[Tips for Caring for a BPD Individual]
Found this circling the tumblr verse. don't know the source, but i'm posting it here. Its a fascinating look. Bolded stuff for emphasis
GO SLOWLY
1. 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 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.
When signs of progress appear, family members can reduce the risk of relapse by not showing too much excitement about the progress and by cautioning the individual to move slowly.
This is why experienced members of a hospital staff tell borderline patients during discharge not that they feel confident about their prospects, but that they know the patient will confront many hard problems ahead.
While it is important to acknowledge progress with a pat on the back, it is meanwhile necessary to convey understanding that progress is very difficult to achieve.
It does not mean that the person has overcome her emotional struggles.
You can do this by avoiding statements such as, “You’ve made great progress,” or, “I’m so impressed with the change in you.”
Such messages imply that you think they are well or over their prior problems.
Even statements of reassurance such as, “That wasn’t so hard,” or, “I knew you could do it,” suggest that you minimize their struggle.
A message such as, “Your progress shows real effort. You’ve worked hard. I’m pleased that you were able to do it, but I’m worried that this is all too stressful for you,” can be more empathic and less risky.
2. Lower your expectations. Set realistic goals that are attainable. Solve big problems in small steps. Work on one thing at a time. “Big”, long-term goals lead to discouragement and failure.
Although the person with BPD may have many obvious strengths such as intelligence, ambition, good looks, and artistic talent, she nonetheless is handicapped by severe emotional vulnerabilities as she sets about making use of those talents.
Usually the person with BPD and her family members have aspirations based upon these strengths.
The patient or her family may push for return to college, graduate school, or a training program that will prepare her for financial independence.
Family members may wish to have the patient move into her own apartment and care for herself more independently.
Fueled by such high ambitions, a person with BPD will take a large step forward at a time.
She may insist upon returning to college full time despite undergoing recent hospitalizations, for example.
Of course, such grand plans do not consider the individual’s handicaps.
The overriding issue about success in the vocational arena is the threat of independence —much desired but fraught with fear of abandonment.
The result of too large a step forward all at once is often a crashing swing in the opposite direction, like the swing of a pendulum.
The person often relapses to a regressed state and may even require hospitalization.
A major task for families is to slow down the pace at which they or the patient seeks to achieve goals.
By slowing down, they prevent the sharp swings of the pendulum as described and prevent experiences of failure that are blows to the individual’s self-confidence.
By lowering expectations and setting small goals to be achieved step by step, patients and families have greater chances of success without relapse.
Goals must be realistic.
For example, the person who left college mid-semester after becoming depressed and suicidal under the pressure most likely could not return to college full time a few months later and expect success.
A more realistic goal is for that person to try one course at a time while she is stabilizing.
Goals must be achieved in small steps.
The person with BPD who has always lived with her parents might not be able to move straight from her parents’ home.
The plan can be broken down into smaller steps in which she first moves to a halfway house, and then into a supervised apartment.
Only after she has achieved some stability in those settings should she take the major step of living alone.
Goals should not only be broken down into steps but they should be taken on one step at a time.
For example, if the patient and the family have goals for both the completion of school and independent living, it may be wisest to work on only one of the two goals at a time.
3. Keep things cool and calm. Appreciation is normal. Tone it down. Disagreement is normal. Tone it down, too.
This guideline is a reminder of the central message of our educational program: The person with BPD is handicapped in their ability to tolerate stress in relationships (i.e., rejection, criticism, disagreements) and can, therefore, benefit from a cool, calm environment.
It is vital to keep in mind the extent to which people with BPD struggle emotionally each day.
While their internal experience can be difficult to convey, here are some of the handicaps summarized;
Affect Dyscontrol:
A person with BPD has feelings that dramatically fluctuate in the course of each day and that are particularly intense.
These emotions, or affects, often hit hard.
We have all experienced such intense feelings at times.
Take for example the sensation of pounding heart and dread that you may feel when you suddenly realize that you have made a mistake at work that might be very costly or embarrassing to your business.
The person with BPD feels such intense emotion on a regular basis.
Most people can soothe themselves through such emotional experiences by telling themselves that they will find a way to compensate for the mistake or reminding themselves that it is only human to make mistakes.
The person with BPD lacks that ability to soothe herself.
We have all had moments in which we feel rage towards the people we love.
We typically calm ourselves in such situations by devising a plan for having a heart-to-heart talk with the family member or by deciding to let things blow over.
The person with BPD again feels such rage in its full intensity and without being able to soothe through the use of coping strategies.
It results in an inappropriate expression of hostility or by acting out of feelings (self damaging behaviors).
Intolerance of Aloneness:
A person with BPD typically feels desperate at the prospect of any separation - a family member’s or therapist’s vacation, break up of a romance, or departure of a friend.
While most of us would probably miss the absent family member, therapist or friend, the person with BPD typically feels intense panic.
She is unable to conjure up images of the absent person to soothe herself.
She cannot tell herself, “That person really cares about me and will be back again.”
Her memory fails her.
She only feels soothed and cared for by the other person when that person is present.
Thus, the other person’s absence is experienced as abandonment.
She may even keep these painful thoughts and feelings out of mind by using a defense mechanism called dissociation.
This consists of a bizarre and disturbing feeling of being unreal or separate from one’s body.
Black & White Thinking (Dichotomous Thinking):
Along with extremes of emotion come extremes in thinking.
The person with BPD tends to have extreme opinions.
Others are often experienced as being either all good or all bad.
When the other person is caring and supportive, the person with BPD views him or her as a savior, someone endowed with special qualities.
When the other person fails, disagrees, or disapproves in some way, the person with BPD views him or her as being evil and uncaring.
The handicap is in the inability to view other people more realistically, as mixtures of good and bad qualities.
This review of some of the handicaps of people with BPD is a reminder that they have a significantly impaired abilitites.
Therefore, family members and loved ones can help them achieve stability by creating a cool, calm environment.
This means slowing down and taking a deep breath when crises arise rather than reacting with great emotion.
It means setting smaller goals for the person with BPD so as to diminish the pressure she is experiencing.
It means communicating when you are calm and in a manner that is calm.
It does not mean sweeping disappointments and disagreements under the rug by avoiding discussion of them.
It does mean that conflict needs to be addressed in a cool but direct manner without use of put-downs.
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. If you chose this path, you’ve got to be very strong and very balanced.
Love: People 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.
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 their behaviors 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
In crisis, stay calm, don’t get defensive, don’t take it personally
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.
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, others who are in the situation at the time) - financially, emotionally, etc.
Be prepared for digressions when they occur - they will.
Protections range from controlling the bank accounts, to educating outsiders, to having a suicide threat plan.
You can help mitigate the difficult.
Preserve Your Emotional Health:
The intensity of the relationship with someone suffering with BPD take a toll on even the strongest. It is 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’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 someone with borderline personality disorder - it’s a decision that should be taken very seriously.
4. Maintain family routines as much as possible. Stay in touch with family and friends. There’s more to life than problems, so don’t give up the good times.
Often, when someone has a severe mental illness, you can become isolated.
The result of this isolation can be only anger and tension.
Everyone needs friends, parties, and vacations to relax and unwind.
By making a point of having good times, everyone can cool down and approach life’s problems with improved perspective.
The environment will naturally be cooler.
So you should have good times outside of your relationship, not only for your own sake, but for the sake of the relationship.
5. Find time to talk. Chats about light or neutral matters are helpful. Schedule times for this if you need to.
Too often, when family members are in conflict with one another or are burdened by the management of severe emotional problems, they forget to take time out to talk about matters other than illness.
Such discussions are valuable for many reasons.
The person with BPD often devotes all her time and energy to her illness by going to multiple therapies each week, by attending day treatment, etc.
The result is that she misses opportunities to explore and utilize the variety of talents and interests she has.
Her sense of self is typically weak and may be weakened further by this total focus on problems and the attention devoted to her being ill.
When you take time to talk about matters unrelated to illness, you encourage and acknowledge the healthier aspects of her identity and the development of new interests.
Such discussions also lighten the tension between you both by introducing some humor and distraction.
Thus, they help you to follow guideline #3.
6. Don’t get defensive in the face of accusations and criticisms. However unfair, say little and don’t fight.
When people who love each other get angry at each other, they may hurl heavy insults in a fit of rage.
This is especially true for people with BPD because they tend to feel a great deal of anger.
The natural response to criticism that feels unfair is to defend oneself.
A person who is enraged is not able to think through an alternative perspective in a cool, rational fashion.
Attempts to defend oneself only fuel the fire.
Essentially, defensiveness suggests that you believe the other person’s anger is unwarranted, a message that leads to greater rage.
Given that a person who is expressing rage with words is not posing threat of physical danger to herself or others, it is wisest to simply listen without arguing.
What that individual wants most is to be heard.
Of course, listening without arguing means getting hurt because it is very painful to recognize that someone you love could feel so wronged by you.
Sometimes the accusations hurt because they seem to be so frankly false and unfair.
Other times, they may hurt because they contain some kernel of truth.
If you feel that there is some truth in what you’re hearing, admit it with a statement such as, “I think you’re on to something. I can see that I’ve hurt you and I’m sorry.”
Remember that such anger is part of the problem for people with BPD.
Keeping these points in mind can help you to avoid taking the anger personally.
7. Self-destructive acts or threats require attention. Don’t ignore. Don’t panic. It’s good to know. Do not keep secrets about this. Talk about it openly with your loved one and make sure professionals know.
There are many ways in which the person with BPD and others in their life may see trouble approaching.
Threats and hints of self-destructiveness may indicate such trouble.
The person may speak of wanting to kill herself.
She may become isolated.
She may engage in self damaging behaviors.
Some parents have noticed that their daughters shave their head and color their hair neon at times when they are in distress.
More commonly, what will be evident is not eating, eating too much, spending sprees, or other reckless behavior.
Sometimes the evidence is blunt - they may discuss wanting to end their life in your presence.
Trouble may be anticipated when separations or vacations occur.
When you see the signs of trouble, you may be reluctant to address them.
Sometimes the person with BPD will insist that you “butt out.”
She may appeal to her right to privacy.
Other times, you dread speaking directly about a problem because the discussion may be difficult.
You may fear that you would cause a problem where there might not be one by “putting ideas into someone’s head”.
In fact, you fear for their safety in these situations because you know them well and know the warning signs of trouble from experience.
Problems are not created by asking questions.
By addressing behaviors and triggers in advance, you can help to avert further trouble.
People with BPD often have difficulty talking about their feelings and instead tend to act on them in destructive ways.
Therefore, addressing a problem openly by inquiring with them or speaking to their therapist helps them to deal with their feelings using words rather than actions.
Privacy is, of course, a great concern when one is dealing with an adult.
However, the competing value in these situations of impending danger is safety.
When making difficult decisions about whether to call your loved one’s therapist about a concern or call an ambulance, one must weigh concern for safety against concern for privacy.
Most people would agree that safety comes first.
There may be a temptation to under-react in order to protect the individual’s privacy.
You must apply judgment to their individual situation.
Therapists can be helpful in anticipating crises and establishing plans that fit the individual’s needs.
8. Listen. People need to have their negative feelings heard. Don’t say, “It isn’t so.” Don’t try to make the feelings go away. Using words to express feelings is good. It’s better to use words than to engage in self damaging behaviors.
When feelings are expressed openly, they can be painful to hear.
They may tell you that they feel abandoned or unloved by you.
You may tell them that you’re at the end of your rope with frustration.
Listening is the best way to help.
People appreciate being heard and having their feelings acknowledged.
This does not mean that you have to agree.
Let’s look at the methods for listening;
One method is to remain silent while looking interested and concerned.
You may ask some questions to convey your interest.
For example, one may ask, “How long have you felt this way?” or “What happened that triggered your feelings?”
Notice that these gestures and questions imply interest but not agreement.
Another method of listening is to make statements expressing what you believe you’ve heard.
With these statements, you prove that you are actually hearing what the other person is saying.
For example, if they tell you they feel like you don’t love her, you can say, even as you are contemplating how ridiculous that belief is, “You feel like I don’t love you?!?”
Notice once again, these empathic statements do not imply agreement.
Do not rush to argue about her feelings or talk her out of her feelings.
As we said above, such arguing can be fruitless and frustrating to the person who wants to be heard.
Remember, even when it may feel difficult to acknowledge feelings that you believe have no basis in reality, it pays to reward such expression.
It is good for people, especially individuals with BPD, to put their feelings into words, no matter how much those feelings are based on distortions.
If people find the verbal expression of their feelings to be rewarding, they are less likely to act out on feelings in destructive ways.
Feelings of being lonely, different, and inadequate need to be heard.
By hearing them and demonstrating that you have heard them using the methods described above, you help the individual to feel a little less lonely and isolated.
Such feelings are a common, everyday experience for people with BPD.
The feelings become a bit less painful once they are shared.
You may be quick to try to talk someone out of such feelings by arguing and denying the feelings.
Such arguments are quite frustrating and disappointing to the person expressing the feelings.
If the feelings are denied when they are expressed verbally, the individual may engage in self damaging behaviors because they feel desperate to get relief of them, and many other reasons.
9. When solving a loved ones problems, ALWAYS: a) involve them in identifying what needs to be done b) ask whether the person can “do” what’s needed in the solution c) ask whether they want you to help them “do” what’s needed
Problems are best tackled through open discussion.
Everyone in the persons life needs to be part of the discussion.
People are most likely to do their part when they are asked for their participation and their views about the solution are respected.
It is important to ask your loved one whether he or she feels able to do the steps called for in the planned solution.
By asking, you show recognition of how difficult the task may be for the other person.
This goes hand in hand with acknowledging the difficulty of changing.
You may feel a powerful urge to step in and help. Your help may be appreciated or may be an unwanted intrusion.
By asking if your help is wanted before you step in, your assistance is much less likely to be resented.
10. If you have concerns about medications or therapist interventions, make sure that both your loved one and his or her therapist/doctor/treatment team know.
Families may have a variety of concerns about their loved one’s medication usage.
They may wonder whether the psychiatrist is aware of the side effects the patient is experiencing.
Can the psychiatrist see how sedated or how behaviors are worsening with the individual?
Is he or she subjecting the patient to danger?
Families and friends may wonder if the doctor or therapist knows the extent of the patient’s non-compliance or history of substance abuse or the side effects being experienced.
When you and others have such concerns, they often feel that they should not interfere, or are told by the patient not to interfere.
If you and others play a major supportive role in the patient’s life, such as providing financial support, emotional support, or by sharing their home, or being important to their life, you/they should make efforts to participate in treatment planning for that individual.
They/you can play that role by contacting the doctor or therapist directly themselves to express the concerns.
Therapists cannot release information about patients who are over the age of 18 without consent, but they can hear and learn from the reports of the patient’s loved ones.
Sometimes they will work with you and others in the patients life, but obviously with their patient’s consent.
11. Set limits by stating the limits of your tolerance. Let your expectations be known in clear, simple language. Everyone needs to know what is expected of them.
Expectations need to be set forth in a clear manner.
Too often, people assume that they should know their expectations automatically.
It is often useful to give up such assumptions.
The best way to express an expectation is to avoid attaching any threats.
For example, one might say, “I want you to take a shower at least every other day.”
When expressed in that fashion, the statement puts responsibility on the other person to fulfill the expectation.
Often, in these situations, family members are tempted to enforce an expectation by attaching threats.
When feeling so tempted, one might say, “If you don’t take a shower at least every other day, I will ask you to move out.”
The first problem with that statement is that the person making the statement is taking on the responsibility.
They are saying “I” will take action if “you” do not fulfill your responsibility as opposed to giving the message, “You need to take responsibility!”
The second problem with that statement is that the person making it may not really intend to carry out the threat if pushed.
The threat becomes an empty expression of hostility.
Of course, there may come a point at which you feel compelled to give an ultimatum with the true intention to act on it.
We will discuss this situation later.
12. Do not protect them from the natural consequences of their actions. Allow them to learn about reality. Bumping into a few walls is usually necessary.
People with BPD can engage in dangerous, harmful, and costly behaviors.
The emotional and financial toll to the individual can be tremendous.
Nonetheless, people in the sufferers life may sometimes go to great lengths to undo the damage, or protect everyone from embarrassment.
The results of these protective ways are complex.
A few examples;
a)
A daughter stuffs a handful of pills in her mouth in her mother’s presence.
The mother puts her hand into the daughter’s mouth to sweep out the pills.
It is reasonable to prevent medical harm in this way.
The mother then considers calling an ambulance because she can see that the daughter is suicidal and at risk of harming herself.
However, this option would have some very negative consequences.
The daughter and the family would face the embarrassment of having an ambulance in front of the house.
The daughter does not wish to go to the hospital and would become enraged and out of control if the mother called the ambulance.
A mother in this situation would be strongly tempted not to call the ambulance in order to avoid the daughter’s uncontrollable and intense emotions, and to preserve the family’s image in the neighborhood.
She might rationalize the decision by convincing herself that the daughter is not in fact in immediate danger.
The primary problem with that choice is that it keeps the daughter from attaining much needed help at a point when she has been and could still be suicidal.
The mother would be aiding the daughter in denial of the problem.
Medical expertise is needed to determine whether the daughter is at risk of harming herself.
Furthermore, if an ambulance were not called for fear of incurring her wrath, she would receive the message that she can control others by threatening to become enraged
b)
A 25-year old woman steals money from her family members while she is living with them.
The family members express great anger at her and sometimes threaten to ask her to move out, but they never take any real action.
When she asks to borrow money, they give the loan despite the fact that she never pays back such loans.
They fear that if they do not lend the money, she may steal it from someone outside the family, thus leading to legal trouble for her and humiliation for everyone else involved.
In this case, the family has taught the daughter that she can get away with stealing.
The daughter’s behavior is very likely to persist as long as no limits are set on it.
The family could cease to protect her by insisting that she move out or by stopping the loans.
If she does steal from someone outside the family and faces legal consequences, this may prove to be a valuable lesson about reality.
Legal consequences may influence her to change and subsequently function better outside the family.
c)
A 20-year old woman who has had multiple psychiatric hospitalizations recently and has been unable to hold down any employment decides that she wants to return to college full time.
She asks her parents to help pay tuition.
The parents who watch their daughter spend most of her day in bed are skeptical that she will be able to remain in school for an entire semester and pass her courses.
The tuition payments represent great financial hardship for them.
Nonetheless, they agree to support the plan because they do not want to believe she is as dysfunctional as they believe.
A more realistic plan would be for the daughter to take one course at a time to prove that she can do it, and then return to school full time only after she has demonstrated the ability to maintain such a commitment despite her disorder.
The plan calls upon her to take responsibility in order to obtain a privilege she desires.
Each of the cases illustrates the hazards of being protective when a loved one is making unwise choices or engaging in frankly dangerous behavior.
By setting limits on these choices and behaviors, you can motivate individuals to take on greater responsibility and have appropriate limits within themselves.
The decision to set limits is often the hardest decision for people to make.
It involves watching a loved one struggle.
It is important for you to remember that it is not your job to spare them of these feelings, but it can be helpful to show them they need to live with those feelings as all people need to do.
13. Do not tolerate abusive treatment such as rage outbursts, threats, hitting, breaking objects, verbal attacks. Walk away and return to discuss the issue later.
There is a range of ways to set limits on these behaviors.
A mild gesture would be to walk out of the room to avoid the behavior(s).
A more aggressive gesture would be to call an ambulance, especially if the person is uncontrollable and at risk of hurting themselves, or others.
Many fear taking the latter step because they do not want an ambulance in front of their home, or they do not want to make things worse.
When torn by such feelings, one must consider the opposing issues.
Safety may be a concern when someone is out of control.
They may end up hurting themselves, or they may end up hurting people around them.
Most people would agree that safety takes priority over privacy.
Furthermore, by neglecting to get proper medical attention for out-of-control behavior, one may turn a silent ear to it.
This only leads to further escalation.
14. Be cautious about using threats and ultimatums. They are a last resort. Do not use threats and ultimatums as a means of convincing others to change. Give them only when you can and will carry through. Let others - including professionals - help you decide when to give them.
When one can no longer tolerate another’s behavior, he or she may reach the point of giving an ultimatum.
This means threatening to take action if the other person does not cooperate.
For example, when one will not take a shower or get out of bed much of the day, one may want to tell her that she will have to move out if she does not change her ways.
They may hope that fear will push her to change.
At the same time, they may not be serious about the threat.
When the sufferer continues to refuse to cooperate, you may back down, proving that the threat was an empty one.
When ultimatums are used in this way, they become useless, except to produce some hostility.
Thus, people should only give ultimatums when they seriously intend to act on them.
In order to be serious about the ultimatum, the person giving it probably has to be at the point where they feel unable to live with the other person.
Think very long and hard before you give an ultimatum. It could make things a lot worse, so perhaps make a con and pro list of giving an ultimatum, and the possible outcomes of doing so. Weigh out the risks and the consequences, but also weigh out the pros and successes that could come of it.
As a side note, if you are considering an ultimatum, for example, having someone stop self harm or you will leave them, maybe first you should ask them to get help for their self harm, and to work on trying to stop[slip ups may happen though, so be wary of that], rather than forcing this massive pressure on them, which can make things so much worse, for the both of you.
Think of other options before ultimatums are given.
GO SLOWLY
1. 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 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.
When signs of progress appear, family members can reduce the risk of relapse by not showing too much excitement about the progress and by cautioning the individual to move slowly.
This is why experienced members of a hospital staff tell borderline patients during discharge not that they feel confident about their prospects, but that they know the patient will confront many hard problems ahead.
While it is important to acknowledge progress with a pat on the back, it is meanwhile necessary to convey understanding that progress is very difficult to achieve.
It does not mean that the person has overcome her emotional struggles.
You can do this by avoiding statements such as, “You’ve made great progress,” or, “I’m so impressed with the change in you.”
Such messages imply that you think they are well or over their prior problems.
Even statements of reassurance such as, “That wasn’t so hard,” or, “I knew you could do it,” suggest that you minimize their struggle.
A message such as, “Your progress shows real effort. You’ve worked hard. I’m pleased that you were able to do it, but I’m worried that this is all too stressful for you,” can be more empathic and less risky.
2. Lower your expectations. Set realistic goals that are attainable. Solve big problems in small steps. Work on one thing at a time. “Big”, long-term goals lead to discouragement and failure.
Although the person with BPD may have many obvious strengths such as intelligence, ambition, good looks, and artistic talent, she nonetheless is handicapped by severe emotional vulnerabilities as she sets about making use of those talents.
Usually the person with BPD and her family members have aspirations based upon these strengths.
The patient or her family may push for return to college, graduate school, or a training program that will prepare her for financial independence.
Family members may wish to have the patient move into her own apartment and care for herself more independently.
Fueled by such high ambitions, a person with BPD will take a large step forward at a time.
She may insist upon returning to college full time despite undergoing recent hospitalizations, for example.
Of course, such grand plans do not consider the individual’s handicaps.
The overriding issue about success in the vocational arena is the threat of independence —much desired but fraught with fear of abandonment.
The result of too large a step forward all at once is often a crashing swing in the opposite direction, like the swing of a pendulum.
The person often relapses to a regressed state and may even require hospitalization.
A major task for families is to slow down the pace at which they or the patient seeks to achieve goals.
By slowing down, they prevent the sharp swings of the pendulum as described and prevent experiences of failure that are blows to the individual’s self-confidence.
By lowering expectations and setting small goals to be achieved step by step, patients and families have greater chances of success without relapse.
Goals must be realistic.
For example, the person who left college mid-semester after becoming depressed and suicidal under the pressure most likely could not return to college full time a few months later and expect success.
A more realistic goal is for that person to try one course at a time while she is stabilizing.
Goals must be achieved in small steps.
The person with BPD who has always lived with her parents might not be able to move straight from her parents’ home.
The plan can be broken down into smaller steps in which she first moves to a halfway house, and then into a supervised apartment.
Only after she has achieved some stability in those settings should she take the major step of living alone.
Goals should not only be broken down into steps but they should be taken on one step at a time.
For example, if the patient and the family have goals for both the completion of school and independent living, it may be wisest to work on only one of the two goals at a time.
3. Keep things cool and calm. Appreciation is normal. Tone it down. Disagreement is normal. Tone it down, too.
This guideline is a reminder of the central message of our educational program: The person with BPD is handicapped in their ability to tolerate stress in relationships (i.e., rejection, criticism, disagreements) and can, therefore, benefit from a cool, calm environment.
It is vital to keep in mind the extent to which people with BPD struggle emotionally each day.
While their internal experience can be difficult to convey, here are some of the handicaps summarized;
Affect Dyscontrol:
A person with BPD has feelings that dramatically fluctuate in the course of each day and that are particularly intense.
These emotions, or affects, often hit hard.
We have all experienced such intense feelings at times.
Take for example the sensation of pounding heart and dread that you may feel when you suddenly realize that you have made a mistake at work that might be very costly or embarrassing to your business.
The person with BPD feels such intense emotion on a regular basis.
Most people can soothe themselves through such emotional experiences by telling themselves that they will find a way to compensate for the mistake or reminding themselves that it is only human to make mistakes.
The person with BPD lacks that ability to soothe herself.
We have all had moments in which we feel rage towards the people we love.
We typically calm ourselves in such situations by devising a plan for having a heart-to-heart talk with the family member or by deciding to let things blow over.
The person with BPD again feels such rage in its full intensity and without being able to soothe through the use of coping strategies.
It results in an inappropriate expression of hostility or by acting out of feelings (self damaging behaviors).
Intolerance of Aloneness:
A person with BPD typically feels desperate at the prospect of any separation - a family member’s or therapist’s vacation, break up of a romance, or departure of a friend.
While most of us would probably miss the absent family member, therapist or friend, the person with BPD typically feels intense panic.
She is unable to conjure up images of the absent person to soothe herself.
She cannot tell herself, “That person really cares about me and will be back again.”
Her memory fails her.
She only feels soothed and cared for by the other person when that person is present.
Thus, the other person’s absence is experienced as abandonment.
She may even keep these painful thoughts and feelings out of mind by using a defense mechanism called dissociation.
This consists of a bizarre and disturbing feeling of being unreal or separate from one’s body.
Black & White Thinking (Dichotomous Thinking):
Along with extremes of emotion come extremes in thinking.
The person with BPD tends to have extreme opinions.
Others are often experienced as being either all good or all bad.
When the other person is caring and supportive, the person with BPD views him or her as a savior, someone endowed with special qualities.
When the other person fails, disagrees, or disapproves in some way, the person with BPD views him or her as being evil and uncaring.
The handicap is in the inability to view other people more realistically, as mixtures of good and bad qualities.
This review of some of the handicaps of people with BPD is a reminder that they have a significantly impaired abilitites.
Therefore, family members and loved ones can help them achieve stability by creating a cool, calm environment.
This means slowing down and taking a deep breath when crises arise rather than reacting with great emotion.
It means setting smaller goals for the person with BPD so as to diminish the pressure she is experiencing.
It means communicating when you are calm and in a manner that is calm.
It does not mean sweeping disappointments and disagreements under the rug by avoiding discussion of them.
It does mean that conflict needs to be addressed in a cool but direct manner without use of put-downs.
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. If you chose this path, you’ve got to be very strong and very balanced.
Love: People 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.
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 their behaviors 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
In crisis, stay calm, don’t get defensive, don’t take it personally
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.
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, others who are in the situation at the time) - financially, emotionally, etc.
Be prepared for digressions when they occur - they will.
Protections range from controlling the bank accounts, to educating outsiders, to having a suicide threat plan.
You can help mitigate the difficult.
Preserve Your Emotional Health:
The intensity of the relationship with someone suffering with BPD take a toll on even the strongest. It is 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’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 someone with borderline personality disorder - it’s a decision that should be taken very seriously.
4. Maintain family routines as much as possible. Stay in touch with family and friends. There’s more to life than problems, so don’t give up the good times.
Often, when someone has a severe mental illness, you can become isolated.
The result of this isolation can be only anger and tension.
Everyone needs friends, parties, and vacations to relax and unwind.
By making a point of having good times, everyone can cool down and approach life’s problems with improved perspective.
The environment will naturally be cooler.
So you should have good times outside of your relationship, not only for your own sake, but for the sake of the relationship.
5. Find time to talk. Chats about light or neutral matters are helpful. Schedule times for this if you need to.
Too often, when family members are in conflict with one another or are burdened by the management of severe emotional problems, they forget to take time out to talk about matters other than illness.
Such discussions are valuable for many reasons.
The person with BPD often devotes all her time and energy to her illness by going to multiple therapies each week, by attending day treatment, etc.
The result is that she misses opportunities to explore and utilize the variety of talents and interests she has.
Her sense of self is typically weak and may be weakened further by this total focus on problems and the attention devoted to her being ill.
When you take time to talk about matters unrelated to illness, you encourage and acknowledge the healthier aspects of her identity and the development of new interests.
Such discussions also lighten the tension between you both by introducing some humor and distraction.
Thus, they help you to follow guideline #3.
6. Don’t get defensive in the face of accusations and criticisms. However unfair, say little and don’t fight.
When people who love each other get angry at each other, they may hurl heavy insults in a fit of rage.
This is especially true for people with BPD because they tend to feel a great deal of anger.
The natural response to criticism that feels unfair is to defend oneself.
A person who is enraged is not able to think through an alternative perspective in a cool, rational fashion.
Attempts to defend oneself only fuel the fire.
Essentially, defensiveness suggests that you believe the other person’s anger is unwarranted, a message that leads to greater rage.
Given that a person who is expressing rage with words is not posing threat of physical danger to herself or others, it is wisest to simply listen without arguing.
What that individual wants most is to be heard.
Of course, listening without arguing means getting hurt because it is very painful to recognize that someone you love could feel so wronged by you.
Sometimes the accusations hurt because they seem to be so frankly false and unfair.
Other times, they may hurt because they contain some kernel of truth.
If you feel that there is some truth in what you’re hearing, admit it with a statement such as, “I think you’re on to something. I can see that I’ve hurt you and I’m sorry.”
Remember that such anger is part of the problem for people with BPD.
Keeping these points in mind can help you to avoid taking the anger personally.
7. Self-destructive acts or threats require attention. Don’t ignore. Don’t panic. It’s good to know. Do not keep secrets about this. Talk about it openly with your loved one and make sure professionals know.
There are many ways in which the person with BPD and others in their life may see trouble approaching.
Threats and hints of self-destructiveness may indicate such trouble.
The person may speak of wanting to kill herself.
She may become isolated.
She may engage in self damaging behaviors.
Some parents have noticed that their daughters shave their head and color their hair neon at times when they are in distress.
More commonly, what will be evident is not eating, eating too much, spending sprees, or other reckless behavior.
Sometimes the evidence is blunt - they may discuss wanting to end their life in your presence.
Trouble may be anticipated when separations or vacations occur.
When you see the signs of trouble, you may be reluctant to address them.
Sometimes the person with BPD will insist that you “butt out.”
She may appeal to her right to privacy.
Other times, you dread speaking directly about a problem because the discussion may be difficult.
You may fear that you would cause a problem where there might not be one by “putting ideas into someone’s head”.
In fact, you fear for their safety in these situations because you know them well and know the warning signs of trouble from experience.
Problems are not created by asking questions.
By addressing behaviors and triggers in advance, you can help to avert further trouble.
People with BPD often have difficulty talking about their feelings and instead tend to act on them in destructive ways.
Therefore, addressing a problem openly by inquiring with them or speaking to their therapist helps them to deal with their feelings using words rather than actions.
Privacy is, of course, a great concern when one is dealing with an adult.
However, the competing value in these situations of impending danger is safety.
When making difficult decisions about whether to call your loved one’s therapist about a concern or call an ambulance, one must weigh concern for safety against concern for privacy.
Most people would agree that safety comes first.
There may be a temptation to under-react in order to protect the individual’s privacy.
You must apply judgment to their individual situation.
Therapists can be helpful in anticipating crises and establishing plans that fit the individual’s needs.
8. Listen. People need to have their negative feelings heard. Don’t say, “It isn’t so.” Don’t try to make the feelings go away. Using words to express feelings is good. It’s better to use words than to engage in self damaging behaviors.
When feelings are expressed openly, they can be painful to hear.
They may tell you that they feel abandoned or unloved by you.
You may tell them that you’re at the end of your rope with frustration.
Listening is the best way to help.
People appreciate being heard and having their feelings acknowledged.
This does not mean that you have to agree.
Let’s look at the methods for listening;
One method is to remain silent while looking interested and concerned.
You may ask some questions to convey your interest.
For example, one may ask, “How long have you felt this way?” or “What happened that triggered your feelings?”
Notice that these gestures and questions imply interest but not agreement.
Another method of listening is to make statements expressing what you believe you’ve heard.
With these statements, you prove that you are actually hearing what the other person is saying.
For example, if they tell you they feel like you don’t love her, you can say, even as you are contemplating how ridiculous that belief is, “You feel like I don’t love you?!?”
Notice once again, these empathic statements do not imply agreement.
Do not rush to argue about her feelings or talk her out of her feelings.
As we said above, such arguing can be fruitless and frustrating to the person who wants to be heard.
Remember, even when it may feel difficult to acknowledge feelings that you believe have no basis in reality, it pays to reward such expression.
It is good for people, especially individuals with BPD, to put their feelings into words, no matter how much those feelings are based on distortions.
If people find the verbal expression of their feelings to be rewarding, they are less likely to act out on feelings in destructive ways.
Feelings of being lonely, different, and inadequate need to be heard.
By hearing them and demonstrating that you have heard them using the methods described above, you help the individual to feel a little less lonely and isolated.
Such feelings are a common, everyday experience for people with BPD.
The feelings become a bit less painful once they are shared.
You may be quick to try to talk someone out of such feelings by arguing and denying the feelings.
Such arguments are quite frustrating and disappointing to the person expressing the feelings.
If the feelings are denied when they are expressed verbally, the individual may engage in self damaging behaviors because they feel desperate to get relief of them, and many other reasons.
9. When solving a loved ones problems, ALWAYS: a) involve them in identifying what needs to be done b) ask whether the person can “do” what’s needed in the solution c) ask whether they want you to help them “do” what’s needed
Problems are best tackled through open discussion.
Everyone in the persons life needs to be part of the discussion.
People are most likely to do their part when they are asked for their participation and their views about the solution are respected.
It is important to ask your loved one whether he or she feels able to do the steps called for in the planned solution.
By asking, you show recognition of how difficult the task may be for the other person.
This goes hand in hand with acknowledging the difficulty of changing.
You may feel a powerful urge to step in and help. Your help may be appreciated or may be an unwanted intrusion.
By asking if your help is wanted before you step in, your assistance is much less likely to be resented.
10. If you have concerns about medications or therapist interventions, make sure that both your loved one and his or her therapist/doctor/treatment team know.
Families may have a variety of concerns about their loved one’s medication usage.
They may wonder whether the psychiatrist is aware of the side effects the patient is experiencing.
Can the psychiatrist see how sedated or how behaviors are worsening with the individual?
Is he or she subjecting the patient to danger?
Families and friends may wonder if the doctor or therapist knows the extent of the patient’s non-compliance or history of substance abuse or the side effects being experienced.
When you and others have such concerns, they often feel that they should not interfere, or are told by the patient not to interfere.
If you and others play a major supportive role in the patient’s life, such as providing financial support, emotional support, or by sharing their home, or being important to their life, you/they should make efforts to participate in treatment planning for that individual.
They/you can play that role by contacting the doctor or therapist directly themselves to express the concerns.
Therapists cannot release information about patients who are over the age of 18 without consent, but they can hear and learn from the reports of the patient’s loved ones.
Sometimes they will work with you and others in the patients life, but obviously with their patient’s consent.
11. Set limits by stating the limits of your tolerance. Let your expectations be known in clear, simple language. Everyone needs to know what is expected of them.
Expectations need to be set forth in a clear manner.
Too often, people assume that they should know their expectations automatically.
It is often useful to give up such assumptions.
The best way to express an expectation is to avoid attaching any threats.
For example, one might say, “I want you to take a shower at least every other day.”
When expressed in that fashion, the statement puts responsibility on the other person to fulfill the expectation.
Often, in these situations, family members are tempted to enforce an expectation by attaching threats.
When feeling so tempted, one might say, “If you don’t take a shower at least every other day, I will ask you to move out.”
The first problem with that statement is that the person making the statement is taking on the responsibility.
They are saying “I” will take action if “you” do not fulfill your responsibility as opposed to giving the message, “You need to take responsibility!”
The second problem with that statement is that the person making it may not really intend to carry out the threat if pushed.
The threat becomes an empty expression of hostility.
Of course, there may come a point at which you feel compelled to give an ultimatum with the true intention to act on it.
We will discuss this situation later.
12. Do not protect them from the natural consequences of their actions. Allow them to learn about reality. Bumping into a few walls is usually necessary.
People with BPD can engage in dangerous, harmful, and costly behaviors.
The emotional and financial toll to the individual can be tremendous.
Nonetheless, people in the sufferers life may sometimes go to great lengths to undo the damage, or protect everyone from embarrassment.
The results of these protective ways are complex.
A few examples;
a)
A daughter stuffs a handful of pills in her mouth in her mother’s presence.
The mother puts her hand into the daughter’s mouth to sweep out the pills.
It is reasonable to prevent medical harm in this way.
The mother then considers calling an ambulance because she can see that the daughter is suicidal and at risk of harming herself.
However, this option would have some very negative consequences.
The daughter and the family would face the embarrassment of having an ambulance in front of the house.
The daughter does not wish to go to the hospital and would become enraged and out of control if the mother called the ambulance.
A mother in this situation would be strongly tempted not to call the ambulance in order to avoid the daughter’s uncontrollable and intense emotions, and to preserve the family’s image in the neighborhood.
She might rationalize the decision by convincing herself that the daughter is not in fact in immediate danger.
The primary problem with that choice is that it keeps the daughter from attaining much needed help at a point when she has been and could still be suicidal.
The mother would be aiding the daughter in denial of the problem.
Medical expertise is needed to determine whether the daughter is at risk of harming herself.
Furthermore, if an ambulance were not called for fear of incurring her wrath, she would receive the message that she can control others by threatening to become enraged
b)
A 25-year old woman steals money from her family members while she is living with them.
The family members express great anger at her and sometimes threaten to ask her to move out, but they never take any real action.
When she asks to borrow money, they give the loan despite the fact that she never pays back such loans.
They fear that if they do not lend the money, she may steal it from someone outside the family, thus leading to legal trouble for her and humiliation for everyone else involved.
In this case, the family has taught the daughter that she can get away with stealing.
The daughter’s behavior is very likely to persist as long as no limits are set on it.
The family could cease to protect her by insisting that she move out or by stopping the loans.
If she does steal from someone outside the family and faces legal consequences, this may prove to be a valuable lesson about reality.
Legal consequences may influence her to change and subsequently function better outside the family.
c)
A 20-year old woman who has had multiple psychiatric hospitalizations recently and has been unable to hold down any employment decides that she wants to return to college full time.
She asks her parents to help pay tuition.
The parents who watch their daughter spend most of her day in bed are skeptical that she will be able to remain in school for an entire semester and pass her courses.
The tuition payments represent great financial hardship for them.
Nonetheless, they agree to support the plan because they do not want to believe she is as dysfunctional as they believe.
A more realistic plan would be for the daughter to take one course at a time to prove that she can do it, and then return to school full time only after she has demonstrated the ability to maintain such a commitment despite her disorder.
The plan calls upon her to take responsibility in order to obtain a privilege she desires.
Each of the cases illustrates the hazards of being protective when a loved one is making unwise choices or engaging in frankly dangerous behavior.
By setting limits on these choices and behaviors, you can motivate individuals to take on greater responsibility and have appropriate limits within themselves.
The decision to set limits is often the hardest decision for people to make.
It involves watching a loved one struggle.
It is important for you to remember that it is not your job to spare them of these feelings, but it can be helpful to show them they need to live with those feelings as all people need to do.
13. Do not tolerate abusive treatment such as rage outbursts, threats, hitting, breaking objects, verbal attacks. Walk away and return to discuss the issue later.
There is a range of ways to set limits on these behaviors.
A mild gesture would be to walk out of the room to avoid the behavior(s).
A more aggressive gesture would be to call an ambulance, especially if the person is uncontrollable and at risk of hurting themselves, or others.
Many fear taking the latter step because they do not want an ambulance in front of their home, or they do not want to make things worse.
When torn by such feelings, one must consider the opposing issues.
Safety may be a concern when someone is out of control.
They may end up hurting themselves, or they may end up hurting people around them.
Most people would agree that safety takes priority over privacy.
Furthermore, by neglecting to get proper medical attention for out-of-control behavior, one may turn a silent ear to it.
This only leads to further escalation.
14. Be cautious about using threats and ultimatums. They are a last resort. Do not use threats and ultimatums as a means of convincing others to change. Give them only when you can and will carry through. Let others - including professionals - help you decide when to give them.
When one can no longer tolerate another’s behavior, he or she may reach the point of giving an ultimatum.
This means threatening to take action if the other person does not cooperate.
For example, when one will not take a shower or get out of bed much of the day, one may want to tell her that she will have to move out if she does not change her ways.
They may hope that fear will push her to change.
At the same time, they may not be serious about the threat.
When the sufferer continues to refuse to cooperate, you may back down, proving that the threat was an empty one.
When ultimatums are used in this way, they become useless, except to produce some hostility.
Thus, people should only give ultimatums when they seriously intend to act on them.
In order to be serious about the ultimatum, the person giving it probably has to be at the point where they feel unable to live with the other person.
Think very long and hard before you give an ultimatum. It could make things a lot worse, so perhaps make a con and pro list of giving an ultimatum, and the possible outcomes of doing so. Weigh out the risks and the consequences, but also weigh out the pros and successes that could come of it.
As a side note, if you are considering an ultimatum, for example, having someone stop self harm or you will leave them, maybe first you should ask them to get help for their self harm, and to work on trying to stop[slip ups may happen though, so be wary of that], rather than forcing this massive pressure on them, which can make things so much worse, for the both of you.
Think of other options before ultimatums are given.
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