Abstract
Poor public access to effective treatment for borderline personality disorder (BPD) and other frequently comorbid disorders remains a serious public health issue in Canada. The stepped-care model presented in Joel Paris’s new book represents a significant advance in caring for this beleaguered population and provides a rational, evidence-supported foundation for those who care for them. Dr. Paris’s careful review of the literature supports the hypothesis that most borderline patients improve over time and often with very little intervention. He points out that long-term individual therapy focused on the past is not cost-effective and that medications are marginally effective for borderline patients.
The stepped-care model offers brief interventions as a default option while offering extended care only to those who are severely disabled or who have not improved or regressed with brief treatment. Brief therapy releases resources for extended programs for the most chronic patients.
The important lessons from this book are that BPD is an eminently treatable disorder, and since its cause is a transaction between genetic temperament variables and learning, the treatment should be based on learning. Trauma and other adverse childhood experiences are not sole causes of BPD: instead, temperament and faulty adaptation to life as a result of adverse life events appear to be causal. The treatment then needs to focus on learning skills to regulate emotion, skills to inhibit impulsive behaviours, and interpersonal skills. The book acknowledges the contribution of Linehan and others in evolving the dialectcal behaviour therapy (DBT) model: Paris goes so far as to say that the concepts behind DBT as well as its techniques are essential for working with this population.
The book is fair and balanced when discussing various, sometimes competing, models for treatment of BPD. What is refreshing is the author’s advocating treatment that integrates the most effective parts of all treatments with shown efficacy. The book is short (178 pages) and easily readable. A downside is the high price; however, it provides an excellent framework for how to address the challenges of treating borderline patients with limited public resources. I highly recommend this book for psychiatrists, nonmedical mental health workers, health care administrators, and those in government who set mental health policy.