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) NUMBERSTRATEGIESNUMBERSTRATEGIES ASSESMENT 1 Functional Analysis Identification of treatment goals DBTi INTRODUCTION1 BPD Biopsychosocial education, DBTi rationale, Treatment contract signing MINDFULNESS 8 Psychoeducation, Group discussion, Skill practice 34 Chain analysis Dialectic strategies Problem solving strategies DISTRESS TOLERANCE 9 INTERPERSONAL EFFECTIVENESS 9 EMOTION REGULATION 8 CLOSING RELAPSE PREVENTION 1Same as above1

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 O1DBTiO2 O3ACTO4 O5ACT06 O7ACTGO8 O5ACT06 09ACT+FAP10 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) NUMBERSTRATEGIESNUMBERSTRATEGIES ASSESMENT 1 Functional Analysis Identification of treatment goals ACT INTRODUCTION1 Same as below + Treatment contract signing 14 Mindfulness Metaphors (or Experiencial excercise) Commited actions ACCEPTANCE 4 Mindfulness Metaphors Experiential exercises Group discussion DEFUSION 3 VALUES CLARIFICATION 3 INTERPERSONAL EFECTIVENESS 7 Same as above + Psychoeducation Group discussion Skill practice CLOSING RELAPSE PREVENTION 1Same as above1

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 O1DBTiO2 O3ACTO4 O5ACT06 O7ACTGO8 O5ACT06 09ACT+FAP10 N=25 clients per group. Treatment integrity assesed. 50% Individual therapists changed across treatments.

ACT AND ACT-G DIFFERENCES

DESIGN O1DBTiO2 O3ACTO4 O5ACT06 O7ACTGO8 O5ACT06 09ACT+FAP10 N=25 clients per group. Treatment integrity assesed. 50% Individual therapists changed across treatments.

ACT+FAP CHARACTERISTICS MODULES GROUP SESSIONS (120 minutes) INDIVIDUAL SESSIONS (30 minutes) NUMBERSTRATEGIESNUMBERSTRATEGIES ASSESMENT 1 Functional Analysis Identification of treatment goals ACT INTRODUCTION1 Same as below + Treatment contract signing 1 Mindfulness Metaphors (or experiential exercise) ACT Matrix ACCEPTANCE 3 Mindfulness Metaphors Experiential exercises Group discussion using the ACT Matrix 2 DEFUSSION 21 VALUES CLARIFICATION 21 VALUED ACTIVATION 2 Same as above + Behavioral Activation 2 FAP INTRODUCTION (FAP/RAP) 1 Same as below + Treatment contract signing 1Identification of CRBs and Os FAP (ACL Skills workshop) 6 Group discussion Evocative excercises for ACL practice ACT Matrix debriefing 6 Evocative excercise (5 rules practice) Challenges and Risks log Sessions bridging form CLOSING RELAPSE PREVENTION 1Same as above1

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.