Borderline Personality Disorder

The best way I have heard borderline personality disorder described is having been born without an emotional skin, no barrier to ward off real or perceived emotional assaults. What might have been a trivial slight to others was for me an emotional catastrophe, and what would be a headache in emotional terms for someone else was a brain tumor for me. This reaction was spontaneous and not something I chose. In the same way, the rage that is often one of the hallmarks of borderline personality disorder, and that seems way out of proportion to what is going on, is not just a “temper tantrum” or a “demand for attention.” For me, it was a reaction to being overwhelmed by present pain that reminded me of the past(Williams, 1998)

What is BPD

Borderline personality disorder (bpd) is a serious, long-lasting and complex mental health problem. Though it has received less attention than other serious mental health problems, such as bipolar disorder or schizophrenia, the number of people diagnosed with bpd is similar or higher than these disorders. People living with bpd have difficulty regulating or handling their emotions or controlling their impulses. They are highly sensitive to what is going on around them and can react with intense emotions to small changes in their environment. People with bpd have been described as living with constant emotional pain and the symptoms of bpd are a result of their efforts to cope with this pain. This difficulty with handling emotion is the core of bpd.

There are many symptoms associated with bpd, some of these are:

1. intense but short-lived bouts of anger, depression or anxiety

2. emptiness associated with loneliness and neediness

3. paranoid thoughts and dissociative states in which the mind or psyche “shuts off” painful thoughts or feelings

4. self-image that can change depending on whom the person is because people have different predispositions and life histories, and symptoms can fluctuate over time

5. impulsive and harmful behaviors such as substance abuse, overeating, gambling or high-risk sexual behaviors

6. non-suicidal self-injury such as cutting, burning with a cigarette or overdose that can bring relief from intense emotional pain (onset usually in early adolescence); up to 75 per cent of people with bpd self-injure one or more times

7. suicide (about 10 per cent of people with bpd take their own lives)

8. intense fear of being alone or of being abandoned, agitation with even brief separation from family, friends or therapist (because of difficulty to feel emotionally connected to someone who is not there)

9. impulsive and emotionally volatile behaviors that may lead to the very abandonment and alienation that the person fears

10. volatile and stormy interpersonal relationships with attitudes to others that can shift from idealization to anger and dislike (a result of black and white thinking that perceives people as all good or all bad)

The types and severity of bpd symptoms experienced may differ from person to person because people have different predispositions and life histories, and symptoms can fluctuate over time.

The term borderline personality disorder was coined in 1938 by Adolph Stern, a psychoanalyst who viewed the symptoms of bpd as being on the borderline between psychosis and neurosis. However, some experts now feel the term does not accurately describe bpd symptoms and should be changed. Some also feel that the existing name can reinforce the stigma already attached to bpd.

The road to specialized treatment and recovery is often hard because the symptoms of bpd can make the affected person emotionally demanding and difficult to engage and retain in treatment. As a result, the disorder is often stigmatized and helping services may be reluctant to accept clients with a bpd diagnosis.

However, with appropriate treatment, people with bpd can make significant life changes, though not all symptoms of bpd will disappear. Remission is more common as people reach the middle years of life. Hope and recovery are important to both the person and family members. These issues are discussed in more detail on p. 39. “The overarching message of ‘recovery’ is that hope and meaningful life are possible. Hope is recognized as one of the most important determinants of recovery” (O’Grady & Skinner, 2007)

What feelings does someone with BPD normally feel

I feel empty and lonely, sometimes like I don’t exist at all, and saying my name feels like a lie because I know there’s nothing inside. I play roles, try to be who I’m “supposed” to be, and I’m good at being anyone but me. I fill in the space with what’s appropriate—my goals, careers, values, it’s all based on the situation. I want to feel something, anything other than nothing. I go from okay to suicidal in an instant and don’t even know why. But one constant is a sense of worthlessness that spills over into a desperate need for self-destruction.

Borderline personality disorder can have degrees of severity and intensity, but at its most severe and intense the emotional vulnerability of a person with bpd has been described as akin to a burn victim without skin. The tiniest change in a person’s environment, such as a car horn, a perceived look, a light touch from another person, can set a person with bpd on fire emotionally. Some of the extreme feelings associated with bpd have been identified and include intense grief, terror, panic, abandonment, betrayal, agony, fury or humiliation.

Family members have feelings around bpd as well. They have described living with a person affected by bpd as constantly “walking on egg shells,” never knowing what will trigger an outpouring of emotion or anger (dbtsf, 2006).

Family members may often feel manipulated by their loved one, but any perceived manipulation is not deliberate. The person living with bpd is trying to manage and deal with intense emotions that greatly affect his or her behaviour.

How common is BPD?

Studies in personality disorders are at an early stage of development. Community surveys of adults have indicated that the prevalence of bpd is close to one adult in 100, similar to that of schizophrenia (Paris, 2005). The most recent (and largest) community survey in the United States found a prevalence of bpd of six per cent. At this time, we don’t have accurate rates for Canada (Grant et al., 2008). It is unclear whether bpd is more common among women than men and some reports state that about 70 to 80 per cent diagnosed are women. Other research suggests that although there are more women in a treatment setting, there is no significant difference between the incidence of bpd in women and men (Grant et al., 2008)

How is BPD diagnosed?

In Ontario, a physician, a psychiatrist or a registered psychologist can make a formal diagnosis of bpd or any other mental health disorder. The first step toward diagnosis is often with a family physician or the emergency department of a hospital. If there is enough reason to be concerned about someone’s mental health, the family physician can make a referral for further assessment.

Whoever makes the diagnosis will use the dsm-iv-tr to ensure that the person fits the criteria for a diagnosis for bpd

What other disorders co-occur with BPD?

It is very common for someone with borderline personality disorder to have other mental health problems that can complicate the diagnosis of bpd. Some disorders that commonly co-occur with bpd include major or moderate to mild depression, substance use disorders, eating disorders, problem gambling, posttraumatic stress disorder (ptsd), social phobia and bipolar (manic-depressive) disorder. Sometimes it can be difficult to diagnose bpd because the symptoms of the co-occurring disorder mimic or hide the symptoms of bpd. As well, relapse in one disorder may trigger a relapse in the other disorder.

When does BPD begin?

Like the onset of other serious mental health problems such as schizophrenia, the symptoms of bpd appear in late adolescence or early adulthood. In some cases, parents may have no warning that something is wrong; their child who had appeared to be functioning well suddenly falls apart with the onset of behaviors such as emotional outbursts and suicidal gestures.

What causes BPD?

As with other mental health disorders, our current understanding of bpd is that a person’s genetic inheritance, biology and environmental experiences all contribute to the development of bpd. That is, a person is born with certain personality or temperamental characteristics because of the way their brain is “wired,” and these characteristics are further shaped by their environmental experiences as they grow up and possibly by their cultural experiences.

Researchers have found differences in certain areas of the brain that might explain impulsive behavior, emotional instability and the way people perceive events. As well, twin and family history studies have shown a genetic influence, with higher rates of bpd and/or other related mental health disorders among close family members. Environmental factors that may contribute to the development of bpd in vulnerable individuals include separation, neglect, abuse or other traumatic childhood events. However, families that provide a nurturing and caring environment may still have children who develop bpd, while children who experience appalling childhoods do not develop bpd.

Though histories of physical and sexual abuse are reported to be high among those with bpd, many other experiences can play a role for a child who is already emotionally vulnerable.

Stigma and BPD

In the world outside I met ignorance, stigma and judgment. I felt isolated, stressed, full of guilt, shame and fear.

Many societies look down on people with mental health and/or substance use disorders. They and their families face negative attitudes, behaviors and comments. This is known as stigma.

Stigma can do many things like:

• shame, isolate and punish the person who needs help

• reduce the chances that a person will get appropriate help

• lead to lower self-confidence

• make the person feel that he or she will never be accepted in society

Family members also experience the effects of stigma. Their social support network may shrink and they may face negative attitudes if they reveal their situation. We know that the risk factors of separation, neglect or abuse in childhood have been associated with the development of bpd in some people. Because of this, family members may be blamed and may feel or be seen by others as “part of the problem.”

Newcomers to Canada may experience greater stigma because of their culture and what is considered acceptable within that culture. Sometimes even asking for help can be difficult for someone whose culture does not encourage counselling or outside help. They may have difficulty finding the service they need because the counselling is not available or when it is, it is not in their language

Some therapists are reluctant to treat people with bpd because they are seen as being resistant to treatment and because of their emotionally demanding behavior. Their tumultuous relationships, mood swings and suicidal gestures can provoke anger and frustration in the therapist. Some programs have formal or informal policies that refuse treatment to people with bpd. Advocacy groups have also identified lack of funding for research on bpd, and exclusion of bpd from research studies.

Sadly, people living with bpd often experience more stigma than people living with other mental health disorders.

Stigma and BPD with a concurrent disorder.

It is common for someone with borderline personality disorder to also have a substance use or other addiction problem, and the stigma experienced by someone with one disorder is magnified for those living with two or even more disorders. Negative and blaming attitudes toward those with substance use and mental health problems (concurrent disorders) are often internalized, and a person with concurrent disorders may experience social isolation, poverty, depression, reluctance to seek treatment and loss of hope for recovery, as well as prejudice and discrimination when seeking health care, housing, employment or other services

What types of mental health services are available?

In the past, specialized treatment for bpd was hard to find, but the disorder is now being better recognized and diagnosed and more communities have established specialized treatment programs that significantly improve outcomes for people with bpd. However, the complexity and variety of bpd symptoms and their overlap with other psychiatric disorders continues to make accurate diagnosis difficult and time-consuming. For those affected and their families, there may be frustration before the right mix of help and resources can be found.

Services for people with mental health problems include hospital emergency departments, acute-stay hospital beds, extended residential care, as well as outpatient care provided by hospital outpatient services, community mental health clinics, assertive community treatment (act) programs or private practice psychiatrists, psychologists and other health professionals. There are also services that provide a variety of programs including housing and employment support, drop-in services and peer support. Some people may prefer to receive services from a health or social service agency, doctor or health practitioner providing language or culture-specific services. More information about specialized mental health services in your community can be found by contacting Mental Health Service Information Ontario or your local branch of the Canadian Mental Health Association. Further information on these and other resources is listed on p. 43. Health professionals such as your family physician, a nurse practitioner or social worker may be your first point of contact. They can determine whether they can assist you and your affected family member or whether you may need a referral to more specialized services. In smaller urban or rural communities, family physicians may provide the majority of mental health services and are often the primary support for people diagnosed with bpd

Treatment for serious mental health problems such as bpd will usually involve:

1. education about bpd (psycho-education) with discussions on what is known about bpd and its causes, what kinds of treatments are available, how to self-manage bpd and how to prevent relapse

2. psychotherapy or counselling on an individual or group basis

3. prescribed medication for specific symptoms of bpd such as mood swings or anxiety.

In most cases, treatment will be on a community or outpatient basis, but some people may require a period of stabilization in hospital if they are experiencing severe symptoms such as suicide attempts, self-harming or psychotic behaviors. Being in the hospital can also give doctors the opportunity to review a person’s current medication regime, start new medications and monitor their impact.

Specialized and effective treatment for bpd requires a long-term commitment, often over a number of years. Families can benefit significantly by obtaining support to better understand bpd and developing their own self-care strategies.

What happens when BPD occurs with other mental health or addiction problems?

It is very common for someone with borderline personality disorder to have other mental health or substance use or gambling problems that can complicate the diagnosis and treatment of their bpd

What types of addiction services are available?

Many people with bpd also have a substance use problem that may require specialized substance abuse treatment either on a community outpatient or residential basis. Community-based outpatient or day programs are effective for most people with a substance use problem, though a person with few resources and supports may require the more intensive treatment and support provided in a residential program. In Ontario, specific admission criteria and standardized assessment tools have been developed to guide individualized treatment planning and referral to the most appropriate treatment program.

As well as assessment and referral, the continuum of specialized treatment resources includes withdrawal management services, community treatment (outpatient), day treatment, residential treatment, supportive residential treatment and continuing care. Some specialized programming based on gender, age, language or culture is also available across the province. You can get information on substance abuse services available in your community from your local addiction assessment and referral service or the Drug and Alcohol Registry of Treatment (dart). Specialized treatment definitions can be found on the dart website

In Ontario, treatment services for people with gambling problems are affiliated with substance abuse treatment services and available in many communities across Ontario. Information on gambling treatment is available through the Ontario Problem Gambling Helpline

What types of concurrent disorder services are available?

Until recently, people with concurrent mental health and substance use disorders fell between the cracks because substance abuse and mental health services operated in isolation from each other. Staff members were often unwilling or felt unprepared to help someone with a concurrent disorder.

However, many services now recognize the importance of providing integrated treatment for both problems, particularly for people with severe mental health and substance use problems. Integrated treatment is a way of making sure that treatment is smooth, coordinated and complete. It also helps to ensure that the client understands the treatment plan. The client receives help not only with the concurrent disorders but also in other life areas, such as housing and employment. In integrated treatment, one person, such as a case manager or therapist, is responsible for overseeing the client’s treatment, which is provided by a team of professionals. The team may include psychiatrists, social workers, psychiatric nurses, psychologists, vocational and occupational therapists, peer support workers and addiction therapists. This treatment may take place in a single setting, such as a residential facility, or through a mixture of different resources such as family doctors, hospital outpatient clinics and community outreach teams Integrated treatment is not always offered, but it is important that the primary therapist or treatment team co-ordinate their treatment with other services being used by your affected family member.

Specialized psychosocial treatments for BPD

It’s still “work” to use most of the skills I learned. I’ve seen some small changes in my interpersonal relationships and in my ability to manage my emotions more effectively.

There are a number of approaches for treatment of bpd. Two major approaches are cognitive behavioral therapy (cbt), which focuses on the present and on changing negative thoughts and behaviors, and psychodynamic therapy, which focuses on early relationships and inner conflicts. Treatment may be offered either individually or in a group. Family treatment is another mode of treatment that engages the whole family and works on relationships and interactions between family members.

There tends to be a high drop-out rate from treatment for borderline personality disorder, and a key to successful treatment is a good match between the therapist and client. Therapy might focus on learning to understand and manage emotions, harmful behaviors and thoughts of suicide. Medication may be used to make concentrating on learning self-management skills easier. Specialized treatments, now being developed and evaluated for bpd, use either a cognitive behavioral or psychodynamic framework. They have been developed and evaluated to be delivered by trained therapists in a specific way outlined in a manual. Some of these treatments have been more extensively evaluated than others. Clinicians may use a variety of treatment approaches depending on the goals of the client and the skills base of the clinician.

These may include:

• dialectical behavior therapy

• cognitive behavioral therapy

• schema therapy

• system training for emotional predictability and problem solving

• transference-focused psychotherapy

• mentalization-based therapy

Medication for BPD

Medication has a role in the treatment of many serious mental health problems. Though there is no specific medication for bpd, medication may be prescribed to reduce the impact of specific symptoms of the disorder. For example, medication may be prescribed to reduce depression or psychotic-like symptoms such as paranoia.

Medication can also be helpful to the person with bpd by providing a period of time when their symptoms are reduced. This allows them to focus on learning new skills to manage their behaviors with the goal of discontinuing medication when they are able to self-manage.

Though medication can reduce the severity of symptoms, medication does not cure bpd and medication is not appropriate for everyone with this diagnosis. The medications can have side-effects, and people may experience many, some or almost none of them. Side effects can usually be addressed by changing the medication dosage or switching to another medication. Because of the number of different symptoms of bpd, there is also a risk that a person may be prescribed too many medications at the same time.

Taking a number of different medications together can increase the risk of medication-related problems when:

• two or more medications, including prescribed, over-the-counter and herbal or other alternative medications, interact with each other to produce unwanted or unexpected effects, such as a greater or lesser effect than intended

• an individual has difficulty managing his or her medications (forgetting to take a medication or inadvertently taking extra doses of the medication

• an individual has difficulty managing his or her medications (forgetting to take a medication or inadvertently taking extra doses of the medication

Most mental health medications are used to help restore chemical balance in the brain. They can help reduce the frequency and severity of symptoms.

Medications are divided into four main groups based on the problems that they were developed to treat:

• antidepressants

• mood stabilizers

• anti-anxiety drugs

• antipsychotics.

Medications have a generic (or chemical) name and a brand (or trade) name that is specific to the company that makes the medication. For example, the generic drug lorazepam is sold under the brand name Ativan. The brand name may change depending on the country in which the medication is marketed.

ANTIDEPRESSANTS

• Antidepressants are used to treat depression, as well as a number of other problems such as anxiety, chronic pain and bulimia. They work by increasing communication between nerve cells in the brain. A class of antidepressants called ssris (selective serotonin reuptake inhibitors) is most often prescribed for bpd. Some of the more common examples of ssri medications are paroxetine (Paxil), fluoxetine (Prozac), sertraline (Zoloft), citalopram (Celexa) and escitalopram (Cipralex)

MOOD STABILIZERS

• Mood stabilizers are used to treat mood disorders, the most common of which is bipolar disorder (manic-depression). Mood stabilizers do not stabilize mood in bpd, but can help with outbursts of anger. Common examples are divalproex (Epival), carbamazepine (Tegretol), lamotrigine (Lamictal) and topiramate (Topamax).

ANTI-ANXIETY MEDICATIONS/SEDATIVES

• The main group of medications in this class are benzodiazepines, commonly used to treat sleep or anxiety problems or as a muscle relaxant. Examples are lorazepam (Ativan), clonazepam (Rivotril) and diazepam (Valium). They are effective for short-term treatment of sleep or anxiety problems, but can be addictive when used over the longer term.

ANTIPSYCHOTICS

• These medications are used to treat schizophrenia and other psychotic disorders. The first generation of antipsychotic medications is called typical antipsychotics. Some examples include haloperidol (Haldol), perphenazine (Trilafon), loxapine (Loxapac or Loxitane) and chlorpromazine (Largactil). Atypical antipsychotics are a second generation of antipsychotic drugs that are categorized together because they work differently from typical antipsychotic drugs, by working primarily on the receptors of the neurotransmitters serotonin and dopamine. Common examples of atypical antipsychotics are olanzapine (Zyprexa), risperidone (Risperdal) and quetiapine (Seroquel). These second generation antipsychotics also have some mood stabilizing properties and are being used this way as well.

Family members can play an important role in supporting their affected family member to:

• manage their medication by following prescribing instructions, and consult their physician or pharmacist if they have any concerns

• determine whether their medication is helpful in reducing unpleasant symptoms

• discuss their medication with their prescribing physician, its effects and side-effects and any difficulties they may be experiencing.

Recovery from BPD

Despite its often devastating effects on the affected person and his or her family, treatment outcome research has found that for many people, treatment does work. Many people with bpd do learn to cope with their symptoms and do things differently, particularly as they reach middle age. Because of the serious and complex nature of their symptoms, people affected by bpd often require long-term treatment, often over several years Treatment accelerates the natural process of recovery. Studies have followed people affected by bpd for extended periods of time and found that most improve with time. About 75 per cent will regain close to normal functioning by age 35 to 40 and 90 per cent will recover by age 50 (Paris, 2005).

It may take a longer time for a person with bpd to have a remission of their symptoms compared to people with other mental health problems, but when symptoms do decline, remission seems stable with few relapses compared to other serious mental health problems.

However, studies have also found that some bpd symptoms endure longer than others in some people. Some of the more harmful behaviors such as self-harm and suicidal behavior decline while other symptoms such as feelings of abandonment and difficulty being alone may last longer.

Hope and recovery are important to both the person with bpd and his or her family members

WHAT TO DO IN A CRISIS

A Family Guide to Concurrent Disorders distinguishes between a crisis and an emergency. A crisis develops when “people feel they cannot control their feelings or behavior and have trouble coping with the demands of day to day life.” Potentially this can develop into outbursts of anger or violence or self-injuring behaviors. A crisis may develop slowly over a number of days or erupt suddenly. A particularly high-risk time for a crisis is when a person with bpd fears abandonment or loss of support. Such times may occur when a family member or a therapist is away for a period of time or when the person becomes fearful that the good progress they are making may lead to pressure to become more independent with consequent loss of support (Gunderson & Berkowitz)

Strategies for managing a crisis in the short term include:

• Stay calm and supportive of your family member. Do not get into a shouting match however difficult their behavior, and even if you are hurt by what they are saying.

• Acknowledge what your affected family member may be feeling or saying, let him or her know you have heard them and are trying to understand what they may be feeling.

• Don’t be afraid to ask about suicidal intentions. Suicidal behaviors can be an attempt to relieve emotional pain or communicate distress.

• Act on the agreed upon crisis plan if one is already in place.

• Support your affected family member in making telephone contact with their doctor, therapist or treatment program or offer to drive them to where they need to go (e.g., therapist, hospital).

• If your family member has broken any agreements you have with them regarding their behavior, wait until the crisis is over to discuss it.

You should also make a long-term plan for managing a crisis:

• Discuss with your affected family member and his or her doctor or therapist the steps to take if a crisis should occur

• Make sure that your affected family member is involved in all decisions regarding the crisis plan and that his or her wishes are respected.

• create a crisis plan with your family member and others in the family as appropriate. (I will include a crisis plan handout in my gallery for you to download and fill out if you would like)

• The crisis plan can include a section on who does what, for example, who should accompany your family member to the hospital, and who should communicate with the treatment team.

• Include important information as part of your crisis plan, for example, telephone numbers for your family member’s family doctor, therapist and local hospital, and a list of the medications he or she is taking.

• Keep the crisis plan in a place that is easily accessible and where it will be looked at without thinking

• You may wish to include information from the crisis plan on a “crisis card” small enough for your affected family member to carry with her or him. The crisis card could also contain personal contact information, e.g., family member phone numbers, as well as a list of medications that he or she is taking and strategies to help them self-calm

• • Find out about crisis services in your community. If your family member is already known to the mental health system, you should ask whom you or your affected family member should contact if his or her behavior deteriorates so this can be built into the crisis plan. Some communities have mobile crisis teams based at a local hospital psychiatric department who will come and assess the situation.

WHAT TO DO IN AN EMERGENCY

Sometimes a crisis can escalate into an emergency.

Emergencies could be situations in which there are threats of suicide, threats of physical violence, reduced judgment and decision-making or substance use that concerns you.

In some circumstances, your family member will voluntarily agree to talk to his or her doctor or therapist or to go to the hospital emergency department. In other situations, you may need to call 911.

Remember that this can be a difficult step to take. Inevitably the arrival of the police or other emergency services will arouse the curiosity of neighbors. Both you and your affected family member may wish to keep his or her mental health problem as a private matter, but safety is a priority, particularly when it involves potential harm or suicidal intentions.

If you perceive any danger to yourself or anyone else, do not hesitate to leave and call 911 from somewhere else. When you call 911, tell the operator that your family member needs emergency medical assistance, give the operator your family member’s diagnosis and tell the operator that you need help transporting him or her to the hospital.

Depending on the kind of training your local police have had in handling mental health crisis situations, you may need to advocate on behalf of your family member. This may be particularly important if your family member is likely to react negatively to the presence of uniformed police. It is useful to write down the names, badge numbers and response times of the officers who respond to the call in case you have any concerns about the way the problem was handled

When the emergency involves suicidality

Threatening suicide is one type of emergency situation. Threatening suicide or expressing a wish to die should ALWAYS be taken seriously.

Some warning signs of suicide include:

• feelings of despair, pessimism, hopelessness, desperation

• recent self-injury behaviors

• withdrawal from social circles

• sleep problems

• increased use of alcohol or other drugs or overeating

• winding up affairs or giving away prized possessions

• threatening suicide or expressing a desire to die

• talking about “when I am gone”

• talking about voices that tell him or her to do something dangerous

• having a plan and the means to carry it out.

SHARING TREATMENT INFORMATION WITH FAMILY MEMBERS

Generally speaking, sharing medical or treatment information about a person with others, either family members or outside health care providers or agencies, requires expressed consent. Consent in these situations would usually be written consent. Family members can play a key role in supporting change and developing newly acquired skills. However, some health care professionals are reluctant to involve or talk to family members, particularly if they perceive the family as “causing the problem.” If your family member is still living at home and/or you are supporting them financially, you may feel you should have some moral right to be involved in their treatment. However, if your family member is capable of making treatment decisions, a health care professional will not be at liberty to share information without your affected family member’s consent. This is achieved by having your family member sign a form in the doctor’s office.

Some treatment programs offer family programming. This may involve family therapy sessions with the person affected by bpd and his or her family members. More commonly, family-specific education/support groups provide information about the disorder, ways for family members to support the person with bpd and strategies for family members’ self care.

CONSENT TO TREATMENT

In Ontario, individuals have the right to consent to or refuse treatment, provided they are capable of doing so. Being capable means that the person is able to understand the information needed to make this decision and is also able to appreciate the reasonably foreseeable consequences of their consent to or refusal of treatment. There is no age requirement on consenting to treatment; if a person is capable, she or he gets to make her or his own treatment decisions, regardless of age.

Consent to treatment must be “informed” (which means that the person has been given all the requisite information and all questions related to the treatment have been answered), must be given voluntarily and must not be obtained through misrepresentation or fraud. In situations where a person is not capable to give informed consent, then a substitute decision-maker would be consulted for treatment consent. The hcca (Health Care Consent Act) sets up a hierarchy of individuals who may provide substitute consent.

Caring for yourself when a family member has BPD

Borderline personality disorder can be as devastating for partners, parents, children and others close to a person with bpd, as it is for the person himself or herself. As a family member, you may have had many years of trying to cope with the intense anger, suicide attempts, self-injury or other impulsive behaviors that are part of bpd. As a result, you may feel weighed down by the burden of your family member’s illness. Depression, anxiety, grief and isolation are some feelings you may have experienced. Even though care and support of your affected family member may seem to be all you can manage, making time to care for your own needs is a priority. Self-care can reduce stress and give you more energy and patience to support a family member with bpd. Self-care can involve seeking support from a community agency that provides family counselling services, joining a mutual-aid group, signing up for an exercise class, or reconnecting with family and friends. Some services for people with bpd offer facilitated family programs on either an individual family basis or as part of a support group for family members. These programs provide information about the issues related to bpd, new communication and coping skills and most important, support from others in the same situation. Groups may be facilitated by a health care professional or by a trained family member. Your community may also have self-help groups for family members. Additionally, some family members may also benefit from individual counselling sessions as well as the family group support.

STRESS MANAGEMENT

Having a family member with bpd can seem overwhelming, especially if that family member is living at home and requires help in managing their activities of daily living and some aspects of their treatment regimen. People experience stress in different ways. We may experience physical symptoms such as headaches, difficulty sleeping, stomach upsets, weight gain or loss. We may experience emotional symptoms such as moodiness, restlessness, feeling overwhelmed or depressed. We may experience cognitive symptoms such as memory problems, racing thoughts, chronic worrying or fearfulness. We may experience behavioral symptoms such as eating less or eating more, using substances to relax, overreacting to situations or isolating ourselves socially.

People pay a high price in terms of their emotional and physical health when they live with chronic stress, so it is important to look at ways to reduce stress. There are many resources, both print materials and on the web, that provide advice on strategies for stress reduction. These include improving one’s diet, building in regular exercise, learning relaxation exercises, building in enjoyable activities (e.g., having a massage, engaging in a hobby), changing the stressful situation (for example, setting limits for your family member’s behavior), obtaining support from others (for example, involving other family members or friends), joining a support group, and drawing on sources of spiritual support.

In developing a self-care plan to reduce your level of stress, it is important to keep your plan realistic and doable. Small changes will make you feel better and have more chance of success than big changes that run the risk of being unsuccessful and thereby further contributing to your stress. Your plan should also be concrete and identify what needs to happen for the plan to be successful. For example, you decide to go to an exercise class once a week; in order for this to be successful you may need to have another family member cook a meal or enlist a friend to go with you for mutual support

Helping children understand and cope with BPD

Children can be affected when a family member has bpd. To protect their children, parents may say nothing. They may try to continue with family routines as if nothing were wrong. This strategy may work in the short term but not in the long term. Children can feel confused and worried about their family member’s behaviour when they are not given the opportunity to talk about it. Children are sensitive and intuitive. They quickly notice when someone in the family has changed, particularly a parent. If the family doesn’t talk about the problem, children will draw their own, often wrong, conclusions.

Young children, especially those in preschool or early grades, often see the world as revolving around themselves. If something happens, they think they caused it. For example, a child may accidentally break something valuable. The next morning, the parent may seem very depressed. The child may then think that breaking the object caused the parent’s depression.

Older children, particularly if they have a sibling with bpd, may worry about developing mental health problems, substance use problems or both. They may worry about the stress and strain that their parents are enduring, and may take on the burden of trying to make up for what their parents have lost in their other child.

At the same time, brothers or sisters sometimes resent the time that parents spend with their sibling. They may become angry to the point of acting out or distancing themselves from family or friends. Siblings may also experience anger, hostility or verbal or physical aggression from their brother or sister. These behaviors can evoke shock, dismay, fear and a sense of abandonment and rejection. Sometimes, children may feel like they have lost their best friend. They may feel guilty that they have a better life than their brother or sister.

It is helpful to tell children three main points:

1. The family member has a problem called borderline personality disorder. The family member behaves this way because he or she is sick. The illness may have symptoms that can cause the person’s mood or behavior to change in unpredictable ways.

2. The child did not cause the problems. Children need reassurance that they did not make the parent or family member sad, angry or unhappy. They need to be told that their behavior did not cause the person’s emotions or behavior. Children think in concrete terms. If a parent or family member is sad or angry, children can easily feel they did something to cause this, and then feel guilty.

3. It is not the child’s responsibility to make the affected person well. Children need to know that the adults in the family, and other people, such as doctors, are working to help the person. It is the adults’ job to look after the person with the problem.

Children need the well parent(s) and other trusted adults to shield them from the effects of the person’s symptoms. It is hard for children to see their parents distressed or emotional. Talking with someone who understands the situation can help sort out the child’s feelings (Skinner et. al., 2004; O’Grady & Skinner, 2007)

Recovery And Hope

Research has shown that people can recover from bpd and that their recovery is often long-lasting.

Everyone’s path to recovery is different, whether you are the individual with bpd or a family member or friend. Recovery involves the development of new meaning and purpose in life as people grow beyond the impact of bpd. We think O’Grady and Skinner (2007) say it best: “Recovery has also been described as a process by which people recover their self-esteem, dreams, self-worth, empowerment, pride, dignity and meaning.”

Both the individual with bpd and their family members will go through this process of recovery. As a family member, you can instill hope that changes can be achieved by providing support to your loved one as you all go through the long journey of recovery.

It is important to understand though that recovery is not a straight path. There will be deviations along the way that can involve relapse into old behaviors, and the person may or may not return to their previous level of functioning. On the path to recovery, your family member may need medication or further contact with the treatment system.

CONCLUSION

For people to achieve and maintain recovery from BPD, they need to:

1. be treated as unique and important

2. be treated as a human being with goals and dreams

3. have the freedom to make choices and decisions about their lives

4. be treated with dignity and respect

5. accept that their unique journey through life has taken a different path

6. recognize that recovery is the potential to become free of symptoms by following an individualized treatment plan

7. acknowledge that relapse is a common and expected part of recovery, but does not mean they have “failed” or that previous gains are lost, rather, it is a chance to learn and move forward again • have hope about their future

8. engage in meaningful relationships with others who care and do not stigmatize

9. have a routine and structure to their day marked by meaningful activities that may or may not include work (paid or volunteer) • receive a reliable and steady source of income

10. live in stable, clean and comfortable housing, whether it is an independent living situation or supportive housing

11. accept that recovery may require a structured community day treatment program or other links to professional mental health and addiction systems of care

12. recognize that pets may be important

13. recognize that spirituality or religious beliefs and practices may be important.

Borderline personality disorder is one of the most common and most misunderstood of the serious mental health disorders. People living with bpd are often stigmatized and avoided by treatment providers. New treatments are emerging and with the right treatment, people with bpd can and do recover. Unlike other serious mental health problems, recovery from bpd is usually stable. Families play a crucial role in supporting their affected family member’s recovery, but families also need support and nurturing to recover from the impact of their family member’s illness.

I hope that this has helped a bit in understanding more about Borderline Personality Disorder and a reminder that there is hope, you are NOT a lost cause. I have included some worksheets in my gallery if you would like and you may also go to the link for more worksheets. Stay tuned for more and I hope to see more of you.

Link for more Worksheets

Growth4Life