Borderline Personality Disorder: A Clinical Guide [Hardcover]

John G. Gunderson (Author)

Book Description

ISBN-10: 1585620165 | ISBN-13: 978-1585620166 | Publication Date: March 15, 2001 | Edition: 1st

Borderline personality disorder is easily the most widely and commonly used diagnosis for personality disorders in clinical practice todayAaffecting about 2%A3% of the general population, 25% of the inpatient population, and 15% of the outpatient population. This sequel to GundersonAs 1984 Borderline Personality Disorder reflects the explosion of information, expertise, and specialization in borderline personality disorder, covering all recognized treatments for the clinical care of borderline patients in todayAs managed care environment. Integrating scientific advances with clinical lore, it offers a sophisticatedAand uniquely comprehensiveAlook at treatment literature, clinical perspectives, and modalities. Beginning with the diagnosis itself (with special attention to the borderline patientAs specialty, self-destructiveness), this remarkable volume presents the following topics: -The authorAs empirically and clinically anchored theory on the sequencing of goals (i.e., the targets for intervention), processes of change, and modalities best suited for a patientAs changing needs. This theory superimposes a logic on treatment planning and anticipates the sequence of subsequent chapters on specific treatment modalities. -The importance of the primary clinician, easily overlooked because borderline patients receive care in multiple settings, further complicating the already difficult process of obtaining the critical treatment authorizations mandated by managed care. Treatment split among caregivers, made necessary by todayAs managed care environment, is here elevated to a virtue because multiple caregivers add breadth to treatment goals and help prevent flight from treatment by these patients. -The different goals, directions, structure, and staffing of the four levels of care: hospitalization, residential/partial hospital care, intensive outpatient programs, and outpatient programs. -Two seemingly conflicting aspects of psychopharmacology: 1) a guide to selecting medication (the single most widely and uniformly used treatment), and 2) the real-life complexities of prescribing medications and evaluating their effectiveness -Cognitive-behavioral therapies (the major therapeutic advance of the 1990s), especially dialectical behavior therapy; family involvement; and interpersonal group treatment. -An in-depth exploration of psychoanalytic psychotherapy, in which the author argues that this modality (until recently, the treatment of choice for borderline patients) should be used selectively because of the motivation and aptitude required by both patients and therapists. Enhanced by both case reports and sidebars that detail newsworthy, timelyAand controversialAtopics found nowhere else in the literature, this captivating text concludes with a refreshingly optimistic look at the future of effectively treating borderline patients. It will prove an invaluable reference for clinicians, patientsA families, health care administrators, and instructors in psychotherapy, psychopathology, and integrated treatment.

Editorial Reviews

From The New England Journal of Medicine

Borderline personality disorder may be one of the most pleomorphic disorders in medicine. Patients with this diagnosis are a complex mixture of strengths and weaknesses that confuse the diagnostician and frustrate the psychotherapist. Such patients may seem charming, composed, and psychologically intact one day and collapse into suicidal despair the next. Impulsivity, affective lability, frantic efforts to avoid abandonment, and identity diffusion are all hallmarks of borderline personality disorder (although the name of the condition does not necessarily reflect these dimensions). Patients with borderline personality disorder often raise hope in the dedicated psychiatrist only to dash that hope by demonstrating that their apparent gains are illusory. Hatred and contempt may be directed at those who attempt to help them, leading to countertransference and feelings of exasperation and impotence.

Although patients with borderline personality disorder were once seen as having an untreatable and irrevocably chronic disease, specially designed psychotherapies and adjunctive pharmacotherapies have resulted in a sea change in the psychiatric attitude toward these patients. Guided by a growing body of empirical research, psychiatrists can now feel guardedly optimistic about the outcome when a carefully thought out treatment plan has been implemented. The reasons for this sea change are comprehensively discussed in this first-rate book. John Gunderson is uniquely qualified to write this overview of borderline personality disorder. He was present at the birth of the diagnosis (i.e., its entrance into the official nomenclature), and his research had much to do with the establishment of borderline personality disorder as a bona fide psychiatric condition. Having also devoted much of his professional life to the treatment of patients with borderline personality disorder, he has successfully followed that rare dual-career path of rigorous researcher and active psychotherapist.

One of the most compelling features of this book is the author's breadth of knowledge and his evenhanded consideration of various diagnostic and treatment perspectives. Although Gunderson has psychoanalytic training and is an expert in psychodynamic therapy for borderline personality disorder, he is open-minded in his consideration of other forms of treatment, such as ``dialectical'' behavioral therapy, group and family approaches, and pharmacotherapy. In chapter after chapter, he evaluates the strengths and weaknesses of all treatments with an admirable levelheadedness, giving credit where it is due while also pointing out the limitations of any conclusions drawn from the empirical approaches. Moreover, Gunderson is ready to drop personal bias and preferences when the data lead him in a different direction. When research is lacking, he fills the gap with abundant clinical wisdom and marvelously illustrative case examples. He lets the reader know what he actually says to patients in particular situations so that other clinicians can evaluate the merits of his approach.

Gunderson also describes the typical course of treatment to help guide the reader through the various phases, each with its own set of goals. He is a firm believer in multimodal strategies, and he repeatedly stresses the value of having multiple clinicians involved in order to dilute the intensity of the transference and countertransference. Whereas the importance of families to intensive long-term treatment of borderline personality disorder was once marginalized, Gunderson strongly advocates the use of family interventions much like those proved so effective in the treatment of schizophrenia.

Despite my overall positive impression of this book, I have several reservations as well. Gunderson uses idiosyncratic terminology that is likely to confuse some readers. Although the term ``boundary violation'' is generally used to describe ethical transgressions by clinicians, Gunderson uses it to describe acting-out behavior by patients who are testing the limits of the therapeutic frame. Unlike therapists, patients have no professional code of ethics to which they must adhere. The use of the term ``boundary violation'' is thus misleading and can be construed as blaming the patient.

Gunderson also draws what I consider a specious distinction between treatments and therapies: ``treatments (e.g., medication, diet, hospitalization) are given to patients; a patient passively receives (or resists) but does not initiate. Therapies require shared goals and at least intermittent collaboration.'' From my point of view, hospitalization, diet, and pharmacotherapy require just as much collaboration as psychotherapy, and separating psychotherapy from the array of psychiatric treatments merely reinforces prejudices in the society at large that psychotherapy is not a ``real'' treatment. I also think that Gunderson defines dynamic therapy too narrowly, since he emphasizes that it may be incompatible with the setting of limits and the managing of safety -- tasks he relegates to a primary clinician involved in ``case management.'' Most dynamic therapists include generous helpings of management in their psychotherapeutic approaches to borderline personality disorder.

My final reservation is one of form rather than content. Throughout the book a number of excellent points are made in sidebars to the text. I found that this approach interrupted the smooth flow of the narrative.

Having stated my quibbles with the author, I would still recommend this book as the best state-of-the-art writing on the subject of borderline personality disorder. The clarity of Gunderson's prose style is marvelous for teaching purposes. Experienced psychiatrists and other mental health professionals will find it equally useful because of its combination of both a scholarly and a practical approach. Even families of patients with borderline personality disorder can gain a great deal from a careful reading of the book. I have always been reluctant to recommend books to patients and their families, but this one is an exception. Gunderson has managed to write a book that bridges the gap between professional clinicians and those they treat.

Glen O. Gabbard, M.D.
Copyright © 2001 Massachusetts Medical Society. All rights reserved. The New England Journal of Medicine is a registered trademark of the MMS.

Review

"This is a state-of-the art integration of clinical, empirical, and theoretical knowledge of the nature and treatment of borderline personality disorder, written by one of the central people who framed the construct of borderline. Gunderson has done a masterful job of weaving together an increasingly empirical portrait of the disorder with a wealth of clinical knowledge, creating a portrait that is both clinically recognizable and empirically sound. He also provides the reader with a broad, balanced view of the multiple ways of understanding and treating the disorder that have emerged since his first authoritative review of the literature over 15 years ago. This book is essential reading anyone working with borderline patients, from trainees through experienced clinicians and researchers."- "Drew Westen, Director, Adolescent and Adult Personality Programs, Center for Anxiety and Related Disorders, Research Associate Professor, Boston University"

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Product Details

• Hardcover: 329 pages
• Publisher: American Psychiatric Publishing, Inc.; 1st edition (March 15, 2001)
• Language: English
• ISBN-10: 1585620165
• ISBN-13: 978-1585620166
• Product Dimensions: 9.2 x 6.1 x 1.1 inches
• Shipping Weight: 1.6 pounds
• Average Customer Review: 3.3 out of 5 stars  See all reviews (7 customer reviews)
• Amazon Best Sellers Rank: #1,834,554 in Books (See Top 100 in Books)

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Most Helpful Customer Reviews

20 of 24 people found the following review helpful:

5.0 out of 5 stars A "must have" for anyone in this field, June 1, 2003

By A Customer

Amazon Verified Purchase

This review is from: Borderline Personality Disorder: A Clinical Guide (Hardcover)

I just got this book and have not read it cover to cover - probably never will, but that's not what I got it for. Rather, for me (as a practicing clinician and supervisor) it is the kind of book I will refer to frequently as needed - it contains a goldmine of up to date synthesis, overview, summary, commentary, advice, nifty tables, etc. in just about any area related to treatment of the Borderline Disorder and beautifully organized and accessible. All that and it combines empirical and theoretical issues very smoothly. It could certainly be read profitably front to back by someone wanting a course in the subject. As an added bonus I have already found it very useful in putting together an insurance review!

19 of 23 people found the following review helpful:

5.0 out of 5 stars A Cornerstone Title for any Borderline Literature Library, October 24, 2001

By A Customer

This review is from: Borderline Personality Disorder: A Clinical Guide (Hardcover)

Covers ALL aspects of the condition from etiology, new theories, treatment and pitfalls. Although technical in nature, treaters should have no problem in getting through the material and greatly enhancing their understanding of Borderline Disorders.

7 of 7 people found the following review helpful:

5.0 out of 5 stars The gold standard, April 19, 2006

By 

Christopher J. Morley "cjm" (Denver, CO USA) - See all my reviews
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This review is from: Borderline Personality Disorder: A Clinical Guide (Hardcover)

If you know about Borderline Personality Disorder, you know that Gunderson is the standard-setter. After years of research, Gunderson demonstrates repeatedly that he has a command of the subject matter unsurpassed by other professionals. His conceptual model is also more helpful than others (e.g., DSM-IV-TR).