General Psychiatric Management (GPM): A Practical Approach to Mental Health Care

The Origins of General Psychiatric Management

People with borderline personality disorder make up about 1.6% of the general population. In clinical settings, 20% of patients have BPD.

Given the high number of BPD patients who seek care, most clinicians will treat people with the condition at some point.

There are many effective treatments for borderline personality disorder, such as:

• Dialectical behavior therapy (DBT)
• Mentalization-based treatment (MBT)
• Schema-focused therapy (SFT)
• Transference-focused psychotherapy (TFP)

These approaches generally take years to master and are typically offered only by therapists or programs specializing in BPD. However, many clinicians lack the resources for this level of training, and many patients cannot access specialized care.

As a result, people with BPD often have too few treatment options and may receive inadequate or misinformed care.

Introducing GPM

General psychiatric management (GPM) is based on the idea that people with BPD should be able to count on their clinicians to be properly trained to treat the condition that most seriously affects their safety and well-being.

While some people with BPD need highly specialized treatment, most benefit from informed, personalized, and “good enough” care. This is what all patients should be able to expect from any clinician.

GPM addresses this need in part by being easy to learn. Grounded in research and clinical expertise, GPM training is delivered in a one-day course for practicing mental health professionals.

The late John Gunderson, MD, a professor at Harvard Medical School and psychiatrist at McLean Hospital, developed GPM. A pioneer in the diagnosis, treatment, and research of BPD, Gunderson spent the last decade of his career working with Lois W. Choi-Kain, MD, MEd, to formalize GPM training.

They believed most clinicians could learn to treat BPD using GPM techniques that are efficient to teach and less costly to deliver than specialized therapies.

Today, GPM is increasingly integrated into psychiatric training as the first-line treatment for BPD.

How Effective Is GPM?

Research shows that GPM is an effective treatment for borderline personality disorder.

A large 2009 study in the American Journal of Psychiatry followed 180 BPD patients who had experienced at least two suicidal or non-suicidal self-injurious episodes in the previous five years.

For one year, half the patients received GPM, and the other half received dialectical behavior therapy, the most extensively researched treatment for BPD.

At the end of the study, both groups showed significant reductions in self-injurious behavior, depression, anger, and other BPD symptoms.

The study found no large differences in the group treated with DBT and the group treated with GPM, even in following them for two years after treatment.

This finding suggests that GPM is as effective as DBT for most patients, despite being less intensive for both clinicians and patients. GPM also yielded better outcomes for people who had other psychiatric disorders in addition to BPD, and those who were more impulsive.

How GPM Works

Gunderson believed several usual interventions used to treat BPD were unhelpful. These included repeated hospitalizations, complex medication regimens, and traditional psychoanalytic treatments.

Part of GPM involves addressing and undoing these problematic approaches to focus on the central issues for patients with BPD.

GPM is organized around the interpersonal hypersensitivity model of BPD.

Addressing Interpersonal Hypersensitivity in BPD

People with BPD have heightened interpersonal sensitivity. They rely heavily on others due to poor self-esteem.

Because of this, they can struggle with intense feelings when they feel a relationship is threatened in any way, whether it be a disagreement or separation of any kind.

This causes them to react in anger or deliberate self-injury to perceived rejection and abandonment. In turn, this may trigger the abandonment they fear and cause them to spiral into more risky thoughts and/or behaviors (including suicide).

The GPM therapist teaches the patient to understand and manage their symptoms and behavior through the lens of the interpersonal hypersensitivity model. Specific BPD symptoms such as self-harming or suicidal behavior are understood as arising from experiences of connection or disconnection regarding others.

For example, a patient who perceives rejection might experience shame, despair, and then push other people away. The therapist would help the patient understand this pattern and then help him or her approach relationships and interactions more effectively.

GPM also encourages building a life to decrease the patient’s reliance on one main relationship. Patients build a network of less intensive but more reliable relationships to manage their intolerance of feeling alone.

Believing Most BPD Patients Get Better Over Time

Another core premise of GPM is that most BPD patients get better over time. This expectation is based on large long-term studies, such as the McLean Study of Adult Development and the Collaborative Longitudinal Study of Personality Disorders, which show that many BPD patients even improve without specialized or long-term treatment.

GPM also educates patients that though symptoms will reduce over time, functional disability usually continues. This encourages a focus on using the treatment to help patients function better, even if functional demands increase symptoms in the short run.

Gunderson believed that any treatment should at least optimize BPD patients’ natural tendency to heal by helping them set and reach realistic goals based on BPD’s typical course of improvement.

Understanding the GPM Process

General psychiatric management has a flexible approach applicable to patients in many walks of life. Because the treatment is built to be accessible to both providers and patients, it is often accessible regardless of an individual’s financial circumstances.

Gunderson promoted the idea that GPM should be considered a basic aspect of health care.

The GPM therapist responds to what the patient wants to change in their life through treatment. Patient and clinician work together to develop treatment goals including the reduction of BPD symptoms.

As therapy progresses, the therapist observes if the patient is improving in their symptoms and making progress towards their goals.

Although GPM sessions typically occur once per week, the therapist and patient can meet at a frequency that makes sense for the patient. They discuss if contact between sessions can occur, and if so, what such communication can entail.

The GPM therapist acknowledges the limitations of any treatment. Unlike other BPD therapies, GPM defines the diagnosis as one that brings the clinician and patient into a relationship. That relationship is evaluated by how well it relieves symptoms and improves functioning.

While the clinician’s job is to provide their informed recommendations, GPM emphasizes an openness to the patient’s point of view.

In GPM, health professionals aim to foster the patient’s self-reliance and freedom to make decisions about their own care. This is achieved via patient education.

People with BPD often engage in all-or-nothing thinking. For example, they may see a relationship or event as all good or all bad.

The GPM therapist models a different way of viewing stressful situations by taking a “not-knowing,” curious, thoughtful stance. They encourage the patient to reflect about events rather than react impulsively.

“Thinking first” and understanding how to act so that the patient gets what they want in the relationship is a basic strategy anyone can use, even if they are not a therapist but rather a primary care provider or prescriber.

If therapy goes well, the patient will have a corrective experience with the therapist. For perhaps the first time in their lives, they may experience a healthy, functional relationship that they can use as a model for relationships outside of treatment.

Other Core Components of GPM

In addition to the therapeutic relationship, GPM includes several practical and evidence-informed components that support patient stability, engagement, and recovery. These elements address key areas of life and treatment, ensuring a comprehensive and adaptable approach to managing BPD.

Case Management

The therapist works with the patient on aspects of the patient’s life outside of treatment.

For example, the therapist checks with the patient on practical matters, such as making sure the patient has paid their rent and health insurance on time.

Life outside therapy matters most to patients and should be the central focus. More complex exploration of the patient’s life can only take place once the patient masters more basic tasks.

Education

The therapist discusses the BPD diagnosis with the patient in the same way a doctor provides information about any newly diagnosed medical condition. This includes the role of genetics and environment in causing and maintaining BPD, the typical course of improvement over time, and available evidence-based treatments.

Psychoeducation empowers the patient through learning what causes, maintains, and improves symptoms. They learn their condition is not their fault. They become interested in their diagnosis and hopeful about the potential to feel better.

Goals

Patients are expected to engage in meaningful activities, such as schoolwork, volunteer activities, and hobbies. Because people with BPD tend to have intense interpersonal relationships, GPM prioritizes such goals over romantic pursuits according to the principle “work before love.”

Meaningful activities, and the structuring of the patient’s time around them, are stabilizing. Once a patient is managing stable employment, getting along with colleagues, maintaining a schedule, and keeping consistent friendships, they can open themselves up to the more complicated and intense realm of romantic relationships.

Having purpose and other relationships can make anyone feel less destabilized by rejection or being alone.

Accountability

Patients are expected to be active participants in treatment. They assume responsibility for their safety and quality of life, though they are encouraged to reach out to the GPM clinician when they need it.

Flexibility

GPM pulls in aspects of other treatments that may work for the individual patient. For example, if the therapist believes the patient would benefit from elements of a 12-step program, cognitive behavior therapy (CBT), or DBT, they can bring these into the treatment plan.

Common combinations include GPM individual sessions plus a DBT skills group, a mentalization group, and peer support groups where those may be available.

Coexisting Disorders

GPM employs unique strategies to organize care for diagnoses that commonly occur with BPD, including mood, anxiety, substance use, and other behavioral disorders.

Informed by lessons learned about how these disorders interact with BPD in long-term research studies, GPM teaches clinicians to treat BPD in order to increase recovery for most mood and anxiety disorders.

Other disorders, such as mania, anorexia nervosa, or severe substance use problems, need to be stabilized for BPD to be effectively treated.

Other treatment models do not instruct clinicians on how to manage this aspect of care routinely.

Medications

GPM also stands out as the only effective BPD treatment to incorporate American Psychiatric Association (APA) guidelines for the management of medications.

The APA rigorously reviews existing scientific literature to develop and update these guidelines.

Family Involvement

GPM distinguishes different types of family involvement from family therapy. Family involvement is helpful for most patients’ situations. In family involvement, the therapist provides education and coaching for the parents’ relationships with each other.

In family therapy, patients and family members work on emotional stability. Family therapy is helpful once patients gain greater independence from their family members.

Who Benefits From GPM?

Many people with a diagnosis of borderline personality disorder can benefit from treatment through general psychiatric management. GPM allows for BPD patients to find stability in many parts of their lives, including work, interpersonal interaction, and their sense of self.

In recent years, GPM has shown promise in treating patients with other mental health concerns.

It has also been fully adapted to treat adolescents for early intervention aimed to curb the detriments of BPD to a young person’s development.

According to a 2020 commentary on psychiatry’s increasing awareness of narcissistic personality disorder (NPD), general psychiatric management can be adapted to treat patients with this disorder by providing diagnostic disclosure and patient education.

In addition, a 2021 article in Personality and Impulse Control Disorders outlines how general mental health clinicians can use GPM to treat obsessive compulsive personality disorder. It adapts GPM to OCPD’s treatment with input from experts on the disorder.

As more clinicians learn GPM, more patients with BPD and other disorders can receive the treatment they need.

Contributors

Lois W. Choi-Kain, MEd, MD, Brandon Unruh, MD