frame to carrying out the therapy.

So you say, "Okay, now the therapy begins," and then what do I do? You say, well, that kind of gets back to what I said—speak freely and say what's on your mind, and I'll be listening.

So in the next session, what's very likely to happen is the patient comes in and there's an awkward silence. And I would say nine out of ten therapists would say, "Oh, what's on your mind?"

In TFP, if you say "What's on your mind?" you are helping the patient avoid a projection onto you.

So if there's that uncomfortable silence, rather than diffusing the anxiety by saying "What's on your mind?" your question as the TFP therapist is: how are they experiencing me that's making it hard for them to report freely what's on their mind?

So you'd wait a couple of minutes and you'd say, "We agreed you'd say what's on your mind, and that's not happening. I wonder how we can understand that."

So they might say, "It's just tough for me to know what to say." So you say, "Oh, that's interesting, because I guess there are things on your mind, but you're not sure they're okay. And I'm wondering if you might be thinking that if you spoke, you'd encounter criticism from me."

What the Therapist Tracks

Abigail Rasol: What are some of the things that you're paying attention to and tracking in the patient, as the therapist, as you're in the active treatment with them? 

Frank Yeomans, MD: What I find most challenging for most therapists is they focus on the verbal content of what the patient says. The patient is telling you information, you process it, you try to understand it.

But what about the other channels of communication? The nonverbal—the patient's actions, facial expressions, gestures, the atmosphere they create. And what about your countertransference—the feelings they evoke in you? We feel in the TFP world that the more important information is the nonverbal and the countertransference.

An example from a supervision I was doing yesterday. The patient is a woman around 30 who is trying very hard to have a successful life in terms of work and intimate relationships, but she isn't getting that far.

And the interesting thing was I read the transcript of the session before I saw the video of the session.

So this patient is saying, "I had the worst weekend, and I had to spend time with my boyfriend's family, and it was awful and everything was terrible." So I thought, oh, this woman's suffering in pain.

When we started looking at the video, the patient is saying this with a kind of smile and lightheartedness. And so at that point it was like, what's going on here? That she seems to be enjoying telling the therapist how bad her boyfriend's family is and how miserable they made her.

So then you might say to her, "You know, it's curious. You're telling me about an awful experience, but your affect in the session seems to be positive. How can we understand that?"

And as the session advanced, we learned that the patient was actually having very harsh, critical thoughts about the boyfriend's family that she didn't want to acknowledge because that made her a mean person.

And a lot of TFP is helping people just see they have an aggressive part. That's okay—we all do. It's better to be aware of it and then figure out how to manage it.

Core Interventions: Clarification, Confrontation, Interpretation

Abigail Rasol: That brings me to my next question in terms of what those active interventions in session look like. From my understanding, there are three core interventions: clarification, confrontation, and interpretation. I'm curious what that one would be labeled as? Also, if you could take us through those three—how and when you choose to use one over the other and the function that each of them serves in the treatment.

Frank Yeomans, MD: Yes, excellent question. We should talk about those three basic interventions, which we consider the core of the interpretive process. And they're not always rigidly carried out stepwise, as in the case I just mentioned.

So let's go to a previous case. I mentioned the man whose girlfriend left him.

In that case, a lot of clarification was necessary. I say, "From what I understand, you had this great relationship with your girlfriend, and after this number of years, abruptly people talked… Is there anything more you could tell me about the relationship, things I might want to know?"

And when the clarification proceeded, it turned out that there were instances when he got physically violent with her. So that's clarification—get more information.

If somebody has a borderline level personality disorder, there are going to be discrepancies in what they tell you because things don't fit together. So that's when you enter into confrontation, which is not a hostile confrontation—we might call it, as Ken Levy has recommended, a "bid for reflection."

We say, "I'm trying to figure out how to put this together. You said it was a perfect, loving relationship, then you said there were these moments of physical violence—how can we put that together?"

And then the patient begins to get uneasy because you're trying to bring to their attention what they've been splitting off and denying in themselves. So you have to proceed very tactfully.

So to get back to the case I just mentioned about the young woman—given the discrepancy between the verbal content and the affect—you might go into confrontation and say, "You're describing a very unpleasant situation, but you seem to be pleased telling me how it unfolded. How could we understand that?"

And that leads toward interpretation.

The interpretation might be: "It seems that it's so intolerable for you to reflect on those flashes of aggression in you that it's better to see it in the other, but maybe we'd make progress by pursuing what seems to have some presence in you that you usually keep at arm's length."

Countertransference: Concept and Clinical Use

Abigail Rasol: I'd like to get back to a topic that you've touched on quite a bit, which I find to be one of the most fascinating parts of TFP — the idea of countertransference.

Countertransference is one of those topics that I think can be very abstract and hard to grasp for a non-psychodynamic clinician. So could you speak a little bit to both what countertransference is on the most basic level and also how it's used as information for the therapist and how it guides your therapeutic interventions?

Frank Yeomans, MD: It's probably what distinguishes our work more than anything else from the other models of treating BPD—the idea that our reactions provide a window into the patient's internal world.

If we define countertransference as the therapist's emotional responses to the patient, there are two sources of my emotional responses. There's my own life—the patient reminds me of my beloved sister, and so I might initially think, "What a lovely person." But of course I process that and don't let that superficial resemblance influence me too much. 

Then we have to talk about the more important part, which is what the patient says and does that evokes a response in you that's from them, not from your past personal history.

And there are two forms of countertransference: one that goes along with what the patient is feeling, and one that is the opposite of what the patient is feeling.

So to give you a simple example: a young man comes in, a university student, and says, "Ah, I'm so bummed out. I failed the exam." And your emotional reaction is, "Oh, the poor guy. I know how hard he tried." That's concordant—you're feeling the sadness and sympathy.

If he comes in and says the same thing and your gut reaction is, "Ah, that lazy son of a — I knew he'd fail the exam," that is probably a complementary countertransference. He's not consciously experiencing that, but that is the internal aggressive object that he's activated in you.

So you might think, "Oh wow, I'm having a really harsh reaction to this guy. Is that something he's exporting from his own mind?" Because he doesn't like to think consciously about that part of him, and he's got it going in me.

And that helps me empathize with him better and understand parts of his internal world he might not be so conscious of.

Abigail Rasol: For clinicians earlier on in their practice, how would you say one is able to really differentiate between whether it is their own life experiences and emotions that are driving their reaction to the patient, or whether it is truly the patient's internal experience being projected onto the therapist?

Frank Yeomans, MD: Well, first of all, you have to know yourself, and having one's own exploratory therapy is very helpful because you want to know what's in you that could be activated.

Even with that, that's why we have supervision groups, because we might have countertransference reactions that we're blind to, but our colleagues might say, "Did you notice in the video the way you said, 'Well, sir…'? That seems to have a little edge to it. So what's going on in you? What's your aggression toward him that came out there, and how can we relate that?"

So we always say, to do good work, you need to have either individual supervision or be in a supervision group.

Using Countertransference in Intervention

Abigail Rasol: In terms of utilizing that countertransference, how actively do you confront that with the client? So are you explicitly sharing your countertransference reactions, or are you using them to inform your interpretation?

Frank Yeomans, MD: We use them to inform. I'd say, "You know, I see how dejected you are. I wonder if another facet of that might be a real harsh attack that's going on in your mind—something telling you you're worthless. Maybe that's a part of your mind we should get to know better, if my hunch is correct."

So we talk about it being in the air, in the room. I wouldn't say, "I'm feeling this—it's actually part of you." I think that sets you up for a lot of problems.

Deciding What Material to Intervene On

Abigail Rasol: Are there any sort of metrics that you use to determine whether and when material is important to intervene on?

Frank Yeomans, MD: I don't think it's going to be a very precise answer, but it's the general principle: we follow the affect.

Where you feel some emotional intensity—either in the patient, as for example in the lady who seemed at ease and even pleased with how badly everybody treated her—you follow that affect.

Or if you're having a strong countertransference reaction, you follow that affect.

You might think, "How is this affect connected to a dyad?" We listen, we try to understand, and then when a dyad becomes relevant, we intervene. And the dyad could be between the patient and us, or between the patient and other people in their life.

Signs of Progress in TFP

Abigail Rasol: What are some of the signs that a therapist can look out for that would signal that a TFP treatment is progressing successfully?

Frank Yeomans, MD: Well, the delightful part of the work is when they begin to have awareness of what they have spent their whole life projecting onto others.

When my patient said, "It was hard for me to come here today because I feel bad about some of that stuff I did," when you see this broadening awareness—this opening up to parts of themselves that were not part of their conscious experience—that's extremely gratifying.

But you have to empathize as the therapist, saying, "I realize how painful it is to feel guilty, to give up the idea you'll find the knight in shining armor, but I think we have to go through this painful part to get you to a state where you'll find a deeper and fuller satisfaction in what life has to offer."

Generally, patients start therapy with what we call a negative or paranoid transference: "You don't like me, you're critical of me, you really want to get rid of me." And we explore all of that.

What emerges over time is that there's a thaw, a lessening of the tension and edge in sessions. And with time, the person seems a little softer with you. And it's very important to actually name that and say, "You know, it seems a little different here than a few months ago—you seem a little more comfortable here. Could that be?"

What we love to see is the unfolding of healthy dependency wishes that were felt to be impossible before because of the conviction that others would be critical and rejecting.

Applying TFP Principles in General Practice

Abigail Rasol: Are there any ways that more generalist practitioners can incorporate specific principles into their work, even if they're not practicing within a strict TFP frame?

Frank Yeomans, MD: That's a whole branch of TFP that's been growing over the past years.

It started out when I was teaching at Bellevue Hospital, a big city hospital. The psychiatric residents treat massive numbers of patients, and I was teaching them TFP.

And they said, "This is great, but in our setting we don't have the opportunity to do long-term individual therapy. We see them for psychopharmacology, we see them in the emergency room, —but we can still use what you are teaching us in all of those settings."

Because they use the object relations conceptualization of the mind. They use the understanding that in the patient's mind there are representations of self and other that get projected onto the treatment interaction, and that if you understand it, you're going to have a better alliance with your patient.

Example: a patient who's coming to you for medication and who's not complying with taking it. A lot of psychiatrists say, "How can I help you if you don't take the prescriptions?" That's probably not going to advance things.

What you could say to the patient instead is, "How can we understand you not taking the medication as prescribed? Do you think I'm just trying to force you to do something and that you have to submit to my will? And of course that would be an unpleasant thing—submitting to someone—so maybe we could think about whether that's your gut-level experience of my prescribing, and that could have something to do with not taking the meds."

So understanding that dyad could help free up the communication between the two parties.

Termination and End of Treatment

Abigail Rasol: I think some people think that therapy—especially psychoanalytic therapy—can be this ongoing, almost lifelong process because there's always more to uncover.

What is the sign that the client is ready to "graduate" from TFP, so to say? 

Frank Yeomans, MD: It has to do with how satisfying the patient's experience in life is.

Are they able to maintain an intimate relationship when they were not before? Are they able to continue on a job or career track, or in their studies, when they weren't before?

And the role of the therapist begins to shift. As the patient has taken in and understood what you've tried to help them know about themselves, your role becomes less active.

You don't have to do all the interpretations—they notice it in themselves. And you become a witness to their better psychological and life functioning. And that's usually when you can stop.

One of my patients said, "You know, I used to automatically think that anything anybody said to me was a criticism or rejection. Now I see how much I was reading into things. Now I see that what a lot of people do in reaction to me is positive. Now I allow for that possibility."

Then she paused for a minute and said, "I hope this understanding of things is real."

And I said to myself, "Okay, she's made it," because she's learned that whatever your reaction is in a situation, it's good to think about it and reflect on it. And once you achieve that capacity to do your own reflection—versus having rigid, automatic reactions—then the person can usually go off and find a satisfying life on their own.

Abigail Rasol: I think that's a really beautiful note to close off on. Thank you, Dr. Yeomans, and thank you so much again to our listeners for joining us today. 

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