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A challenge for perinatal psychiatry: Therapeutic management of maternal borderline personality disorder and their very young infants

Authors:
  • Groupe Hospitalier Le Havre, Le Havre France, Université de médecine Rouen Normandie

Abstract

Borderline Personality Disorder is one of the most common referrals in psychiatry of young adult women. The course of Borderline Personality Disorder (BPD) is frequently associated with Major Depression orienting some of the postnatal mood disorders towards a more complex entity. The relationship-based disorder with impulse control and emotional regulation as core symptoms cannot but impact directly and indirectly, on fetal and infant development and on mother-infant interaction. History of abuse and unresolved trauma are often connected to the borderline mother’s confused perception of herself; she has lost the capacity to share experience as if deprived of the ability to share “time” with her infant. Borderline mothers interact intrusively, off-beat, with their infants, as if keeping in track with their inner agenda, adapting not to the infant’s emotional cues, but to their own. The therapeutic settings that need to be implemented must address both mother and infant disorders, the interactions, and the different rhythm and speed with which each of the partners of the dyad react to intervention. Considering our new data on BPD, and mother-infant programs for high-risk population, intensive therapeutic interventions including specialized infant psychiatric care should be organized. Infant Mental Health professionals offer multiple weekly meetings, based on mother-infant psychotherapeutic sessions, tailored for this hard-to-follow population, and one or more weekly interventions by psychomotricians and/or play therapists, focused on the infant in the mother’s presence. Adjunctive maternal psychotropic medication is not within the realm of this paper and therefore will not be discussed.
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Clinical Neuropsychiatry (2005) 2, 5,
© 2005 Giovanni Fioriti Editore s.r.l.
302-314
RECEIVED OCTOBER 2005, ACCEPTED DECEMBER 2005
Summary
Borderline Personality Disorder is one of the most common referrals in psychiatry of young adult women. The
course of Borderline Personality Disorder (BPD) is frequently associated with Major Depression orienting some of
the postnatal mood disorders towards a more complex entity. The relationship-based disorder with impulse control
and emotional regulation as core symptoms cannot but impact directly and indirectly, on fetal and infant development
and on mother-infant interaction. History of abuse and unresolved trauma are often connected to the borderline mothers
confused perception of herself; she has lost the capacity to share experience as if deprived of the ability to share
time with her infant. Borderline mothers interact intrusively, off-beat, with their infants, as if keeping in track with
their inner agenda, adapting not to the infants emotional cues, but to their own. The therapeutic settings that need to
be implemented must address both mother and infant disorders, the interactions, and the different rhythm and speed
with which each of the partners of the dyad react to intervention. Considering our new data on BPD, and mother-
infant programs for high-risk population, intensive therapeutic interventions including specialized infant psychiatric
care should be organized. Infant Mental Health professionals offer multiple weekly meetings, based on mother-infant
psychotherapeutic sessions, tailored for this hard-to-follow population, and one or more weekly interventions by
psychomotricians and/or play therapists, focused on the infant in the mothers presence. Adjunctive maternal
psychotropic medication is not within the realm of this paper and therefore will not be discussed.
Key Words: Mother-infant interaction  Maternal Borderline Personality Disorder  Infant development  Mother-
infant psychotherapy  Infant development  Psychomotricity  Perinatal care
Declaration of interest: none
Gisèle Apter-Danon, MD, PhD, Perinatal Psychiatry and Psychopathlogy Lab, Erasme Hospital,
University Denis Diderot, Clinical Human Sciences, Paris 7. Aubier, Centre du Tout-Petit,
Drina Candilis-Huisman, Maître de Conférences HDR Université Denis Diderot Paris 7 Sciences Humaines Cliniques
Corresponding Author
Gisèle Apter-Danon, MD, PhD, Perinatal Psychiatry and Psychopathlogy Lab, Erasme Hospital,
University Denis Diderot, Clinical Human Sciences, Paris 7. Aubier, Centre du Tout-Petit,
121 bis Avenue du General Leclerc - 92340 Bourg-la-Reine, France. Tel. +33 1 41 87 04 01,
Fax +33 1 41 87 04 05 - Email Gisdanap@aol.com  gisele.apter-danon@eps-evasme.fr
A CHALLENGE FOR PERINATAL PSYCHIATRY: THERAPEUTIC MANAGEMENT OF MATERNAL
BORDERLINE PERSONALITY DISORDER AND THEIR VERY YOUNG INFANTS
Gisèle Apter-Danon, Drina Candilis-Huisman
Introduction
Adult and child psychiatrists have now been con-
sidered as specialists for decades. Perinatal Psychiatry
is however a newer discipline. It is both the search for
the earliest recognizable risk factors of child and /or
adult psychiatric disorders as well as the quest for pre-
vention. Pushing back the boundaries of general psy-
chiatry has led clinicians and researchers to explore such
subjects as infant, or perinatal psychiatry, thus study-
ing the psychological aspects of different periods of
life, that turn out to be distinctive fields in themselves
with their own diagnostic criteria and symptomatology.
As children have been continually referred at an
ever younger age, parental role has captured more at-
tention. Abandoning the too simplistic idea of causal
etiopathogeny in childrens pathology, parents and par-
ent-child relationship have come under new scrutiny.
Understanding actual disorders and their outcome with
greater complexity in mind is one aspect; enhancing
the more positive aspects of parent-child relationship
and alleviating the negative ones in a nonjudgmental
approach is another. Traditionally, in child psychiatry
the consultant meets with the childs parents and as-
sesses family functioning as part of the global evalua-
tion of the situation (this is still not standard in adult
psychiatry). If the child is an infant, the parents are
immediately in the forefront. Parent-infant interaction
will therefore be primarily focused on. The younger
the infant, the more the parental story, the pregnancy
and its circumstances will become the center of atten-
tion. Adult and child psychiatry are combined and in-
tertwine around the major event of the birth of an in-
fant. A new developmental and psychopathological field
is thus elicited, possessing two main branches: the vi-
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Therapeutic Management of Maternal Borderline Personality Disorder and their very Young Infants
Clinical Neuropsychiatry (2005) 2, 5
cissitudes of access to parenthood for the adult and the
study of the fetus, neonate and infants early emotional
development. The two domains are linked by a com-
mon paradox, the patient is not one but twofold. Both
mother and infant are the centre of interest, diagnosis,
assessment and treatment, alternatively one more than
the other.
The family as a whole may be impaired both by
the childs and the parents symptomatology, each one
having negative impact on the other in an often inextri-
cable way. It becomes impossible, and often non-perti-
nent for treatment (even if not so for research), to de-
termine how much of the adverse relationship is in re-
action to either the environment or the childs inner
capacity to cope. If original research is to continue in
view of determining different genetic, epigenetic, bio-
logical and environmental elements as risk factors to
relationships, it seems obvious that the need to manage
situations for which we have little therapeutic arsenal
stays a priority. It is especially the case, since part of
the factors, whether originally or not innate, are influ-
enced by environment and therefore by early life con-
ditions. In fact, what is known is that cumulative ef-
fects of adverse life events or social conditions always
increase negative outcome of psychiatric disorders
(Torgersser 2002).
Screening for infants at risk of emotional devel-
opmental and psychiatric disorders remains a challenge.
Many situations are not known or not recognized until
the disorders have set in. Moreover, ethical considera-
tions incite to great caution towards systematic assess-
ment. On one hand, it is necessary to avoid doubtful
diagnostic claims not only because of undue treatment
but also because of the impact of a diagnosis of mental
health disorder both directly on the immediate circle
and the social environment; and indirectly because of
the risk of stigmatization of patients (and in this case
both parents and infants are concerned) still exists.
Moreover, in infant psychiatry parental guilt feelings
are often very strong. Their painful emotions will need
to be sufficiently alleviated in order for families to seek
help and accept management and treatment of the dis-
tortions involved.
Womens mental health and maternity have re-
ceived specific attention especially in two domains,
puerperal psychotic episodes and their links both with
bipolar disorder and schizophrenia and Major Depres-
sive Disorder (MDD) (Kumar and Robson 1984). The
issue of gender has always been integrated into research
concerning personality disorders (PD), and particularly
borderline personality disorder (BPD) because of its
feminine prevalence (Golomb et al. 1995). However
maternity and personality disorder have not been stud-
ied. Considering the high rates of BPD and PDs in
general in psychiatric settings, it seems legitimate to
focus on such an issue. Moreover BPD is an impairing
condition for individuals during most of their young
adult years which happen to be for women the privi-
leged childbearing age. Focus on this pathology dur-
ing this period of life should now be upheld.
Since PDs are relationship-based and relationship-
oriented disorders with history of abuse, neglect and
trauma, more often than enough the question of
transgenerational transmission is investigated. Animal
studies have shown that neglected offspring of rodents
will display compromised behavior with their own
young (Newport et al. 2002). The different mechanisms
through which this takes place are still being explored,
even though different biological and neuro-endocrine
hypothesis are under way (Nemeroff 1996).
Both maternal and infant individual symptoms and
relationships therefore need to be looked into and cared
for. Ways of inadequately relating and coping are often
difficult to change. However at an earlier stage, when
both the infant and its manner of communicating and
connecting to the environment are still malleable to an
unknown degree, intervention can be quick and effec-
tive. Treatment designs need to keep the triple aspect
of mother, child and interaction in mind. In the field of
perinatal pathology a common consensus would be to
at least attempt to define and prevent what is prevent-
able, including infant developmental psychopathology
and psychiatric disorders.
The management of mothers with borderline per-
sonality disorder and their young infants therefore en-
tails a comprehensive approach, broaching across many
different fields, in order to develop adequate therapeu-
tic strategies. :
I. Knowledge of infant development in utero and dur-
ing the first two years of life;
II. Assessment and diagnosis of borderline personal-
ity disorders per se and its specificities during the
pre and postnatal period;
III. Evaluation of parent-infant interaction and envi-
ronmental impact on developmental milestones;
IV. Expertise of diverse psychotherapeutic techniques
including dyadic specific focused brief and me-
dium-term therapies.
We will examine all of these topics successively,
concluding on perspectives for clinical research and
their therapeutic applications.
I. Infant development and its mishaps
The human infant is an oddity in the mammal
world because of its premature birth even when it is
full-term. If the newborn was to have even the equiva-
lent of brain growth and competence of the young of
one of the large primates, it would possess at birth a
head the size of a six or eight-month old baby; there-
fore Gould argues with Passingham that it would ei-
ther never be able to cross the maternal pelvis or dam-
age it irrevocably (1979). This massive immaturity,
generally defined as infant neoteny creates a situation
in which the infants brain grows in a rich interactive
setting where the environment is incessantly multiply-
ing interactions, with considerably less filtering and
protection than in the maternal womb on one hand, but
with much more biological independence and autonomy
on the other.
The infants apparent helplessness, in itself, gen-
erates considerable impact on the environment; the
mother or caregivers must scaffold the infants needs
for many months (Vigotsky 1998). This in turn leads to
specific psychological aspects of parental attitude. Par-
ents will project and identify on and with the infant,
empathizing with the infants feelings, interpreting the
infants emotional expressions, gestures and
vocalizations, in tune with the infant. These non-patho-
304
Gisèle Apter-Danon, Drina Candilis-Huisman
Clinical Neuropsychiatry (2005) 2, 5
logical projective identifications are part of the moth-
ers aptitude for creative anticipation (Manzano et
al. 1998, Lamour and Lebovici 1989). The necessary
conditions for an infants well-being therefore enclose
both an adequate environment, and intact capacities to
interact with it.
The newborns neurodevelopmental states and
sensori-motor aptitudes, even if essential are not in
themselves sufficient to establish relationships. Their
functionality and the manner in which the babys
competences will be able to grow and prosper are linked
to the environmental conditions that they will meet.
One of the main ways of assessing the vulnerability
and resilience of the infant will be by examining how it
reacts to different situations and its way of coping with
novelty and complexity.
Ethological and experimental studies have paved
the way for research on the human neonates behavior.
We now know that the infant has already developed its
sensorial capacities in utero. Smell, taste, feel (touch
and pain), proprioception, audition and vision are all,
even if at different stages ready to develop in organ-
ized ways at birth. The neonate recognizes its mothers
specific odor (Schaal et al. 1980, 1998); it prefers sweet
tastes to others and is calmed by sucking on sugary
water (Tudella et al. 2000, Steiner et al. 2001). Audi-
tion has been studied for many years, both in the fetus
and the newborn, showing the infants early auditory
complex perceptive capacities, for sound, pitch and
rhythm (De Casper and Fifer 1980, De Casper and
Spence 1986), and its preference for its mothers voice
(Johnson et al. 1980) As for vision, if the infant is inca-
pable of accommodating, this does not impair the other
visual capacities which allow the baby to recognize and
favor human faces and to have a marked preference as
early as day two for its mothers face (Bushnell et al.
1989). Not only is the infant receptive to the world, but
he/she reacts and sends out signals in numerous ways.
These pointers will in turn induce reactions from the
caregiver sending the kick-off for interactive spirals of
different forms. Among these activating signals, emo-
tional expressions and particularly reactive smiles
(those triggered by a face-to-face positive interaction)
are of major importance (Campos and Stenberg1980,
Izard 1978). The relational smile progressively replaces
the automatic one and as early as six weeks may send
out encouraging messages, enhancing the
intersubjective dialogue between a mother and child
on beat with the vocalizations that the infant is rap-
idly able to express (Trevarthen 1979, 2001). Reversely,
whining, gaze avoidance and cries send off alert mes-
sages requiring interruption of current mode of inter-
action, indicating the infants early ability for expres-
sion of coherent intentionality and motivation (Tronick
et al. 1978, Tronick and Weinberg 1994). The infant is
also capable of imitation, if not from birth, very rap-
idly (a few hours or days) and swiftly develops expect-
ancies concerning the relationship it establishes with
an adult. Very early on, research has shown that
memory, and specifically implicit or procedural
memory, is at work combining infant positive and nega-
tive experience (Meltzoff and Moore 1992). For exam-
ple, the neonate remembers painful procedures dem-
onstrated by a quicker reaction of retreat when re-ex-
periencing blood-sample testing (Andrews and
Fitzgerald 1994). Memory of novel experiences has also
been established in a fascinating research by Nagy and
Molnar (2003). They suggest that the infant is a pro-
voking being; not only are human beings innately ca-
pable of remembering and imitating, but also of pro-
voking (intentionality of) interaction. Their research
took place in a setting where neonates interacted at a
distance of days with the same experimenter; and dis-
played at the second meeting the imitated gesture of
the first interactive experimental sequence while wait-
ing for the response of the researcher. They therefore
demonstrated how the infant is not only able to imi-
tate, but also to sustain an interaction at a distance within
the same interactive pattern, thus paving the way for
specific interactive communication between the baby
and its privileged partner. The active field of develop-
mental research tends to prove, that not only does the
infant display numerous skills, but also that he/she is
an active partner in interaction with the environment,
and therefore in the relationships that will emerge.
However, the infants complex neurobehavioral
development is difficult to appreciate comprehensively
and even more to characterize in such a way as to give
concrete signs of some predictive value of future de-
velopmental disorders. For instance, Developmental
Quotient (DQ) as assessed by such scales as the
Bayleys or the Brunet-Lezine in France is not signifi-
cantly correlated to IQ at a later age (Brunet and Lezine
1983). Infant developmental research has given infor-
mation, which at least tentatively suggests that at birth
and postnatally, maternal characteristics such as mood,
anxiety and stress have an impact on the fetus, on the
newborn child and on mother-infant interaction. Infants
of prenatally depressed mothers have been found to
have less ability to regulate changing of states and to
have more fine motor dysregulation (Diego et al. 2002).
Other maternal and infant pathology, such as high lev-
els of prenatal stress and anxiety and infant premature
birth seem, whats more, to influence jitteriness and
motor deregulation in the neonate (Pesonen et al. 2005).
These last two variables however are not independent,
since assessment of stress and anxiety prenatally is also
positively correlated to premature onset of labor and
even to intrauterine growth delay (Hougaard et al.
2005). Gender has also revealed itself an issue, boys
tend to have poorer regulatory mechanisms of emo-
tional states than girls, both alone and during mother-
infant interaction (Bornstein et al. 1986, Weinberg et
al. 1999).
Therefore, even if the mechanisms through which
this takes place remain essentially unknown, it is now
agreed that maternal emotional states and mood during
pregnancy have an impact on the infants development
in utero (OConnor et al. 2005, Van Der Bergh B. 2005).
There are no data available, as yet, as to which period
of the gravidum and/or even if the preconceptional
emotional state of the future mother has the most influ-
ence on fetal development.
The clinical impact of these research studies is
nevertheless strong. BPD with its own characteristics
of mood swings, feelings of emptiness or reversely of
rage and its frequent comorbidity of depression and high
levels of anxiety is a good candidate for impact on the
infants development and neonatal characteristics
through antenatal stress and mood. The infants envi-
305
Therapeutic Management of Maternal Borderline Personality Disorder and their very Young Infants
Clinical Neuropsychiatry (2005) 2, 5
ronment will most certainly be altered through hectic
management of interactions.
To better examine the organization of mother-in-
fant interactions of BPD mothers it is necessary to enu-
merate the characteristics of borderline personality with
an infant in the foreground as the privileged partner.
II. Maternal Borderline Personality Disorder:
stormy weather
Study of personality disorders still remains an open
challenge for psychiatry. Is Personality disorder a ma-
jor psychiatric illness in itself or does it represent a
fertile background amidst which pathology is more
susceptible to emerge? (Trull 2001). Categorically de-
fining each personality disorder contains risk of reduc-
ing and rigidifying diagnosis (Morey 1988). These is-
sues are particularly pertinent when studying Border-
line Personality Disorder. If most clinicians have a
strong agreement when clinically diagnosing BPD, dif-
ferent theoretical concepts are often implicated
(Zimmerman and Mattia 1999). BPD is the disorder
where psychiatry and psychoanalytic concepts are the
most susceptible to meet, where attempts to objectivate
intrapsychic mechanisms such as defense mechanisms
are endeavored, and where environment and social is-
sues are persistently relevant because of the history of
these patients.
BPD in this paper will be defined by DSM4 crite-
ria, however difficult this may have been across the
last decades, notwithstanding the fruitful intricacies of
the psychodynamic perspective (Kernberg 1984). It
appears to be the most restrictive but agreed upon clini-
cal and research approved judgment of this relation-
ship-centered disturbance. BPD is now seen as a valid
construct and has a complex but increasingly known
course (Kroll et al. 1981; Zanarini et al. 2003, 2005). It
is, in the US, a common disorder (estimated 1.8% of
American adult population), as common as Bipolar I
Disorder (Zimmerman et al. 2005). Classically, it re-
mains a gender specific disorder, more prevalent in
women (approximately two-thirds of clinical diagno-
sis of BPD are women) (Golomb et al. 1995). Whether
this depends on the symptomatological definition and
therefore is part of an entity englobing a feminine
half that would be BPD and a masculine counterpart
defined as Antisocial Personality Disorder or is an en-
tity of its own remains open for debate (Paris 1997).
Studies on the different aspects of BPD have ac-
cumulated over the years, whether etiological, diagnos-
tic, treatment or course. Co-morbidity is high among
BPD both between Axis 2 disorders (other PDs and
BPD) and with Axis 1, especially Major Depressive
Disorder (MDD). A review of the different scopes of
theoretical diagnostic questions on BPD in general is
not in order in this paper (for review see Kornstein and
Clayton 2002). However each of the possible co-mor-
bid or diagnostic issues that have implications for treat-
ment during the peripartum cannot be neglected. Co-
morbidity of PDs and specifically BPD, with anxiety
disorders, dysthymia and major depressive disorder is
high, over 10% (Nurnberg 1989, Pepper 1995). These
elements have received very little attention in the peri-
natal literature. In our own study we examined the re-
search population for co-morbid situations and PD and
found both high rates of other PDs with Borderline
personality disorder and of MDD ( Apter-Danon et al.
2003, 2005). History of MDD, notwithstanding any
pregnancy, is responsible for a 25 % risk of postnatal
depression, and history of prenatal or postnatal depres-
sion rises the risk to 33 and 50 % respectively, whereas
the probability for postnatal depression without any
history whatsoever of mood disorder is less than 5%
(OHara 1996). For Axis I mood disorders (MDD and
bipolar disorders), women are at equal or higher risk
for occurrence of depression (Viguera et al. 2000, Cohen
et al. 2004). Co-morbid Major Depressive Disorder with
BPD might mean both pharmaceutical and psychothera-
peutic treatment for the mother before and after the birth
of the child (Kelly et al. 2000). Knowledge of specificity
of psychotropic prescriptions during pregnancy and the
peripartum will then be mandatory. Acute hospitaliza-
tion could be necessary during the immediate postpar-
tum because of the co-morbid depression, and access
to resources such as mother-infant baby units needs to
be investigated. For other Axis 2 co-morbidity, the peri-
natal field has not been explored.
It remains to be studied whether risk of any Axis
1 and 2 psychiatric disorders is the same during the
perinatal period as during the rest of the course of life.
In BPD, history of childhood physical and sexual
abuse and neglect, in itself also a major risk factor for
depression across the life cycle, is often found (Zanarini
et al. 1989, Bezirganian et al. 1995, Bernstein 1999).
History of trauma and unresolved abuse are known to
have direct consequences on capacity to relate. Animal
studies show that neglected offspring of rodents will
display ulterior visible perturbation of maternal
behavior such as grooming and feeding of their own
young (Francis et al. 1999). This represents a theoreti-
cal background for some of the hypothesis concerning
the transgenerational transmission of psychopathology.
BPD should therefore be looked at from the in-
fants point of view. Each one of the DSM4* criteria
takes on new appearances when considering the rela-
tionship-centered symptoms addressed to an infant.
Frantic efforts to avoid real or imagined abandon-
mentmight rapidly permeate any interpretation the
mother would make of her infants rhythms. This has
already been described for toddlers, when they start
walking and acquiring independence, threatening their
mothers of a theoretical abandonment. Even in the first
few months, anything that will capture the babys at-
tention, especially if it is a manifestation of autonomy
(sleeping, sucking ones hand) is potentially antago-
nizing for the BPD mother. The unstable and intense
relationships alternating between extremes of ideali-
zation and devaluationare by definition incompatible
with infant needs. Basis for infant care is security, even
more specifically, emotional security. Extremes of ide-
alization and devaluation may only have indirect im-
pact on the baby if they solely concern the mother.
Nonetheless, a constant low maternal self-esteem will
* Each of the nine DSM-IV criteria will appear in sum-
mary in italics
306
Gisèle Apter-Danon, Drina Candilis-Huisman
Clinical Neuropsychiatry (2005) 2, 5
confer doubt and unsteadiness, sometimes to the point
of reaching total incapacity and neglect; reversely, an
irresponsibly narcissist self-centered caregiver, inca-
pable of questioning her own attitudes will be unable
to adequately interpret the infants demands. Chronic
feelings of emptiness will either emotionally vacate
the relationship between mother and infant or the baby
will be at risk of being the sole void-filling object. In-
appropriate and intense anger and impulsivity are also
obvious discrepancies for infant care. An infant requires
availability and acceptation of frustration and restraints;
thoughtlessness and unexpected strong impulsive re-
actions already imply that distorted interactions are
being installed. Identity disturbance and transient dis-
sociationare essentially maternal symptoms of dis-
turbance. They nonetheless, can have negative conse-
quences for the infant. A clinical example of how the
dissociative process can harm the infant is available in
this clinical example: one BPD mother moving, chang-
ing apartments after the birth of her first child entered
a brief but acute state of dissociation and left her house
inadequately dressed in winter, totally disoriented to
find her real home leaving the infant alone in the
new apartment, so imperative was the drive to return
back to the initial one. Finally, self-mutilation or self-
harm taking place in a relationship context could even-
tually render the infant unwittingly responsible for its
mothers impossible regulation of emotion and affec-
tive instability. The baby would then acquire the im-
pression that the environment is forever changing, un-
stable and uncontrollable. This would bring on a sense
of inefficacy and impeach the infants capacity of mean-
ing-making of the surrounding world.
The considerable emotional upheaval of BPD dis-
order is connected to the Borderlines impossibility to
empathize with others, not because of cognitive inca-
pacity to recognize or define others emotional states but
because of the overwhelming feelings that submerge the
BPD mother when identifying with someone elses sen-
timents (Fonagy et al. 1995). It is as if the borderline
mother cannot deal with her own heightened sensitivity
and reacts alternately with anger and rejection or empti-
ness and dejection. In the mother-infant context, the dif-
ficulty to feel for, and identify with, can be a severe draw-
back, since the very young infant totally dependent on
the caregiver requires and relies on its mother to cor-
rectly anticipate and recognize its needs. The infants
aptitude to understand and make the world emotionally
coherent for him or herself will depend on how interac-
tive patterns in which it takes part are organized.
III. Interactions: Maternal frantic frozen
flickers, Infant scanty contingency
Considering the numerous predicaments in emo-
tional regulation and impulse control of BPD mothers,
it seems plausible to assume that interactions between
mother and child will be impaired. However, charac-
terizing these distortions and their impact on the childs
development is still open for research that has up until
now been sparse. A number of clinical and methodo-
logical difficulties might explain the rarity of mother-
infant studies in this aspect of the personality disorder
field as compared to the abundant research on BPD in
the general psychiatric literature. The first is a general
remark about studies on BPD ; patients with this psy-
chopathology are difficult to sustain for any durable
period of time, therefore any type of longitudinal re-
search will be rendered difficult by the characteristics
of the pathology itself. Nonetheless, research on course
of pathology has now been implemented thanks to stud-
ies in out-patient clinics (Zanarini et al. 2005). Research
in clinical settings uses precisely this way of obtaining
facts and outcome. However, infant research essentially
belongs to the world of Developmental psychology and
therefore either ignores clinical populations or observes
them from an experimental observatory separate from
the clinical setting in which families and parents are
eventually treated. Therefore Developmental Psychol-
ogy is often deprived of access to clinical population
or the possibility to sustain it. This specific feasibility
problem might also be due to the lack of facilities in
perinatal and infant psychiatry. Mother-baby hospital
units are scarce (non-existent in the US) and parent-
infant out-patient clinics with programs with enough
resources to treat BPD even sparser.
The second essential issue in the perinatal field is
of ethical nature. If adults suffering from any psychiat-
ric disorder may choose whether or not to receive care
(given that the system gives access to appropriate health
services) the presence of an infant at risk, by contrast,
has opposite radical consequences. As in most Western
countries, France has policies of child protection against
abuse and neglect and specific programs are carried
out nationally along this line. Therefore research among
population at risk for abuse and neglect needs to offer
systematic clinical care for the families involved in the
studies. For the same reasons, there are no randomized
therapeutic studies in our population (in France) since
absence of care when families are assessed as at risk
is considered unethical. Research designs comparing
different types of mental health care management could
however be imagined but, to our knowledge, have not
been implemented to this day. General head-start pro-
grams for deprived families have shown efficacy and
Postnatal depression has also been under scrutiny for
different therapeutic trials but not PDs (Fonagy 2004).
A number of methodological problems that make
research not only difficult to carry out but also to dis-
cuss and interpret have as yet, not been resolved. How
are we to define the interactions? And what will the
comparison criteria be for these distorted interactions?
How much of the impairment that will be observed can
be linked to the actual interaction per se and how were
these visible interactive patterns constructed at two or
three months postnatally? What infant characteristics
are already linked to the influence of maternal pathol-
ogy in utero or to the infant itself (gender) and how do
these features in turn impact on the infant influencing
the interactive spiral? These interrogations are not only
theoretical. The answers suggested by research will
influence the therapeutic techniques and who or what
they will first focus on: the hic et nunc of interaction,
the infant and its emotional development and/or ma-
ternal psychopathology. The preferential moment to
target intervention (prenatal, immediate prepartum,
delivery, postpartum) is also a crucial question. Lim-
ited resources compel the making of critical choices.
The study of mother-infant interactions has led to
307
Therapeutic Management of Maternal Borderline Personality Disorder and their very Young Infants
Clinical Neuropsychiatry (2005) 2, 5
models of interactive patterns of mutual regulation; the
interactions are perceived as open systems, where room
for error and repair is available while contingent and
synchronic interactions take place approximately a third
of the time (Cohn and Tronick 1988). The infant is prone
to interact, ready for intersubjectivity and communica-
tion through the privileged modulating canals of his
emotions and sophisticated sensori-motor system
(Trevarthen 1989, 2001). Psychopathology has nega-
tive impact on interaction through complex bidirec-
tional ways (Weinberg and Tronick 1997). The mother
and the infant are thwarted in their attempts to engage
positively.
Two teams have been able to show that BPD
mother when confronted with young infants in a face-
to-face interactive interlude, display strong interactive
distortions as compared to control mothers: Crandell
et al. at the Tavistock and our own team. The first study
examined eight dyads with borderline mothers and com-
pared them to twelve controls. The interactive play was
videotaped and coded with a real-time coding sys-
tem (Murray et al. 1996). The design consisted of an
interactive sequence between mothers and their two-
month-old infants using the Face-to-Face Still face
Paradigm. This Paradigm was developed by Tronick
and Cohn to create a setting where infants could be
observed displaying emotional expressions and move-
ments in reaction to a mildly stressful and unexpected
experience (Cohn and Tronick 1989). The experience
is composed of three two-minute sequences. During the
first two minutes, the mother is asked to play with her
infant as she would usually do at home but without the
use of any toy object. The mother and infant are face-
to-face with the infant in a baby seat. Then, after two
minutes, the mother is asked to stop whatever she is
doing and make a poker face, sitting very still. She is
in front of her infant but impassible. After another two
minutes, she may resume interacting with the infant in
what is called Reunion Play. This Paradigm has been
extensively used in developmental research both with
non-clinical (control) population and with depressed
mothers. However, it had not been used with PD. Ma-
ternal diagnosis of BPD in this research was based on
DSM-IV criteria and used the SCID as a diagnostic tool.
The mothers were also offered the Adult Attachment
Interview and mothers with BPD were found, not sur-
prisingly, to be insecurely attached with Enmeshed and
Unresolved attachment. The Attachment literature has
shown that Insecure Disorganized attachment in infants
and Enmeshed Unresolved attachment in adults is posi-
tively correlated to higher prevalence of any psychiat-
ric disorder. Maternal unresolved Attachment is itself
positively correlated to their own childrens Disorgan-
ized Attachment as assessed in the preschool years (Ly-
ons-Ruth et al. 1993). The main findings of the
Tavistock study were, first, that the interactions between
BPD mother and infant had a definite intrusively in-
sensitive style on the part of the mother, even though
the infants behavior before the Still Face Stress was
not significantly different from controls. Secondly, the
infants were unsettled longer, and apparently more so
during the reunion play, than the infants of controls even
though, reunion play is a challenge for all infants
(Weinberg and Tronick 1996).
In our own study, we compared mother-infant
interactions of BPD mothers against controls with in-
fants of three months of age. Even though we recruited
a much larger population (109 mothers of which one
third received a diagnosis of BPD) in a longitudinal
study of the first year postnatally, the coding of the in-
teractions has only been completed for 25 dyads of
which 11 are BPD. The complete results of this first
part of the large ongoing study have been presented at
the APA 2005 in Atlanta (Apter-Danon et al. 2005) and
are completely made explicit in another paper under
submission (Apter-Danon et al. submitted 2005). The
study design consisted of 5 minute free-play interac-
tion, the Face-to-Face Still face Paradigm and a
neurodevelopmental and emotional assessment of the
infant with the Brunet-Lezine. Diagnostic criteria for
mothers was made with two different interviews, the
SIDP4 (structured Interview for the Diagnosis of Per-
sonality Disorder DSM-IV) and the BID-R (Border-
line Interview Diagnosis-Revised). Controls did not
meet criteria for any PD; however mothers with BPD
most often had co-morbid diagnosis of other PDs. Axis
I diagnosis were not included in study except for co-
morbidity of postnatal depression. BPD was strongly
associated with depression. However Postnatal depres-
sion was either equally distributed with or without co-
morbid PD. This first finding on the entire group of
109 mothers has already led us to discuss elsewhere
the necessity to reconsider the concept of postnatal
depression (Apter-Danon et al. 2003). The 25 dyads
were micro-analytically analyzed with a frame by
frame, second-by-second coding system (Tronick and
Weinbergs Maternal Regulation Scoring Scale and
Infant Regulation Scoring Scale). Coding was of course
blind to maternal status. The interactive behaviors were
separated quantitatively on the mothers and the infants
side and then contingency and synchrony were matched
by crossing different categories of same behavior, such
as maternal and infant gaze on a second-to-second ba-
sis. The main results concerned both mother and in-
fant. Not only were the BPD mothers more intrusive
all along the Still Face procedure during Play 1 and
Reunion Play but paradoxically they interacted with
generally less variety of behaviors. Most behaviors were
qualitatively different, with more poking and jabbing
for example, but with less diverse gestures and elicit-
ing, when all coding was put together. The other main
finding was that BPD mothers fail to readjust after the
Still Face per se much more than control mothers. This
is visible through measures comparing each group in-
tra-play, BPD mothers differ very little between Play 1
and Reunion Play therefore keeping on a track that does
not take the interruption into account. Control moth-
ers, even if they at first also seem to try to reconnect
with the infant by picking up where they left of, vary
and generally lower their requirements as compared to
Play 1, leaving more room for infant initiative or even
accepting less interactive play then in Play one. They
seem to understand that a certain lapse of time is nec-
essary to get past this unexpected derailment in the
course of their interaction with the infant.
The infants in the two groups displayed different
behaviors, with infants of BPD mothers already show-
ing many more behaviors of the autonomic nervous
system such as hiccupping and spitting up during Play
1. These vegetative behaviors either do not appear in
308
Gisèle Apter-Danon, Drina Candilis-Huisman
Clinical Neuropsychiatry (2005) 2, 5
babies of control mothers or do so only during other
episodes of the Paradigm.
Analysis of vocal interactions also showed lack
of common rhythm on the part of both infant and mother
and has also been extensively described (Gratier and
Danon 2000).
If in fact both studies are in agreement on the in-
trusiveness of mothers, some of the infant findings dif-
fer. Our study tends to describe at three months an al-
ready complex interactive pattern of dysregulation of
infant and mother emotional configuration. This could
partly be due to the difference in the infants age in the
two studies. At three months, the babies have a some-
what larger display of actions and emotions than at two,
and the interactive patterns with the mother have had
more time to be repeatedly organized in such a way
that the infant has expectancies with its caregiver.
The limitations of both studies are the same as
concerns small group size. There of course always re-
main the possibility of confounders; however in both
studies demographic and socio-economic status was
comparable in controls and BPD. In our study, all were
full-term well-babies and substance abuse mothers were
excluded because of the neurological impact of toxics
on the infant neural system in utero.
In total, research revealed what was not only clini-
cally obvious, at-risk relationship, but unperceivable
elements of the interactions as well. Mothers seemed
to be off-beat with infants, as if incapable of adapting
when a small event derails the infants behavior. And
the infants were emotionally dysregulated with hyper-
sensitive arousal to external events. These aspects im-
ply that maternal guidance and counseling will most
certainly be ineffective or at best only partially so, if
they do not take into account both infant emotional regu-
lation disorder and maternal lack of sense of infant tim-
ing and rhythm. These different specificities need to
be implemented in the therapeutic programs that one
would offer BPD mothers and their infants during the
first months postnatally.
IV. Treatment
Mother-infant therapy setting
Because of their relationship-oriented disorder,
management of BPD deals first in compliance. The
essential aspect is of continuity of treatment. Border-
line patients because of impulsivity and fear of aban-
donment tend to interrupt treatment or in fact put the
treatment to test. They either do not honor appoint-
ments, missing them or soliciting impossible replace-
ment of the ones that were not met; therefore nourish-
ing and confirming the impression that no one can truly
meet their needs. This typical aspect of BPD has been
described by a number of authors and different ap-
proaches have been used with long-term favorable out-
come if programs and treatment are followed (Kernberg
1984, Fonagy 1991, Hurt et al. 1992).
With an infant, BPD mothers have the opportu-
nity to seek care for someone else than themselves; this
has many advantages even though fallbacks are always
possible. Pregnancy and early motherhood are a period
of upheaval that creates an opening for intervention.
The infant is in need of protection and the mother if
adequately sustained will respond positively at first to
most offers of help during that particular time. How-
ever, this window or opening moment is short-
lived. It therefore needs to be seized if the wish to fos-
ter intervention is to be granted.
If, as has been mentioned, compliance and adher-
ence to therapeutic management is essential to BPD,
then the earliest possible moment during pregnancy or
the immediate postpartum is the time to offer interven-
tion. Pregnancy or the immediate prepartum is the pe-
riod to target in high-risk families. Different programs
with poor, low-supported families have shown that early
intervention was more effective (Heinicke et al. 1999,
2000). Making resources available to patients whether
through the different professionals in contact with the
mother or directly to the patient is an essential element.
Even if specialized therapeutic setting for such psy-
chopathology is scarce wherever it is available, ad-
equate screening and referral are rare. Creating what
could be the most long-lasting durable relationship for
the BPD mother that she has ever experienced is a chal-
lenge. Opportunity for such a therapeutic relationship
could be made possible at this particular time of life.
Pregnancy in France is a time of mandatory free
care. Mothers are required to attend at least 3 visits to
the Ob-gyn or midwife with gynecologic examination
and ultra-sound. These moments are on the one hand
the opportunity to meet with other caregivers (such as
psychologists or psychiatrists), and create a frame for
care on the other. The infant is unborn, thus the mother
is taken care of, both for herself as a mother and as a
person, in the common interest of both her child and
herself to establish a relationship as trustworthy as pos-
sible. Intervention before birth allows for diverse con-
tacts and enmeshment with other disciplines such as
obstetricians, gynecologists, pediatricians, nursery
nurses, and nurses, all creating a secure therapeutic
setting (Raphael-Leff 1993).
Pregnancy is a moment of intervention that is ca-
pable of offering care for two persons even if one is
still virtual. This is a new experience for BPD women
that hits right on the spot of one of BPDs main co-
nundrums, i.e. being either rejected or engulfed. Room
exists for thought and concrete medical care for two,
both mother and infant. It is often obvious that the
mothers health and self-care will have an impact on
the infant : how the mother eats, exercises, takes medi-
cation or toxics (tobacco, alcohol) directly influences
fetal and infant development. The infant itself can have
negative impact on the mothers health even if it is less
systematically perceived in this way, through gesta-
tional diabetes or high blood pressure for example.
These not uncommon and highly preoccupying medi-
cal situations have direct therapeutic consequences that
show the pregnant woman how both her health and the
infants are intertwined in two-way reciprocity, a man-
ner of implicitly suggesting that split situations are not
valid at least during this period.
Care for the infant and ones self is not something
the mother needs to seek, it is available and yet obliga-
tory. It is also defined in time, pregnancy is a time-
limited situation and the first two years of life of the
infant, during which mandatory visits for vaccination
and psycho-developmental assessment take place also
309
Therapeutic Management of Maternal Borderline Personality Disorder and their very Young Infants
Clinical Neuropsychiatry (2005) 2, 5
delimit intervention. Since time is also a major issue
with PD, this gives milestones and benchmarks that
serve as representations for the borderline mother or
mother-to-be.
The birth of an infant is generally a privileged
moment for change. The hope that the next generation
will be more successful and in better health than the
past one is a powerful drive to favor transformation.
BPD mothers often have the incentive to seek for the
infant what they feel they are unworthy of or even what
seems worthless for themselves. They have generally
not benefited from any type of care up until the preg-
nancy. The infant, according to professionals and
mother alike is the actor that is perceived as needing
the health services, the one to be offered help, and if
possible the mothers will benefit from the programs to
better mother their infants. This gives potential energy
for change. Change over time is another major issue
for BPD. Their behavior is often disruptive, chaotically
repetitive as in a frozen frenzy. As observed in the
research, in clinical settings, they jab and jolt their in-
fants, repetitively elicit their attention both verbally and
physically, not aware or unable to take in the infants
cues for less intense or slower interactive play. And
even more so, during forced interruption of play, when
the infant searches for sleep or abandons activity, they
seem to never leave the track that they are on, notwith-
standing the infants manifestations; as if they cannot
take in what happens when the infant is not actively,
directly interacting with them. The mother has knowl-
edge that the infant is immature. It is her incapacity to
act upon what she knows of the infant that is visible.
She is overwhelmed by the feelings triggered in the
direct situation with the infant that she therefore con-
tinues to hassle. Emotional regulation, adjusting dis-
tance and perception of time are the main issues that
the therapeutic setting will tackle through intervention
with the dyad.
Mother-infant psychotherapeutic techniques
Most psychotherapeutic techniques have focused
on enhancing maternal capacities and mother-infant
relationships either directly through guidance and psy-
cho-pedagogical support, or by modifying maternal
representations and distorting projections on the infant.
The former act upon visible behavior stressing posi-
tive aspects of interactions in non-judgmental ways,
whatever the origins of the troubled parent-infant rela-
tionship might be. They are equivalent to personal sup-
portive therapy with the particularity of having two or
more patients in mind. The latter presume the existence
of an inner conflict and base the intervention on the in-
terpretation of the visible externalized conflict played
out during the consultation between the parent and the
infant. All these techniques essentially assume that early
intervention will have sufficient medium and long-term
impact to ensure positive outcome of the infants health
and development. As if allowing the infant to pursue its
development without being infringed by its mothers
actual or past difficulties will be sufficient. Most of these
programs lead to positive results for infants. They are
often carried out in experimental, pilot or strictly clini-
cal situations. Outcome studies have met methodologi-
cal issues that reduce the conclusions that can be made.
It is however apparent the early intervention is useful
preventively for adverse social and cognitive outcome
in high-risk families, and that relationship-centered in-
terventions have positive impact on infant symptoms,
parental capacities and family relationships such as vio-
lence and abuse for example (Eckenrode et al. 2001,
Heinicke et al. 2001, Fonagy 2004).
All parent-infant therapies have something in com-
mon that render them useful and effective according to
Daniel Stern (1995). Because research has often been
centered on what technique is the most efficient, it has
generally not been interested in the how of what
makes all of them worthwhile.
Stern (1995) describes the general psychotherapeu-
tic system with mother and infant in the following way:
I is the infant and M the mother; b codes for
behavior while r is for representation. The visible
behavior of mother and infant interaction are associ-
ated with the representational world of mother and in-
fant respectively. Even if one is not equivalent to the
other, we can assume that what happens at the visible
interactive level is influenced and impacts on each of
the participants representational world. The therapist
then intervenes directly with one (or more) of the ele-
ments of this model. Guidance (G) is focused on the
mothers behavior with infant while psychotherapy (Pst)
addresses her inner representational world. Infant fo-
cused intervention such as psychomotriciy (Psm) will
be centered on infant development and behavior while
psychotherapeutic play (Psp) involves even if some-
times indirectly, the infants inner world.
Ir [ Ib Mb ] Mr
Th
Psm G
Psp Pst
Ir Ib Mb Mr
310
Gisèle Apter-Danon, Drina Candilis-Huisman
Clinical Neuropsychiatry (2005) 2, 5
Psychotherapeutic techniques used in mother-in-
fant psychotherapy are generally inspired by psychody-
namic theory.
Selma Fraiberg was the initiator of work with
multiple problem families, installing psychodynami-
cally  based interventions including infants and their
caregivers together, in innovative modalities, often in-
side the home (1980). She advocated for work with
parents chasing out the ghosts in the nursery that were
hindering infant development by distorting parent-in-
fant relationships. Lifting projections of the past linked
to unresolved conflicts or trauma that make parents
unable to deal with their infant was the motor of these
therapeutic interventions. Psychodynamic psycho-
therapy (Cramer and Palacio 1993) or repeated psy-
chotherapeutic consultations (Lebovici 1999) are two
original psychotherapeutic designs in direct line with
this model. Brief mother-infant psychotherapy is
uniquely focused on maternal representations and pro-
jections on the infant, assuming that modification of
these projections will have very rapid direct conse-
quences on maternal management of infant behavior,
therefore altering interaction and ensuring that reac-
tive behavior of the infant will in turn be modified, thus
symptoms such as crying or sleeping problems will
disappear. Intervention is concentrated on the mother
during sessions where her actions with the infant are
underlined and eventually interpreted by the therapist.
Awareness and a certain capacity for self-reflection are
required for this type of therapy. Psychotherapeutic
consultations are implicitly theoretically very close to
the brief psychotherapy design. However, the therapist
uses another technique concerning the content of the
consultation. He will be centered on the child, playing,
and eventually verbalizing directly to the child or indi-
rectly through the child, to the mother. The interven-
tion is oriented towards what is happening with the child
in the hic et nunc of the consultation. It differs from
guidance in the sense that it still tries to intervene at
the representational level even if verbalization might
have counseling aspects. The therapist stays guided by
the necessity, in both techniques to play back and forth
with identification both to mother and infant.
Interaction guidance interventions were developed
for difficult to engage families often with multiple-risk
factors such as very young parents, socially and eco-
nomically deprived and family psychiatric disorders.
Videotaping is used in these interventions and the ses-
sions are organized in questions about family life and
play sessions with the infant. They are based on six
assumptions: 1. that the family is doing the best they
know how to do; 2. that what the parents believe to be
the problem must first be addressed, 3. that the family
must be asked what help they need, 4. that information
must be provided and family questions answered to the
best of the therapists capacity, 5. that definition of treat-
ment success is defined jointly with the family, 6. that
treatment progress is to be closely monitored
(McDonough 1993). All of these aspects could be con-
sidered in Attachment theory as providing a secure base
for the family in treatment and in Winicottian terms as
furnishing a good enough environment.
Infant-Parent psychotherapy often assumes that
part of what the guidance therapy proposes is already
available, i.e. capacity to verbalize thoughts and con-
flicts and sufficient insight to attribute causes and con-
sequences to parent-infant relationship. Coherent un-
derlining and empathic observation often lead to ver-
balization of past parental conflicting relationships with
their own parents, and of contradictory thoughts and
feelings towards the infant and themselves as parents.
Eventually interpretation in the form of linking the past
to the present helps alleviate guilt and lifts anxiety
modifying representations and interactions as an after-
math (Lieberman and Pawl 1993).
Therapy with borderline mothers and their infants
needs to benefit from both these techniques and even-
tually to add a little something more. The interaction
guidance aspects are the necessary conditions to create
the therapeutic alliance. Most borderline mothers, even
if in great need, because of their lack of confidence in
any kind of external support and of low self-esteem do
not leave room for search for care for themselves. On
the opposite spectrum, their narcissistic defenses
mechanisms when in the forefront, also forbid accept-
ance of any help whatsoever.
First meetings need to define the setting and en-
sure security of treatment since adherence is so essen-
tial. In general, as in any psychotherapeutic enuncia-
tion of the way the therapy will take place, the neces-
sary rules concerning abuse and neglect are verbalized.
Parents are informed and assured that if any fear of
major harm is susceptible to be known to the therapist,
this cannot be kept secret. It is accompanied by a way
of saying this that makes parents feel protected and not
threatened. It will be formulated in such a way that
parents perceive that by averting harm to the infant,
they will protect themselves and therefore avoid abu-
sive and neglectful relationships with their infants
which is often the main focus of their fears.
When meeting with borderline mothers and their
infants, as in most mother-infant therapies, the risk of
identifying with either partners of the dyad is great.
Mothers who are prone to pouring out their woes and
drowning the therapist with information that seems to
make no sense and are not emotionally connected may
provoke intense rejection and massive identification to
the woe-begotten infant who is not even an object of
preoccupation in the midst of this maelstrom. Or, the
mothers past history leads to forgetfulness of the in-
fant, so involved does the therapist get with the mater-
nal relationship. In both situations, it is obviously nec-
essary to keep at a distance both massively empathic
movements without totally denying them. Feeling for
the mother and her circumstances gives room for pa-
tiently working out problems that will not be solved as
quickly as often infant development would want them
to be. Empathizing with the infant stimulates direct
interventions, and reminds the therapist of the neces-
sity to keep in mind that the infants development and
time agenda is very different from that of its mother
and of the therapist.
Intervention on the interactive level has the aim
to establish a balance between mother and infant where
each is able to take into account the others behavior
and emotions and acquires progressively capacity for
emotional regulation. Each session tries to enhance
greater interactive mutuality by different approaches
even during a brief period of time.
Verbalization of infant behavior is suggested to
311
Therapeutic Management of Maternal Borderline Personality Disorder and their very Young Infants
Clinical Neuropsychiatry (2005) 2, 5
the mother when she is available to hear it : for exam-
ple, commenting on the infants hiccupping or crying
or on its capacity to explore objects or to gaze at new
toys etc. If the description is a positive one it opens the
way to support of maternal parenting capacity and even-
tually to better access to other difficulties because the
confidence of being well-looked upon is ensured. It also
pre-establishes a difference between what is thought
of psychotherapist, i.e. that they usually only explore
what is going wrong and care nothing of parental strong-
points. If the comment underlines a babys negative
manifestation, it serves two points. One, it confirms
that the child has feelings and emotions that mean some-
thing. That even if it is only that it is negatively so, at
that moment, the baby perceives what is going on in
the environment and especially what comes from its
mother. Borderline mothers often oscillate between feel-
ings that their infants do not care about them (and that
might even be positively considered by a depressed
borderline mother) and that everything that they feel
or do will impact totally negatively on the child. This
last consideration might lead to preferring that the child
ignore her, in that way nothing will pass between the
infant and herself creating the only protection the
mother is able to offer, neglect rather than what is felt
as abusive. Two, it can be used as a technical tool to
involve the mother in a positive interactive spiral. By
suggesting that the infant is in need of something that
its mother will be able to give during the consultation,
interaction can be enhanced creating a positive experi-
ence for the mother and the infant. Even if, for the bor-
derline mother it will be necessary to repeat these epi-
sodes numerous times before any possibility of believ-
ing that they are repeatable per se, it also provides the
infant with memory of the possibility of experiencing
positive adequate, coherent emotionally appropriate
interaction with its mother. In fact when therapy has
been implemented in such a way that a positive rela-
tionship has developed (transference is too strongly
analytically defined to be used in this case), mothers
will confide that they try to repeat or imitate in the same
way, transposing interactive interludes at home that
have been experienced in the clinic. All this takes place
long before mothers have any kind of self-conscious-
ness or capacity to self-reflect on why they were un-
able to communicate with their infant without being
overwhelmed emotionally.
Apart from mother-infant therapy, both partners
can benefit from individual management considering
the risk and often the symptoms presented by BPD
mothers. This often greatly penalizes personal function-
ing, while their infants are prone to emotional
dysregulation, symptoms that we have observed in the
interaction studies. However, it is more effective to
suggest first working directly with the infant in the
mothers presence than the reverse. Maternal individual
therapy whether or not associated with pharmaco-
therapy cannot be suggested too early. Risk of feeling
rejected as parent is too strong even if the therapist of-
fers to add separate meetings with the mother alone
and even more so if it is referring her to someone else.
This is both because the borderline mother is not seek-
ing treatment for herself, at least consciously except as
a parent, and also because she is does not acknowledge
that help for herself alone will be of interest to her in-
fant and the relationship that will then be developed.
Working directly with the infant however has a
double advantage. It is a possibility for the infant to
regularly experience positive interactions and sense of
efficacy, being scaffolded in its development by a be-
nevolent competent infant specialist, generally a
psychomotrician**. In this case, the psychomotrician
helps the baby stay on the course of its usual develop-
ment, either by filling in with appropriate stimulation
what has been neglected, or by setting brakes on what
could be an emotional marathon to always keep up with
maternal mood swings. Not only does this furnish more
contingent and synchronous interactions for the infant,
allowing restoration of sense of time and inner regula-
tion, but it also leaves room for the mother as an ob-
server and eventually after a while for her to become
an active participant. It is as if the borderline mother
were sustained in slowing down emotionally while not
refusing creative discovery with her infant. In this way,
the infants natural desire for exploration is not re-
strained but the emotional upheaval that it often trig-
gers is modulated. The rapid change that this often in-
duces because of the babys rapid development during
the first months of life has a major positive impact on
the mother, her self-esteem and her capacity for estab-
lishing that specific relationship differently from those
that she has experienced until then. The risk of feeling
persecuted by the treatment or by the fact that the
psychomotrician is able to do what she cannot but
should be doing with her infant is modulated by two
important facts. One is that this is not the sole aspect of
treatment, and that all that happens in these sessions is
discussed and commented in the mother-infant meet-
ings. Two, the psychomotrician is introduced as an in-
fant specialist and one that will center on what belongs
specifically to the infant, notably its psychomotor de-
velopment. In this way the treatment is for something
at risk or wrong with the infant and not for some-
thing that the mother is not able to do. This also creates
the possibility to discuss what was not offered to the
mother as a child. Again instead of working through
the rivalry by verbalizing, creating a setting where both
mother and child are offered each according to their
need supports treatment and favorable outcome.
In general when using the supportive guide rules
to establish therapeutic alliance while keeping in mind
general psychotherapeutic rules for borderline therapy
with the mother (no interpretation until negative and
overwhelming emotions have not been attended to), the
double focus treatment is composed of three phases that,
in total, last no more than two years. The first is mother-
infant psychotherapy with psychomotricity, a once a
week session for each. The second is reached more or
less when the infant has achieved the stage of walking
and psychomoticity stops. Mother-infant therapy is then
able to address some of the maternal issues concerning
family history and even though one might be tempted
Psychomotricians are specific French mental health
practitioners that have knowledge of motor and emotional
development close to the alliance of a physiotherapist and a
psychologist. They were first recommended for all types of
children that had or didnt have motor delays but needed
developmental stimulation.
312
Gisèle Apter-Danon, Drina Candilis-Huisman
Clinical Neuropsychiatry (2005) 2, 5
to end treatment at this stage, the second year is one of
great risk because of the childs newly developmental
capacities (walking, climbing etc) and questions of
separation and the risk that it involves for the border-
line mother must be addressed; the third period is when
it becomes possible for the mother to decide whether
or not she will accept care for herself. If she seeks per-
sonal psychotherapy a period of overlap is necessary
where she will still come in with the infant, while her
own personal therapy has started. Otherwise, the risk
that again she will feel rejected or have split feelings
towards the future or the former therapist is high. If
personal therapy is seen as too great an effort or unnec-
essary, a common decision of end of treatment is to be
decided. Whatever difficult aspects of the relationship
subsist, one of the main points is that the possibility of
again asking for help for the child is acquired. What-
ever mishaps they both will meet, they have better cop-
ing capacities and have enhanced their emotional ex-
pression and regulation with one another.
Change has occurred; the possibility that it can
again occur in the future now exists.
Conclusion
The long-term outcome of both the infant and the
mother will still take years of research to be effica-
ciously assessed. The interaction studies that are now
being developed, because they are able to measure
change micro-analytically, could initiate insight into
what has changed along these therapeutic pathways.
More research is most certainly required and will pave
the way for better clinical management at this early
stage of life.
Acknowledgements
Research results of the Perinatal and Psychopathology
Lab cited in this paper are from an ongoing research grant
supported by the French Ministry of Health and lAssistance
Publique des Hôpitaux de Paris (AOM 98001). The work
included was made possible thanks to: Rozenn Graignic-
Philippe, EbD, Marina Gianoli-Valente, Cli Psych, MA.,
Emmanuel Devouche, PhD.
The therapeutic aspects have been developed in col-
laboration with the clinical team of lAubier and its head of
department Annick Le Nestour, MD.
Special thanks are addressed to Pr. Ed Tronick who has
helped initiate, encouraged and supported, both scientifically
and affectively, the mother-infant research described in this
paper. He has opened and enriched discussion for innovative
therapeutic interventions based on developmental research.
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... compte tenu de l'importante prévalence du trouble de personnalité borderline (Gunderson et Lyons-ruth, 2008) et de son impact sur les relations interpersonnelles (Kernberg, 1989), les études sur les enfants de mères présentant ce trouble se développent depuis une quinzaine d'années. Les interactions mère-bébé au sein de cette population ont ainsi été l'objet de quelques recherches récentes, avec notamment la première étude de crandell et al. (2003) et des études issues d'une cohorte française (apter, 2004 ;apter-danon et candilis-huisman, 2005 ;Genet, 2012 ;apter et al., 2016). une revue de la littérature concernant les enfants de ces mères (Genet et al., 2014) met toutefois en lumière le peu d'études existantes. ...
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represents a veritable crisis: the process of becoming a parent demands a renegotiation of the maternal imagoes that can disrupt the identity of mothers already afflicted by borderline pathology, and may have an impact on the quality of their attachment behaviors toward the expected child. This article presents an evaluation of the attachment behaviors of 13-month-old babies of mothers presenting a borderline personality disorder (BPD). This evaluation was part of a longitudinal prospective study of a cohort of mother-baby dyads comprising 14 mothers presenting BPD with or without depressive episode(s), and 13 "control" mothers without disorders. The quality of attachment patterns at 13 months was evaluated using the Strange Situation Classification (Ainsworth et al. 1978), as part of a research study that aimed more broadly to clarify how such attachment behaviors are rooted in specific dysfunctional mother-child interactions at three months, as reported in other publications. Our results show that the children in the control group are generally very consistent in the expression of their attachment behaviors during the course of the Strange Situation. On the contrary, the babies in the BPD group display a variety of behaviors that would make it yet more difficult for their mothers to anticipate their reactions. We thus observed more insecure and disorganized attachment behaviors among the BPD group of babies. Such disorders in attachment behavior amplify already existing weaknesses in the mother-baby relationship. © Presses Universitaires de France. Tous droits réservés pour tous pays..
... compte tenu de l'importante prévalence du trouble de personnalité borderline (Gunderson et Lyons-ruth, 2008) et de son impact sur les relations interpersonnelles (Kernberg, 1989), les études sur les enfants de mères présentant ce trouble se développent depuis une quinzaine d'années. Les interactions mère-bébé au sein de cette population ont ainsi été l'objet de quelques recherches récentes, avec notamment la première étude de crandell et al. (2003) et des études issues d'une cohorte française (apter, 2004 ;apter-danon et candilis-huisman, 2005 ;Genet, 2012 ;apter et al., 2016). une revue de la littérature concernant les enfants de ces mères (Genet et al., 2014) met toutefois en lumière le peu d'études existantes. ...
... Considering the importance of emotional experience and the sensitive attention to qualities of embodied expression infants are capable of from a young age, it is surprising how few studies have focused on interactions with partners presenting distorted emotional regulation such as "borderline personality disorder. " In one study of mother-infant interaction, based on the Still Face procedure, BPD mothers and their 3-month-old infants present altered interactive patterns and infants more frequently display negative emotional configurations ( Apter et al. submitted;Apter and Candilis 2005). Specifically, infants of BPD mothers looked less at their mothers, manifested less positive vocalization and less non-autonomic self-regulation behavior than infants of mothers with no psychopathology. ...
... However, even though it is a prevalent disorder, little research has focused on the interactive patterns of young infants and partners with BPD. One clinical research study on mother-infant interaction described altered interactive patterns and negative infant emotional configurations among infants of mothers with BPD (Apter-Danon, & Candilis-Huisman, 2005). Another small-scale study of mothers affected with BPD showed that although mothers were more insensitively intrusive with their 2-monthold infants after an interactive disruption (the Still-Face [SF]), at baseline and during the SF episode, the infants did not significantly differ in their behavior from controls (Crandell, Patrick, & Hobson, 2003). ...
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This study assessed the structural relations between borderline personality disorder (BPD) features and purported etiological correlates. Approximately 5,000 18-year-old nonclinical young adults were screened for BPD features, and 2 cohorts of participants (total N = 421; approximately one half of whom endorsed significant borderline features) completed the laboratory phase of the study. Measures included self-report and interview-based assessments of BPD psychopathology, personality, psychopathology in biological parents, and childhood physical and sexual abuse. Significant relations between BPD features and purported etiological correlates of BPD were found. A multivariate model that included parental psychopathology, childhood abuse, and personality factors provided an adequate fit to the data and supported the contention that the personality traits disinhibition and negative affectivity underlie BPD features.
Conference Paper
This paper addresses an intersubjective issue that arises out of our model of therapeutic change: Why do humans so strongly seek states of emotional connectedness and intersubjectivity and why does the failure to achieve connectedness have such a damaging effect on the mental health of the infant? A hypothesis is offered-the Dyadic Expansion of Consciousness Hypothesis-as an attempt to explain these phenomena. This hypothesis is based on the Mutual Regulation Model (MRM) of infant-adult interaction. The MRM describes the microregulatory social-emotional process of communication that generates (or fails to generate) dyadic intersubjective states of shared consciousness. In particular, the Dyadic Consciousness hypothesis argues that each individual, in one case the infant and mother or in another the patient and the therapist, is a self-organizing system that creates his or her own states of consciousness (states of brain organization), which can be expanded into more coherent and complex states in collaboration with another self-organizing system. Critically understanding how the mutual regulation of affect functions to create dyadic states of consciousness also can help us understand what produces change in the therapeutic process.
Article
Eighty-one 6-month-old infants and their mothers were videotaped in Tronick's face-to-face still-face paradigm to evaluate gender differences in infant and maternal emotional expressivity and regulation. Male infants had greater difficulty than female infants in maintaining affective regulation during each episode, including the still face. Mother-son dyads had higher synchrony scores than mother-daughter dyads but took longer in repairing interactive errors. In addition, maternal affect, matching, rate of change between matching and mismatching states, and synchrony in the play preceding the still face differentially mediated male and female infants' responses to the still face and reunion play. The developmental implications of these gender differences are discussed.
Chapter
In considering emotion development in infancy, it is important to remember that the emotions and the emotion system cannot be studied in isolation. The infant is a whole human being and the personality of the infant, like the personality of the adult, consists of an organization of a complexly interrelated set of subsystems. In a general sense, infant development can be considered as the process whereby these systems become effectively organized so that they interact and interrelate harmoniously in producing integrated behavior (Izard, 1971; Sroufe, 1977).