Experiences of mothers with borderline personality disorder following an intervention to support mother‐infant relationships: “more tools in my toolbox”

Abstract

Motherhood is inherently demanding, and some of these demands may be amplified for women with borderline personality disorder (BPD). The exacerbation of BPD symptoms from parenting‐related stressors can have adverse impacts on mother‐infant relationships and infant development. This qualitative study explores Australian mothers’ views of the impacts of mother‐infant dialectical therapy plus (MI‐DBT+). MI‐DBT+ is an innovative therapeutic intervention which integrates mother‐infant dialectical behavior Therapy (MI‐DBT), a known effective intervention for the mental health of mothers with BPD, with attachment and biobehavioral catch‐up (ABC) therapy. Specifically, eight mothers completed semi‐structured interviews about their experiences of intervention following completion of the MI‐DBT+ program. A thematic analysis of this interview data found that mothers appreciated learning more skills to enhance their understanding of their infants’ needs, behaviors and emotions. Mothers also reported improved reflective functioning and better control of their emotional responses. These skills assisted in managing emotional distress at both the individual and dyadic level. The study was limited due to available demographic data, with only maternal and child age available. Discussion also focuses on the fit between DBT and ABC, longer term developmental concerns and sustainability.

1. INTRODUCTION

Borderline personality disorder (BPD) is a complex personality disorder characterized by an extensive pattern of instability within psychosocial functioning, interpersonal relationships, emotion regulation, empathy and self‐image (American Psychiatric Association, 2013; Gunderson et al., 2018). For a clinical diagnosis, an individual must meet five or more from nine BPD symptom criteria (American Psychiatric Association, 2013). Individuals with this diagnosis often experience heightened emotions, impulsivity and sensitivity to perceived abandonment, often leading to significant levels of distress (Mishra et al., 2023).

While the prevalence of BPD is relatively low within the general population (approximately between 1% and 6%; Crowell et al., 2009; Grenyer et al., 2017), there is a heightened prevalence within perinatal (including both ante‐ and postnatal) populations of 14% (Prasad et al., 2022). Postnatally, mother‐baby units often have a high prevalence of mothers with BPD with Yelland et al (2015) finding that 23% of admitted women had this clinical diagnosis, increasing to a prevalence of 46% when the diagnosis was self‐reported. In general, BPD is prevalent among women who may encounter unique challenges related to accepting their identity as mothers (Zalewski et al., 2023) and expressing and regulating emotions when triggered by distress (Trull et al., 2018). The disorder often presents with comorbid conditions such as complex post‐traumatic stress disorder (cPTSD) (van Dijke et al., 2018), depression, and anxiety (Crowell et al., 2009). Notably the transition to motherhood is particularly challenging for women with BPD (Wendland et al., 2014).

The increase in BPD prevalence postnatally is not surprising given that mothers with BPD are easily dysregulated by the typical stressors associated with the postnatal period. These include challenges such as sleep deprivation, infant crying, and strain on relationships, which make providing consistency in parenting an infant difficult (Geerling et al, 2019; Sved Williams & Apter, 2017). Disrupted affective communication or disoriented behaviors have been noted by a number of authors (Geerling et al., 2019; Hobson et al., 2009; Petfield et al., 2015). Moreover, a systematic review of parenting behaviors associated with BPD found lower levels of maternal sensitivity, with decreased instances of smiling, play, and imitation during mother‐infant interactions, when compared to mothers without BPD (Eyden et al., 2016). Mothers with BPD also report a decreased sense of self‐competence in maternal roles (Gillespie et al., 2022), difficulties in correctly identifying and responding to infant emotions and needs when their infant is displaying prolonged distress (Geerling et al., 2019) and are more likely to show hostility or reactivity toward their infants (Eyden et al., 2016).

Substantial evidence demonstrates an association between maternal BPD and poorer outcomes in a variety of domains across childhood (Eyden et al., 2016; Petfield et al., 2015). In infancy, infants of mothers with BPD display low soothability, negative affect, and poorer responsivity when compared to infants of mothers with no diagnosis (Petfield et al, 2015). This impact extends into later childhood, where children of mothers with BPD are at increased risk of behavioral problems such as aggressive and oppositional behavior, and deficits in socioemotional skills and relationship building (Eyden et al., 2016; Mesquita & Figueiredo, 2025). The need for support for this population is evident to support healthy development. Interventions delivered during infancy may have a protective effect against the known negative child outcomes associated with the mother's diagnosis (Stepp et al., 2012).

Despite the prevalence of perinatal BPD and its consequences for family members, surprisingly few therapies have been described to help these families (Florange & Herpertz., 2019). May et al's systematic review (2023) found only seven relevant publications, with only low quality evidence of improvement. Hellberg et al's scoping review (2024) similarly found few studies, and of these, there was little to provide clear direction for positive outcomes for relevant families with perinatal BPD.

Recently, there has been increasing interest in interventions designed for mothers with BPD, with particular focus on emotional regulation and responsive parenting skills. In Germany, Rosenbach et al (2020) have advanced their dialectical behavior therapy (DBT) therapy for this patient population, described in a recent manual. Their approach supports early parenting strategies and aims to prevent negative impact on child development such as socioemotional, child attachment (Rosenbach et al, 2022). Herpertz et al (2025) reported encouraging shorter‐term improvements in parenting practices following a five session/12 h mentalisation‐based intervention, delivered in addition to standard clinical care for mothers with BPD.

In Australia, a four session, psycho‐education program for parents with BPD has shown some promising improvements in reducing parenting stress (Grenyer et al, 2025). Another longer intervention with developing evidence is an adaptation of dialectical behavior therapy (DBT) (Linehan & Wilks, 2015) which incorporates a number of elements of mother‐infant therapy into DBT (MI‐DBT). In evaluations, MI‐DBT has shown improvement in mental health symptoms including depression, anxiety and BPD symptoms as well as parenting confidence and competence (Sved Williams et al, 2018; 2021). However, objective measures of parent‐infant relationship did not show significant improvement and it is clear that mothers who have undertaken MI‐DBT “want more” to support them in their parenting role (Giles et al., 2024).

Attachment and Biobehavioral Catch‐up (ABC) (Dozier & Bernard, 2017) is a ten‐week annualized home‐visiting program which aims to improve carer‐infant relationships for carers from a range of vulnerable circumstances (e.g. Berlin et al., 2018).

Research provides a good evidence base to show that ABC can result in improved maternal sensitivity and responsive caregiving in foster mothers (Bick & Dozier, 2013), improve mothers’ responses when emotionally dysregulated (Korom & Dozier, 2021) and address issues of parental withdrawal (Yarger et al., 2020). Infant outcomes are also improved representing reciprocal changes within the dyadic relationship, including the enhanced capacity for both mother and infant to emotionally self‐regulate more quickly after feeling distress (Grube & Liming, 2018) and increased displays of secure attachment between mother and child (Zajac et al., 2020). However, there have been no previous studies to assess outcomes for dyads receiving ABC when mothers have a BPD personality structure.

This study aims to understand whether adding 10 sessions of ABC either before or after MI‐DBT will further enhance outcomes for mother‐infant relationships and infant outcomes. The overarching study explores both quantitative and qualitative outcomes, with this paper reporting only on qualitative data collected through semi‐structured interviews (quantitative data will be published separately).

Key Findings

1. Mothers whose emotional dysregulation is triggered postnatally who have completed a 24 week group program of dialectical behavior therapy followed by a 10 week home‐visiting dyadic therapy, Attachment and Biobehavioral Catch‐up, describe a synchrony between the skills learned in each distinct therapy.

2. An improvement in reflective functioning is readily apparent in the mothers’ statements and description of their interactions with their infants following the two therapies.

3. Despite intense therapy, some infants show signals of concern, highlighting need for interventions as early as possible in infants’ lives, further follow‐up and more resources for this cohort.

STATEMENT OF RELEVANCE

Borderline Personality Disorder (BPD) in the postnatal period is associated with an increase in emotional dysregulation that can have significant, negative effects on the developing parent‐infant relationship. Research suggests that difficulties in maternal emotional regulation may contribute to adverse developmental outcomes for infants. For example, disruptions in early mother‐infant interactions such as inconsistent responses to infant cues (crying, gaze, body movement) may affect their infants’ own emotional regulation, sense of security, and social development, with long‐lasting effects. For mothers with BPD, these responses may be inconsistent, delayed, or poorly matched to the infant's needs due to their own challenges with emotional regulation, thereby missing early signs of distress or responding in ways that may be intrusive or overstimulating. Interventions which address both maternal emotional dysregulation and the quality of the mother‐infant relationship may support the long‐term social and emotional developmental outcomes of infants, more specifically, by supporting mothers’ capacity to respond sensitively and consistently to their infants, promoting secure and responsive behaviour within mother‐infant interactions. This qualitative study provides evidence of the benefit mothers perceive at the conclusion of both therapies.

2. RESEARCH AIMS

This research aimed to explore how mothers with a diagnosis of BPD perceive their relationships with their infants, and their capabilities and identity as mothers, following participation in MI‐DBT+. The following research questions were used to guide this study:

1. How did mothers reflect on their relationships with their infants following the interventions?

2. How did mothers talk about their maternal capabilities following the interventions?

3. METHOD

In this study, mothers with a full or partial diagnosis of BPD (defined as at least 3 of 9 diagnostic criteria from DSM5 with sufficient emotional dysregulation to disrupt mother‐infant relationship) and an infant less than 2 years of age when commencing MI‐DBT were offered 10 additional therapy sessions of ABC therapy (a home‐based parent‐infant dyadic therapy; Dozier & Barnard, 2017). Mothers who completed both MI‐DBT and ABC (called MI‐DBT+) were invited to participate in a semi‐structured interview in the weeks following completion of both therapies (Sved Williams et al, 2024).

MI‐DBT is an adaptation of DBT (Linehan 2015) for mothers with an infant up to the age of 2.5 years of age. MI‐DBT involves four modules (mindfulness, distress tolerance, emotional regulation and interpersonal effectiveness) with a total of 24 skills‐based group sessions for up to 12 mothers. All material is focused on the parenting experience and includes information from The Joy of Parenting (Coyne & Murrell 2009), Circle of Security (Marvin et al 2002) and The Psychology of Infants (Murray et al 2014) (for more information on the content, see Sved Williams et al (2018). Mothers learn parent‐focused DBT skills whilst their infants are cared for nearby in creche facilities, and practice newly learned skills at a 20 min reunion with their infants at the conclusion of the 2‐h group. Mothers can also access individual therapy which reinforces DBT skills and explores barriers to progress.

ABC therapy involves three key goals: 1) help parents behave in nurturing ways when their children are distressed, 2) help parents learn to behave in more synchronous and delighted ways with their young children, as expressed through smiling, laughter, and warm interaction which is seen as crucial for fostering a secure attachment, building a child's self‐worth, and promoting healthy brain development, and 3) help parents recognize how their behavior may be frightening to a child and learn alternative strategies to using frightening or intrusive parenting behaviors (Korom & Dozier 2021). These goals are achieved by providing 10 sessions of one‐hour duration in the participant's home with an ABC trained therapist. These sessions first target the identification of challenges for the mother (being frightening, providing nurturance or following with delight) and then follow procedures to help improve these challenges. There may be challenges in all three areas, but there is a hierarchy from Frightening Behaviour, Nurturance, and following with delight. Dyads are visited by the therapist weekly for the ‘Infant’ (6–24 months) and ‘Early Childhood’ versions (24–48 months), and up to 12 sessions fortnightly for the ‘Newborn’ version (antenatal to 6 months). Mother‐infant dyads are video recorded during the home visits and clips are selected to provide demonstrations to the mother at the following session as examples of when they are nurturing, following or delighting.

A key component of the ABC program is the In the Moment comments made by the Parent Coach related to each of the target areas which encourage and support parents to follow their child's lead, which in turn encourages sensitive caregiving. There are 3 components to the In the Moment Comments: Describing the behavior of the child and parent; Linking the behavior to the intervention target; and Linking the behavior to child outcomes. By session 7, the Parent Coach identifies the areas that challenge the participant and focuses on these in the remaining sessions. By session 10, a collage video of the parent nurturing, following and/or delighting in their child is presented to the participant.

3.1. Research design

This qualitative research was underpinned by a critical realist (or contextualize) epistemological framework (Fletcher, 2017). This approach acknowledges the existence of an objective reality whilst recognizing that knowledge of this reality is influenced by personal perspectives and broader social contexts in which individuals operate (Braun & Clarke, 2022). Therefore, this approach facilitates the exploration of participants' lived experiences as mothers while also recognizing the broader health system and social structures that may influence these perspectives (Braun & Clarke, 2006, 2013).

3.2. Procedure

Semi‐structured interviews were conducted post‐treatment by MI‐DBT researchers either in‐person at the mother's residence, at the local mother‐baby unit, or via phone call. All interviewees consented to being audio‐recorded for the purpose of transcription. Open‐ended questions were used however, discussions were largely participant led. Interviews ranged from 18 to 47 min (M = 31.4 min). Appendix A contains an outline of the interview questions. Interviews were de‐identified and transcribed verbatim, with the digital assistance of Microsoft Word for an initial automatic transcription.

3.3. Ethics approval

Approval for this research was obtained from the relevant institutional human research ethics committee. As a sub‐study within the broader intervention, an amendment was requested for access to the specific subset of participant data described above. This was approved on June 19 2024.

3.4. Data analysis

Reflexive thematic analysis (RTA) was used to explore the research aims, as it prioritized participants' lived experiences while acknowledging the influence of broader social contexts including their own experiences within health systems and personal diagnoses (Braun & Clarke, 2021). The analysis followed an inductive process, ensuring that themes were derived directly from the data rather than being driven by pre‐existing theories (Braun & Clarke, 2022). The six‐phase framework outlined by Braun & Clarke (2021) began with data familiarization, in which the first author became immersed in the data through multiple readings of the transcripts. Following this, codes were generated and tracked using a coding table created by the first author. Initial themes were generated through grouping codes that held relevance to the study aims. These were later refined and finalized with multiple readings by two further authors, and reviewed to ensure themes accurately represented the data.

4. RESULTS

4.1. Participant demographics (Table 1)

TABLE 1.

Participant demographics table.

Participant name *	Participant age (Y) **	Number of infants	Infant age (M)
Mia	29	1	30
Harper	30	2	15
Ellie	37	1	26
Sophia	23	2	27
Charlie	36	1	7
Zoe	32	1	4
Victoria	24	1	13
Naomi	36	1	30

^*De‐identified names chosen.

^**Y = Years, M = Months. Infant ages are recorded as of MI‐DBT+ enrolment. If mothers had more than one child, only one infant was selected for inclusion in the ABC intervention.

The first 8 participants who were all referred to the groups by mental health clinicians because of significant emotional dysregulation sufficient to fully or partially satisfy a diagnosis of BPD and/or compromised parenting of their infant who enrolled for MI‐DBT and agreed to a semi‐structured interview were included in the current study. Participants' mean age was 31 years (SD = 5.41), and infant mean age was 19 months (SD = 10.53) (Table 1). Due to the sensitive nature of this research, limited demographic details are provided (Saunders et al., 2015), for instance educational level and ethnicity. One of the participants had received ABC therapy prior to MIDBT and the other 7 following MIDBT.

4.2. Themes

Analysis of the interview data identified five themes relevant to the research aims and questions, namely: how did mothers reflect on their relationships with their infants, and how did mothers talk about their maternal capabilities, following participation in MI‐DBT+?

4.3. Theme 1: “More tools in my toolbox”

Most participants described acquiring and applying new parenting skills, referring to these new behaviors as “tools”, emphasizing their practical utility in managing their daily lives with their children, and responding to high‐stress situations. Mothers reflected that these new skills complemented their existing parenting strategies and that ABC enhanced the MI‐DBT skills they had learnt.

Ellie stated: “[MI‐DBT+] adds to all the stuff I was already trying to do, but it's given me the tools needed to actually like, get the progress”. Similarly, Charlie stated, “I think that the tools that we learn about communicating [with my child] and responding to his needs and wants in different ways [are helpful] like, [MI‐DBT+] gave us extra tools.”

Mothers discussed how adapting and transforming their communication styles with their children could de‐escalate triggering behaviors or infant distress quickly. Harper noted that by replacing commands like “No, you can't do that!” with calmer statements such as “I don't think you should be doing that” or an enquiry to understand the child's need eg: “why are you doing that?” she achieved better responses from her children:

I get a better response as well as the situation can [de]‐escalate a lot quicker with following how [ABC therapist] has taught me how to [respond] then it would if I had just kept going ‘you need to share! You need to share! You need to share! (Harper, 30 years)

Additionally, Ellie also emphasized the importance of reframing negative language when dealing with her child's behavior: “Instead of calling him naughty or any of those negative things… I make sure that I don't”. During the post‐intervention interview, she demonstrated these skills by calmly addressing her child and redirecting their behavior to another activity during the interview, coloring in: “I understand that I have to let you explore to some degree, but putting things in the fan is not one of them”.

Some mothers found benefit from understanding that the response to their child emanated from their own past, as Ellie described: “So the part with {ABC therapist} that was really focusing on the voices from the past, turns out that that's like a massive thing even if you don't realize it or have like a specific voice you, you still it's so easy to fall back into the…(patterns from my own childhood)”—with this realization came an enhanced ability to choose a different pathway in her own parenting.

Skills learned in MI‐DBT prior to ABC were part of the toolbox—mindfulness was often discussed as a key strategy, as explained by Harper:

I've found it really helpful to find the mindfulness and the program, the MI‐DBT+, the emotion regulation… So, it means that you've got that time, and you've got that patience there to open up to these things. And then to learn that you actually need to help with the children's feelings. It's so much easier when I found mindfulness. (Harper, 30 years)

4.4. Theme 2: Following the lead as a pathway to connection

Participants discussed their experiences of the ABC component of the intervention, particularly regarding ‐the Following the Lead target intervention of ABC. Charlie described the activity as letting her child “run the show” as she follows and “[goes] along with him” during playtime. She reflected on the positive impact of this intervention component on her child's independence, saying:

And I've found that he's a lot more confident that way as well. Like uh, when we're around other kids and stuff he's not, like, stuck to us. He's quite happy to go off and play and then he will look back and see that I'm there and know that it's OK and just keep going. (Charlie, 36 years)

Additionally, several perceived benefits of following the child's lead in interactive play were described, such as feeling less parental pressure and more frequent mindful engagement with their infants. Zoe asserted the intervention “takes the pressure off [her]”, while Naomi described how it was “easier to be in the moment” when following her infant's lead during playtime. Initially finding one‐on‐one time with her child “quite challenging”, Mia observed that her child “looked forward to [ABC therapy]” and “really enjoyed playing with [her]”. She added, “it made me feel good because he was enjoying it” (Mia). These quotes implied mothers felt the reciprocal relationship between themselves and their infants had improved, with naturally greater instances of enjoyment during mother‐infant interactions. Following the lead of their child was directly mentioned by several women for example Naomi: “spending more time just following his lead … at any point I've got time and that I can sit with his feelings and that what he's going through and just take the time that he needs.”

In addition to recognizing the importance of fostering a secure environment for their children for their child's growing autonomy, many participants reported significant improvements to their infants’ emotional literacy skills. Sophia noted “It's really strange like, he's also getting better at vocalizing how he's feeling too.” Harper shared a similar experience, noting her daughter's development in emotional literacy following participation in MI‐DBT+:

I've found that [infant] is finding her own ways of actually coming back to me and identifying and letting me know that she's sad. And, and she'll actually tell me sometimes why… and without having to ask her! Like, ‘I'm sad, mummy.’ (Harper, 30 years)

Mothers reported that engaging in more child‐led interactions appeared to increase their child's confidence and autonomy, including their abilities to engage in play with other children. This was accompanied by a perceived reduction of parental pressure and enabled mothers to feel more present and emotionally attuned during these interactions. From this, mothers reported they had developed an enhanced capacity to recognize, validate and respond to their infants’ emotional experiences, particularly during distress, moving away from dismissive responses towards greater sensitivity.

4.5. Theme 3: Parental reflective functioning: A space between the trigger and the parental response

Participants described an increased ability to interpret, understand and recognize their child's emotions as a result of the ABC component of the intervention. This enhanced awareness enabled them to better appreciate children's perspectives, including their emotional responses to distress, and to validate the child's behavior. This newfound awareness led mothers to perceive their infants as autonomous individuals, as Charlie described, “you see them as more like a little person, rather than just you know, you're the boss and they have to follow along”. Charlie further described her prior tendency to minimize her infant's emotional distress as instinctual, noting, “it's as easy as a parent to just dismiss their feelings”. The importance of recognizing and responding to her child's emotional experiences was further described by Charlie:

Um, you know, like me saying ‘oh, it'll be okay’ when you know, I should be more understanding about his…feelings and stuff and not just dismissing his feelings and things like that. (Charlie, 36 years)

Harper later explained that her child can “identify a lot of emotions” and will ask her questions such as “why aren't you sharing?” when her child is upset, as opposed to becoming frustrated to “try and put an emotion to it, if she hasn't already put one to it.”. She advised her strategy is to “take the time to find out what emotion they're going through”, to “help them regulate their own emotions.” She explained:

I used to jump at telling them they need to share, but now instead, I actually look at the reason why [Infant #1] doesn't want to share with [Infant#2]. Her emotion that she's feeling at that time. So, I can attend to her need before the actual situation, I think is more important, which is actually her‐ why is she doing it and why is she feeling the way she's feeling because she's done it. So, and it's brought me to be a lot more mindful of actual thinking about their thoughts and feelings.

Similarly, Naomi described maintaining perspective and acknowledging her child's frustration in difficult moments, saying:

“(I) try and keep in mind … it's just really hard for him … [if there is] something he doesn't know how to say…or what to do. So then trying to keep that in mind and being like …it's not personal.”

These discussions reflected the realization that effective parenting involves the recognition and validation of children's emotional experiences and capacity for internal states, rather than dismissing or minimizing their feelings. Mothers described being able to pause and consider their child's perspective before responding, which supported more thoughtful and emotionally responsive caregiving.

4.6. Theme 4: Emotional regulation

All mothers acknowledged their ongoing struggles with emotional and physical health and suggested that prior to MI‐DBT+, experiencing distress or feeling overwhelmed was perceived as unacceptable, or was needed to be immediately suppressed. In particular, the expression “feeling overwhelmed” was frequently raised as a barrier to daily functioning, cognitive clarity and task completion, with Sophia stating:

I'm just so overwhelmed that I can't even finish a thought in my head without another one cutting it off and it just gets very overwhelming and the noise. The noise is um, a big one for me. (Sophia, 23 years)

She found it was difficult to “do a lot of things at once” and would “freak out”, cause her to cancel or postpone meetings, social hangouts or daily tasks. Similarly, others expressed having low social batteries, preferring to focus on themselves and their infants, due to the challenges they already encounter within their own daily lives. However, mother's recognized that it was normal to not be a perfectly regulated “100% parent all time”. Naomi expanded on this by saying:

I've really been taking in the fact that you can't get it right all the time. And sometimes, like, sometimes we make mistakes, sometimes we, yeah, do show versions of ourselves that you're like, I didn't want that to be in there, but it is. And it's just about, like, managing all those parts too. (Naomi, 36 years)

Despite these challenges, mothers frequently reported notable improvements in their own emotional well‐being following the completion of the MI‐DBT+ program. Many described an increased sense of calmness, which was reflected not just in their interactions with their infants but also in their child's response. One participant described her infant as “having a lot less tantrums” (Harper), whilst another said that her child could emotionally regulate and “calm down a lot quicker” (Zoe).

Through MI‐DBT+, mothers described learning that it was acceptable to feel upset at times, with a greater emphasis placed on recognizing emotional states and understanding when and how to regulate them. There were however some noted difficulties regarding the combined stress of parenting and concurrent management of their own health. Some participants expressed that they focused on their children to their own detriment. Charlie stated: “I often push the diabetes to the back of my mind and focus on him”, However, a need to prioritise their own wellbeing for the sake of their children was also noted, as Sophia described:

I can't help my kids and put them first, if I don't help myself too. So, one of the other things from the DBT group I really took in was having to [make] sure that I don't put myself second, I need to put myself up there with my kids because otherwise if I don't have anything to give, then I can't give them what they need. So, just trying to focus on, like mindfulness and that self‐care. (Sophia, 23 years)

Most of the mothers mentioned their need for ongoing care, either from therapists or contact with group members or from written material, as they knew that therapy, whilst helpful, had not provided a guarantee of ongoing sustained good mental health. Ellie had pro‐actively enrolled herself in another local DBT group as she noticed she needed reinforcement of the skills learned in MI‐DBT and others had sought out ongoing psychology input. Sophia was clear about her wish for ongoing DBT input: “I feel like you forget half the stuff as you is going through it because you don't, I mean, three hours a week, like, it's a decent amount of time, but it's a lot of… It's when you've got young kids; it's really hard to take it, a lot of it in throughout the week. So I definitely think even just an extra session at the end, that's like a recap of, or really main points, would be, and would be really handy I think.”

4.7. Theme 5: Personal growth: “I can do this”

Participant's appraisal of the outcomes they received through MI‐DBT+ were positive, with women often reporting an increased sense of self‐worth and self‐efficacy. Participants cited feeling greater self‐confidence in their maternal roles, with one expressing “[I] feel like I can do this” (Mia), while others described “[feeling] like a better parent” for being able to emotionally regulate more often (Victoria).

So, I'm definitely finding that…I'm still not always emotionally regulated, but I am getting much better. …[I] especially noticed probably in the last month or so a lot of improvement, like specifically with myself with actually… I don't know how to explain it… I guess catching myself? (Ellie, 37 years)

A similar sentiment was shared by Harper, who described herself as “getting further [at] being a better mum”, emphasizing that although she may not be as emotionally regulated and stable as mothers without BPD, she was working toward being her best self. She later described herself as “obviously not the best, but the best of what I can be,” indicating an awareness of the impacts that BPD has had, and how she has improved.

Mothers expressed their child's development as a major motivating factor for participating in the intervention. Many women cited wanting to receive adequate support for themselves to ensure their child had the best foundations for development they could provide within the circumstances. As Harper explained, “I just kept thinking about [Infant]. And they do say that if you can't deal with your own emotions, you can't really show your child [how to do it]”. This echoed Sophia's feelings of her kids as her “top priority” while recognizing the challenges with her BPD as barriers to supporting her children that needed addressing. She described a significant improvement in her caregiving capabilities after involvement in MI‐DBT+, comparing differences in her relationships between her older and younger children. She attributed this change to MI‐DBT+, stating that her youngest child has “ten times more” of a secure relationship than her first child. Moreover, she emphasized her increased emotional regulation and emotional availability post‐intervention, noting, “I'm a lot more [emotionally regulated] now than I was when [Infant 1] was a baby”. This improvement in her capacity and skills as a caregiver was bolstered by her ongoing commitment to self‐improvement, as she stated, “I'm constantly working on myself.” Her motivation to enhance her mothering capabilities was clear, underscoring the positive benefits of MI‐DBT+ on both participant self‐awareness and mother‐infant relationships.

5. DISCUSSION

This qualitative study explored themes in the mother‐infant relationship and mothers’ views of themselves and their parenting, provided by mothers with BPD following completion of both 24 weeks of MI‐DBT and additional 10 weeks of ABC mother‐infant therapy.

5.1. Overview, summary and discussion of the study findings

Overall, our findings indicated that the combination of MI‐DBT and ABC enhanced parental capabilities, self‐efficacy, and the mothers’ ongoing commitment to prioritizing the development of secure relationships with their infants. Several key improvements including greater control over emotional dysregulation and impulsive or maladaptive behaviors were identified, particularly when emotional triggers or infant distress occurred. There appeared to be an iterative process between the skills learned in MI‐DBT and those new skills found with ABC therapy. Ongoing challenges with motherhood, including the prioritization of the infant over the individual self were noted as barriers to maintaining maternal health and wellbeing. Additionally, mothers identified that MI‐DBT+ enhanced several parenting processes, including mentalisation, and reframing communication regarding what mothers saw as “inappropriate” infant behaviors. These developments were framed by mothers as supportive of the mother‐infant relationship and their ability to effectively parent their child. Participants reflected a strong awareness of the potential lasting impacts of their interactions and relationship with their child, which motivated their ongoing implementation of skills learned through MI‐DBT+.

Overall, analysis identified five themes—each of which are considered in the remainder of this Discussion. Consistent with existing literature (Francis et al., 2023; Sved Williams et al., 2018, 2021), participants reflected on numerous benefits from their participation in the MI‐DBT component, particularly regarding emotion regulation and the use of mindfulness strategies—hence More Tools in My Tool Box (Theme One). Mothers reported feeling more capable in regulating their emotions, as they became more responsive rather than reactive to emotional triggers and therefore more confident in their maternal role. As found in earlier perinatal DBT skills groups, reductions in emotional dysregulation supported mother's feelings of self‐efficacy in their maternal abilities (Greaves et al., 2021). The avoidance of yelling or “losing control” for the cohort of MI‐DBT+ completers were regarded as important behavioral changes to implement and maintain post‐MI‐DBT+, as mothers noted improved earlier recognition of their emotional reactions and the conscious use of new de‐escalation skills. This finding is significant given the known emotional impact of maternal loss of control on infants’ emotional wellbeing (Stepp et al., 2012). More research in this area would be beneficial, since it remains unclear whether de‐escalation skills are protective for children's emotional development in the long‐term, particularly in the case of children's ability to regulate their own emotions (Britto et al., 2017).

Theme Two (Following the Lead as a Pathway to Connection) supported prior literature regarding the importance of responding appropriately to infant cues for the development of positive parent‐infant relationships (Barnes & Theule, 2019; Dozier & Bernard., 2017; Geerling et al., 2019; O'Byrne et al., 2023). The findings of this theme also indicate that MI‐DBT+ may contribute to the development of improved parent‐infant relationships through fostering positive, responsive interactions, including building trust within mother‐infant dyads.

Mothers articulated a marked shift in their perception of their infants as autonomous individuals with valid emotional experiences, contributing to Theme Three (Parental Reflective Functioning). When mothers focused on their infant and the mother‐infant relationship with the help of the ABC therapist, recognition of their infant's emotions was enhanced, and participants were able to identify the mirrored presentation of their own emotional dysregulation in their child. This understanding allowed mothers to assume better control over their reactions to their child's emotions and employ learnt skills and strategies to manage them. This could be considered improved mentalisation or reflective function; a finding which supports prior literature on MI‐DBT (Osborne et al., 2023). The adoption of more reflective parenting approaches with a focus on understanding underlying emotions, rather than immediate behavior correction, indicates enhanced maternal mentalisation capacities (Camoirano, 2017) and corresponds with greater abilities to effectively provide sensitive caregiving (Hellberg et al., 2024; Sved Williams et al., 2021; Wilson & Donachie, 2018).

Better Emotional Regulation, Theme Four, made a clear contribution to research regarding the positive impacts on mothers’ own confidence as a result of developing self‐efficacy; a finding echoed in previous DBT‐related qualitative research (Gillespie et al., 2022). Mothers’ improvements in their abilities to self‐regulate emotions, particularly in responding rather than reacting to their infants, aligns with previous findings on DBT's effectiveness in teaching emotional regulation (Linehan & Wilks, 2015; Sved Williams et al., 2021; Wilson & Donachie, 2018). Likewise, the findings support evidence of effectiveness in developing parental sensitivity when responding to distress or triggers, as reported in other ABC‐related programmers (O'Byrne et al., 2023).

Finally, the fifth identified theme, “I can do this”, demonstrated mothers’ strong motivation to parent their children differently to the parenting they had received, as seen in other literature (Bozzatello et al., 2021; Schulze et al., 2022; Sved Williams et al., 2018). While extensive research has been conducted regarding the effects of maternal BPD on children, relatively little attention has been given to understanding the motivations of mothers with BPD in seeking treatment. What limited research there is suggests that mothers who engage in treatment are highly motivated to break intergenerational cycles of unstable caregiving, in order to provide adequate care for their infants (Renneberg & Rosenbach, 2016; Sved Williams et al., 2021). This current paper supports this body of prior literature, with Theme Five demonstrating mothers’ interest in seeking support for their BPD‐related symptoms. This theme mirrors the findings of Francis et al.’s (2023) study on the subjective experiences of women in an MI‐DBT program, which found that mothers aimed to improve their capacities as mothers in order to subsequently provide better support to their children. Moreover, high completion rates (71%) observed in previous studies of MI‐DBT (Sved Williams et al., 2021), could be interpreted as an indication of mothers being highly motivated to improve their maternal capabilities and mental health to better care for their infants.

Overall, the findings of this study showed that mothers exhibited self‐awareness of the impacts of BPD‐associated behaviors on their infants and reported a desire to develop secure, nurturing dyadic relationships, using skills they learnt during MI‐DBT+. This included balancing the needs of their infants with their own, including recognizing when they may need to look after themselves—an issue of relevance to the existing evidence base (Zalewski et al., 2015, 2023; Sved Williams et al., 2024). Finally, the mothers in this study recognized the need to maintain adequate parenting in the face of the ongoing, underlying emotional turbulence, a finding which also reflects recent literature, which posits that mothers with BPD often struggle with their own parental self‐efficacy (Eyden et al., 2024; Francis et al., 2023; Zalewski et al., 2023). In general, the mothers in this study echo the concerns of many others with mental illness that identify similar challenges (Blegen et al., 2014).

5.2. Strengths & limitations

This study's primary strength is within its women‐centred , qualitative approach, allowing for rich, nuanced insights into the lived experiences of mothers with BPD. The qualitative methodology allowed their complex realities to be captured, leading to greater understandings of the ongoing challenges and triumphs within their navigations of motherhood alongside their BPD symptomatology. This research approach validates more holistic views of their experiences of motherhood and the mother‐infant relationship and uncovers valuable insights that may be overlooked in quantitative studies.

Many mothers had their infants present during the interviews. This could be viewed as simultaneously a strength and a limitation—with infants potentially allowing mothers to demonstrate skills and build rapport, while they also led to interruptions and potentially some loss of interview data as a result.

Limitations include the lack of a theoretical base for both the dyadic therapy chosen (ABC) and the BPD treatment (DBT). ABC therapy was chosen as the additional mother‐infant therapy partly for its substantial evidence base for efficacy (Grube & Liming, 2018), the length of therapy (10 sessions) fitted perfectly with the realities of research and the womens’ preferences, and partly because of therapist availability. The findings of this study suggest that MI‐DBT+ was well‐received by the women who participated in this study, with participants reporting benefits as outlined above. Nevertheless, other mother‐infant therapies such as ‘Video Interactional Guidance’ (Balldin et al, 2018) together with a range of therapies which mitigate trauma in infants (Guyon‐Harris, K & Humphrey K, 2026) may provide equivalent or better outcomes when provided with MI‐DBT. Similarly, it is difficult to determine whether ABC added to another structured therapy (rather than MIDBT), would produce different results. Some meta‐analyses have found only modest gains with structured therapies such as DBT when compared to treatment‐as‐usual (Cristea et al, 2017) whereas others had a more optimistic view of the efficacy of psychotherapies generally, and DBT in particular (Setkowski et al., 2023).

The intensive time and resources demanded by the delivery of two evidence‐based structured therapies has not only limited the research team's ability to provide a comparison group to follow‐up women who did NOT receive the additional ABC therapy but may also limit the reproducibility of this intervention by future research teams and/or in clinical settings. This further potentially limits accessibility for families who would benefit from participation. The feasibility of implementing this intervention to a broader population warrants exploration as both cost and therapist training/availability is likely to be limiting factors. Future studies which examine ongoing benefits of such intense therapy should include appropriate economic evaluations which compare the cost‐benefit of such combined therapy, potentially offered earlier in infant's lives of such intense therapy with groups who are not offered such therapy. Economic benefits may be compelling evidence for better Government funding (Bauer et al, 2016; Luca et al, 2020).

While not relevant for this qualitative study, it is worth noting that parental reflective functioning was not assessed using a formal measure, and findings are therefore based on mothers’ self‐reported perceptions of their changed ability to interpret and understand their child's thoughts, feelings and behaviors.

Finally, a note of concern is raised regarding maternal report that several infants in the study had evident development concerns and this aspect will be examined further in quantitative studies at a future date. There is concern that despite the mothers’ obvious motivation and efforts to improve their mental health and their parenting that most of these infants commence MI‐DBT when they are already toddlers due to intake capacity in the program. It is possible that this occurs too late for infants to maximize the effect of MI‐DBT+ on children's healthy development. It may be that earlier commencement of MI‐DBT+ is better able to support the development of positive parent‐infant relationships, and sensitive parenting early in an infant's life, and that this could lead to lower levels of developmental concerns for these children.

Overall, these strengths and limitations highlight some of the many outstanding questions of the broader research project as well as the current study.

5.3. Future directions and implications

This study contributes to a growing body of research which focuses on helping the difficulties faced by perinatal women with BPD and their infant. Despite increased interest in this area, the current evidence lacks sufficient quality to guide and inform all future therapy programs (Hellberg et al, 2024). It is clear that further studies on the intervention are needed to better understand the significant complexities of the personality problems of the mother as well as the parenting style and nature of the mother‐infant relationship and what is helpful. Additionally, longitudinal studies are needed to understand whether changes found at the conclusion of the intervention persist long term, and how these may impact children's developmental trajectory. Various other related factors remain unexplored, such as the role of partners in either mitigating or providing an extra source of stress.

5.4. Conclusion

Parenting for mothers with BPD remains challenging, with mothers acknowledging ongoing difficulties with emotional regulation and self‐care despite a total of 34 weeks of therapy which addresses emotional regulation (DBT), parenting confidence and competence (aspects of mother‐infant work incorporated into MI‐DBT) and parent‐infant relationships (ABC). Findings of this study indicate that mothers value these various sets of skills, and suggest that they have a positive impact both on mothers themselves and mother‐infant relationships. Further work is needed to quantify changes described in this qualitative work, particularly regarding the benefit of the specific therapies offered (compared to the impact of simply having access to therapy generally) (Giles et al, 2024). Future studies must address both maternal skill retention and long‐term outcomes for infants. The impact of trauma throughout much of the childhood of many women diagnosed perinatally with BPD is clearly substantial and intense and prolonged therapy from several aspects is likely necessary—and at the earliest time possible in the infants’ lives. In many countries and health systems therapeutic services are stretched to offer intensive ongoing therapies and yet child outcomes without therapy may make the availability of appropriate therapies a worthwhile investment from both human and financial viewpoints.

CONFLICT OF INTEREST STATEMENT

The authors declare no conflicts of interest.

APPENDIX A.

A.1.

Post‐Intervention (MI‐DBT+) Interview Questions for Mothers with BPD:

The following topics were covered during the semi‐structured interviews:

• Participant's current thoughts and feelings for example, “how has everything been going since finishing MI‐DBT+?”

• General health and wellbeing of mother and infant.

• General thoughts on relationship with infant for example, what's your relationship like with [infant] / have there been any changes in your relationship?

• General thoughts on being a mother.

• General thoughts on their experiences with MI‐DBT+.

• Improvements, if any, to mother‐infant relationship, or just individually that is infant development, emotion regulation.

• Participant support systems that is social circles, family, relationships.

• Favourite parts of MI‐DBT+ intervention components.

• Least favourite parts of MI‐DBT+ intervention components.

• Any suggestions on improvements that could be made to future applications of MI‐DBT+.

DATA AVAILABILITY STATEMENT

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.