Borderline Personality Disorder: Challenges During the Perinatal Period

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There is limited evidence-based information about interventions that can help patients with borderline personality disorder (BPD) transition to parenthood. Although dialectical behavioral therapy (DBT) is accepted as the mainstay of treatment for BPD, perinatal-focused DBT is under pilot research at this time.

Current research is focused on DBT in combination with skill sets that can improve the patient’s confidence. This article will focus on a discussion of some BPD traits and how these traits can affect the transition to parenthood. We will also look at treatments and interventions that can support this difficult transition.

As Joan Raphael-Leff, PhD, observed in 1982, “We often tend to forget that the purpose of pregnancy is not merely to create a baby but to produce a mother [parent].”¹ Becoming a mother involves reprioritizing all the roles that are integrated into a woman’s self-concept. This process is a balance between the external expectations of society and the internal demand for maintenance of self-image. The transition to parenthood can be a challenging psychological process in which there is a discrepancy between role perception and self-image.

This transition is even harder for patients with mental illness, traumatic life events, socioeconomic difficulties, and/or lack of early positive parenting experiences. Parents with BPD have most of these risk factors. For parents with BPD who already struggle with marked and persistent unstable self-image or sense of self, attainment of the parental role can be very challenging. There is growing evidence regarding the benefits of supportive interventions in the perinatal period for all parents in general, but even more so for parents with BPD.

BPD and Parenting

According to Donald W. Winnicott, FRCP, a “good enough” parent is a “container” for the baby’s distress and should have the critical ability to create a holding space for this distress.² For parents with BPD, the baby’s distress can evoke their own trauma memories and responses, making it difficult for them to provide that “holding environment” for their baby.³

Following is a detailed discussion of some BPD traits and parenting behaviors. A summary of BPD traits as mentioned in DSM-5-TR and their effects on parenting is also detailed in the Table.^4-14

Table. BPD Traits and Their Effects on Parenting^4-14

Possibly due to their own traumatic experiences, parents with BPD may be overprotective and overinvolved (intrusive parenting) with their offspring during both infancy and adolescence.⁴ When exposed to manageable, age-appropriate stressors, children plan, initiate behaviors, detect errors, and learn from those errors. This helps with ego resilience and distress tolerance. Intrusive parenting takes away such opportunities in a child’s play.⁵

Fear of abandonment in the parent can create a “role reversal” in the home, with the child taking on the role of a caregiver. This boundary violation between the child and the mother can create role confusion and affect the development of the child’s identity in the long run.⁴

Parents with BPD may have difficulties understanding their own feelings and may lack skills to manage their own emotions. In turn, they may have a hard time modeling to their children appropriate expression and management of emotions.⁶ They may also have a decreased ability to interpret and respond to their child’s emotions⁷ and may invalidate the emotions of their children.⁸ This can lead to children denying or questioning their own emotions and emotional responses.⁹

A child’s sense of self is determined by multiple factors including, but not limited to, the various social interactions they have and how they interpret these experiences. Children’s self-views may reflect both early emotional tendencies and the ways in which parents differentially respond to these emotions.¹⁰

We can hypothesize that parents with BPD who struggle with their own sense of self and have difficulty recognizing and responding to the child’s emotions will not be able to create an ambient environment for a child to develop their own sense of self.¹¹ Additionally, children may be a witness to the parent’s intense mood swings and stormy relationships, suicide attempts or self-harming behaviors, and/or substance use.¹²

Intrusive parenting and inconsistent interactions with offspring can result in role confusion, poor concept of self, and difficulty identifying and expressing emotions in the offspring. Children who have these difficulties in their own development may grow up to be parents and have the same struggles with their own children. In brief, these effects on child development and behavior imply a vertical transmission of BPD traits to the child.¹⁵ Thus, BPD can be transmitted through generations.

Interventions

Most individuals struggle with the transition to parenthood, especially due to a lack of knowledge and skills concerning infant care. This sense of incompetency can increase identity confusion.¹⁶ Every parent, especially first-time parents, can benefit from training and support through interventions that focus on decreasing their anxieties surrounding infant care. This will help improve parental role attainment and identity formation.^16-18

Although DBT is considered the mainstay of treatment for BPD, attachment-based interventions might be more helpful for the transition to parenthood. Attachment-based interventions focus on encouraging parents to talk about their own childhood experiences and to make a connection between those experiences and their current relationship with the child.

Attachment-based interventions can be helpful in addressing some core conflicts for parents with BPD; however, the lack of knowledge and skill in caring for a child can also be a huge source of distress.⁶ Psychoeducational interventions that focus on education regarding childhood development and skills to provide consistent care—including consistency in environment, consistency in warmth and nurture, and consistency in behavioral and emotional responses—may also be helpful in increasing parental confidence.

Emphasizing these needs, several pilot programs have been developed. Florange and Herpertz highlight 2 DBT-based parenting programs and 1 group therapy based on general parenting interventions. These were designed specifically for mothers with BPD.^15,19-22

In their systematic review, May et al concluded that preliminary evidence indicates that a combination of DBT group skills, mother-baby unit admissions, child-parent psychotherapy, and home visiting programs can help with BPD symptomatology, healthy attachment, and enhancement of parenting capability. However, further research is required to develop more specific guidelines.²³

Concluding Thoughts

Study findings show that there is no evidence to suggest that parents with BPD lack a desire to care for their child—they simply may not be fully equipped with the full range of tools for parenting.⁴ The skill sets that they lack do not appear to be only related to the core symptoms of BPD but are also related to a lack of proficiency in providing basic care to a child.

Lack of mastery in childcare is a common problem for any mother. For mothers without BPD, this lack of knowledge can easily be overcome with family involvement or through infant-care classes. Parents with BPD often do not have parental role models to support them and may be afraid to seek out classes or treatment because of concerns about child protective services. Theymay also experience ambivalence between a desire to engage and a fear of accessing support or asking for help.²⁴

Our goal should be to develop programs that can help improve confidence and emotional regulation in parents with BPD and the mother-offspring relationship. Given the stigma related to BPD and mental health treatment in general, we should be creative in bringing such skill-improving programs to all parents and to parents with BPD in particular. These steps can impact several generations by putting a halt to the intergenerational effects of parenting with BPD.

Dr Nagalla is the residency program director in the Department of Psychiatry at Western Michigan University Homer Stryker M.D. School of Medicine in Kalamazoo. Dr Riba is deputy editor emeritus of Psychiatric Times, and a clinical professor in the Department of Psychiatry and director of the PsychOncology Program at the University of Michigan Rogel Cancer Center in Ann Arbor.

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