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Review Article
General Psychiatric Management (GPM) for Borderline Personality Disorder:
A Generalist Model for Latin America

Marcos S. Croci1,a, Marcelo J. A. A. Brañas1,a, Carl Fleisher2,b ,Teresa Carreño3,c, Maria D. J.

Andia4,d, Eduardo Martinho Jr.1,e, Lois W. Choi-Kain5,f
Article information Abstract

Correspondence: For many years, borderline personality disorder (BPD) has

Marcos Signoretti Croci been regarded as an untreatable mental health condition.
However, several effective evidence-based treatments
E-mail: developed in the last decades, such as dialectical behavior
marcoscroci@hc.fm.usp.br therapy (DBT), mentalization-based treatment (MBT) and
marcoscroci@gmail.com transference focused psychotherapy (TFP), proved otherwise.
The problem from a public health perspective is that their
Conflict of interest: Lois Choi-Kain availability is limited. In this context of increased need for
receives royalty from the publication of trained clinicians, general psychiatric management (GPM) and
GPM textbooks. Marcelo Brañas and other generalist approaches emerged. This article reviews
Marcos Croci received royalty for coediting GPM’s major foundations and framework that guide non-
the book Psychiatry Clinic – Practical Guide. specialized clinicians to structure a treatment based on
medicalization of the disorder, case management and
Financing supportive psychotherapeutic interventions. We also illustrate
Self-financed the approach with a case example and finally present newer
developments, such as integration with DBT and GPM for
How to cite this article? adolescents (GPM-A).
Croci, M.; Brañas, M.; Fleisher, C.; Carreño, Key words:
T.; Andia, M.; Martinho, E. & Choi-Kan, L. borderline personality disorder; good psychiatric
(2020). General Psychiatric Management management; case management; psychotherapy; generalist
(GPM) for Borderline Personality Disorder: treatment
A Generalist Model for Latin America.
Rev.latinoam.pers., 1(2), 24-40.
Recuperado de:
http://revistalatinoamericanadela
personalidad.org/revista-1-2/
1: Department of Psychiatry, School of a: Psychiatrist, Medical Supervisor Adolescent BPD
Medicine, University of São Paulo, São Outpatient Clinic
Paulo, Brazil; 2: Department of Psychiatry
and Biobehavioral Sciences, University of b: Psychiatrist, Assistant Clinical Professor
California, Los Angeles, USA c: Psychiatrist, Voluntary Assistant Professor
3: Department of Psychiatry and d: Psychiatrist, Mental Health Chief of Hospital Antonio
Behavioral Sciences, University of Miami Lorena
Miller School of Medicine, Miami, USA
e: Psychiatrist, Doctor in Medicine, Director Adolescent BPD
4: Hospital Antonio Lorena, Cusco, Peru Outpatient Clinic
5: Harvard Medical School, Boston, USA; f: Psychiatrist, Master of Education, Assistant Professor of
Gunderson Personality Disorders Institute Psychiatry, Director of the GPDI
(GPDI), McLean Hospital, Belmont, USA

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Introduction generalist treatments can be applied more

Empirically validated manualized broadly, making good care for BPD more
psychotherapies for borderline affordable and sustainable for healthcare
personality disorder (BPD) have systems worldwide. The empirical
revolutionized attitudes towards this foundation for generalist clinical
prevalent, once thought to be an management for BPD was established
untreatable illness associated with severe with the publication of the two largest
morbidity, mortality, and costs to society outpatient BPD psychotherapy studies
(Hastrup, Jennum, Ibsen, Kjellberg, & pitting DBT and MBT against less
Simonsen, 2019; Paris & Zweig-Frank, intensive but well-informed treatment for
2001; Soeteman, Verheul, & Busschbach, BPD (McMain et al., 2009; Bateman &
2008; Trull, Jahng, Tomko, Wood, & Fonagy, 2009). Based on John
Sher, 2010). These intensive, evidence- Gunderson’s essential clinical guide
based treatments for BPD, most notably (Gunderson & Links, 2008), general
dialectical behavioral therapy (DBT; (a.k.a. good) psychiatric management
Linehan, 1991), mentalization-based (GPM; Gunderson & Links, 2014) led to
treatment (MBT; Bateman & Fonagy, similar reductions in suicidality and self-
1999), and transference focused harm, BPD symptoms, and depression as
psychotherapy (TFP; Clarkin, Levy, DBT, with no differences in improvement
Lenzenweger, & Kernberg, 2007), yield in social functioning and quality of life
comparable effects (Cristea et al., 2017). (McMain et al., 2009). These outcomes
These BPD treatments employ distinct were maintained 24 months post-
positions on theory, practice, and training treatment (McMain, Guimond, Streiner,
to underscore their validity and reliability. Cardish, & Links, 2012). Similarly, while
However, there is to date no proof these improvements for MBT occurred at a
specific distinctive features provide one of faster rate than its generalist comparator,
the brands an edge over another. structured clinical management (SCM;
Bateman & Krawitz, 2013), MBT was
Furthermore, there is a significant otherwise comparable in outcomes to
disparity between the short supply of SCM (Bateman & Fonagy, 2009). A recent
trained treaters and the vast demand meta-analysis confirmed similar efficacy
created by the high prevalence of patients of both specialized and generalist
with this disorder (Iliakis, Sonley, Ilagan, protocolized treatments for BPD in adults
& Choi-Kain, 2019). The intensive, (Oud, Arntz, Hermens, Verhoef, &
rigorous, and often lengthy team-based Kendall, 2018).
structure of many of these treatments
renders broad implementation impossible This review will present GPM as a
outside highly-resourced healthcare prototype of a protocolized, but flexible
systems (Choi-Kain, Albert, & Gunderson, approach integrating key effective
2016; Iliakis et al., 2019). The good news elements of BPD-specific treatments,
is a handful of generalist clinical packaged in a practical way to be
management approaches for BPD for both implemented in the usual settings
young people and adults have empirically practitioners see the majority of patients
demonstrated comparability to gold with BPD. The basic ingredients of GPM—
standard treatments for BPD in major that is, diagnostic disclosure,
outcome parameters such that they can psychoeducation, goal setting, safety
now be considered a generic variant management, conservative
(Bateman & Fonagy, 2009; Chanen et al., psychopharmacology, and management of
2008; McMain et al., 2009). Stripped comorbidities—will be described.
down to the basic essential ingredients of
effective treatment for BPD, these
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Overview of General Psychiatric Usually, GPM is offered weekly, but this is

Management not mandatory. The frequency, duration,
GPM is a generalist treatment for BPD and treatment continuation depend on its
patients that incorporates three essential usefulness, i.e., if associated with clinical
elements: the medicalization of the improvement. The rationale of this
disorder, case management, and approach is to avoid treatments that
supportive psychotherapy (Gunderson, reinforce excessive dependence while
Masland, & Choi-Kain, 2018). There is being ineffective or even harmful since the
also a fourth component: the strategical natural course of BPD—even without
coordination of complementary specific or intensive treatment— is of
treatments, when useful (e.g., symptom - symptomatic remission (Zanarini,
targeted psychopharmacology, Frankenburg, Reich, & Fitzmaurice,
comorbidity management, and family or 2012).
group interventions).
In GPM, the medical aspects of BPD (e.g., Since GPM is a less intensive and
psychoeducation) are comfortably resource-demanding intervention for
disclosed initially in treatment. As BPD—while still being effective—, a
treatment progresses, clinicians focus on reasonable approach is that this treatment
life outside treatment and manage could be the primary intervention for
patients' psychopathology and BPD, reserving more intensive and
functioning with a plurality of specialized evidence-based treatments
psychotherapeutic techniques and (EBTs) to those who do not respond
treatment principles. During this process, (Choi-Kain, Albert, & Gunderson, 2016).
treater and patient work collaboratively to Also, GPM is easily integrated with other
set and achieve realistic goals that are EBTs' based interventions. The
flexibly chosen based on patients' integration with DBT, MBT, and TPF, and
preferences while still maintaining its implementation in a vast range of
attention to improving patient role clinical settings (e.g., inpatient psychiatric
functioning (Kolla et al., 2009). Although units, emergency departments,
GPM is psychotherapeutically oriented consultation-liaison service, outpatient
and uses cognitive-behavioral (e.g., units, college mental health services) has
homework, contingencies) and been detailed in a published practical
psychodynamic (e.g., monitoring of guide (Choi-Kain & Gunderson, 2019) and
countertransference, interpretation of scientific journals (Finch, Brickell, & Choi-
aggression) interventions, its primary Kain, 2019; Hong, 2016).
approach is not psychotherapy
ambitioning a deep psychological change GPM training is currently offered in a one-
(Unruh, Sonley, & Choi-Kain, 2019). It is day workshop. It's manual, and the
"good enough" psychiatric case accompanied online video
management to improve vocational and demonstrations are currently available in
social functioning. English and Portuguese (Gunderson &
Links, 2014, 2018). Furthermore,
The GPM-oriented clinician is expected to strategies to teach GPM in psychiatry
keep in mind basic principles and residency programs have been described
fundamentals (Table 1) that indicate the (Bernanke & McCommon, 2018; Unruh &
clinician's stance, therapeutic relationship Gunderson, 2016).
functioning, essential treatment
framework, and patient expected
responsibilities towards oneself and
treatment.

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Table 1. GPM’s principles and fundamentals (Gunderson & Links, 2014; Finch, Brickell, & Choi-
Kain, 2019).
Area Principles and fundamentals
Psychoeducational
Active and non-reactive
Supportive
Clinician Stance
Thoughtful
Adaptable to uniqueness of patients and clinical situations (i.e.,
flexible and pragmatic)

Therapeutic Relationship Professional and Real

Change is expected
Case management is primary: Focus on getting a life
Safety management principles
Essential treatment
framework Eclectic interventions
Coordinated complementary treatments: Conservative
psychopharmacology, collaboration among providers, family and
group interventions

Expected patient role Accountable (self-agency) and active participant in treatment

Diagnostic disclosure blaming, thereby increasing their

It is quite common for BPD patients to collaboration. Furthermore, co-occurring
seek treatment for another co-occurring disorders (e.g., depression, anxiety) are
problem, such as self-harm, substance less likely to or more slowly remit when
abuse, or usual misdiagnoses, such as BPD is not addressed (Keuroghlian et al.,
bipolar disorder and refractory 2015), and focusing on Axis I disorders
depression. In more subtle cases, the BPD can increase the risk of iatrogenic
diagnosis only becomes evident along with polypharmacy (Chanen & McCutcheon,
treatment (e.g., negative reactions to 2013; Fineberg, Gupta, & Leavitt, 2019).
inter-session availability, angry outbursts,
distrustfulness, misuse of prescriptions). One of the most straightforward strategies
of disclosing the BPD diagnosis is to read
Due to healthcare professionals and the DSM-5 criteria item by item with the
patients' stigma related to BPD (Aviram, patient, asking the patient if each
Brodsky, & Stanley, 2006; Rüsch et al., symptom is in accordance with their
2006), many clinicians avoid disclosing experience. Patients often feel relieved to
the diagnosis under many beliefs (e.g., the know that other people feel the same way
patient will be discriminated against or and that a medical condition explains
offended, it will convey hopelessness, Axis their symptoms.
I disorders better explain the
psychopathology or should be treated GPM's theory
first, BPD is intractable and does not get Gunderson's core formulation of BPD is
better over time) (Chanen & McCutcheon, the interpersonal hypersensitivity model,
2013). GPM strongly favors disclosing the which explains the oscillations in
BPD diagnosis early in treatment since it psychopathology along a continuum of
will usually diminish the sense of connectedness (see Figure 1).
alienation, anchor expectations about the
course of the disorder and the role of
medications, foster treatment alliance,
reassures patients of the clinician
competence, and decrease parent
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Figure 1. Interpersonal hypersensitivity (Gunderson & Links, 2014)

Connectedness
idealizing, dependent,
rejection-sensitive
Interpersonal stress
(perceived hostility,
separation, criticism)

Feeling Threatened
devaluative, self-injurious, angry,
anxious, help-seeking

Withdrawal by other
Support by the other
(physical or emotional)
(↑ involvement, rescue)

Aloneness
dissociation, paranoia, impulsive,
help-rejecting

Holding
(hospital, jail,
rescue)

Despair
suicidal, anhedonic

When patients feel connected, held, or

attached to significant other, their Psychoeducation
idealizing, dependent, anxious, and Psychoeducation is, per se, an efficacious
collaborative self is visible. When they form of treatment and is associated with
perceive or are rejected, antagonized, or significant improvement of BPD
abandoned, borderline patients become symptomatology (Ridolfi, Rossi,
devaluing, angry, self-harming, and Occhialini, & Gunderson, 2020; Zanarini,
suicidal. While in this state, if they feel Conkey, Temes, & Fitzmaurice, 2018).
rescued by others, they go back to the Patients and families learn that BPD is
"held" position. On the other hand, if others highly heritable (Skoglund et al., 2019)
withdraw, they feel alone, dissociated, have a good chance of symptomatic
paranoid, and even more impulsive. If they remission, but the functional recovery is
continue without experiencing supportive less optimistic (Zanarini et al., 2012).
responses from others—such as the Patients also learn the interpersonal model
clinician—, they move to further despair outlined above. Books, guidelines, and
and suicidal state where physical holding online resources suggestions are offered to
and structured environments become patients and families, such as the Family
necessary (e.g., hospital, residential facility, Guidelines (Gunderson & Berkowitz,
intensive outpatient units). 2006), available in six languages (including
This model helps the clinician to anticipate English, Spanish and Portuguese) at the
changes in psychopathology due to social National Educational Alliance for
support. The GPM-oriented clinician Borderline Personality Disorders website
actively probes for adverse interpersonal (https://www.borderlinepersonalitydisord
events when noticing these symptomatic er.org/)
changes (see below).
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Active, supportive and thoughtful, treaters. These experiences can be a

not reactive valuable source of interpersonal processes
Clinicians who are neutral or passive may that are key in personality functioning
unintentionally trigger fear of according to modern diagnostic manuals
abandonment and other negative (Bach & First, 2018; Oldham, 2015).
emotions. That may explain why traditional Careful self-disclosure of your feelings is a
psychoanalytic techniques were ineffective source of validation and can serve to show
(Gunderson, Bateman, & Kernberg, 2007). the effect of their behavior on you (reality
Clinician activity in responding to what testing). Showing your mistakes model
patients say or do, questioning what humility. These “real” phenomena can
happened, and showing interest is crucial. strengthen a relationship alliance that is a
This doesn’t mean being reactive. Patients corrective experience (Schiavone & Links,
may behave impulsively or disclose suicidal 2013).
ideation that can cause clinicians to act
rather than to “think first” and reflect. For Case management: Focus on life
example, reflexively hospitalizing patients outside therapy
due to suicide threats may reinforce these As stated before, clinicians focus more on
behaviors as a dysfunctional way of calling the patient’s life outside therapy (“getting a
for help or escaping real-world problems life”). Self-harm and impulse control are
encouraging secondary gain. important but secondary targets (Links et
al., 2015). The treater works pragmatically
During this active exploration process, it is and collaboratively to problem-solve life
also of paramount importance to use difficulties that prevent the patient from
support and empathy, as it is in any other achieving their goals while advocating in
treatment for BPD (Weinberg, favor of taking small steps at a time (e.g.,
Ronningstam, Goldblatt, Schechter, & volunteering before paid work, taking few
Maltsberger, 2011). It is not only classes before full-time academic
interpersonal stressors that distress enrollment).
patients but also the other way around, that
is, the patient’s BPD symptoms aggravate Borderline patients might expect to work
interpersonal interactions (Conway, on their inevitable relationship issues. Still,
Boudreaux, & Oltmanns, 2018; Stepp et al., their basic needs, such as daily living
2014; Winsper, Hall, Strauss, & Wolke, activities, education, health issues, and
2017). The clinician promoted employment, should be prioritized due to
interpersonal connectivity, calms them, their interpersonal vulnerabilities
and paves the path to forming an incipient (Bernanke & McCommon, 2018). “Work
alliance. During impulsive behavior and first,” then love. Regular vocational and
affective storms, this can be challenging. educational activities can provide structure
Still, instead of being reactive, taking it and help them build more stable self-
personally or withdraw, clinicians should esteem (Gunderson et al., 2018). Then, a
thoughtfully and curiously “lean in” (Links, successful partnership becomes more
Ross, & Gunderson, 2015) and help them likely. Moreover, underscoring
metabolize their experience, keeping the occupational and social function is a
assumption that interpersonal distinctive aspect of GPM that was added
hypersensitivity processes are in play. due to longitudinal data that showed that a
significant portion of BPD patients had
Therapeutic relationship: difficulties attaining a stable full-time job
professional and real and long-lasting partnership (Zanarini et
The clinician is also subject to the al., 2012).
interpersonal dynamics involved in BPD
psychopathology. Besides the clinician role Management of suicidality and self-
as someone who works within a treatment harm
frame and is intervening based on his Suicidal behavior and self-harm are a
training and knowledge, treating BPD source of worry for everyone involved in
evokes intense emotional reactions in taking care of borderline patients. In GPM,
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suicidality can be understood as extreme The patient’s current state guides decision-
reactions to interpersonal stress, and there making. For acutely but mildly distressed
are a series of principles that clinicians can patients, do not prescribe; they must learn
follow to manage safety while at the same to use coping skills. If a patient requests
time promoting self-agency and decreasing medication but is not severely distressed,
liability. The most important is discuss thoroughly to avoid undermining
demonstrating concern to any suicidal agency. For severely distressed patients,
communication while at the same time prescribers can suggest medication, though
evaluating risk. The estimation of the watchful waiting is reasonable.
dangerousness of the current behavior
(e.g., differentiation of nonsuicidal self- When prescribing, challenge dichotomous
harm and suicidality) and suicide risk views, i.e., medication either works or it
assessment are major strategies. Since doesn’t. Instead, establish concrete metrics
most patients have some chronic suicidality related to treatment goals. We recommend
level, one useful way to do the latter is the starting any medication at a low/sub-
"acute on chronic" model. This kind of therapeutic dose. Likewise, titrate more
assessment helps clinicians monitor factors gradually than usual. Antidepressants
that increase (e.g., depression, substance (Bozzatello et al. 2020; Mercer, Douglas, &
use, interpersonal loss) or decreases the Links, 2009), mood stabilizers (Bozzatello
risk (e.g., coping skills, new supports, et al. 2020; Abraham & Calabrese, 2008),
recognition of alternatives) of suicide or antipsychotic medications (Bridler et al.,
beyond BPD's baseline level (Links, Gould, 2015; Nosè, Cipriani, Biancosino, Grassi, &
& Ratnayake, 2003). Barbui, 2006) may be helpful for different
symptoms. It is imperative to avoid
Other components in risk management are polypharmacy (Bozzatello et al., 2020). We
the clarification of precipitants, patient advise that medications be discontinued
involvement in safety, transparent after a specified duration unless they
communication about clinicians' limits, use provide a clear benefit.
of consultation, and wise choice of the level
of care (e.g., outpatient, inpatient, Comorbidity with BPD is expected.
residential). Hospitalizations are seen as Prioritize treating BPD over depression,
ultimate resources, and clinicians should anxiety, or narcissistic personality
weigh this intervention's risk and benefits disorder. However, attention deficit
(Vijay & Links, 2007). hyperactivity disorder (ADHD), mania,
hypomania and anorexia nervosa are
The use of suicidal contracts is discouraged, priorities over BPD (Grilo et al., 2010).
but patients and clinicians should With post-traumatic stress disorder
collaboratively construct a crisis plan to (PTSD), substance use disorders, bulimia
identify warning signs and helpful nervosa, and bipolar disorder type 2, use
directions for patients to soothe themselves clinical judgment.
and search for help. This procedure fosters
self-agency (Palmer, 2015). Multimodal treatment
Multimodal treatments can improve
Psychopharmacology treatment and reduce clinician burnout.
Two principles define the approach to The most common structure includes a
pharmacotherapy in GPM. First, less is medical professional (psychiatrist, primary
more. (Bozzatello, Rocca, De Rosa, & care physician, or nurse practitioner) and a
Bellino, 2020). Second, the relationship psychotherapist. The medical provider can
with the prescriber is more critical than also offer family guidance. Additional
whether medication is prescribed or which modalities (e.g., group, school support) can
one (Gunderson & Choi-Kain, 2018). Tools boost treatment effectiveness further. The
including alliance, psychoeducation use of any modality should follow need, not
(Ridolfi et al., 2019) and tracking may reflex.
preclude the need for medication.

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Roles must be clearly defined, and

communication open among all involved. Case Illustration
The primary therapist will manage safety, This clinical vignette illustrates the GPM
evaluate progress, and lead treatment approach to a case in which previous
decisions. Providers must avoid vilifying treatments focused on medication
each other and encourage patients to voice management of mood disorders.
complaints directly. Clarifying Camila is a twenty-year-old woman who
confidentiality is crucial. Offer validation, comes to your office with her parents. She
psychoeducation and shared goals to has been recently discharged from an
promote collaboration, especially if the emergency service three days after a suicide
diagnosis or treatment frame are threat after a relationship breakup. This
questioned. When the other parties remain young, somewhat baby-faced patient tells
disengaged, re-evaluate whether or how to you that she has been experiencing
continue treatment. depression "since always" and have self-
harming (cutting) episodes that started at
Family involvement is integral (Fruzzetti, twelve years old. She was on venlafaxine,
Shenk, & Hoffman, 2005). Typically, this quetiapine, lithium, and alprazolam, with
involves problem-solving rather than no consistent effectiveness. After exploring
therapy. Include step-parents when her symptomatology over time, you notice
possible. Build an alliance by providing that her symptoms wax and wane according
psychoeducation and validation (Kim & to interpersonal stressors, without any
Miklowitz, 2004). With siblings, evaluate evidence of mood episodes typically
their needs for support and make explicit associated with bipolar disorder. Due to
recommendations. Common challenges conflicts with peers, which evinced her high
may include requests to violate sensibility, she had to move schools several
confidentiality, allegations of abuse, times. Her parents find it hard to
parents who are critical of therapy, or are understand her behavior, which they
disengaged. characterize by sudden mood vacillations,
and frequent anxiety and anger episodes.
College staff can provide treatment and are Over the last semester, she felt pressured by
uniquely positioned to support the young her parents to get a job or go to college and
adult main “job”: learning. blame her distress on them. When she is
Accommodations may be useful if specific overwhelmed, her mother provides her
and predictable. Common challenges with more support and deals with her
include parents’ concerns about stigma, issues.
managing hospitalizations and the return
to class, and balancing the risks and You agree to work with her once a week and
benefits of accommodations (Lawn & schedule an appointment with her parents
McMahon, 2015). for psychoeducation. You review the DSM-
5 criteria with her, asking her to give you
Groups are highly valuable (Bo et al., real-life examples that exemplify each
2020). Therapeutic (including skills criterion. She instantly likes your approach
training) or extracurricular (clubs or and says that "these symptoms explain all."
sports) groups provide for socialization, Camila says, "you have to tell my parents
mentalization, identity formation, that I am borderline." You validate her
supportive adult relationships, goal feeling of being understood but says that
pursuit, self-regulatory and social skills you will work together so she will be able to
(Fonagy, Luyten, & Allison, 2015; learn how to cope with BPD. And if the
Driessens, 2015; Oberle, Ji, Guhn, treatment does not prove to be useful, that
Schonert-Reichl, & Gadermann, 2019). is, she does not show signs of improvement
Common challenges may include resistance on self-control and, eventually, "get a life"
due to interpersonal hypersensitivity, (get a job or return to college), treatment
interfering behaviors, contagion (Hooley & continuation should be reevaluated. She
Franklin, 2018), relationship exclusivity or quickly nods and says, "I will do anything to
conflict, or repeated absences. move out from my parents as soon as
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possible." In the next session, her parents such an idiot?". After listening and
express doubts about her having a real supporting her, she cries. Revising what
diagnosis: "When she was in the ER, soon happened in the last week, Camila felt all
after self-harming, she was laughing!". At alone after realizing all her friends were
the same time, they were uneasy about the already in college, "living a happy life full of
idea of tapering off her meds: "They are the exciting parties," which she closely follows
only thing that makes her comes to her in her social media feeds. That is why she
senses and make her sleep." You empathize tried to reach him. You revise the safety
with their struggles, educate them about plan you made, adding a few coping
the interpersonal hypersensitivity model strategies for anxiety but underline, she
and the role of medications. Her mother is needed better social support. "Again,
grateful, and her father displays 'better social support and structure in my
skepticism, but both are willing to learn life.' You seem a broken record, you
more about the diagnosis and be more know?". You were surprised by her
supportive. You provide them the Family comment. When you were about to start
Guidelines and other helpful online replying, she says, "you are right. I should
resources. You emphasize that it is vital start move on". Then, you say: "I will be
that they learn how to work "together as a glad to help you with that."
team to help her" since splitting may
reinforce "black and white thinking." You She agrees to enroll in a preparatory course
agree to meet with them in the future to to apply for college entrance exams at
evaluate if this new set of techniques they night, where she made some new friends.
learned has been useful. Camila had a couple of binge drinking
episodes but was consistently trying to
Over the next weeks, you get a better prepare herself for the test at the end of the
picture of what triggers most of her year. You were working with her, advising
interpersonal hypersensitivity and work on her studies, and trying to help with her
with her to be more conscious about it. fears of failure. While Camila continues to
Moreover, you start to know her a little have episodes of symptomatic flare-ups,
better and discover that she is a great with your reassurances, she manages them
photographer. During the first couple of with decreasing reliance on intervention by
months, she gradually feels better and others as well as fewer disruptions to her
tolerates tapering off alprazolam and efforts to build a life. Her life's demands,
lithium, which improved her cognitive that is school, relationships, and
function. She was inconsistently studying obligations begin to structure her decisions
by herself to enter college some days of the and her way of managing her time and
week, spending much of her time seeing loneliness.
videos online. Still, she was more active,
going for jogs and attending English Future Directions
classes. You had to remind the treatment GPM is a flexible, pragmatic,
assignments you gave her periodically and psychotherapeutically informed case
providing a structured mood diary helped management approach to treating BPD that
her get more involved in monitoring can be easily integrated into most
herself. clinicians’ practices. Guidelines on how to
adapt the GPM approach to a wide array of
After three months, she told you that she settings (e.g., inpatient units, emergency
took a handful of her mother's anxiolytic departments) and practitioners (e.g.,
pills to "shut down." Camila accuses you of primary care providers,
taking out the only medication that made psychopharmacologists), and in
her better. After acknowledging you are combination with different treatments
sorry, she feels that way. You point out she (e.g., MBT, DBT, TFP), have been provided
had been sending messages to her ex- (Choi-Kain & Gunderson, 2019). A volume
boyfriend but had no response from him. on GPM and DBT: Integration and Stepped
She looks angry and says, "he is an awful Care, a practical guide in navigating the
guy that never loved me. How could I be stepped care model and combining or
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sequencing components of the two Structured Clinical Management for

treatments, has been recently published Borderline Personality Disorder. American
(Sonley & Choi-Kain, 2020). Furthermore, Journal of Psychiatry, 166(12), 1355–1364.
GPM for Adolescents (GPM-A) was https://doi.org/10.1176/appi.ajp.2009.09
developed to be specifically tailored for an 040539
emerging adult population (Choi-Kain & Bateman, A., & Krawitz, R. (2013).
Sharp, in press). With a larger emphasis on Borderline Personality Disorder: An
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