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Don’t have a DBT center near you? Dr. Lois Choi-Khan has developed a new form of psychotherapy that may work almost as well. In this interview she shares her top tips from this pragmatic approach called Good Psychiatric Management. Featuring archival audio from the late John Gunderson courtesy of borderlinethefilm.com.

Published On: 6/22/20

Duration: 24 minutes, 1 second

Article Referenced: “A Pragmatic Approach to Borderline Personality Disorder,” The Carlat Psychiatry Report, June 2020

Transcript:

What do you do when a patient with borderline personality disorder storms out of your office? Or comes on a long list of medications that they swear but look to you like irrational polypharmacy? Lois Choi-Kain offers up some answers in today’s interview…

Welcome to the Carlat Psychiatry Podcast, keeping psychiatry honest since 2003. I’m Chris Aiken, the editor in chief of the Carlat Report. And I’m Kellie Newsome, a psychiatric NP and a dedicated reader of every issue.

The idea came from Robert Michels, a psychoanalyst, psychiatric provocateur, and long-time editorial adviser to the American Journal of Psychiatry. He was reviewing a paper for that journal on Dialectical Behavior Therapy, it was one of those pivotal randomized controlled trials that was meant to show that DBT worked better than placebo. But Dr. Michels saw something else. The placebo looked pretty good. This placebo was a thoughtfully designed approach to borderline personality called “Good Psychiatric Management,” and after one year it worked as well as DBT, with similar reductions in self-harm, suicidality, and many of the core symptoms of the disorder. Michels suggested this is no placebo but a legitimate therapy all its own.

So if you treat borderline patients, but don’t have a DBT center to refer them to, this therapy is for you. Unlike the other evidence-based therapies for borderline ─ DBT, mentalization, and psychodynamic ─ Good Psychiatric Management wasn’t built on any fancy theories. It developed out of John Gunderson’s experience in working with borderline personality over the past 40 years. It’s very pragmatic, and mean to be used by everyday psychiatrists. And it addresses many of the problems that come up in the every day care of borderline personality ─ medications, emergencies, comorbidities, and treatment goals. You can even use it if your sessions are spaced out every few months.

One thing I like about this therapy is that it tells you what NOT to do. Without that guidance, things can go really wrong with this disorder. In fact, that’s how borderline personality was discovered in the 1960’s: These were the patients who got worse with the therapy of the day: Psychoanalysis. When they laid back on the psychoanalytic couch and started free associating things got real bad real fast. They decompensated, developed persecutory fantasies about their analyst; one started hallucinating snakes crawling up her analyst’s chair. As the analysis went on, their lives fell apart. That was only supposed to happen to psychotic patients ─ analysts had learned by then not to put them on the couch ─ not neurotic patients as these borderline cases appeared. And thus the term borderline was born: They were thought to be on the border of psychosis and neurosis.

The lesson here is that you can’t just jump into this kind of treatment with good intentions and eclectic therapy tools. Today, we’ll interview Lois Choi-Kahn who worked with Dr. Gunderson to develop Good Psychiatric Management ─ or GPM. Dr. Gunderson passed away last year from cancer. He was a pioneer in the field of borderline personality disorder ─ or BP ─ and helped transition it from a psychoanalytic concept to a scientifically validated DSM diagnosis. Let’s start with some clips from him on the nature of this disorder.

Dr. Choi-Kain has more tips on navigating relationships with borderline patients in our online interview. In Good Psychiatric Management, relationship problems are the core feature of Borderline Personality disorder, and they are usually driven by a symptom called Interpersonal Hypersensitivity. That means intense emotional distress in the face of real or perceived relationship problems, or in the face of loneliness. Here’s John Gunderson on Interpersonal Hypersensitivity:

Dr. Lois Choi-Kain is the director of the Gunderson Personality Disorders Institute at Mass General’s McClean hospital. You can learn more about Good Psychiatric Management for borderline personality disorder in her 2019 text from APA press. Thanks to https://borderlinethefilm.com/ for the archival audio of John Gunderson.

And now for the word of the day…. Projective Identification

Projective Identification is a defense mechanism that derives from Melanie Klein’s object-relations theory. But listen up because this is one of the defense mechanisms you need to know, because you’ll see it in borderline patients and if you don’t get wise to what’s happening it can quickly blow up.

This is when patients take their own personal qualities that are unacceptable to them ─ such as dishonesty, selfishness, aggression ─ and PROJECT them onto their clinician. Well, actually that’s what projection is, like if I were to yell at my psychiatrist for being an angry, hateful person when what’s really going on is I can’t deal with my own hatred and anger. But projective identification takes it one step further. In this dance, the patient starts to act in a way that practically turns the psychiatrist into the angry, hateful person they imagine them to be.

In jargon-free speech, it’s known as self-fulfilling prophecy or gas-lighting.

Here’s how it might look. The patient comes in and fires you because you, “I can’t work with a doctor who is as self-centered as you. I called your answering service all night and never heard from you.” Before you can explain that you tried to call back but their cell wouldn’t pick up, she throws your bill in your face and says she’s never going to pay it, then calm as a cucumber she walks out the room, tipping over your lamp and breaking it in the process. She’s calm because she’s projected all the anger onto you. Furious, you hire a collections agency to go after her for the bill, tacking on the cost to replace the lamp. You’ve never used a collections agency before, but this one really stung.

And that’s part of why Dr. Choi-Khan emphasizes that we need to treat borderline patients much like we would other patients. Watch out for times where you are overly nice, offering free sessions or extra time, or overly harsh like in the story above. Those are the boundary crossings that can end up in an accident.

You can learn more about Good Psychiatric Management for Borderline Personality Disorder in our June-July Double issue, which has a useful table on all the do’s and don’t’s. And you’ll get  $30 off your first year’s subscription with the promo code PODCAST.

Join us next week where we’ll bring you updates from the International Bipolar Disorders Conference which just wrapped up yesterday ─ including an unpublished breakthrough for bipolar depression.

And thank you to all our subscribers for helping us stay free of advertising, industry support, and other kinds of insidious boundary crossings.

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