Reflection
Borderline Personality Disorder: The Truth, the Difficulty, and the Hope
More than twenty-five years ago, when I was becoming a psychotherapist, one of my supervisors gave me this advice: you should have one borderline patient in your practice, to give back to the community. But do not take two, because two is too much trouble. At the time, the belief was that these patients could not improve. We now know that is false: long-term studies show that with the right therapy, and sometimes medication to stabilise the mood, a person with borderline personality disorder can have a fulfilling life. My supervisor was right about the difficulty. He was wrong about the hope.
What borderline personality disorder is
The picture is made of a few traits that are quickly recognised. Extreme variation of mood: from zero to a hundred in one second. An extreme fear of being left alone. Unstable, intense relationships, alternating between you are perfect and I hate you. An unstable sense of self: goals that change all the time, a self-image that does not hold. And impulsivity, which is a major one: with drugs, with food, with sex, reckless driving, binge eating. These people create a lot of problems, and find themselves, very often, in a lot of trouble.
There are also, sometimes, self-harm behaviours and suicide attempts. Rapid, intense mood swings. And a chronic feeling of emptiness, which the person tries to fill with intensity. If you recognise yourself here and thoughts of suicide pass through you, speak to a professional or an emergency service without waiting: this is precisely a suffering that can be treated.
Living with someone who is borderline
To be in a relationship with a borderline person is to walk on eggshells all the time. It is to be bewildered by the sudden shifts between affection and anger. It is a nonstop, intense experience, in which one can move from idealisation to hatred within the same day. The partners and families who come to see me often arrive exhausted, and guilty about being exhausted.
Where it comes from
The roots are double. There is a genetic part: a temperament, a high emotional intensity, which often overlaps with the high sensitivity I have written about elsewhere. And the childhood environment plays a role: an invalidating environment, made of emotional neglect, abuse, or inconsistent parenting. Invalidation means the repeated experience of expressing an emotion and having it dismissed: you are too sensitive; you are a sissy, like a girl. A child who is answered this way every time he feels something never learns healthy emotional regulation. The sensitive child who is invaded becomes a highly sensitive adult; the sensitive child who is invalidated, or abused, can become borderline.
The therapies that work
Treatment goes through therapies that have proven themselves: dialectical behaviour therapy (DBT), mentalization-based therapy, schema therapy, and sometimes medication to stabilise the mood. It must be said honestly: these are difficult patients for therapists. They cancel sessions. They create problems inside the consulting room itself. I remember one place where I practised: the manager told me, we like you, but your patients are too troubled; if they continue, we will have to stop renting to you. That was a borderline patient.
In my practice
I have borderline patients in my practice. I generally allow a little more time before and after their session, so that the session has all the space it asks for. There are many cancellations. There are texts and calls between sessions. But something must also be said that never is: these people know how to laugh, and they know how to be deeply loyal to the people in their lives. They are not bad; they are ruled by emotion. It is a little like watching a child in a tantrum: what is needed is not a judge, but an adult who stays. A large part of the work, in the end, is exactly that: staying. The borderline patient tests, often without knowing it, whether you will abandon them like the others. The therapy truly begins the day they discover that you will not.
I see patients in English and in French, at Harley Street in London, in Paris, and by secure video. See also the highly sensitive person, binge eating, and the work on trauma. Book a consultation.
Download the free guide: this essay is part of the book The Hold: Recognising Narcissistic Abuse, Understanding the Fear of Abandonment, and the Way Out, with seven art therapy exercises. Download it freely (PDF). No sign-up, no email: it is a gift.
On the attachment that often underlies this picture: Disorganised Attachment.
