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Borderline and beyond



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.

Main image: Rorschach inkblot test. (Getty images)

Topic tags: Neil Jeyasingam, Borderline, BPD, Therapy, Acceptance



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Existing comments

This article made absorbing reading, thanks. I’ve sometimes wondered about the link between what we term “eccentricity” and personality disorders. On being asked why he wrote the brilliant novel “The Name of the Rose” Umberto Eco replied “I felt like poisoning a monk.” Maybe the inspiration and creativity involved in the arts can be as therapeutic as religious belief. And I like to think that religious belief is a gift given to the well and the not so well alike.

Pam | 08 November 2023  
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Since no one has ever moved a mountain into the sea, we must assume that everyone who has a spiritual belief is spiritually unwell. If the condition is a disc, complacency and scrupulosity are merely the opposing rims, not the condition itself.

s martin | 09 November 2023  

I’m not so sure about no one ever moving a mountain into the sea. Some people have done so in a metaphorical sense. Which is very important spiritually.

Pam | 10 November 2023  

When we say that a God for which nothing is impossible was only speaking metaphorically about a thing which he could easily have meant literally, are we really believing that for God nothing is impossible?

Isn't fiction what a human author has to resort to because s/he can't find a factual situation to support the point s/he is trying to make? If the situation was known, the author would simply report it like a journalist.

Isn't fiction, therefore, only a poor relation of fact, a necessity only because humans are not in possession of all the facts?

Why would a God for which nothing is impossible have to speak fiction? For any point that God wants to make, he can ordain a factual situation to demonstrate it.

Complacency and scrupulosity are neither here nor there. The real unwellness is that nobody has that minimal amount of faith which can change topography. And a derivative unwellness is the modernist preference to substitute metaphor for literal because it allows their private preferences to be normalised.

s martin | 12 November 2023  

Dear Neil,
Thanks for your article which included a mix of relevant information and a pathway towards a compassionate and effective response to sufferers.
The "inner critic" which has been remarked upon by people that I know, seems to dominate the sufferer's thoughts,and the concept of "Radical Acceptance" would appear a good antidote.
The problem with diagnosis is that it may lead to a person experiencing shame and stigma which may be counter-productive.The Psychiatric profession have essentially been coming from a purely medical model for too long and some of us have links to those who died under the "experimental therapies"(vaccination therapies) in the 1920s in Asylums in Victoria see Dr.Alison Watts research online to verify.
If those helping those with a mental illness,came from a liberation perspective then "Radical Acceptance" might have some success.
See the quote by Aboriginal activist Lilla Watson,which suggests that if you have come to help me then I'm not interested but if your liberation is tied up with mine then maybe we will be able to work together.
This would require a good dose of humility coming from the health professional involved.
As you suggest it may need to include a spiritual element,a bio pyscho spiritual model is worth exploring.Many thanks to Sr Cairns and Fr Thomas for the Mental Health and Spirituality Conferences held in past years,where this subject has been thouroughly explored.Dr R Lloyd has also written some good responses to the pitfalls in the current mental health system on the Pearls and Irritations website,he has also recommended "Dadirri"the Aboriginal practise which has been shared and made known by the beautiful and wise Indigenous elder and former senior Australian if the year,Dr Rose Ungermerr Bauman
I have other stray thoughts which may be of use but which this forum isn't able to accommodate due to lack of space.

Roz | 12 November 2023  

Thank you Neil. I have had the privilege of being there while you delivered it to a patient. You said you really “ wanted to help her”. It was amazing. May I spread this article about? Cheers Fi

Fiona Lucas | 12 November 2023  
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Great to hear from you Fiona. Yes, happy for it to be distributed.

Neil Jeyasingam | 13 November 2023  

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