Handbook of Good Psychiatric Management for Borderline Personality Disorder

We have learned a great deal about borderline personality disorder. It is a moderately heritable condition that, when precipitated by environmental stress, generally has its onset in late adolescence or early adulthood. Although long thought to be stable and enduring over time, we now know that, as defined in DSM-IV-TR (and DSM-5, section II), borderline personality disorder demonstrates quite high rates of remission over time (1, 2). In spite of high rates of diagnostic remission, however, inherent pathological traits and impaired levels of social, interpersonal, and occupational functioning remain relatively persistent (1–3).

Brain imaging studies have shown, among other things, that patients with borderline personality disorder have reduced connectivity between the prefrontal cortex and the amygdala (4), suggesting that borderline patients have a “double hit”—the limbic emotional motor is hyper-reactive to real or perceived stress, and the cortical brakes don’t work, making it very difficult for the borderline patient to down regulate intense emotion once it has been activated—and it gets activated all too frequently in the context of interpersonal turbulence. In 2001, the APA issued the first evidence-based practice guideline for the treatment of patients with borderline personality disorder, which recommended psychotherapy as the primary, or core, treatment for the disorder (5). Subsequently, borderline personality disorder practice guidelines have been developed in the Netherlands, the United Kingdom, Germany, and, most recently, Australia, all of which make the same recommendation. At the time of the APA guideline, two specific manual-guided types of psychotherapy (dialectical behavior therapy and mentalization-based therapy) had been shown by randomized controlled trials to be effective for borderline personality disorder. Since then, randomized controlled trials have demonstrated the efficacy of many other types of psychotherapy for borderline personality disorder, including schema-based therapy, transference-focused therapy, cognitive-behavioral therapy, and general psychiatric management. Developed by a clinical research team in Toronto, General Psychiatric Management was aligned with the treatment principles outlined in the APA practice guideline and compared with dialectical behavior therapy in a randomized controlled trial with borderline patients. Both treatments were effective, and there were no significant differences between the treatments (3).

As a follow-up to the published randomized controlled trial, Paul Links and the general psychiatric management research team developed a treatment manual to assist practitioners interested in utilizing this method. In order to make this material widely available, Links teamed up with the master borderline clinician, John Gunderson, to build a superb guide for clinicians, now available in this new work, a gem of clinical wisdom chock full of pearls to guide the novice but also to rejuvenate the expert. For routine clinical work, the term “general psychiatric management” was changed to “good psychiatric management.” The impact of this book is powerful, since it presents clear and persuasive principles, then presents rich case descriptions with “decision points,” presenting the reader with a set of choices around key issues in therapy, followed by gentle and wise guidance about the pros and cons of each choice. And that’s not all, since the book is vastly enriched by a set of videos, demonstrating the therapeutic approach. Guiding principles include 1) offer psychoeducation; 2) be active, not reactive; 3) be thoughtful; 4) understand that both you and the relationship are real; 5) convey that change is expected; 6) expect the patient to be accountable; 7) focus on life outside of therapy; and 8) be flexible, pragmatic, and eclectic. Simple-sounding yet elegant principles that are wonderfully helpful to have in mind when working with borderline patients, and to reread frequently after stormy sessions when all of these principles seem to evaporate from our minds.

One of the many strengths of this book is the repeated emphasis on helping patients with borderline personality disorder develop the capacity for restraint and the power to push the pause button before acting on impulse. Many years ago at New York University, the neuroscientist Joseph LeDoux said that the goal of psychotherapy was to teach the cortex how to control the amygdala (6). We now know how right he was, and we’re beginning to be able to see the changes in the brain that occur in the course of psychotherapy. Patients with borderline personality disorder no longer need to lose hope, in spite of inevitable struggles and spells of hopelessness. This book has the potential to help therapists of all stripes to sit side by side with their patients and eventually get to a much better place. Overall, this book is a masterpiece of clinical wisdom, a gift from two experienced clinicians who have devoted their careers to improving the lives of borderline patients and who openly share what they have learned. An important part of their message is that it takes time—meaning years—for therapists to become comfortable and confident in this work, but it can happen, and it is worth it.