From: Borderline personality disorder: An information guide for families. (© 2009 CAMH)
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How can I support a person with BPD in seeking treatment?
How can I support my family member during treatment?
Taking the steps to get help for a mental health problem can often seem overwhelming and frightening, even more so if the
person has had distressing experiences in earlier contacts with the mental health treatment system. This is particularly true
for people with BPD because of the complexity of their problems and the perception that they are “treatment resistant.” As
well, the person with BPD may not be able to see the value of treatment, particularly if prior treatment has not worked for
them, and they may respond angrily or defensively to suggestions that they go for help.
Sometimes even asking for help can be difficult for someone whose culture does not encourage counselling or outside help.
They may have difficulty finding the service they need because the counsel-ling is not available or when it is, it is not
in their language. You could contact your local cultural group to find out about culturally specific services or request an
interpreter to work with the available treatment services.
If a person also has a substance use problem or some other problem that is the responsibility of “another system,” he or she
may have been turned away and told to go elsewhere. Unfortunately in some communities, the mental health and substance abuse
treatment systems are not well coordinated, but progress is being made in many communities to better integrate them.
In the past, it was felt that “confronting” a family member about his or her problems would induce the person to accept treatment.
In fact it often had the opposite effect. We cannot make someone go for treatment if they do not want to, however, there are
some steps you can take to support your affected family member if and when they are ready to consider treatment:
- Learn about borderline personality disorder. It is important to understand that your affected family member has a health problem
as much as anyone with a physical health problem, and that the behaviours you are observing are the symptoms of this health
problem. It is also helpful to understand that BPD is a result of the interaction between genetic, biological and environmental
vulnerabilities, rather than behaviours that the person has developed as a result of their own actions or intentions. Useful
print materials and websites are listed at the end of this booklet.
- Find out about treatment resources in your community. Talking to your family doctor can be a good place to start to find out
what kind of assistance your family member needs and what is available. You can also contact the Mental Health Service Information Ontario line (see p. 43) or your local branch of the Canadian Mental Health Association (see p. 47) if you have one. Other places to contact for help include psychiatric services at your local hospital, community mental
health clinics, health and social service agencies serving specific cultural or language groups, your spiritual leader or
faith-based counselling services, or a counsellor with your workplace Employee Assistance Program.
- Ask questions like these to determine the best match to the needs of your affected family member:
- Where is the facility located?
- Is it community- or hospital-based?
- Is the program outpatient, day or residential?
- What are the admission criteria and how does your family member get referred to the facility?
- What type and length of program(s) is offered? Is it a specialized treatment program for BPD?
- What languages are services offered in? Are translation services available?
- What levels of professional staff are employed by the facility?
- Is there an aftercare or continuing care program?
- What level of involvement is available to family members? Is there a program for family members?
- If your affected family member is female, is a female therapist available for individual counselling?
- If your affected family member is female and if treatment is offered in groups, are they (co-)facilitated by a female therapist?
- If the program is residential, are female-only areas such as sleeping areas provided?
- If your affected family member has dependent children, is there any child care and/or programming available for children?
- Is there a fee?
- Assist your family member to make an appointment.
- Offer to accompany her or him to the appointment if she or he would like your support.
- Obtain support for yourself either by attending a professionally run treatment/support program for family members or by attending
a mutual-aid group. Education and support from others can help you in your relationship with your affected family member and
may encourage him or her to seek help.
- Take care of yourself and encourage other family members to do the same.
Involuntary hospital admission
Family members often find it difficult to understand why their affected family member cannot always be involuntarily admitted
to hospital for treatment so he or she can get the help needed. However, in Ontario and most other Canadian jurisdictions,
a person can only be certified as an involuntary patient if a physician believes that he or she is likely to harm himself
or herself (self-harming or suicidal) or someone else (violent) or suffer serious physical impairment (not eating, drinking,
or taking required medications) due to a mental disorder. Under the Ontario Mental Health Act (MHA), a person can be brought into hospital under the following three conditions:
- When a person is acting in a disorderly manner, the police are allowed to bring the person to be examined by a physician if
they believe the person is a danger to himself or herself or others or the person cannot care for himself or herself.
- In situations where there is no immediate danger, anyone can bring evidence to a Justice of the Peace (JP) that the person
is a danger to himself or herself or others or cannot care for himself or herself and the Justice of the Peace can order that
the person be examined by a physician. The JP is required to fill out a Form 2 that authorizes the police to take the person
to a physician.
- If a physician has assessed a person within the last seven days and feels that a person may be a danger to himself or herself
or to others or cannot care for himself or herself, the physician can order that the person be examined by a psychiatrist.
The physician is required to fill out a Form 1 that authorizes the police to take the person for an examination.
Once the person is brought to a psychiatric facility, a physician may detain the person for up to 72 hours for psychiatric
assessment, but no treatment is permitted without patient consent. After that time, a person must either be released or admitted
as a voluntary or involuntary patient, as indicated in the Mental Health Act.
Recent changes to the MHA and the Health Care Consent Act, 1996 (HCCA) allow family members of those with a serious mental illness and health care professionals to act at an earlier
stage of a person’s mental illness with revised committal criteria. These revised commital criteria allow them to implement
procedures for treatment, care and supervision in the community through community treatment order (CTO) provisions. CTO's
are designed to provide treatment in the community for individuals who may otherwise meet criteria for ongoing hospitalization.
Specifically, a CTO candidate is someone who is likely to harm himself or herself or others or who is likely to suffer substantial
mental or physical deterioration or physical impairment as a consequence of mental disorder, unless she or he receives continuing
treatment/care or supervision in the community. Certain other criteria must also be met before the CTO is signed by the physician.
Further information on CTOs can be found at
What to do in a crisis
A Family Guide to Concurrent Disorders distinguishes between a crisis and an emergency. A crisis develops when “people feel
they cannot control their feelings or behaviour and have trouble coping with the demands of day to day life.” Potentially
this can develop into outbursts of anger or violence or self-injuring behaviours. A crisis may develop slowly over a number
of days or erupt suddenly. A particularly high-risk time for a crisis is when a person with BPD fears abandonment or loss
of support. Such times may occur when a family member or a therapist is away for a period of time or when the person becomes
fearful that the good progress they are making may lead to pressure to become more independent with consequent loss of support
(Gunderson & Berkowitz).
Strategies for managing a crisis in the short term include:
- Stay calm and supportive of your family member. Do not get into a shouting match however difficult their behaviour, and even
if you are hurt by what they are saying.
- Acknowledge what your affected family member may be feeling or saying, let him or her know you have heard them and are trying
to understand what they may be feeling.
- Don’t be afraid to ask about suicidal intentions. Suicidal behaviours can be an attempt to relieve emotional pain or communicate
- Act on the agreed upon crisis plan if one is already in place.
- Support your affected family member in making telephone contact with their doctor, therapist or treatment program or offer
to drive them to where they need to go (e.g., therapist, hospital).
- If your family member has broken any agreements you have with them regarding their behaviour, wait until the crisis is over
to discuss it.
You should also make a long-term plan for managing a crisis:
- Discuss with your affected family member and his or her doctor or therapist the steps to take if a crisis should occur.
- Make sure that your affected family member is involved in all decisions regarding the crisis plan and that his or her wishes
- Using the Family Crisis Information Sheet on p. 57, create a crisis plan with your family member and others in the family as appropriate.
- The crisis plan can include a section on who does what, for example, who should accompany your family member to the hospital,
and who should communicate with the treatment team.
- Include important information as part of your crisis plan, for example, telephone numbers for your family member’s family
doctor, therapist and local hospital, and a list of the medications he or she is taking.
- Keep the crisis plan in a prominent place.
- You may wish to include information from the crisis plan on a “crisis card” small enough for your affected family member to
carry with her or him. The crisis card could also contain personal contact information, e.g., family member phone numbers,
as well as a list of medications that he or she is taking and strategies to help them self-calm.
- Find out about crisis services in your community. If your family member is already known to the mental health system, you
should ask whom you or your affected family member should contact if his or her behaviour deteriorates so this can be built
into the crisis plan. Some communities have mobile crisis teams based at a local hospital psychiatric department who will
come and assess the situation.
For more information on how to handle a crisis, see A Family Guide to Concurrent Disorders, listed on p. 44.
What to do in an emergency
Sometimes a crisis can escalate into an emergency. Emergencies could be situations in which there are threats of suicide,
threats of physical violence, reduced judgment and decision-making or substance use that concerns you.
In some circumstances, your family member will voluntarily agree to talk to his or her doctor or therapist or to go to the
hospital emergency department. In other situations, you may need to call 911. This can be a difficult step to take. Inevitably
the arrival of the police or other emergency services will arouse the curiosity of neighbours. Both you and your affected
family member may wish to keep his or her mental health problem as a private matter, but safety is a priority, particularly
when it involves potential harm or suicidal intentions. If you perceive any danger to yourself or anyone else, do not hesitate
to leave and call 911 from somewhere else. When you call 911, tell the operator that your family member needs emergency medical
assistance, give the operator your family member’s diagnosis and tell the operator that you need help transporting him or
her to the hospital.
Depending on the kind of training your local police have had in handling mental health crisis situations, you may need to
advocate on behalf of your family member. This may be particularly important if your family member is likely to react negatively
to the presence of uniformed police. It is useful to write down the names, badge numbers and response times of the officers
who respond to the call in case you have any concerns about the way the problem was handled.
When the emergency involves suicidality
Threatening suicide is one type of emergency situation. Threatening suicide or expressing a wish to die should always be taken
Some warning signs of suicide include:
- feelings of despair, pessimism, hopelessness, desperation
- recent self-injury behaviours
- withdrawal from social circles
- sleep problems
- increased use of alcohol or other drugs or overeating
- winding up affairs or giving away prized possessions
- threatening suicide or expressing a desire to die
- talking about “when I am gone”
- talking about voices that tell him or her to do something dangerous
- having a plan and the means to carry it out.
Sharing treatment information with family members
Generally speaking, sharing medical or treatment information about a person with others, either family members or outside
health care providers or agencies, requires expressed consent. Consent in these situations would usually be written consent.
Family members can play a key role in supporting change and developing newly acquired skills. However, some health care professionals
are reluctant to involve or talk to family members, particularly if they perceive the family as “causing the problem.” If
your family member is still living at home and/or you are supporting them financially, you may feel you should have some moral
right to be involved in their treatment. However, if your family member is capable of making treatment decisions, a health
care professional will not be at liberty to share information without your affected family member’s consent. This is achieved
by having your family member sign a form in the doctor’s office.
Some treatment programs offer family programming. This may involve family therapy sessions with the person affected by BPD
and his or her family members. More commonly, family-specific education/support groups provide information about the disorder,
ways for family members to support the person with BPD and strategies for family members’ self care.
Consent to Treatment
In Ontario, individuals have the right to consent to or refuse treatment, provided they are capable of doing so. Being capable
means that the person is able to understand the information needed to make this decision and is also able to appreciate the
reasonably foreseeable consequences of their consent to or refusal of treatment. There is no age requirement on consenting
to treatment; if a person is capable, she or he gets to make her or his own treatment decisions, regardless of age.
Consent to treatment must be “informed” (which means that the person has been given all the requisite information and all
questions related to the treatment have been answered), must be given voluntarily and must not be obtained through misrepresentation
or fraud. In situations where a person is not capable to give informed consent, then a substitute decision-maker would be
consulted for treatment consent. The HCCA (Health Care Consent Act) sets up a hierarchy of individuals who may provide substitute
How to deal effectively with the legal system if a family member has a legal problem
Ontario has court support and diversion programs in many communities. The role of these programs is to provide advocacy and
support for people with mental health problems and their family members when they are involved with courts, police or other
legal situations. Diversion programs are intended to divert people with a mental health problem who have committed minor offences
from the criminal justice system into treatment and community support. The Mental Health Service Information Ontario line
has a listing of advocacy and support programs, many of them sponsored by the Canadian Mental Health Association. This information
line is listed under Resources on p. 43 at the end of this booklet.
The legal system can be a potentially frightening experience for a newcomer to Canada, particularly if they are not comfortable
communicating in either English or French. Possible resources for advice and support might include an ethno-specific agency,
a legal aid clinic experienced in serving newcomers to Canada, faith community leaders and cultural interpreter programs.
Your family member may also be referred for an assessment and possible treatment at a forensic facility if she or he has been
found either unfit to stand trial or not criminally responsible for an offence by reason of mental disorder. Information about
the forensic mental health system in Ontario can be found in The Forensic Mental Health System in Ontario: An Information Guide listed under Publications on p. 44 at the end of this booklet.
Treatment for BPD is a long-term endeavour, often requiring a commitment of a number of years. Progress is not always straight
forward and there will be diversions along the way with relapse back to old behaviours in times of stress or crisis. Some
guidelines suggested for helping your affected family member include:
- Support your affected family member in the treatment program by encouraging him or her to attend treatment, take the medication
as prescribed and lead a healthy lifestyle by eating well, exercising, getting enough rest and remaining abstinent from substances
if this is a problem area.
- Recognize that change can be stressful and difficult to achieve. Making progress in treatment, acquiring new skills, and becoming
more independent can bring up fears that family members will start to withdraw protection and support and the person will
be abandoned to manage on his or her own. These fears can lead to a relapse back to previous negative coping methods such
as self-injury or a suicide attempt. It is important that family members support progress with words and encouragement that
let their affected family member know they understand how difficult change is.
- Support your family member to set realistic goals, and to work on them one at a time, one step at a time. Though you don’t
want to discourage your family member, it is very important to keep in mind the fine balance between a desire for independence
and fears of abandonment. For example, a realistic goal might be enrolling in one university course for a semester rather
than signing up for full-time classes; finding employment that he or she can manage or moving into a group home rather than
moving out of the family home directly into independent living.
- Maintain a cool and calm environment when dealing with conflict or a crisis. It is important to recognize that some of the
symptoms of BPD, including intense and painful emotions, inability to deal with even small separations from significant people,
and black and white (all good, all bad) thinking about people or situations can easily lead to family conflict or a crisis.
Take time to listen, or make a time later if you are unable to deal with it at that moment. The important thing is for your
family member with BPD to be heard and validated.
- Remain optimistic, though change may be slow. The periods of time when symptoms are absent or much reduced will increase as
your family member and you learn new skills for dealing with relapses.
- Most important, don’t feel the responsibility is all yours to solve problems and be responsible. It is important to allow
your affected family member to be in charge, try new behaviours and be responsible for negative behaviours.
- If you are concerned, contact your family doctor or your family member’s treatment provider, or in emergency situations call