A FUNCTIONAL CONTEXTUALIST THEORY OF BORDERLINE PERSONALITY DISORDER

1. A FUNCTIONAL CONTEXTUALIST THEORY OF BORDERLINE PERSONALITY DISORDER Michel André Reyes Ortega PhD * ** *** Angélica Nathalia Vargas Salinas MA * ** *** Edgar Miranda TerresMA ** *** Iván Arango de Montis MD ** * Associationfor Contextual BehavioralScienceMexicoChapter ** Instituto Nacional de Psiquiatría Juan Ramón de la Fuente Muñiz *** Instituto de Ciencias Conductual Contextuales y Terapias Integrativas

2. PERSONALITY STRUCTURALIST VIEW FUNCTIONAL VIEW Repertoireof behaviourimpartedby an organized set of contingencies. (Skinner, 1974) Personality and hence personality disorder, is only a series of overt and covert behaviours. (Swales & Heard, 2009) • Internalpsychologicalorganizationwhichmanifests in thepublicbehaviorsspecified in diagnosticcriterias. (Sturmey, 2008)

3. FUNCTIONAL VIEW Related to context REMEMBER motivationaloperations STRUCTURALIST VIEW Constitutional BORDERLINE TOPOGRAPHY(adaptedfromMillon, 2004) PATHOLOGY Sensitive to rejection. Complexrelationshipswithrealisticexpectations. Experimental identity, curiosityforalternativelifestyles. Sensationsseeking. Emotionaly intense – Spontaneous and prone to exaggeration. Concernedabout social life, creativity and continuoussearchingforhaving and entertaininglife. No paranoidideationordisociativesymptoms. NORMALITY • Franticefforts to avoid real orimaginedabandonment. • Unstablerelationshipscharacterizedbyalternating extremes of idealization and devaluation of others. • Identitydisturbance / Unstable and polarizedself-image. • Impulsive and self-destructivebehavior. • Affectiveinstability – Suicidal and parasuicidalbehavior. • Chronicemptynessrelated to difficulties to identifyvalues and commit to them. • Transientparanoidideation and dissociativesymptoms. Behaviorunderaversive control Behaviorunderapetitive control Age Treatment (Paris, 2008)

4. FROM THE ACT MATRIX MODEL(MatrixadaptedfromPolk, 2014) Adaptideographically Complexrelationships. Experimental identity. Intense sensationsseeking. Exaggeration and spontaneity. Continuousentertainingseeking. Realisticexpectancies. Curiosityforalternativelifestyles. Emotionaly intense. Iterestfor social life and creativity. FIVE SENSES EXPERIENCE • Franticefforts to avoidabandonement. • Unstablerelationships. • Impulsivity. • Suicidal and parasuicidalbehavior. • Difficulties to manteincommitments. • Dissociativesymptoms. PERSPECTIVE ------------------ CHOICE POINT AVOIDANCE ÁPROACHING • Fear of abandonement. • Idealization and devaluation. • Identitydiffusion • UnstableSelf-image. • Affectiveunstability. • Cronicemptynessfeelings. • Paranoidideation. MENTAL EXPERIENCE

5. DIVERSITY STRUCTURALIST VIEW Seekingfordescription and categorization OUR CONTEXTUAL VIEW Topographicvariationrelated to context Sensitive to limitations of nomoteticapproaches. BPD diagnosedpersonspossessdifferenttemperamets, haveuniclearning histories, and show differentproblematicbehaviors (self-mutilation, alcohol abuse, bingeeating, etc.) (Morton & Shaw, 2012). Millon (2004).

6. ¿ETHIOLOGY? • INSTABILITY • COGNITIVE, AFFECTIVE, INTERPERSONAL AND BEHAVIORAL • (Linehan, 1993)

7. BIOLOGICAL TRAITS AND LEARNING IMPLICATIONS • Great discounting. • Needs more rehearsal and examples to stablishself-regulationskills. • Perspectivetaking, emotionregulation, rule following. • Lowthreshold to aversivestimulus. • Prone to aversiveconditioning. • Paris (2008) • Geneticfactors, hostileuterineenvironment, etc. (Gottman & Katz, 1990)

8. LEARNING HISTORY-EMOTIONAL INSTABILITY- 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. • EXPERIENTIAL AVOIDANCE • (PREVENTS COPING SKILLS LEARNING) • (PREVENTS STIMULUS HABITUATION AND RESPONDENT EXTINTION) • EMOTION DYSREGULATION AT RELEVANT SD

9. 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. (Kohlenberg, Tsai, Kanter & Parker, 2009) 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 (Kohlenberg & Tsai, 1991) (Morton & Shaw, 2012)

10. LEARNING HISTORY-BEHAVIORAL INSTABILITY- 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

11. LEARNING HISTORY-INTERPERSONAL INSTABILITY- 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 • EXPERIENTIAL AVOIDANCE • (FEAR-ANGER-YEARN) TOWARDS AFFECT NEEDS • AMBIVALENCE • OSCILATION BETWEEN IDEALIZATION, AVOIDANCE AND AGRESSION

12. DISTAL ANTECEDENTS BEHAVIORAL MODEL OF BORDERLINE PERSONALITY DISORDER SYNDROME(Reyes, Vargas & Tena, 2014) Emotionaldysregulation Self-referentbehaviorunderpublic control Defficientperspectivetaking Self-harm as Self-regulationstrategie Fearful-disorganizedattachmentbehaviors Traumaticexperiences → Invalidation → Differentialreinforcement → DBT CONSIDER SKILLS TRAINING TO REDUCE EMOTIONAL VULNERABILITY. *FRAME THEM AS VALUED ACTIONS. (MO) MOTIVATING OPERATIONS Biologicalneedsdeprivation→ Rejection ↔ Atention-affectdeprivation→ Frustration / Repetitive stress → CognitiveFussion ExperientialAvoidance Identityunstability ∙ (A) ANTECEDENT (B) BEHAVIOR (C) CONSECUENCE SR+ = Attention / Care SR-= Calm ________________________________________________ Valuesincongruence Emptinessfeelings Depression SE → Postraumatic and/or dissociative symptoms SD =Invalidation PROBLEMATIC EMOTIONAL AND INTERPERSONAL REGULATION BEHAVIORS PASSIVE AVOIDANCE Reinforcing Aversive

13. COMMON ELEMENTS ON EBT • (Paris, 2008) OUR TREATMENT PROPOSAL

14. EVIDENCED BASED TREATMENTS FOR BPD • MentalizationBasedTreatment (Bateman & Fonagy, 1999, 2001)(P). • TransferenceFocusPsychotherapy(Clarkin et al., 2001) (P). • SchemaTherapy(Geisen-Bloo et al., 2006) (P). • DialecticalBehaviorTherapy(Scheel, 2000; Verheul et al. 2003) (P-B). Evidence shows theireffectivenessisbasedontheircommonelements, validation, self-discriminationdevelopment and application of in vivo correctiveinterventions, (Paris, 2008). Data shows moderatedimpacts and isstilllimited (Bailey, Mooney-Reh, Parker & Temelhovski, 2009; Navarro-Leis & Hernández-Arrieta, 2013).

15. CHALLENGES FOR DOING CONTEXTUAL BEHAVIORAL THERAPY FOR BPD IN MEXICO Challenges Solutions FormingACBS MexicoChapter. Introducingfunctionalcontextualism and CBA in clinicalpsychology and medical trainings. Introducingfunctionalcontextualism and CBA to non professionals. Startingresearchlinesabout contextual behavioralinterventions. Seeking training oportunities and establishingcolaborationswithrest of theworldcolaborators. • Currentdominance of mentalistic and structuralistmodelsonclinicalpsychology training programs and personalitytheories. • Ignoranceaboutadvances and advantages of clinicalbehavioranalysis (CBA). • Skepticismand ignorance of functionalcontextualismonacademicbehavioralcircles. • Ignorance of learningtheory (behaviorism) onpsychiatricresidentialprograms. • Insufficient data on contextual behavioraltherapiesforpersonalitydisorders. • Few training oportunities and fewtrainedcliniciansin BPD treatment and contextual psychotherapy.