Borderline personality disorder is a serious mental health disorder that affects the way someone relates to themself and others around them. People with borderline personality disorder usually have difficulty managing emotions, forming stable relationships with other people, and developing a clear and coherent identity. They may fear abandonment by others, experience chronic feelings of emptiness, and engage in impulsive and self-destructive behaviours.

BPD is a disorder that’s stigmatised on many levels, from within the healthcare profession to the general public. This stigma includes the belief that individuals can’t recover from BPD – or that recovery is very difficult. In reality, with effective support, many people recover from BPD and lead fulfilling, independent lives.

There are several different evidence-based treatment approaches for borderline personality disorder, including dialectical behavioural therapy (DBT), mentalisation-based therapy (MBT), and trauma-focused therapies. Treatment programs often combine several forms of support, including psychotherapy, occupational, and social support. 

Crucially, effective treatment recognises that a person with BPD does not exist in isolation. They exist within social systems that have the potential to offer support and reinforce positive behaviours – or (often unintentionally) maintain unhelpful or harmful ones. For many people with BPD, their family represents one of their closest and most important social systems. Consequently, family members and the family system can play a key role in the recovery process.

Why Are Family Interventions Important?

There are several reasons that family interventions are important in BPD treatment. These include:

Reinforcing Positive Behaviours

Family dynamics and interpersonal relationships can sometimes reinforce and maintain harmful behaviours. But they also have the potential to encourage positive ones. Family interventions can help identify unhelpful behaviours and dynamics and replace them with interactions conducive to recovery.

Creating a Stable Support System

People with BPD often struggle to maintain close relationships, including with family members. During recovery, unstable relationships (or a lack of close relationships) make it more difficult to manage symptoms, difficult situations, and distressing experiences. They may lack sources of emotional support and find themselves triggered by interpersonal conflicts, complicating the recovery process.

Improving a Therapist’s Understanding

Involving the whole family in BPD treatment also allows therapists the gain a better understanding of a person’s relationships and family dynamics. They may obtain a more comprehensive insight into past experiences that have shaped their development and present behaviours.

Forming Alliances with Therapists

Family interventions help create positive alliances between family members of a person with BPD and their treatment team. These connections can help reduce conflicts within the family, improve communication between family members and the treatment team, and positively impact a person’s recovery.

Family interventions may be particularly effective when they create a sense of mutual purpose and understanding between family members. This can happen by validating a family’s shared challenges and encouraging a collective commitment to overcome them. 

Families as a Mode of Change, Not Blame

Sometimes, family interventions for BPD are misconceived as holding families responsible for the development of the disorder in a person with BPD. However, the current available evidence does not suggest that BPD is always rooted in family dysfunction. 

While some aspects of a person’s childhood (such as parental warmth, attachment, hostility, and harsh punishment) may be risk factors for BPD, there are several different patterns that lead to the development of the disorder. For example, some people who have strong biological vulnerabilities to the disorder (such as emotional dysregulation and behavioural problems) may still develop BPD within a supportive and stable family environment because even effective parenting skills are inadequate to enable healthy emotional development.

What Are Some Types of Family Interventions for People with BPD?

There are many different types of family interventions, including family systems therapy, psychoeducation, and family skills training. Interventions may be directed towards the whole family (with or without the presence of the person with BPD) or to specific members such as parents or caregivers.

Family Skills Training

Some family interventions focus on skills training for parents and other family members of a person with BPD. These skills help families to interact, respond, and create home environments that support a person’s recovery. 

Skills training programs acknowledge the important role family members can play in supporting a person with BPD and either maintaining or changing problematic patterns of behaviour.

DBT-Family Skills

Several family skills training approaches are based on dialectical behavioural therapy (DBT). DBT is the most established treatment for borderline personality disorder, emphasising the radical acceptance of emotions and experiences while teaching skills that promote positive change.

Some key DBT-family skills are validation, mindfulness, radical acceptance, and emotional regulation.

Emotional Validation

People with BPD often experience intense emotional reactions. These emotions can be painful, distressing, and difficult to soothe. When other people invalidate these emotions (by reacting with anger or judgement or claiming they are not legitimate), they can become even stronger and longer-lasting. On the other hand, validating another’s emotions usually helps soothe emotional pain.

People with BPD may also struggle to express their emotions accurately, particularly if they are already experiencing intense and distressing feelings. This can make it more likely that they receive invalidating responses from others who misunderstand their experiences.

When family members of people with BPD frequently invalidate their relative’s emotions, it may lead to cycles of escalating emotions that end in self-destructive behaviours. Sometimes, families can be caught in cycles of invalidation and increasing emotional distress that act as barriers to recovery.

DBT skills sessions teach family members to validate each other’s emotions, helping to reduce pain, distress, and harm. They support families to learn the same skills, language, and theory that a person with BPD is learning in treatment. This encourages better communication, shared understanding, and emotional validation.

Mentalisation-Based Approaches

Mentalisation-based interventions include mentalisation-based skills training. Mentalisation is the process of understanding the mental states behind your own or someone else’s actions. People with BPD often lack mentalisation skills, leading to strong emotional reactions and impulsive behaviours.

Mentalisation-based programs for families teach mentalisation (and other) skills that help family members manage interpersonal and emotional crises. Specific mentalisation-based interventions may be delivered from families to families, encouraging a sense of acceptance and mutual understanding in place of hopelessness and isolation. There may also be space for families to speak openly and freely about the difficulties they face.

Family Psychoeducation

Family interventions for BPD may include psychoeducational approaches. Family psychoeducation programs typically offer information about mental health disorders and how families can access different forms of support.

However, some research suggests that standard psychoeducation programs may be counter-productive for families of people with BPD, causing greater distress and hostility towards the person with the disorder. This has led to the development of alternative psychoeducation programs that are proactive and focus on the future rather than analysing the causes of BPD. 

Collaborative Treatment Plans

Sometimes, families may have the opportunity to contribute to a collaborative treatment plan for a person with BPD. This process can be empowering and open up the therapeutic process to different members of the family system. A broad, collaborative treatment plan allows unhelpful behaviours of different family members to be addressed, helping to dismantle the patterns and relationships that reinforce BPD symptoms.

Why Are Family Interventions for BPD Still Relatively Uncommon?

Despite evidence that supports involving the family in treatment for BPD, family therapy and other family interventions are still uncommon in BPD treatment programs. This may be because:

• People with BPD sometimes have negative perceptions of their families and prefer not to involve them.
• Many healthcare professionals still stigmatise and discriminate against people with BPD. This means that they may choose to use the resources required for family therapy in the treatment of individuals with other mental health conditions.
• Inpatient treatment programs and experiences of hospitalisation often focus on the safety and control of self-destructive behaviours. People with BPD can find themselves in a restricted and controlled environment with limited contact with friends and family.

Encouraging Research into Family Interventions

While there are some clinical studies investigating the effectiveness of family interventions for people with BPD, randomised controlled trials are still lacking. There is preliminary evidence to support the effectiveness of several different approaches – including DBT-family skills training and family psychoeducation – but more research is required to confirm and clarify their benefits. 

Given the promise of family-based interventions for people with BPD, further research is important to enable and encourage the widespread application of these approaches, moving towards more effective treatment and, consequently, a better quality of life for people with BPD.