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

A FUNCTIONAL CONTEXTUALIST THEORY OF BORDERLINE PERSONALITY DISORDER

• Internal psychological organization which manifests in the public behaviors specified in diagnostic criterias.

(Sturmey, 2008)

STRUCTURALIST VIEW 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)

PERSONALITY

1. Sensitive to rejection.2. Complex relationships with realistic expectations.3. Experimental identity, curiosity for alternative

lifestyles. 4. Sensations seeking.5. Emotionaly intense – Spontaneous and prone to

exaggeration.6. Concerned about social life, creativity and

continuous searching for having and entertaining life.

7. No paranoid ideation or disociative symptoms.

1. Frantic efforts to avoid real or imagined abandonment.

2. Unstable relationships characterized by alternating extremes of idealization and devaluation of others.

3. Identity disturbance / Unstable and polarized self-image.

4. Impulsive and self-destructive behavior.

5. Affective instability – Suicidal and parasuicidal behavior.

6. Chronic emptyness related to difficulties to identify values and commit to them.

7. Transient paranoid ideation and dissociative symptoms.

REMEMBERmotivational operations

BORDERLINE TOPOGRAPHY(adapted from Millon, 2004)

PATHOLOGY NORMALITY

AgeTreatment

(Paris, 2008)

Behavior under aversive control

Behavior under apetitive control

STRUCTURALIST VIEW

Constitutional

FUNCTIONAL VIEWRelated to context

FROM THE ACT MATRIX MODEL(Matrix adapted from Polk, 2014)

FIVE SENSES EXPERIENCE

MENTAL EXPERIENCE

ÁPROACHINGAVOIDANCEPERSPECTIVE------------------

CHOICE POINT

• Frantic efforts to avoid abandonement.• Unstable relationships.• Impulsivity.• Suicidal and parasuicidal behavior.• Difficulties to mantein commitments.• Dissociative symptoms.

• 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.

• Realistic expectancies.• Curiosity for alternative lifestyles. • Emotionaly intense.• Iterest for social life and creativity.

Adapt

ideographically

DIVERSITYSTRUCTURALIST VIEWSeeking for description and categorization

OUR CONTEXTUAL VIEWTopographic variation related to context

• 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).

¿ETHIOLOGY?

BIOLOGICAL FACTORS

(BIOLOGICAL TRAITS)

ENVIRONMENTAL FACTORS

(LEARNING HISTORY)

BPDINSTABILITY

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

• Paris (2008)

•G

eneti

c fa

ctor

s, h

ostil

e ut

erin

e en

viro

nmen

t, et

c. (G

ottm

an &

Kat

z, 1

990)

LEARNING HISTORY-EMOTIONAL INSTABILITY-

DEPRIVATION / CONTINUOUSABUSE

(MULTIPLE EXEMPLARS)

RESPONDENT LEARNINGRESPONDENT GENERALIZATION

AVERSIVE FUNCTIONS DERIVATION

EXCESSIVE NEGATIVE EMOTIONS

INTENSITY OR DEACTIVATION

EMOTION DYSREGULATION AT

RELEVANT SD

EXPERIENTIAL AVOIDANCE(PREVENTS COPING SKILLS LEARNING)(PREVENTS STIMULUS HABITUATION

AND RESPONDENT EXTINTION)

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.

INVALIDATION

TRIVIALIZATION OF INTERNAL EXPERIENCE

UNDERDEVELOPEDDEICTIC FRAMMING

ATTACHMENT TO A NEGATIVE SELF AS

CONTENT

DIFFICULTIES FOR SHIFTING

PERSPECTIVES

“I” TACTS UNDER PUBLIC CONTROL

UNSTABLE IDENTITY

EXPERIENTIAL AVOIDANCE

OF INVALIDATION

(Kohlenberg, Tsai, Kanter & Parker, 2009)

(Kohlenberg & Tsai, 1991)

LEA

RN

ING

HIS

TO

RY

-CO

GN

ITIV

E

INS

TAB

ILIT

Y- ACT

SELF AS CONTEXT DEVELOPMENT AND

VALUES CLARIFICATION TO ACHIEVE

PSYCHOLOGICAL FLEXIBILITY

AND INTEGRATE A SENSE OF IDENTITY

*USE EXERCISES AND METAPHORS.FAPDEFINE “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

(Morton & Shaw, 2012)

LEARNING HISTORY-BEHAVIORAL INSTABILITY-

SELF HARMING BEHAVIORS AS EXPERIENTIAL AVOIDANCE STRATEGY

SELF HARM MODELS

FEW ALTERNATIVE MODELS

EMOTIONAL VULNERABILITY

INVALIDATION –DIFFERENTIAL REINFORCEMENT OF EXTREME BEHAVIORS

TEACH COPING SKILLS AND FRAME

THEM AS VALUED COMMITED

ACTIONS

*DBT, MDT SKILLS WILL WORK.

*USE ACT METAPHORS AND

EXPERIENTIAL EXCERCISES TO CLARIFY

VALUES

*PREVENT THIS STRATEGIES TO FUNCTION AS EXPERIENTIAL AVOIDANCE.*PREVENT COUNTERPLIANCE.*BALANCEACCEPTANCE-CHANGE FOCUS

LEARNING HISTORY-INTERPERSONAL INSTABILITY-

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

AMBIVALENCEOSCILATION BETWEEN

IDEALIZATION, AVOIDANCE AND AGRESSION

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

SE → Postraumatic and/or dissociative symptoms

SD = Invalidation

PROBLEMATIC EMOTIONAL AND INTERPERSONAL

REGULATION BEHAVIORS

PASSIVE AVOIDANCE

SR+ = Attention / Care

SR- = Calm________________________________________________

Values incongruence

Emptiness feelings

Depression

∙ (B) BEHAVIOR(A) ANTECEDENT (C) CONSECUENCE

(MO) MOTIVATING OPERATIONSBiological needs deprivation →

Rejection ↔ Atention-affect deprivation →Frustration / Repetitive stress →

DISTAL ANTECEDENTSTraumatic experiences →

Invalidation →

Differential reinforcement →

Emotional dysregulationSelf-referent behavior under public controlDefficient perspective takingSelf-harm as Self-regulation strategieFearful-disorganized attachment behaviors

Cognitive FussionExperiential AvoidanceIdentity unstability

Rein

forc

ing

Aver

sive

DBT

CONSIDER SKILLS TRAINING TO

REDUCE EMOTIONAL

VULNERABILITY.

*FRAME THEM AS VALUED ACTIONS.

BEH

AV

IOR

AL

MO

DEL

OF

BO

RD

ER

LIN

E

PER

SO

NA

LITY

DIS

OR

DER

SYN

DR

OM

E(R

eyes,

Varg

as

& T

en

a,

20

14

)

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

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.