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Review of "Understanding and Treating Borderline Personality Disorder"

By John G. Gunderson and Perry D. Hoffman (Editors)
American Psychiatric Association, 2005
Review by David A. Flory on Jul 18th 2005
Understanding and Treating Borderline Personality Disorder

Borderline Personality Disorder is a very depressing topic. As the authors of this book point out, research on BPD is about twenty to thirty years behind other mental disorders. Learning more about BPD seems to worsen stress and depression in affected families. The prognosis for people suffering from this disorder is highly variable, recovery is extremely difficult, and treatment options are limited at best. Many books and Internet sites on this disorder are biased and inaccurate, to put it mildly.

Fortunately, Understanding and Treating Borderline Personality Disorder is one of the most complete and responsibly written books I have found on any mental illness. I recommend it without reservation to anyone who needs a comprehensive introduction to what is known--and not known--about BPD.

This book is written in a textbook style with glossaries and summaries at the end of each chapter. The chapters are written by a number of authorities in the field and can be read independently of each other. The editors obviously went to considerable effort to make their work comprehensive and accessible to the general reader.

The intended audiences for this book are the families and therapists of those who suffer from BPD. The relationship between a person with BPD and other family members is often very difficult, with a great deal of disappointment, blame, guilt, and resentment on all sides. It is common for therapists to assume that BPD is simply the result of bad parenting, which can lead to therapy that does more harm than good. While many individuals with BPD have abusive backgrounds, many do not; and most people who suffer abuse do not develop BPD. The authors stress the importance of validating the feelings of clients and loved ones while avoiding patterns of blame and guilt, and give concrete advice on how to achieve this difficult balance.

The authors give detailed descriptions of all the major therapies and treatment programs used with BPD, and discuss the evidence for the effectiveness of each type. The reader may be discouraged to learn that the outcome of therapy and medication is very unpredictable. Certain types of therapies, like Dialectical Behavioral Therapy, have been shown to be helpful in the short term, but the long-term benefits are less certain. Medications can relieve symptoms but rarely cause dramatic improvement.

This book also includes four personal accounts of BPD: two by persons suffering from the disorder and two by family members. I was somewhat disappointed by the former two accounts. They were clear and heartfelt, but seem to play into the stereotype of the "good BPD patient"--female, showing great improvement with treatment, and devoted to (and able to afford) apparently perpetual therapy. Unfortunately, the research in this book suggests that many people with BPD are not helped much by medication or therapy, assuming they can afford it at all. While I understand the authors' desire to be optimistic, it would be helpful to have an idea of how people with this disorder manage despite ineffective or unaffordable treatment, poor emotional support, and employment troubles.

In my opinion, the most serious failing of this book is that it presents BPD as a purely female disorder. Twenty-five percent of people diagnosed with BPD are male, but the reader never gets a basic idea of what a man with this condition would be like. Many borderline behaviors are stereotypically female, and it is hard to imagine how they would appear in a male. The authors mention that substance abuse and acting out is more common in males, but give no examples.

In general, the prognosis for BPD is highly variable. Some patients improve, some stay the same and some get worse. Up to 10% of people diagnosed with the disorder eventually commit suicide. The authors emphasize the poor state of research and treatment options, and hopefully their articulate summary of what is and is not known about BPD will lead to more vigorous study of this serious condition.


2005 David A. Flory


David Flory is a writer and musician with a long-term interest in clinical psychology. He has a B.S. in math from the University of Texas, and he lives in Texas.