Introduction

Definitions of personality disorders (PD) seem to change almost every time a committee convenes to review psychiatric classifications (Tyrer, 2011). PDs lack a robust evidence and theoretical base (Allik, 2002; Farmer, 2000; Widiger, 2012b) and are a source of intense professional disagreement (Bolton et al., 2014). They are commonly under-recognized and disliked by professionals (Appelby and Lewis, 1988), and the academic community by and large dismisses their relevance to parenting and families. For example, the Oxford Handbook of Personality Disorders (Widiger, 2012a) does not mention “parenting” except as an etiological factor for PDs, despite evidence that PD (parental) also begets PD (child) (e.g., Barnow et al., 2013). The reluctance to “own” the parenting agenda is persistently evident. The UK National Office of Statistics carried out an epidemiological survey of mental health in the general population that included data on whether someone was a parent looking after children and on the quality of parent–child relationships (Singleton et al., 2001). However, data relevant to parental PD was archived and not reported. A recent “handbook” of PDs in the community – in many ways an excellent text – is completely silent on parental PD (Bolton et al., 2014). To our knowledge, no one has made the argument that parental status is less important than marital status, and yet the latter is routinely reported while the former is not. This denial of the status of a person as parent in the research arena is a recurring theme across editions of this book; the reason commonly given for the omission is that it is methodologically too difficult to study. However, the absence of such data clearly creates a bias in the evidence that needs addressing (e.g., Howard et al., 2008).

Hengartner and colleagues (2014) conducted the only epidemiological survey of PD we could find that reported on parental status. All subjects qualifying for a DSM-5 PD diagnosis had significantly fewer children compared with the general population except for parents with a schizoid or obsessive-compulsive PD. For the last two, a similar trend did not reach statistical significance. Generally, people with all categories of PD reported relationship stress except for avoidant PD, and, apart from people with a schizoid, dependent, or obsessive-compulsive PD, were less likely than the general population to be married or have a partner. In summary, people with PD tend to be less likely to have children and to feel lonely (except for paranoid, antisocial, and narcissistic PD). Apart from this study, the evidence base for parental PD is small and skewed, with an overwhelming focus on mothers with a diagnosis of borderline personality disorder (BPD) (Laulik et al., 2013). This contrasts with findings that the most common (though not necessarily most commonly diagnosed) PD is obsessive-compulsive PD (Coid et al., 2006). One possible reason for the focus on BPD might be that people so diagnosed tend to ask for help in one way or another, e.g., by self-harm, and, therefore, come to the attention of clinicians. Others with a diagnosable PD rarely ask for help; in fact, they rather avoid it (Tyrer, 2009).

A recent survey of the parents of routine referrals to Child and Adolescent Mental Health Services (CAMHS – tier 3) in Liverpool (UK) indicated that approximately one-third of all participating parents would probably qualify for a diagnosis of PD as indicated by the Standardised Assessment of Personality: Abbreviated Scale (SAPAS) (Moran et al., 2003; Ramasubramanian et al., 2012). This is possibly an underestimate since the SAPAS does not cover all PDs equally well (Hesse and Moran, 2010). The impact on treatment outcomes of their children remains to be clarified (Pembelton et al., 2014). However, we tentatively conclude from these data that parental PD, as well as being omnipresent in adult services, may be an integral, substantive part of everyday work in CAMHS. We suspect that this might be even more the case at the more severe end of children’s services, such as child-protection and forensic CAMHS. Arguably, the survey finding is not surprising since a review of any version of DSM PD variables will persuade the reader that none are conducive to optimal parenting. Although we know that some parents with diagnosable PD are good parents, we also know that parental PD is an established risk factor for children (Laulik et al., 2013). Furthermore, parental PD has been associated with abusive parenting (though the evidence seems to focus on mothers (e.g., Famularo et al., 1992) and in extreme cases (more commonly of fathers) with infanticide (Kauppi et al., 2010). Understanding parental PD is therefore central to safe and effective treatment planning for children and families across all domains of mental health service provision. This chapter will focus on parents with a primary presentation of complex personality issues and not address the largely uncharted territory of the “comorbidity” of parental PDs with, for example, substance-use, affective, or psychotic disorders. The chapter aims to assist clinicians in recognizing and working with parental PD by providing:

Readers may find it difficult to engage with the material in this chapter, as the term “personality disorder” itself may be considered pejorative, especially when associated with parents. The discourse dominated by terms such as “disorder,” “psychopathology,” and “dysfunction” does not always reflect empathic understanding, and neither do diagnostic checklists nor the language of some of the test manuals used for research (e.g., MCMI-III, Millon et al., 2006). A formulation that is nonblaming and strength-based is more useful for clinicians and parents. However, the resulting “normalization” of sometimes severe conditions may collude with denial and place children at risk, especially since we do not have a valid measure of severity (e.g., Bateman and Fonagy, 2013; Dolan et al., 1995). Without some way of marking a serious condition, there would not be any allocation of resources to risk assessment or to preventive interventions. There is no simple solution to the diagnostic labeling dilemma. As Bruner says (1962, p. vii), “Man … is shaped by the tools that he comes to use.” Meanwhile, we need to carry on using some imperfect tools shaping as yet imperfect services.

PD – brief overview

DSM-5 (APA, 2013) delineates ten subtypes of PD, categorized into three distinct clusters: Cluster A (characterized by odd or eccentric behavior) comprises paranoid, schizoid, and schizotypal; Cluster B (characterized by dramatic, emotional, or erratic behavior) comprises antisocial, borderline, histrionic, and narcissistic; and Cluster C (characterized by anxious or fearful behavior) comprises avoidant, dependent, and obsessive-compulsive PDs. PDs are presented as distinct entities; however – apart from the common overlaps – commonalities do exist across the clusters, including failure of the capacity to understand the perspectives of others and to empathize, difficulty in taking responsibility, and, most notably, pervasive interpersonal relationship difficulty. Current ICD-11 proposals plan for a primary classification of personality pathology based on severity alone, with a secondary diagnosis based on trait domains (Tyrer, 2011).

The developmental context and etiology of PDs are of profound interest to clinicians and researchers, yet little is known about these intractable conditions. Current research points towards genetic, psychological, and social factors in the etiology of PDs. Personality is in part inherited, with a heritability proportion of 40–50% (Johnson et al., 2008). Shared environmental factors such as the influence of family seem to play a relatively modest role (e.g., Torgersen et al., 2012). The nature–nurture interplay is potentially quite complex (Loehlin, 2009), and our models might not yet be mature enough to provide pragmatically useful answers to etiological questions. In any particular condition, the exact proportion of nurture over nature may vary (Vondra et al., 2005). For instance, antisocial tendencies may have a stronger genetic basis than other traits (Vondra et al., 2005), suggesting that we need to understand the survival value of such conditions and their persistence over time.

Many PDs seem strongly associated with childhood adversity and nonoptimal parenting (Hernandez et al., 2012). Indeed, most patients with PD present with stories of childhood adversity and difficulties (Bolton et al., 2014). A strong association between abusive experiences in the context of the parent–child relationship and PD in adulthood is commonly found (e.g., Cohen et al., 2014), but we need to better understand the adaptive value of PDs and the causative pathways. Thus far, there are only tentative constructions as to how childhood adversity and adult PD might be linked (e.g., see Chapters 4 and 16).

Conclusive data are difficult to obtain, partly because of the variance of definitions and concepts of “adversity” (e.g., Burgermeister, 2007; Daniel, 2010) and partly because of the nonspecificity of findings, although, overall, the strength of association between childhood adversity and all classes of psychiatric disorders in adulthood is solidly established (e.g., Kessler et al., 2010). In our clinical experience, a common thread in stories of patients is that they had to fit into a parent’s or other adult person’s reality, be it through becoming “parentified” (see Chapter 7) or through outright abusive experiences. The negative long-term effect of traumatic experiences depends more on the quality of the child’s relationships than on the severity of the trauma itself. For instance, patterns of “grooming” or disbelief in the case of untoward sexual experiences might be more predictive prognostically than the actual nature of what took place.

PD and parenting

The concepts of equifinality (different causes leading to the same outcome) and multifinality (same cause leading to different outcomes; see Chapters 1 and 10) are both of relevance in this area. However, they are difficult to prise apart, and it is not always clear how much difference it makes clinically whether a specific PD can lead to different parental dysfunctions, or whether many different PDs can lead to the same parental dysfunction, and how much of the difference depends on the nature of the children. The difference between equifinality and multifinality seems to be most relevant when designing preventive measures since the correct identification of risk factors is important in preventive medicine (e.g., Frick and Viding, 2009). We are not yet in a position, however, to identify specific preventive measures that can address the pathways from parental PD to parental dysfunction.

A recent systematic review (Laulik et al., 2013) on links between PDs and parenting behaviors confirmed a strong association between a diagnosis of PD, poor parent–child interactions, and problematic parenting practices. Of the eleven studies reviewed by the authors, nine found that parental PD was identified as a risk factor for impaired parenting behaviors and disturbed parent–infant interactions. Significantly, Cluster B disorders were found to exert a negative effect on parenting in eight of the studies, with four having specifically examined the effect of BPD on parenting. Mothers with BPD had difficulty in taking their infant’s perspective, interpreting their infant’s affective state, and meeting the infant’s needs. This also has consequences for the quality of the attachment relationships and long-term emotional, psychological, and behavioral development (see Chapter 16). Only three studies included fathers, making it difficult to draw conclusions on the paternal role. Some of the studies attempted to have pure samples of individuals with one diagnosable PD only. Because the norm seems to be that most people qualify for more than one diagnosis, this might make the clinical validity of any such study questionable.

Overall, Laulik et al.’s (2013) review found PDs to be related to the following: ill-advised parenting and infant-care practices, inconsistent parental discipline, low parental affection, and low praise and encouragement; less satisfaction, less reported competence, and more disappointment in the parenting role; insensitive, intrusive, poorly attuned, and disrupted parent–infant interactions; harsh behavior, frightened and disorienting parental behaviors; and status as an abusive parent.

Practice guidelines for clinicians

Tyrer and colleagues (2003) differentiated treatment-seeking and treatment-rejecting PDs. Importantly, “treatment seeking” does not mean the person is motivated to change, nor does “treatment-rejecting” imply that the person so described is unable to change. The psychopathology of PDs might be more about an early adjustment to adverse circumstances, and change might be more about “discovery” of different possibilities of living rather than “recovery” from an illness (Bolton et al., 2014). A precondition for any intervention planning will be that the child is safe within his or her environment. Interventions may enhance the resilience of the child and the family resources, including the parent’s functioning in the parental role. This is too wide a field to cover comprehensively in one chapter, but there are extensive materials available (see also Lenz, 2010 – not yet available in English). We will provide some general guidance on identification of problematic parental personality patterns, and how clinicians can use their experience to formulate the family where a parent has PD. Following this, we will present three case examples illustrating (1) a treatment-rejecting parent, (2) a treatment-seeking parent, and (3) an example of how important it is to be aware of the possibility of missing the diagnosis of PD in the parent. A general outline of ethical principles to guide the management of and work with a parental PD will conclude this section.

Treatment issues

Whole-family approach

A “whole-family” approach as set out in Chapter 7 offers a compassionate and nonblaming view of individual distress. It enables resources of the whole family to be put to good use, enhancing resilience and containment. Assessment, formulation, and treatment planning for parental PDs involves professional responsibility for the welfare of both child and parent, best achieved by liaising with all services (Göpfert et al., 2010). This may present difficulties for an adult service (without explicit child-assessment competence) or for any service (child or adult) without competence in adult PD assessment. Some services in the UK now have service agreements that allow comprehensive, collaborative assessment and treatment. Paying attention to each family member’s story is crucial, so that everyone feels understood and validated.

“Push where it moves”

(1) A good assessment of the resources (strengths) at a family’s disposal creates the foundation of all intervention planning.

(2) Children themselves often benefit from support outside the family, which has been shown to enhance resilience (Grossman and Rhodes, 2002; Werner and Smith, 1982). This is particularly effective if a child has the capacity to engage other adults. Screening such relationships may enable professionals to identify supportive potential for children in complex families and facilitate such support. The adult can be a family friend, a neighbor, a clergyman, a teacher, a worker at a youth club, or – exceptionally – a staff person within the mental health services. What seems to be important is that the person is easily and frequently accessible to and accepting of the child.

(3) It is essential to clarify whether a family is able to use the service available. There is little point in referring parents for parent training if they do not have the capacity to use the service, no matter how much they may want to. For instance, a parent with high levels of impulsivity and little capacity to reflect might not be able to do the homework required (see Chapter 16). A very obsessional parent might not be able to reflect and learn due to the need to get things exactly right and to follow explicit instructions. This is illustrated in Case A (see below).

While not adhering to particular models of psychological intervention, we advocate a formulation-driven, dyadic (e.g., Roff, 2008; see also Chapter 16), family-focused (e.g., Asen and Schuff, 2004; Henggeler et al., 2009), or parent-focused approach (e.g., Puckering et al., 1994) if a parent can meaningfully engage in the parenting role. Frequently, parents may not see anything wrong with themselves and therefore feel no need to attend services or to change. This creates a dilemma for clinicians, since change requires the person to want to change. Sometimes a family might be motivated for one particular piece of work and then want to stop, but come back later for more. It is important, whenever possible, that this occur within a continuous relationship with the same professionals.

(4) Thinking outside the treatment box is essential. When traditional approaches do not work, alternatives might be needed, such as merely aiming for engagement without any requirement of change. One of us (M.G.) developed paradoxical “nontherapy” for the Liverpool psychotherapy service during the 1990s. This later became one of the underlying principles for the establishment of day-therapeutic community treatment for people with severe PDs (Barr et al., 2010). The experience here was that, whenever professionals became too therapeutically ambitious, the individuals concerned deteriorated. The point is that the task of engagement and maintaining engagement is potentially so demanding that further change becomes temporarily impossible. Tyrer’s nidotherapy (Tyrer and Bajaj, 2005) is in-between change and no change. The aim of nidotherapy is not to change people but to create a better fit between them and their environment. As a consequence, people improve not as a direct result of treatment but indirectly due to a more harmonious relationship with their environment. These approaches have not yet been reported as applied to family situations and parenting issues.

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