Working with families when Mum has a diagnosis of BPD

Workshop: How to do itAnne Sved Williams

So what we will cover this afternoon

• 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

• 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 WAILS11.Support for staff: group and individual

supervision, ward round discussion12.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

• VALIDATE

• MODEL WHAT TO DO WITH INFANT• ASK QUESTIONS TO CLARIFY• REFRAME BABY’S INTENTIONS• SUPPORT MOTHER AND BABY • 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

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

PlayfulnessAcceptanceCuriosityEmpahty

Dialectical Behaviour Therapy (DBT)

• What it is?• Is it the best or only treatment for BPD?• Who else is using it with infants?

Infant Mother Grandmother

Maternal Calming

AND ENHANCING MATERNALREFLECTIVE CAPACITY

BY THE CLEVER THERAPIST

Infant Mother Grandmother

Maternal Calming

AND ENHANCING MATERNALREFLECTIVE CAPACITY

BY THE CLEVER THERAPIST

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 familyThe “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

Enhancing grandparental reflective functioning

AND IN AN IDEAL WORLD….

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 pathwayHow 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?