The Borderline Mother and Her Child: A Couple at Risk

Introduction

The child of a mother diagnosed with borderline personality disorder (BPD) is at risk for developing this personality disorder (Zanarini, Frankenburg, Yong, Raviola, Reich et al, 2004; Feldman, Zelkowitz, Weiss, Vogel, Heyman & Paris, 1995; Gerull, Meares, Stevenson, Korner & Newman, 2008; Herr, Hammen & Brennan, 2008). The mother with BPD may be limited in her ability to negotiate successfully a secure attachment with her baby. In addition, the environment may not be supportive, since BPD traits are found more commonly in relatives of individuals with BPD (New, Hazlett, Buchsbaum, Goodman, Mitelman, et al. 2007; Kendle, Aggen, Czajkowski, Roysamb, Tambs et al., 2008; Siever, 2005; Torgensen, 2009). Psychiatrists should consider the ability of their pregnant patients who have BPD to meet the demands of being a mother.

Unfortunately, most women with BPD entering treatment do not discuss difficulties they may be having with their infant interactions, and may lack insight into those issues. Problematic maternal-infant interactions have been observed in mothers with postpartum depression (Barker, 2012; Rishel, 2012). Studying the psychodynamic underpinnings of a mother with a dysfunctional internalized object as she is transitioning to motherhood may positively impact her role as a maternal object. The clinician can intervene with early education and referrals to maternal child programs.

The author presents two cases of patients with BPD who underwent weekly Dynamic Deconstructive Psychotherapy (DDP). This treatment helps to connect patients to their experiences, to enhance authentic relatedness, and to remediate neurocognitive deficits in emotion processing (Gregory & Remen, 2008). It has been shown to improve symptoms and social interactions among individuals with BPD and concomitant alcohol use disorders (Gregory, Delucia-Deranja, & Mogle, 2010).

The first case presents a mother who received DDP treatment for two years after she surrendered custody of her two children to their father. During treatment the patient developed insights regarding her relationships both with her mother and her children, and how the former influenced the latter, including how she functioned as a mother. The second case describes a mother who presents for dyadic therapy with her three-month-old daughter. The patient had been receiving DDP therapy for one and a half years and welcomed parent-child intervention.

Case I.

Beth entered therapy at the age of 24 years following multiple serious suicide attempts, chronic self-injurious behaviors, and a psychiatric history that included years of therapy for bipolar disorder, posttraumatic stress disorder (PTSD), dissociative identity disorder, and BPD. Hospitalizations often occurred only weeks apart and following a serious suicide attempt. Multiple medication trials only dulled her cognition. She was referred for psychodynamic therapy following discharge from another facility.

Beth questioned the reason for her painful existence when she entered weekly DDP. She was extremely intelligent, frustrated, and ambivalent about having to meet yet another therapist since she had fired so many others. However, this time she felt trapped. She was unemployed and living at home with her mother who also had BPD. Beth’s two children were placed in the custody of her husband, and she had no communication with them.

Approximately one year after starting therapy, Beth felt she could tolerate life without dissociating daily. And one day she recalled a memory that made her feel connected to the past: When Beth was about two years old, her father would read to her at bedtime. Unfortunately, her parents soon divorced, and Beth’s next vivid memory was the day her father walked out of her life. She remembered and could identify that feeling: It was the cold and numbing state of “abandonment.”

Beth recalled that her mother was a “super nurse” who worked endless hours to fulfill her own needs. Her mother remarried one year after Beth’s father left the house. The new “father” brought guilt, shame and anger into the house. Her stepfather repeatedly molested her younger brother. As the older sister, Beth decided to protect her brother by distracting her stepfather and hiding her brother. This resulted in Beth being physically abused by her stepfather. When Beth’s mother later learned of the situation, she attributed the “story” to the children not liking their “new father.” This was beginning of Beth’s need to dissociate as a defense mechanism. She could detach herself and stay in a dreamlike state or watch herself and others as if she were performing.

Beth recalled her preschool years consisted of endless hours alone in a rocking chair staring at the wall. She used a fantasy of being rescued from her circumstances to fill the emptiness within her. When Beth was 11 years old, her mother incidentally mentioned Beth’s biological father died. Instantly Beth gave up all of hope of becoming a person. She became more hopeless and helpless and lost all connectedness to life.

During junior high school, she needed to self-mutilate to feel “something.” Soon, she was cutting deeper and deeper to see the flow of warm, pulsatile blood. She recalled wanting to feel anything, even pain, so that she would know that she had life within her. The flow of blood reassured her that she was alive.

Beth reported that she fell “in love” with a guy who “loved her.” She noted that sex was mechanical and traumatic, however, she soon became pregnant. She tried to keep her pregnancy a secret as long as possible, but soon married to please her mother. Beth tolerated a loveless, abusive, unfaithful marriage. Her husband controlled her, and she obeyed as if she were a child. Three years after they married, she had a second child. Beth lived in emotional extremes, as a good/bad mother and wife. When Beth felt that she was “bad,” she self–destructed physically and mentally. She used knives to inflict deep cuts over her body, and she scourged herself with a thick, handmade braid. She remained isolated and lost her sense of self and time. This resulted in hospitalization due to an overdose.

Beth’s husband left her and he remarried. Her periods of dysphoria and dissociation continued to increase in severity and duration. She struggled to raise the children, who often stayed with family members for months at a time due to Beth’s frequent (up to 10 per year) hospitalizations. She was treated with multiple medications, which just made her life more of a blur.

Eventually, child protective services removed Beth’s children from her care due to neglect. In therapy she could not recall her children’s childhoods. She spoke of the shame she felt from the days when she had custody of her children, and having had her son find her unconscious after the overdoses. She came to realize that no matter how hard she tried, she could not be the mother that her children deserved. Finally, she when her children were ages six and eight years old, she gave custody of the children to her husband. They moved to another state and refused all contact with her. She began to wonder: “When will my daughter will start cutting?”

Case II.

Ann is an 18-year-old single mother raising her three-month-old daughter with the support of her adoptive parents. She had been treated with DDP for 18 months.

Ann was adopted at the age of three months from a foster home. She reported her adoptive home was restrictive, “cold,” and unemotional and that she endured years of physical abuse by her adoptive father and verbal and emotional abuse by her adoptive mother. Subsequently, she ran away from home at the age of 13 years, living in multiple places. She returned home and attended high school, during this time she was quite popular. At the age of 15 years, she was sexually assaulted by a stranger at a party. When she was 16 years old she was again sexually assaulted by a “friend.”

Ann was admitted to inpatient psychiatry for multiple suicide attempts, including trying to cut her jugular vein and multiple overdoses. Ann’s history reveals that her biological mother had been diagnosed with BPD. Ann became more depressed when she learned she was four weeks pregnant. At eight weeks into her pregnancy, she discontinued her anti-depressant medications and attempted suicide. She knew the father of the baby and stated that the child was not conceived in an abusive relationship or by rape. She considered an abortion; however, she could not get an appointment at the Planned Parenthood Clinic.

Ann worried that the baby would have a congenital or mental defect. She had a sensation in her heart and her mind that she was not carrying a healthy baby. She was also concerned that because both she and her biological mother had psychiatric disorders that these might may be passed on to her offspring. Ann told her doctors that she wished her parents had aborted her. She said that she did not feel psychologically or mentally stable enough to have a child. She often pondered whether she should have had an abortion, followed by suicide.

Ann and her baby attended dyadic therapy. Ann appeared content, bottle-feeding her baby, and the baby was very bright and happy. Ann hesitated before allowing the therapist to hold the baby, who responded to the cosseting with smiles and coos. When the baby was returned to Ann, held the baby in a mechanical fashion and talked without attending to the child in her arms. She explained she was worried because her baby did not look into her eyes and seemed to look away. Ann had many questions regarding child development and parenting skills. She needed to be instructed regarding brushing the baby’s cheeks and tummy and simple methods of gaining the baby’s attention. Ann practiced initiating and making eye contact with her baby. She practiced engaging her baby, which was reinforced by the baby smiling and cooing. Ann was developing an attachment that was a unique experience for her. Ann learned to “check in” with her baby periodically when she was attending to another task. However, she was worried that the baby would grow up and no longer need her, despite all that she was doing for her child now. Dyadic therapy for the mother and child as well as individual DDP therapy for the mother was recommended. These two therapies would foster attachment between mother and child while promoting Ann’s mental health.

Discussion

Infants seek proximity to another human, which is most commonly the mother figure. This is the beginning of distinguishing self from the “other” and development of a cohesive self. Congruent with the theories of Freud, Bowlby, and Klein, an infant “takes in” or internalizes the essence of a mother (Evans & Porter, 2009). The image that is internalized may be that of a “good” mother, who is a source of comfort, pleasure and safety, or conversely, a lack of maternal image due to neglect, an unavailable, or incomplete maternal image (in these cases because of a mental disorder) will impact the baby’s perception of the world. Many important events occur during this bonding period, which is critical to the infant’s successful psychosocial development. It is during this time that the mother with BPD may need interventions and encouragement to facilitate the process of bonding.

Mutual gaze between infant and mother, the mother’s proximity to the infant, and the mother’s response to baby’s sounds and movements mark the beginning of reciprocity and bonding between mother and infant (Hobson, Patrick, Crandell, Garcia-Perez & Lee, 2005). The mother and baby develop rhythmicity and remain in tune for feedings and during periods of frustrations and pleasure. Mothers imitate the “external” behaviors such as cooing, babbling, reaching, smiling and clinging to their infants very early in the child’s life. By the time the child is six months of age, the mother should also imitate the baby’s “internal” behaviors. For example, a content infant will smile and make eye contact with the mother. Through the process of mirroring, the mother makes a comforting gesture or smile. This reinforces a prosocial facial expression in the infant, which in turn, reinforces the mother’s role in this reciprocal relationship The latter may be problematic for the mother with BPD. This awareness and imitation of feelings or “affect attunement” may be difficult for a mother who is unable to identify her own feeling states. Affect attunement involves the mother being capable of identifying the infant’s inner feelings, followed by her ability to convey an appropriate emotion back to the infant, who then mirrors and internalizes the maternal response to the original emotion (Legerstee, Markova & Fisher, 2007; Stern, 1982; Jonsson, Clinton, Fahrman, Mazzaglia, Novak et al., 2001). Without affect attunement, the baby may not develop a secure attachment (Bowlby, 1988).

Mirroring is another important response of a mother when an infant attempts an interaction. If an infant smiles and the mother mirrors back a smile or makes pleasurable contact, this prosocial facial expression is reinforced in the child. Without mirroring, the infant will not gain awareness of mother’s behaviors. Mirroring also teaches the baby that she has a role in reciprocal interactions. Maternal mirroring is believed to influence the social expectancies of the baby (Legerstee, Markova & Fisher, 2007; Fonagy & Bateman, 2008). The temperament of the baby, as well as the psychological constructs of the BPD mother, may interrupt any or all of these events. The dyad may not ever attain rhythmicity, harmony and mutual contentment (Stern, 1982).

When a mother with BPD looks into the eyes of her child, she may not share the feelings of contentment or happiness that other mothers experience. Her personality deficits may not allow her to attach securely, mirror or separate from her child. Fragmentation prevents her from feeling emotionally connected. She may look at her baby as someone who requires perfunctory duties. Mother and child may remain chronically mismatched. As a result, the baby will not internalize a good mother object since the baby does not have a bond with the mother. Through DDT, Ann worked through and understood her own insecure attachment with her mother. She was able to individuate and develop a self. She learned that a great deal of her anxiety was related to the fear of annihilation that might occur if she were to separate from the mother she so longed to please. She learned to self sooth herself in non-destructive ways. As she became an unfragmented self, she was able to meet the needs of her child. Ann was free to form an attachment and tolerate the separation-individuation of her child.

Ann also developed the ability to mentalize. This is the capacity to accurately assess or interpret another’s thoughts, needs, desires, beliefs, goals, or feelings, requires mirroring (Fonagy & Bateman, 2008). A mother needs to internalize her child and reflect the feelings and emotions back to her child. It is through this process that the individual develops self-regulation and a sense of being connected to others. If the mother is unable to construct an internal representation of the child, affect attunement is not attained and the ability for mentalization may be compromised. Normally, a baby individuates from the mother to develop a sense of self. The baby can then understand that the mother has her own thoughts and feelings. Mothers BPD often have personal boundaries issues. The mother may have overly rigid boundaries so that the baby cannot bond. Conversely, a lack of boundaries may prevent the baby from becoming emotionally differentiated and individuated (Gregory & Remen, 2008).

Mirroring, and consequently mentalization, cannot occur without the presence of the “other” that has a permanent unique existence. The mother as the agent of trust becomes the basis for the development of the baby’s self and “object constancy.” Following separation-individuation from the mother, the baby becomes a “self” and can distinguish the presence of another that is constant, distinct and separate. Mahler, M.S. (1971).

It is through mirroring and internalization that the child learns emotional regulation. (Newman & Mares, 2007; Newman, Stevenson, Bergman & Boyce, 2007; Newman, & Stevenson 2008). A lack of ego boundaries and the inability to separate the needs of mother and child will prevent the child from acquiring the skills to self-regulate emotions. The mother cannot function as a mirror by which the child also learns about himself and his ability for emotional regulation. The mother may fear a loss of part of herself if the child learns to become separate. The inability to mirror herself and the inability to self-reflect prevents her from seeing the impact of her poor parenting on her child and the child’s response to her. It may take an outside observer to help the mother mirror herself, the infant and the dyad. Infants who lack object constancy, cannot sense a“ holding environment.” This is a condition provided by the mother in which the infant feels contained and can self-integrate. The persistent lack of a holding environment may begin with the child protesting and progressing without a secure attachment (Bowlby, 1988; Blum, 2004; Sroufe 2005; Newman & Mares, 2007). Development without object constancy, self-integration and evocative memory, will prevent the baby from developing the ability to self-soothe and there is a risk regression as a means of managing stress (Adler & Buie, 1979). This, in turn, may affect the child’s ability to internalize and express emotion. (Crandall & Hobson, 2003)

Women with BPD often describe an intense desire to have a baby. They unconsciously believe that this baby will develop into the idealized object that will “complete” them, fill the internal “emptiness,” or become the idealized person. This new entity provides the mother with BPD an opportunity to create something good because the baby is split from the “badness” within the mother. This baby is concrete proof (in a delusional sense) that the mother is good and worthy for a period of time. To the mother with BPD, the baby symbolizes the person who will love and never abandon her. However, as the infant begins to make demands that the mother is not able to meet, the BPD mother may feel incompetent and find less satisfaction in parenting (Newman, Stevenson, Bergman & Boyce, 2007). In addition, as the infant begins to develop and learn the word “no” along with increasing demands for autonomy, the mother may begin to feel anxious. The mother may interpret these strivings towards individuation as rejection or abandonment (Masterson, 1986).

Beth dealt with the shame of inadequate parenting. She inflicted self-injury to punish herself for the mental torture she felt that her mothering had imposed on her children. However, the children were a reason for her existence. She knew the terrible feeling of abandonment and did not want that for her children. With treatment, she learned that this intensity of abandonment is not a universal feeling. With resolution of her conflicts, she was able to relinquish her children without fearing that they would suffer from the same horrific feeling. Ann was able to overcome her feelings of abandonment by her mother through early treatment.

If the mother with BPD was a trauma victim prior to pregnancy, she is at risk for reenactment of the trauma during periods of stress. Birth and the postpartum period are stressful times so that previous trauma may recur and impact her relationship with her infant (Newman, Stevenson, Bergman & Boyce, 2007). The traumatic experience includes the “fight and flight” phenomenon and this can negatively impact maternal-child bonding (Lyons-Ruth, Alpern & Repacholi, 1993). Resentment and disconnection may occur if the mother with BPD questions the need to nurture her baby since she was victim and needs nurturing herself The relationship between the mother and infant may then be hostile (Hobson, Patrick, Crandell, Garcia-Perez & Lee, 2005). Conversely, trauma may induce a more intense bond, with an inability to separate from the child (Reich & Zanarini, 2001). As a result, rapprochement may be negatively impacted by a mother who is unable to let go. During the rapprochement phase, the child needs maternal empathy since there is a tendency for the child to split the mother into good and bad. The mother must tolerate the child’s unpredictability, which is difficult for the BPD mother (Mahler, 1971; Mahler, Pine & Bergman, 1975). If the mother with BPD reflects emotions of anxiety, anger or shame at the time of separation, the infant may not develop a secure base to which to return to upon experimental parting during individuation.

Mothers with BPD may not be able to cope as well as other new mothers due to a lack of social supports. Unfortunately, BPD mothers often have difficulties with establishing long-term, supportive relationships. The baby’s father or other significant individuals may not be present. There is a struggle between their desire for closeness and fears of intrusiveness and being consumed by another individual. In fact, due to the mother’s boundary inconsistencies, the baby may be seen as intrusive upon mother’s sense of self, and closeness to the baby may result in anxiety and distress. The mother may reject the infant due to an inability to tolerate feelings of intrusiveness. In addition, the incorporation of a new object threatens the loss of any previous introject or the loss of the self (Alder & Buie, 1979). In contrast, some mothers with BDS may lack sensitivity to infant cues and be more intrusive, causing these mothers to emotionally “consume” the infant in an inconsistent and extreme way, causing distress in the infant (Hobson, Patrick, Crandell, Garcia-Perez & Lee, 2005).

Having BPD may impact the ability to parent. There may be chronic feeling of guilt secondary to aggression during the new mother’s own separation and individuation process. This guilt and anger can then be projected on to her child during the individuation. The child will meet with resistance and anger as he/she attempts independence, resulting in feelings of shame, anger, and depression. The child needs to know that a mother will love him/her (despite aggressive acts toward her) and will be accepted and loved unconditionally. The child can then move beyond feelings of badness and depression cause by the intrapsychic conflict of staying dependent upon the mother and becoming independent. As a result of individuating, the child can go on to develop fantasy, communication skills, affect (a personal unconscious state that cannot be easily expressed by language), and feelings (sensations that are compared with prior experiences and have biographical and personal components). Following independence, the mother-child relationship continues and allows for the development of language and other developmental skills.

Borderline personality disorder often interrupts parenting because of maternal hospitalizations, and may result in difficulties for the child, who is ambivalent and unsure of the connection to the maternal figure. The child may appear “hungry” for attachment, but then reject the often-missing mother. The fragile ego of this toddler is especially vulnerable toward fragmentation in the presence of a mother who does not function as a “good enough” mother (Winnecott, 1960; Winnecott, 1965). When the mother is absent due to hospitalization, the child may experience “recognition memory rage with severe anger and rejection upon her return” (Adler & Buie, 1979). Anna Freud (1969) found that brief absences at critical developmental periods, such as the second year of life without an empathic“ good enough” support places the child at risk for later vulnerabilities.

Adolescent girls whose mothers have BPD often have difficulties with self-perception and social interactions, in addition to problematic mother-daughter relationships. Environmental and genetic factors contribute to problems in adolescence. A lack of social skills and poor role modeling for emotional regulation and interpersonal functioning makes the adolescent period especially difficult to master (Herr, Hammen & Brennan, 2008).

Conclusions

There is evidence that children of women diagnosed with BPD are at risk for developing BPD. (Feldman, R.B., Zelkowitz, P., Weiss, M., Vogel, J. Heyman, M., & Paris, J, 1995; Gerull, F. Meares, R. Stevenson, J. Korner, A. & Newman, L., 2008; Herr, N.R., Hammen, C., & Brennan, P.A., 2008; Zanarini, M., Frankenburg, F., Yong, L., Raviola, G., Reich, D. et al., 2004). Mothers with BPD may have difficulties with bonding, internalization, affect attunement and attachment. The child may fail to develop object constancy and master the tasks of individuation, separation and rapprochement. It is through mirroring and mentalization that a child can learn emotion regulation and master the early stages of development. BPD mothers may require interventions to help them improve their maternal-infant relationship. Psychiatrists need to assess their pregnant patients, especially those with depression and BPD, for potential problems in the maternal role. They may benefit from dyadic therapy for mothers and their babies.

Other medical disciplines need to increase their awareness of this association. Primary care physicians, as well as obstetricians, need to address women’s and the new mother’s mental health. A screening questionnaire for BPD might be considered as a means of referral for a psychiatric evaluation in high risk individuals. Pediatricians can utilize psychoeducation to discuss the responsibilities of having babies with their adolescence girls. This may help dismiss the myth that having your own baby makes you feel loved. Treatment of women with BPD prior to motherhood would highly impact the lives of their children and their relationships.