Working with families when
Mum has a diagnosis of BPD
Workshop: How to do it
Anne Sved Williams
So what we will cover this afternoon
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Making the diagnosis of BPD
Psychoeducation for the patient and her family
The protocol which HMH staff use
The effects for staff of our changed practice
Validating MAR’S WAILS
Discharge plans
Using Dialectical Behaviour Therapy with BPD
And Watch, Wait and Wonder
THE DIAGNOSTIC INTERVIEW
• Working through 9 criteria of DBT in DSM V
• Patient given our written information about
BPD and lots of opportunity to discuss
• A library established in unit with a lot of other
books on BPD
The information we give the woman
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What is BPD
What caused it?
What difference will it make to stay in HMH?
What effects on your infant?
What can you tell your partner and family
What can you do about it? – how to learn
more about it
• What will happen after discharge from HMH
Working with women with BPD & their
infants in our MBU (HMH)
• Mothers self-report on MPAS show their
concerns about their relationship with infant
• Observer reports on RF show substantial
problems which may not change during
admission
• Mother-infant therapy is difficult
• Some women are not ready to “embrace” a new
diagnosis and treatment pathway
• Length of stay is greater
• We use a Bank of Days approach
And what about the staff?
• We have provided more training eg 1.5 days of
DBT for all
• Find working with this group a challenge –
excellent staff communication and supervision
essential
• Staff tensions increase when patients with BPD
OOC (TLA) -NB Thomas Main: The Ailment
• Taking an interest in this group is not totally
curative
• But we have got better….
Staff survey
• We are doing better with our patients
• Staff feel more supported
• There is a common sense of purpose/a sense
that ALL of us have a common understanding
• They particularly value the sense of team, the
reflective supervision, and the shared sense of
how to work these patients
HMH Protocol
1. Identify early in admission with McLean and
clinical diagnosis/patient behaviour
2. Discuss diagnosis w patient, partner (family) and
inform all staff
3. Validate woman’s concerns about her issues
including current diagnosis
4. Contracts both verbal and/or written and
individualised but as per protocol “love and
limits”
5. Set a discharge date and plan overnight leaves
etc (attempt to stick to discharge date….)
The protocol (Cont.)
6. Care for the woman: psychoeducation ++
including our own written information and
access to multiple books and articles
7. Individualised therapy including DBT style
where necessary ( !!!!)
8. For the infant: routine care including
paediatric check
9. Mother-infant therapy as per usual at the
moment
Protocol (cont.)
10. VALIDATE MAR’S WAILS
11.Support for staff: group and individual
supervision, ward round discussion
12.Discharge planning in detail
- DBT group
- Individualised DBT therapy and other TAU
(Treatment as usual)
(average referral sites = 4)
And remember at all times:
• It is very easy to love the baby and hate the
mother
• And in the long term highly problematic for
BOTH!
Frameworks for our work: Attachment
theory and systems theory
And:
• Encouraging the positives
• Remembering resilience and protective factors
from other family
members/personality/professionals/work etc
• And it is a wonderful time to work with
women who havent had the sense of self to
undertake therapy for themselves but often
have that motivation when they have an
infant they (want to ) love
Parental Reflective Functioning:
helping the woman to increase
• Parental RF - PRF (Slade) or RF (Fonagy, Steele)
• Can it be increased by therapy? seemingly yes
Parental Reflective Functioning (PRF)
VALIDATE MAR’S WAILS – tx to Rebecca Hill – extracted from the work of Arietta Slade
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VALIDATE
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MODEL WHAT TO DO WITH INFANT
ASK QUESTIONS TO CLARIFY
REFRAME BABY’S INTENTIONS
SUPPORT MOTHER AND BABY
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WONDER ALOUD ABOUT WHAT IS GOING ON INSIDE INFANT
ATTEND TO BABY’S STATE
IMITATE THE BABY TO HIGHLIGHT BABY CUES
LABEL FEELINGS OF BOTH MOTHER AND BABY, LINK MENTAL STATES WITH
BEHAVIOURS
SPEAK FOR THE BABY
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VALIDATE!
• “this looks really hard for you”
Model…
….What to do for baby
Ask questions to clarify..
• “What do you think your baby is feeling right
now?”
• “I really wonder what is going on in your
baby’s head? What do you think?”
• “what should I do next to help you with your
baby?”
Reframe baby’s intentions
• “Isnt your baby so curious to learn about the
world” (NOT – “that bloody kid is into
everything) NB Baby Strengths Cards from St
Luke’s Innovative Resources
http://www.innovativeresources.org
• “Doesn’t your baby give you gorgeous
cuddles” (NOT – “that baby just wants to cling
on me all the time”)
Support both mother and baby
• “Looks like you’re BOTH having a hard time of
it here”
• “who will I help first: Mum or baby?”
Wonder aloud about what is going on
inside baby
• “I wonder what is happening in your baby’s
head right now”
• “now what ARE you thinking?”
• “I’m trying to guess what’s on your mind right
now.”
Attend to baby’s state
• “Oh, you don’t like that. Ok, lets pick you up
and see if you prefer that?”
• “Oh you don’t like that? Lets put you down on
the floor and see if that works better for you?”
• “Are you trying to tell me you’re
hungry/tired/cold/hot/lonely”
Imitate the baby to highlight the cues
the baby is giving
• “goo goo goo!”
• (Smiling) “you look so happy you gorgeous
boy”
• (Making pouting face)”Oh I don’t like THAT!”
Label feelings of both mother and baby
and link mental states with behaviours
• “Oh, looks like both mum and baby are upset
– no wonder its hard for each of you to tell the
other one clearly where you are at”
• “Oh dear, it looks to me you are both feeling
really sad. Maybe that’s why you are turning
away from each other as you cant help the
other one when you cant help yourself so
well”
Speak for the baby
• “Mummy, I really want you to feed me RIGHT
NOW!”
• “Mummy, I know I look like I am angry and
getting at you but really I love you and I want
you to cuddle me”
So is that the end of the story?
• Absolutely not! (but nice thought….)
• Some women accept diagnosis but not ready
for further work
• Some women don’t accept diagnosis
• Many want to go further with DBT and do so
• Of those, many do well but they still have
their crises
• But then don’t we all??
Why DBT after discharge?
• Louise Newman is using Watch, Wait and Wonder
• Arietta Slade: Minding the Baby
• Perhaps we have chosen DBT first not just
because it is (relatively) available but because we
have “started” with the mother and then move to
the infant – and looking at the brain level …
• All have won and all must get prizes (Lewis Carroll
– a la Luborsky)
6 Common Features of Psychotherapy
(Jerome Frank)
• An intense confiding relationships with a
trusted (and trustworthy) therapist
• A shared belief system of what will help
• Provision of new information
• Provision of success experiences
• Promoting optimism through the setting, the
persona of the therapist etc
• Facilitation of emotional arousal
Therapist Stance: PACE
Daniel Hughes: Attachment based FT
Playfulness
Acceptance
Curiosity
Empahty
Dialectical Behaviour Therapy (DBT)
• What it is?
• Is it the best or only treatment for BPD?
• Who else is using it with infants?
Maternal Calming
BY THE CLEVER
THERAPIST
Infant
AND ENHANCING MATERNAL
REFLECTIVE CAPACITY
Mother
Grandmother
Maternal Calming
BY THE CLEVER
THERAPIST
Infant
AND ENHANCING MATERNAL
REFLECTIVE CAPACITY
Mother
Grandmother
Our Research DBT group
• Before and after evaluations: EPDS, Beck, MPAS, PRFS
(Luyten)
• Before and after videos using CARE index (Crittenden)
• 20 sessions of 90 minutes with mothers and 1 DBT
trained therapists and 2 learners whilst infants cared
for next door
• 20 mins with infants
• 7 women started, 6 finished
• Changes there?
• Group being run again with more time with the infants
as main focus - WWW
Next, adding in Watch, Wait, Wonder
(Muir and Muir)
• Using infant’s free play to enhance mother’s
sensitivity and responsiveness
• Mother is encouraged by the process to
reflect on her infant’s inner world of feelings,
thoughts, and desires, which helps her to
understand her infant as a separate being and
her own responses to her infant.
• We will be doing our own adaptation
Extended family
The “ogres”
New work coming out of Project Air: Dr
AnneMaree Bickerton and Toni Garretty working
with Prof Brin Grenyer at University of
Wollongong: New ways of working with Families
who have a member with BPD
Look it all up online under PROJECT AIR
The crux of that program
• Psychoeducation
• Moving people along a pathway to accept and
understand
• 4 carer dances
• 5 strategies to manage – which begin with
self-care and calming strategies!
And in some cases, the grandparents
CAN work when the mother cannot
Enhancing grandparental reflective
functioning
Enhancing grandparental reflective
functioning
Enhancing grandparental reflective
functioning
AND IN AN IDEAL WORLD….
Enhancing grandparental reflective
functioning
Enhancing grandparental reflective
functioning
Enhancing grandparental reflective
functioning
Take Away Messages today
1. BPD is a common troublesome condition for women and
their families presenting postnatally and can lead to
intergenerational transfer of problems for the infant
2. Identification of the condition, providing information and
treatment pathways will help the patient, the infant and
the staff/team particularly by providing clarity and a
shared approach
• We can only go so far: “I can honestly say that my misery
had been transformed into common unhappiness, so by
Freud's definition I have achieved mental health.”
• ― Susanna Kaysen, Girl, Interrupted
Take away messages?
4. An information sheet for families
5. A protocol for staff including VALIDATING MAR’S WAILS
6. Information for families a la Project Air based at University
of Wollongong, NSW, Australia
7. And for the mothers and babies: dialectical behaviour
therapy with the mothers (or maybe another intense mode of
therapy) and then WWW + DBT with mothers and babies
A long but worthwhile pathway
How do you access if not in an inpatient unit?
And so finally…
Rebadging Borderline Personality
Disorder
Rebadging BPD 2
• BPD an unpopular label
• Calling it complex trauma implies trauma is
always the cause
• Disorder of Emotional Regulation
= DER
It IS a TLA…
And will rebadging it make the patients cuter?