Treatment of Borderline Personality Disorder: A Guide to Evidence-Based Practice

Joel Paris has conducted some of the most important research in the field of borderline personality disorder, particularly early studies of childhood adversity and a well-respected follow-back study of the longitudinal course of borderline personality disorder, published approximately 20 years ago. He is also one of the few investigators in the field to have consistently worked as a frontline clinician over the past two decades. More recently, he has been part of a multidisciplinary team, which treats borderline patients from the Montreal community, both individually and in groups.

Paris’ latest book is divided into two sections. The first chapters review what is known about the risk factors for borderline personality disorder, its course, and diagnostic controversies, including high rates of co-occurring axis I disorders. The results of randomized controlled trials of various forms of psychotherapy developed for borderline personality disorder and randomized controlled trials of various psychotropic medications used frequently by borderline patients but developed for other disorders are also reviewed. The reviews of the existing literature in these areas of borderline personality disorder research and clinical thought are not exhaustive but somewhat impressionistic. Paris moves through this material rapidly to a series of clinically informed syntheses. These clinical conclusions (e.g., childhood adversity is not the sole or even main ”cause” of borderline personality disorder; borderline personality disorder has a better prognosis than previously recognized) are generally sound, but more attention to the complexity and ambiguity of the results of the reviewed studies would have improved what is already a good book.

The second half of the book details the author’s own “practical” approach to this always complicated and often stigmatized disorder. This approach recognizes that most clinicians do not have the time, training, or resources to implement one of the four main empirically supported forms of psychotherapy for patients with borderline personality disorder (dialectical behavioral therapy, mentalization-based treatment, schema-focused therapy, and transference-focused psychotherapy). This approach also suggests that it is no longer acceptable to practice treatment-as-usual without knowledge of these empirically based treatments and the common factors and principles that they share (apart from their intensity and considerable length).

This approach centers around three main propositions. The first is that short-term outpatient treatments that provide structure and validation as well as a focus on problem solving may be as good as or better than long-term psychotherapies, whether empirically based or informed treatment-as-usual. In the same vein, Paris suggests that these therapies may be linked together over time to provide a somewhat planned or at least anticipated form of intermittent therapy. The second suggestion is that borderline patients should not be treated with psychotropic medications unless they are suffering from a clear-cut form of comorbidity that is generally responsive to one class of medication or another. Paris is particularly adamant about avoiding aggressive polypharmacy, given its lack of documented efficacy and proven tendency to lead to substantial weight gain. The third suggestion is that suicidal patients with borderline personality disorder should not be hospitalized under most circumstances and, if so, only briefly.

It is difficult to argue with these treatment suggestions. The field is converging on a treatment paradigm very much like the one suggested by Paris. In fact, the eclectic but informed outpatient treatment program in which Paris works provides far more therapy than the average patient with borderline personality disorder would receive in most settings. It is also difficult to dispute the mounting evidence that all medication classes take the edge off borderline symptoms but none are curative. However, a more detailed and nuanced discussion of the reasons most borderline patients are medicated would have been helpful. In a like manner, no one disputes the idea that repeated hospitalizations for suicidal threats or gestures may lead to a regressive spiral that erodes a patient’s sense of self-worth and actual competence. However, it is important to remember that the 10% suicide rate cited by Paris was derived from long-term studies of the course of borderline personality disorder, studies that were conducted during periods when a patient’s statement that he or she felt unsafe was generally a sufficient reason to justify inpatient care. We simply do not know what the suicide rate would be in the absence of such inpatient care. It might remain the same or it might increase, particularly since many clinicians are less experienced, skilled, and knowledgeable than Paris and work in treatment settings that are far more fragmented.