This book represents a seminal contribution to the field of mental health. In my opinion, it is indispensable reading for any therapist who ever comes in contact with patients and clients who have borderline personality disorder (BPD) --- all of us, in other words. Not least is his contribution in affirmatively diagnosing BPD. My own synthesis from this book is that when a person has a history of trauma, overarching feelings of shame, and a reliance on splitting as a defense against shame, that person has BPD. The whole thing fits together well and feels right. I have bought extra copies of this book and lend them to patients and colleagues. It is tremendously helpful.

Dr. Langley begins by looking at how borderline personality disorder came to be called "borderline" personality disorder. It seems that people with BPD have difficulty with boundaries in the context of intense relationships. Since psychoanalysis involves an intense relationship in which one becomes vulnerable to the therapist (my first therapy instructor used to joke that "therapist" stood for "the rapist"), people with BPD simply could not tolerate psychoanalytic sessions. They engaged in a variety of defenses which, when encountering typical countertranferences, caused major blow-ups which often ended therapy. Because they behaved outside the therapy setting as if they were psychoneurotic but behaved inside therapy sessions as if they were psychotic, persons with BPD were considered by psychoanalysts to be on the borderline between neurosis and schizophrenia. Dr. Langley then lays out the remaining history of the disorder to the present day, introducing the major defense of splitting and including the contributions of object-relations theory. He traces how our field finally recognized that the development of BPD in a person usually involves a history of trauma.

Dr. Langley then looks at the dimensions of BPD, considering developmental aspects and associated disorders (e.g. --- substance abuse). One conclusion he draws is that BPD may not necessarily be a disorder of early childhood, but a problem arising across the life span through adolescence. He treats splitting more fully, showing that it is a form of dissociation, that there are "regulatory" (adaptive) and "defensive" (maladaptive) forms of splitting, and that we all engage in splitting to some degree. He introduces shame as the core emotion involved in BPD. He differentiates healthy shame from toxic shame and shows how splitting is a defense against shame. He shows how the person with BPD is unable to modulate her own emotions in an intimate relationship, and suggests that therapy would be more successful if the therapist "titrated" (adjusted) the intensity of a therapy session so that a BPD client is not overwhelmed.

Dr. Langley spends a whole chapter on shame, showing how the "failure to integrate shame experience into the self leaves the shame experience split off and having to be managed by another psychological system." He speculates that this is how the "false self" of BPD develops. He identifies splitting as "a psychological form of toxic shame" and shows how projective identification becomes important to the person with BPD by representing a social form of toxic shame.

Dr. Langley then takes two chapters to cover psychotherapy approaches with borderline clients and the contrasts between self-management therapy and "psychoanalytic-infused therapy." He says, "Self-management therapy conceptualizes and treats shame as the core emotion in BPD. Anger and rage are recognized as prevalent emotions but they are seen as self-projective defensive strategies against the more debilitating emotion of shame." And: "Two major deficits in borderline clients are self-determination and self-competence. The entire premise underlying self-management therapy is that all borderline clients can improve these two sets of self skills."

In a chapter on therapy goals for BPD clients, Dr. Langley first notes that these clients, who are infamous for terminating therapy, have a history of staying in therapy for months and even years, even in psychoanalytic therapy. He then examines the outcomes, and looks at therapist-determined goals (optimum mental health) and apparent client goals (a state of mental health good enough to survive without severe discomfort). He proposes that rather than an goal of optimum mental health, a "good enough" standard would be "sufficient to allow borderline clients to live autonomous and self-determining lives." He proceeds from there to look at what this would mean for therapy goals.

Dr. Langley then proceeds to outline a method for conducting therapy with BPD clients. His guidelines flow from the picture of the disorder and the goals for therapy he has developed. The guidelines are general enough to provide broad guidance while concrete enough to let one see "how to." Finally, he concludes the chapter with an example of a case in therapy.

The last chapter is "Iatrogenic Factors That May Disrupt Therapy." I must confess that I read this chapter first. It helped convince me to read the whole book (even at 200 pages, a book represents a relatively enormous time commitment for me). I found myself there. If you are a therapist, you will find yourself there. If you are a patient or client, you will find your doctor or therapist there. Humbling but educational, it is an example of healthy shame. It is also very helpful in learning to do this therapy thing right so that we can help our patients and clients.

This book costs $29.50, and can be ordered directly from the publisher at (212) 431-4370.

The publisher is

Springer Publishing Company, Inc.
536 Broadway
New York, NY 10012-3955

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