Family Interventions for Borderline Personality Disorder The current evidence Kate Sloan Nurse Practitioner in Psychotherapy

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. Although some advances have been made working with families with BPD it is well behind other disorders.

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

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)

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)

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)

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.

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

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

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

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.

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

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

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

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