Borderline Personality Disorder: A Clinical Guide

If this book were a new opera composed by John Gunderson and conducted by him at a worldwide premiere performance at one of the famed houses in Milan, Paris, London, or New York, everyone in the audience, including this critic, would stand up impulsively and cheer. Indeed, stand up and cheer we must.

John Gunderson became interested in borderline patients during his psychiatric residency at the Massachusetts Mental Health Center in Boston. In 1971 he went to the National Institute of Mental Health and, together with William Carpenter and John Strauss within the framework of the International Pilot Study of Schizophrenia, compared a sample of 29 patients with schizophrenia and a group of 24 borderline patients who had all recently been admitted for hospitalization on the severity of 27 psychopathological dimensions ranging from anxiety to withdrawal (1). They demonstrated that in regard to symptoms, these severely ill borderline people, until then often diagnosed and lumped together with patients with schizophrenia, were clearly distinct from the group with schizophrenia.

In the course of this work, Gunderson also reviewed the then existing descriptive accounts, theories, psychodynamic formulations, psychological testing results, and treatment recommendations of borderline patients, some 25–50 papers in all, including important and seminal contributions by Adolph Stern (2), Roy Grinker (3), Otto Kernberg (4), James Masterson (5), and Gerald Adler (6). Some of the publications were semantically confusing, discrepant, or simply a jumble of words describing behavior, dynamic formulations, or symptoms. In an audacious, vigorous, youthful, and memorable article, Gunderson and Singer (7) distilled this material and identified six coherent factors they judged characteristic of most borderline patients according to most of the publications. I well remember reading that article with astonishment and saying to myself that this essay would change the world of borderline patients. It did.

Gunderson’s work, together with the brilliant contributions of Grinker (3), Kernberg (4), Masterson (5), and Michael Stone (8) on the one hand and Kety, Rosenthal, and Wender (9) on the other, enabled Spitzer, Endicott, and Gibbon to develop a 22-item set that they mailed to 4,000 members of the American Psychiatric Association in January 1977. There were 808 usable responses, and these ultimately resulted in the first formulation of criteria for borderline personality disorder and schizotypal personality disorder (10). Thus, to a very large extent, not only Gunderson’s conception but also his delivery led to the birth of borderline personality disorder in DSM-III for the first time in 1980. This in turn brought this large group of very ill and difficult patients, once the subject mostly of theorizing and treatment in the psychoanalytic community, into mainstream general psychiatric thought and investigation.

And a large group of patients it is. As Michael Stone (11) has pointed out, estimates of the prevalence of borderline personality disorder in the United States are in the range of 2.5%–3.0%—about the size of the population of Denmark or Sweden. To be sure, the specific diagnosis of borderline personality disorder defines a significantly more selective universe of patients than Kernberg’s very creative and valuable category of borderline personality organization, a structural diagnostic qualifier encompassing several specific diagnoses that includes approximately “10% or more of the entire population, or, in the case of the United States, a separate ‘nation’ of patients with borderline disorder as populous as Canada” (11) or Argentina.

Since Gunderson and Singer’s 1975 article, thousands of books, clinical reports, and research studies have been published on borderline personality disorder in the United States alone, not counting the entirely independent French work on les états limites or les psychoses blanches and the influence of U.S. work on German publications on das Borderline-Syndrom and die Borderline-Persönlichkeitsstörung. Gunderson’s innovative persistence and his findings, together with Zanarini and Frankenburg (12), first hinted at in 1975 (1), that brief, transient, and reversible psychotic (“quasi-psychotic”) experiences are a characteristic of the lives of many patients with borderline disorder led to the inclusion of transient paranoid ideation and severe dissociative symptoms among the nine criteria for borderline personality disorder in DSM-IV.

Borderline Personality Disorder: A Clinical Guide is an utterly distinguished and unerringly honest book, a meticulously crafted state-of-the-art summary of our knowledge about the diagnosis, the levels of treatment, and modalities of psychotherapy for this illness. This volume gives the reader Gunderson’s expert views as refracted through the prism of his 30-year-long experience in research on borderline disorders as well as teaching, consulting, and treating borderline patients.

Unfortunately, at present, a disquieting and unbridgeable moat separates the estimated 7–8 million people in our nation with borderline personality disorder from the resources necessary for its successful treatment, so graphically illustrated—with evidence from about 700 publications—in this work. While reflecting on Gunderson’s timetable for changes in these patients in the course of at least 5 years of psychotherapy (Figure 3-2, p. 73), I recalled my last conversation with a utilization manager of a company “managing” psychiatric benefits for health insurance firms and their authorization of seven psychotherapy appointments for one of my patients! Our society has made the anachronistic decisions to provide vigorous financial support for research on neuroscience and mental illnesses but to withhold the funds necessary for the implementation of the practical conclusions of these projects for the benefit and treatment of mentally ill people—thus abandoning them.

Two early chapters of the book provide background on diagnosis and differential diagnosis. Gunderson goes over in great detail the provenance of the diagnostic criteria for borderline personality disorder from the research of the major contributors to the field and the subjective suffering patients experience living life with borderline disorder. He makes the point that borderline personality disorder, by far the most important type of personality disorder, is such a major disorder of the self that it requires priority in planning meaningful rehabilitative treatments and therefore deserves categorical status of equal weight with axis I disorders. This then leads to dilemmas in differential diagnosis thoughtful psychiatrists can encounter in having to decide on a primary diagnosis of borderline personality disorder versus one of bipolar disorder, major depression, posttraumatic stress disorder, narcissistic personality disorder, or antisocial personality disorder.

The ensuing three chapters provide an overview for the treatment of borderline patients. These include therapeutic processes and the functions they serve; a potential sequence and timetable of expectable changes in behavior, affect, social functioning, and object relations; three sequential levels of alliance; case management and the responsibilities of the primary clinician; assessing and responding to recurrent suicidality; boundary violations; and various modalities of care, i.e., hospitalization, residential treatment, partial hospitalization, and outpatient psychotherapy. Here Gunderson distinguishes between treatment that is prescribed to patients, e.g., hospitalization or medications, who receive them with acceptance or resistance, and psychotherapy that to be successful requires assertive collaboration, inquisitiveness, and sharing of goals on the part of the patient.

There are valuable nuggets to be harvested in these chapters: initial “no-therapy” therapy (p. 90); “contracting for safety” (p. 93); responding to chronic suicidality with “false submission” (p. 97); sequential responses to boundary transgressions (p. 102); and the concept that the splits of patients with borderline disorder are not solely the product of their projections (p. 103). However, the language of Sidebar 3-2 (p. 80) is confusing. Patients with borderline disorder are certainly able to contract for therapy and to sometimes experience their therapists as caring and likable (Table 3-4, p. 79), but their internalized representations of others and of themselves are partial and polarized, typically leading to split-off, alternating idealized or persecutory perceptions of their therapists. As a result, they cannot establish a reliable collaborative working alliance until well into treatment, hence, the “myth of the alliance” described by Gerald Adler (13).

Along the way, Gunderson introduces pharmacotherapy; cognitive behavior therapies, including dialectical-behavior therapy and psychoeducation; family therapies, including suggestions for psychoeducational materials; and interpersonal group therapy. The detailed discussion of working with families of patients with borderline disorder as potential supports for their treatment, beginning with initial meetings and then establishing an alliance and on through psychoeducation to possible selectively used psychodynamic family therapy, is immensely helpful.

Gunderson is straightforward in regard to dynamic psychotherapy: appropriate patients need to be able to control their impulses and be introspective, psychologically minded, and motivated to change. Even so, the dropout rate is very high. Many psychiatrists, psychologists, social workers, and advance practice nurses are not interested in the issues borderline patients struggle with and are not competent to do psychotherapy with them. Those who are competent have their own lives together, are capable of “holding” patients, believe the patient is suffering and can change, are convinced they can help with issues of dependency and anger, and are themselves nothing less than attentive, authoritative, challenging, clear, confident, conscientious, durable, engaged, and responsive. Competence, not gender of the therapist, is the issue. Table 11-5 (p. 254) helps patients choose such a paragon of virtue as a therapist, and Table 12-5 (p. 272) lists the expectable ultimate results of intensive, long-term psychodynamic therapy.

According to Gunderson, patients move in therapy from engagement to a relational alliance, then through acceptance of a positive dependency on their therapists to secure attachment and a true working alliance, and, finally, to consolidation and integration of their selves. In the course of these phases of therapy, they need, at different junctures, both Gerald Adler’s deficit-oriented Kohutian validating corrective relationship and Otto Kernberg’s conflict-model interpretive transference analysis. These theoretical perambulations are judiciously sprinkled with examples of inquisitive, gentle, and nonauthoritarian interventions, Gunderson’s style in conducting psychotherapy.

Throughout, Gunderson champions split treatment, i.e., treatment that involves “two treaters, two modalities, or any two components…e.g., hospital and psychotherapist, psychopharmacologist and family therapist, a primary clinician and self-assessment group” (p. 104) to safeguard the psychotherapist from becoming a “bad object” from which the patient must flee. I applaud the principle and goal of these suggestions. Unfortunately, such multiple modalities, other than two treaters, are not readily available in a noninstitutional, office-based practice where the vast majority of patients with borderline disorder are seen as outpatients. If it is difficult to find one competent psychiatrist for dynamic psychotherapy, as the author avers, what are the chances of finding two competent, independent professionals, in agreement on goals and methodology, to take care of a single borderline patient? Split treatment by two independent treaters, in a noninstitutional setting, is fraught with great dangers and difficulties for a person with borderline personality disorder. No one knows that better than Gunderson, who, together with Sara Bolton (14), has eloquently described the tragic result such split treatment had for a female physician with borderline personality disorder.

That said, this volume is a first-rate work of scholarship that I highly recommend to all those interested and involved in the treatment of persons with borderline personality disorder, including and especially psychiatric residents. Gunderson writes affectingly and gives an attuned, resonant account of the conflicted lives and deficits of these uncommitted people and the dilemmas their physicians face. The writing tempers rigor with compassion, is minutely detailed, and puts these dislocated people and our growing understanding of them into context. Gunderson’s work and this book are admirable and immensely valuable achievements.