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The Development of Self in Early Experience: Borderline Mothers and Their Infants

Danon, G., Rosenblum, O. and LeNestour, A., 2001. The Development of Self in Early Experience: Borderline Mothers and Their Infants. Reformulation, ACAT News Autumn, p.x.

L’Aubier, Centre Psychologique du Tout-Petit, Laboratoire de Psychopathologie Périnatale, Paris 7

"It is now clear that the development of the critical capacity to create and maintain an internal sense of emotional security comes from the inner, not necessarily conscious knowledge that during times of stress, one can cope, either by auto-regulation or going to others for interactive regulation." (Schore 2001)

This affirmative statement on the part of developmental psychology is now strongly corroborated by numerous studies on mother-infant interaction and on the developing neonate and infant.

Schore and others are in this way stating that the circumstantial research evidence is now strong enough to assume that, not communicating socially and emotionally, not striving to feel and "learn" about others is a highly unnatural and pathological state for the infant. The neonate is "precabled" for all kinds of developments with others, for relatedness, indeed excessively so. The first year(s) of life will witness a considerable amount of energy spent on selecting and refining different aspects of exchange, affective and cognitive, between the infant and its environment. This is neurologically the case, as in neuronal pruning. It is also behaviourally so: motor co-ordination follows on from infant clumsiness.

But how does the infant come to acquire such knowledge? Pre cabling, predisposition, natural possibility and implicit knowledge are other ways of formulating innateness. E. Tronick (1998) suggests that the "motivation to establish emotional connectedness or inter-subjectivity [is] an inherent characteristic of all humans". All the recent biological and neurological data (even the recent decoding of the genome) show that, on the road to inter-subjectivity, almost everything is set up for humans in such a way that almost nothing is determined or definitely pre-established. In fact, one could say that in the genome there is predetermined room for aleatory movement of genes, therefore unpredictability. If the infant is ready to start building a complex bio-psycho-social individual from conception, many mysteries are still to be solved regarding how it comes to do so.

Perhaps the question that now arises is, how does it happen that whatever or whomsoever the infant encounters, it must develop and integrate others and the knowledge of others on the way, for better and for worse?

Inherent motivation for inter-subjectivity seems to be already active at birth (probably linked to foetal life) - a meta-sixth sense progressively integrating what it is seeing, hearing, smelling, touching and tasting using transmodal capacities to enrich and enhance more complex inter-relatedness.

Even so, as E. Tronick underlines:" What experience makes such powerful connections in our lives?" He suggests a concept derived from systems theory that he calls Dyadic Expansion of Consciousness.. If we agree that regulation of emotional states in infants is a dyadic process, then when infant and mother mutually create a dyadic state, they "fulfil the first principle of systems theory of gaining greater complexity and coherence".

"The states of consciousness of the infant and the mother are more inclusive and coherent at the moment when they form a dyadic state (a moment of meeting according to Daniel Stern) because it incorporates elements of the state of consciousness of the other".

This hypothesis has the advantage of considering psychopathology as something different from a derailment. The emergent force behind the dyadic expansion of consciousness is stronger than whatever originally helped to build it (systems theory) and cannot be simply broken down into different parts to explain it. Expanding complexity means a system is being created. Whatever is available will feed the system, positive as well as negative affect, rich interactions as well as retreats. Since the infant needs the mother or caregiver to regulate its needs (such as feeding, changing etc.), the system is operational and will evolve whatever the quality of the relationship may be.

Research Study

With this background in mind, in our clinical setting, l’Aubier*, we set out to study, pragmatically, what we found to be a large part of our clinical population, one that set new challenges for psychotherapy and that had been as yet practically unstudied in the field of mother-infant research.

Our pilot study had three main objectives :

To determine if there are specific sets of interactions between borderline mothers and their infants which are distinct from those of other psychopathological groups

To examine the quantitative and qualitative characteristics of these interactions and infant and maternal emotional states

To determine any initial implications for clinical and research work of this type of study

We used the clinic’s video bank. Systematic filming of new patients when arriving at the clinic is standard procedure. Most initial consultations at l’Aubier are filmed, with a particular emphasis on infants under 6 months of age. Therefore, we systematically looked at all initial consultations of infants under 7 months, before secondary inter-subjectivity has developed.

Coding was done with a French interaction scale during 10 minutes of video, from the tenth to the twentieth minute. This gives families time to settle down for the consultation and yet is not far enough into the interview to suppose that some of the behaviour may already be attributed to therapeutic effects.

After excluding main DSM 4 Axis 1 Diagnosis, no psychosis and no bipolar disorder were included in the coding; 36 first interviews of mother-infant dyads were coded. The group was divided in two, 18 mothers had received a diagnosis of Borderline personality disorder and 18 did not meet criteria for BPD. However, postnatal depression was checked for in both groups and diagnosed in each group after having separated them into BPD and non BPD. In each group, 11 mothers were depressed: major depression was not differentiated from post-natal depression. The motive for consultation for infant symptoms were not significantly different in each group. The mean age of infants at first interview was 4 months and the sex ratio was not different in the two groups : 11 boys to 7 girls in BPD group and 12 boys to 6 girls in non-BPD group.

Our methodology involved a coding system which characterised interaction according to the following criteria :

Synchrony and mutuality: harmonious time, contingent, turn-taking interactions

Trans-modality: mono-channel, multi-channel interactive modalities

Continuity/discontinuity: rupture of interaction without repair such as: jolting infant limb or abruptly changing attitude towards infant

Repetition: same interactive pattern and sequence over time

Intrusiveness such as poking, jabbing or force feeding

Synchrony, mutuality and trans-modality were considered positive interactions, the other categories were put together as negative interactions.

Maternal behavior and infant behavior: gaze, vocalizations, touch, gestures (these same items are commonly used when videocoding interactions in research literature).

Infant affective tonality and emotional quality: to look into infants’ internal worlds, we particularly focused on emotional manifestations. Emotional characteristics were subdivided into three groups.

Positive emotions were defined by: pleasure, tenderness

Passive negative emotions were defined by: emptiness, dullness, sadness, indifference

Active negative emotions were defined by: displeasure, cries, hostility

Results

Infants of the Borderline Personality Disorder group compared to the non-borderline group showed:

LOWER positive emotions: pleasure, tenderness

HIGHER passive negative emotions: dullness, indifference, sadness, emptiness

EQUAL active negative emotions: displeasure, excitement, cries, hostility

This is the first study to show significant differences in interactions between mothers with personality disorders and their infants (whether or not they are depressed) and a group of mothers without personality disorders. However, this is also the first study of its type since borderline personality disorders are difficult to follow-up in a non-clinical situation.

Discussion

Implicitly, since both groups are part of a clinical population, the differences maybe considered valid against controls. However as a pilot and retrospective study, it needs to be confirmed by a prospective and formal study.

What is being looked at, when observing the infants’ behavior, is organized according to maternal personality and not only by maternal symptomatic manifestations such as anxiety or depression. Could we consider this an opening for looking at the construction of the infant, interacting with its caregiver on the basis of structural personality traits and therefore in terms of defense mechanisms?

The infants in the study were very young, therefore the emotional manifestations were limited by the infants’ stage of development itself. In experimental conditions and with micro-analytic video techniques, one is able to observe the young infants or even the neonate’s extraordinary capacities and competence. These are not so obvious during an average consultation in a clinical setting. However, the interactive emotional differences in the infants, in both groups, are sufficient to allow for some speculative hypotheses and discussion.

Assuming the borderline personality disorder is, in a linear sense, more pathological than the "ordinarily neurotic" mother even if depressed, then the initial result showing less positive emotions in infants of borderlines compared with infants of non borderlines comes as no surprise. Borderline mothers have less frankly positive feelings and emotions towards their infants; their ambivalence is greater and this is manifested by less positive interactions, with less synchrony and less mutuality and therefore less "positive" interactive spirals. More negative type interactions occur, there is more repetition and discontinuity in the interactive patterns of the Borderline group as opposed to the non-borderline one.

However, the results concerning negative emotions are less obvious. There is no difference if one looks at the outward active manifestations of the infants. Of course, they came to the clinic with the same type of symptoms (functional symptoms). By contrast, the negative passive emotions are more highly expressed in the infants of the borderline group than in the other group. How are we to understand such very early behavior in these infants? It seems as if the infant had already "tuned out", saying "this too much for me, I will just switch off for a while"?

This leads to two different observations:

It is important to look at infant emotions from a behavioural point of view. Infants are known to be able to recognise emotions visually and express essential emotions such as pain, and anger and joy (cry, scream, smile, coo). Sadness, depression, emptiness may be inadequate terms to characterise infant emotions when they are described as still, blank, distant, without protest and excessively compliant physically, in their body contact and tonico-motor responses.

If infants of mothers with borderline personality disorder develop passive, negative affective emotional states early in life, do we consider this to be defensive, a reaction to intrusion, discontinuity, chaotic, non-contingent interactive stimulation and engagement or more a temperamental predisposition perhaps linked to biological conditions during pregnancy or even family predisposition factors (genetic)?

One cannot exclude this last hypothesis. Some studies have looked into genetic, trans-generational aspects of borderline personality disorder, and one concluded that children of parents (mothers) with borderline personality disorder were more at risk of psychopathology than control groups (Paris). It seems, perhaps, more fruitful to expand on the first point about defense mechanisms, or reactions to, or even construction of, infant emotions -with and against -particular maternal affective states whilst taking into consideration the dyad as a system and the hypothesis of expansion of dyadic consciousness. We may say that these infants regulate excessive input by lowering output. Their particular way of bringing down excitement is by disengaging, lowering attention and through a slumped posture.

Distancing

It has been shown, in studies of mothers with postnatal depression, that they develop particular patterns of interactive styles with their infants. They tend to intervene rarely, and express a mechanical style to their behavior. When asked about their feelings during moments of exchange with the infant, such as feeding or nappy-changing, they express wishes for the exchange to be as short and effective as possible - as if being with the baby is too difficult, too much of an effort, requiring too much energy. Therefore keeping the infant at a distance, physically and emotionally, helps to maintain homeostasis between the mother and the infant at a low energy cost.

Mothers with borderline personality disorder features have difficulty establishing the right distance, particularly the emotional one, in a relationship. Being too close, too far away, being emotionally overwhelmed by a relationship and changing from rage to tears are usual. A new relationship with an infant necessarily means all sorts of emotional upheaval and the absolute obligation to be close and not too far, and yet not too near.

Infants for their part need to be fed, bathed, changed, handled many times daily. The infant’s mere existence will provoke reactions and cause turmoil. It will engage and adapt itself to the mother and to her chaotic inner self. The dyadic system expands at the cost of any continuity of feelings of connectedness. Relatedness is lowered to a minimum: switching to "sleep mode".

Borderline mothers when depressed also show more distancing than mothers who are not depressed even if borderline in our study. Distancing, here, could be interpreted as better for the infant than chaotic intrusion, even if interactions seem somewhat repetitive. In this context could it be hypothesized that, paradoxically, depression in borderline mothers is a protective factor for the developing infant? A protection from more chaos and less contingency than if the mother were not depressed? Such a view would modify the simplistic equation: depressed mother = negative infant outcome. This study points to more complexity to the generation of the mother infant dyadic system than has been supposed until now.

Infants of borderline mothers need to be followed up longitudinally and groups separating depressed from non depressed in mothers with and without personality disorders should be our next step in clinical research.

References

*L’Aubier is an out-patient clinic, with a referral of 200 families each year of parents with infants under 2 years of age. Families may be referred during pregnancy or the perinatal period from GPs, community services, maternity wards or any type of specialized care. Care is offered by a team of child psychiatrists, psychologists, body therapists, play therapists, a speech therapist and a social worker. The general background of the clinic is psychodynamically oriented and families may be offered care from one or two therapeutic consultations or brief psychodynamic psychotherapy to long-term, intensive multi-modal management (for example, once a week play group for a 2 year-old, once a week body therapy for its 6 month-old sibling, once a week or twice a month mother-infant interaction centred sessions and regular meetings with a social worker for a high-risk family)

Paris J. (1998) "Does childhood trauma cause personality disorders in adults?", in Can. J. Psychiatry,43(2), pp. 148-153.

Rosenblum O., Mazet P., Benony H. (1997) "Mother and infant affective involvement states and maternal depression", Infant Mental Health Journal, 18,4

Schore A.N. (2001) "Effects of a secure attachment relationship on right brain development, affect regulation, and infant mental health", Infant Mental Health Journal, 22 (1-2), 7-66

Stern D.N. (1985) "The interpersonal world of the infant", New York : Basic Books

Tronick E. Z. et al. (1998) "Dyadically expanded states of consciousness and the process of therapeutic change", Infant Mental Health Journal, 19, 3,290-299

Weinberg K., Tronick E.Z. (1998) "The impact of maternal psychiatric illness on infant development", Journal of Clinical Psychiatry, 59, 53-61

Gisèle Danon

Ouriel Rosenblum

Annick LeNestour

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Full Reference

Danon, G., Rosenblum, O. and LeNestour, A., 2001. The Development of Self in Early Experience: Borderline Mothers and Their Infants. Reformulation, ACAT News Autumn, p.x.

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Type in your search terms. If you want to search for results that match ALL of your keywords you can list them with commas between them; e.g., "borderline,adolescent", which will bring back results that have BOTH keywords mentioned in the title or author data.

Book Review of: Beatrice Beebe and Frank Lachmann (2002). Infant Research and Adult Treatment: Co-constructing Interactions. Published London: Analytic Press.
Lloyd, J., 2009. Book Review of: Beatrice Beebe and Frank Lachmann (2002). Infant Research and Adult Treatment: Co-constructing Interactions. Published London: Analytic Press.. Reformulation, Summer, pp.34-35.

Reconstructing the Infant : Review of 'The Interpersonal World of The Infant' by Daniel Stern
Scott Stewart, M., 2001. Reconstructing the Infant : Review of 'The Interpersonal World of The Infant' by Daniel Stern. Reformulation, ACAT News Autumn, p.x.

CAT and Attachment Theory: A Reply to Tony Ryle
Jellema, A., 2001. CAT and Attachment Theory: A Reply to Tony Ryle. Reformulation, ACAT News Autumn, p.x.

Book Review of: How Infants Know Minds. Reddy, V. (2008). Harvard University Press.
Ryle, T., 2009. Book Review of: How Infants Know Minds. Reddy, V. (2008). Harvard University Press.. Reformulation, Summer, pp.33-34.

Diagrammatic Psychotherapy File
Dunn, M., 2002. Diagrammatic Psychotherapy File. Reformulation, Spring, p.17.

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The Development of Self in Early Experience: Borderline Mothers and Their Infants

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