Guidelines for loved ones of a person with BPD

“The roots of resilience…are to be found in the sense of being understood by and existing in the mind and heart of of a loving, attuned, and self-possessed other.” ― Diana Fosha

It is important that…

…you find support for yourself. Not only will this be of benefit for you but will be most helpful for the person you are supporting if you are well.

…you don’t promise to keep someone’s suicidal thoughts or feelings a secret from everyone else. If you do, and you break your promise, you may lose their trust. This can be discussed about together.

…you work with the person you are supporting to involve more people in their support group. Such people can include family members, friends, GP, mental health professional, etc. You can vary how much you explain depending on their involvement.

PROJECT AIR STRATEGY – Staying connected for families & carers of BPD

Educate yourself

BPD symptoms can be confusing and play havoc to relationships with family, friends and supporters. You may fear the safety of your loved one with BPD or feel misunderstood, frustrated, angry, guilty, etc. These emotions are understandable but it is essential to understand that the person with BPD is not choosing to behave like this. Their volatile behaviour is a response and expression of their emotional dysregulation.

Supporters of a person with BPD cope better when they recognise, accept and learn about the condition, and how to communicate and relate to the person. It’s also good to know how to recognise a crisis and know what to do when a crisis occurs.

It is important you look after yourself. Communicating and staying connected with carer support groups can help you manage BPD in the family positively.

Access BPD information from leading health focused organisations in Australia at mindhealthconnect.

Be a listener

Listen actively and be sympathetic and focus on emotions rather than the words. Ensure that you demonstrate that the person with BPD feels heard. When someone is upset or angry, it’s easy and understandable to reciprocate, but it is not helpful.

Go slow with GOALS

Change is difficult to achieve and often comes with fear.

Be cautious of suggesting “great” progress or giving “you can do it” reassurances as progress can be perceived as near completion or minimising the emotional struggle and this is fraught with the fear of abandonment.
Do not show excitement about progress but rather inform the person with BPD that they have many more problems ahead. A message such as “I’m pleased you were able to do it, but I’m worried that this is all too stressful for you” can be more empathetic and less risky.

Set realistic and attainable goals to be achieved one small step at a time.

Too large of a step forward may backfire to relapse into a regressed state and possible hospitalisation.
Success in the education or work carries the overriding issue of gaining independence which is desired but also evokes fear of abandonment.
Develop goals on individual strengths, skills and abilities with considerations of BPD symptoms.
g. the person who left university mid-semester would unlikely be able to return to full-time study but will show greater stabilising by try one course at a time.

EMPATHETIC family environment

Keep things cool and calm.

A person with BPD has trouble distinguishing real emotions from perceived ones and therefore has difficulty with handling stress in relationships.
Stress includes rejections, criticism and disagreements.
Be understanding of these emotional vulnerabilities and imagine how distressed they must be feeling to be reacting in that way.
Avoid sarcasm or other tones that may be misunderstood. Tone it down and slow down to allow the person a moment to process their feelings.
Listen without expressing personal judgement and blame and reflect back their own words in a calm manner.
Set a “contagious calm”

Emotional dysregulation

A person with BPD is highly sensitive to emotional fluctuations on a regular basis.
Most people can cope with such emotional experiences by reminding themselves that mistakes are of human nature.
A person with BPD may feel uncontrollable anger, sadness or dysphoria and can result in inappropriate expression of hostility or acting out impulsively.

Intolerance of Aloneness

A person with BPD will go to great length to avoid rejection or abandonment as their memory fails them and they only feel calm when their support person is present.
The distress from fear of separation may lead to falling into dissociation.

All-or-nothing thinking

A person with BPD may have the inability to view others more realistically as a mix of good and bad qualities.
When crises occur, family members can help achieve emotional stability by encouraging slow breathing to reduce pressure.
Once calm, the family can together have an open discussion and achieve setting small goals for the person with BPD.

MAINTAIN family routines

Continue to attend parties and holidays.

Do not hide the problem into a stigmatising and shameful secret within the family as this will create an isolating environment for the family.
Keep in touch with other family and friends and continue to enjoy good times to relax and unwind.

Find time for light and neutral chats.

Conflicts and the burden of managing severe emotional problems often lead to forgetting to take time to talk about other life matters.
Such discussions are valuable to encouraging the person with BPD in exploring and using their skills and interests. Consequently, strengthening their sense of self and identity.
Light chats with an agreement of no discussion of problems and conflicts during these times allow for some humour and distraction to lighten the tension between family members.

MANAGING crises

Listen and don’t get defensive in the face of accusations and criticisms.

People with BPD may feel a great deal of anger and may make heavy insults in a fit of rage to loved ones.
Although it is unfair to listen and get hurt, arguing suggests that you believe the other person’s anger is uncalled-for and this will lead to greater rage.
Anger in a person suggests that the individual wants to be heard no matter how much the feelings are based on distortions. If there is some truth in what you’re hearing, admit and say something like “I think you’re onto something. I can see that I’ve hurt you and I’m sorry.”
Do not tell people with BPD how they should be feeling or behaving.
Anger in people with BPD may represent one side of their feelings which can rapidly reverse so keeping this point in mind can help avoid taking the anger personally.
Sit with them through it and remind them their feelings are valid and you are there to support them.

Self-harm or suicidal threats and behaviour require attention within the family and be made aware to professionals.

When families see signs of trouble they may be reluctant or dread discussing about the issue as they think they may put forward ideas that didn’t exist before talking.
Problems are not created by asking questions so by addressing destructive acts and triggers in advance, the family can avert further trouble.
Don’t ignore or panic. Families must weigh concern for safety against concern for privacy and must apply judgement to their individual situation about whether to call the therapist or an ambulance.
People with BPD tend to have difficulty expressing their feelings through words and instead act on them destructively. Having an open discussion with the individual and therapist will help deal with these feelings, anticipate crises and establish crisis plans that fit the family’s needs.
It is important that the person is not isolated or discriminated against. Remember to follow up after presenting harmful or emotional behaviours.

Listen and let negative feelings be verbally expressed rather than acted out in destructive ways.

People appreciate being heard and having their feelings acknowledged. Expressing fear, loneliness, inadequacy, anger, or needs in words become less painful once shared.
Listen – remain silent while being interested and concerned. Ask questions to convey your interest but not necessarily agreement. For example: “How long have you felt this way?” or “What happened that triggered your feelings?”
Listen and make statements expressing what you believe you’ve just heard. Empathetic statements do not need to imply agreement. For example: “You feel like I don’t love you?”
Family members may be quick to deny or argue the feelings experienced the person with BPD. If these feelings are ignored, the individual may resort to self-destructive ways to express their emotions.

ADDRESSING problems

Collaborate in problem-solving.

ALWAYS:

Involve the family member in identifying what needs to be done.
Ask whether the person can “do” what’s needed in the solution.
Ask whether they want you to help them “do” what’s needed.

Consistency in perspectives, strategies and responses.

Family members need to openly communicate about their contrasting views on a problem, hear each other’s opinions and then develop a plan that everyone can stick to. This will prevent having tension and resentment within the family and allow for progressing with overcoming the problem.

Let the therapist/doctor/treatment team know of intervention or financial concerns.

Since family members play a major supportive role in the patient’s life, such as providing financial support, emotional support, or sharing their home, they should make efforts to participate in treatment planning for that individual.
Therapists can take note from the reports of the patient’s loved ones and with the patient’s consent, can work with them.
Concerns can include: medication usage and side effects, non-compliance, history of substance abuse, etc.

SETTING limits

Set expectations in a clear and simple manner.

Avoid attaching any threats with expectations so that the responsibility is put on the other person to fulfill.
Make sure everyone knows of the expectations.
Attaching a threat and not following through with it means it becomes an empty expression of hostility from which the person with BPD may show these behaviours outside the family setting and face greater harm and loss in the real world.

Allow person with BPD to learn from the consequences of their actions.

By setting limits on choices and behaviours, family members can motivate individuals to take on greater responsibility and have appropriate limits within themselves.
Overprotection from the family will lead to greater emotional and financial toll to the individual and family in the long-term. It may be difficult to watch a loved one struggle with frustration and anger, but it is important to prepare the individual for the real world by teaching them to live with the consequences as all people need to do.

Do not tolerate abusive treatment.

A mild response to a tantrum would be to walk away and a more aggressive gesture would be to call an ambulance.
Neglecting proper medical attention for violent behaviour will only escalate out-of-control behaviour.
Prioritise safety over privacy and return for open discussion later.

Threats and ultimatums are a last resort.

Threats and ultimatums should only be used when you seriously intend to act on them.
Let others, including professionals, help with deciding when to give a threat or ultimatum.
An ultimatum should only occur at the point when the person giving it feels unable to live with the other person’s behaviour.

The above guideline has been summarised from Family Guidelines by John G. Gunderson, M.D. and Cynthia Berkowitz, M.D.

Take care of yourself

Family and friends are very important factors for someone recovering from BPD. However, not many BPD treatments offer support for loved ones. You must remember that to be a great supporter, your health matters too.