Supporting a Loved-one with Borderline Personality Disorder

Written by John G. Gunderson, M.D. and Cynthia Berkowitz, M.D., Harvard University (2006)

People with Borderline Personality Disorder are highly sensitive, emotionally immature, and, at times, abusive. To be in a relationship with someone who has BPD requires a great deal of strength, patience, understanding, caring, and sometimes self-sacrifice.

Recovery is significantly faster and at higher rates for people that are supported by family (as opposed to those isolated and on their own). But very little is intuitive, and anyone supporting a loved one needs to be trained. For example, except in extreme circimstances, you should not protect the person affected by Borderline Personality Disorder from the natural consequences of their actions. According to Dr. John Gunderson, MD, it is important to allow them to fail in a loving way - to learn about reality.

Defining and constructively enforcing limitations is important, too. You set them by stating them in advance in clear, simple language. Too often, people assume that the person with BPD should know and respect their limits as any other adult would. This is not a realitic assumption for people with this disorder. This five part guide was written by John G. Gunderson, MD, author of the clinical textbook "Psychotherapy for Personality Disorders."

Remember that change is difficult to achieve and fraught with fears. Be cautious about suggesting that “great” progress has been made or giving “You can do it” reassurances. Progress evokes fears of abandonment.

The families of people with Borderline Personality Disorder can tell countless stories of instances in which their son or daughter went into crisis just as that person was beginning to function better or to take on more responsibility. The coupling of improvement with a relapse is confusing and frustrating but has a logic to it. When people make progress - by working, leaving day treatment, helping in the home, diminishing self-destructive behaviors, or living alone- they are becoming more independent. They run the risk that those around them who have been supportive, concerned, and protective will pull away, concluding that their work is done. The supplies of emotional and financial assistance may soon dry up, leaving the person to fend for herself in the world. Thus, they fear abandonment. Their response to the fear is a relapse. They may not make a conscious decision to relapse, but fear and anxiety can drive them to use old coping methods. Missed days at work, self-mutilation, a suicide attempt, or a bout of overeating, purging or drinking may be a sign that lets everyone around know that the individual remains in distress and needs their help. Such relapses may compel those around her to take responsibility for her through protective measures such as hospitalization. Once hospitalized, she has returned to her most regressed state in which she has no responsibilities while others take care of her.

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It Takes Special Skills to Support a Family Member with Borderline Personality Disorder - Little is Intuitive.

Written by R. Skip Johnson

Being in a relationship with an individual affected by Borderline Personality Disorder is complex and demanding - even self sacrificing.

I believe it requires several things - strength, love, realistic expectations, assuming the role as "Emotional Caretaker", protecting your family, preserving your own emotional health, and understanding yourself in the context of all of this.

Strength: It takes a great deal of strength to be in a relationship with someone affected by Borderline Personality Disorder and not be emotionally injured by it. A person in a weak emotional state, who feels wounded/abused, or depressed is likely to be consumed by the relationship, confused by the intense rages and idealization, and finding their self worth in decline. If you chose this path, you've got to be very strong and very balanced.

Love: Family members with Borderline Personality Disorder have very high sensitivities to rejection (rejection sensitivity) - they require a great deal of expression and protection to feel loved and safe.

Realistic Expectations: It is important to recognized that a person with Borderline Personality Disorder is emotionally underdeveloped and does not have "adult" emotional skills - especially in times of stress. If you are in this type of relationship it is important to have realistic expectations for what the relationship can be in terms of consistent respect, trust and support, honesty and accountability, and in terms of negotiation and fairness, or expectations of non-threatening behavior. It is important to accept the relationship behavior for what it is - not hope the person will permanently return to the idealization phase, not accept the external excuses for the bad behavior, and not hope that changing your behavior will improve things.

Assuming the Role of "Emotional Caretaker": According to Kraft Goin MD (University of Southern California), "borderlines need a person who is a constant, continuing, empathic force in their lives; someone who can listen and handle being the target of intense rage and idealization while concurrently defining limits and boundaries with firmness and candor". To be in this type of relationship, you must accept the role as emotional caretaker - consistently staying above it.

Maintaining routine and structure

Setting and maintain boundaries

Being empathetic, building trust,
even in difficult times

Don’t tolerate abusive treatment,
threats and ultimatums

In crisis, stay calm, don’t get defensive, don't take it personally

Don’t protect them from natural consequences of their actions -
to a degree - let them fail

Self-Destructive acts/threats
require action

And at the same time, its important to understand that you and your behavior cannot rehabilitate anyone - you can only mitigate the situation. Rehabilitation requires an individual's deep personal commitment, consistently, and over time.

Self Protection: Difficult things will likely happen in a "Borderline Personality" family and it is important that you try to protect everyone (yourself, the BP, the children) - financially, emotionally, etc. Be prepared for digressions when they occur - they will. Protections range from controlling the bank accounts, to educating the children, to having a suicide threat plan. You can help mitigate the difficult.

Preserve Your Emotional Health: The intensity of emotional reactions, and the rage take a toll on even the strongest. Since you cannot escape the natural human impulses to "recoil when raged" upon or "be overly protective" when idealized, it really important to have other outlets / escapes to keep yourself grounded. It's important not to become isolated. It's important to have a significant emotional support system for yourself (e.g., close friends) that goes beyond and is outside of the relationship. Many professionals enter therapy when they are treating a person with Borderline Personality Disorder to stay grounded. It is a good idea for you too.

Understand Yourself: There are a many reasons to be in relationship with someone with Borderline Personality Disorder. It's a deeply personal decision.

It's very important to decide, up front, what your "break points" are. It not unlike deciding before you enter a casino that you will quite when you loose a specified amount of money.

It's also important to understand your own emotional health and what motivates you to build a life that evolves around and has to continually compensate for the acts of a destructive person. Sometimes the reasons are unhealthy - such as BPD / NPD relationships, BPD / Co-dependent relationship, etc.

It takes special skills and a commitment to support a family member with borderline personality disorder - it's a decision that should be taken very seriously.