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Advances in Interventions for Families with a Relative with a Personality Disorder Diagnosis Perry D. Hoffman, PhD, and Alan E. Fruzzetti, PhD and Harvey [4] found that these family members report Perry D. Hoffman, PhDPresident, NEA-BPD, 734 East Boston Post Road, Mamaroneck, higher levels of psychological distress compared with community norms. However, the challenges facing family members of the mentally ill are of such magnitude that Current Psychiatry Reports 2007, 9:68–73
they often deplete the family members' capacity to cope Current Medicine Group LLC ISSN 1523-3812 effectively, compromising their health and life agenda. Copyright 2007 by Current Medicine Group LLC Families cannot do it alone. Thus, it is essential to develop and disseminate accessible programs that help family members reduce their stress, distress, and burden (while Considerable research has demonstrated the important increasing education and effectiveness), both as a means role that families play in the trajectory of recovery when to help disordered family members recover (and to prevent partners or children have Axis I disorders, and that fami- relapse) and as an end in itself for family members.
lies need help, given the impact of a family member's This paper will describe family psychoeducation mental illness on them. These factors have spurred the (FPE) and family education (FE) programs that have been development of a variety of programs and interventions shown to be useful for families when they have a member for families of people with Axis I disorders, but pro- with any one of a variety of Axis I psychiatric disorders, grams for family members of people with personality and then provide more detailed descriptions of programs disorders (PDs) are few. This is surprising given research developed specifically for families with a relative with a that has demonstrated the important role of families in personality disorder (PD). Because the vast majority of the course of illness in borderline personality disorder work with families and PD has been developed with bor­ (BPD) in particular and the emerging evidence of the derline personality disorder (BPD), we will focus on BPD salutary effects of family involvement in treatment for family programs.
BPD. Thus, although some advances have been made in working with families in which a member has a PD, this field is well behind other disorders. Despite the Intervention Programs slow start, several programs have been developed for There are a variety of approaches to family intervention families with BPD; they are described, along with data that are relevant when a family member has a serious supporting their utility.
psychological or psychiatric disorder. Of course, a variety of family therapy approaches may be very use­ ful when they are available. However, our focus will Regardless of diagnosis, families always have been the be on more programmatic approaches, especially those first line of care for their mentally ill relatives, and this that may be offered in groups and/or efficiently dissemi­has presented modern challenges since the mandate of nated. The reasons for this focus are that families often deinstitutionalization in the 1960s [1]. Viewed as neces­ have enormous difficulties gaining access to services in sary resources, family members have assumed multiple general, and finding family therapists who are knowl­roles (eg, advocate, caregiver, confidant, coach, guard­ edgeable about the specific disorders in their family and ian) for their relatives. However, these roles do not come that are affordable can be a challenge. There also may without a price. It has long been recognized that family be certain advantages to groups with common connec­members run the risk of developing psychiatric problems tions, which we will note. Thus, first we will discuss themselves [2]. Data document that stress from having these types of family interventions in general and then a relative with mental illness is associated with burden, go on to describe interventions developed specifically for depression, grief, and isolation [3]. Similarly, Winefield families with a relative with a PD.
Family Programs for Personality Disorders Hoffman and Fruzzetti 69 and 3) the clinician perception that family member­clini­ The intervention modality for families of people with men­ cian contact would not provide significant benefits [24].
tal illness that has been most researched is FPE [5,6••].
FPE is provided by many different types of professionals FE
as an adjunct to the identified patient's treatment. Early Some family member concerns, in particular a lack of
FPE interventions focused primarily on family member program dissemination and lack of focus on family mem­
change in order to improve patient functioning [7]. Since ber well­being, are now being addressed in a nonclinical
the initial studies in the 1970s documenting the value of (ie, groups led by trained family members, not clinicians),
FPE [8], more than 30 randomized clinical trials have community­based adaptation of FPE called FE [25].
demonstrated that FPE is effective in reducing relapse Unlike FPE, which is often seen as a treatment interven­
rates. In fact, empirical research supports FPE as the most tion targeting family member pathology, FE is more often
successful family intervention for schizophrenia [5]. The promoted and experienced as an education and support
FPE model also has been adapted to serve other diagnoses intervention for families. Although it shares the same
such as bipolar disorder [9] and major depression [10,11].
strategies as FPE (education, learning effective coping FPE is grounded in the psychosocial construct of skills, and social support from the group), the primary expressed emotion (EE) [12]. After administering a semi­ targets of FE are the needs of the family members them­ structured interview to a family member, an expert rates selves, not the patient per se. Other differences between hostility, emotional overinvolvement (EOI), and criticality FPE and FE include the following: 1) family member based on comments family members make about their ill leadership versus professional (clinical) leadership; 2) no relative. High EE scores are documented to predict patient treatment requirement for the patient (thus, FE may also relapse in general [13]. Thus, the central goal in FPE since its serve family members with ill relatives who are not in inception has been to reduce the level of EE in family mem­ treatment; and 3) shorter course duration (eg, 12 weeks is bers in order to improve outcomes for the identified patient.
typical for FE, as opposed to the 9­ to 36­month duration The centerpiece of FPE is information and education of FPE programs). Data on FE show encouraging family on the targeted psychiatric disorder. However, research member outcomes [22,26,27].
has shown that illness knowledge alone is not enough to produce positive results [14,15]. Therefore, the course Theorycurriculum also includes teaching skills to families so Rather than EE underpinnings focusing on family mem­they may modify their attitudes and behavior toward bers' problematic attitudes and putative weaknesses the patient. Typically conducted in a multifamily group or pathology, the FE model builds on theories of stress serving six to eight families, it also has a social support reduction, coping, and support [20]. In this model, component that participants highly value.
because there is no presumption of family pathology, the Since its inception, the model has increasingly expanded focus is on the participating family member's capabilities, its focus to consider family member well­being, as well as the development of coping skills and strategies to enhance patient outcomes [16,17]. With the model encompassing a the family member's own well­being, and the effective competence­based approach that promotes increased capa­ management of mental illness in the family, as well as bilities, coping, and support for family members [18], data basic education about the patient's disorder. Of note is show improved family member well­being is associated with that lower levels of family member coping and a lack of coping styles that foster mastery and social support. These social support account for more feelings of burden than findings are consistently associated with lower burden, dis­ the stressors associated with the ill relative's disorder. In tress, and isolation for families. A review of 43 empirical addition, coping behavior, when assessed as a mediator, studies showed that psychoeducation interventions led to significantly affected the explanatory power of symptoms a decrease in burden and an increase in functioning and per se in predicting outcomes [25].
enhanced coping strategies, as well as improvement in fam­ily member mental health [19].
Description of FE programs Despite the documented value of FPE programs, Most FE programs, conducted by trained family members, only approximately 10% of families dealing with men­ last about 12 weeks, typically meeting once per week. tal illness participate in these programs [20]. This small Generally provided in group format, the meetings are held percentage may be due to the number of "requisite clini­ most often in the community, independent of the mental cians, resources, time and reimbursement requirements," health system. Typically, family members have relatives [21] clinicians' lack of expertise in working with families, with a variety of Axis I diagnoses, and time is devoted to and/or the required program length, which may last up to each disorder.
2 years [22]. Further interfering with broad participation The most broadly disseminated and well­known are three additional factors: 1) possible implicit blame of FE model is the family­to­family program (FTF) of the families associated with the EE theory, 2) the fact that National Alliance on Mental Illness [22]. Structured family member well­being is only of secondary focus [23], around a highly scripted manual, the series provides 70 Personality Disorders information on schizophrenia, bipolar disorder, major family psychoeducational approaches for schizophrenia. depressive disorder, panic disorder, and obsessive­ The intervention program has a joining phase and a mul­ compulsive disorder, with emphasis on treatment, tifamily group phase. In the joining phase, the diagnosis medication, and rehabilitation. The receptivity to FTF of BPD is explained to the family members without the has been high, with more than 100,000 participants in patient in attendance. The joining phase also allows for 45 states across the country. Although FTF is in its infancy the therapists to build an alliance with the family mem­in comparison to FPE, its availability and popularity are bers and to invite them to participate in the multifamily increasing, and at its current rate of availability, partici­ group. The multifamily group involves four to seven pation may surpass that of the FPE.
families, and the sessions focus on developing effective problem­solving approaches to common family concerns regarding their relatives with BPD.
FPE and Intervention for Families of People Hoffman/New York Hospital program (DBT-family
Although people with BPD typically have co­occurring skills training [DBT-FST])
Axis I disorders, the essence of their difficulties and the Hoffman et al. [33] developed a family treatment approach
associated problems that their families encounter are not based on DBT called DBT­FST. This approach stresses the
really addressed in traditional FPE or FE. Thus, clinicians importance of education, skill development, and environ­
who work predominantly with people with BPD (the most mental change. Specifically, the program attempts to have
common PD) and their families have developed specialized family members interrupt the cycle of invalidation that
family intervention programs. Few family programs of any may play a role in maintaining the borderline disorder
kind for other PDs have been reported and evaluated.
in their affected relative [34]. DBT­FST is based on the In contrast, there have been three manualized FPE concept of EE in family members of borderline patients, programs for BPD described in the literature. One pro­ in which research has documented that in these families gram, designed and conducted by Gunderson et al. [28] with BPD, EOI with the BPD relative had positive effects at McLean Hospital in Belmont, Massachusetts, is based longitudinally [35]. This finding is in contrast with find­on the work of McFarlane et al. [16] but has been adapted ings in families of patients with schizophrenia and other and extended to BPD families. The second program, dia­ Axis I disorders (in which higher EOI predicted poorer lectical behavior therapy (DBT)­family skills training, long­term functioning [13]) and suggests that borderline designed by Dr. Perry D. Hoffman and colleagues at New patients need the involvement of family as long as emo­York Presbyterian Hospital in White Plains, New York tional validation accompanies any criticism or hostility.
(in consultation with Dr. Alan E. Fruzzetti), is based on DBT­FST is an intervention that includes the patient Linehan's [29,30] DBT. The third program is the work and his or her family members in a group that meets of Fruzzetti [31••] and colleagues at the University of weekly for approximately 6 months. The sessions are Nevada. Interestingly, despite encouraging pilot data, organized into two parts: The first part is a didactic ses­dissemination of these programs also has been modest, sion focusing on skill development, and in the second perhaps for reasons similar to those that have limited dis­ part, the group applies the skills using Linehan's dialectic semination of FPE programs for Axis I disorders as noted concept of balancing acceptance with change.
previously. In the following sections, each of these pro­ Several other DBT programs have taught the indi­ grams will be described.
vidual DBT skills to family members [36], providing a variant of DBT­FST, or added traditional family therapy components to ongoing DBT for adolescents [37], high­ Family interventions for BPD, in many ways, have been bor­ lighting the need for more family involvement in treatment rowed and adapted from the psychoeducational approaches of severe PDs.
that were developed for schizophrenia [28]. For example,
high negative emotional expression (ie, criticality, hostility, Fruzzetti/University of Nevada, Reno program
and EOI) in the relatives of patients with schizophrenia has (DBT with couples and families)
been found to be related to poorer patient outcomes [13]. This family program was developed as an integral part of
The need for psychoeducational programs for families of a standard outpatient DBT treatment program [29,30,38].
patients with PDs was also related to the fact that generally, Recognizing the utility of having patients and family
families were ill informed about PD diagnoses, although members learning complementary skills and using simi­
they may have been informed about the current clinical lar language, this family intervention program includes a
disorder [32]. Gunderson and Hoffman [32] found that core FPE component that may be delivered to individual
families identified three major problem areas: problems families or in groups and may include the patient with
with communication, anger, and suicidality.
family members or include only family members of the With these in mind, Gunderson et al. [28] developed patient. Certain core skills from individual DBT [30] are an intervention for families of patients with BPD based on included, such as mindfulness and components of emotion Family Programs for Personality Disorders Hoffman and Fruzzetti 71 regulation. In addition, family skills such as relationship about family functioning); 2) individual and family skills, mindfulness, accurate expression, validation, problem to manage their own negative reactions and those of their management, and closeness skills (for couples) and par­ family members and to build better and more satisfying enting skills (for parents) are included [31••,39,40].
relationships; and 3) social support, from other group These skills are based on a transactional, or bioso­ members who have lived through similar experiences.
cial, model of the development and maintenance of BPD To date, most FC programs have been led by family [34]. This model suggests that individuals bring certain members, although some clinicians also offer the same vulnerabilities to reacting with negative emotion to curriculum. Thus, community FC is more similar to various situations and that these vulnerabilities may be FE programs, whereas clinic FC has more in common temperamental (biological) or learned over time. A per­ with FPE programs. Either way, the curriculum includes son with these vulnerabilities is then at greater risk when the following modules: 1) introduction and orientation living in an "invalidating" family environment in which (goals and guidelines for the group, overview of the his or her private experiences, such as emotions, wants, program, and introduction); 2) FE (eg, understanding and beliefs, are not understood by others and are criti­ BPD, research on treatments); 3) relationship mindful­ cized, ridiculed, or simply misunderstood and ignored ness skills (describing a "validating family environment" (all forms of invalidation). Therefore, invalidation can and the role of mindfulness of others in increasing take many forms, ranging from harsh, critical, and judg­ understanding, managing negative emotions, and reduc­ mental to well­intentioned but terribly mismatched or ing invalidating responses); 4) family environment skills not understanding. The theory thus suggests that helping (understanding reciprocity in relationships and how people find ways to express their experiences accurately individual and family well­being are interdependent); and skillfully will make it easier for others to validate, 5) validation skills (what to validate and how to do it); and that being validated in turn makes it easier to iden­ and 6) problem management skills (how to use all the tify important emotions and wants and to express them previous skills to choose whether to accept a situation accurately. The skills in DBT with couples and families or problem or to try to change it, and how to engage are built around this particular transaction [31••].
effectively in collaborative change in a family).
The format of the program may vary. For example: Each group has a teaching component, a practice and 1) If sufficient numbers of couples are available, a couples discussion component, and a support component, all built group may be offered (Fruzzetti and Mosco, Unpublished around handouts developed for each module. Group lead­data); 2) if many parents of adolescents or young adults ers, whether they are family members or professionals, go are in need of services, a parent group may be appropri­ through extensive training in delivering the FC education ate; 3) a mixed­constellation family group can be provided and skills components and in managing the group, and all (similar to FST, previously described); or 4) skills can be participants complete assessments before they begin the taught in ongoing family therapy. In addition to skill train­ program, after its completion, and at a follow­up several ing, ongoing individual family sessions (couples therapy months later.
or family therapy) typically are provided. This provides Two studies about the effectiveness of FC have valuable opportunities for assessment and intervention, been conducted [6••,43•]. In both studies, participants especially around key targets such as suicidal behavior, reported significant improvements (reductions) in subjec­self­injury, aggression, and drug use [40,41•].
tive burden, objective burden, and grief, with significant Recent studies suggest that this approach may be improvements (increases) in empowerment and mastery. effective with couples (Fruzzetti and Mosco, Unpublished In all cases, improvements were enhanced or maintained data), with parents of adolescents with significant BPD at the time of the follow­up evaluation. In addition, in features [42], and as an adjunct to augment outcomes for the second study, participants also reported significant individuals with BPD in standard DBT [31••].
improvements in depression. Further research is needed to determine whether all components are contributing to these improvements (ie, education, skills, and group sup­ Family Connections (FC) Program port) or if there is differential contribution to outcome. As noted, the dissemination of family interventions such Regardless, FC is a promising program that is now avail­as FPE for BPD has been slow. In order to provide access able in more than a dozen states, in Canada, and in sev­to many more families, a family education version of DBT eral European countries.
with families called FC was developed by the authors within the National Education Alliance for Borderline Personality Disorder [6••]. The FC program was designed What More Is Neededfor family members of individuals with BPD, and only The prevalence of BPD alone hovers around 1% of the family members attend.
population, and considerably more than one half of The FC program was designed to meet three different these individuals engage in suicidal and self­injurious needs of family members: 1) education (about BPD and behavior [44]. These are severely disordered individuals 72 Personality Disorders whose problems can be very stressful for family mem­ bers. In addition, family members can act in ways that Neither of the authors has a possible conflict of interest, help or exacerbate the emotional difficulties that people financial or otherwise.
with BPD have. However, despite the advances noted previously, the vast majority of these families still do not have access to any specialized services, much less References and Recommended Readingevidence­based services, if they have a family member Papers of particular interest, published recently, with a severe PD.
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