ANNE* ALWAYS felt she was different from everybody else and, having had a difficult early childhood, by the time she was a teenager she did not think she belonged in this world.
“I believed I was invisible – I didn’t think people saw me,” she says. “I was insecure and very mixed up about my own identity; I did not know who I was, or how to fit in to life.”
From her mid-teens on, she attended a succession of psychiatrists and counsellors and was prescribed various medications for her “mood”. However, becoming a wife and mother gave her a new, positive feeling of belonging, and she moved on to become a mature student, followed by short-term work placements and voluntary work.
But when, in her 40s, life threw up challenges over which she had no control, her thoughts and emotions began to change rapidly.
Old fears of being abandoned returned; she became angry and impulsive. She started to self-harm and contemplate suicide; she misused alcohol and became dependent on prescribed medication.
It was only then that she was diagnosed with borderline personality disorder (BPD) and she began to understand the impact it had on her.
BPD is a broad category of mental health problems, often defined by “really powerful emotional distress and sometimes a lot of problems in relationships”, says Jim Lyng, a counselling psychologist with Cluain Mhuire, a community-based adult mental health service in the southeast of Dublin.
Affecting an estimated 1-2 per cent of the population, the disorder is characterised by impulsive and often life-threatening, self-destructive behaviour. Problems tend to start to show before a person reaches adulthood, as they begin to cope with their emotions in extreme ways.
“In a heightened state, people start to make desperate choices,” he explains. Talking of deliberate self-harm or attempts at suicide as “cries for help” misses the point, he suggests. “They are desperate attempts to cope.”
Luckily for Anne, she is living in one of the few areas of Ireland where the successful, evidence-based treatment programme of dialectical behaviour therapy (DBT) is available. Within weeks of diagnosis, she started DBT at Cluain Mhuire.
DBT was developed by Dr Marsha Linehan from the University of Washington to help people with a history of repeated self-harm and suicidal behaviour, many of whom would be classified as having borderline personality disorder.
And it was only this year Linehan disclosed that she has struggled with the disorder herself – so first-hand experience informs the therapy.
It involves a minimum of one year of treatment, with both a weekly one-to-one session of psychotherapy and a weekly group session for learning new skills in managing emotions.
Participants keep a daily diary of their feelings and responses to them. Telephone support is also provided for difficulties that may arise in between sessions.
“Fifty per cent of DBT is learning to accept and 50 per cent is learning to change,” says Lyng. “It sounds simple, but it is very difficult to put into practice.”
For people struggling with extreme emotions, DBT can be “the difference between complete chaos and not being understood, to having some framework to cope with what’s going on and to start building a life worth living”.
When DBT was piloted in Cluain Mhuire more than 10 years ago, the benefits were so overwhelming – a dramatic reduction in the use of inpatient psychiatric beds and in attendance at hospital emergency departments by participants in the two-year follow-up period – it quickly became a “serious option for many of our clients”, he says.
Now a special DBT group for people aged 18-25 who are self-harming has been started on a pilot basis at Cluain Mhuire and it is thought that they will benefit faster as the behaviour they are trying to change is less entrenched.
Self-harm is on the rise in Ireland. The 2010 annual report of the National Registry of Deliberate Self-Harm showed hospital attendance for self-harm was up for the fourth year in a row.
A total of 11,966 presentations to hospitals in 2010 were due to self-harm and these involved 9,630 individuals.
With a 4 per cent rise in the rate of self-harm overall, the most notable increase in 2010 was among 20-24 year olds.
There is a strong link between self-harm and suicide; it is estimated that between a quarter and a half of those who take their own lives have previously carried out a non-fatal act.
DBT is not for everybody, says Lyng, but it is the treatment with the most international research supporting its effectiveness.
And he is frustrated and concerned at its limited availability across the State in a mental health system that is effectively a “post code lottery”.
To be able to avail of DBT, people have to live in the catchment area of the approximately 10 teams of mental health professionals that are offering it, in the east of the State and across Co Cork.
Private services offer elements of DBT, he says, but not “comprehensive” DBT programmes.
There are between 20 and 25 participants in the two DBT programmes currently running at Cluain Mhuire and it has had people moving into its catchment area to try to access the treatment.
Although DBT requires a lot of resources initially, it is, in the long term, a much better use of the health services, Lyng argues, rather than leaving people to turn up at emergency departments with the physical consequences of their disturbed emotions or admitting them for very costly inpatient psychiatric care, which has not proven to be effective.
There is a good chance that people completing the programme can be discharged completely from the mental health services.
Anne has not reached that stage yet, but DBT has “given me hope”, she says.
“It is a new way of living.” If she is having a bad day, she can now draw on coping skills to manage her emotions.
“I know what to do when I become overwhelmed. I am beginning to know who I am and I am not struggling so much with identity issues. It allows me to function in the real world,” adds Anne, who believes it is a “massive injustice” to people like her who can’t have this treatment.
*Name has been changed
