Caregivers of individuals with borderline personality disorder: The relationship between leading caregiver interventions and psychological distress/positive mental well-being.

Burden and psychological distress are higher in informal caregivers (ICs) of people with severe emotional and behavior dysregulation who have been given a diagnosis of borderline personality disorder (BPD) compared with non-caregivers. The current cross-sectional study examines the difference in outcomes of ICs of people with BPD who have received the intervention Family Connections (FC) and who also led interventions for other caregivers (caregiver-leaders) compared with those who have attended FC but not led caregiver interventions (non-leader-FC participants). The sample for this research is from a larger study (Hayes et al., 2023, Borderline Personality Disorder and Emotion Dysregulation, 10, 31). Data for 347 participants who self-reported receiving FC and completed the McLean Screening Instrument for BPD-Carer Version, the Brief COPE, the Multidimensional Scale of Perceived Social Support, the Kessler Psychological Distress scale, the WHO-5 Well-being Index, and the Coronavirus Anxiety Scale were analyzed. The results found that being a caregiver-leader was associated with higher positive mental well-being and lower psychological distress compared with non-leader-FC participants. Being a caregiver-leader was also associated with significantly greater use of the coping strategy of positive reframing and lower use of behavioral disengagement and self-blame than non-leader-FC participants. The study provides preliminary evidence that for those who have received FC, becoming an intervention leader is associated with better outcomes than caregivers who do not become leaders and provides support for caregiver-led rollout of FC across services.

Hopelessness for family members of individuals with borderline personality disorder.

Family members and loved ones of individuals with Borderline Personality Disorder (BPD) can experience high levels of distress. Types of distress reported by family members include burden, grief, depression, guilt, and powerlessness. Hopelessness is a construct that has received little attention despite its potential relevance for this group. This study sought to examine, and assess potential change in, hopelessness among individuals attending a 12-week Family Connections (FC) program. Participants were 75 family members, 29 men and 46 women. Most participants were parents (n = 43; 57%). Data were collected at four time-points and outcomes included hopelessness, burden, and grief. The majority of participants (82%) reported scores within the 'minimal' or 'mild' ranges of hopelessness before the FC program. A greater proportion of participants in the 60-70 year age group reported scores in the 'moderate/severe' category when compared with younger age groups. The mean hopelessness score for all participants before FC was 4.61 which is considered mild. There was no significant difference in hopelessness scores after program completion. Although mean scores increased at both 3-month and 12-month follow-ups, they continued to remain in the 'mild' category. Hopelessness scores in the current study are similar to those reported in previous studies, although no significant change was found after FC completion. Concepts of personal vs. situational hopelessness should be considered, as well as the relevance of assessing personal hopelessness for this participant group. Further research is needed to determine the relationship between family member hopelessness and index client wellbeing.

Family connections vs treatment at usual optimized in the treatment of relatives of people with suicidal behavior disorder: study protocol of a randomized control trial.

BACKGROUND: Relatives of people diagnosed with suicidal behavior disorder (SBD) feel guilty, afraid, hopeless, depression and anxiety. It is necessary to help the relatives of people with SBD to reduce their discomfort and burden. Family Connections (FC) is a program that has been shown to be effective in reducing burden, depression, and anxiety, and increasing dominance and validating behaviors in relatives of people with borderline personality disorder. However, there are no RCTs that demonstrate the efficacy of the FC program in patients with SBD. Our research team adapted FC for relatives of people with SBD for delivery in the Spanish population (FC-SBD). The FC-SBD program contains 12 two-hour sessions held once a week. The first aim is to verify the efficacy of the FC-SBD intervention for relatives of people diagnosed with SBD in a randomized control trial with a Spanish sample. The second objective is to analyze the feasibility and acceptance of FC-SBD in relatives. The third aim is to analyze whether the changes produced in the psychological variables in the relatives after the intervention are related to changes in the psychological variables of the patients. This paper presents the study protocol. METHODS: The study design consists of a two-arm randomized controlled trial with two conditions: FC-SBD or Treatment as usual optimized (TAU-O). Participants will be relatives of patients who meet DSM-5 criteria for SBD. The caregivers` primary outcome measures will be the BAS. Secondary outcomes will be DASS-21, FES, DERS, QoL. The patient's primary outcome measures will be the frequency of critical incidents with the family member with SBD. Secondary measures will be the INQ, PHQ-9, OASIS. Participants will be assessed at pretreatment, post-treatment, and 6-month follow-up. The intention-to-treat principle will be used when analyzing the data. DISCUSSION: This study will provide results that confirm the efficacy of the FC-SBD in relatives of people with SBD. These results will also confirm its good acceptance by family members and help us to find out whether it is a good program to improve the prevention of suicidal behaviors in the family environment. TRIAL REGISTRATION: ClinicalTrials.gov ID: NCT05157607 . Registered 15 December 2021.

Efficacy of "Family Connections", a program for relatives of people with borderline personality disorder, in the Spanish population: study protocol for a randomized controlled trial.

BACKGROUND: Patients with borderline personality disorder (BPD) experience significant affect regulation difficulties that cause serious consequences in their work, emotional, and social environments. This dysfunctional pattern also produces great suffering and a heavy burden on their relatives. Fortunately, some studies show that treatment of relatives of people with BPD begins to be important in the patients' recovery and in improving family dynamics. One of the treatments that has obtained the most empirical support is Family connections (FC). This 12-session program is an adaptation of different Dialectical Behavior Therapy strategies. To test the efficacy of FC, five uncontrolled clinical trials were conducted, with pre-post treatment and follow-up assessments. The results of these studies and subsequent replications showed an improvement in family attitudes and caregiver burnout. Our research team adapted FC for delivery in the Spanish population. We intend to test the efficacy of this program versus a treatment as usual condition. Moreover, we aim to test the efficacy of this program and study its effectiveness (in terms of participants' acceptance). This paper presents the study protocol. METHODS: The study is a randomized controlled trial. The participants will be recruited in a Personality Disorders Unit and randomly assigned to one of two treatment conditions: Family Connections group (FC) or Treatment As Usual (TAU). Primary outcome measures will be the BAS and FAD-GFS. Secondary outcomes will include DASS-21, FES, GS, and QLI. Participants' treatment acceptance and degree of satisfaction will also be measured. Participants will be assessed at pre-, post-treatment, and 6-month follow-up. Intention to treat and per protocol analyses will be performed. DISCUSSION: This is the first study on FC for relatives of people with borderline personality disorder (BPD) compared to an active condition (TAU), and this is the first time relatives' and patients' data will be analyzed. In addition, it is the first study to test the efficacy of the program in Spain. This intervention could contribute to improving the efficiency and effectiveness of current treatment programs for relatives of people with BPD, help to decrease burden, and improve the family connection. TRIAL REGISTRATION: ClinicalTrials.gov ID: NCT04160871. Registered November 15th 2019.

The lived experience of French parents concerning the diagnosis of their children with borderline personality disorder.

BACKGROUND: Psychiatrists often hesitate to diagnose borderline personality disorder (BPD). While individuals with BPD have reported both positive and negative experiences upon receiving their diagnosis, no study has specifically explored this issue among parents. Parents of children diagnosed with BPD can benefit from recently developed family-support interventions such as the Family Connections program. Our study aimed to explore the experiences of parents learning about their child's BPD diagnosis and to investigate the impact of the Family Connections program on their experiences. METHODS: This qualitative study, conducted in France following the five-stage IPSE method, involved parents of children with BPD recruited through the Family Connections association in Versailles. We conducted semi-structured interviews and used purposive sampling for data collection until data saturation was reached. Data analysis was performed using a descriptive and structuring approach with NVivo 12 software to elucidate the structure of lived experiences. RESULTS: The study included 21 parents. The structure of the lived experiences was characterized by three central axes: (1) the long and difficult road to diagnosis; (2) communicating the BPD diagnosis to parents: a necessary step; (3) the pitfalls of receiving the diagnosis. The Family Connections program provided significant support in these areas, particularly in understanding the diagnosis, enhancing communication with their child, and reducing social isolation. CONCLUSION: These findings highlight the challenges parents face when receiving a BPD diagnosis for their child and underscore the need for an early, clear, and detailed explanation of the diagnosis. The specific experiences of receiving the diagnosis are indicative of the broader care experience parents undergo and highlight their need and right to be informed, supported, and guided throughout their child's treatment.

Early Exposure to Orthopaedic Surgery.

INTRODUCTION: Disparities in early orthopaedic experiences among medical students prompt a critical examination of factors influencing the availability and nature of these exposures. While the current body of literature underscores the significance of early surgical exposure and mentorship in medical education, a notable gap exists in investigating early orthopaedic exposure and its specific impact on students from diverse backgrounds. METHODS: A 16-item questionnaire, approved by our institutional review board, was administered to fourth-year medical students (MS4) and first-year orthopaedic residents (PGY-1) across U.S. orthopaedic surgery programs during the 2022-2023 application cycle. The questionnaire assessed participants' initial orthopaedic exposures and factors influencing interest in the field. Two-proportion Z-test analyses were conducted to analyze the data, and thematic analysis was used to assess qualitative data involving free-response questions. RESULTS: Out of 72 total respondents, the study revealed that 83% of respondents encountered orthopaedics before medical school, with initial exposures stemming from various sources such as familial connections (28%), athletics (17%), and high school or college exposures (15%), including shadowing, athletics participation, and occupation-related exposure. Disparities were observed in the availability of orthopaedic mentors and early exposure opportunities between demographic groups. Statistical analyses highlighted significant differences in access to mentors who reflected students' identities between male and non-male participants (70% vs. 39%, p=0.02) and between white and non-white participants (69% vs. 36%, p=0.02). White participants were also more likely to first interact with a surgeon who treated them or their family members than non-white participants (35% vs 7%, p=0.04). Non-white participants were more likely than white participants to come by their first orthopaedic opportunity by searching for it independently (21% vs. 4%, p=0.03). Family and friend connections in orthopaedics were found to be influential in motivating students to pursue orthopaedics, with 40% of respondents indicating personal connections in medicine and 12% reporting family members who are orthopaedic surgeons. Research experiences were identified as important contributors to students' initial interest and motivation to ultimately pursue orthopaedics, especially those with diverse backgrounds. CONCLUSION: The findings underscore the importance of early orthopaedic exposures in shaping students' interest in the field, highlighting the need for more immersive pre-clinical year opportunities and enhanced mentorship programs. Addressing disparities in mentorship access and early exposure opportunities requires systemic changes and increased support for underrepresented minorities in orthopaedics. Initiatives like mentorship programs and research opportunities can help bridge gaps in access to early orthopaedic experiences. Medical schools should prioritise targeted early access to orthopaedic exposures for all students, regardless of background. This initiative aims to promote inclusivity and cultivate a more diverse orthopaedic workforce capable of meeting the evolving healthcare needs of society.

Implementing digital devices to maintain family connections during the COVID-19 pandemic: Experience of a large academic urban hospital.

INTRODUCTION: The COVID-19 pandemic lockdown imposed drastic measures at hospitals internationally to rapidly pivot their approaches to patient care. Early on when the pandemic was declared, hospitals responded to local public health restrictions by limiting all non-essential visits for their patients. Digital devices allowed Canadians to remain connected with their friends and families during the imposed isolation restrictions. The aim of this clinical perspective is to share the experience with the immediate implementation of digital connections for patients by exploring the impact as well as to describe key learnings from the initiative. METHODS: 150 iPads were distributed to clinical teams for use by patients, for either clinical care or for social connection. An iterative evaluation process, guided by quality improvement methodology, was followed which ensured that any changes to the iPad implementation process were responsive in real time. The evaluation measures included a clinician survey and collection of narratives from patients and clinicians. RESULTS: All clinician respondents (n=7) indicated that the iPads were a valuable tool to support patients and families. Narratives from patients indicated that virtual connections brought joy to them especially given that they were isolated from their support systems during the initial days of COVID-19. Key learnings for the Implementation Team were: the importance in maintaining cognitive stimulation as an enabler to recovery for patients; staff members provide support beyond direct clinical care; technology needs to be harnessed to facilitate clinical care; technology should be leveraged to support clinical care; and interprofesssional collaboration of the entire Implementation Team is a key enabler of success. CONCLUSION: Since implementation, iPads have been integrated as a supporting digital tool for both social connections as well as clinical care as a result of the benefits seen during this initiative. The iPads have also been recognized as a tool to complement patient connection and care and currently being expanded as part of services to patients, families and their clinicians.

Family connections in the treatment of relatives of people with eating disorders and personality disorders: study protocol of a randomized control trial.

BACKGROUND: Eating disorders (EDs) are serious disorders that significantly affect not only the lives of patients, but also those of their family members who often experience high levels of burden, suffering and helplessness. If, in addition to ED, the patient has a personality disorder (PD), the psychological distress experienced by family members can be devastating. However, few treatments have been developed for family members of people with ED and PD. Family Connections (FC) is a programme that has been shown to be effective for family members of people with borderline personality disorder. The overall aims of this work are: (a) to adapt FC for application to family members of patients with BPD-PD (FC: ED-PD); (b) to analyse, in a randomised controlled clinical trial, the efficacy of this programme in a Spanish population, compared to a control condition consisting of treatment as usual optimised treatment (TAU-O); (c) to analyse the feasibility of the intervention protocol; (d) to analyse whether the changes that may occur in relatives are related to improvements in the family climate and/or improvements observed in patients; and (e) to analyse the perceptions and opinions of relatives and patients about the two intervention protocols. METHODS: The study uses a two-arm randomised controlled clinical trial with two experimental conditions: adaptation of FC programme (FC: ED-PD) or Treatment as usual optimised (TAU-O). Participants will be family members of patients who meet DSM-5 criteria for ED and PD or dysfunctional personality traits. Participants will be assessed before and after treatment and at one-year follow-up. The intention-to-treat principle will be used when analysing the data. DISCUSSION: The results obtained are expected to confirm the effectiveness of the programme and its good acceptance by family members. Trial registration ClinicalTrials.gov Identifier: NCT05404035. Accepted: May 2022.

"Family Connections", a DBT-Based Program for Relatives of People with Borderline Personality Disorder during the COVID-19 Pandemic: A Focus Group Study.

The COVID-19 pandemic has had a significant impact on the family environment due to the difficulties that have been generated by job losses, deaths, increase rates of family and domestic violence, poor mental health outcomes, and estrangement in personal relationships. "Family Connections" (FC) is an internationally renowned DBT-based program that supports the families and caregivers of people with borderline personality disorder. The study took place at a Specialized Health Centre in Spain. A focus group with seven participants was organized for people who had previously attended an FC group. The participants were asked about their experiences during the confinement periods that was caused by COVID-19 as well as their experiences and opinions on relatives, skills practiced, their need to and the advantages of attending the group, and satisfaction with the FC group. The qualitative research web program Dedoose was used for the thematic analysis of the data. The results showed that the participants experienced various experiences during confinement; validation and radical acceptance were determined to be the most useful skills; the importance of professionals and the content as well as the sincerity of attendees and having a safe space were determined to be the greatest benefits of the programs; and the participants all indicated great satisfaction of the program. This study allowed us to explore the experiences of family members of people with BPD with their loved ones during the confinement period caused by the COVID-19 pandemic. We evaluated the use of the FC program skills in the family environment during confinement, and we analyzed the acceptability and satisfaction with the FC program.

Exploring staff perceptions of the utility of clinician connections when working with emotionally dysregulated clients.

BACKGROUND: Borderline personality disorder (BPD) is considered to be a challenging condition for clinicians to treat. Clinicians routinely working with individuals who experience severe emotional dysregulation often do not receive appropriate training and support to work with this client group. This article describes an intervention, Clinician Connections (CC), which was developed to support practitioners who work with individuals with BPD. CC aims to increase practitioner's knowledge of BPD, develop a skillset to work with emotionally dysregulated individuals and enhance practitioner's self-efficacy with regard to working effectively with this client group. The aim of this study is to investigate the perceived utility and acceptability of CC, and identify areas for further development of the intervention. METHOD: A seven-hour CC workshop was provided to Emergency Department and community mental health clinicians. Three focus groups were completed following completion of the intervention with 13 clinicians (12 female; 1 male) and were audio recorded. The study utilised a thematic analysis framework. RESULTS: Six master themes emerged from the focus group data which included 10 subordinate themes. The master themes identified were: the need for training; a new understanding; validation; barriers to applying new skills; overcoming barriers to skill application; and future direction: practical application of skills. Participants reflected on how their new understanding of transactions and their own experiences affects their practice. They also noted improved client interactions and client relationships resulting from the use of validation. While there was an increase in participants' self-efficacy in working with individuals with BPD, a need for further skills and practice was also highlighted. CONCLUSION: The evidence presented here suggests that CC is both beneficial and feasible. Qualitative feedback suggests there is a need for further support in the strengthening and generalisation of skills. Suggestions were made by practitioners regarding potential improvements to the delivery of the workshop. Future research could evaluate the changes made to CC and focus on a quantitative approach to quantify the impact of CC.

Family Connections in different settings and intensities for underserved and geographically isolated families: a non-randomised comparison study.

BACKGROUND: Family Connections (FC) is a multi-family skills training program for relatives of individuals with borderline personality disorder (BPD) and related difficulties, typically offered once per week for 12-14 weeks. Families with loved ones receiving residential Dialectical Behaviour Therapy DBT (DBT-R) in a different community, or those with multiple caregiving demands may have difficulty participating in weekly standard FC (FC-S). The aims of this paper are to: 1) Evaluate the results of the FC-S approach compared with an intensified weekend FC model developed for family members whose relatives are in DBT-R (FC-R); 2) Evaluate outcomes of FC-R for families with loved ones returning home from DBT-R, as little is known about how this population fares. METHODS: Data were collected at pre-treatment (T1), post-treatment (T2), and at six-to-seven-month follow-up (T3) in this non-randomized comparison study. A total of 82 family members participated, 34 of whom completed the FC-S program and 48 of whom completed the FC-R program. The evaluation was based upon outcomes derived from a standard battery used in FC research, analyzed by time and treatment setting. A composite score to evaluate family distress was generated. Two-way mixed multivariate analyses of variance (MANOVA) were employed to evaluate time (pre-versus-post versus follow-up) and group (FC-S versus FC-R). RESULTS: Scores on measures of mental health difficulties (General Severity Index), sense of burden (Burden Assessment Scale), and Global Family Functioning showed improvement over time. Having a loved one return home from DBT-R was associated with worsening on the GSI and the BAS at post-test. Notably, this deterioration was not found at follow-up. CONCLUSIONS: Little is known about families with loved ones receiving DBT-R other than the fact that their loved ones had not responded to previous services, which suggests greater complexity and chronicity. Because the family members receiving the weekend intensive FC-R version of FC demonstrated improvement, preliminary support exists for service providers to use the weekend intensive FC-R model as a time-and-cost efficient option whenever barriers exist to participating in weekly FC-S. Our findings also suggest that booster sessions may be indicated for families receiving loved ones home from DBT-R programs.

Family Connections versus optimised treatment-as-usual for family members of individuals with borderline personality disorder: non-randomised controlled study.

BACKGROUND: Borderline personality disorder (BPD) is challenging for family members who are often required to fulfil multiple roles such as those of advocate, caregiver, coach and guardian. To date, two uncontrolled studies by the treatment developers suggest that Family Connections (FC) is an effective programme to support, educate and teach skills to family members of individuals with BPD. However, such studies have been limited by lack of comparison to other treatment approaches. This study aimed to compare the effectiveness of FC with an optimised treatment-as-usual (OTAU) programme for family members of individuals with BPD. A secondary aim was to introduce a long term follow-up to investigate if positive gains from the intervention would be maintained following programme completion. METHODS: This study was a non-randomised controlled study, with assessment of outcomes at baseline (pre-intervention) and end of programme (post-intervention) for both FC and OTAU groups, and at follow-up (3 months post-intervention; 12 or 19 months post-intervention) for the FC group. Eighty family members participated in the FC (n = 51) and the OTAU (n = 29) programmes. Outcome measures included burden, grief, depression and mastery. Linear mixed-effects models were used to assess baseline differences in the outcome measures by gender, age group and type of relationship to the individual with BPD. Linear mixed-effects models were also used to estimate the treatment effect (FC versus OTAU) utilising all available data from baseline and end of programme. RESULTS: The FC group showed changes indicating significant improvement with respect to all four outcome measures (p < 0.001). The OTAU group showed changes in the same direction as the intervention group but none of the changes were statistically significant. The intervention effect was statistically significant for total burden (including both subscales; p = .02 for subjective burden and p = .048 for objective burden) and grief (p = 0.013). Improvements were maintained at follow-up for FC participants. CONCLUSIONS: The findings of the current study indicate that FC results in statistically significant improvements on key measures while OTAU does not yield comparable changes. Lack of significant change on all measures for OTAU suggests that a three session psycho-education programme is of limited benefit. Further research is warranted on programme components and long-term supports for family members.