“This study was designed to align with social work values by emphasizing interdisciplinary and multiple agency collaboration, the rights of family members with lived experience to actively direct their care, and the expertise of social workers in the provision of psychotherapy and family interventions.”

Last Edition:
September 2018


Making Connections:
A Study Examining the Impact of Support Provided to Family Members of Individuals with Borderline Personality Disorder

By Megan Cameron, MSW, RSW;   Tracey Holz, RN, MN, RP, CPMHN(C);   Krystle Martin, PhD, C.  Psych; Jennifer Muller, RN, RP;   Gwenne Woodward, MSW, RSW

Borderline personality disorder (BPD) is one of the most functionally disabling mental disorders.1-3It is characterized by pervasive patterns of emotional dysregulation and is often accompanied by self-harm behaviours and suicidal ideation.1,4,5These behaviours are often poorly understood by family members who may perceive communications with their loved one as frightening, unexpected, demanding, or unrealistic. As a result, individuals with BPD often feel invalidated and the cycle of emotion dysregulation and invalidation can lead to worsening symptoms and a breakdown of family relationships. It is not uncommon to hear a family member of an individual with BPD describe feeling overwhelmed4, burdened, and blamed for their loved one’s illness. Due to the significant impacts of BPD, access to effective treatments and supports are needed for both the individual with BPD and their family. Social workers try to support individuals and their family members to manage these stressors; however, BPD is highly stigmatized and is often an exclusionary criteria for many services due to difficulty providing effective treatment.9 Compounding the problem, evidence-informed family supports are not often included in treatment and social workers often have difficulties finding appropriate resources to support a family member. While dialectical behavior therapy (DBT) is the gold standard treatment for individuals with BPD, it does not intervene directly at the environmental level.7 In response to this gap in treatment service, the National Education Alliance for Borderline Personality Disorder’s Family Connections™ (FC) program was developed. The FC program is an evidence-informed, peer-led educational model that provides education, DBT skills, and support for family members. The 12-week program is led by trained family member volunteers10who are non-professionals with the lived-experience of being a family member of an individual who has BPD. The value that this program places in engaging people with personal experiences as partners in the helping process truly embodies social work values.12In many areas in Ontario, the FC program is currently offered free of charge to family members through the Sashbear Foundation, a foundation dedicated to increasing awareness, reducing stigma, and increasing access of affordable treatment/ support for individuals with emotional dysregulation and their families.13Despite growing availability of family support across Ontario and throughout other parts of the country, there is minimal research available to understand the impact of BPD on family functioning and the impact of family relationships on the client with BPD. Additionally, evidence exists to support the inclusion of family interventions as an important component of treatment for other psychiatric disorders;8,10,11however, little research has focused on the needs of family members of individuals with BPD.3,7 The purpose of this study was to address the gaps in research and service provision to explore the impact of FC on both family members and their loved ones receiving treatment for BPD in our clinic.

Study Design
This study was designed to align with social work values by emphasizing interdisciplinary and multiple agency collaboration, the rights of family members with lived experience to actively direct their care, and the expertise of social workers in the provision of psychotherapy and family interventions. This mixed-methods study evaluated the impact of the FC program on the family members and their loved ones with BPD. Participants were recruited from a Borderline Personality Self-Regulation Clinic (BPSRC) at a tertiary level mental healthcare facility (Whitby, Ontario), which offers DBT to individuals with BPD. Integrated family support is offered only intermittently due to limited resources within the clinic.

Interested family members and loved ones of clients within the BPSRC volunteered to participate in the 12-week FC program. Both clients of the BPSRC program and their family members took part in focus groups and completed standardized measures before (pre), immediately after (post), and 3 months following (follow-up) the intervention. The study is currently in the data analytic and interpretation phase. The impact of the intervention on family members and clients is being assessed by examining the change in burden and coping for family members and the change in coping, BPD symptoms, and emotion regulation in clients. Additionally, qualitative thematic analysis of the focus group responses to open-ended questions are expected to illuminate the families’ and clients’ perceptions of and experiences with coping, communication, and relationships as a result of the FC program. Responses will also be examined to identify themes with respect to barriers and facilitators to group involvement and positive outcomes. 


Future Implications

The intent of this study is to improve our understanding of the effects of family-led interventions for family members of people with BPD on family members and their loved ones. Findings will help to address the knowledge and service gaps that currently exist. There is a need to implement treatment models that help the complex and highly stigmatized experiences of individuals with BPD and their families. The outcomes of this study will contribute to our understanding of the usefulness of family interventions for individuals with BPD, their family members, and their health of their overall relationship.14 While the focus of this study is at the micro-level of impact of the intervention on the individuals involved, it has the potential to influence system-level changes by highlighting the value of the provision of direct support to family members as a method that can impact both the family member and the individual receiving services.

Megan Cameron, MSW, RSW; Tracey Holz, RN, MN, RP, CPMHN(C); Krystle Martin, PhD, C. Psych; Jennifer Muller, RN, RP; Gwenne Woodward, MSW, RSW.

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2. Gunderson JG, Lyoo IK. Family problems and relationships for adults with borderline personality disorder. Harvard review of psychiatry. 1997;4(5):272-278.

3. Wagner AW, Rizvi SL, Harned MS. Applications of dialectical behavior therapy to the treatment of complex trauma-related problems: when one case formulation does not fit all. Journal of traumatic stress. 2007;20(4):391-400.

4. Hoffman PD, Fruzzetti AE, Buteau E, et al. Family connections: a program for relatives of persons with borderline personality disorder. Family process. 2005;44(2):217-225.

5. Linehan M. Cognitive-behavioral treatment of borderline personality disorder. Guilford press; 1993.

6. Glick IDL, E.L. Family treatment of borderline personality disorder. In: MacFarlane MM, ed. Family Therapy and Mental Health: Innovations in Theory and Practice. Newyork, NY: Haworth Clinical Practice Press; 2001:134-154.

7. Fruzzetti AES, D.A.; Hoffman, P.D. Dialectical behaviour therapy with families. In: Dimeff LAK, K., ed. Dialectical Behaviour Therapy in Clinical Practice: Applications Across Disorders and Settings. New York, NY: The Guildford Press; 2007:222-263.

8. Hoffman PD, Fruzzetti AE, Swenson CR. Dialectical behavior therapy–family skills training. Family process. 1999;38(4):399-414.9. Aviram RB, Brodsky BS, Stanley B. Borderline personality disorder, stigma, and treatment implications. Harvard review of psychiatry. 2006;14(5):249-256.

10. Dixon L, Stewart B, Burland J, Delahanty J, Lucksted A, Hoffman M. Pilot study of the effectiveness of the family-to-family education program. Psychiatric services (Washington, DC). 2001;52(7):965-967.

11. Health Quality Ontario. Quality Standards, Schizophrenia: Care for adults in hospital. www.hqontario.ca/Evidence-to-Improve-Care/Quality-Standards/Schizophrenia. Accessed March 12, 2017.

12. National Association of Social Workers (NASW). (2008). Code of ethics of the National Association of Social Workers. Washington, DC: Author. https://www.socialworkers.org/LinkClick.aspx?fileticket=KZmmbz15evc%3D&portalid=0.

13. The Sashbear Foundation. (2011). Family Connections TM Program. http://sashbear.org/en/family-connections/family-connections-2.

14. Fruzzetti AE, Fruzzetti, AR.; Borderline Personality Disorder. In: Snyder DK, Whisman M., ed. Treating Difficult Couples: Helping Clients with Coexisting Mental and Relationship Disorders. New York, NY: The Guildford Press; 2003: 235-260.