1. BPD, Parental Self-Harm, and
Child Protection:
Confronting Stigma
While
Ensuring Safety
Jenn Crowell
April 27, 2014

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. Agenda
• Case Study: Fran Lyon
• BPD and Child Welfare Concerns
• Intervention Options
• Recommendations

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. ETCHED ON ME
• 1st published fictional account of Dialectical
Behavior Therapy
• Inspired by the true story of Fran Lyon (case
study to follow)

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. 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. 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. 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. 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. BPD Child Welfare Concerns
• MSbP
• Disturbed attachment
• “Parentification” of child
• Sequelae of childhood sexual abuse

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. 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. 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. Still, salient issues remain …
Schrier posits that MSbP is
“an attempt to avenge and repair past
perceived or real humiliations of
childhood.”

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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. Be Trauma-Informed!
Instead of asking
“What’s wrong with you?”
ASK:
“What’s happened to you?”

31. Thank you!
• For more information:
www.jenncrowell.com

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. 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.