Abstract
There are now a large number of publications on borderline personality disorder. Most of these publications describe treatment models from particular theoretical perspectives. This book is different in that it attempts to integrate several treatment models and considers issues presented by specific treatment settings.
I understand that this book is largely based on the treatment guidelines of Spectrum, the Personality Disorder Service of Victoria, which offers consultation and advice to public mental health services. This book therefore addresses many of the issues that arise in the care of people with borderline personality disorder in the public mental health setting.
The authors begin by addressing the misconception that people with borderline personality disorder are not treatable. They note: ‘The belief that these clients were untreatable, whilst understandable at the time [historically], has had far-reaching and long lasting effects. It has been used to support individual and institutional policies of not providing resources and treatment, policies no longer tenable.’ They then proceed with a succinct overview of the treatment options that are available and the evidence for their efficacy.
They present an approach which integrates pharmacological and psychological treatments and discuss the systemic and organizational issues that impinge on the delivery of care.
Deficiencies in a care-giving system are often highlighted when that system attempts to respond to the treatment needs of people with borderline personality disorder, a reminder to everyone of the deficiencies in the care they received in their own childhood. One such deficiency that often emerges in the public mental health system is the lack of a cohesive and consistent treatment. In this care-giving system, treatment is usually provided by multiple carers from various teams or components of a service. Such a care-giving environment is most vulnerable to splitting.
The authors emphasize the importance of a treatment plan as a way of addressing some of these issues and ensuring consistent care. In their model, patients are actively involved in the formulation of the treatment plan and this includes a discussion of possible crises and their management. Clinicians working with these patients in individual therapy settings may ask: ‘So, what's new?’ This approach, which has its origins in dialectical behavioural therapy and is psychoanalytically informed, may not be new, but its widespread implementation in a public mental health system would involve a radical cultural shift.
Some rightly criticize the extent to which the treatment plan is focused on, as it may be misused and become more important to clinicians than the patients themselves. This caveat aside, treatment plans can be rather helpful to the clinician trying to assist a patient with borderline personality in crisis, in the emergency department, at 2 o'clock in the morning.
There is, nowadays, little opportunity for thinking, let alone reverie, in the public mental health setting. However, unless we think clearly through the complexities these patients bring, our responses will continue to be ad hoc and as impulsive as these patients can be themselves. The framework presented in this book, with its emphasis on the treatment plan, could create some thinking space and help to process the anxieties that often emerge in the care of these patients.
One of the anxieties of that clinician in the emergency department at 2 o'clock in the morning may be the risk of suicide by the patient and the likely medico-legal liabilities. The authors note that unless such anxieties are adequately contained, clinicians are likely to be defensive and over-protective in their approaches. Such over-protective responses to chronic suicidality, which often involve prolonged hospitalizations, usually undermine the sense of competence in these patients and can therefore lead to increased long-term risk.
Concerns about medico-legal liabilities are poorly addressed in most books on borderline personality disorder. This book devotes a whole chapter to it. The authors point to the importance of carefully considered responses, consistent treatment plans, peer and organizational support, comprehensive documentation, risk benefit analyses and ‘professionally indicated risk taking’ as critical to a response that is medico-legally responsible.
This book is strongly recommended to all who manage the resources of a public mental health service and are concerned about medico-legal responsibilities. Consultant psychiatrists will find this book either helpful in formulating their approaches or simply in providing the ‘evidence’ that supports their already sound practice. If a registrar or case manager asked me to recommend a book on borderline personality disorder, this would be my first book of choice.