Tuesday, March 4, 2014

Mom is not Really a Monster or a Psycho, She Just Has Borderline Personality Disorder

Attachment Theory: What it is Attachment theory is a useful framework by which to understand BPD, because problematic attachments or pathological attachment styles often serve as the basis for BPD (Bowlby, 1973; Mahler et al., 1975). Attachment theory recognizes four categories that exist between child and caregiver: 1) Secure, 2) Ambivalent/ Resistant, 3) Avoidant, and 4) Disorganized (Fonagy, 2001). When a caregiver is sensitive to an infant’s signals and appropriately responds to the infant’s needs, the child feels secure, having come to “possess a representational model of attachment figures as being available, responsive, and helpful” (Bowlby, 1980, p.242). Infants who do not develop feelings of security from a caregiver tend to become distressed in novel surroundings. These children typically exhibit clingy behavior, are difficult to soothe, and are not comforted through interactions with the attachment figure (Ainsworth, 1970). Children who are avoidant often experience the caregiver as insensitive or rejecting of their needs (Ainsworth, 1979). Such a caregiver may withdraw from helping behavior during difficult tasks and become emotionally unavailable during times of emotional distress (Stevenson-Hinde, & Verschueren, 2002). Rather than orientating to their attachment figures when exploring new surroundings, these avoidant children exhibit independent behavior. When the caregiver mistreats the child, is intrusive, or exhibits frightening behavior (all forms of child abuse) the child develops a contradictory attachment strategy, lacking in coherence. For example, such a child characteristically may approach the attachment figure with eyes averted and facing away (Ainsworth, Blehar, Waters, & Wall, 1978; Main & Solomon, 1986). Emotional distress may result when affectional bonds are threatened by loss or disruption, leading to sadness and anxiety (Fonagy, 2001). Hence, when a caregiver is either insensitive or unavailable to the infant, certain pathogenic self-deficits may result (Gabbard, 2005; Goldfried & Wolfe, 1996; Gratz & Gunderson, 2006; Ogden, 1986; Pos, Greenberg, Goldman, & Korman, 2003; Mulder, Joyce, & Luty, 2003; Pynoos, 1993; Vocisano, Klein, Arnow, Rivera, Blalock, Rothbaum, & Thase, 2004). Bowlby (1973, 1977) wrote that both psychopathological and normal development are rooted in attachment processes. Well-adjusted, “healthy” individuals have a balanced and seemingly realistic and coherent narrative about early relationships. People free of psychopathology describe attachment-related experiences as having been influential to their emotionally-sound development and later wellness (Fonagy, 2003; Fonagy & Target, 1996; Levy, et al., 2006). Conversely, Bowlby (1973, 1977) wrote that early difficulties in attachment may predispose a person to vulnerabilities and resultant psychopathology. Bowlby (1973, 1977) postulated that attachment difficulties lead to the specific psychological deficits of BPD. Disturbed attachment styles give rise to emotional distress that manifests in personality disturbances, rage, anxiety, anger, self-destructive, para-suicidal and suicidal ideology, depression, and emotional detachment (Fonagy, 2003; Fonagy & Target, 1996; Levy, et al., 2006). Bowlby further theorized that problems with attachment during early childhood may lead to problems with later close relationships and child rearing. Moreover, according to Bowlby (1973, 1977), attachment patterns persist with potentially long-lasting negative reverberations throughout a person’s lifespan (Fonagy, 2003; Fonagy & Target, 1996; Levy, et al., 2006). Treating Mothers Who Have BPD Extensive empirical evidence supports a psycho-educational intervention for the identified patient as well as the spouse and children (Cohen et al., 2008). Psycho-educational information about childhood developmental stages and milestones from infancy forward would aim to reduce family stressors and risk of relapse (Cohen et al., 2008; Gunderson et al., 1997). A systems-based approach in treating mothers with BPD would encourage the patient to form or join a support network comprised of other mothers with BPD (Cohen et al., 2008). Presently no manualized form of structured treatment exists, although treatment models have been proposed, and at least one peer reviewed article has been written (Stepp et al., 2012) on the efficacy of treating the entire family. A pilot program called Multiple Family Group (MFG) (Gunderson et al., 1997) advocates for a psycho-educational approach to wellness for BPD sufferers. MFG is comprised of three forms of treatment: (1) Family Connections (FC) (Fruzzetti & Hoffman, 2004), (2) Systems Training for Emotional Predictability and Problem Solving (STEPPS) (Blum, Pfohl, St. John, Monahan, & Black, 2002), and (3) Multigroup Family Skills Training (MFST) (Miller, Rathus, & Linehan, 2006). FC and STEPPS focus on the sufferer within the context of the family system, while MFST focuses on the entire family. Gunderson et al (1997) furnish empirical evidence that MFG improves family communication and lessens family burden after 6 months of treatment.

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