Family Interventions for Family Interventions for Borderline Personality DisorderBorderline Personality Disorder

The current evidenceThe current evidence

Kate SloanKate SloanNurse Practitioner in Nurse Practitioner in

PsychotherapyPsychotherapy

Family Interventions – Mental Family Interventions – Mental HealthHealth

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

Expressed Emotions - relapseExpressed Emotions - relapse

Robust psychosocial predictor of relapseRobust psychosocial predictor of relapse– SchizophreniaSchizophrenia– Major depressionMajor depression– Anorexia Nervosa Anorexia Nervosa – Bi-polarBi-polar– AlcoholismAlcoholism

Stanbridge, et al, (2003) Onwumere et al, (2009)Stanbridge, et al, (2003) Onwumere et al, (2009)

Expressed Emotion - BPDExpressed Emotion - BPD

Criticism and hostility is not predictive of Criticism and hostility is not predictive of outcomeoutcome

Criticism and hostility did not predict rates Criticism and hostility did not predict rates of hosptilisationof hosptilisation

Higher expressed emotion is associated Higher expressed emotion is associated with better outcome.with better outcome.

Hoffman and Perry, (1999)Hoffman and Perry, (1999)

Invalidating Environment – the Invalidating Environment – the impact on the individualimpact on the individual

1. Are not able to label emotional experience1. Are not able to label emotional experience

2. Do not learn the skills of tolerating emotional 2. Do not learn the skills of tolerating emotional experiencesexperiences

3. Do not learn how to trust their own emotional 3. Do not learn how to trust their own emotional responsesresponses

Linehan, (1993)Linehan, (1993)

Impact of KnowledgeImpact of Knowledge

Schizophrenia – Knowledge decreased burden, Schizophrenia – Knowledge decreased burden, depression, distress and expressed emotion.depression, distress and expressed emotion.

BPD – Knowledge increased burden, distress BPD – Knowledge increased burden, distress and depression and there was greater hostility. and depression and there was greater hostility. – Recommendations about the quality of the information Recommendations about the quality of the information

given.given.

Hoffman and Hooley, (2003)Hoffman and Hooley, (2003)

Interventions for Families of People Interventions for Families of People with BPD with BPD

Three manualised Family psycho education Three manualised Family psycho education programs are described in the literature.programs are described in the literature.

Gunderson/Mclean programGunderson/Mclean program

Hoffman – New York, hospital programHoffman – New York, hospital program

Fruzzetti – DBT with couples and familiesFruzzetti – DBT with couples and families

Dissemination of these programs has been Dissemination of these programs has been modest.modest.

Gunderson/ McLean programGunderson/ McLean program

Borrowed from psycho educational Borrowed from psycho educational approaches developed for schizophreniaapproaches developed for schizophrenia

Families identified with three major Families identified with three major problem areas:problem areas:– CommunicationCommunication– AngerAnger– SuicidalitySuicidality

Hoffman/New York Hospital Hoffman/New York Hospital programprogram

Family treatment approach based on DBTFamily treatment approach based on DBT– EducationalEducational– Skills developmentSkills development– Environmental changeEnvironmental change

Interruption of the invalidating cycleInterruption of the invalidating cycleBased on the concept of expressed Based on the concept of expressed emotionemotionGroup meets weekly for approximately 6 Group meets weekly for approximately 6 monthsmonths

Fruzzetti - DBT with couples and Fruzzetti - DBT with couples and familiesfamilies

Developed as part of standard DBT out-Developed as part of standard DBT out-patient treatmentpatient treatment

Value of family / partners learning Value of family / partners learning complementary skillscomplementary skills

Core skills from DBT are included Core skills from DBT are included

Invalidating ResponsesInvalidating Responses

Not necessarly - Cruel, abusive, Not necessarly - Cruel, abusive, neglectful or uncaring.neglectful or uncaring.

But may lead to – wants and But may lead to – wants and emotions being missed criticised emotions being missed criticised or not tended to or Invalid or not tended to or Invalid behaviors being legitimised.behaviors being legitimised.

Validating responsesValidating responses

Listening, paying attention Listening, paying attention

Acknowledging the other’s points Acknowledging the other’s points

Working to understand; asking questions Working to understand; asking questions

Understanding his/her problems in context Understanding his/her problems in context

Normalizing his/her responses when they are Normalizing his/her responses when they are normative (“of course”) normative (“of course”)

With actions that convey understandingWith actions that convey understanding

Vulnerability

Temperament

History of invalidating responses

Event

Judgments

Heightened emotional arousal

Inaccurate emotional expression

Invalidating emotional response

OutcomesOutcomes

Reduction in symptomsReduction in symptoms

Relationship satisfactionRelationship satisfaction

Increase in validating responsesIncrease in validating responses

Positive impact on relationships with Positive impact on relationships with childrenchildren

What next?What next?

Accessible programs.Accessible programs.

A framework to inform working with BPD A framework to inform working with BPD families and carers.families and carers.

Randomised control trials.Randomised control trials.