Observing Borderline Personality Family First-Hand
To understand the causes of borderline personality, observation counts.
Posted September 23, 2021
- Direct observation is essential for understanding behavior patterns which may be triggered by interpersonal interactions.
- Some models suggest that problematic family interactions are at least partially causative of borderline personality disorder.
- In a new study, parents of kids with borderline personality disorder were more punitive and devaluing than parents in two control groups.
The controversy over the role of problematic interactions in people’s families of origin in causing various psychiatric disorders has always been at the heart of the mental health field. Because the brain is so complicated and the number of interpersonal interactions almost limitless, there is obviously much we don’t know. This fact has also led to extreme and nonsensical positions: Some folks believe all the diagnoses in the DSM are brain diseases and the environment doesn’t count, while others believe they are all behavioral disorders that somehow occur in the absence of biological involvement by the brain. The book of diagnoses, the DSM, recognizes the limitations and ignores the causes of the disorders listed within, just describing them.
Even the science we do have is suspect. Sometimes it seems like it is determined mostly by economic interests (pharma, insurance companies, and guild issues among academic disciplines).
This problem is prominent in the diagnosis of borderline personality disorder (BPD). Some people think it’s just a variety of bipolar disorder. Readers know how I feel about that idea. On the other hand, the idea of dysfunctional family interactions being at least partially causative is at the heart of several prominent theoretical psychotherapy schools: DBT (family invalidates their kid’s ideas, emotions and opinions); interpersonal psychotherapy (episodes of traumatic abandonment interspersed with periods of traumatic over-involvement); Masterson’s psychodynamic (family abandons their child when they try to function autonomously). It is also true that most studies done show a significant probability that patients with BPD were victims of child abuse.
The problem with much of the research is that family interactions are so seldom actually observed. For example, there are several studies that had people with BPD keep diaries of their emotional reactions over many weeks, but subjects are not asked at all about any interpersonal interactions they may have been reacting to.
The Importance of Observational Studies
Luckily, this situation is changing as the number of observational studies has increased. Of course, this method has a lot of limitations: the necessity for small sample sizes, the fact that interactions are observed in the lab rather than at home where things may be different, and the fact that the interactions are being observed which may cause the family to change its behavior. There is no way of knowing about the prior interactions and feelings of the observed parties. Still, these studies are better than nothing. There have been enlightening studies by Edward Sharpiro, Karlen Lyons-Ruth, Jenny Macfie, Melges & Schwartz, Walsh, and Bezirganian, Cohen & Brooks (references available on request).
Almost all of these studies were consistent with a model that suggests that angry and guilty parents who feel conflicted over the role of parenthood and who give out confusing messages to their kids may play a role in BPD. The model is based on the idea that children act out certain roles to try to stabilize parents who are emotionally unstable. In families with children with borderline personality disorder, the parents may have felt pressured to have children even when they didn’t really want them, due to a variety of beliefs and customs. This inner conflict may lead them to give mixed messages to their children, often with a tone of anger or resentment. Children may take it upon themselves to regulate their parents’ guilt and anger. I have observed this over and over again in my clinical psychotherapy practice of 45 years, in which I often have conjoint sessions with, or found other ways of observing, an adult patient with BPD and a parent.
BPD and Attachment
A recent, small study by Khoury et. al. also lends credence to this model, but of course, by no means proves it. It was done from the perspective of attachment theory. Attachment theory defines disorganized attachment as when a child exhibits behavioral disorganization or disorientation in the form of wandering, confused expressions, freezing, undirected movements, or contradictory patterns of interaction with a caregiver. Secure attachment is characterized by trust, an adaptive response to being abandoned, and the belief that one is worthy of love. These patterns were first defined for toddlers but were later seen in both older children and adults using the Adult Attachment Interview.
The young adults in the study were females with borderline personality disorder between the ages of 18 and 28 with their mothers. In one control group, there were 13 adult children who suffered primarily from anxiety and depressive disorders, while 36 adult children in a second group had no psychiatric diagnoses. The study observed discussions of topics of disagreement between the parents and children. These disagreements were identified after the mothers and daughters completed a “Conflict Issues Checklist.” The young adults wrote a statement on their position on an issue picked by the researchers, and then the mothers and daughters were observed while they discussed the matter for 10 minutes. Attachment issues were scored using a validated measure called the GPACS.
No adult children in the study with BPD were classified as showing secure attachment. The subjects with BPD were eight times more likely to show disorganized attachment than the controls. There was strong evidence that the parents of BPD were more punitive and devaluing than those in the two control groups and showed more seemingly out-of-context behavior. The BPD kids, in response, also showed odd and seemingly out-of-context responses and tended to ramble. They tended to make a lot of critical, mocking, or rejecting comments toward the mothers. Some also showed caring responses such as offering guidance or defusing parental hostility by entertaining them.
The authors noted what they believed to be two opposite behaviors of the children with BPD: those that indicate caring about parental well-being, and those characterized as controlling their parents through being punitive. However, the responses can be both caring and punitive. The BPD offspring may be caring about parental well-being when they are being nasty, because nastiness may be what their parents seem to need from them. It may help the parents feel justified for their own anger at their children and assuage their guilt.
Khoury et. al.: “Disorganized attachment interactions among young adults with BPD, other diagnoses, and no diagnoses.” (2020) Journal of Personality Disorders 34(6), 764-784.