Un partido islamista ante la cuestión kurda

Literature was systematically searched and assessed to identify whether the ways that family, a partner and/or carers interact with a person with borderline personality disorder (BPD) can influence clinical outcomes, social outcomes or wellbeing (clinical question 25).

The search strategy and evidence synthesis process are detailed in appendices D to H

7.1.1

Summary of evidence: influence of families, partners and carers

The UK national BPD clinical practice guideline1 _{(in the absence of a systematic evidence} review) identified limited evidence from prospective longitudinal studies of people with BPD that included baseline measurement of the quality of family relationships242 _{and with family levels} of expressed emotion.243

7.1.2 Discussion: influence of families, partners and carers

The relationship between the family environment and the prognosis for BPD is complex.1 _{There is} some tentative evidence that families of people with BPD could interact in ways that are not helpful for the person.1 _{In one prospective study,the quality of participants’ relationships with} family members (parents, spouse, siblings and children) at baseline was associated with BPD outcome after 2 years.242

Another prospective study found that people with BPD whose families scored higher on an interview-based measure of emotional over-involvement (reflecting exaggerated emotional response to the illness, devoted or self-sacrificing behaviour, dramatisation or overprotective behaviour) experienced fewer admissions for BPD than those whose families scored lower on this measure.243 This limited evidence suggests a lack of association between family hostility and criticism and re-admission rates for family members with BPD.1 _{The findings of one study among families of} people with BPD suggested that higher knowledge of BPD was associated with higher burden, depression, distress and hostility towards the person with BPD.244 _{This unexpected finding} suggested that people may have been obtaining misleading information through unhelpful information sources.

It is difficult to interpret findings from studies assessing the influence of family relationships on BPD because it is not possible to determine the degree to which temperamental vulnerability explains BPD outcomes, compared with family environment.1 _{Based on current evidence and} expert opinion, it is incorrect for health professionals to assume that all family environments are ‘toxic’ and have ‘caused’ the person’s BPD.1

suPPoRTInG faMIlIes, PaRTneRs anD CaReRs

Clinical Practice Guideline for the Management of Borderline Personality Disorder 108

Adolescents with BPD experience high rates of family breakdown. Australian data suggest that by a mean age of 16 years, approximately 37% of people with BPD are not living with either biological parent,184 _{and this increases to 53% by mean age 18 years.}189

The Committee determined that there was insufficient evidence to make specific evidence-based recommendations on the potential influences of family, partners and/or carers on health outcomes for people with BPD. In making consensus-based recommendations for health professionals working with families and carers, the Committee agreed on the following considerations.

Some actions or behaviours by family, partners or carers might worsen BPD symptoms or reduce the effectiveness of treatment for BPD:

• Denial that the person has BPD might prevent the person getting help.

• Misunderstanding of the illness might lead to unrealistic expectations of treatment. For example, a false belief that “if they can only find the right treatment they will be completely cured” could result in unhelpfully encouraging the person to keep seeing new health professionals. This could disrupt ongoing treatment.

• Although some types of habitual self-harm are distressing for the person’s family or partner, demands to stop this behaviour can be counter-productive and increase the person’s distress. The person may need treatment and time before they can give up this behaviour. An empathic response may be more helpful.

• If families, partners or carers become aggressive when communicating with the person with BPD, this might cause further distress or worsen symptoms.

• While trying to avoid a hostile or aggressive emotional response from the person with BPD, their family, partner or carers may give in to the person’s wishes and agree to an action or decision that they do not believe will really help the person, rather than risk confrontation. A person with BPD may learn over time that they can achieve short-term goals by manipulating family/partner/ carers’ emotions. This pattern could prevent them learning new, more helpful ways of behaving towards people.

• Family members, partners or carers can be overly protective and repeatedly try to ‘rescue’ the person with BPD. These behaviours might prevent the person learning to become independent. • If families, partners or carers feel overwhelmed or intimidated by health professionals, they

may not ask questions or ask for clarification of things they don’t understand. This could result in treatment decisions being made without a full understanding of options and their potential advantages and disadvantages.

• Accessing highly stigmatising, blaming information about BPD may be counterproductive. Family members, partners and/or carers can support people with BPD by:

• gaining knowledge and an understanding of BPD – learning about BPD and how to cope with their own distress caused by the illness; understanding that BPD is an illness like any other illness helps avoid guilt, blame, stigma

• developing helpful attitudes towards the person

– showing empathy – being willing to try to understand the experience of the person with the illness, including internal emotional pain

– showing a non-judgemental attitude – accepting that when people with BPD experience uncontrollable emotions they often direct their anger or difficult behaviour towards those closest (family, partner, carers); understanding that during an episode of difficult emotions the person with BPD may say or do things that they would not say or do at other times, and that do not express how the person normally feels about the family member, partner or carer

• encouraging independence

– allowing the person to retain independence – avoiding the temptation to try to control the person’s life for them; giving support and help when the person needs it yet allowing them to make their own decisions

– negotiating with the person about their decisions for managing their illness. However, occasionally families or carers may need to take action that overrides the person’s wishes (e.g. for their safety)

– trying to balance their own needs and wishes with the amount of support the person with BPD needs to manage their illness well

• developing helpful styles of communication

– allowing the person with BPD to discuss their problems and worries honestly

– listening to the person with BPD when they express their desires, and respecting their desires even if they do not agree with them

• cooperating with healthcare services

– building good working relationships with healthcare services and providers, and including the person with BPD when dealing with healthcare services

– being honest and frank when dealing with healthcare services and providers

– making an agreement with the person about what information can be shared between health services and the family, partner and/or carer. When a person with BPD negotiates a management plan with a health provider, it may be essential to communicate this information to the

person’s family, partner or carer. The person’s illness may make them unwilling to include the family, partner or carer sometimes. During periods of illness, a person with BPD may request their family, partner and/or carers not be involved with their care. A pre-established consent agreement can help in this situation. When families, partners and/or carers discuss the person’s situation with healthcare services, the need for disclosure of information that will help health professionals plan appropriate care must be balanced by respect for the person’s privacy. It is best for families, partners and/or carers to negotiate confidentiality while the person is well, and then negotiate with health services to establish an agreed set of ‘rules’ for sharing information, so that when the person is unwell and cannot make decisions capably, health services and families, partners and/or carers can share appropriate information as necessary to plan their care. The agreement may include information about diagnosis, medication and management plans.

7.1.3 Recommendations: influence of families, partners and carers

Recommendations directed towards family members and carers are outside the scope of this guideline. Recommendations for health professionals, based on the above considerations, are shown at Section 7.2.3.

7.2

Interventions directed at families, partners and carers to support