General psychiatric management: An evidence-based treatment for borderline personality disorder in the college setting

ABSTRACT

Borderline personality disorder (BPD) is a prevalent psychiatric illness that often first presents at college. If left untreated, BPD can lead to severe disability or fatality. While multiple evidence-based treatments for BPD exist, most are resource intensive and, therefore, difficult to implement at the typical college mental health center. However, general psychiatric management (GPM) is an evidence-based intervention for BPD that can be flexibly implemented in nonspecialized, resource-constrained environments. This principle-driven alternative to more intensive BPD-focused treatments provides a practical framework for treating college students with BPD. The aim of this article is to provide an introduction to the techniques of GPM within the college mental health setting. With a case vignette, we illustrate how GPM techniques might be brought to bear on such a treatment.

KEYWORDS:

• Borderline personality disorder
• college mental health
• evidence-based treatment
• general psychiatric management

Borderline personality disorder in the college setting

Borderline Personality Disorder (BPD) is a complex mental illness characterized by intense, labile emotions, chaotic relationships, impulsive behavior, and an unstable sense of self (5th ed, DSM-5, American Psychiatric Association, 2013) that may lead to severe disability or fatality (Gunderson et al., 2011; Zanarini, Frankenburg, Reich, & Fitzmaurice, 2010). BPD onset typically overlaps with entry into college (Kessler et al., 2005; Zanarini, Frankenburg, Khera, & Bleichmar, 2001), and prevalence rates rise from puberty and then steadily decline with each subsequent decade (Johnson et al., 2000; Samuels et al., 2002). One in three youth suicides in the United States is associated with BPD (Bolton & Robinson, 2010) and by age 24 individuals with BPD are markedly different than their peers both socially and in terms of overall health and functioning (Moran et al., 2016). Although the exact scope of BPD on college campuses is unknown, a recent meta-analysis found a 10% pooled prevalence rate of BPD among college students (Meaney, Hasking, & Reupert, 2016), notably higher than the 3% prevalence rate of the general population (Tomko, Trull, Wood, & Sher, 2014; Trull, Jahng, Tomko, Wood, & Sher, 2010). This prevalence spike in college populations is likely in part due to the separation and individuation inherent to transitioning to college, which leads to turmoil in psychological functioning (Conley, Kirsch, Dickson, & Bryant, 2014).

College students with BPD are more likely to self-harm or feel suicidal, and some may abuse substances, experience anger, depression, and anxiety, and struggle with identity disturbances (Hersh, 2013). Symptomatic behavior such as cutting or angry outbursts often leads to mental health referral, and individuals with BPD tend to seek help on their own accord when they are in distress (Bender et al., 2001; Zanarini, Frankenburg, Reich, Conkey, & Fitzmaurice, 2014; Ansell, Sanislow, McGlashan, & Grilo, 2007). Taken together, the trajectory, characteristics, and prevalence of BPD suggest that college mental health practitioners must adapt to the difficulties of treating a large number of students who experience BPD’s challenging symptoms.

Despite the prevalence of the disorder, there is a paucity of literature on BPD treatment in college. Two studies (Engle, Gadischkie, Roy, & Nunziato, 2013; Pistorello, Fruzzetti, MacLane, Gallop, & Iverson, 2012) have shown that students with BPD or BPD traits respond well to treatment, and that students treated with comprehensive dialectical behavior therapy (DBT; Linehan, 1993) experienced greater improvement in symptomatology and functioning than those treated with usual treatment, which included both individual and group therapies within the college system. However, the funds, time, and training required for intensive evidence-based treatments like DBT (Choi-Kain, Albert, & Gunderson, 2016) may not be feasible for college counseling center clinicians who are already burdened by an increase in demand (Beamish, 2005; Gallagher, 2013; Kitzrow, 2003). As an alternative, pared-down adaptations of DBT, including a short-term skills group, have some empirical support (Chugani, Chali, & Brunner, 2013; Meaney-Tavares & Hasking, 2013). This demonstrates that lower-intensity interventions may be efficacious with this population. We propose that college mental health practitioners adopt General Psychiatric Management (GPM) (Gunderson & Links, 2014) as a framework for standard BPD treatment.

General psychiatric management (GPM)

GPM is developed from Dr. John Gunderson’s clinical guide for BPD (Gunderson, 2008), a landmark textbook founded on years of clinical expertise. This clinical guide was manualized by an independent research group to provide a useful comparator for a randomized controlled trial, and GPM is the resulting manualization. GPM is a BPD treatment model designed to be “good enough” for the majority of patients with BPD and easily learned and applied by their providers. Instead of relying on complicated psychotherapeutic techniques and theories, GPM prioritizes feasible and effective management of BPD patients and their challenging symptomology. GPM provides a relatable formulation and guidelines for nonspecialized mental health clinicians. Over the past 5 years, GPM has quickly developed into a well-respected, widespread approach to managing the complex problems of individuals with BPD. It is deliberately flexible and pragmatic, designed for generalist mental health practitioners and environments with limited resources. Standard training in GPM consists of one 8-hour workshop and is also distilled in a short handbook (Gunderson & Links, 2014). GPM’s training requirements can be lower than those of other evidence-based treatments (Choi-Kain et al., 2016), and the approach is adaptable to college mental health centers.

GPM’s evidence base is derived from a large outpatient randomized controlled trial of psychosocial treatment for BPD, which compared comprehensive DBT to weekly GPM (McMain et al., 2009). Over the course of 1 year of treatment and again at 24-month follow up, patients receiving both treatments demonstrated similarly significant improvements in suicidal behavior, nonsuicidal self-injury, emergency room visits, depression, anger, and interpersonal functioning (McMain, Guimond, Streiner, Cardish, & Links, 2012). Additionally, after a 1-day workshop in GPM clinicians reported an increased sense of competence in treating BPD and a decreased dislike of borderline patients (Keuroghlian et al., 2016).

GPM is viable for college counseling centers because it is not dependent on a predetermined number of providers, sessions, or other resources. Standard GPM occurs in once-weekly individual sessions, but this schedule can be adjusted to fit restrictions of the academic calendar or their own counseling centers policies. If providers can only see a patient once a month or are limited to a certain number of sessions, they can and should still practice GPM. In fact, an abbreviated version of GPM (10 individual sessions total) is shown to be effective (Kramer et al., 2014). While GPM is multimodal and can incorporate adjunctive family work, groups, and psychopharmacology, these elements are not required.

Importantly, GPM is not a definitive treatment and is not meant to replace more intensive evidence-based treatments for BPD. Instead, GPM provides a helpful structure to approach BPD cases preliminarily and can be started in the early phases of BPD by clinicians in primary care settings. When the illness becomes more intractable to care or more severe, with repeated hospitalizations, then a more intensive approach may be needed outside a college counseling center. Rather than consider GPM the only treatment option, we hope college mental health clinicians simply use these fundamentals as a standard of care for their emotionally dysregulated and interpersonally hypersensitive students.

This article aims to provide college mental health practitioners with an introduction to GPM practice in the college mental health setting. We introduce the fundamentals of using GPM in the college counseling environment (Table 1) and then use a case presentation to illustrate the application of these fundamentals.

Table 1. GPM fundamentals.

GPM fundamentals	Essential elements
Diagnostic disclosure	Provides validation and hope, not devastation Withholding diagnosis blocks patient from receiving appropriate treatment, can cause iatrogenic harm
Psychoeducation	Interpersonal hypersensitivity and cautiously hopeful prognosis Useful treatment in and of itself
Getting a life	Primary goal: Build a meaningful life Secondary goal: Symptom reduction, self-control Intermediaries: Short-term, feasible goals
Suicidality and self-harm management	Suicidality and self-harm are reactions to interpersonal distress Response: Expression of concern and clear-headed evaluation of level of risk Collaboration to make safety plan
Conservative psychopharmacology	Adjunctive to psychosocial treatments No one medication is uniformly or dramatically helpful
Coordination of care	Family psychoeducation recommended Adjunctive group treatments (i.e., DBT skills groups) when resources allow Collaboration among providers

Note. GPM = General Psychiatric Management; DBT = Dialectical Behavior Therapy.

General psychiatric management fundamentals

If only a few sessions are possible, as is the case at many college counseling centers, clinicians should focus on two GPM fundamentals: diagnostic disclosure and psychoeducation.

Diagnostic disclosure

A first step towards helping the patient improve is making and sharing the diagnosis of BPD. However, a recent review of psychiatric diagnosis in college students (Conway, Tackett, & Skodol, 2017) found that true prevalence of personality disorders was 40 times higher than the diagnosed prevalence. Because of the stigma associated with BPD among healthcare providers (Chanen & McCutcheon, 2013), many clinicians fear that disclosing the diagnosis of BPD will devastate the patient. Another common barrier to diagnosis is that clinicians may make the common decision to “defer” the BPD diagnosis and focus on the axis I disorder. This is misguided—even one symptom of BPD can differentiate subjects who will develop suicidal ideation and attempts, inpatient hospitalization, and comorbidity (Zimmerman et al., 2012). Furthermore, symptoms of commonly co-occurring disorders such as depression and anxiety do not remit until the BPD is treated (Gunderson & Links, 2014; Keuroghlian et al., 2015). As is the case for mood disorders, psychotic disorders, and substance abuse, intervention for BPD is most effective when it is done early (Chanen & McCutcheon, 2013).

Promptly disclosing the BPD diagnosis informs the direction of care, allows accurate communication with colleagues, and is a good risk-management strategy. Perhaps most importantly, it allows the clinician to speak openly and honestly with the patient and their family about what is driving their chaotic behavior and how to predict vulnerabilities in the future.

Secrecy around the diagnosis can increase the risk of iatrogenic harm (e.g. polypharmacy) and block the patient from receiving appropriate treatment (Chanen & McCutcheon, 2013).

Due to stigma surrounding around the disorder, some clinicians may find sharing the diagnosis of BPD challenging. We recommend clinicians go through the DSM-5 criteria with the student item by item, asking for input from the student regarding whether these criteria fit their experience. Patients will frequently feel relieved to know that their struggles are explained by a medical diagnosis and that there are other people who have the same problems. Of course, as is the case with any medical diagnosis, the patient may have a more negative reaction. The clinician should understand that a reactive negative response is symptomatic of BPD. The clinician should remain confident in their diagnosis and help the student see how an accurate BPD diagnosis is the first step to feeling better. Once the diagnosis of BPD is established, the clinician should proceed to the second critical step: psychoeducation.

Psychoeducation

There is evidence to suggest that psychoeducation about the symptoms of BPD is a useful form of treatment in-and-of itself. As compared to 20 wait-listed patients, 30 adult outpatients with BPD showed reduced impulsivity and instability in relationships in the 12 weeks following a psychoeducation workshop on BPD (Zanarini & Frankenburg, 2008). While the long-term impacts of psychoeducation have not been empirically studied, simply understanding the nature of their struggles and knowing they are not alone is likely to remain a powerful positive force for those with BPD.

Students should learn that BPD is significantly heritable, that the expected course is one of gradual improvement (Zanarini, Frankenburg, Reich, & Fitzmaurice, 2012), and that many of their struggles and symptoms are rooted in a core of interpersonal hypersensitivity (Gunderson, 2007; Gunderson & Lyons-Ruth, 2008). The model of interpersonal hypersensitivity outlines that a dependency on connection coupled with a sensitivity to feeling rejected, criticized, or abandoned drives symptomatic expression in someone with BPD. According to the interpersonal hypersensitivity model, a person with BPD can be expected to present as compliant and even idealizing when they feel connected and important, but angry and self-destructive when that sense of connection is threatened. Learning this model can help the patient understand their own vulnerabilities.

College mental health clinicians may find psychoeducation around BPD more challenging than for other disorders that students are more familiar with, such as anxiety and depression. Some websites such as the ULifeline website (www.ulifeline.org) and Britain’s Youngminds mental health charity (www.youngminds.org.uk) include accessible BPD psychoeducation material for the college age population. Students and their parents may also find the National Education Alliance for Borderline Personality Disorder (www.borderlinepersonalitydisorders.com) to be a helpful resource.

If a college mental health clinician provides a diagnosis and psychoeducation in the time they have with a student, that is valuable in and of itself. The student will have the foundation of a correct diagnosis for future treatments and an awareness of their own vulnerabilities going forward. If the clinician is allotted more time to meet with the student, they can continue GPM with the following strategies.

“Getting a life”

After diagnosis and psychoeducation, the primary goal of GPM is to help the patient live a meaningful and functional life outside of treatment. To achieve this, the clinician and patient should work together to develop realistic short-term goals to guide the treatment and keep the patient and clinician focused, such as making a budget, finding a tutor, going to the gym, or maintaining hygiene. This supersedes secondary goals of symptom reduction and self-control. While therapists and patients alike may be inclined to delve into the patient’s developmental history, GPM focuses on the here and now. GPM recommends a shift from abstract, psychodynamically oriented discussions to concrete, practical steps that the patient can take to better function at school. The patient is accountable for achieving these goals.

Suicidality and self-harm management

In the GPM model, both suicidal behavior and nonsuicidal self-harm are expected symptoms of the illness that most likely result from an interpersonal stressor. It is important for the clinician to respond with a level-headed evaluation of the actual degree of risk, while still expressing concern about the behavior. The therapist should balance their knowledge that these behaviors may be a communication of distress with the understanding that the baseline risk for suicide is chronically elevated in BPD patients as compared to the general population. Acute exacerbations of risk occur as a result of comorbid mood disorders, substance use, withdrawal of support (such as recent hospital discharge) and negative interpersonal events.

In a crisis, the GPM therapist involves the patient as an active participant in creating a safety plan. The patient should help come up with alternative ways to feel better, paying attention especially to how to recruit additional social support. In addition to promoting a sense of agency and autonomy, this collaborative approach provides another means of assessing risk—a patient who is readily engaged and can easily create a safety plan is at lower risk than one who cannot. Of note, this is a different process than asking the patient to passively agree to a “safety contract” that has been established by the provider alone.

The suicidal or self-injurious patient can understandably create high anxiety in the clinician. GPM strongly encourages seeking support, supervision, and consultation from colleagues, in line with the adage that one should “never worry alone.” It is also important for the GPM therapist to be open and clear about their limits. No therapist can be omniscient, omnipresent, or omnipotent, and it is, therefore, unreasonable for a patient’s safety to depend on the therapist’s availability.

Conservative psychopharmacology

Medications should be considered adjunctive to psychosocial interventions for BPD. Medications can be helpful when they are targeted to specific symptoms (e.g., selective serotonin reuptake inhibitors for co-occurring major depressive disorder), but no medication is uniformly or dramatically helpful, nor has been approved by the Federal Drug Administration for the treatment of BPD (APA, 2001; Ingenhoven, 2015; Ingenhoven, Lafay, Rinne, Passchier, & Duivenvoorden, 2010). Prescribing multiple different medications (i.e., polypharmacy) can increase the risk for side effects, promote dependency, and may send the message that the patient can passively expect to improve by taking medications, as opposed to working hard to build a life.

Coordination of care

When resources allow, GPM recommends incorporating group therapy and family coaching. Encouraging the student to attend group therapies offered at the college or in the community is highly compatible with GPM. In particular, students with substance abuse problems may benefit from concurrent alcoholics anonymous or narcotics anonymous groups. A typical college process group could also be an excellent experience for the patient with BPD. The specific type of group is less important than the patient experiencing a social environment and receiving feedback on their interpersonal communications and behaviors. Involving the family whenever permitted by the student and school policy, even if just to provide psychoeducation about BPD over the phone, is recommended. Additionally, sharing the case with another clinician can help create a more robust support network for both the patient and the clinician, provided that there is collaborative communication between providers.

General psychiatric management techniques: The case of June

In the following case vignette, we show how the fundamentals of GPM can integrate into practice for you, the college mental health professional.

June is an 18-year-old second-semester freshman referred to university health services after requiring medical attention for alcohol poisoning. She admitted to the doctor in the emergency room that she has already blacked out three times this semester. June tearfully tells you that she has been struggling since Thanksgiving break, when her long-time high school boyfriend broke up with her. During the first semester, she spent so much time traveling to see him that she never really bothered to connect with her suitemates, and now she is feeling left out. June reveals that when her feelings of aloneness and hopelessness get too bad, she cuts or scratches herself across her forearm or the insides of her thighs using a razor blade that she carries with her.

After meeting with June and listening to her describe her current struggles, you suspect the diagnosis of BPD and sit down with her to share your diagnostic impression. You review the DSM-5 criteria for BPD with June and collaboratively discuss if each criterion fit her struggles. June identifies with many of the criteria, and responds with sadness, but also with relief, stating that the description of BPD makes a lot of sense to her. She offers further examples of how sensitive she is to her interpersonal environment and agrees that her precarious social situation is likely making things much worse for her. For the remainder of that session, you offer psychoeducation, emphasizing how her sensitivity to feeling connected (vs. being rejected) can explain and predict what happens with her symptoms. You explain that her acute feelings of hopelessness are a result of feeling abandoned by her former boyfriend. Her cutting, her drinking, and her risky sexual activity can be understood as self-destructive reactions to these intense negative feelings. You also tell June that, while it makes sense that the transition to college has been particularly challenging for her, the natural course of BPD is one of improvement. You explain that you can help facilitate that natural course if these symptoms are things that June herself would like to work on.

June agrees to meet once a week until the end of the semester. You are clear with June that you consider her alcohol use to be a big problem that is likely to exacerbate her other symptoms. You, therefore, insist that she also attend the college’s alcohol education and support group or, if available, a local young person’s Alcoholics Anonymous meeting. In addition to addressing her problematic alcohol use, these groups have the added benefit of providing social support.

You invite June to include her parents (by phone) in the next meeting, where you will share some more basic information about her disorder. She is reluctant to involve her parents at first, but agrees when you point out that she is much more likely to get their support if they understand what is going on for her. When speaking with the parents, you describe the phenomenology of BPD and explain that the prognosis is generally one of gradual improvement. You confidently say that there are multiple evidence-based treatments available for BPD, including GPM. You also refer her parents to the National Education Alliance for BPD website (www.borderlinepersonalitydisorder.com) and suggest they attend a Family Connections program that is being offered in their area. You and June then work together to create a treatment plan.

During your next session, June is eager to discover “how I got to be this way” and makes interesting and insightful comments about the ways in which her relationship with her mother affected her self-image growing up. However, you remember that GPM maintains focus on improving functioning in the here and now and, while it may be tempting to explore June’s interesting past, it is most effective for you to prioritize her current life over history. You inquire about her academic progress and her follow-through with schoolwork. You work out a plan to regularly attend office hours and to get established in a study group—which is helpful but of course also poses its own set of interpersonal challenges. You remind her that developing strong friendships on campus is more important than delving into her past and are pleased when she joins an intramural soccer team and starts practicing regularly.

June comes in the following week with fresh scratches across her forearms. She explains that she overheard her roommate making fun of her. She is devastated and says that she “can’t go on like this.” Because you had predicted that this might happen, you don’t panic or jump into a suicide assessment. Instead, you validate her feelings of shame and anger, and ask her to elaborate on what she means. She says that she is sick of feeling incompetent and worries that she will drive herself crazy if she doesn’t catch up with her work. June begs you to write a note stating that she had to drop a class “for medical reasons.”

You share with June your concern about “lowering the bar” for her and treating her as though she were incapable. You convey that you expect her to take an active role in improving her situation at the school, and you and June work together to come up with a plan to improve her academic standing. She successfully requests the opportunity to complete extra-credit assignments in order to bring up her grade and agrees to stay on campus on weekends in order to engage in activities, focus on schoolwork, and make new friends.

When the semester ends, June decides to spend the summer at home. June is still highly symptomatic and is nervous to spend the summer with her parents, but confident that her diagnosis will help her parents understand her struggles. You help her find a therapist familiar with treating BPD and encourage her to continue attending AA meetings in her hometown.

Conclusion

BPD typically onsets during college age, has a high prevalence rate on college campuses, and can lead to significant disability and fatality if left untreated. Therefore, it is a critical target for intervention at college mental health centers. Clinicians and patients should have access to a treatment modality that is more feasible than evidence-based specialized psychotherapies for BPD and also effective for treating BPD. GPM addresses the need for evidence-based care that does not require intensive time commitments or training. Through following GPM guiding principles and employing GPM techniques, college mental health practitioners can provide their BPD patients with a basic evidence-based treatment designed to help them lead a meaningful life and support the clinician. Even with only a few sessions, the clinician can disclose the BPD diagnosis and provide psychoeducation, which is valuable in and of itself. As shown in the case vignette, GPM favors efforts to keep the student engaged in their developmental trajectory in college and out of the hospital when possible, despite behavioral dyscontrol and suicidal ideation. While this article does not exhaust the ways in which GPM can be applied to the college mental health setting, it offers an introduction to how the GPM therapist and student with BPD can collaborate to effectively manage both a major mental illness and a college career.

Disclosure statement

No potential conflict of interest was reported by the authors.

Additional information

Funding

This work was generously funded by donors to the challenge grant for expanding access to BPD care.