This handbook by Arthur Freeman and
Gina Fusco offers advice to clinicians working with patients who have mild to
moderate symptoms associated with Borderline Personality Disorder (BPD). The
purpose of this book is to help clinicians to take control of therapy, an idea
that suggests that, otherwise, BPD patients threaten to control its direction.
While patients with this diagnosis have a reputation for being manipulative,
there are reasons to worry about instruction books that warn clinicians about
these patients. (Cf. Nancy Potter, 2006, "What is manipulative behavior,
anyway? Journal of Personality Disorders 20(2): 139-156.) On the other
hand, the authors treat prospective patients with respect and grant them a role
as collaborator in therapy: Taking Control (as this program is called)
"asks patients how they wish to focus treatment, what areas they feel they
need help in, and how they want to alter, modify, and change maladaptive
behaviors that have resulted in discomfort or difficulty functioning" (p.
18). While I worry that Taking Control is overly rational for patients who are
purportedly mentally ill, I admire Freeman and Fusco's belief that patients
have the ability to be or become more rational. For example, they ask patients
to "examine their thoughts and try to prove themselves wrong" and to
"not only weigh the evidence, but also draw conclusions from that
evidence" (p. 89).
Drawing heavily on Beck's framework
for cognitive behavioral therapy, the authors frame the difficulties that BPD
patients face as that of incongruent schemas. A central aim of therapy, then,
is to identify problem schemas and to restructure them. To that end, Freeman
and Fusco set out the structure for therapy sessions (allowing for some
flexibility) and then move through each of the nine criteria for BPD, giving
explicit suggestions for how to conduct each segment of sessions on a given
criterion. A combination of therapist observation, what they call Socratic
questioning, and patient self-monitoring are used. A patient workbook (Borderline
Personality Disorder: A Patient's Guide to Taking Control) accompanies the
therapist guide, which workbook looks quite useful itself.
Freeman and Fusco illustrate how
therapists, in conjunction with the patient workbook, can assist patients in
identifying automatic thoughts that arise in situations that are problematic
for the patient. They state that "a goal of treatment is considerable
reality-testing aimed at resisting the impulse to dismiss the entire human race
as neglectful and abandoning and remaining cautious enough to know when a
situation may not be for the best" (p. 85). This is plainly put and is an
important point to emphasize to other clinicians.
Each criterion of the diagnosis is
introduced to the patient and defined for them. As Freeman and Fusco say,
"Each detailed definition includes definitions and synonyms for critical
words--as defined in Webster's Dictionary..." (p. 26). I find this an
appealing idea; unfortunately, by relying on Webster's, they fail to offer a
richer conceptual analysis, and this limits its usefulness. For Criterion 1,
"frantic efforts to avoid real or imagined abandonment", the authors
identify "frantic" and "abandonment" as the terms to be
defined; they say of "frantic" that it means "marked by extreme
excitement, confusion, agitation" (p. 80). I would expect that BPD
patients, who are typically characterized as bright, would know this. The
definition of "abandonment" is just confusing: "The state of
having been given up and left alone; the act of forsaking." The change in
focus from being the one acted upon to the one doing the acting cannot help but
On the other hand, at times the
treatment of a criterion is very useful. When discussing identity disturbance,
Freeman and Fusco write, "Your patients have identities--they are just not
defined" (p. 114). They urge clinicians to help patients identify aspects
of themselves, for instance by reminding them of parts of their lives that are
clear such as a role in the family or a job or even prior decisions. This is an
unusual and refreshing take on the criterion of identity disturbance.
Each criterion is accompanied by a
specific worksheet. Worksheet 11 addresses techniques for a patient's
self-assessment of cognitions related to triggers; I think this one is
especially good in addressing the so-called black-and-white thinking of BPD
patients. Included are The Catastrophic Thinking Chart, Challenging Dichotomous
Thinking, the Disputation Chart, the Negative and Positive Consequences Chart,
and the Impulsivity Chart. The patient brings in the worksheet into the
sessions related to that specific criterion and patient and therapist use the
worksheet as part of the discussion.
Some of the advice is quite
helpful. For example, "It is imperative that you reframe disorder
by describing the personality problems as a pattern of how he or she copes and
interact (sic) with his- (sic) or herself and the world" (p. 17; emphasis
in original). When discussing the criterion of inappropriate and intense anger,
Freeman and Fusco say that clinicians should explain to patients that "as
humans we are a system of sensors and alarms. Alarms warn us of pending
danger" (p. 185), thus normalizing anger for them. And regularly, the
authors suggest how clinicians can explain things to patients in ways that are
clear but not condescending. Frequently, they offer sample questions in quotations
so readers can try out different ways of putting them to patients. To challenge
patients who feel hopeless and want to engage in self-injurious behavior, they
suggest clinicians ask "How did you manage to...parent children? Maintain
employment? Manage past stressors without hurting yourself?" (p. 150).
They hasten to add that clinicians must know their patients' strengths
beforehand, though, as they could otherwise become embroiled in argument.
It should be said that, given their
target patient population, the authors expect treatment to take "1 ½ to 6
½ months of weekly outpatient sessions; in cases where a personality disorder
has been diagnosed more sessions may be warranted" (p. 14); this short
time span works well with time-limited insurance plans but probably will fall
far short for most BPD patients.
Another problem has to do with the
therapeutic relationship. The authors devote a mere four sentences to the
subject of "rapport building," which is an abysmally short amount.
Given their own claim that BPD patients can be "extremely
challenging" (p. 23) and their stated emphasis on collaboration, one would
expect at least a short chapter on the subject. As someone who has researched
clinicians' highly pejorative attitudes towards BPD patients, I find this tantamount
to a form of negligence.
Finally, numerous typos exist, which readers may
find an annoying distraction; either the authors or the publishers were
careless. To mention typos when only a few exist would be petty, but this book
has them in abundance. There just doesn't seem to be any excuse for so many of
2006 Nancy Nyquist Potter
Potter is working on a book on a philosophical analysis of Borderline
Personality Disorder. She is editor of Trauma, Truth and Reconciliation
(Oxford University Press, 2006), and is author of How Can I Be Trusted? A
Virtue Theory of Trustworthiness (Rowman & Littlefield, 2002).