Hope in fight against borderline disorder

It is almost impossible to write about this important issue in a calm and reflective way. The “issues” of self-harm, chaotic or risky behaviour, and overwhelming emotional instability and distress are often too raw for individuals, families and care services to discuss calmly.

The important themes of adolescent self-harm, youth suicide and emotionally volatile young adults who struggle to engage with services continue to attract public attention and often overwhelm us as a community.

But among these struggles, there is hope. There are established and effective therapies, and the majority of young people with existing or emerging features of borderline personality disorder go on to lead meaningful lives.

Borderline personality disorder is characterised by unstable relationships, volatile emotions and self-esteem, and impulsive behaviour. Feelings of emptiness and abandonment, as well as self-harming, are common. The impact on function can be significant, and the emotional distress severe.

Borderline personality disorder is not the same as bipolar disorder. Less than one in 50 people have borderline personality disorder but more people than this have milder symptoms which are not as intrusive. Tragically, about 10 per cent of people with borderline personality disorder suicide in their lifetime — it’s not a low risk.

Past trauma such as sexual abuse is common in this group, so much so that the term “chronic post-traumatic stress disorder” has been used as an alternative diagnosis.

While all of the features can be challenging, self-harm is one of the most difficult and distressing to understand — although not every person who harms themselves has borderline personality disorder.

There are numerous reasons why a person might harm themselves and I have heard many heartbreaking stories throughout my career. One of the most harrowing involved a young woman who felt so numb, empty and detached that she cut herself just to feel real, to know she was alive.

Self-harm can release “internal painkillers” in the body, which may ease emotional, as well as physical, pain and some people feel no physical pain when they self-harm.

A person may have one, many or no immediately apparent reasons for self-harm, and as such the reasons behind self-harm must be clarified.

Often the reasons for self-harm are too confronting for an individual to discuss — the self-harm itself is a way of expressing the pain. Self-harm is usually not “manipulation” but powerful help-seeking. Sadly, over time it can become a repeated and destructive way to reach out to others.

From a clinician’s perspective, working with an individual with borderline personality disorder can be some of the most challenging and confronting therapy work. But it can be extremely rewarding and also very successful — albeit it does take time.

There is no magic pill for borderline personality disorder. In fact, research shows little evidence for the use of medicines in this illness though associated episodes of other mental illnesses like depression should be treated vigorously.

Many individuals are treated in the private sector but research shows that public mental health services also have an important role in the treatment of this disorder. We need to do better to provide our grassroots clinicians with enhanced mentoring when they are working with people with borderline personality disorder.

WA is active in skills training, and only recently the Child and Adolescent Mental Health Service brought world leaders to Perth to train local staff in a newer strategy for working with young people with personality disorders and their families.

The role of the hospital is another controversial discussion often debated in the media. We frequently hear that there are not enough hospital beds for these individuals. In reality, hospitals are not the main solution, although they are important at certain times for specific circumstances.

My experience, also reflected in research and international guidelines, shows that longer term hospital stays for people with borderline personality disorder are not necessarily helpful and in some cases are associated with a worse longer term risk.

Hospitals tend to take away control from patients — they become dependent on others to direct care. This is not always helpful in personality disorders as inpatients can find it difficult to practise the skills to take control of their own lives. The critical (and often life-saving) part of therapy for an individual with borderline personality disorder is to help them take control of their own life. This happens best in community-based therapy.

There are services to treat borderline personality disorders in WA including access to therapies, as well as intensive follow-up in the community if needed. But we can always do better. We need more clinicians trained in working with borderline personality disorder, and enhanced supervision for them.

Families need support during the long journey, and while the course to recovery can be rocky, the vast majority of people with borderline personality disorder do well.

Dr Nathan Gibson is the WA Chief Psychiatrist