Borderline personality disorder (BPD) is characterized by a pervasive pattern of instability in affect regulation, impulse control, interpersonal relationships, and self-image (1,2). Community-based studies report a prevalence of 0.7 to 2.7% whereas in clinical settings the disorder concerns up to 22.4% of adults (3). Dialectical Behavioral Therapy (DBT) is one the most empirically-validated interventions for borderline personality disorder (4,5).
It is based on the principles of cognitive and behavioral therapy, dialectical thinking, and mindfulness practice. It focuses on skills training regarding distress tolerance, emotional regulation, interpersonal effectiveness and mindfulness practice (6). The DBT framework posits a developmental model of borderline personality disorder, with a focus on the role of early family interpersonal interactions (7,8). According to Marsha Linehan’s biosocial theory, BPD is defined as an emotion dysregulation disorder that develops within an invalidating social environment (7). Invalidation occurs through intolerance toward the expression of private emotional experiences, in particular when not supported by observable events (8). In DBT, interpersonal validation thus becomes a key component of psychotherapy (9).
Extending Linehan’s theory, Fruzzetti, Shenk and Hoffman elaborated a family transactional model of development and maintenance of BPD (10). In this model, the person with borderline personality disorder and their family members reinforce each other’s emotional dysregulation and problematic behaviors through invalidating transactions. The emotionally vulnerable person is more likely to behave in ways that reinforce the use of invalidating responses from the family members. In turn, invalidating responses reinforce the use of problematic behaviors from the person with BPD. It emphasizes the need for a specific work on transactions within the family system to improve emotional regulation.
Regarding the families of people with borderline personality disorder, quantitative research shows a high amount of psychological distress (11–14). Qualitative research points out daily challenges for families such as dealing with stigma and a constant feeling of threat (15,16). Moreover, this high psychological burden is associated with important financial costs (17). Relatives also report feeling insufficiently involved in institutional care and struggling to obtain clear information (18). They express their need of a better understanding of the disorder to help their loved one adequately (15,16,19,20) as well as to develop day-to day coping strategies for their own well-being (19–21).
Based on their transactional model, Fruzzetti and colleagues designed the Family Connections® program, a specific intervention for families of people with BPD. The program is also grounded in the stress and coping adaptation model by Lazarus and Folkman, where the use of coping strategies are thought to be key resources in managing stressful situations (22).
FC is a 12-week group intervention for families of people with borderline personality disorder. Its aim is to support relatives’ needs for information on the illness, develop coping strategies, and build a support network (23,24). The program is manualized and structured into six modules of two sessions each (Table 1). Emotional regulation and interpersonal validation skills are particularly emphasized (9).
Table 1
Content of the Family Connections program (23,24)
Module 1: | Current information and research on BPD |
Module 2: | The development of BPD, available treatments, comorbidity, emotion reactivity and dysregulation. |
Module 3: | Individual skills and relationship skills to promote participant emotional well-being • Emotion self-management • Mindfulness • Letting go of judgments • Decreasing vulnerability to negative emotions • Skills to decrease emotional reactivity |
Module 4: | Family skills to improve the quality of family relationships and interactions • Letting go of blame and anger, • Acceptance skills in relationships |
Module 5: | Accurate and effective self-expression: how to validate |
Module 6 | Problem management skills • Defining problems effectively, • Collaborative problem solving, |
All modules include specific practice exercises and homework (23). The program is typically delivered weekly, as a complementary intervention for families of people with borderline personality disorder. In its original format (23), it is delivered only by family members who previously attended the program and received an additional specific training. The program can also be part of an integrated framework of care in mental facilities, with the participation of professionals as co-leaders.
Two uncontrolled pre/post studies with follow up measures were first published in 2005 (n = 44) (23) and 2007 (n = 55) (24). Measures of burden, depression, grief, and mastery were chosen to enable comparison with research studies undertaken on relatives of people with other mental illness than BPD. Both studies showed a decrease in burden and grief scores after completion, and an increase in mastery. One study, led on a larger sample (24), also showed a decrease in depression symptoms.
To date, only one non-randomized controlled study on the program was published that compared the FC program (n = 51) to treatment as usual (n = 29) (25). It also showed a decrease of burden, grief, and depression, and an increase in mastery after completion. Effect of the intervention was significantly superior to the treatment-as-usual group regarding burden and grief. One study compared the traditional weekly setting (FC-S, n = 34) with a shorter setting of two full-day weekend sessions of 2 days (FC-R, n = 48) with follow-up measures (26). The authors evaluated global psychological suffering, family burden, quality of family functioning, quality of life and mindfulness skills. Global psychological suffering was similarly reduced in both groups. Regarding burden, both groups experienced a reduction over time. Quality of family functioning improved similarly in both groups. Quality of life and mindfulness skills did not increase over time.
Finally, three studies evaluated the Family Connection program for relatives of people suffering of a larger range of symptoms than only those of BPD. One pre/post study evaluated the program adapted for families of suicide attempters (n = 13) (27). The results showed significant reduction in burden, improved psychic health and an increase in well-being regarding the relation with the patient. Two studies evaluated the program for caregivers of youth with diverse mental health challenges, one quantitatively on a larger sample (n = 94) (28) and one qualitatively (29). Quantitative results showed reduction in burden and grief and improvement of coping strategies (28). Qualitative results showed that participants felt more able to manage their loved one’s mental health challenges, that the perceived quality of the relationship with their loved one improved, and that sharing caregiving experiences within a group was supportive (29).
Nevertheless, among the specific population of participants from families of people with BPD, quantitative studies were conducted only on small samples.
Besides, in Europe, the program has been implemented in several countries, and a francophone section of the NEA-BPD has been settled in 2017 to spread the intervention. A first implementation report of the French-speaking groups in Switzerland was published in 2016 (30). Notwithstanding the current dissemination of the program, no quantitative study has been conducted so far in French-Speaking Europe.
The aim of this work was to investigate the implementation of the francophone version of the program on a large sample of families of people with BPD in Switzerland and France. The program aiming at reducing psychological suffering of relatives and teaching them new adaptive skills, we chose to explore the impact of the program on burden and depression, as it has already been done in previous studies, furthering exploring changes in coping strategies and emotional regulation. We hypothesized that suffering of participants (i.e., burden and depression) would decrease and resources of participants (i.e., coping, and emotional regulation) would increase after completion of the program. A secondary hypothesis was that improvement in coping and in emotional regulation resources would be associated with burden decrease.