Systemic Safety Planning: Therapy with Suicidal Borderline Personality Disordered Couples

In an era where the mental health field is highly influenced by insurance companies and managed care, borderline personality disorder (BPD) is often not treated systemically but individually. The National Alliance on Mental Illness estimates that 1.6% of the adult U.S. population has Borderline Personality Disorder (BPD) but hypothesizes that number may be as high as 5.9% (NAMI, 2017). Because of this significance, it is suggested that MFTs, regardless of their level of experience, will treat BPD at some point in their career. BPD is associated, according to the Substance Abuse and Mental Health Services Administration (SAMHSA), with higher rates of suicide and self-harming behaviors, with nearly 80% of persons with BPD reporting a history of suicide attempts (2014) and completed suicide deaths between 8-10% (American Psychiatric Association; APA, 2013). The DSM-5 classifies BPD as “a pervasive pattern of instability in interpersonal relationships, self-image, and affects…(APA, 2013, p. 663), yet is traditionally treated individually through modalities such as Cognitive Behavioral Therapy (CBT), Dialectical Behavior Therapy (DBT), psychoanalytic theories, and psychiatric services (National Institute of Mental Health; NIMH, 2016). Consequently, most individuals suffering from BPD are currently involved with a romantic partner (Clarkin, Levy, Lenzenweger, & Kernberg, 2007; Zanarini, Frankenburg, Hennen, Reich, & Silk, 2005), to which these specific modalities do not always focus on the couple, but rather the individual. These couples have difficulty creating and maintaining romantic relationships, as well as have lower rates of relationship satisfaction and an increase in couple conflict (Bouchard & Sabourin, 2009; Zanarini et al., 2005). Because of the alarming rates of suicidality and self-harming behaviors, it is suggested that systemic safety planning could be beneficial to help partners de-escalate conflict, communicate more effectively, and ideally decrease safety concerns within the relationship.

BPD and suicidality

Suicide continues to be a major health concern with over 44,000 Americans dying by suicide in 2015 (Centers for Disease Control and Prevention; CDC, 2017). As the U.S. Centers for Disease Control and Prevention notes, “while the causes of suicide vary, suicide prevention strategies share two goals: to reduce factors that increase risk and to increase factors that promote resilience or coping. Prevention requires a comprehensive approach that occurs at all levels of society—from the individual, family, and community levels to the broader social environment” (CDC, 2019, para. 1).

Borderline personality disorder is associated with higher rates of suicide and self-harming behaviors (SAMHSA, 2014; APA 2013). Self-harming behaviors are also very common among those with BPD, particularly cutting and burning. Greater than 75% of individuals with BPD engage in intentional self-harming behaviors (SAMHSA, 2014).  These behaviors are considered “non-suicidal self-injury” or “parasuicidal” behaviors, and can be habit-forming for BPD clients (Jobes, 2016). Clinicians can become desensitized to self-injurious behaviors and suicidal threats when working with clients with BPD due to the commonality and frequency of such threats. With a suicide completion rate 50 times higher than the general population, however, it is critical for clinicians to recognize self-injurious behaviors as serious and immediately address them (SAMHSA, 2014).

BPD and couples therapy

The diagnostic criteria for BPD note this disorder has a pervasive pattern of instability of interpersonal relationships, self-image, and affects … (APA, 2013). Given the interpersonal challenges of BPD, one can understand why there has been debate over whether couple therapy should be attempted until the client with BPD successfully completes individual therapy (Oliver, Perry & Cade, 2007). Historically, providers have often felt couple therapy would be too intense for a BPD client already struggling with intense emotional dysregulation. This conventional wisdom appears to be shifting, however. Some clinicians and researchers now believe couple therapy may be beneficial as a stand-alone treatment or as an adjunct to individual treatment of a client with BPD. Persons with BPD often exhibit chaotic relational patterns that can exacerbate and maintain disordered thoughts, affects, and behaviors that conjoint therapy can directly address (Oliver, Perry, & Cade, 2007). Links and Stockwell (2001) note that treatment of BPD has historically discounted the healing aspects of intimate relationships that may serve to stabilize the challenging symptoms found in BPD. 

With the application of evidence-based treatments, clients with BPD may be able to reduce presenting symptoms and improve their overall quality of life and functioning (SAMHSA, 2019). Choi-Kain, Finch, Masland, Jenkins, and Unruh (2017) note there are several specialized evidence-based treatments (EBT) for BPD including DBT; Mentalization-Based Treatment (MBT); Transference-Focused Psychotherapy (TFP); Schema-Focused Therapy (SFT); as well as generalist approaches including General Psychiatric Management (GPM) and Structured Clinical Management (SCM). Of note, CBT and DBT are also evidenced-based treatments for reducing suicidality, and Collaborative Assessment and Management of Suicidality (CAMS) has been shown to reduce suicidal ideation and cognitions (Brodsky, Spruch-Feiner, & Stanley, 2018).   

The lack of specific conjoint EBTs for clients with BPD will not shock couple and family therapists, as these approaches are traditionally difficult to study. Nichols (2013) notes that family therapy researchers are faced with a unique set of challenges due to the complexity of family interactions and the treatments designed to influence them. SAMHSA (2019) states it is important for patients with BPD to receive evidence-based, specialized treatment from an appropriately-trained mental health professional. While this is sage advice, where does this leave clinicians when it comes to approaching couple therapy with a client diagnosed with BPD? The Practice Guidelines for Borderline Personality Disorder (Work Group on Borderline Personality Disorder, 2007) include goals for couple therapy with patients with BPD as stabilizing and strengthening the couple relationship, clarifying nonviable relationships, and educating the spouse of the borderline patient about BPD and its interpersonal aspects (as cited in Oliver et al., 2007).

Detailing the specific modalities, interventions, and techniques surrounding effective conjoint therapies is beyond the scope of this article, however several conjoint therapies for treating BPD have emerged in recent years. Some theorists have focused on therapy for couples with BPD and other personality disorders, such as borderline and schizoid personality disorders (McCormick, 2000), or borderline and narcissistic personality disorders (Lachkar, 1998). Others, like Fruzzetti and Fruzzetti (2003), have successfully adapted the basic tenets of DBT (Linehan, 1993) to couple therapy. In this model of couple therapy, several DBT dialectics are targeted with the couple including acceptance v. change, closeness v. conflict, one partner’s needs v. the other partner’s needs, intimacy v. autonomy, and individual satisfaction v. relationship satisfaction (as cited in Oliver et al., 2007). Fruzzetti and Fruzzetti (2003) have identified five salient functions to include in conjoint DBT therapy, including skill acquisition (individual/relational skills taught in session), skill generalization (transferring skills learned in therapy to real life), client motivation/behavior change (collaborating with clients to identify and change dysfunction), counselor capability enhancement and motivation (acquiring and maintaining the requisite skills while maintaining motivation), and structuring the environment (treatment and home environments; as cited in Oliver et al., 2007). Oliver and colleagues (2007) report success with using components of Linehan’s DBT model (1993) and Gottman’s (1999) “sound relational house,” including the fostering of marital friendship by use of cognitive space for partners, enhancing fondness and admiration, turning toward each other versus turning away, positive sentiment override, conflict regulation, physiological soothing, and creating a shared sense of meaning within the couple (p. 69).                     

Challenges to couple therapy

BPD has been viewed as challenging to treat on the individual level, let alone the dyadic level. Adding to this challenge, some clinicians feel uncomfortable having frank discussions with clients regarding suicide and may tend to gloss over safety issues during initial assessment, and never revisit the subject. The relational instability and impulsivity associated with BPD requires thorough and comprehensive safety assessment as well as continuous safety monitoring throughout the therapeutic process, utilizing referrals as indicated for individual therapy or higher levels of care.  So, how can we determine who may be viable candidates for conjoint therapy when one party has BPD?    

Links and Stockwell (2001) proposed a three-level hierarchy for assessing whether a couple would be suitable for couple therapy. This was based on work by Hurt, Clarkin, and Marziali (1992) and identified three common BPD behavioral clusters: impulsive, identity, and affective. Links and Stockwell (2001) noted that while “selection of patients for couple therapy requires careful individual assessment of both spouses and a characterization of their psychological health and personality pathology” (p. 495), clients in the identity and affective clusters may benefit from couples therapy, however, those in the impulsive cluster were not generally good candidates for couple therapy due to “self-destructive and treatment-threatening behaviors” (p. 496). Other factors to consider whether couple therapy for BPD may be appropriate include the presence of children being affected by relational conflict, the additional financial cost that individual therapy before or during couple therapy would require, and therapeutic autonomy—the extent to which a client has a say in their treatment process (Oliver et al., 2007).

Protective factors and safety planning

Families of clients with BPD can benefit from therapy, since interactions with one with BPD can be distressing. Additionally, family members may benefit from understanding the behavior patterns within BPD and to learn strategies to avoid conflict, reduce problematic symptoms, and improve overall functioning (SAMHSA, 2019). Couple therapy can help families better understand and support a relative with BPD. Some couple therapies focus on skill building to address BPD symptoms, while others identify the needs of family members to better understand the strategies and challenges for assisting family with BPD (SAMHSA, 2019). Couples engaging in conjoint therapy must be assessed and monitored continuously for other safety concerns including Intimate Partner Violence (IPV) and parasuicidal, self-harm behaviors such as cutting. Any time safety is in serious question, whether from suicidal, parasuicidal, IPV, or substance use, it is time to pause couple therapy and immediately address the safety concerns.

Formal safety planning, such as Stanley & Brown’s (2012) Safety Planning Intervention (SPI) has been shown to be beneficial, and is considered a best practice by the Suicide Prevention Resource Center (Joint Commission, 2020). SPI is used for assessing suicidal persons in a variety of inpatient, outpatient, and crisis settings, and includes the following steps:

a) Recognizing the warning signs of an impending suicidal crisis

b) Using internal coping strategies

c) Using social contacts and settings to distract from suicidal thoughts

d) Contacting family members or friends to help resolve the crisis

e) Contacting mental health professionals or agencies

f) Reducing the means to complete suicide (Stanley & Brown, 2012)

Safety planning can be a particularly useful tool in the context of couple therapy, as having a partner involved may prove helpful to accurately recognize warning signs, assist to identify social contacts, settings, and family members who could be helpful when in crisis, and keep the environment safe for the client by reducing lethal means of harm.

The authors each spent part of their doctoral practicum in a psychiatric hospital inpatient setting completing safety planning sessions with patients and their family members prior to discharge. This process utilized a plan similar to Stanley & Brown’s (2012) SPI model, and proved to be very helpful getting families involved directly and collaboratively with patients and clinicians to address patient safety. This hospital also used the question of why the patient wanted to use their safety plan to stay safe. The answer to this question often included family members such as children, partners, siblings, parents, and even pets, and also contained reasons of values, religious or spiritual beliefs, and future plans such as travel, college, or a dream job. 

The authors further broke down the warning signs to include specific thoughts, feelings, behaviors, and physiological symptoms that may be red flags for patient or family; internal coping strategies to include both physical and mental activities; clarifying different boundaries between persons utilized for distraction, and family and friends utilized for more personal help; the various levels of professionals who can assist, including the importance of calling 911 anytime one feels unsafe and crisis hotlines and text lines anytime in crisis; and collaborating with patients and their family to reduce lethal means. This last step offered a unique opportunity for partners to actively assist the patient in making the environment safer. Securing any firearms was critical, and often allowed patient and family to start conceptualizing suicidality as something outside of the couple they could address together. Another common safety concern was that of medication, particularly when the patient was compelled to use medication to overdose.  Here, a patient and partner could collaborate to secure and distribute medications, allowing for patient medication compliance, as well as peace of mind for family worried about an overdose.

Having a partner involved with safety planning enhanced patient safety by bringing the couple closer together and working collaboratively to support the patient. This also reassured the partner, and allowed for an open, honest, empathic, and collaborative conversation between patient, partner, and clinician. Revisiting the safety plan throughout the course of couple therapy keeps the couple at the center of the safety discussion.    

The relationship between a client and partner can be a valuable protective factor for clients with BPD. Lewis (1998) noted the natural healing aspects of relationships were present even in clients with disorders particularly difficult to treat (as cited in Links & Stockwell, 2001). The significance of healing relationships has not been fully recognized despite the potential advantages couple therapy may have for clients with BPD (Links & Stockwell, 2001). Accurate assessment of clients and their appropriateness for couple therapy is paramount, as is safety planning, and continuous monitoring for suicidality, parasuicidal behaviors, substance use disorders, and IPV. This consideration allows the clinician to safely explore the possible benefits of couple therapy for clients with BPD.  See safety plan example on next page.