Borderline Personality Disorder: A Clinical Guide, Second Edition

I remember encountering the first edition of this book soon after graduating from my residency. It was one of the few I’d read that pragmatically addressed the tremendous difficulties in treating borderline personality disorder patients. It gave me the feeling that I was neither crazy nor alone.

Along comes this second edition, about which there is much to feel grateful. If you treat borderline personality disorder patients and want to deepen your understanding of these patients, read this book. This recommendation applies whether you are a resident, a clinician in private practice, a teacher, or a supervising administrator. There is something here for everyone. I’ll tell you why.

For the resident, you need definitions, many clinical examples, and direct talk about navigating the minefields, especially, I believe, that of countertransference. There are whole chapters on getting started with individual therapy, descriptions of dialectical behavior and cognitive-behavioral therapies as well as psychodynamic therapies. You need ways to assess your readiness to treat a borderline personality disorder patient. This book gives you explicit guidelines about the process (e.g., p. 239). You need specific advice on the characteristics of effective therapy. This book provides it. In fact, reading Gunderson’s text will likely feel to you like working with a good supervisor.

If you are a clinician in private practice, your greatest problem in treating borderline personality disorder patients may be isolation (this might well be said about the whole enterprise of private practice). Gunderson’s book firmly and repeatedly reminds us of the necessity of what Sheldon Bach (1) calls the “daily mental hygiene of…clearing up the countertransference,” with consultation or a peer group. At what might be called the operational level, Gunderson elaborates a template of four levels of care that constitute a menu for the treating physician. He discusses (chiefly in chapter 5) the separate uses of hospital care, partial hospitalization, the intensive outpatient setting, and their interdependence with traditional outpatient treatment.

The teacher wants all of this and more, i.e., a thorough narrative of the history of the evolution of the diagnosis—from Adolf Stern to Robert Knight—that considers also the massive contributions of Kernberg, Grinker, and Gunderson himself. Intriguing “sidebars”—one- to two-paragraph historical vignettes found throughout the book—raise the question of whether Freud’s “Wolf Man” patient, Van Gogh, and Martha Stewart can be diagnosed as having borderline personality disorder. Stories are useful classroom material.

I have emphasized the psychodynamic sections of the book, but Gunderson also devotes chapters to pharmacotherapy as well as group and family therapies. Using tables, he comparatively rates the efficacy of a number of pharmacologic agents in the treatment of anger and impulsivity, affective dyscontrol, and cognitive-perceptual symptoms.

The physician-administrator will welcome the chapters on case management and public awareness and advocacy.

I have few disappointments with the book. One is the timing of its publication. Gunderson pointedly highlights the intense debate between Kernberg and Linehan and gives special emphasis to Linehan’s dismissal of transference-focused psychotherapy: “Where’s the data?” (p. 287).

Alas, two articles from Kernberg’s group (2, 3), which undoubtedly appeared subsequent to Gunderson’s publication deadline, replied to Linehan’s advocacy of dialectical behavior therapy. In one of the studies (3), both dialectical behavior therapy and transference-focused psychotherapy produced improvements in suicidality as well as several other areas of dysfunction. However, only transference-focused psychotherapy demonstrated clear improvements in impulsivity, irritability, verbal assault, and “direct assault.”

It’s too bad this book could not have come out a little later. It would have been fun to read Gunderson’s take on the newest installment of such a provocative debate.