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Personality disorders are probably the least understood but most prevalent mental health issues — ten percent of the general population experience them. Part of the difficulty in understanding personality disorders is the same basic problem encountered in much of psychiatry: it is difficult to determine what is happening inside the brain only by seeing a person’s external behaviours.
One way to think of a personality disorder is as a cartoonish exaggeration of a normal personality trait to the point that it affects daily life. The self-absorbed become narcissistic, unable to love anyone but themselves. The grandiose become histrionic, with garish, outlandish behaviours intended to draw others to them in a lifelong but ineffective desperation for human connection.
Unlike the other personality disorders, those with borderline personality disorder (BPD) are heavily over-represented in mental health care services, with about 40 per cent of all mental health inpatients having the condition, despite only one to two per cent of the population suffering from it (BPD Foundation Consensus statement).
BPD is not merely an exaggerated personality trait, but a complex mental health condition that profoundly affects an individual’s emotional regulation, relationships, and self-image. Contrary to the notion of BPD as merely a response to trauma, recent research, including studies cited by the BPD Foundation and work by scholars like Skaug (2022), points to a more nuanced understanding that includes genetic factors.
The borderline are driven by a fear of abandonment. Patients with BPD often experience intense emotional pain and may exhibit behaviours that can be challenging for both themselves and the professionals seeking to help them. For instance, during my early years in psychiatry, I still vividly remember meeting with a patient in crisis who berated me so severely I was unable to tolerate talking to her any longer, and left her to be assessed by the morning doctors. The interaction lasted five minutes and happened twenty years ago.
Such episodes underscore the complexity of providing care in these situations.
Patients with BPD have frequent suicidality, low self-esteem and severe mood swings. My textbooks advise that this condition usually arises during adolescence. That’s a bland, academic way of describing the horrific truth — that one in 50 children from the age of twelve can one day wake up with the belief that they have to kill themselves.
‘One of those concepts, that we are loved and deserve life, is at the heart of this targeted psychotherapy — and surely at the heart of human experience itself.’
I once spoke to a father and his daughter, who presented after ten years of difficulty. Their own doctor had dissuaded them from seeing psychiatrists, believing that she would grow out of the condition, until he was finally convinced by her therapist to refer her. I asked my standard initial question: ‘Do you have a voice in your head telling you that you are a horrible person?’ Her father was shocked to hear that this voice had been present since she was eleven, and she’d never mentioned it before, out of fear.
BPD has the reputation of being one of the most difficult mental disorders to treat — as well as being one of the most controversial. Most antidepressants have minimal impact on the mood features, often leading to early despondency in treatment. Early research found that 70 per cent of psychiatrists did not tell their patients that they had the condition, simply because of the stigma associated with it, and clinicians feared the potential negative impact of the diagnosis.
I once worked at a service where several clinicians explained to me how important it was for patients to remain uninformed about their condition so they wouldn’t keep turning up for help. And that is one of the few saving graces of the syndrome: it pushes the sufferer to keep looking for help, in the hope that someone will be able to rescue them.
There was a young woman I once met, who, after three years of repeated admissions, finally had the BPD diagnosis given to her. I was worried that she was going to take it badly, but was amazed at her relief. ‘All this time, I thought I was just a bad person. Now I know what I have.’
One breakthrough in treating BPD has been the development of Dialectical Behaviour Therapy (DBT), which I came across a few years ago. DBT has revolutionized the treatment landscape, with remission rates significantly improving, from remission rates after completed treatment of barely 30 per cent to 85 per cent. For the first time, many patients who had access to the therapy were granted a modicum of control over their inner darkness.
Early critics suggested that the proponent, Dr Marsha Linehan, merely happened to be highly charismatic, but when others started replicating her methods, they continued to prove effective. One of the key components of DBT is mindfulness, something most of the public is aware of, possibly because of how simple it is to market. (Those adult colouring books you see in newsagents emerged from one of the suggested DBT exercises).
Mindfulness is an acquired skill that is beneficial to the mental wellbeing of anyone, not just those with borderline personality disorder. In BPD, the mindfulness practice is directed at acknowledging and accepting one’s feelings, thoughts and sensations. It’s about learning to think in the opposite direction to the way the borderline mind wants to go. I’ve had patients liken it to learning to ride a bicycle uphill.
Dialectical Behaviour Therapy is not easy. Dropout rates for initial engagements are usually higher than 60 per cent. Those who persist, succeed.
It was only a few years ago that Dr Linehan admitted that she herself had borderline personality disorder. It had failed to respond to medication, or electroshock therapy, and she spent two years at an inpatient unit, largely in seclusion as its ‘worst patient’.
She describes what led to change. The condition usually leads to the sufferer having a persistent voice in their head that feeds a nonstop torrent of abuse — that they are worthless, devoid of value, and do not deserve existence, let alone love. And in the throes of this, it was in church that, as clichéd as it sounds, a miracle occurred. As The New York Times reported:
‘One night I was kneeling in there, looking up at the cross, and the whole place became gold — and suddenly I felt something coming toward me. It was this shimmering experience, and I just ran back to my room and said, “I love myself.” It was the first time I remember talking to myself in the first person. I felt transformed.’
She later called this concept of ‘radical acceptance’— accepting that she was the person she was, with all her faults and her strengths. This was the foundation of the school of psychotherapy she created.
I once met someone with BPD presenting all the criteria, with one unusual issue: she had never self-harmed, or attempted to, despite 10 years of suicidal thoughts. When I asked her why she had never self-harmed, her expression suddenly changed and, looking remorseful, she muttered, ‘I just don’t deserve to harm myself’. I nearly fell off my chair at her brilliance — she had inadvertently figured out a way to trick her own brain into safety.
Today, there are some newer medications not previously trialled that are showing promise of reducing the symptoms of borderline personality disorder. None of these have proven as effective as DBT, although it is no longer the only evidence-based psychotherapy. DBT is not a magic bullet; it is difficult, and can be frustrating for the sufferer to do well. But when they are able to utilise the technique well, it can be transformational. Through therapy and personal growth, patients with BPD often learn to counteract the harsh internal criticism characteristic of the disorder.
There’s an obvious overlap here between DBT and religious practice and patient transformation through DBT echoes the spiritual journey of finding one’s intrinsic value and being at peace with oneself. The benefits of religion to mental health have been well documented, with its emphasis on community, on shared experience, and belief in a higher power. The teachings of religion encourage compassion to the self and others, and offer structure and guidelines to live by that bring stability and a sense of purpose to life. Connection with others of similar beliefs provides a community of support when coping with life’s challenges. The rituals of religion bring a sense of peace, acceptance and gratitude. Being religious — believing in something greater than the self — has been shown to have a powerful positive impact on mental wellbeing, and is linked to reduced suicide rates and addictive behaviours such as alcoholism and drug use.
In a similar way, DBT focuses on ‘radical acceptance’ of the self — or, as Therese Borchard likes to think of it, ‘practising and learning to live the Serenity Prayer: accepting the things we cannot change, finding the courage to change what we can, and using our therapists and guides to help us distinguish between the two’. That dynamic between acceptance of the self and changing unhelpful ways of thinking and behaving teaches participants to find connection — between themselves and others, and between themselves and the world — to achieve a meaningful life.
In the ongoing quest for truth, there is mystery as well as revelation, but there are some religious concepts that are simple to describe and universal in their application. They offer a new world to the mentally ill, but also to anyone. One of those concepts, that we are loved and deserve life, is at the heart of this targeted psychotherapy — and surely at the heart of human experience itself.
Neil Jeyasingam is Clinical Associate Professor of Psychiatry at the University of Sydney, and an Associate of the Centre for Public Christianity.
This article first appeared in Eureka Street Magazine.
