Transcript Presentación de PowerPoint - Association for Contextual Behavioral

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
• Internal
psychological
organization
which
manifests in the public
behaviors
specified
in
diagnostic criterias.
(Sturmey, 2008)
FUNCTIONAL VIEW
• 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
STRUCTURALIST
FUNCTIONAL
VIEW
(adapted from Millon, 2004)
VIEW
REMEMBER
motivational
operations
Related to context
Constitutional
PATHOLOGY
NORMALITY
1.
Frantic efforts to avoid real or imagined abandonment.
1.
Sensitive to rejection.
2.
Unstable relationships characterized by alternating
extremes of idealization and devaluation of others.
2.
Complex relationships with realistic expectations.
3.
Experimental identity, curiosity for alternative
lifestyles.
3.
4.
5.
Behavior under
Identity disturbance / Unstable and polarized self-image.
aversive
Impulsive and
self-destructive behavior.
Affective instability
– Suicidal and parasuicidal behavior.
control
4.
5.
Behavior under
Sensations apetitive
seeking.
Emotionaly intense – Spontaneous and prone to
exaggeration.
control
6.
Chronic emptyness related to difficulties to identify values
and commit to them.
6.
Concerned about social life, creativity and
continuous searching for having and entertaining
life.
7.
Transient paranoid ideation and dissociative symptoms.
7.
No paranoid ideation or disociative symptoms.
Age
Treatment
(Paris, 2008)
FROM THE ACT MATRIX MODEL
(Matrix adapted from Polk, 2014)
FIVE SENSES EXPERIENCE
•
•
•
•
•
•
Frantic efforts to avoid abandonement.
Unstable relationships.
Impulsivity.
Suicidal and parasuicidal behavior.
Difficulties to mantein commitments.
Dissociative symptoms.
AVOIDANCE
•
•
•
•
•
•
•
Fear of abandonement.
Idealization and devaluation.
Identity diffusion
Unstable Self-image.
Affective unstability.
Cronic emptyness feelings.
Paranoid ideation.
•
•
•
•
•
Complex relationships.
Experimental identity.
Intense sensations seeking.
Exaggeration and spontaneity.
Continuous entertaining seeking.
PERSPECTIVE
-----------------CHOICE
POINT
ÁPROACHING
•
•
•
•
MENTAL EXPERIENCE
Realistic expectancies.
Curiosity for alternative lifestyles.
Emotionaly intense.
Iterest for social life and creativity.
DIVERSITY
STRUCTURALIST VIEW
Seeking for description and categorization
OUR CONTEXTUAL VIEW
Topographic variation related to context
• Sensitive to limitations
nomotetic approaches.
of
• 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).
¿ETHIOLOGY?
BIOLOGICAL
FACTORS
(BIOLOGICAL
TRAITS)
INSTABILITY
BPD
COGNITIVE,
AFFECTIVE,
INTERPERSONAL AND
BEHAVIORAL
(Linehan, 1993)
ENVIRONMENTAL
FACTORS
(LEARNING
HISTORY)
• Genetic factors, hostile uterine
environment, etc. (Gottman & Katz, 1990)
BIOLOGICAL TRAITS AND LEARNING
IMPLICATIONS
IMPULSIVITY
EMOTIONAL
UNSTABILITY
COGNITIVE
UNSTABILITY
• Paris (2008)
• Great discounting.
• Needs more rehearsal and
examples to stablish selfregulation skills.
• Perspective taking, emotion
regulation, rule following.
• Low threshold to aversive
stimulus.
• Prone to aversive conditioning.
LEARNING HISTORY
-EMOTIONAL INSTABILITYEXCESSIVE
NEGATIVE
EMOTIONS
INTENSITY OR
DEACTIVATION
DEPRIVATION / CONTINUOUS
ABUSE
(MULTIPLE EXEMPLARS)
RESPONDENT LEARNING
RESPONDENT GENERALIZATION
AVERSIVE FUNCTIONS
DERIVATION
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
(Kohlenberg, Tsai, Kanter &
Parker, 2009)
EXPERIENTIAL
AVOIDANCE
OF INVALIDATION
UNDERDEVELOPED
DEICTIC FRAMMING
“I” TACTS UNDER
PUBLIC CONTROL
(Kohlenberg & Tsai, 1991)
ATTACHMENT TO A
NEGATIVE SELF AS
CONTENT
DIFFICULTIES FOR
SHIFTING
PERSPECTIVES
(Morton & Shaw, 2012)
UNSTABLE IDENTITY
LEARNING HISTORY
-BEHAVIORAL INSTABILITYSELF HARM MODELS
FEW ALTERNATIVE MODELS
EMOTIONAL VULNERABILITY
INVALIDATION –DIFFERENTIAL
REINFORCEMENT OF EXTREME BEHAVIORS
SELF HARMING
BEHAVIORS AS
EXPERIENTIAL
AVOIDANCE
STRATEGY
LEARNING HISTORY
-INTERPERSONAL INSTABILITYFEARFUL AND
DISORGANIZED
ATTACHMENT
STYLE
INVALIDATION, MISTREATMENT,
CONDITIONAL ACCEPTANCE
(MULTIPLE EXAMPLES)
MILD AFFECT (SCR+) AND
UNATENTION (SCEXT), AND HIGH
RATES OF PUBISHMENT (SCC+) OF
ATTACHMENT BEHAVIOR
(Mansfield &
Cordova, 2007)
EXPERIENTIAL AVOIDANCE
(FEAR-ANGER-YEARN) TOWARDS AFFECT
NEEDS
AMBIVALENCE
OSCILATION BETWEEN
IDEALIZATION, AVOIDANCE AND
AGRESSION
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
(MO) MOTIVATING OPERATIONS
(A) ANTECEDENT
SE → Postraumatic
and/or
dissociative
symptoms
SD
= Invalidation
∙
(B) BEHAVIOR
PROBLEMATIC
EMOTIONAL AND
INTERPERSONAL
REGULATION
BEHAVIORS
Cognitive Fussion
Experiential Avoidance
Identity unstability
(C) CONSECUENCE
SR+ = Attention / Care
SR- = Calm
________________________________________________
Values incongruence
Emptiness feelings
PASSIVE AVOIDANCE
Reinforcing
Biological needs deprivation →
Rejection ↔ Atention-affect deprivation →
Frustration / Repetitive stress →
Depression
Aversive
(Reyes, Vargas & Tena, 2014)
BEHAVIORAL MODEL OF
BORDERLINE PERSONALITY
DISORDER SYNDROME
DISTAL ANTECEDENTS
OUR TREATMENT PROPOSAL
Self-validation
(acceptance)
(G+I / 1-8)
COMMON
ELEMENTS
ON EBT
(Paris, 2008)
In vivo resolution of
interpersonal
problems
(I / 9-18)
Skills training
(G+I / S:1-8)
•
•
•
•
Mindfulness
Relate discomfort to values
Radical acceptance
Validation
• FAP 5 rules
• Bridging questions
• Evocative excercises
• Deffine ineffective attachment behaviors and “I” under
public control as CRB1s
•
•
•
•
Emotion regulation skills training.
Interpersonal effectiveness skills training.
Values clarification strategies.
Weekly valued based behavioral activation.
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
Challenges
• 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.
Solutions
• 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.