1. MINDFULNESS MEDIATES THE RELATION BETWEEN EMOTIONAL REGULATION AND BEHAVIORAL SKILLS USE IN A CLINICAL SAMPLE Gaj, N., Roder, E., Visintini, R., & Maffei, C. - San Raffaele Hospital, Milan, Italy Second International Conference on Mindfulness, May 11-15, 2016 - Rome, Italy

2. Introduction  Emotional problems figure prominently in many psychopathological conditions.  For example: 1. Borderline Personality Disorder: pervasive and persistent emotional dysregulation is accounted as the core feature of BPD (DBT Biosocial Theory) * 2. Panic and anxiety: “the way in which individuals with anxiety and mood disorders experience and respond to their emotions represents an underlying, unifying factor across these disorders” ** 3. Psychiatric syndromes: “problems with emotions or emotion regulation characterize more than 75% of the diagnostic categories of psychopathology in the DSM-IV” *** * Source: Linehan, 1993; Crowell, Beauchaine & Linehan, 2009 **Source: Barlow, 1988; Fairholme, Boisseau, Ellard, Ehrenreich, & Barlow, p. 283 ***Source: Werner, & Gross, 2004, p. 13 2

3. Emotion regulation fosters difficulties in problem solving  Difficulties in emotion regulation are associated with problems concerning attentional deployment and, consequently, with dysfunctional ways of addressing problematic situations. Emotion dysregulation Problems concerning attention deployment Difficulties in solving problems 3

4. Some applications of mindfulness  Mindfulness based treatments are recommended for a variety of psychological problems*:  Generalized anxiety disorders  Eating disorders  Psychosis  Borderline personality disorders  Depression  Couple’s problems  … *Source: Baer, 2006 4

5. Action mechanisms of mindfulness  Learning new responses to unwanted internal or external experiences  Increasing attentional control  Decreasing the influence of dysfunctional, distorted thoughts  Decreasing the burden of emotional dysregulation  Attention regulation  Body awareness  Emotion regulation  Change in perspective on the self Source: Lynch, Chapman, Rosenthal, Kuo and Linehan, 2006 5 Source: Hölzel, Lazar, Gard, Shuman-Olivier, Vago, and Ott, 2011

6. Mindfulness and adaptive behaviors Welch, Rizvi and Dimidjian (2006) focused on mindfulness actions in DBT with BPD clients. They believe that other (functional behavioral) skills can be learned only if mindfulness is learned and practiced. In DBT theory, mindfulness is the primary factor which fosters the acquisition of new, adaptive behaviors. 6

7. Aim of the present study  To explore the association among the following variables in a clinical sample:  Emotion dysregulation  Mindfulness skills  Use of adaptive/disadaptive behavioral strategies  To test the mediating effect of mindfulness skills on the relation between emotional vulnerability and functional behavioral strategies. 7

8. Method  T0 assessment with the following self-administered questionnaires:  Difficulties in Emotion Regulation Scale (DERS) (Gratz & Roemer, 2004)  Five Facet Mindfulness Questionnaire (FFMQ) (Baer et al., 2006)  Dialectical Behavior Therapy Ways of Coping Checklist (DBT-WCCL) (Neacsiu et al., 2010) 8

9. DERS - FFMQ 9 DERS 1)Non acceptance 2)No goals 3)Impulse 4)Awareness 5)No strategy 6)No clarity FFMQ 1)Observe 2)Describe 3)Acting with awareness 4)No judge 5)No react

10. DBT-WCCL  Subscales: 1) One assessing coping via DBT skills, the DBT Skills Subscale (DSS) 2) One assessing coping via dysfunctional means, the Dysfunctional Coping Subscale (DCS) 10

11. Sample  130 adult clinical subjects asking for a personality assessment at Clinical Psychology and Psychotherapy Unit, San Raffaele Hospital, Milan, Italy. Mean (SD)Range Age30.37 (11.089)15-61 PDs num1.02 (.648)0-4 Frequences% Male3627.5 Female9572.5 Marital status Unmarried10378.6 Divordced1410.7 Married118.4 Widower32.3 Frequences% PD diagnosis10083.3 Borderline5142.5 Narcissistic1714.2 NOS1815.1 Ax I diagnosis3327.3 11

12. MeanSDNorms DERS Nonacceptance19.647.144 + 1SD DERS Goals19.055.066 + 1SD DERS Impulse19.437.066 + 1SD DERS Awareness17.185.535 + 0,5 SD DERS Strategy27.248.181 + 1SD DERS Clarity14.745.588 + 1SD DERS Total117.2829.018 + 1SD FFMQ Observe24.976.793 - 0,5 SD FFMQ Describe24.716.845 - 0,5 SD FFMQ Acting with awareness24.317.806 - 0,5 SD FFMQ No judge23.156.852 - 0,5 SD FFMQ No react16.14.848 - 0,5 SD DBT Skills Use1.36.52 on average * Dysfunctional Coping Subscale1.82.474- 0,5 SD * There is a significant correlation between DERS Total score and the number of dysfunctional personality traits: DERS Total – PDs number: r p =.246, p <.05 (controlling for age & sex) * Normative data based on BPD clinical samples

13. DBT SKILLS USE β =.089 p = n.s. DYSFUNCTIONAL COPING Age and sex: ps = n.s. Relation between DBT-WCCL subscales Independence between knowledge and utilization of effective strategies and dysfunctional strategies (e.g., rumination, anger dyscontrol, blaming others)

14. Single Regression Analyses: DERS/FFMQ with Dysfunctional Coping DYSFUNCTIONAL COPING DERS Total score Age and sex: ps = n.s. β =.351 p <.001 DYSFUNCTIONAL COPING FFMQ Acting with awareness β = -.287 p <.005 14

15. Overall Regression: DERS & FFMQ with Dysfunctional Coping DYSFUNCTIONAL COPING DERS Total score β =.341 p <.001 FFMQ Acting with awareness Age and sex: ps = n.s. 15

16. Single Regression Analyses: DERS/FFMQ with DBT Skills Use 16 DBT SKILLS USE DERS Total score β = -.549 p <.001 Age and sex: ps = n.s. DBT SKILLS USE FFMQ Describe β =.256 p <.005 β =.403 p <.001 FFMQ No react

17. Overall Regression: DERS & FFMQ with DBT Skills Use 17 DBT SKILLS USE DERS Total score β = -.407 p <.005 FFMQ Describe β =.308 p <.001 Age and sex: ps = n.s.

18. Toward a mediation model… 18 DBT SKILLS USE DERS Total score β = -.407 p <.005 FFMQ Describe β =.308 p <.001 Age and sex: ps = n.s. β = -.489 p <.001

19. A mediation model 19 DBT SKILLS USE DERS Total score c β = -.01 p <.001 Panel 1 Age and sex: ps = n.s.

20. A mediation model 20 DBT SKILLS USE DERS Total score β = -.11 p <.001 FFMQ Describe c’ β = -.007 p <.001 β =.024 p <.001 Panel 2 Variance explained: 35%Age and sex: ps = n.s. ab

21. In conclusion  The ability to describe inner experiences (FFMQ Describe) mediates the capacity to functionally interact with the environment (DBT Skills use) in individuals who have difficulties in regulating negative emotions (DERS Tot). 21

22.  Mindfulness skills (FFMQ Describe, No react) predict the use of functional strategies of coping.  The presence of difficulties in regulating negative emotions (DERS Total score) predicts problems in the use of functional strategies of coping. 22

23. Describing inner experiences: a relevant skill for clinical psychology  The mediating role of FFMQ Describe confirms the assumption that putting inner experiences into words is a relevant capacity. It is conceivable that describing mental experiences fosters an objectified stance, in virtue of which inner experiences become understandable, analyzable and consequently more manageable. 23 Source: Lynch, Chapman, Rosenthal, Kuo, & Linehan, 2006

24. Describing as a relevant psychotherapeutic dimension  This is relevant in that most psychotherapeutic techniques aim at increasing the capacity to describe what is going on in one’s mind and to become familiar with mental events. 24 Source: Bliss & McCardle, 2014

25. Some references  Baer, R. A., Smith, G. T., Hopkins, J., Krietemeyer, J., & Toney, L. (2006). Using self-report assessment methods to explore facets of mindfulness. Assessment, 13(1), 27-45.  Bliss, S., McCardle, M. (2014). An exploration of common elements in Dialectical Behavior Therapy, Mentalization Based Treatment and Transference Focused Psychotherapy in the treatment of borderline personality disorder. Clinical Social Work Journal, Vol. 42, 1, 61-69.  Fairholme, C. P., Boisseau, C. L., Ellard, K. K., Ehrenreich, J. T., & Barlow, D. H. (2009). Emotions, emotion regulation and psychological treatment. In A. M. Kring, D. M. Sloan (Eds.), Emotion regulation and psychopathology. A transdiagnostic approach to etiology and treatment, p. 283-309, The Guilford Press, NY.  Gratz, K. L., & Roemer, L. (2004). Multidimensional assessment of emotion regulation and dysregulation: Development, factor structure, and initial validation of the Difficulties in Emotion Regulation Scale. Journal of Psychopathology and Behavioral Assessment, 26(1), 41-54.  Lynch, T. R., Chapman, A. L., Rosenthal, M. Z., Kuo, J. R., & Linehan, M. M. (2006). Mechanisms of Change in Dialectical Behavior Therapy: Theoretical and Empirical Observations. Journal of Clinical Psychology, 62 (4), 459- 480.  Neacsiu, A.D., Rizvi, S.L., Vitaliano, P.P., Lynch, T.R., & Linehan, M.M. (2010). Dialectical Behavior Therapy Ways of Coping Checklist (DBT-WCCL): Development and Psychometric Properties. Journal of Clinical Psychology, 66(6): 563-582.  Werner, K., & Gross, J. J. (2004). Emotion regulation and psychopathology. A conceptual framework. In A. M. Kring, D. M. Sloan (Eds.), Emotion regulation and psychopathology. A transdiagnostic approach to etiology and treatment, p. 13-37, The Guilford Press, NY. 25

26. Thanks for your attention nicolo.gaj@hsr.it 26