A FUNCTIONAL CONTEXTUALIST THEORY OF BORDERLINE PERSONALITY DISORDER Michel André Reyes Ortega PhD * ** *** Angélica Nathalia Vargas Salinas MA * ** *** Edgar Miranda Terres MA ** *** Iván Arango de Montis MD ** * 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

PERSONALITY STRUCTURALIST VIEW FUNCTIONAL VIEW Internal psychological organization which manifests in the public behaviors specified in diagnostic criterias. (Sturmey, 2008) Repertoire of behaviour imparted by an organized set of contingencies. (Skinner, 1974) Personality and hence personality disorder, is only a series of overt and covert behaviours. (Swales & Heard, 2009)

BORDERLINE TOPOGRAPHY (adapted from Millon, 2004) FUNCTIONAL VIEW Related to context REMEMBER motivational operations BORDERLINE TOPOGRAPHY (adapted from Millon, 2004) STRUCTURALIST VIEW Constitutional PATHOLOGY NORMALITY Frantic efforts to avoid real or imagined abandonment. Unstable relationships characterized by alternating extremes of idealization and devaluation of others. Identity disturbance / Unstable and polarized self-image. Impulsive and self-destructive behavior. Affective instability – Suicidal and parasuicidal behavior. Chronic emptyness related to difficulties to identify values and commit to them. Transient paranoid ideation and dissociative symptoms. Sensitive to rejection. Complex relationships with realistic expectations. Experimental identity, curiosity for alternative lifestyles. Sensations seeking. Emotionaly intense – Spontaneous and prone to exaggeration. Concerned about social life, creativity and continuous searching for having and entertaining life. No paranoid ideation or disociative symptoms. Behavior under aversive control Behavior under apetitive control Age Treatment (Paris, 2008)

FROM THE ACT MATRIX MODEL (Matrix adapted from Polk, 2014) Adapt ideographically FIVE SENSES EXPERIENCE Frantic efforts to avoid abandonement. Unstable relationships. Impulsivity. Suicidal and parasuicidal behavior. Difficulties to mantein commitments. Dissociative symptoms. Complex relationships. Experimental identity. Intense sensations seeking. Exaggeration and spontaneity. Continuous entertaining seeking. PERSPECTIVE ------------------ CHOICE POINT AVOIDANCE ÁPROACHING Fear of abandonement. Idealization and devaluation. Identity diffusion Unstable Self-image. Affective unstability. Cronic emptyness feelings. Paranoid ideation. Realistic expectancies. Curiosity for alternative lifestyles. Emotionaly intense. Iterest for social life and creativity. MENTAL EXPERIENCE

DIVERSITY Sensitive to limitations of nomotetic approaches. OUR CONTEXTUAL VIEW Topographic variation related to context STRUCTURALIST VIEW Seeking for description and categorization Sensitive to limitations of nomotetic approaches. BPD diagnosed persons possess different temperamets, have unic learning histories, and show different problematic behaviors (self-mutilation, alcohol abuse, binge eating, etc.) (Morton & Shaw, 2012). Millon (2004).

BPD ¿ETHIOLOGY? INSTABILITY BIOLOGICAL FACTORS (BIOLOGICAL TRAITS) ENVIRONMENTAL FACTORS (LEARNING HISTORY) BPD INSTABILITY COGNITIVE, AFFECTIVE, INTERPERSONAL AND BEHAVIORAL (Linehan, 1993)

BIOLOGICAL TRAITS AND LEARNING IMPLICATIONS Great discounting. Needs more rehearsal and examples to stablish self- regulation skills. Perspective taking, emotion regulation, rule following. Low threshold to aversive stimulus. Prone to aversive conditioning. COGNITIVE UNSTABILITY IMPULSIVITY EMOTIONAL UNSTABILITY Genetic factors, hostile uterine environment, etc. (Gottman & Katz, 1990) Paris (2008)

LEARNING HISTORY -EMOTIONAL INSTABILITY- DEVELOP ACCEPTANCE AND WILLIGNESS ACT: EXPERIENTIAL EXERCISES AND METAPHORS TO DEVELOP DISCOMFORT ACCEPTANCE AND RELATE IT TO VALUES. DBT: VALIDATION STRATEGIES. FAP: IN VIVO REINFORCEMENT OF REGULATED EMOTION EXPRESSION. DEPRIVATION / CONTINUOUS ABUSE (MULTIPLE EXEMPLARS) RESPONDENT LEARNING RESPONDENT GENERALIZATION AVERSIVE FUNCTIONS DERIVATION EXCESSIVE NEGATIVE EMOTIONS INTENSITY OR DEACTIVATION EXPERIENTIAL AVOIDANCE (PREVENTS COPING SKILLS LEARNING) (PREVENTS STIMULUS HABITUATION AND RESPONDENT EXTINTION) EMOTION DYSREGULATION AT RELEVANT SD

LEARNING HISTORY -COGNITIVE INSTABILITY- INVALIDATION TRIVIALIZATION OF INTERNAL EXPERIENCE UNDERDEVELOPED DEICTIC FRAMMING ATTACHMENT TO A NEGATIVE SELF AS CONTENT DIFFICULTIES FOR SHIFTING PERSPECTIVES “I” TACTS UNDER PUBLIC CONTROL UNSTABLE IDENTITY EXPERIENTIAL AVOIDANCE OF INVALIDATION SELF AS CONTEXT DEVELOPMENT AND VALUES CLARIFICATION TO ACHIEVE PSYCHOLOGICAL FLEXIBILITY ACT AND INTEGRATE A SENSE OF IDENTITY *USE EXERCISES AND METAPHORS. (Kohlenberg, Tsai, Kanter & Parker, 2009) FAP DEFINE “I UNDER PUBLIC CONTROL” EXAMPLES AND DIFFICULTIES TO UNDERSTANDING OTHERS VIEW AS CRB1s. IDENTIFICATION, ASSERTION OF NEEDS AND EMOTIONAL EXPRESSION AS CRB2s AND O2s. *APPLY 5 RULES LEARNING HISTORY -COGNITIVE INSTABILITY- (Kohlenberg & Tsai, 1991) (Morton & Shaw, 2012)

LEARNING HISTORY -BEHAVIORAL INSTABILITY- TEACH COPING SKILLS AND FRAME THEM AS VALUED COMMITED ACTIONS *DBT, MDT SKILLS WILL WORK. *USE ACT METAPHORS AND EXPERIENTIAL EXCERCISES TO CLARIFY VALUES SELF HARMING BEHAVIORS AS EXPERIENTIAL AVOIDANCE STRATEGY SELF HARM MODELS FEW ALTERNATIVE MODELS EMOTIONAL VULNERABILITY INVALIDATION –DIFFERENTIAL REINFORCEMENT OF EXTREME BEHAVIORS *PREVENT THIS STRATEGIES TO FUNCTION AS EXPERIENTIAL AVOIDANCE. *PREVENT COUNTERPLIANCE. *BALANCE ACCEPTANCE-CHANGE FOCUS

LEARNING HISTORY -INTERPERSONAL INSTABILITY- FAP MADE IDEOGRAPHIC CONCEPTUALIZATIONS OF IDEALIZATION, DEPENDENT, AMBIBALENCE, HOSTILITY, ETC. AND DEFFINE THEM AS CRB1. DEFFINE INTIMACY REPERTOIRE AS CRB2 AND O2. *APPLY 5 RULES INVALIDATION, MISTREATMENT, CONDITIONAL ACCEPTANCE (MULTIPLE EXAMPLES) MILD AFFECT (SCR+) AND UNATENTION (SCEXT), AND HIGH RATES OF PUBISHMENT (SCC+) OF ATTACHMENT BEHAVIOR FEARFUL AND DISORGANIZED ATTACHMENT STYLE (Mansfield & Cordova, 2007) EXPERIENTIAL AVOIDANCE (FEAR-ANGER-YEARN) TOWARDS AFFECT NEEDS AMBIVALENCE OSCILATION BETWEEN IDEALIZATION, AVOIDANCE AND AGRESSION

(MO) MOTIVATING OPERATIONS DISTAL ANTECEDENTS Traumatic experiences → Invalidation → Differential reinforcement → Emotional dysregulation Self-referent behavior under public control Defficient perspective taking Self-harm as Self-regulation strategie Fearful-disorganized attachment behaviors CONSIDER SKILLS TRAINING TO REDUCE EMOTIONAL VULNERABILITY. DBT *FRAME THEM AS VALUED ACTIONS. BEHAVIORAL MODEL OF BORDERLINE PERSONALITY DISORDER SYNDROME (Reyes, Vargas & Tena, 2014) (MO) MOTIVATING OPERATIONS Biological needs deprivation → Rejection ↔ Atention-affect deprivation → Frustration / Repetitive stress → Cognitive Fussion Experiential Avoidance Identity unstability ∙ (A) ANTECEDENT (B) BEHAVIOR (C) CONSECUENCE SE → Postraumatic and/or dissociative symptoms SD = Invalidation SR+ = Attention / Care SR- = Calm ________________________________________________ Values incongruence Emptiness feelings Depression PROBLEMATIC EMOTIONAL AND INTERPERSONAL REGULATION BEHAVIORS PASSIVE AVOIDANCE Reinforcing Aversive

OUR TREATMENT PROPOSAL Self-validation (acceptance) (G+I / 1-8) Mindfulness Relate discomfort to values Radical acceptance Validation In vivo resolution of interpersonal problems (I / 9-18) FAP 5 rules Bridging questions Evocative excercises Deffine ineffective attachment behaviors and “I” under public control as CRB1s Skills training (G+I / S:1-8) Emotion regulation skills training. Interpersonal effectiveness skills training. Values clarification strategies. Weekly valued based behavioral activation. COMMON ELEMENTS ON EBT (Paris, 2008)

EVIDENCED BASED TREATMENTS FOR BPD Mentalization Based Treatment (Bateman & Fonagy, 1999, 2001)(P). Transference Focus Psychotherapy (Clarkin et al., 2001) (P). Schema Therapy (Geisen-Bloo et al., 2006) (P). Dialectical Behavior Therapy (Scheel, 2000; Verheul et al. 2003) (P-B). Evidence shows their effectiveness is based on their common elements, validation, self-discrimination development and application of in vivo corrective interventions, (Paris, 2008). Data shows moderated impacts and is still limited (Bailey, Mooney-Reh, Parker & Temelhovski, 2009; Navarro-Leis & Hernández-Arrieta, 2013).

CHALLENGES FOR DOING CONTEXTUAL BEHAVIORAL THERAPY FOR BPD IN MEXICO Solutions Current dominance of mentalistic and structuralist models on clinical psychology training programs and personality theories. Ignorance about advances and advantages of clinical behavior analysis (CBA). Skepticism and ignorance of functional contextualism on academic behavioral circles. Ignorance of learning theory (behaviorism) on psychiatric residential programs. Insufficient data on contextual behavioral therapies for personality disorders. Few training oportunities and few trained clinicians in BPD treatment and contextual psychotherapy. Forming ACBS Mexico Chapter. Introducing functional contextualism and CBA in clinical psychology and medical trainings. Introducing functional contextualism and CBA to non professionals. Starting research lines about contextual behavioral interventions. Seeking training oportunities and establishing colaborations with rest of the world colaborators.