4 BRIEF INTERVENTIONS FOR BPD: THE PROCESS

OF BUILDING AN EMPIRICALLY SUPORTED

TAU Michel André Reyes Ortega PsyD * ** ***Angélica Nathalia Vargas Salinas PsyD * ** ***Edgar Miranda Terrés MPs ** ***Iván Arango de Montis***

* Association for Contextual Behavioral Science Mexico Chapter ** Mexico’s Contextual Science and Therapy Institute

***Mexico’s National Institute of Psychiatry Ramón de la Fuente

CONTEXT-INPRF BPD CLINIC-MEXICO’S NATIONAL INSTITUTE OF PSYCHIATRY• Decentralized public organization

with its own budget and administration. Part of the system of National Institutes of Health in Mexico.• It’s functions are to:

• Conduct scientific research.• Provide research and clinical training• Psychiatric patients treatment• Give advice other official and private

institutions.• Contribute to the development of health

policies at the national level in the areas of mental health and substance use.

BORDERLINE PERSONALITY DISORDER CLINIC

• Only public sector BPD clinic in Mexico.• 3 years old.• Clients treated per year range = 200• Clients waitlist range = 100.• All clinic personal are volunteers and

residents, first psychologist was hired on May 2015.

CONTEXT-INPRF BPD CLINIC-

PSYCHOTHERAPY TREATMENT OPTIONS

• Transference focused psychotherapy

OBSTACLES

• Expensive and unrealistic• Lenght of treatment• Number of therapists

needed• Amount of treatment

needed

SOLUTIONS

• Call the ACBS guys

BEHAVIORAL THERAPIES FOR BPD

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

improvements 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).

DBTi CHARACTERISTICS

MODULES

GROUP SESSIONS(120 minutes)

INDIVIDUAL SESSIONS(30 minutes)

NUMBER STRATEGIES NUMBER STRATEGIES

ASSESMENT 1Functional Analysis

Identification of treatment goals

DBTi INTRODUCTION 1BPD Biopsychosocial

education, DBTi rationale, Treatment contract signing

MINDFULNESS 8Psychoeducation, Group discussion, Skill practice 34

Chain analysisDialectic strategies

Problem solving strategies

DISTRESS TOLERANCE 9INTERPERSONAL EFFECTIVENESS 9

EMOTION REGULATION 8CLOSING

RELAPSE PREVENTION1 Same as above 1

WHY THIS PILOT STUDY?

• 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).

DESIGN

O1 DBTi O2O3 ACT O4

O5 ACT 06O7 ACTG O8

O5 ACT 0609 ACT+FAP 10

• N=25 clients per group.• Treatment integrity assesed.• 50% Individual therapists changed across treatments.

ACT CHARACTERISTICS

MODULES

GROUP SESSIONS(120 minutes)

INDIVIDUAL SESSIONS(30 minutes)

NUMBER STRATEGIES NUMBER STRATEGIES

ASSESMENT 1Functional Analysis

Identification of treatment goals

ACT INTRODUCTION 1 Same as below +Treatment contract signing

14

MindfulnessMetaphors

(or Experiencial excercise) Commited actions

ACCEPTANCE 4 MindfulnessMetaphors

Experiential exercisesGroup discussion

DEFUSION 3

VALUES CLARIFICATION 3

INTERPERSONAL EFECTIVENESS 7

Same as above +PsychoeducationGroup discussion

Skill practiceCLOSING

RELAPSE PREVENTION1 Same as above 1 Same as above

VARIABLES AND MEASURES

• BPD symptoms severity – Borderline Evaluation of Severity Over Time Scale (Pfohl et. al. 2009; Reyes & García, 2014).• Emotion Dysregulation – Difficulties in Emotion Regulation Scale (Gratz &

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

(Ciarrochi & Bilich, 2006; Patrón 2010). • Experience of Self – Experience of Self Scale (Kanter, Parker, & Kohlenberg,

2001; Patrón 2010; Valero-Aguayo, Ferro-García, López-Bermúdez & Selva-López de Huralde, 2014).• Mindfulness Skills – Five Facets Mindfulness Scale (Baer, Smith, Hopkins,

Krietemeyer, & Toney, 2006; Loret de Mola, 2009). • Attachment – Adult Attachment Questionnaire (Cuestionario de Apego

Adulto; Melero & Cantero, 2008).

ACT AND DBTi DIFERENCES

DESIGN

O1 DBTi O2O3 ACT O4

O5 ACT 06O7 ACTG O8

O5 ACT 0609 ACT+FAP 10

• N=25 clients per group.• Treatment integrity assesed.• 50% Individual therapists changed across treatments.

ACT AND ACT-G DIFFERENCES

DESIGN

O1 DBTi O2O3 ACT O4

O5 ACT 06O7 ACTG O8

O5 ACT 0609 ACT+FAP 10

• N=25 clients per group.• Treatment integrity assesed.• 50% Individual therapists changed across treatments.

ACT+FAP CHARACTERISTICSMODULES

GROUP SESSIONS(120 minutes)

INDIVIDUAL SESSIONS(30 minutes)

NUMBER STRATEGIES NUMBER STRATEGIES

ASSESMENT 1 Functional AnalysisIdentification of treatment goals

ACT INTRODUCTION 1 Same as below +Treatment contract signing 1

MindfulnessMetaphors

(or experiential exercise)ACT Matrix

ACCEPTANCE 3 MindfulnessMetaphors

Experiential exercisesGroup discussion using the ACT Matrix

2DEFUSSION 2 1

VALUES CLARIFICATION 2 1

VALUED ACTIVATION 2 Same as above +Behavioral Activation 2

FAP INTRODUCTION (FAP/RAP) 1 Same as below +

Treatment contract signing 1 Identification of CRBs and Os

FAP(ACL Skills workshop) 6

Group discussionEvocative excercises for ACL practice

ACT Matrix debriefing 6

Evocative excercise(5 rules practice)

Challenges and Risks logSessions bridging form

CLOSINGRELAPSE PREVENTION 1 Same as above 1 Same as above

ACT AND ACT+FAP DIFFERENCES

POSTEST VISUAL COMPARISON

TREATMENT IMPLICATIONS

• Group + Individual Therapy worked better than Group alone.• ACT+FAP treatment costs where acceptable enough to clinic possibilities.• The use of the Matrix seems to be a valuable tool to improve ACT

treatment with BPD.• FAP exposure-like quality seems to potentiate previous ACT impacts on

psychological flexibility and BPD clinical variables.• FAP seems to be a valuable adition to BPD behavioral treatments in

interpersonal variables.• Supervision groups are needed to adress treatment integrity.• Helping the helper programs are needed to manage team stress.• ACT+FAP treatment runs as TAU at this moment.

RESEARCH IMPLICATIONS

• There’s need to asses mediational processes to identify which clients could benefit of group therapy alone.• There’s need to asses mediational variables related to outcome.• This preliminary findings justify running a RCT comparing different

treatment and controling therapists experience.• A DBT informed group adapted to 18 sessions needs to be included.• Mediational processes are going to be assesed to contribute with the

understanding of BPD treatment.