This book is about the understanding and treatment of severe personality disorders. The essays contained in it are all original, having been written specifically for this volume. The thrust is essentially clinical and pragmatic, based on best practice, and, whenever possible, the best evidence. Eschewing biological, psychoanalytic and cognitive behavioral theories, the book focuses upon issues of day-to-day management of patients with severe personality disorder. The topics covered range from early predictors, treatability, common elements of effective therapies, psychopharmacological interventions, countertransference, disruptions of the therapeutic alliance, and suicidal crises, to the management of the dangerous, refractory, and stalking patient. The book is a collective effort by distinguished investigators and innovators in the field of severe personality disorders. A common link among them is that they all have been involved with “Psychiatrie in Progressie,” a postgraduate educational program of Zon and Schild, a Dutch psychiatric hospital, now part of the Symfora groep. The book is a tribute to Henk-Jan Dalewijk, who until 2005 was Executive Director of the Symfora groep. As a psychiatrist and administrator, he enabled the development of excellent teaching programs on psychiatry and psychotherapy, inspiring all the friends and colleagues who contributed to this volume.

The book comprises 13 chapters. In the first chapter, Michael H. Stone, an early researcher on the course and outcome of personality disorders, addresses one of the major issues of everyday practice: severity and treatability.

Borderline personality disorder (BPD) is a severe but not hopeless condition. Gradual improvement over time can be expected (Paris, 2003), and active psychotherapeutic treatment may be effective (Bateman and Fonagy, 2004; Giesen-Bloo et al., 2006; Linehan, 1993; Perry et al., 1999). However, not all patients respond well: some do not improve at all while others become very self-destructive, drop out of therapy, or worsen. This chapter will focus on treatment strategies and the management of severe, refractory patients.

The refractory borderline patient

Every treatment setting has its own difficult, “refractory” borderline patients: they do not respond well to any treatment, have had multiple therapists, multiple suicide attempts, severely harm themselves, and make frequent use of emergency services. Most are unemployed, and have no stable support system or are still dependent on exhausted parents. Some are left without any treatment at all. Several factors contribute to this unfortunate outcome.

First, BPD in itself is a severe, to some extent chronic, disorder (Paris, 2003). Though recent longitudinal studies on personality disorders show that borderline patients improve on a psychopathological level, their functional impairment improves much less (Skodol et al., 2005). Moreover, since personality psychopathology usually begins in early adulthood or adolescence, the risks of severe, accumulating derailments in psychosocial functioning are substantial: “The possibility of chronic, residual impairment from which a person never completely recovers is real” (Skodol et al., 2005). Psychopathological improvement is less for what seem core dimensions of BPD: affective instability and anger.