Buddhist-Derived Psychotherapies for Borderline Personality Disorder

Borderline personality disorder (BPD) is a mental health condition that includes a pattern of unstable relationships, impulsivity and intense emotional reactions to stressors. The diagnosis is strongly associated with a high risk of suicide attempts and death by suicide. This risk is partly due to the challenges of effectively treating BPD.

Following our years of experience in research and psychotherapy, we created a dedicated center specializing in BPD at the University Hospital of Montpellier — the Therapy Center for Mood and Emotional Disorders, which serves as the national standard of care in France.

Our research suggests that the root of many symptoms of BPD is a poor, distorted or inaccurate sense of self. In our work helping people with BPD, we have found that third-wave cognitive behavioral therapies (Buddhist-derived psychotherapies), through the practice of meditation, can change self-identification and play an important role in treating this condition.

Understanding BPD Symptoms

For people with BPD, a sense of self is often based on a feeling of separation or lack of connection to anyone else. This can lead to a lack of satisfaction, security, value and, often, something that patients describe as a distressing existential “void.” As a result, these individuals may feel a desperate need to feel satisfied, secure and valued.

So how does this “void” manifest? We explored that question in our research published in 2019. Our answer: Obsessive self-preoccupation and relationship addiction. Faced with chronic feelings of existential void, people with BPD will perceive close relationships as a way to overcome the lack of security and value they feel.

The result of this feeling is often engaging in unstable and intense interpersonal relationships — relationships in which the person with BPD will alternate between idealizing someone when things are going well (generating attachment) and devaluing them when they do not meet expectations (generating aversion). Fear of abandonment, characteristic of BPD, can be understood as “the fear of losing the person upon whom my happiness — or my satisfaction, my security, my value, etc. — depends.”

In other words, a person with BPD is often dependent on their relationships to feel “ok,” driving the emotional intensity and instability of these relationships. When things don’t work out, the individual with BPD may feel intense emotional distress. Impulsive behavior, including suicidal behavior, then becomes a way to escape the distress as quickly as possible.

Finding a Different Approach to Treating BPD

As we published in the Journal of Affective Disorders in 2019, practitioners and those with BPD should be aware that “if the understanding of self-concept is impaired, all the interventions implemented to decrease the self’s suffering will be subsequently impaired.”

Ultimately, our self-perception underlies all our daily experiences. If our self-perception is incorrect, then so will be our perception of our daily experiences — including treatment.

Accordingly, we looked into how a person with BPD could improve their sense of self and we found that meditation can be a helpful pathway.

Meditation is a way to examine the beliefs and preconceptions we have about ourselves, others and the world. It supplies the tools for each of us to test the validity of our beliefs and develop our awareness. Then, we are able to incorporate that acquired awareness into our behavior, cognition and identity. Therefore, meditation is an act of transforming how we see ourselves.

Ultimately, a healthy self-representation established through meditation demonstrates that feelings of well-being, security and value are already present in our own mind.

Exploring Buddhist-Derived CBT

In the realm of brain science, the intersection of modern psychiatry and traditional Buddhism has given rise to Buddhist-derived meditation practices or third-wave cognitive behavior therapies (CBT).

Buddhist-derived psychotherapies, through the practice of meditation, aim to change self-identification from an illusion of a “limited self” that is separated from everything that surrounds it, as well as from the feeling of satisfaction, to an understanding of an already content and connected self. At present, there are more than 15,000 international peer-reviewed scientific publications covering this topic.

There are three progressive stages of Buddhist-derived practices (BDP) described in scientific literature. In line with the traditional Buddhist “three trainings,” BDP have been categorized into (1) meditation, (2) ethics and (3) wisdom.

Meditation: Observing Inner Experiences without Grasping at Them
Mindful meditation involves welcoming each moment and experience with curiosity and openness, without automatic attachment to what is pleasant, aversion to what is unpleasant or indifference to what is neutral.

By identifying ourselves as an observer, rather than as a victim of internal and external factors, therapies based on mindfulness meditation can help:

1. Develop awareness of our emotional states
2. Identify how we usually react (our dysfunctional habits)
3. Decrease our automatic behaviors that cause suffering

The benefit of these practices has been widely studied and demonstrated in several areas of medicine and psychiatry, including treatment of BPD.

Ethics: Choosing to Self-Identify with Compassion
Delving deeper into third-wave CBT/BDP makes it possible to go from acknowledging our harmful automatic behaviors without identifying with them to instead identifying with positive intentions, such as loving-kindness and compassion.

Positive states of mind have been associated with greater resilience, and training in familiarizing with these positive states of mind has been associated with increased self-acceptance for people with BPD.

Wisdom: Developing an Accurate Sense of Self
Wisdom-based practices aim to develop the perspective that all things and all people exist interdependently. This can help a person think of themselves as a part of something, rather than as an independent being, and, in result, reduce their obsessive self-preoccupation.

Third-wave CBT aims to familiarize patients with the power to make the mind peaceful and content, to create and experience happiness and to align ourselves with these positive states of mind. This process can teach us how to turn stressful situations into opportunities to grow: Forming a resilient, empathetic and creative sense of self.

Developing a Third-Wave CBT Program

Recently, we coordinated a collaboration between an experienced Buddhist meditation teacher and a health care worker team specialized in third-wave CBT/BDP to create a program to help individuals reframe the way they see themselves.

This innovative program follows the stages of the path for training the mind described in Buddhism. Each stage has been adapted into a secular format, while retaining its therapeutic function, in order to facilitate a gradual change in self-identification.

The preliminary results are very encouraging. Participants described an improved sense of inner well-being, safety and value. They perceived an improved ability to manage emotional states and a decreased urgency to use destructive behaviors. These positive results led us to the inception of a new project focused on providing public mental health workers around the world with online training in third-wave CBT.

It is our goal to unite the modern approach of CBT with millennia-old therapeutic knowledge in order to improve the lives of people with BPD.

Déborah Ducasse, M.D., is a doctor and psychiatrist-psychotherapist.

Véronique Brand-Arpon, M.A., is a doctor of health biology and a nurse-psychotherapist.

Together, Ducasse and Brand-Arpon created a dedicated center specializing in borderline personality disorder at the University Hospital of Montpellier in France named the Therapy Center for Mood and Emotional Disorders. Their therapeutic workbook for BPD patients, The Borderline Personality Disorder Workbook: Understanding Your Emotions, Managing Your Moods, and Forming Healthy Relationships, was published in English (translated by Alison Duncan) in June 2021 by Johns Hopkins University Press. Their work was recently presented to the United Nations during the international exhibition on resilience in June 2021 in Geneva organized by the World Health Organization (WHO). This presentation highlighted the efficacy of Buddhist-derived meditation practices in patients diagnosed with mood and emotional disorders, including borderline personality disorder.