Personality Disorders

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Borderline Personality DisorderReview - Borderline Personality Disorder
A Therapist's Guide to Taking Control
by Arthur Freeman and Gina M. Fusco
W. W. Norton, 2004
Review by Nancy Nyquist Potter, Ph.D.
Jun 6th 2006 (Volume 10, Issue 23)

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 puzzle patients.

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 them.


2006 Nancy Nyquist Potter

Nancy Nyquist 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).


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