Family Interventions for Borderline Personality Disorder The current evidence

1. Family Interventions for Borderline Personality DisorderThe current evidence Kate Sloan Nurse Practitioner in Psychotherapy

2. Family Interventions – Mental Health • Considerable research has demonstrated the important role that families play in recovery. • Evidence within Schizophrenia and this has progressed within other mental health diagnosis. • Although some advances have been made working with families with BPD it is well behind other disorders.

3. Expressed Emotions - relapse • Robust psychosocial predictor of relapse • Schizophrenia • Major depression • Anorexia Nervosa • Bi-polar • Alcoholism • Stanbridge, et al, (2003) Onwumere et al, (2009)

4. Expressed Emotion - BPD • Criticism and hostility is not predictive of outcome • Criticism and hostility did not predict rates of hosptilisation • Higher expressed emotion is associated with better outcome. • Hoffman and Perry, (1999)

5. Invalidating Environment – the impact on the individual • 1. Are not able to label emotional experience • 2. Do not learn the skills of tolerating emotional experiences • 3. Do not learn how to trust their own emotional responses • Linehan, (1993)

6. Impact of Knowledge • Schizophrenia – Knowledge decreased burden, depression, distress and expressed emotion. • BPD – Knowledge increased burden, distress and depression and there was greater hostility. • Recommendations about the quality of the information given. • Hoffman and Hooley, (2003)

7. Interventions for Families of People with BPD Three manualised Family psycho education programs are described in the literature. Gunderson/Mclean program Hoffman – New York, hospital program Fruzzetti – DBT with couples and families Dissemination of these programs has been modest.

8. Gunderson/ McLean program • Borrowed from psycho educational approaches developed for schizophrenia • Families identified with three major problem areas: • Communication • Anger • Suicidality

9. Hoffman/New York Hospital program • Family treatment approach based on DBT • Educational • Skills development • Environmental change • Interruption of the invalidating cycle • Based on the concept of expressed emotion • Group meets weekly for approximately 6 months

10. Fruzzetti - DBT with couples and families • Developed as part of standard DBT out-patient treatment • Value of family / partners learning complementary skills • Core skills from DBT are included

11. Invalidating Responses Not necessarly - Cruel, abusive, neglectful or uncaring. But may lead to – wants and emotions being missed criticised or not tended to or Invalid behaviors being legitimised.

12. Validating responses • Listening, paying attention • Acknowledging the other’s points • Working to understand; asking questions • Understanding his/her problems in context • Normalizing his/her responses when they are normative (“of course”) • With actions that convey understanding

13. Vulnerability Temperament History of invalidating responses Event Judgments Heightened emotional arousal Inaccurate emotional expression Invalidating emotional response

14. Outcomes • Reduction in symptoms • Relationship satisfaction • Increase in validating responses • Positive impact on relationships with children

15. What next? • Accessible programs. • A framework to inform working with BPD families and carers. • Randomised control trials.