FAP IMPACT, AND MECHANISMS OF CHANGE, AS AN ADJUNCT TREATMENT FOR PEOPLE DIAGNOSED WITH BPD Michel André Reyes Ortega PsyD 1 Nathalia Vargas PsyD 1 Jonathan W. Kanter PhD 2 1Contextual Science and Therapy Institute (Mexico City) 1 National Institute of Psychiatry Ramón de la Fuente 2 Center for the Science of Social Connection, University of Washington

CONTEXT -INPRF BPD CLINIC- MEXICO’S NATIONAL INSTITUTE OF PSYCHIATRY BPD CLINIC (ONLY EXISTING PUBLIC SECTOR CLINIC) 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. Clinical team: Only on hired clinical psychologist. Rest of Therapists are non payed volunteers. Clinical Psychology master degree students (Clinical Behavior Analysis Oriented). 2 Professors of the same program serve as clinic advisors and students supervisors. Clients characteristics: Clients treated per range = 100 (waitlist 100). Clients with possible lethal behavior not admitted (yet symptoms pervasive enough to impair quality of life and treatment engagement). So, first I’m going to tell you about our context… Greatest authority in psychiatric research, teaching and consultation in Mexico. But with limited resourses… Example: BPD clinic, which is 3.....

CONTEXT -INPRF BPD CLINIC (3 YEARS AGO)- TREATMENT OPTIONS DBT, NOT POSSIBLE  Transference focused psychotherapy Clinic psychiatrists (2) trained in that model. TAU back then (wasn’t working). Dialectical Behavior Therapy? Desirable for clients with severe behavioral dyscontrol (Stage 1) and/or severe trauma related symptoms (Stage 2). Expensive and unrealistic. Lenght of treatment. Number of therapists needed. Amount of training needed. We tried ACT (Current TAU). Good outcomes in: Reductions on self- harm behavior, emotion dysregulation, experiential avoidance, BPD symptoms severity, anxiety and depression (Gratz & Gunderson, 2006; Morton, Snowdon, Gopold & Guymer, 2012). Students receiving training in ACT.

CONTEXT -BPD TREATMENT FOR STAGES 3/4- DBT TREATMENT OUTCOMES STAGES 3-4 (BPD Severity) Most researched for BPD clients on stage 1-2 (severity). Reductions on self-harm behavior, medical emergencies frequencies, anger and impulsivity; depression; 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). No specific protocol researched for clients on Stage 3/4. Self instability and Interpersonal Related Variables (attachment, intimacy) aren´t usually researched in behavioral treatments. Both described in FAP literature. Literature suggests FAP can enhance other EST as DBT and ACT (Kohlenberg & Callaghan, 2010; Luciano, 1999; Busch, Manos, Rusch, Bowe & Kanter, 2010). Our clients didn’t seemed to improve in this dimensions after ACT. Stage 1 Behavioral Dyscontrol Stage 2 Traumatizing Emotional Experience

DESIGN Based on that reasoning we did a pylot study on Fap as an enhancement for our TAU.

HYPOTHESIS ACL-G will outperform IS-G in all the assessed variables. Intimacy will significantly improve in ACL-G compared to TAU and IS-G. Intimacy will mediate BPD severity in ACL-G. Experience of Self will mediate Emotion Regulation in ACL-G.

VARIABLES AND MEASURES Intimacy – Functional Analytic Psychotherapy Intimacy Scale (Leonard et. al. 2014; Reyes & Vargas, non published). α = .84 (.86 to .90); r=.75; p<.05 BPD symptoms severity – Borderline Evaluation of Severity Over Time Scale (Pfohl et. al. 2009; Reyes & García, 2014). α =.88; r=0.62; p<.001 Emotion Dysregulation – Difficulties in Emotion Regulation Scale (Gratz & Roemer, 2004; Marín Tejeda et al. 2012). α=.93 (.85 to .68); r=.76; p<.05 Experience of Self – Experience of Self Scale (Kanter, Parker, & Kohlenberg, 2001; Valero-Aguayo, Ferro-García, López-Bermúdez & Selva-López de Huralde, 2014). α = .941 (.59 to .95) Anxiety and Depression also assessed. Not described in this presentation. α = Internal consistency; R=Test Retest; P= Concurent validity

ACL-G CHARACTERISTICS

FAP ACL MODEL OF SOCIAL CONNECTION AWARENESS of the other, And the transactional nature of the interaction AWARENESS of thoughts/feelings, needs, goals, values, and AWARENESS of thoughts/feelings, needs, goals, values, and AWARENESS of thoughts/feelings, needs, goals, values, and COURAGE Vulnerability experience and Self-Disclosure of experiences and needs. LOVE Responsive provision of Safety, Validation, Giving COURAGE to receive love and express connection AWARENESS Analysis of the Interaction and Generalization possibilities COURAGE to receive love and express connection Awareness – Meditation/Reading Courage – Sharing / Love – Responsiveness – Courage / Giving loving feedback to responder / Awareness – Debriefing and generalization plan. FAP ACL MODEL OF SOCIAL CONNECTION

IS-G CHARACTERISTICS

PARTICIPANTS CLIENTS This where the clients.

PARTICIPANTS THERAPISTS ACL-G IS-G Group leader: PhD, FAP certified therapist, 9 years of clinical experience (male, 33 years old). Co-therapists: PhD 2nd year student, 6 years of clinical experience (female, 30 years old). Monitor 4th year psychiatry resident, (female, 31 years old). Group leader: MPs, REBT certified therapist, 15 years of clinical experience (male, 42 years old). Co-therapists. MPs student, 2 years of clinical experience (female, 28 years). Monitor 4th year psychiatry resident, (male, 32 years old).

RESULTS -DIFFERENCES INSIDE GROUPS-

RESULTS -DIFFERENCES BETWEEN GROUPS-

VISUAL INSPECTION FAP n=22, Int.S.=22 Attrition = FAP (0%), Int. S. (8.8%) Crisis = FAP=0, Int.S. = 0 FAP mechanisms of change. E. of Self on E. Regulation (R2=.325) E. Regulation on BPD Severity (R2=.457)

BPD Symptoms Severity 51.4% RESULTS -MEDIATION- Hierarchical linear regression (Pre FAP) Hierarchical linear regression (Post FAP) Intimacy 32.4% BPD Symptoms Severity 51.4% Emotion Regulatio n 19% Intimacy 1.1 % BPD Symptoms Severity 1.9% Emotion Regulatio n0.8% R2 Durbin-Watson F Sig. t FIV .514 1.883 10.064 .001d 2.728 .013 1.032 R2 Durbin-Watson F Sig. t FIV 0.19 1.911 .186 .832 .400 .694 1.011

MAIN CONCLUSSIONS ACL-G will outperform IS-G in all the assessed variables. FAP could be an effective treatment for BPD clients on Stage 3-4 experiencing social connection difficulties. Intimacy will significantly improve in ACL-G compared to TAU and IS-G. Evidence on FAP social connection model as tested in previous research (Haworth, Kanter, Tsai & Kohlenberg, 2015). Intimacy will mediate BPD severity in ACL-G (didn’t in TAU or ISG-G). Preliminary evidence on Intimacy as a FAP distinctive process. Social disconnection may be an important factor in BPD maintenance. Experience of Self will be related to Emotion Regulation in ACL-G. Preliminary evidence to previous FAP theory on Disorders of the Experience of Self as an important mediator in BPD severity and FAP impact on this variable.