Family Dysfunction and BPD Behavior: A Chicken And Egg Situation

 

A new article in a nursing journal discusses the experience of Swedish families of people with members who have borderline personality disorder (BPD), and who have access to something they call “Brief Admission” to the hospital because of recent self-injurious behavior (SIB). In their study, 12 patients, whose age range is not specified in the article, have picked out one of their family-of-origin relatives or spouses for the researchers to interview. The relative is then interviewed by phone by two of the authors and asked to describe their experiences as the parents or spouse of someone with disorder. The two authors basically coordinate with each other so they are basically covering the same types of questions.

The authors mention almost in passing that the interviewers had to remind the relatives repeatedly not to focus their discussion on the patient, but rather talk about their own experiences. Not only that, but they also make the claim that “the burden experienced by families of someone diagnosed with BPD involves greater suffering than those with other mental disorders."

Now of course, if a loved one is acting in ways like SIB that reminds everyone that suicide is an issue, they are going to worry more about that person than they may have before. But how are we to know whether the obsession with the patient that is described by the family members over and over again was not what triggered the self-injurious behavior in the first place? After all, some people with BPD hide the self injury from their families (or at least the families are ignoring the evidence for it), while these research subjects obviously did not.

What distinguishes one from the other? Well, in my clinical experience, there are two reasons for this. When SIB is hidden, it’s sole purpose is to stop the panic attacks that occur when a patient feels helpless to alleviate a family problem. When it is not, the behavior does that and also feeds into the parent’s preoccupation with the patient’s mental health.

Of course, the parents will all claim that it was the patient’s behavior that created their preoccupation. This is the basic reasoning espoused by two support groups for parents of offspring that have BPD (TARA4BPD and NEA-BPD). They say such parents are sick and tired of being blamed by the psychiatric profession for their child’s condition. 

As my readers know, I agree that blaming parents is counterproductive because it sidetracks any and all attempts at actually solving problems that are shared by all members of the family and which were caused by events that took place over at least three generations.

So how do we know which came first: the parents’ preoccupation with the patient, or the patient’s self injurious behavior? A true chicken-and-egg type question. My readers already know my answer: the parents’ anxious and guilty preoccupation comes first, which then leads to their child developing the role of spoiler designed to somewhat control both the guilt and anger they see in their parents. The family members then all continue to simultaneously feed into and make worse one another’s problem behavior, especially over the long run.

The parents’ overblown preoccupation, albeit after the SIB has started, can be seen in comments the authors make throughout the study, starting with the above-mentioned statement comparing it to the parents of people with other psychiatric disorders. 

Other examples: the family members’ fear about the children makes “it difficult for them to prioritize their own well being.” The family members have “a hard time allowing themselves to have fun” – due to their feelings of “guilt and shame,” – not fear for their child’s life. “Constantly prioritizing their loved one and ignoring their own well being meant that many of the families suffered from their own mental illness and fatigue diagnoses…” “In this study, feelings of helplessness and anger and a constant need to monitoring their loved ones...”

It seems doubtful that the interviewers asked certain questions about the parent’s pre-occupation having perhaps pre-existed before their child’s SIB began. At least in their article, there is no mention by the authors about the possibility that this was the case, despite their making the following points: “…children can see if someone is unwell and can withdraw and try to make themselves invisible” (that’s only one of many other possible “helpful” responses). “When a parent suffers from mental illness, the children can become carriers of their anxiety.” “Children of parents with mental illness can take a great responsibility for their ill parents.” “…the families and their loved ones’ lived experiences are considered to be linked and interaction with each other.”

The other big problem with this study was that this was a highly biased set of subjects. As mentioned, the SIB of the subjects was known to their families. Also, recall that the patients had to pick a relative for the authors to interview, and the relative had to agree to it. Parents that were sexually or physically abusive would probably not be suggested by the patients, who often go to great lengths to hide the family’s secrets because of dire consequences. 

They know what will happen if they spill the beans. In the family, such revelations are responded to with denial, or alternatively, with an accusation that the patient was at fault for, say, being molested because of being seductive. Usually, everyone in the family including the victim just pretends it never happened – as illustrated by mothers who had been sexually abused by their father letting that man baby sit their own small children when rest of the family suggests it.

And even if the subjects picked the abusive parent, and the abusive parent agreed to be interviewed, it would be highly unlikely that such abuse would be divulged. After all, if it were indulged, the interviewers might have to turn them in!