Transcript 4 BRIEF INTERVENTIONS FOR BPD: THE PROCESS OF BUILDING AN EMPIRICALLY SUPORTED TAU Michel André Reyes Ortega PsyD * ** *** Angélica Nathalia Vargas.

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 CLINICMEXICO’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 CLINICPSYCHOTHERAPY
TREATMENT OPTIONS
• Transference
focused
psychotherapy
OBSTACLES
SOLUTIONS
• Expensive and
unrealistic
• Call the ACBS
guys 
• Lenght of treatment
• Number of therapists
needed
• Amount of treatment
needed
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)
NUMBER
STRATEGIES
ASSESMENT
INDIVIDUAL SESSIONS
(30 minutes)
NUMBER
STRATEGIES
Functional Analysis
1
Identification of
treatment goals
DBTi INTRODUCTION
1
BPD Biopsychosocial
education, DBTi rationale,
Treatment contract signing
MINDFULNESS
DISTRESS TOLERANCE
INTERPERSONAL EFFECTIVENESS
EMOTION REGULATION
CLOSING
RELAPSE PREVENTION
8
9
9
8
Psychoeducation, Group
discussion, Skill practice
34
1
Same as above
1
Chain analysis
Dialectic strategies
Problem solving
strategies
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
O1
O3
DBTi
ACT
O2
O4
O5
O7
ACT
ACTG
O5
09
06
O8
ACT
ACT+FAP
• N=25 clients per group.
• Treatment integrity assesed.
• 50% Individual therapists changed across treatments.
06
10
ACT CHARACTERISTICS
MODULES
NUMBER
GROUP SESSIONS
(120 minutes)
STRATEGIES
ASSESMENT
ACT INTRODUCTION
1
ACCEPTANCE
DEFUSION
4
3
VALUES CLARIFICATION
3
INTERPERSONAL
EFECTIVENESS
7
CLOSING
RELAPSE PREVENTION
1
INDIVIDUAL SESSIONS
(30 minutes)
NUMBER
STRATEGIES
Functional Analysis
1
Identification of treatment
goals
Same as below +
Treatment contract signing
Mindfulness
Metaphors
Experiential exercises
Group discussion
Same as above +
Psychoeducation
Group discussion
Skill practice
14
Mindfulness
Metaphors
(or Experiencial excercise)
Commited actions
Same as above
1
Same as above
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 & SelvaLópez 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
O1
O3
DBTi
ACT
O2
O4
O5
O7
ACT
ACTG
O5
09
06
O8
ACT
ACT+FAP
• N=25 clients per group.
• Treatment integrity assesed.
• 50% Individual therapists changed across treatments.
06
10
ACT AND ACT-G DIFFERENCES
DESIGN
O1
O3
DBTi
ACT
O2
O4
O5
O7
ACT
ACTG
O5
09
06
O8
ACT
ACT+FAP
• N=25 clients per group.
• Treatment integrity assesed.
• 50% Individual therapists changed across treatments.
06
10
ACT+FAP CHARACTERISTICS
MODULES
NUMBER
GROUP SESSIONS
(120 minutes)
STRATEGIES
ASSESMENT
INDIVIDUAL SESSIONS
(30 minutes)
NUMBER
STRATEGIES
1
ACT INTRODUCTION
1
ACCEPTANCE
DEFUSSION
3
2
VALUES CLARIFICATION
2
VALUED ACTIVATION
2
FAP INTRODUCTION
(FAP/RAP)
1
Same as below +
Treatment contract signing
Mindfulness
Metaphors
Experiential exercises
Group discussion using the ACT Matrix
Same as above +
Behavioral Activation
Same as below +
Treatment contract signing
FAP
(ACL Skills workshop)
6
Group discussion
Evocative excercises for ACL practice
ACT Matrix debriefing
CLOSING
RELAPSE PREVENTION
1
Same as above
Functional Analysis
Identification of treatment goals
1
2
1
1
Mindfulness
Metaphors
(or experiential exercise)
ACT Matrix
2
1
Identification of CRBs and Os
6
Evocative excercise
(5 rules practice)
Challenges and Risks log
Sessions bridging form
1
Same as above
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.