Integrative Treatment for Borderline Personality Disorder

Severe personality disorders are at the top of the list for many clinicians when asked which group of patients are the most challenging to treat. These challenges often result in clinicians' questioning their skills or feeling resentful toward the patients. Although personality disorders as a group are fairly prevalent in the general population, little attention is paid to them and how they affect the delivery of medical care. In a somewhat cynical view, this is because there are no novel therapeutic agents approved for the treatment of personality disorders, which would then provide the army of pharmaceutical company representatives and hosted lectures. These heterogeneous groups of patients are high utilizers of services, have longstanding illness, are entrenched in the mental health care system, and at first blush offer little hope for a “cure.” Of the list of personality disorders, borderline personality disorder meets many of these criteria, and insurance companies have often seized on this in an attempt to limit expenditures. Although this portends a challenging therapeutic encounter, it also offers a potential for therapist growth and mastery. The motivation behind Integrative Treatment for Borderline Personality Disorder is to provide the therapist with the necessary toolbox to survive and even thrive when treating patients with borderline personality disorder. Although this volume is primarily aimed at therapists treating patients with borderline personality disorder, in the course of the book the author identifies diagnostic concepts and treatment strategies that make the text a valuable read for all therapists. Acknowledging up front some of the difficulties encountered in treating this population, the text seeks to develop in the reader an awareness of where the common pitfalls are and how to successfully navigate them in a typical treatment course. The target audience is mental health care workers at all levels of experience and does not require significant prior experience with psychodynamic or cognitive-behavioral therapy (CBT). However, those clinicians who have struggled in treating this population will undoubtedly see some of their interactions in the clinical scenarios detailed. In focusing on borderline personality clients, the author meets 2 difficult challenges: first. clarifying diagnostic issues for this population and providing etiological evidence; and second, integrating diverse treatment modalities, ranging from traditional psychodynamic theories to the more modern CBT/dialectical behavioral therapy, with a sprinkling of psychopharmacology on top. Dr. Preston is a practicing psychologist and has served on the faculty of the University of California, Davis, medical school. Moreover, he has earned his writing chops by authoring over 17 books on the subject of mental illness. His personal experience treating patients with borderline personality disorder shows in his clinically focused text. His prior authorship has given him a clear and concise writing style, which is easily digested and relatively jargon free for the novice reader. This book at times reads like a therapy manual and at other times seems more like a casual conversation with a learned colleague. However, it is full of clinical vignettes, which bring the material to life by detailing therapist-client dialogues that demonstrate key points and serve to clarify theoretical observations. To accomplish the task at hand, the author has divided the text into 4 sections. The first ensures that an accurate diagnosis is made. In doing so, Dr. Preston argues that borderline personality disorder more accurately represents a spectrum of presentations. The concept of identifying and working with the client's ego strengths rather than the DSM-IV criteria is what he feels is tantamount. The second provides etiologic evidence for the diagnosis by summarizing the key points under both neurobiological and environmental development theories. The third section outlines some of the core characteristics of the disorder with an eye to how this will affect treatment. Additionally, the fundamental and common components of the varied treatment approaches are identified. Against this backdrop, the fourth section of the text details specific treatment strategies, often invoking the language of cognitive-behavioral techniques with an eye toward the briefer therapy often mandated by insurance. Specific sections on self-injurious behavior and emotional dysregulation make it easy to absorb the recommendations. One of Dr. Preston's greatest accomplishments is getting all of the above done in a text under 200 pages. For the novice therapist, it distinguishes the forest from the trees with respect to the treatment of borderline personality disorder. For the more seasoned clinician, the text provides a thorough summary of the disorder with updated information and a more integrated approach than typically given by authors who have sworn an allegiance to a particular psychotherapy school. Perhaps even more important is the anti-burnout reminder scattered throughout the text; the treatment goal for these individuals may not be “cure” but rather relieving some of their psychic pain. This makes the tempest we experience in the office an opportunity for successful interventions that can accomplish this goal, leaving both participants better off for the encounter.