Essay: Personality disorders

Introduction
Personality disorders are known as a class of mental disorders characterized by a stable and continuous pattern of thoughts, feelings and behavior during adolescence or early adulthood, deviating from the norm accepted by the individual’s culture, which are inflexible about many aspects in life and are associated with significant distress or disability (Ashton, 2013). The life time prevalence of personality disorders is 6% (Tyrer et al., 2010) and in clinical settings, 75% of those carrying a BPD diagnosis are women (Skodol & Bender, 2003).
One of the most common personality disorders is Borderline Personality Disorder (BPD), which has a prevalence of 1-2% in the general population (Farrell, Shaw, & Webber, 2009). BPD is chacterized by emotional, behavioral and interpersonal dysregulation (Lavner, Lamkin, & Miller, 2015) and the DMS V (American Psychiatric Association, 2013) has the following concise criteria for the diagnosing of BPD: (1) significant impairment in personality functioning manifested by impairment in self functioning (in identity of self-direction) and impairment in interpersonal functioning (in empathy or intimacy); (2) pathological personality traits in the following domains: negative affect (e.g. emotional liability, anxiousness, separation insecurity and depressive symptoms), disinhibition (e.g. impulsivity and risk taking) and antagonism (e.g. hostility); (3) the impairment in personality functioning and the individual’s personality trait expression are relatively stable across time and consistent across situations; (4) the impairment in personality functioning and the individual’s personality trait expression are not better understood as normative for the individual’s developmental stage or socio-cultural environment; (5) the impairment in personality functioning and the individual’s personality trait expression are not solely due to the direct physiological effects of a substance or a general medical condition. Although BPD is not diagnosed until early adulthood, it is notable for difficulties in areas conceptually similar to developmental tasks in early childhood reworked in adolescence (Sroufe, Egeland, Carlson, & Collins, 2005). First, BPD has been characterized as a disorder of self development (Westen & Cohen, 1993), which include an extreme instability in self-image, symptoms of dissociation and feelings of emptiness. This leads to a little sense of personal identity or meaning in life (American Psychiatric Association, 2013; Ashton, 2013), limited capacities to empathize with others (Putnam & Silk, 2005) and a paranoid, hostile worldview that leads them to be suspicious of the intent of others (Kernberg, 1967). Secondly, people with BPD show difficulties with self-regulation (Posner et al., 2003), with symptoms of extreme impulsivity, inappropriate angry outbursts and mood swings. The impulsive behavior causes possible drug and alcohol abuse, spending sprees, sexual escapades and eating binges and the self-harming behaviors including self-mutilation or suicide attempts (Ashton, 2013). At last, people with BPD often have unstable and intense ‘love/hate’ relationships with others and frantic worries about the possibility of being abandoned (Ashton, 2013), due the fact that BPD has been characterized as a disorder of attachment (Fonagy, Target, & Gergely, 2000). Attachment is a deep and enduring emotional bond that connects one person to another across time and space (Bowlby, 1969). John Bowlby and Mary Ainsworth (1991) developed the attachment theory and emphasized the importance of the earliest relationship between mother and child. Attachment was approached from an evolutionary perspective, meaning that an attachment relationship has survival value because it ensures that the infant will receive nurturance. The relationship between mother and child is built and maintained by an interlocking repertoire of inborn behavior patterns that create and sustain proximity between parent and child (Boyd & Bee, 2014). Ainsworth (year) distinguished between secure attachment and two types of insecure attachment, resistant/ambivalent attachment and detached/avoidant attachment. The fourth type of attachment, disorganized/disoriented attachment has later been added by Main (Main & Solomon, 1990). Secure attachment, is formed by infants whose parents are emotionally available, perceptive and are sensitive and responsive in the interactions to the infant’s mental states and needs. The children see the adult as a secure base from which to explore the environment and become more independent. The resistant/ambivalent attachment is a result of inconsistent responses and availability to the child. Adults react ambivalent in that they sometimes show appropriate and nurturing behavior, while other times they are intrusive and insensitive. The infants are confused and insecure, not knowing what kind of treatment to accept and are consequently more anxious, clingy, and demanding at home. The third attachment style, detached/avoidant attachment, is often seen by parents who are emotionally unavailable, imperceptive, unresponsive, and rejecting. As a result, the parents are insensitive to and unaware of the needs of their children. The infants then protect themselves from this difficult situation by dissociating from contact with their normal need for connection, and generally repress their emotions more often. Lastly, disorganized/disoriented attachment is observed by children whose parents are abusive to a child. As a result, the infant experiences emotional and physical cruelty and frightening behavior. The child is in a dilemma because it actually wants to look for safety with the person who is terrifying him. The children dissociate from their selves and from the situation and block their consciousness (Main & Solomon, 1990).
It is thought that BPD has a three-factor origin: (1) genetics and temperament; (2) childhood experiences in the family and outside world; and (3) the interaction between the child’s temperament and the reactions of the caregivers and their parenting styles. The childhood experiences concerning family environment that can contribute to the development of BPD are (1) an unsafe and unstable family environment; (2) a depriving family environment, whereby the family does not threat the child adequately in respect to his age; (3) a harshly punitive and rejecting family environment; and (4) a subjugating family environment, including (emotional) suppression of the child. Besides the neglect in family environment, a significant number of BPD patients experienced sexual, physical and/or emotional abuse in childhood (Kellogg & Young, 2006). With respect to the infant-parent interaction, retrospective studies on childhood and family characteristics show that individuals diagnosed with BPD have neglectful, dysfunctional or abusive (e.g. emotional or sexual) relationships with their parents, including domestic violence, maltreatment, early loss and incest (Bezirganian, Cohen, & Brook, 1993).
Because both genetic and environmental influences play a role in the development of BPD, children of mothers with BPD may be at increased risk of developing BPD themselves. It may be useful to explore the effects of a mother with BPD on the attachment of her child to identify potential points of application for interventions. During the perinatal period, women with BPD will experience several difficulties, due to their pervasive psychological difficulties (Wendland et al., 2014). In some cases, women diagnosed with BPD experience the period of pregnancy as an idyllic and highly idealized moment, with feelings of omnipotence, plenitude and of having full control over the unborn child (Le Nestour, 2004). However, other women experience the physical symptoms of pregnancy very intense and as unbearable, or they ignore them completely (Aidane et al., 2009). Attendance to prenatal care is often irregular. Consequently, the mother may be inadequately prepared to welcome the baby at birth (Wendland et al., 2014). These women may also show mood disturbances during the perinatal period and are sensitive to major depression (Apter-Danon & Candilis-Huisman, 2005). Also cases of addiction, self-harm or suicidal behaviours have been reported in this period (Newman & Stevenson, 2008). Clinical reports show, that when mothers idealize the infant during pregnancy and expect to repair the shortcomings in her own past and present life, the baby is unable to fulfil these expectations after birth (Aidane et al., 2009). In reality, the baby reflects the mothers own childhood and her infantile dependence, distress and fear of abandonment. (Le Nestour, 2004). Despite their wish to have a child, mothers with BPD may feel overwhelmed, angry and/or estranged with their infants immediately after birth (Newman, Stevenson, Bergman, & Boyce, 2007). These mothers struggle between the desire to be a good mother and give adequate care to their baby, and their own affective needs, which often exclude or postpone the child needs (Aidane et al., 2009). The psychological task of parenting, including attachment security promotion, consistent and empathic care, tolerance of dependency, physical proximity, and frustration of their own needs, are particularly demanding for adults with BPD. The first months after birth, the mothers may show a state of intense and chronic fatigue and irritability and have difficulties with establishing steady rhythms in the child’s daily care (Aidane et al., 2009). These new mothers feel more distressed, less competent and less satisfied in their maternal role than mothers in the general population (Newman et al., 2007).
However, little empirical evidence exists concerning the outcomes of children whose mother has BPD, in particular for infants and young children. However, interaction with the child may be comparable to other close interpersonal relationships. The transition to parenthood does not significantly change the psychological functioning of women with BPD which implies the disorder’s distortions may have a major impact on parent-child interactions and therefore on the child’s own development (Wendland et al., 2014). Different behaviours from mother to child may occur including: unexpected, paradoxical and frightening responses to the child’s needs, as well as the child’s needs being put after the mother’s own (Aidane et al., 2009). The mothers may also avoid or misinterpret the asks for interaction (Newman et al., 2007) and experience difficulties to communicate with the child when the infant is unable to speak (Wendland et al., 2014). Hence, the child may experience high levels of unpredictability and discontinuity in daily care. This lack of attention for basic emotional and physiological needs can go as far as denial of the child’s individuality and subjectivity by the adult (Mazet, Rabain, Downing & Wendland, 2002). These behaviours may limit important parental tasks, such as monitoring practices and emotional validation. This affects the infant’s ability to understand his own feelings and those of other ad hamper to form secure, steady and predictable relationships. Consequently, mother and infant may be thwarted in their efforts to engage each other positively, and both are likely to get disappointed and to withdraw from interaction (Apter-Danon & Candilis-Huisman, 2005). Research showed that children between the age of four and seven years old having a mother with BPD, told stories with the following characteristics: (1) more negative mother-child and father-child relationship expectations, more fear of abandonment and more parent-child role reversal; (2) more shameful and incongruent representation of the self; and (3) poorer emotion regulation with more confusion of boundaries between reality and fantasy and between self and fantasy, more tendency to fantasy, less narrative coherence and more encroachment of traumatic themes, compared to children having a mother with no BPD (Macfie & Swan, 2009)
With respect to the mother-child interaction, clinical observations have shown a mixed maternal interactive style including unpredictable variety of forced interaction, intrusion and withdrawal (Aidane et al., 2009; Apter-Danon & Candilis-Huisman, 2005; Newman & Stevenson, 2005). The child of the mother with BPD may react with apparent calm and withdrawal, instead of noisy symptoms such as crying (Wendland & Medeiros, 2010; Wendland et al., 2010). Due to the maternal discontinuity, the baby may be forced to develop self-protective strategies, such as inhibiting the expression of his needs (Fraiberg, 1982). In a study using the still face paradigm (Tronick, Als, Adamson, Wise, & Brazelton, 1978), mothers with BPD were described as being more intrusive and less sensitive during the interaction with their 2-month-old babies compared to nonclinical control mothers (Crandell, Patrick, & Hobson, 2003). On the other hand, the babies showed less positive affect during and after the still face procedure, were more likely to display a dazed look and looked away from mothers more often. A research with mothers with BPD and their 1-year-old infants resulted in similar findings (Hobson, Patrick, Crandell, Garcia-Perez, & Lee, 2005). Distressed children of mothers with BPD show after a brief separation from their mother during the strange situation, a typical pattern of disorganized attachment behaviour. This behaviour, like mentioned before, is characterized by simultaneous contradictory behaviours and the struggle between a desire to approach the parent and a fear of doing so. The interactive patterns found in a structured situation such as the still face paradigm, were also found in a free-play session (Newman et al., 2007). Mothers with BPD were more inconsistent, more intrusive, less sensitive and show less structure during their interactive behaviours. On the other hand, the children seemed less interested in interaction with their mothers and gave them less attention. It can be concluded that manifestations of BPD in mothers, are likely to negatively affect their interactions with their children which may have an effect on the child’s attachment. As mentioned before, the attachment of children whose mother has BPD will now be profoundly discussed. In one of the theoretical models of BPD it is mentioned that patients with borderline personality disorder have not successfully achieved the separation individuation process (Mahler, Pine, & Bergman, 1975). In fact, mothers with BPD may show over involvement with their child and the child’s attempts to separate may lead to withdrawal of love, which may result in regressive behaviour and consequently leading to poor individuation in the child (Macfie, 2009). Separation experiences may be considered as threatening for the maternal sense of identity and self-confidence (Aidane et al., 2009). According to these ideas, the attachment theory is viewed as a meaningful and almost indispensable way to approach people with BPD and their interpersonal relationships (Barone, Fossati, & Guiducci, 2011). As mentioned above, the interactions of mothers with BPD and their infant seems on the mother’s part disrupted, insensitive and intrusive, while the infants show various patterns of disorganized behaviors and withdrawal, which may lead to the development of attachment disorder or later psychopathology (Wendland et al., 2014). Children and adolescents whose mothers have BPD meet significantly more criteria for psychiatric diagnoses, especially BPD itself or borderline traits, compared to control children raised by mothers without any psychiatric diagnosis (Weiss et al., 1996). Besides, the children of mothers with BPD are more likely to show behavior and attention disorders, depression and anxiety symptoms, and suicidal thoughts or attempts (Barnow et al., 2006). Research has shown a link between BPD and attachment disturbance in adults. Specifically unresolved attachment, a representational form of disorganized attachment in adulthood is found (Barone, 2003). Conversely, secure attachment is rare among adults with BPD (Levy, 2005). When the caretaker appears afraid, quits the protective function of caretaking , or if young children fear their primary caretaker, the children will experience disorientation and helplessness. Effects of these experiences, if continued during adulthood, may increase the risk of developing BPD (Crittenden & Newman, 2010).When this adult becomes a parent the risk arises of reenacting these distortions in interaction with his or her own children, especially in showing atypical parental behaviors (Fonagy, Target, & Gergely, 2000). In this way the attachment model shows one of the pathways for the potential intergenerational transmissions of borderline personality disorder (Solomon & George, 2006). Family studies assessing the rates of BPD diagnoses and related traits in first-degree relatives have found a four to twenty fold increase in prevalence of morbidity risk for BPD compared with the general population (Barnow et al., 2006). Moverover, the children diagnosed with borderline traits are more likely to describe their parents as neglectful, unaffectionate, controlling, rejecting and aggressive than a control group of children (Lefebvre, Howe, & Guilé, 2004). Because BPD is not diagnosed until adolescence (Ludolph et al., 1990) or early adulthood (American Psychological Association, 2013), it is important to treat BPD in the mother, or to design an intervention preventing development of attachment disorders and BPD itself.
A successful treatment for adults with BPD should focus on the ability to make sense of oneself’s and others’ behaviour in terms of mental states such as feelings, beliefs and thoughts, which is denominated as mentalization or reflective functioning (Fonagy, Target, Steele, & Steele, 1998). The aim of this review is twofold: (1) to compare and contrast three therapies for treating mothers having BPD, and (2) to explore the effect of these therapies on the attachment their children. More specifically, the schema-focused therapy, the mentalization-based therapy and the attachment based therapy are compared each other. Schema-focused en mentalization-based therapy are chosen because they have shown to be an efficient treatment (Farrell et al., 2009). The attachment-based therapy is chosen because of the special interest in the disturbed attachment by the mothers and thereby the disorganized attachment behaviour of the child. As it was shown that a mother having BPD has influence on the child’s attachment, the effects of the mothers therapy on the child’s attachment are examined on an exploratory basis First we will examine the general content of the therapies. Then, we will discuss (1) the application of schema-focused therapy, (2) the application of the mentalization-based therapy and (3) the application of a specific kind of attachment-based therapy, namely Watch Wait and Wonder. How these therapies may influence the mother and through this the attachment of the child will be discussed aswell. In the discussion we will discuss and compare the results and mention possible shortcomings of the studies and suggestions for further research.
Schema therapy and applications
Young, the developer of schema-therapy (Young, Klosko & Weishaar, 2003), mention that the inner world of the borderline patient is characterized by five aspects of the self, called modes. These modes interact with each other in destructive ways, whereby the patient is living in a kind of inner theatre. Each mode tries to take their turn on the stage, which results in rage, cruelty, submission and self-numbing (Kellogg & Young, 2006). The five central modes in the borderline constellation are: (1) the abandoned and abused child, (2) the angry and impulsive child, (3) the detached protector, (4) the punitive parent, and (5) the healthy adult modes (Young et al., 2003). One of the goals of schema-therapy is the development of the healthy adult, who is typically first embodied in the therapist and then, through the therapy process, internalized by the patient. There are four mechanisms of change and healing that are at the core of schema-therapy: (1) limited reparenting, (2) emotion-focused work— specifically imagery and dialogues, (3) cognitive restructuring and education, and (4) behavioral pattern breaking (Kellogg & Young, 2006). These mechanisms are used during three phases of the treatment that include a variety of interventions. The three phases of treatment are (1) bonding and emotional regulation, (2) schema mode change, and (3) development of autonomy (Kellogg & Young, 2006).
The effectiveness of schema therapy was examined using a single case series trial of six women with BPD (Nordahl & Nysæter, 2005). The treatment included the core elements of schema therapy, had his emphasis on limited reparenting and schema mode work and implemented follow-up assessment at 12 months. There was a great improvement from the baseline to the follow-up and was clinically meaningful for five of the six patients. At the end of the treatment, three of the six patients did not longer meet the criteria for BPD (Nordahl & Nysæter, 2005). Another study examined the effects of schema therapy in group format in a small randomized clinical trial (N = 32) (Farrell, Shaw, & Webber, 2009). In this study, female patients received either treatment as usual (largely individual psychotherapy offered once per week), or treatment as usual plus an eight-month, thirty session schema-therapy. The schema therapy treatment included schema change work, emotional awareness training, psychoeducation and distress management. Patients in the schema therapy group showed significant reductions in BPD symptoms and in global severity of psychiatric symptoms. They also achieved increases in overall global function, whereby 94% of schema therapy patients did no longer meet criteria for BPD, compared to 16% in the treatment as usual group (Farrell, Shaw, & Webber, 2009). Another study with a bigger sample size compared schema-therapy with psychodynamically based transference-focused psychotherapy (Giesen-Bloo, et al., 2006). Patients received three years of either schema therapy (N = 44) or transference-focused therapy (N = 42), with sessions twice a week. Measurements were made after 1-, 2-, and 3 years of treatment and results showed a significant improvement for both treatments on all measurements. However, after 3 years of treatment, analyses demonstrated that significantly more schema-therapy patients were recovered or showed reliable clinical improvement. Patients in the schema-therapy group also showed more improvement in the overall psychopathologic dysfunction and showed a greater increases in quality of life, compared with the transference-focused therapy (Giesen-Bloo, et al., 2006). Other research demonstrated patients in the transference-focused therapy had significantly higher levels of suicidality compared with those receiving schema therapy (Yeomans, 2007) and that schema therapy has better cost-effectiveness than transference-focused therapy at one year follow up (van Asselt, Dirksen, Arntz, et al., 2008).
These studies support schema therapy as an effective treatment for BPD that leads to improvement of overall functioning and recovery. Recovery of BPD symptoms and maternal behaviour from an healthy adult-mode may positively influence the mother-child interaction. The mother may act more responsible and consistent. Consistent and responsible behaviour of the mother may lead to an improvement of the attachment of the child.
Mentalization-based therapy and applications
Mentalization is the capacity to understand and interpret human behaviour in terms of underlying mental states. It develops during childhood through a process of experiencing oneself in the mind of another within an attachment context. Mentalization matures adequate within the context of a secure attachment (Bateman & Fonagy, 2003).
People with borderline personality disorder have difficulties with mentalization, even compared to people with other disorders (Fonagy et al., 1996). A therapy focussing on this is mentalization-based therapy. As mentioned before, there is evidence that BPD is linked with disorganized attachment, resulting in difficulties with attention, self control and affect regulation. Some authors suggest that these problems are moderated through a failure in developing a powerful mentalizing capacity (Bateman & Fonagy, 2010). The mentalization theory of BPD suggests four things: (1) individuals are constitutionally vulnerable and/or exposed to psychological trauma; (2) the development of social and cognitive capacities necessary for mentalization, can be undermined by this vulnerability/exposure, via neglect in early relationships (Battle et al., 2004), especially by non-congruent contingency between the emotional experience and the caretaker’s mirroring (Crandell, Patrick, & Hobson, 2003); (3) this leads to an hypersensitive attachment system within interpersonal contexts; and (4) this results in an underdevelopment of the ability to control attention capacity and represent affect (Posner et al., 2002).
During the mentalization-based therapy (MBT), the focus is stabilizing the sense of self and helping the patient reaching and maintaining an optimal level of arousal in the context of a well-managed attachment relationship between the patient and the therapist (Bateman & Fonagy, 2010). The initial task in MBT is to stabilize emotional expression, which is necessary for the consideration of internal representations. MBT uses different techniques and patients are asked to modify their current practice focussing on mentalizing rather than behaviours, cognitions, or insight. In the beginning they have to develop a specific therapeutic stance and achieve a series of steps and the therapist tries to engage the patient in a process of mentalizing. Firstly by using psychotherapy techniques as support, empathy and clarification, and then changing to other interventions specially designed to ‘stress’ the attachment relationship within controlled conditions, including a focus on the patient-therapist relationship through ‘mentalizing the transference’ (Bateman & Fonagy, 2010). The mentalizing of the transference consists of different steps: (1) the validation of the transference feeling by determination of the patient’s perspective; (2) exploration, also identification of the events which generated the transference feelings; (3) accepting enactment on the therapist’ part, because it would be unhelpful if the therapist acts in some ways consistent with the patient’s perception of him/her and the therapist should also initially explicitly acknowledge even partial enactments of the transference as inexplicable voluntary actions that he/she accepts agency for, rather than identifying them as a distortion of the patient; (4) collaboration in arriving at an interpretation; (5) the therapist has to present an alternative perspective; and (6) the therapist has to monitor carefully reaction of the patient as well as one’s own (Bateman & Fonagy, 2010).
A study compared the effectiveness of MBT in the context of a partial hospital program with routine general psychiatric care for 44 patients with BPD. A significant decrease on all measures was found for patients in the MBT condition, while people in the control group showed limited change or deterioration over the same period. The patients in the MBT condition showed an improvement in depressive symptoms, a decrease in self-mutilatory and suicidal acts, reduced inpatient days, and even interpersonal and social function improved after six months and continued to the end of the intervention at 18 months. After the treatment, the patients were assessed at three month intervals, which showed a continued improvement in interpersonal and social function for the MBT group. This result suggest that longer-term changes in rehabilitation were stimulated (Bateman & Fogany, 2010). A comparable study examined these possible long-term effects of mentalization-based treatment (Bateman & Fonagy, 2008). In this study 22 patients with BPD received a MBT by partial hospitalization and were compared with 19 patients with BPD receiving a treatment as usual. The patients were compared 8 years after the beginning of the controlled, randomized trial and 5 years after the MBT was completed. The results showed that the MBT group continued to do well 5 years after all mentalization-based treatment had ceased. Compared with the treatment as usual, the MBT group showed clinical and statistical improvement on global functioning, diagnostic status, suicidality, service use, vocational status and use of medication. Although the mentalization-based therapy lead to a reduction in BPD symptoms and subjective distress, at the end of the intervention and at the long-term follow-ups, the general social function remained impaired (Bateman & Fonagy, 2008). Another study with a bigger sample size (N = 134) compared mentalization-based therapy in weekly individual and group therapy with structured clinical management in a similar format (Bateman & Fonagy, 2009). Both treatments showed improvement in symptoms and in social function, as well a reduction in self-harm, suicidality and hospitalization. However, the changes in symptoms, self-harm and suicidality, were superior in the MBT-group (Bateman & Fonagy, 2009).
These three studies indicate that mentalization-based treatment is an efficient treatment for BPD. BPD-patients receiving MBT will improve their mentalization and have less BPD symptoms. The patients will be more able to understand and interpret other’s behaviour and act more consistent and predictable. These improvements will positively influence the mother-child interaction. The mother will be more able to interpret the child’s ask for needs and security. Besides, her more consistent behaviour will positively effect this interaction, because the mother’s behaviour is more predictable. All these positive changes may lead to an improvement in the attachment of the child.
Attachment-based therapy and a specific application
In general, attachment-based interventions are intended to prevent the transmission of disorganized and/or insecure attachment from the parent to the child. This intervention can be conducted in two ways: (1) individual psychotherapy with the mother and (2) psychotherapy with the mother-child dyad. The aim of the individual psychotherapy is to provide ‘corrective’ attachment experiences through interactions and experiences with the therapist. (Lieberman & Zeanah, 1999). During this therapy, the therapist encourages the mother to talk about her own childhood experiences and connect these events to her current relationship with her infant. In this way, the mother may gain insight into how she perpetuates the cycle of disorganized and/or insecure attachment. The individual psychotherapy with the mother for improving attachment security is not well manualized, which has impeded dissemination and evaluation efforts (Stepp, Whalen, Pilkonis, Hipwell & Levine, 2012). The second mode of intervention of attachment-based therapy intervenes at the level of the relationship between the mother and the child (Stern, 1995). During this therapy the mother discusses her own developmental history in term of experiences and interaction with caretakers. However, during this approach the therapist observers the interaction between the mother and the infant to facilitate the mother linking her own attachment style and past experiences to that of her current relationship with her child (Stepp et al, 2012). This infant–parent therapy focuses on supporting parents in reflecting on the infants’ internal experiences, needs and motivations which should promote the development of attachment security and emotional regulation (Newman & Stevenson, 2008). One specific kind of attachment-based therapy, is Watch Wait and Wonder (WWW). This application is chosen because it is the only attachment-based therapy applied to mothers with BPD thus far. During the WWW intervention, the mother is required to focus on the infant’s bids for communication. The aim of this intervention is to improve the interaction between the mother and the child and to promote security of attachment. This is achieved by promoting the maternal capacity to observe and reflect on the meaning of the behaviour of the child and emotional communication. It is an ‘infant-led’ approach, because the goal is to provide the infant with an experience of self-agency and to develop the capacity of the mother to see her infant as actively communicating and psychologically independent. This intervention aims to improve the parental sensitivity and reflective capacity (Newman & Stevenson, 2008). The WWW intervention takes places in a therapy room with standard toys (e.g. dolls, doctor’s kit, soft toys). Each session starts with the parent being invited to ‘get down on the floor’ and to observe and follow their child’s lead in playing with toys. During the first half of the session, the therapist is present in the room, but does not interact with the mother or the child. During the second half of the session a discussion takes places between the parent and the therapist about the activities initiated by the child as well as the mother’s understanding of the child’s behaviour and play (Newman & Stevenson, 2008). A special WWW intervention program for mothers with BPD examined the nature of transgenerational attachment in mothers with BPD and their children. The program was designed for participation of 20 mothers. Regretfully, only six mothers participated. These mothers were asked to attend twelve to fourteen WWW therapy sessions with their child, over a period of five months. The authors made different observations during the application of WWW to mothers with BPD. These include: (1) the mother’s surprise at the nature of the intervention; (2) meeting the families basic needs for routine and structure; (3) mother’s tolerance for interaction with their child; (4) maternal resentment for the attention their child was receiving; (5) re-enactment of past trauma; (6) child’s need to engage the therapist; and (7) the reflective functioning of the mothers (Newman & Stevenson, 2008). Nevertheless, the authors mentioned that additional issues need to be considered when WWW intervention is implemented with high-risk mothers, such as those with BPD. They concluded that therapists must be aware of the complex issues that traumatized parents bring to the therapy. Secondly, therapists must minimalize maternal distress and anxiety and make sure that mothers do not feel dismissed. Thirdly, it is important for the therapist to maintain focus on the aim of the therapy, namely supporting parents in the development of their capacity to reflect on the child’s inner world and through this to promote security and self-organization. The authors end with concluding that interventions focusing on infant-parent interactions may play a role in the improvement of the relationship of mothers with BPD and their children (Newman & Stevenson, 2008). Unfortunately, no evaluation of the intervention’s effectiveness was included in maternal–infant relationship outcomes, so the