Lois W. Choi-Kain, MEd, MD, director of the Gunderson Personality Disorders Institute and its research program, is the guest editor of a new issue of the American Journal of Psychotherapy, titled “Good Psychiatric Management of Borderline Personality Disorder.”
The journal issue, published March 15, contains original research studies, including several from Mass General Brigham researchers.
The focus of the issue is good psychiatric management (GPM), also known as general psychiatric management, a treatment for borderline personality disorder (BPD) that was designed to allow clinicians to take a generalist approach to treat the disorder.
This concept originated from the understanding that specialized BPD treatments that are effective—such as dialectical behavior therapy (DBT), mentalization-based treatment (MBT), schema-focused therapy (SFT), and transference-focused psychotherapy (TFP)—require many years of training and are not offered by all therapists, and as a result, access to such care can be limited.
On the other hand, any mental health (or other) clinician can use GPM techniques, and some studies have shown that this approach is just as effective as some of the specialized psychotherapies.
In a commentary published in the same journal issue, Choi-Kain explained that a GPM-care approach for BPD can meet patients’ mental health needs despite the disorder’s complexities.
In this Q+A, Choi-Kain explained the unique treatment needs for people with BPD and how research efforts such as those featured in this new journal edition could benefit the patient community.
What is borderline personality disorder and how might it impact an individual’s life?
Borderline personality disorder (BPD) is a common psychiatric condition related to instability in managing oneself—in terms of self-direction, self-esteem, and identity—as well as in managing relationships with others. Its most high-risk symptoms, like suicidality and self-harm, arise from behavioral disinhibition that people with BPD experience in the face of stress.
Relatedly, emotional experiences are also reactive, volatile, and extreme for people who live with this condition—leading, on one end, to emptiness and numbness and, on the other, to pervasive anxiety, punctuated at times with fits of rage, especially in males.
While life-threatening—related to its heightened risk for death by suicide, victimization by trauma, and other co-occurring psychiatric and medical problems—BPD is treatable and responds to numerous psychotherapies designed to treat its core features.
Describe some of the treatment challenges for patients with BPD?
While psychotherapies are quite effective for BPD, no medications have ever been proven consistently effective for this diagnosis. The problem is that most of the manualized therapies are highly specialized and require training and structured resources for their implementation.
Furthermore, these psychotherapy interventions are short-term, and may lead to remission of symptoms but don’t address functional recovery to enable those with BPD to resume the human project of developing a life with meaning, purpose, and connection to the community.
A primary care approach to supporting those with BPD is needed, and this might come before, after, or instead of specialized therapies, especially when they are not available.
Can you explain “good psychiatric management” and what people whose lives are touched by borderline personality disorder should know about it?
Following the lead of John Gunderson, MD, who believed people with BPD would respond to treatments that were developed with their needs in mind, GPM carries the spirit of egalitarianism and a push to offering something good enough to everyone.
Clinicians of all stripes can do some version of GPM, so that we can save the limited resources we have in the specialized therapies for when and where they are really optimal and feasible.
GPM relies on a model of understanding BPD as a problem of interpersonal hypersensitivity, where those with this disorder are so insecure they fear being alone. Therefore when important relationships are threatened, they may react with fight (devaluation, blame, volatile reactivity towards others) or flight (turning anger inward with self-criticism, self-harm, and self-sabotage).
Leaning in to help those with BPD so they can master life’s challenges instead of blowing up or shutting down can empower them to rely on themselves in times of stressful challenges. Clinicians are urged to use good and informed judgment, falling back on basic principles of good health care such as diagnostic disclosure, patient education, focus on functioning with the condition, and rehabilitation in the community.
We have adapted GPM to provide early intervention in adolescence (GPM-A; Choi-Kain & Sharp, 2022) as well as with other disorders that commonly co-exist with BPD such as alcohol use disorder (GPM-AUD; Choi-Kain & Connery, 2024).
We are also currently drafting an adaptation of GPM for primary care providers (PCPs) who are increasingly shouldering responsibility for a growing segment of individuals seeking mental health care.
John Gunderson had a great quote in the GPM Handbook: “You don’t need to be a specialist or selflessly devoted to be good enough; you need to be warm, reliable, interested, and unintimidated, and you need basic knowledge about case management to provide GPM to patients with BPD.”
I think this is a much-needed message to expand the reach of the many advances we have collectively made in the treatment of BPD and other severe personality disorders.
What advice do you have for newly diagnosed patients and/or their families when it comes to seeking care?
Young people need to balance a need for freedom and autonomy with the steady support of a secure base at home. When young people have BPD emerging in their lives, they need a consistent support system that helps them stay on track in school and among their communities of social connection, while also attending to their unique needs and sensitivities.
The good news is that all the ingredients of treatments that work for BPD arm people with useful psychological toolkits to be more resilient to stress, effective in managing one’s inner life, and collaborative with others around them. These psychosocial skills are helpful for us all, and more necessary for people with the stress and interpersonal hypersensitivities of BPD and its related conditions.
