Presentation on theme: "Michel André Reyes Ortega PhD * ** *** Angélica Nathalia Vargas Salinas MA * ** *** Edgar Miranda Terres MA ** *** Iván Arango de Montis MD ** * Association."— Presentation transcript:
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 VIEWFUNCTIONAL 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. REMEMBER motivational operations BORDERLINE TOPOGRAPHY (adapted from Millon, 2004) PATHOLOGYNORMALITY Age Treatment (Paris, 2008) Behavior under aversive control Behavior under apetitive control STRUCTURALIST VIEW Constitutional FUNCTIONAL VIEW Related to context
FROM THE ACT MATRIX MODEL (Matrix adapted from Polk, 2014) FIVE SENSES EXPERIENCE MENTAL EXPERIENCE ÁPROACHINGAVOIDANCE PERSPECTIVE ------------------ 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
DIVERSITY STRUCTURALIST VIEW Seeking for description and categorization OUR CONTEXTUAL VIEW Topographic 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).
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) Genetic factors, hostile uterine environment, etc. (Gottman & Katz, 1990)
LEARNING HISTORY -EMOTIONAL INSTABILITY- DEPRIVATION / CONTINUOUS ABUSE (MULTIPLE EXEMPLARS) RESPONDENT LEARNING RESPONDENT GENERALIZATION AVERSIVE FUNCTIONS DERIVATION EXCESSIVE NEGATIVE EMOTIONS INTENSITY OR DEACTIVATION EMOTION DYSREGULATION AT RELEVANT S D 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 UNDERDEVELOPED DEICTIC 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) LEARNING HISTORY -COGNITIVE INSTABILITY- ACT SELF AS CONTEXT DEVELOPMENT AND VALUES CLARIFICATION TO ACHIEVE PSYCHOLOGICAL FLEXIBILITY AND INTEGRATE A SENSE OF IDENTITY *USE EXERCISES AND METAPHORS. FAP DEFINE “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. *BALANCE ACCEPTANCE-CHANGE FOCUS
LEARNING HISTORY -INTERPERSONAL INSTABILITY- INVALIDATION, MISTREATMENT, CONDITIONAL ACCEPTANCE (MULTIPLE EXAMPLES) MILD AFFECT (S CR+ ) AND UNATENTION (S CEXT ), AND HIGH RATES OF PUBISHMENT (S CC+ ) OF ATTACHMENT BEHAVIOR FEARFUL AND DISORGANIZED ATTACHMENT STYLE (Mansfield & Cordova, 2007) EXPERIENTIAL AVOIDANCE (FEAR-ANGER-YEARN) TOWARDS AFFECT NEEDS AMBIVALENCE OSCILATION 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
S E → Postraumatic and/or dissociative symptoms S D = Invalidation PROBLEMATIC EMOTIONAL AND INTERPERSONAL REGULATION BEHAVIORS PASSIVE AVOIDANCE S R+ = Attention / Care S R- = Calm ________________________________________________ Values incongruence Emptiness feelings Depression ∙ (B) BEHAVIOR(A) ANTECEDENT(C) CONSECUENCE (MO) MOTIVATING OPERATIONS Biological needs deprivation → Rejection ↔ Atention-affect deprivation → Frustration / Repetitive stress → DISTAL ANTECEDENTS 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 Cognitive Fussion Experiential Avoidance Identity unstability Reinforcing Aversive DBT CONSIDER SKILLS TRAINING TO REDUCE EMOTIONAL VULNERABILITY. *FRAME THEM AS VALUED ACTIONS. BEHAVIORAL MODEL OF BORDERLINE PERSONALITY DISORDER SYNDROME (Reyes, Vargas & Tena, 2014)
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.