by John D. Preston, Psy.D.; Oakland, California, New Harbinger Publications, 2006, 177 pages, $24.95 softcover
Dr. Levin is medical director at Westchester Jewish Community Services, Hartsdale, New York, and assistant clinical professor of psychiatry, Columbia University, New York.
In this brief but wide-ranging text, John Preston strives to integrate the extensive literature on the diagnosis and treatment of borderline personality disorder with particular emphasis on the formulations and techniques of Marsha Linehan (1). A neuropsychologist and American Board of Professional Psychology member in counseling psychology, Preston has also authored the popular and useful Handbook of Clinical Psychopharmacology for Therapists. This new text serves an analogous function: to distill essentials of the area of treatment of borderline personality disorder for the outpatient therapist. Preston speaks in an unpretentious, nontechnical style accessible to practitioners from a variety of disciplines. His stated goal is to help them navigate the daunting responsibility of treating borderline personality disorder in the "brief" treatments—weekly sessions for six to 18 months—dictated by current economic realities.
The first half of the book reviews various diagnostic schemes and explanatory frameworks for borderline personality disorder. Ambitious in its scope, this section is loosely presented and at times repetitive, shifting rapidly between multiple perspectives. The relative superficiality of the discussion and lack of attention to the contradictions in current formulations of borderline personality disorder are expectable shortcomings for such a brief overview, which also reflects the inherent weakness of the diagnosis of this disorder. Preston favors psychoanalytic formulations, touching briefly on possible neurobiological underpinnings and the traumatic origins of the disorder. The discussion gives relatively short shrift to trauma despite the growing evidence of traumatic antecedents among a majority of patients with the disorder. A more powerful approach, as Preston himself suggests, might have been to focus on several distinct groupings—the affectively disturbed patients with the disorder who have mood instability identified in the DSM, those with prominent attention and learning difficulties, individuals along the schizophrenia spectrum, and persons with a strong trauma history who present with "complex posttraumatic stress disorder" (2). Appropriately tailored treatment approaches exist for each of these groups. Nonetheless, Preston succeeds in providing a user-friendly framework for identifying and interpreting behaviors of patients with borderline personality disorder, an essential "grounding" for the therapist embarking upon treatment.
The second half of the text presents techniques for addressing the core manifestations of the disorder including cognitive dysfunctions and distortions, interpersonal instability, emotional dysregulation, intense anger, primitive defenses, and ease of regression. The techniques of Linehan's dialectical behavior therapy—such as challenging characteristic automatic thoughts and core beliefs, grounding, affect management, and reduction of self-destructive behaviors—form the centerpiece. Additional forays into psychopharmacology and sleep maintenance are useful additions for the nonpsychiatrist. Like the descriptive and theoretical discussions, the approach is wide ranging but somewhat disappointing because of its disorganized and repetitive presentation—headings and subheadings are particularly confusing.
Despite these organizational problems, the author presents many useful principles and techniques, particularly around the development of clearly defined goals for the treatment. The discussion of limits was especially clear and applicable. Although one might long for more detail, Preston fulfills the goal of a brief and highly accessible introduction for the therapist unfamiliar with this area. Interested readers can explore the excellent bibliography to deepen their understanding and strengthen their armamentarium before going into battle.
Linehan M: Cognitive-Behavioral Treatment of Borderline Personality Disorder. New York, Guilford, 1993
Van der Kolk B, Roth S, Pelcovitz D, et al: Disorders of extreme stress: the empirical foundation of a complex adaptation to trauma. Journal of Traumatic Stress 18:389—399, 2005