Q: In your book, you talk about an emotional whirlpool where a person with BPD is triggered by some event that’s unpleasant or scary for them. Then they struggle with a torrent of emotions, which can lead to impulsive behavior. Loved ones can feel especially helpless in these moments. What can loved ones do?
The first thing that loved ones should do is regulate their own emotions. It is so difficult to watch someone you love who is in agony and behaviorally out of control. Loved ones can become fearful, angry, judgmental, guilty, a whole gamut of emotions and thoughts. When family members regulate their own emotions, they are better able to think about how to help their loved one.
Q: What’s the difference between self-harm and suicidal behavior?
Suicidal behavior is behavior with the intention of being dead. Many people with BPD engage in behaviors that inflict physical harm that aren’t about killing themselves. Self-harm behaviors often function to bring down (relieve) painful, extreme emotions. People with BPD can have suicidal behaviors only, self-harm behaviors only or a combination of both.
Q: What should you do if your loved one is suicidal?
There are many reasons for suicidal behavior. Studies have shown that some people feel emotional relief by picturing themselves dying. Thinking, talking, planning suicide may work to relieve emotions, at least for a little while. Some people are planful about how they will kill themselves and meet all of the warning signs that are on suicide prevention websites.
However, about 30 percent of suicide attempts are impulsive, meaning that the person thought about it for just a few minutes. One problem is that people with BPD often fall into the impulsive suicide attempts. So, it is important to remember that if your loved one says that she is going to commit suicide, you have to take it seriously.
That being said, our responses to suicidal behavior can reinforce the behavior. If every time your loved one gets suicidal, you go get her, bring her to your house, feed her and tuck her into bed, you could be inadvertently reinforcing her behavior, especially if you don’t do the same thing when she is doing well.
Figuring out the reinforcers for suicidal behavior is complicated work and the consequences for being wrong can be catastrophic. If you think you are reinforcing suicidal behavior, go talk to a behavioral or cognitive behavioral therapist. Create an alternative plan with your loved one that reinforces non-suicidal behavior. If your loved one is suicidal in the moment, here are a few steps to take with him:
- It may sound strange, but the first thing to do is to tell him not to kill himself.
- Focus on tolerating the moment. Don’t drag up old issues.
- Ask what emotions your loved one is having.
- Validate his emotions and his experience.
- Ask how you can help (if you are willing to help).
- Communicate your faith in your loved one’s ability to get through the crisis.
- If you are ever in doubt, call a professional.
Q: BPD is highly treatable. But what can family or friends do if their loved one refuses to get treatment or there’s no professional in their area who treats people with BPD?
Access to effective treatment for BPD remains an issue. Twenty years ago, clinicians considered BPD untreatable and it takes time to change perception, even when we have data that say that there are effective treatments. If there is no treatment available, start a grassroots campaign with the local community mental health center, NAMI (National Alliance for the Mentally Ill) Chapter or other advocacy groups. I have encouraged people to find a cognitive-behavioral therapist in their area if there is no one who specializes in treating BPD.
If your loved one refuses to get treatment, the key is to support her and take care of yourself. Make sure you are regulating your emotions and communicating limits about what behaviors you can tolerate and which you can’t tolerate. Be supportive when possible but try not to reinforce out of control behaviors. Validate, validate, validate while encouraging your loved one to get treatment.
Often people with BPD have had negative experiences in therapy. They have been fired by therapists, gotten worse, thought they were getting worse or were left with thoughts that they cannot be helped. Have honest, nonjudgmental conversations with your loved one about her reasons for refusing treatment and problemsolve if possible.
Remember that changing behavior is often like water over rocks: gently, consistently and in a validating way, continue to encourage her to go to therapy while communicating your belief in your loved one’s ability to have a life worth living.
Finally, find help for yourself. Many Dialectical Behavior Therapy programs have Friends and Family groups. Join a support program for family members of people with BPD. NEA-BPD and TARA and the Treatment Implementation Collaborative and others have distance programs for family members that provide support while teaching family members about BPD and how to help their loved one and themselves.
Q: Anything else you’d like readers to know about BPD and what loved ones can do to help themselves and the person with BPD?
At the end of the day, compassion is effective. If you are compassionate, you will try to help your loved one without judging or condemning him. If you are compassionate, you will care for your own physical and emotional health.
When in doubt about what to do, I always ask myself what the most humane response is that I can have. Then, I do it.
(You can also read Part 1 of How to Help a Loved One with Borderline Personality Disorder.)