Staying connected
Staying connected: for families and carers of Borderline Personality Disorder
Staying Connected for Families and Carers of Borderline Personality Disorder BPD: A family, partner and carer resource for improving relationships with people with a personality disorder.
Professor Grenyer: Hi I'm Professor Brin Grenyer and I lead the Project Air Strategy. Today you're going to see a set of powerful strategies for communicating with people you care about. Every moment of our day we're communicating to others. Some of our communications are effective and some are less effective. The best communications are those that help both you and the other person grow together, in a mature and effective way.
The following scenarios are part of a series of training and research resources developed by the Project Air Strategy for Personality Disorders at the University of Wollongong. This presentation is made in partnership with our family and carer team from the Mental Health Service.
The Project Air Strategy begins with a simple relationship model. Relationships are at the core of our mental health, particularly for people who have a personality disorder or related emotional problems. Our goal is to improve key relationships for people with these emotional problems - with their carers, partners, families, and colleagues, with the Health Service, and the clinicians who offer their help, and with themselves. To value yourself first is the basis of being able to value, and get on well with others.
Dr Bickerton: I'm Dr Anne-Marie Bickerton and I'm a psychiatrist working with the Family and Carer Mental Health Program in South East Sydney and the Illawarra Shoalhaven. Research has shown that it's essential that we involve families and carers when we are working with someone with a personality disorder.
Today, you will learn about strategies a carer can use to help someone with a personality disorder, especially when they are in distress. When our loved ones are feeling good, we are feeling good. When those around us are hurting, we are hurting too. So, as human beings we are often contagious with our emotions.
People with a personality disorder are very sensitive in relationships. They tend to react with very strong emotions to changes in relationships. This makes it tough for them, but also tough for those close to them. Someone with a personality disorder may feel so overwhelmed with their own feelings they push them out of themselves and onto someone close to them. Clinicians call this projection, but you might describe this person as contagious in their anger, rage and hopelessness. Someone with a personality disorder may also invite others to take responsibility for their problems. Families and carers have sometimes talked of walking on eggshells, with our constantly fearful of triggering explosions or distress.
We have developed five key relationship strategies to assist carers. Firstly, care for yourself to care for others, be contagious, with calm, draw your line in the sand, listen without fixing and finally, develop a safety plan, like a fire drill.
We will begin with a series of scenarios we call the four carer dances. These interactions can happen in all relationships, but especially for carers of someone with a personality disorder.
Let's now meet Mandy and Jill who will demonstrate the four carer dances. Mandy is a 24 year old university student with a long standing history of emotional and relationship challenges. She was diagnosed with a personality disorder at 19. Jill is a 47 year old personal assistant. She is Mandy’s mum and her primary carer. Their characters are based on the everyday struggles of families we have worked with. In the four carer dances scenes you will see how Jill's different approaches impact on Mandy's ability to manage her distress.
Dance 1: The too too bossy carer
Phone rings: “Where are you?”
“Mum, it's Lucy. She's cancelled and I've……”
“Where are you?”
“I even told you this morning I'm at the cinemas. The film starts in 20 minutes. I need you to come here now”
“You haven't already bought the tickets?”
“I had to”
“How many times have I told you about wasting money? I told you that Lucy was unreliable. I can't believe you went and bought those tickets again”
“Mum, you're always criticizing me. Just come up here!”
“I criticize you because you deserve it. I try to teach you but you just never listen. Now you take that ticket back to the salesperson and you return it, otherwise call Lucy and get her to pay. You’ve just totally wasted our money. Just throw it away. Again!”
(cross conversation – hang up)
Dance 2: The too too busy carer
Phone rings: “Who is it?”
“Mum, it's Lucy, she's cancelled and I've already brought our tickets. I need you to come here now.”
“I've had such a terrible day. The other secretary has been (cross conversation) and now she's called in and she needs another three days off. I think she's going off to Fiji with her new boyfriend and now I've got to do all her work (cross conversation). I'm already so busy!”
“(crying)Lucy hates me. Everybody hates me”
“(cross conversation) Thank god I've got this one who needs a new house. She's always good for a laugh. (cross conversation). It's nearly 6 o'clock. I'm sorry darling, I've gotta go. Bye”
Dance 3: The too too kind carer
Phone rings: “Darling, are you okay? Are you still at the movies? Is everything all right?”
“Mum, it's Lucy, she's cancelled and I've already brought our tickets. She just let me down mum”
“I'm so sorry. When I knew you're going to the movies with Lucy I was worried she'd stand you up. I'll be there straightaway.”
“Mum, you're not listening. It's not your fault. I'm just upset about Lucy”
“I’ll call Auntie Pat and I'll tell her that I can't make it out for dinner. It's all my fault.”
“Mum, it's not your fault! I don't want you here (cross conversation)
“She is always letting you down”
“You make me so angry. You never listen. Just forget about it!”
Dance 4: The good enough carer
Phone rings: “Hello.”
“Mum, it's Lucy, she's cancelled and I've already brought our tickets.”
“Hello darling. You sound upset. You still gonna go and see a film tonight?”
“Well that's the problem, Lucy cancelled and I've already paid for the tickets.”
“Well that is disappointing.”
“I'm angry cuz she's done this before. I don't trust her. I feel like everyone hates me. Please can you come to the movies with me?”
“I can hear you're upset but you and Lucy, you've had your ups and downs, and you've told me what a good friend she's been to you.“
“She has been a good friend. I'm just disappointed. Can you please come with me?”
“Mandy, it's Tuesday night. You know that's when I go down to the club with Auntie Pat and have dinner. You're welcome to join us.”
“But I've already paid for the tickets.”
“Well, you've still got time to make the best decision for yourself. How about you get back to me in ten minutes and tell me what you'd like to do?”
“Mum, I still want to see the film. I think I'll ask them to refund one of my tickets and I'll just go in anyway.”
“That's a great idea Mandy. That's a great plan. Well you enjoy the film and I'll see you and get home tonight.”
Reflecting on the Four Carer Dances
Dr Bickerton: Parenting research looks at two key components - firmness and control, connection and warmth. Each of the four carer dances fit within one quadrant of this grid. Let's reflect on the too too bossy carer:
“I told you that Lucy was unreliable. I can’t believe you went and bought those tickets!”
“Mum, you're always criticizing me. Just come up here!”
“I criticize you, because you deserve it. I try to teach you but you just never listen.”
Dr Bickerton: The two too bossy carer has an ‘I know it all’ approach. They are stressed and unable to listen. They try to help by fixing and impose their values and beliefs on others. They leave no space for the person with a personality disorder to think for themselves. This carer does everything to the person.
Let's reflect on the too too busy carer:
“I’ve go to do all her work and I'm already so busy”
“Lucy hates me”
(cross conversation) “Thank God she's always good for a laugh. I know be shouting Saturday night.”
Dr Bickerton: The too too busy carer takes an ‘it's all about me approach’. They are preoccupied with their own issues and their stress is contagious. They are unable to listen. They have no room to consider the needs of the person with the personality disorder. This carer does nothing for the person.
Let's reflect on the too too kind carer:
“I’m so sorry. When I knew you're going to the movies with Lucy I was worried she'd stand you up. I'll be there straightaway”
“Mum, you're not listening. It's not your fault. I'm just upset about Lucy.”
Dr Bickerton: The too too kind carer can't say no, and takes an ‘it's all my fault’ approach. They are contagious with stress and unable to listen. They care for others before themselves. They help by fixing but give up their beliefs and values to please others. They leave no space for the person with a personality disorder to think for themselves. This carer does everything for the person.
Let's reflect on the good enough carer:
“Well, you've still got time to make the best decision for yourself. How about you get back to me in ten minutes and tell me what you'd like to do?”
Dr Bickerton: The good enough carer has an, ‘I believe in you’ approach. They demonstrate the first four key relationship strategies. They balance self-care with caring for others. They are contagious with their calm. They draw their line in the sand, and stay true to their beliefs and values. They listen without fixing. They encourage the person with the personality disorder to think for themselves. This carer does everything with the person.
Relationships as a dance
Conceptualizing relationships as a dance has been a helpful way to think about ourselves in our relationships. Humans are creatures of habit - we tend to dance the same steps over and over, with little time to stand back and think about what's most helpful. Worry and fear can drive us to take up certain steps, but if worry and fear take over our relationships we stop thinking and start reacting, like a knee-jerk. These reactive steps may be helpful in the short term but cause their own problems in the longer term. As humans, we are good at seeing the other person's steps but not as good at looking at our own part. We can't change other people, but by working on our own behaviour we can change our steps, and influence those close to us. By observing the dance steps we begin to understand the part we play in our relationships.
This framework allows families to be kinder and less judgmental to themselves, and to the person with a personality disorder. Families recognise that their intentions are good, however new ways of relating may bring better outcomes.
Safety planning – Like a fire drill
People with a personality disorder often become overwhelmed with distress. Planning together in times of calm, with the help of professionals if needed, equips you to be most helpful in a situation of distress.
I would now like to introduce to you the fifth key relationship strategy - safety planning. Like a fire drill, keeping safe is the essential right of everyone, and all five key relationship strategies are essential. We will now see Mandy and Jill in some very difficult situations. In each scenario Jill uses the good enough carer approach.
The good enough carer responds for safety: Contagious anger
“Mandy, Is that you? I'm in the kitchen”
“I’m gonna kill him Mum, I'm gonna kill Jack. I can't believe he said he wouldn't go out for dinner. He promised. We had a fight. He’s with his ex-girlfriend. I said it was over and he said fine. Then I tried to ring him but he won't answer. I hate him. Don’t just sit there - this is all your fault! You should have told me to stay at home. I hate you. This is all your fault and I hate you!”
“Mandy I can see you're very upset.”
“Of course I am very upset. He’s needy and so are you! Nobody understands me. You all hate me!”
“I'm very sorry to see you so distressed, but it's not okay for you to talk to me like that and to throw things around when you're angry.”
“Well it's not my fault!”
“Mandy, it's not helpful for us to be together now. I'm gonna leave you so you can think about how you can use your strategies to calm yourself down. I'm going to go for a short walk and think about how things got like this”
“That's right, you just want to leave me!”
“I will call you in 10 minutes, just as we agreed.”
“Don’t go mum”
“Mandy, I'll call you in 10 minutes.”
(Crying)
“Hi Aunty Pat. Have you got a moment? Oh it's Mandy, she's really gone off. She's so angry.” “Yeah, I'm following the safety plan.” “Yeah, she's safe and she seems to be coming down. I'm a bit shaken though. I'm okay…. Yeah, I'll give her a call back in ten minutes and see how she's doing.” “Yeah, I'm following the safety plan. The doctor said that as an act of love that we should call the police, just to keep us both safe. I'll do it this time if I have to. Can I stay overnight if I need to? I'll call you back later and let you know how we've gone. Thanks for supporting me.”
The good enough carer responds for safety: Non-suicidal self injury
“Is that you Mandy? I'm in the kitchen. Do you want a cuppa?”
“Mum, Jack left me. He's an idiot. I hate him. I said I didn't love him and to go away. He wouldn't even answer my calls!”
“Oh Mandy, I'm so sorry. You look upset. Why don't you sit down for a minute?”
“I pushed someone good away, but he made me scared when he talked about his ex-girlfriend. I'm um, I'm angry with myself cause I did it again.”
“What did you do Mandy? Do you mean you cut again?”
“Yes, I thought I'd stopped but I did it and all that work with my psychologist was nothing.”
“Mandy, I remember when the psychologist told us that in tough times things like the cutting might come back, said it often happens when things get too big. Why don't you try and use some of those skills you and your psychologist talked about?”
“Yeah”
“Are you feeling like you're still what a harm yourself for can you keep safe?”
“I’m feeling a bit better now, I just felt so bad and I hate myself for doing it again!”
“Remember what they said - a cut is just a cut. You don't have to panic. You're safe now. What do we need to do about your arm?”
“Mum, it's not deep like the last time - just a Band-Aid. I'll go to the bathroom and I'll talk to my counsellor on Monday.”
“Okay. While you're in there why don't you have a nice warm bath? You told me how that makes you feel better.”
“Thanks mum, I will have a bath. What activity/movie have you got?”
“Oh haven't watched it yet. Do you want me to wait for you till you finish your bath? I’ll make another cuppa and I've got a few more chocolates left over from Aunty Pat.”
“It sounds great mum. I hope he rings me.”
The good enough carer responds for safety: Life threatening self harm
“Mandy, is that you? I'm in the kitchen”
“Mum it's over with Jack. He won't ring me”
“Oh Mandy, you don't look well”
“I hate him. I shouldn’t have trusted him. I just wanna die. Let me die Mum. I just wanna die!”
“Oh, you told me how much you liked Jack”
“I did it again”
“What did you do Mandy?”
“I cut myself. I did it again”
“Well sweetie, you've been trying so hard. The psychologist said that if you come up against a really hard situation the cutting could come back. It’s more than the cutting. You don't look well.”
“I took something, um, tablets.”
“I’m really pleased you told me. Just like we said with the counsellor, what tablets and how many?”
“Panadol. I didn't mean to take the tablets. I got them myself. I just felt so bad so I stopped at the chemist up the road. I just took them. I wanted to die Mum. I feel really sick. I just wanted to die Mum. I'm scared Mum”
“Well, I'm really pleased you told me Mandy. I'm just remembering what the doctor told us, what we had to do next. Do you remember? He wrote it down in the safety plan?”
“I don’t want to go to the hospital Mum. Oh, I feel sick”
“The doctor was very clear. I need to keep you safe and you're going to need treatment. I know you'll get back on track, just as you've done before.”
“Mum”
“I'm gonna call the ambulance and I'll get you a card”
“Will you come to the hospital with me Mum?”
“If it helps, of course. It's gonna be okay”
(crying)
Dr Bickerton: In these scenes the good enough carer always uses the five key relationship
Strategies. These five strategies ensure that safety comes first. People with a personality disorder often become overwhelmed with distress. They can sometimes seek a quick fix to escape the distress. Their solutions may include dumping their distress, withdrawing from others or using coping mechanisms which may be self-destructive. Typical self-destructive mechanisms include cutting, burning, overdosing, binging, and vomiting. These quick fix solutions often provide immediate relief but create serious problems of their own. This will include compromising the safety of themselves, or others.
When carers use the five key relationship strategies safety always comes first. It is important to distinguish between life-threatening situations that may need emergency services, versus situations where you could invite the person with a personality disorder to take responsibility. We also remind carers that it's an act of love to call emergency services, if needed, to keep everyone safe.
A few years later, our characters Mandy and Jill are individually interviewed. Here they tell us about their personal journey and how the five key strategies supported Mandy and Jill in times of distress. Both characters now feel empowered and confident to manage situations that arise in their daily lives.
Jill: It's been a long road - nearly 10 years - for such a long time I have been so alone and nobody told me what to do. My whole life narrowed down to Mandy's problems. I lived in constant fear and worry. I feel like I was walking on eggshells, waiting for the next crisis in the air. So I lost weight and I got down, and sometimes I thought Mandy or I would be better off dead - only briefly.
When Mandy's doctor and psychologist invited me to be part of Mandy's sessions, I was scared at first. I thought ‘here we go again, they’ll blame me’, but it was different. They didn't judge me or criticize me, and they told me that I was a team member on Mandy's support team, and they invited me to work with them to help Mandy on her way to her recovery. Self-harm was the scariest part. The doctor explained that the cutting helped Manny feel better but she didn't necessarily wanna die.
Working with the team to help develop the safety plans together, well that really helped. It was like a fire drill we practice when things were calm. So when a crisis flared up I knew what to do. It wasn't my responsibility to fix things. I could help by listening. And this helped Mandy take responsibility for herself. I learned that it's important to look after myself and keep my own self-care up. They talked about it like being on an aeroplane and you put your own oxygen mask on first when you've got a child on your lap. In the tough times I pictured that oxygen mask and it reminds me to look after myself.
I can see a future for us both. I know we'll have our ups and downs but I think it looks good.”
Mandy: It's hard, you know, having a personality disorder. It helps when I knew what it was. I trusted the psychologist and doctor, because when we talked about it I could tell they knew what they're dealing with. I've been doing the treatment, learning skills the past two years. It wasn't easy and it took time and practice. It's good when we got mum involved. When I first got sick I would push mum away. I know I dumped my anger on mum, but it was like the hospital could see it was all true. It helps when they could say that mum is the most important person to me. I worried at times about mum. She's by herself and I was scared my distress will break her. My mum started to see my counselling team and doctor and got her own help. It really helped me.
I was angry when Mum first start saying no. At first I felt rejected but then I started to see that I could make good decisions and take responsibility back for my own life. Somehow it helped when my mum start saying no and caring for herself too. I can see hope now. Don't get me wrong, I still find things hard, but I just don't take it to heart. I've learned to cope - surfing the wave of distress is better. My mum is calm. It helps me to think more clearly”
Core messages
Professor Grenyer: We hope you enjoyed this presentation and the scenes with the characters Mandy and Jill. The core message of this presentation is that we need to work hard to improve our relationships. By using the examples shown here, and by following a few simple principles of caring - being safe, being calm, being firm, and most importantly, being open to truly listening to the other person - we can learn to grow together and hopefully have some laughter and fun along the way.