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BPD, Parental Self-Harm, and
Child Protection:
Confronting Stigma
While
Ensuring Safety
Jenn Crowell
April 27, 2014
Learning Objectives
• Increased awareness regarding stigma and
controversies in the treatment and child
welfare proceeding...
Agenda
• Case Study: Fran Lyon
• BPD and Child Welfare Concerns
• Intervention Options
• Recommendations
About Me
• Author of Etched On Me (Washington Square
Press, 2014)
• Mental health consumer
• Recovered self-harmer
• DBT g...
ETCHED ON ME
• 1st published fictional account of Dialectical
Behavior Therapy
• Inspired by the true story of Fran Lyon (...
Case Study: Fran Lyon
•Trauma survivor
•History of self-harm
•Diagnosed with BPD in
her teens
•Hospitalized for 1 yr in a
...
Fran’s Custody Battle
• Became pregnant in her early 20s
• Declared recovered by treating psychiatrist
• UK social service...
Perils of Risk Management
Social services’ concerns re: Fran Lyon case:
• Fit profile of an MSbP perpetrator
• Potential f...
What was the outcome?
• Major media attention and political outcry
• Fran Lyon left the UK for Sweden while 7
months pregn...
Two major questions:
• Were social services’ concerns legitimate?
• If so, could those concerns be addressed with
targeted...
BPD Child Welfare Concerns
• MSbP
• Disturbed attachment
• “Parentification” of child
• Sequelae of childhood sexual abuse
MSbP
• Munchausen Syndrome by Proxy
• AKA “Factitious Disorder Imposed on
Another” (preferred term)
“Falsification of phys...
MSbP and BPD
• Perpetrator profile (Bools et al):
– History of self harm (55%)
– Cluster B personality disorder, incl BPD ...
But not without controversy!
• Multiple criminal convictions of mothers
accused of MSbP overturned
– Angela Cannings, Sall...
Still, salient issues remain …
Schrier posits that MSbP is
“an attempt to avenge and repair past
perceived or real humilia...
Regardless of MSbP risk …
• Children of mothers w/BPD have higher risk of
psychiatric disturbances
• Infants/toddlers of m...
Intervention Options
• Individual therapy
• Parent-child dyadic therapy
• Peer support
• Therapeutic communities/intensive...
Individual Therapy Options
• DBT
• STEPPS
• Schema therapy
• Mentalization-based therapy
None of these are parenting inter...
DBT
• “Dialectical Behavior Therapy”
• Linehan et al demonstrated effectiveness in
several RCTs
• First-line treatment of ...
STEPPS
• “Systems Training for Emotional Predictability
and Problem Solving”
• Brief, manualized intervention (much shorte...
Schema Therapy (Young)
• Directly addresses the impact of mother’s own
childhood experiences
• Offers a “limited reparenti...
MBT
• Mentalization-based therapy (Fonagy)
• Mentalization = ability to reflect upon and
understand one’s own thoughts/fee...
Parent-Child Therapy
• Dyadic psychotherapy
• Watch, Wait and Wonder
• Circle of Security
Important to note: Study outcome...
Peer Support
• Recognized as an evidence-based practice in
general psychiatric population
• Guidance has been prepared for...
TCs and IOP
• Inpatient TC instrumental to Fran Lyon’s recovery
(Cassel Hospital)
• Outpatient example: The Haven Project
...
A Haven client speaks:
“I’ve done [another] parenting course and this is in
a different league. I did a six-week social se...
Mother-Baby Units
• Allow for observation of mother and child as a
dyad (usually for up to 12 weeks)
• May be particularly...
Lots of interventions, but …
• We need to remember to:
– Focus on strengths
– Validate! (crucial for people w/BPD)
– Recog...
Marginalized voices matter!
• Many women with BPD are doubly
disenfranchised:
– By abuse
– By negative attitudes of clinic...
Be Trauma-Informed!
Instead of asking
“What’s wrong with you?”
ASK:
“What’s happened to you?”
Thank you!
• For more information:
www.jenncrowell.com
References
American Psychiatric Association. (2013). Diagnostic and statistical manual of
mental disorders (5th ed.). Arli...
References, Cont’d.
Linehan, M. (1993). Cognitive-behavioral treatment of borderline personality disorder.
New York: Guilf...
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BPD, Parental Self-Harm, and Child Protection

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BPD, Parental Self-Harm, and Child Protection

  1. 1. BPD, Parental Self-Harm, and Child Protection: Confronting Stigma While Ensuring Safety Jenn Crowell April 27, 2014
  2. 2. Learning Objectives • Increased awareness regarding stigma and controversies in the treatment and child welfare proceedings of parents who self-harm or have a BPD diagnosis. • Increased knowledge of innovative models for tailored parent support.
  3. 3. Agenda • Case Study: Fran Lyon • BPD and Child Welfare Concerns • Intervention Options • Recommendations
  4. 4. About Me • Author of Etched On Me (Washington Square Press, 2014) • Mental health consumer • Recovered self-harmer • DBT graduate • Parent of a young child
  5. 5. ETCHED ON ME • 1st published fictional account of Dialectical Behavior Therapy • Inspired by the true story of Fran Lyon (case study to follow)
  6. 6. Case Study: Fran Lyon •Trauma survivor •History of self-harm •Diagnosed with BPD in her teens •Hospitalized for 1 yr in a therapeutic community
  7. 7. Fran’s Custody Battle • Became pregnant in her early 20s • Declared recovered by treating psychiatrist • UK social services suspected risk of grave harm to her unborn daughter … … even though this was Fran’s first child & she had no offending history.
  8. 8. Perils of Risk Management Social services’ concerns re: Fran Lyon case: • Fit profile of an MSbP perpetrator • Potential for emotional abuse/neglect Social services’ care plan: • Removal of infant at birth
  9. 9. What was the outcome? • Major media attention and political outcry • Fran Lyon left the UK for Sweden while 7 months pregnant • Swedish social services determined Fran was not a risk to her unborn child • Fran went on to deliver a healthy baby without incident
  10. 10. Two major questions: • Were social services’ concerns legitimate? • If so, could those concerns be addressed with targeted supports instead of loss of custody? My research on both queries says YES.
  11. 11. BPD Child Welfare Concerns • MSbP • Disturbed attachment • “Parentification” of child • Sequelae of childhood sexual abuse
  12. 12. MSbP • Munchausen Syndrome by Proxy • AKA “Factitious Disorder Imposed on Another” (preferred term) “Falsification of physical or psychological signs or symptoms, or induction of injury or disease, in another, associated with identified deception.” (DSM-5)
  13. 13. MSbP and BPD • Perpetrator profile (Bools et al): – History of self harm (55%) – Cluster B personality disorder, incl BPD (36%) – Sexual abuse (25%) – Frequent (75%) history of somatoform disorders (potential issue in Fran Lyon case)
  14. 14. But not without controversy! • Multiple criminal convictions of mothers accused of MSbP overturned – Angela Cannings, Sally Clark, Trupti Patel • Sir Roy Meadow (originator of concept) • Expert witness in all 3 cases • Was at one point stripped of license to practice in the UK
  15. 15. Still, salient issues remain … Schrier posits that MSbP is “an attempt to avenge and repair past perceived or real humiliations of childhood.”
  16. 16. Regardless of MSbP risk … • Children of mothers w/BPD have higher risk of psychiatric disturbances • Infants/toddlers of mothers w/BPD display disorganized attachment • Mothers w/BPD display unresolved attachment patterns • Dissociation/triggers prove problematic for abuse survivors who are parenting
  17. 17. Intervention Options • Individual therapy • Parent-child dyadic therapy • Peer support • Therapeutic communities/intensive day treatment • Mother/baby unit admission Can be used to prevent custody loss or improve reunification prospects!
  18. 18. Individual Therapy Options • DBT • STEPPS • Schema therapy • Mentalization-based therapy None of these are parenting interventions per se, but can be used to address parenting issues.
  19. 19. DBT • “Dialectical Behavior Therapy” • Linehan et al demonstrated effectiveness in several RCTs • First-line treatment of choice for women who chronically self-harm • Teaches affect regulation, distress tolerance, and interpersonal effectiveness – all skills that can generalize to parenting improvement • Downside: Time consuming (1 yr) and costly.
  20. 20. STEPPS • “Systems Training for Emotional Predictability and Problem Solving” • Brief, manualized intervention (much shorter term than DBT) • Takes place in skills groups similar to DBT’s. • Provides a psychoeducation component for family members
  21. 21. Schema Therapy (Young) • Directly addresses the impact of mother’s own childhood experiences • Offers a “limited reparenting approach” (mothering the mother) • Encourages reflection on and reframing of early attachment-based negative concepts of self and others (“schemas”) • Like DBT, time-consuming (can be several years)
  22. 22. MBT • Mentalization-based therapy (Fonagy) • Mentalization = ability to reflect upon and understand one’s own thoughts/feelings and those of others • Fonagy finds that people with BPD lack this skill • Skills training could increase parent’s receptivity to child (ex. not assuming that child is “angry” when in reality h/she is expressing a need)
  23. 23. Parent-Child Therapy • Dyadic psychotherapy • Watch, Wait and Wonder • Circle of Security Important to note: Study outcomes with parents with BPD have been mixed, but these interventions have never been adapted specifically to this population.
  24. 24. Peer Support • Recognized as an evidence-based practice in general psychiatric population • Guidance has been prepared for peer support of women who self-harm (Beth Filson) – adapt for parenting? • Pilot study: Temple Collaborative • Also: peer support for children! (mitigate “parentification”)
  25. 25. TCs and IOP • Inpatient TC instrumental to Fran Lyon’s recovery (Cassel Hospital) • Outpatient example: The Haven Project – Long-term day program for people with personality disorders – Includes parenting support programs – Stepdown/transitional services BUT: Both UK-based and NHS-funded. Virtually unheard of in US. Closest intl. approximate: Spectrum BPD Service in Australia.
  26. 26. A Haven client speaks: “I’ve done [another] parenting course and this is in a different league. I did a six-week social services one and it was like a kindergarten one – “don’t pick your children up by the ears”!! – kind of thing. The content of this course is fuller ... It’s targeted at adults and it’s looking at things from both sides to bring adult and child together. It has also confirmed some of the good things we are doing. After you’ve been poked and prodded by social services this course validates and gives confidence in what you are doing that is right.”
  27. 27. Mother-Baby Units • Allow for observation of mother and child as a dyad (usually for up to 12 weeks) • May be particularly useful in cases of suspected MSbP • Fran Lyon offered this as a potential compromise in her case, but was denied. Barriers: Costly, lengthy, few spaces available (none exist in US).
  28. 28. Lots of interventions, but … • We need to remember to: – Focus on strengths – Validate! (crucial for people w/BPD) – Recognize the huge motivator for recovery that children can be. Remember the words of that Haven client!
  29. 29. Marginalized voices matter! • Many women with BPD are doubly disenfranchised: – By abuse – By negative attitudes of clinicians Ample information for parents whose CHILDREN have mental illness (NAMI etc.), but where are the voices of PARENTS with mental illness?
  30. 30. Be Trauma-Informed! Instead of asking “What’s wrong with you?” ASK: “What’s happened to you?”
  31. 31. Thank you! • For more information: www.jenncrowell.com
  32. 32. References American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing. Black, D. W., Blum, N., & St. John, D. (2009). Borderline personality disorder: STEPPS is practical, evidence based, easier to use. Current Psychiatry (8:10), 18-36. Bools. C., Neale, B., & Meadow, R. (1994). Munchausen syndrome by proxy: a study of psychopathology. Child Abuse and Neglect (18:9), 773-788. Farrell, J. & Shaw, I. (n.d.). Group schema therapy borderline personality disorder: a catalyst to mode work. [PowerPoint slides]. Retrieved from: http://www.istos.ch/pdf/Keynote_GroupSchemaTherapy.pdf. Filson, Beth. Engaging women in trauma-informed peer support: a guidebook [PDF document]. Retrieved from: http://www.nasmhpd.org/docs/publications/EngagingWomen PeerEngagementGuide_Color_REVISED_10_2012.pdf. Harrison, D. (2007, August 26). Threat to take newborn over emotional abuse. The Telegraph. Retrieved from http://www.telegraph.co.uk/.
  33. 33. References, Cont’d. Linehan, M. (1993). Cognitive-behavioral treatment of borderline personality disorder. New York: Guilford Press. Macfie, J. (2012). Mothers with BPD and their children’s development: what do we know? [PowerPoint slides]. Retrieved from: http://www.borderlinepersonalitydisorder.com/wp- content/uploads/2012/10/Dr+J+Macfie+Talk_12_NEA_BPD+Oct+7+2012.pdf. Newman, L. & Stevenson, C. (2005). Parenting and borderline personality disorder: ghosts in the nursery. Clin Child Psychol (10:3), 385-394. Parental Mental Health Network. (2009). Living with personality disorders supporting better parenting [PDF document]. Retrieved from: http://www.pmhcwn.org.uk/files/pdbooklet.pdf. Royal College of Paediatrics and Child Health. (2002). Fabricated or induced illness by carers. London: RCPCH. Schreier, HA. (1992). The perversion of mothering: Munchausen syndrome by proxy. Bull Menninger Clin, 56, 421-437. Sir Roy Meadow struck off by GMC. (2005, July 18). BBC News. Retrieved from: http://news.bbc.co.uk/2/hi/health/4685511.stm.

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