What Is ‘Good Psychiatric Management’ for Borderline Personality Disorder?

Most psychiatrists dislike and avoid treating patients with borderline personality disorder (BPD), according to John Gunderson, M.D., a professor of psychiatry at Harvard Medical School and director of the BPD Center for Treatment, Research, and Training at McLean Hospital. This is truly unfortunate, he said, because it is based on misinformation about the disorder. It is against this backdrop that Gunderson introduced a new therapy for BPD called “Good Psychiatric Management” (GPM). GPM was shown to have been as effective as good quality DBT in a multi-site Canadian study (McMain et al., Am J Psychiatry, 2009). A new book that Gunderson co-wrote with Paul Links, Handbook of Good Psychiatric Management for Borderline Personality Disorder, offers practical “how to” instructions.

GPM’s message, said Gunderson, is that psychiatrists should no longer refer their borderline patients to specialists; they can and should become “good enough” to help the majority of borderline patients recover—and then enjoy the bonus of seeing them stay recovered.

Gunderson emphasized four distinguishing features of GPM. The first is its emphasis on psychoeducation. Patients and their families are taught about the disorder’s natural course, and with this, they are encouraged to expect change and to raise questions about treatments where change isn’t occurring. They are also taught about the interaction of BPD’s genetic disposition with the family environment. The take-home messages are that parental interactions were—and still are—important, but that these are children whose interpersonal hypersensitivity made them particularly difficult to parent.

A second distinguishing feature of GPM is that it is more case management-oriented than psychotherapies, that is, the focus is on the patient’s life outside therapy more than on the interactions within the therapy.

A third distinction is that GPM encourages flexible use of other modalities such as group therapies, family interventions, and medications. Indeed, psychiatrists are encouraged to integrate medication management alongside their other clinical activities. GPM offers specific guidelines about how to select medications and, given the common comorbidities, when BPD should be the primary treatment target (for example, depression and bulimia) and when it is secondary (for example, substance dependence or mania).

The fourth distinction is that GPM maintains a focus on the big goals of “getting a life,” meaning stable partnerships and vocations. Gunderson said he hopes this model of treatment may prove useful in addressing the social adaptational handicaps that often limit the life satisfaction of these patients.

APA members may purchase Handbook of Good Psychiatric Management for Borderline Personality Disorder at a discount here. The book is published by American Psychiatric Publishing.