TESTING THE MATRIX AS AN ENHANCEMENT OF ACT FOR PEOPLE DIAGNOSED WITH BPD Michel André Reyes Ortega PsyD 1,2,3,4 Angélica Nathalia Vargas Salinas PsyD 1,2,3,4 Benjamin Schoendorff, MPs, MCs5 Edgar Miranda Terrés, MPs 1,3,4 1Association for Contextual Behavioral Science Mexico Chapter 2Instituto Nacional de Psiquiatría Juan Ramón de la Fuente 3Instituto de Ciencia Conductual Contextual y Terapias Integrativas 4Contextual Psychology Institute

CONTEXT -INPRF BPD CLINIC- MEXICO’S NATIONAL INSTITUTE OF PSYCHIATRY (INPRF) INPRF BPD CLINIC (ONLY EXISTING PUBLIC SECTOR CLINIC) 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. Clinical team: Only one hired clinical psychologist. Rest of Therapists are non payed volunteers (help from 3-6 months only). 1 or 2 Clinical Psychology master degree students (Clinical Behavior Analysis Oriented). 2 Professors of the same program serve as clinic advisors and students supervisors. Clients characteristics: Clients treated per year = 100 (waitlist 100). Clients with possible lethal behavior not admitted (yet symptoms pervasive enough to impair quality of life and treatment engagement). So, first I’m going to tell you about our context… Greatest authority in psychiatric research, teaching and consultation in Mexico. But with limited resourses… Example: BPD clinic, which is 3.....

CONTEXT -INPRF BPD CLINIC (3 YEARS AGO)- TREATMENT OPTIONS DBT, NOT POSSIBLE  Transference focused psychotherapy Clinic psychiatrists (2) trained in that model. TAU back then (wasn’t working). Dialectical Behavior Therapy? Desirable for clients with severe behavioral dyscontrol (Stage 1) and/or severe trauma related symptoms (Stage 2). Expensive and unrealistic. Lenght of treatment. Number of therapists needed (and clients). Amount of training needed. We tried ACT (Current TAU). Good outcomes in: Reductions on self- harm behavior, emotion dysregulation, experiential avoidance, BPD symptoms severity, anxiety and depression (Gratz & Gunderson, 2006; Morton, Snowdon, Gopold & Guymer, 2012). Students receiving training in ACT. Now, our clinic is only 3 years old, my team was invited to colaborate from 2 years.

CONTEXT -WHY TRYING THE MATRIX- The next problems where observed applying ACT treatment: Understanding treatment strategies (metaphors of experiential exercises). Relate treatment strategies with each other. Coordinate in session experience with daily life experience. Daily life behavioral changes observed between 6th and 8th session. Related to neuropsychological problems identified in BPD (difficulties in attentional control, verbal fluency and memory fixation, consolidation and recovery processes). Related to DRR fluency problems? Could the Matrix, as a visual cue for DRR, improve ACT performance? Stage 1 Behavioral Dyscontrol Stage 2 Traumatizing Emotional Experience

DESIGN Based on that reasoning we did a pylot study on Fap as an enhancement for our TAU.

HYPOTHESIS ACT Matrix enhanced will outperform ACT in all the assessed variables. Psychological Flexibility will significantly mediate BPD severity in both groups.

VARIABLES AND MEASURES Experiential Avoidance – Acceptance and Action Questionnaire-II (Ciarrochi & Bilich, 2006; Patrón 2010). α = .89 BPD symptoms severity – Borderline Evaluation of Severity Over Time Scale (Pfohl et. al. 2009; Reyes & García, 2014). α =.88; r=0.62; p<.001 Emotion Dysregulation – Difficulties in Emotion Regulation Scale (Gratz & Roemer, 2004; Marín Tejeda et al. 2012). α=.93 (.85 to .68); r=.76; p<.05 Experience of Self – Experience of Self Scale (Kanter, Parker, & Kohlenberg, 2001; Valero-Aguayo, Ferro-García, López-Bermúdez & Selva-López de Huralde, 2014). α = .941 (.59 to .95) Anxiety and Depression also assessed. Not described in this presentation. α = Internal consistency; R=Test Retest; P= Concurent validity

ACT-TAU CHARACTERISTICS 1st 3 sessions

THE USUAL GROUP SESSION STRUCTURE Feedback: What did you noticed? Was your reaction in this experience similar or different to the way you reacted to your pain this last week? Whay was useful about this experience? Behavioral rehearsal: How could you practice noticing this next week?

THE USUAL INDIVIDUAL SESSION STRUCTURE

ACT-MATRIX CHARACTERISTICS

THE SMALL BIG CHANGE GROUP SESSIONS

THE SMALL BIG CHANGE INDIVIDUAL SESSIONS

PARTICIPANTS THERAPISTS ACT ACT-MATRIX Group leader: MPs, 15 years of clinical experience (male, 42 years old). Co-therapists: MPs, 6 years of clinical experience (male, 43 years old). Monitor MPs, 2 years of clinical experience (female, 28 years). Group leader: PhD, 10 years of clinical experience (male, 33 years old). Co-therapists. PhD 2nd year student, 6 years of clinical experience (female, 30 years old). Monitor MPs, 2 years of clinical experience (male, 33 years old). All therapist have the same training, ACT-MATRIX therapist received aditional 20 hours training in Act Matrix.

RESULTS PRE – POST -DIFFERENCES INSIDE GROUPS- Both groups showed statistical changes and big size effects

RESULTS PRE – FOLLOW UP -DIFFERENCES INSIDE GROUPS- Same in follow up

RESULTS -DIFFERENCES BETWEEN GROUPS- Matrix better than ACT

RESULTS -DIFFERENCES BETWEEN GROUPS- Attrition less in 2 groups…

RESULTS -MEDIATION POST-TREATMENT- Hierarchical linear regression (Matrix) Hierarchical linear regression (ACT) Psychological Flexibility 32.7 % BPD Symptoms Severity 34.5% Emotion Regulation 1.8% Psychological Flexibility 6.5 % BPD Symptoms Severity 37.3% Emotion Regulation 30.8% R2 Durbin-Watson F Sig. t FIV .345 1.630 4.994 .018 .716 .483 1.183 R2 Durbin-Watson F Sig. t FIV .373 1.689 9.229 .001 3.906 .000 1.246

MAIN CONCLUSSIONS ACT Matrix enhanced will outperform ACT in all the assessed variables. ACT Matrix significantly enhanced classic ACT impact. Possibly because its simplicity, repetitive and graphic nature makes its more adequate to clients with the neuropsychological characteristics associated with BPD (difficulties in attentional control, verbal fluency and memory fixation, consolidation and recovery processes). Future studies could asses this characteristics impact as mediator of change. Psychological Flexibility will significantly mediate BPD severity in both groups. Preliminary evidence of ACT Matrix clinical value as a visual cue for DRR that improves psychological flexibility. Future studies could asses Matrix impact in DRR (IRAP?). Analysing single cases and finding moderators in Anxiety and Depression