ACT+FAP TREATMENT OF BORDERLINE

PERSONALITY DISORDERMichel André Reyes Ortega PhD * ** ***Angélica Nathalia Vargas Salinas MA * ** ***Edgar Miranda Terres MA ** ***Iván Arango de Montis MD **María de Lourdes García Anaya MD, PhD **

* Association for Contextual Behavioral Science Mexico Chapter

** Instituto Nacional de Psiquiatría Juan Ramón de la Fuente Muñiz

*** Instituto de Ciencias Conductual Contextuales y Terapias Integrativas

PSYCHOTHERAPY IMPACTS ON BPD

Retrospective studies(15 years)McGlashan (1986)Plakun et al. (1985)Stone (1990)Paris et al. (1987)Paris & Zweig-Frank (2001).

Scenario = Mental Health HospitalsFound M=52.2%Age M= 42.8 N= 142 m, 359 wDiagnose system = DSM IIIStill BPD = 16.5%% suicide = 7.75%

Estudios prospectivos(7, 2, 2 y 10 años)Links et al. (1998).Skodol et al. (2005).Grilo et al. (2004).Zanarini, Frankenburg et al. (2005)

Scenario = General Health HospitalsAge M= 31 at baselineN= 63 m, 237 wDiagnose = DSM III y DSM IVStill BPD = 33.3%% suicide = 5.85%

Improvement associated factorsSkills acquisition.Absence of stable couple.Economic independence.

Non improvement associated factors.Early sexual abuse and other forms of mistreatment.Substance abuse.

BEHAVIORAL THERAPIES FOR BPD

• Dialectical behavior Therapy (DBT)(P-B).• Reductions on self-harm behavior, medical emergencies frequencies, anger and impulsivity;

improovements on social adjustment and treatment adherence (Lieb, & Stoffers, 2012; Linehan et. al. 1999; Lieb, Zanarini, Schahl, Linehan & Bohus, 2004; Turner, 2000; Verheul et. al. 2003).

• Acceptance and Commitment Therapy (ACT)(B).• Reductions on self-harm behavior, emotion dysregulation, experiential avoidance, BPD symptoms

severity, anxiety and depression (Gratz & Gunderson, 2006; Morton, Snowdon, Gopold & Guymer, 2012).

• DBT + ACT(B).• Better outcomes than ACT or DBT alone (Shearin & Linehan, 1994).

• Functional Analytic Psychotherapy (FAP) (P-B).• Improvement on identity stability and interpersonal dimensions (Callaghan, Summers & Weidman,

2003; Koerner, Kohlenberg & Parker, 1996; Kohlenberg & Tsai, 1991; Kohlenberg & Tsai, 2000).• Improvement of ACT impacts (Kohlenberg & Callaghan, 2010; Luciano, 1999) and DBT (Busch, Manos,

Rusch, Bowe & Kanter, 2010).

WISE CHOICES: ACT GROUP TREATMENT FOR BPD(Morton & Shaw, 2012)

• Group sessions - 1st module.• Introduction• Avoidance and values• Willingness and acceptance• Awareness of thoughts• Mindfulness of pleasure• Awareness of emotions, sensations and urges• Responding to emotions, sensations and

urges• Acting on values• Obstaces and choice points

18 sessions (25 patients,1 therapist, 1 cotherapist, 2 monitors)

WISE CHOICES: ACT GROUP TREATMENT FOR BPD(Morton & Shaw, 2012)

• Group sessions – 2nd module.• Values in interpersonal relationships• Listening mindfully• Practising courage to share ourselves• Brainstorming alternative perspectives• Assertively making requests• In the other person’s shoes• Giving and receiving positives• Negotiation

18 sessions (25 patients,1 therapist, 1 cotherapist, 2 monitors)

WISE CHOICES: ACT GROUP TREATMENT FOR BPD(Morton & Shaw, 2012) “ENHANGEMENT”

• Individual sessions• 1st session: Assesment.

• Functional analysis: Identifiation of experiential avoidance patterns.

• Sessions 2-9: Wise Choices enhangement.• Review of group week group session.

• Free use of ACT strategies to solve motivation problems.

• Assistance in use of current week skills to main problems.• Use of FEAR-DARE acronyms

• Assigning weekly homework.• Use of SMART acronym.

16 sessions (4 therapists)

WISE CHOICES: ACT GROUP TREATMENT FOR BPD(Morton & Shaw, 2012) “ENHANGEMENT”

• Individual sessions• 10th session: Assesment.

• Functional analysis: Identifiation of CRBs.

• Sessions 11-18: Wise Choices FAP enhangement.• Review of group week group session.

• Free use of ACT strategies to solve motivation problems.

• Assistance in use of current week skills to main problems.

• Use of FEAR-DARE acronyms.• Use of 5 rules to work on CRBs and draw parallels

to Os.• Assigning weekly homework.

• Use of SMART acronym.

16 sessions (4 therapists)

PILOT STUDY JUSTIFICATION

• Contribute to psychological well being of BPD diagnosed patients: Diminishing entry to emergencies services, symptoms of emotion dysregulation, impulsivity, suicidal risk, fear of emotions and experiential avoidance; Improving quality of life and interpersonal adjustment.

• Need to start a research line based about the development and effectiveness of low cost interventions for BPD (Lieb et al., 2004; Marquis & Wilber, 2008). • INPRF BPD had one year at pilot study start, TFP (1 year / 2 sessions per week) and

DBTinformed where TAU (9 months / 1 group and individual session per week).

HYPOTHESIS

• ACT+ will show better lobal outcomes tan TAU on• Reduction on BPD symptoms severity – Borderline Evaluation of Severity Over Time Scale

(Pfohl et. al. 2009; Reyes & García, 2014).• Reduction on Suicide Risk – Plutchik Suicide Risk Scale (Plutchik & Van Pragg, 1989).• Reduction on Impulsivity – Plutchik Impulsivity Scale (Plutchik & Van Pragg, 1989; Páez et al.

1996).• Reduction on Emotion Dysregulation – Difficulties in Emotion Regulation Scale (Gratz &

Roemer, 2004; Marín Tejeda et al. 2012).• Reduction on Experiential Avoidance – Acceptance and Action Questionnaire-II (Ciarrochi &

Bilich, 2006; Patrón 2010). • Reduction on Fear of Emotions – Affective Control Scale (Williams, Chambless & Ahrens, 1997;

Ramírez, Ascencio, Reyes & Vargas, 2014). • Improvement of Quality of Life – WHO Quality of Life Scale (World Health Organization, 1993).

*Results not shown in this presentation

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PILOT STUDY RESULTS

PILOT STUDY RESULTS

PILOT STUDY RESULTS

PILOT STUDY RESULTS

DISCUSSION AND CONCLUSION

HIPOTHESIS TESTING AND IMPACT

• ACT+ showed to be and effective brief intervention as needed by the INPRF-BPD clinic.

• ACT+ enhanged could achieve better outcomes, specially on interpersonal satisfaction and social adjustment domains.• Include DBT crisis survival and emotion regulation

skills on the fist module.• Use of Matrix model to integrate ACT and FAP

elements.• Drawing paralels between CRBs and Os since treatment

start including group sessions.• Formal FAP on second module individual sessions.

• ACT+ is the new TAU of the INPRF-BPD clinic.

SOLUTIONS TO STUDY LIMITATIONS

• Need of a wider N• Compare groups by age and diagnosis.

• Need of a RCT to prove effectiveness compared to time equivalent treatments.• Asses treatment integrity of all treatments.• Refinement of selection criteria.

• Need of mediational analysis.• Asses relation between hypothesized

mediational variables and treatment outcomes.

CASE CONCEPTUALIZATION(Reyes, 2014; adapted from Polk, 2014)

FIVE SENSES EXPERIENCE

MENTAL EXPERIENCE

ÁPROACHINGAVOIDANCEPERSPECTIVE------------------

CHOICE POINT

I-CRB1sG-CRB1s

O1s

I-CRB3sG-CRB3s

Problematic rules

CRB2sG-CRB2s

O2s

Values

I-T1sG-T1s

I-T2sG-T2s

T3s I-T ValuesG-T Values

CURRENT RESEARCH

• Participants:• 150 participants with BPD diagnosis confirmed by SCID-II; 50 randomly assigned to each group.• Schizofrenia, current psychosis, bipolar disorder, neurological conditions and antisocial

personality diagnosed participats will be excluded.• Age range: 18 – 45 years.

RG1 01 ACT+FAP+DBT(18 G+I sessions)

02(6 months)

03(12 months)

RG2 04 ACT+(18 G+I sessions)

05(6 months)

06(12 months)

RG3 O7 DBTi(18 G+I sessions)

08(6 months)

09(12 months)

RC

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IS• H1: ACT+DBT+FAP will show better outcomes than TAU in• Reduction on BPD symptoms severity – Borderline Evaluation of Severity Over Time Scale (Pfohl

et. al. 2009; Reyes & García, 2014).• Reduction on Suicide Risk – Plutchik Suicide Risk Scale (Plutchik & Van Pragg, 1989).• Reduction on Impulsivity – Plutchik Impulsivity Scale (Plutchik & Van Pragg, 1989; Páez et al. 1996).• Reduction on Emotion Dysregulation – Difficulties in Emotion Regulation Scale (Gratz & Roemer,

2004; Marín Tejeda et al. 2012).• Reduction on Experiential Avoidance – Acceptance and Action Questionnaire-II (Ciarrochi & Bilich,

2006; Patrón 2010). • Reduction on Fear of Emotions – Affective Control Scale (Williams, Chambless & Ahrens, 1997;

Ramírez, Ascencio, Reyes & Vargas, 2014). • Improvement of Quality of Life – WHO Quality of Life Scale (World Health Organization, 1993).

• H2: Hypothesized change mechanisms will significantly mediate impact of treatments.• Psychological Flexibility – Acceptance and Action Questionnaire-II (Ciarrochi & Bilich, 2006; Patrón

2010). • Mindfulness – Five facets of mindfulness questionnaire (FFMQ; Baer, Smith, Hopkins, Krietemeyer,

& Toney, 2006) • Emotion Regulation – Difficulties in Emotion Regulation Scale (Gratz & Roemer, 2004; Marín Tejeda

et al. 2012).

• H3: Significant differences on mediational mechanism contribution to change between treatments will be found.