Carer 101

What can families/friends/supporters/carers do to help

101

Carer 101

During times of extreme stress, people with borderline personality disorder (BPD) may become overwhelmed. They may want something from us …but may not actually know what they need. Sometimes the only way they know how to communicate their ‘need’ is by becoming agitated. This is frequently expressed as anger/rage (externalising) or as withdrawal, self-hatred and potentially self-harming behaviours (internalising).

Often the person is trying to feel heard, to feel understood, or is struggling to make sense of their experience and/or intense emotions and feels like no one truly understands them. Their stress levels may be so high that they are unable to think or act logically no matter how obvious a solution may seem to others.

What can we do to help?

Stay calm and compassionate

People with BPD, when distressed, may often try to off-load some of their overwhelming emotions onto others, particularly people who they feel closest to. This emotional offloading may cause further distress for the person with BPD, as they fear their emotions may be too much and it will push others away. If we respond to someone in distress by blaming, problem solving, or becoming distressed ourselves, their feelings of not being heard or understood can become even more overwhelming.

Try to avoid becoming defensive about what you believe is not true or valid

If the person is accusing or blaming you, admit to what is true, or acknowledge that they are speaking the truth as they see it at that moment. Arguing and justifying your position will only compound the issue.

Acknowledge their distress

Whilst you do not need to agree with or feel that their behaviour is appropriate, it is essential to acknowledge that the distress they are feeling in very real for them. Actively listen to what they are saying, often the meaning behind the words. Focus on their feelings instead of reacting to their accusations/words. Be receptive rather than reactive. 

Some ways to tell if you are hearing and understanding correctly is to ask “I am not sure if I understood you properly and I need some help here.” “Do you mean………?” or “I notice that………… Is that how it feels for you?” 

Adopting an approach of caring curiosity with a genuine interest in supporting the person will help support them in their struggle.

It’s OK to take time out

You may need time to consider what has been said before responding. Shifting the focus is sometimes helpful (e.g., moving outside, or asking if the person would like a cup of tea). IMPORTANT: The focus needs to stay on the other person and their needs, not on the doing or fixing.

When both of you are upset, it is exceedingly difficult to be calm and things are often said that may be best left unsaid. It is often unhelpful to continue the conversation at this time. Explain that you need some time to consider what has been said and that you will hang up the phone / leave the room / go for a walk / drive around the block and call them or be back in 5-10 minutes. Encourage the person with BPD to use some strategies to soothe themselves whilst you are gone. Make sure that you are back or phone within the time frame you state, otherwise you risk inadvertently reinforcing the person’s concept of abandonment and untrustworthiness.

Have your own support person you can contact.

You are also likely to be feeling quite distressed and uncertain about what may happen in your absence. (You may be afraid that the person may self-harm as a way to manage their distress.) It may be helpful for you to have a support person you can contact to help you to debrief, and to support you; maybe to provide a place for you to stay if it becomes necessary.

It is extremely helpful to have your own therapist/counsellor to support you as you work through some of the challenges and assist you to develop helpful strategies and new skills to support the person with BPD.

Develop a plan

For you: Learn strategies to calm yourself in times of stress. Deep breathing, count backwards, visualisation…whatever works best. This will assist you to continue to engage, in a more supportive way, with the person as you promised.

For the person living with BPD: The safety and/or crisis plan is a living document and needs to be reviewed when things are calm, preferably with the person themselves, a mental health professional/s, the person’s main (and extended) support network. This should include discussion about helpful (and unhelpful) ways for carers to react to certain situations. The plan needs to be dynamic in nature, clearly describing how the plan can be implemented and what is expected of all family members.

Speak with others in the person’s support network about common situations that cause the person distress. This will help them to understand what is happening for the person with BPD, and how they can respond in supportive ways.

Be consistent

If you have previously agreed to some boundaries, be consistent and kind when enforcing them. Remember that during a crisis is not a good time to make a new boundary. Remember, too, that boundaries refer to your own behaviours, what you can/cannot do or tolerate. Healthy boundaries are essential for healthy relationships. Be mindful not to use boundaries as a punishment, as this increases the difficulty of distinguishing between healthy and unhealthy boundaries.  

Self-care

Similar to the pre-flight video we see before take-off, we need to care for ourselves to be able to care for others. Making sure we get enough sleep, exercise, nutrition, and time to engage in activities we enjoy, helps us to remain as calm and as focused as possible during times of stress. This improves our ability to manage difficult situations and decreases feelings of resentment and burnout.

Sometimes, no matter how hard we try, we may get emotionally involved in the crisis and respond in an unhelpful way. If this happens, acknowledge to yourself that you’re doing the best you can at this particular time. As challenging as it may seem there is always the possibility, when things are calm again to open a discussion acknowledging that it appears something you said or did was distressing for the other person and explore together what would have been more helpful at the time.

What to do in a crisis

During a crisis, the involvement of police or ambulance services may increase the person's distress and should preferably be avoided.

First try using de-escalation techniques, such as:

  • RESPECT: personal space, ask permission before approaching/touching.
  • LISTEN: give your full attention and be curious as to what is happening for them, avoid changing the subject or interrupting.
  • VALIDATE: the person's emotions (not behaviours), noting their verbal and non-verbal cues.
  • EMPATHISE: offer genuine concern and a willingness to understand without judging.
  • TONE: speak calmly and slowly to demonstrate empathy.

Keeping safe

Keeping safe and staying safe is an essential right for everyone.

When faced with verbal and/or physical violence, reinforce with the person that you can see they are distressed/angry/upset, and that it is not OK to yell, be violent, to be threatened (or threaten others) or to damage property. Be prepared to (calmly) stand your ground and maintain your distance if you feel unsafe. Use ‘I statements’ e.g., "I ….(can’t think/hear when you’re yelling at me) and, as we discussed, I’ll ……..(e.g., go for a walk around the block) ……… and be ……(back in 5 minutes)"

Have crisis phone numbers readily available - on your phone, on a piece of paper in the car, with a friend - so that you always have access to this information.

If the person says (or you believe) that they have taken an overdose, or engaged in other potentially lethal self-harming behaviours, phone 000. When the person has engaged in non-lethal self-harm, a decision will need to be made whether medical (or mental health) intervention is required, based on your assessment of the situation, and also considering the person’s wishes. Acknowledging and validating the person’s distress (not focusing on their actions) often helps to de-escalate the situation.

If you become concerned for your own or another’s – especially children’s – safety, leave the scene and phone 000.