Parenting Behaviors of Mothers with Borderline Personality Disorder: A Call to Action

We sincerely thank Alan Fruzzetti, Karlen Lyons-Ruth, Jenny Macfie, Maureen Zalewski and Liliana Lengua for providing rich commentaries on our conceptual article. Each of these distinguished scholars affords a unique perspective on issues related to parenting with borderline personality disorder (BPD) and approaches to interventions for this population. A common thread throughout this series is that a dearth of knowledge exists about parenting practices of mothers with BPD and more research is sorely needed. Parenting practices may be an important factor in the transmission of this disorder from mother to offspring, making parenting an ideal target for early intervention and prevention efforts. We will highlight some of the authors’ observations in hopes of sparking further discussion and interest in this area of research.

Operationalizing and Measuring Oscillations in Parenting

Parenting deficits are usually described in general terms (harsh punishment, low warmth, low monitoring), obfuscating specific deficits that may be tied to particular diagnostic groups. Based on clinical characteristics and prior research, we posit that oscillations in parenting (e.g. rapid changes from sensitive to punishing responses) may be a specific deficit characterizing the parenting behaviors of mothers with BPD (Stepp, Whalen, Pilkonis, Hipwell, & Levine, this issue). These rapid-cycling parenting behaviors may be important contributors to the transmission of this disorder and, thus, important targets for intervention. However, as Macfie (this issue) points out, more research is needed to test this hypothesis.

Zalewski and Lengua (this issue) note the complexity in defining oscillations in parenting behaviors. They describe how a behavioral perspective can help clarify the specific parenting behaviors exhibited by mothers with BPD, including shifts in both affective and control aspects of parenting, and provide a roadmap for defining this construct. The importance of basic research cannot be overstated, and a naturalistic assessment approach seems fitting to answer many of these questions. Just as ecological momentary assessment has been used to chart the naturalistic time course and pattern of affective instability (Trull et al., 2008) and interpersonal behaviors (Russell, Moskowitz, Zuroff, Sookman, & Paris, 2007; Stepp, Pilkonis, Yaggi, Morse, & Feske, 2009) in BPD, we think this method could also be used to describe parenting behaviors in this population.

Measures have not been developed to assess parenting problems that are specific to a clinical group. Thus, Lyons-Ruth (this issue) advises researchers to use a well-validated parenting instrument or coding scheme and incrementally expand these instruments and coding schemes to include clinically relevant variables.

Expanding the Assessment of Risk Factors

We appreciate Fruzzetti’s (this issue) ideas regarding ways to enrich the assessment of risk factors for children of mothers with BPD. This type of assessment approach will allow for more dynamic and individualized approaches to assessment and treatment. He conceptualizes parent-child relationship risk factors as direct (those that are a direct consequence of BPD symptoms), indirect (those behaviors that the child learns through modeling), and general (environmental effects). By including the broader context of the parent-child relationship, a more complete picture of risk and protective factors can be obtained.

Heterogeneity

One of the challenges to identifying parenting deficits specific to mothers with BPD is the heterogeneity of the disorder, as well as the high rates of comorbidity (Fruzzetti, this issue). In order to determine if specific parenting behaviors are linked to BPD, Lyons-Ruth (this issue) highlights the need for researchers to take special care when defining the population of interest. Researchers should select psychiatric comparison groups (e.g., patients with other personality disorders) in addition to healthy controls. This practice will allow us to understand how BPD impacts parenting and influences the transmission of psychopathology (Fruzzetti, this issue).

Another problem that interferes with our ability to understand specific parenting deficits in mothers with BPD is that many previous studies have lumped together children from different developmental periods to examine parenting behaviors and children’s outcomes. Lyons-Ruth (this issue) sensibly advocates for researchers to restrict the age range of the children sampled to a particular developmental period, such as infancy, and ensure that parenting practices that are assessed are developmentally appropriate.

Interventions for Mothers with BPD

A general consensus from this series is the need to start with parenting interventions or treatments for BPD that work based on results from randomized clinical trials. The modification of treatment components specifically designed for this population should be based on empirical evidence (Lyons-Ruth, this issue). Zalewski and Lengua (this issue) suggest behavioral parent training and emotion regulation skills that are in sync with components of Dialectical Behavior Therapy. Fruzzetti (this issue) highlights the importance of brief, focused interventions with this population due to their high levels of distress. Macfie (this issue) posits that parents may have difficulty learning new parenting skills while still experiencing symptoms. However, we feel that targeting parenting skills may be particularly helpful in reducing symptoms, as these parents experience extremely high rates of distress specifically around issues related to parenting and the parent-child relationship (Newman, Stevenson, Bergman, & Boyce, 2007). A general approach may be to first reduce parenting and symptom distress, then promote mood independent parenting behaviors and provide psychoeducation and training regarding parenting techniques and child development.