Advertisement

Using Acceptance and Commitment Therapy in the Treatment of Borderline Personality Disorder: Rationale, Preliminary Evidence, and Future Directions

  • Theresa A. MorganEmail author
  • Rawya Aljabari
Personality Disorders (M Zimmerman, Section Editor)
  • 5 Downloads
Part of the following topical collections:
  1. Topical Collection on Personality Disorders

Abstract

Aims

Recent iterations of behavior therapy emphasize transdiagnostic processes highlighting commonalities of human experience, mindfulness, language, and acceptance. In contrast to traditional treatment models—which emphasize symptom reduction—these therapies instead prioritize improving quality of life and life engagement. Acceptance and commitment therapy (ACT) is one such approach with over 300 randomized controlled trials, 40 meta-analyses, and countless uncontrolled studies published on its use. ACT not only shares features of many existing evidence-based treatments for borderline personality disorder (BPD) but also proposes some unique skills that may be of benefit to patients with BPD.

Purpose of review

The purpose of the current review is to outline commonalities and distinct features of ACT that may not be familiar to providers currently treating BPD, to present a rationale for using ACT with these patients, and to provide a summary of preliminary evidence supporting this use.

Recent findings

Existing research incorporating ACT and ACT processes in the treatment of BPD is reviewed, results from which suggest that ACT provides a promising approach for use with these patients. Nonetheless, several deficits in the research body exist.

Summary

ACT provides an alternative to existing treatments for BPD with a burgeoning evidence base. However, additional research is needed documenting its use in this patient group.

Keywords

Acceptance and commitment therapy Borderline personality disorder Psychotherapy Personality disorders Behavior therapy 

Notes

Compliance with ethical standards

Conflict of interest

Theresa A. Morgan declares that she has no conflict of interest.

Rawya Aljabari declares that she has no conflict of interest.

Human and animal rights and informed consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

References and Recommended Reading

Papers of particular interest, published recently, have been highlighted as: • Of importance

  1. 1.
    Hayes SC, Strosahl KD, Wilson KG. Acceptance and commitment therapy: an experiential approach to behavior change. New York, NY: The Guilford Press; 1999.Google Scholar
  2. 2.
    • Hayes SC, Strosahl KD, Wilson KG. Acceptance and commitment therapy: the process and practice of mindful change. 2nd edition) ed. New York, NY: The Guilford Press; 2012. Current version of the ACT treatment manual containing details of the ACT model, research support, and clinical examples/exercisesGoogle Scholar
  3. 3.
    Hayes SC. Acceptance and commitment therapy and the new behavior therapies: mindfulness, acceptance and relationship. In: Hayes SC, Follette VM, Linehan M, editors. Mindfulness and acceptance: expanding the cognitive behavioral tradition. New York: Guilford; 2004. p. 1–29.Google Scholar
  4. 4.
    Linehan MM. Cognitive-behavioral treatment of borderline personality disorder. New York, NY: The Guilford Press; 1993.Google Scholar
  5. 5.
    Segal ZV, Williams JMG, Teasdale JD. Mindfulness-based cognitive therapy for depression: a new approach to preventing relapse. New York, NY: The Guilford Press; 2002.Google Scholar
  6. 6.
    Jacobson NS, Christensen A. Acceptance and change in couple therapy: a therapist’s guide to transforming relationships. New York: Norton; 1998.Google Scholar
  7. 7.
    Kohlenber RJ, Tsai M. Functional analytic psychotherapy: a guide for creating curative therapeutic relationships. New York, NY: Plenum; 1991.CrossRefGoogle Scholar
  8. 8.
    Hayes SC. State of the ACT Evidence. 2019. https://contextualscience.org/state_of_the_act_evidence. Accessed 22 May 2019.
  9. 9.
    APA Presidential Task Force on Evidence-Based Practice. Evidence-based practice in psychology. Am Psychol. 2006;61:271–85.CrossRefGoogle Scholar
  10. 10.
    American Psychological Association, Division 12 Society for Clinical Psychology. 2019. https://www.div12.org/psychological-treatments/. Accessed 22 May 2019.
  11. 11.
    Substance Abuse and Mental Health Services Administration. 2019. https://www.samhsa.gov/ebp-resource-center. Accessed 22 May 2019.
  12. 12.
    Ellison WD, Rosenstein LK, Morgan TA, Zimmerman M. Community and clinical epidemiology of borderline personality disorder. Psychiatr Clin North Am. 2018;41:561–73.PubMedCrossRefGoogle Scholar
  13. 13.
    Sansone RA, Songer DA, Miller KA. Childhood abuse, mental healthcare utilization, self-harm behavior, and multiple psychiatric diagnoses among inpatients with and without a borderline diagnosis. Compr Psychiatry. 2005;46:117–20.PubMedCrossRefGoogle Scholar
  14. 14.
    Choi-kain LW, Albert EB, Gunderson JG. Evidence-based treatments for borderline personality disorder: implementation, integration, and stepped care. Harv Rev Psychiatry. 2017;24:342–56.CrossRefGoogle Scholar
  15. 15.
    Stoffers JM, Vollm BA, Rucker G, Timmer A, Huband N, Lieb K. Psychological therapies for people with borderline personality disorder. Cochrane Syst Rev. 2012;8:CD005652.Google Scholar
  16. 16.
    Hermens ML, van Splunteren PT, van den Bosch A, Verheul R. Barriers to implementing the clinical guideline on borderline personality disorder in the Netherlands. Psychiatr Serv. 2011;62:1381–3.PubMedCrossRefGoogle Scholar
  17. 17.
    Lieb K, Zanarini MC, Schmahl C, Linehan MM, Bohus M. Borderline personality disorder. Lancet. 2004;364:453–61.PubMedCrossRefGoogle Scholar
  18. 18.
    Soetman DI, Verheul R, Busschbach JJ. The burden of disease in personality disorders: diagnosis-specific quality of life. J Personal Disord. 2008;22:259–68.CrossRefGoogle Scholar
  19. 19.
    Zimmerman M, Chelminski I, Dalrymple K, Rosenstein L. Principal diagnoses in psychiatric outpatients with borderline personality disorder: implications for screening recommendations. Ann Clin Psychiatry. 2017;29:54–60.PubMedGoogle Scholar
  20. 20.
    Strosahl K. Cognitive and behavioral treatment of the personality disordered patient. In: Austad C, Berman B, editors. Psycho-therapy in managed health care. The optimal use of time and resources. Washington, DC: American Psychological Association; 1991. p. 185–201.CrossRefGoogle Scholar
  21. 21.
    Hayes SC, Wilson KG, Gifford EV, Follete VM, Strosahl K. Experiential avoidance and behavioral disorders: a functional dimensional approach to diagnosis and treatment. J Consult Clin Psychol. 1996;64:1152–68.PubMedCrossRefGoogle Scholar
  22. 22.
    Paris J. Treatment of borderline personality disorder: a guide to evidence-based practice. New York, NY: The Guilford Press; 2008.Google Scholar
  23. 23.
    Morgan TA, Chelminski I, Young D, Dalrymple K, Zimmerman M. Differences between older and younger adults with borderline personality disorder on clinical presentation and impairment. J Psychiatr Res. 2013;47:1507–13.PubMedCrossRefGoogle Scholar
  24. 24.
    Powers AD, Gleason MEJ, Oltmanns TF. Symptoms of borderline personality disorder predict interpersonal (but not independent) stressful life events in a community sample of older adults. J Abnorm Psychol. 2013;122:469–74.PubMedPubMedCentralCrossRefGoogle Scholar
  25. 25.
    Frías Á, Palma C, Solves L, Martínez B, Salvador A. Differential symptomatology and functioning in borderline personality disorder across age groups. Psychiatry Res. 2017;258:44–50.PubMedCrossRefGoogle Scholar
  26. 26.
    Springer T, Silk K. A review of inpatient group therapy for borderline personality disorder. Harv Rev Psychiatry. 1995;5:268–78.Google Scholar
  27. 27.
    Livesley W. Moving beyond specialized therapies for borderline personality disorder: the importance of integrated domain-focused treatment. Psychodyn Psychiatry. 2012;40:47–74.PubMedCrossRefGoogle Scholar
  28. 28.
    • Cameron AY, Reed KP, Guadiano BA. Addressing treatment motivation in borderline personality disorder: rationale for incorporating values-based exercises into dialectical behavior therapy. J Contemp Psychother. 2014;44:109–16 Helpful adaptation of values work to existing treatment models to help with the overall goal of treatment adherence in individuals with BPD.CrossRefGoogle Scholar
  29. 29.
    Watters CA, Bagby RM, Sellbom M. Meta-analysis to derive an empirically based set of personality facet criteria for the alternative DSM-model for personality disorders. Personal Disord. 2018;10:97–104.PubMedCrossRefGoogle Scholar
  30. 30.
    Waugh MH, Hopwood CJ, Krueger RF, Morey LC, Pincus AL, Wright AGC. Psychological assessment with the DSM–5 Alternative Model for Personality Disorders: tradition and innovation. Prof Psychol Res Pr. 2017;48:79–89.PubMedPubMedCentralCrossRefGoogle Scholar
  31. 31.
    Classin CC, Pain C, Field NP, Woods P. Posttraumatic personality disorder: a reformulation of complex posttraumatic stress disorder and borderline personality disorder. Psychiatr Clin North Am. 2006;29:87–112.CrossRefGoogle Scholar
  32. 32.
    Akiskal HS. The temperamental borders of affective disorders. Acta Psychiatr Scand. 1994;89:32–7.CrossRefGoogle Scholar
  33. 33.
    Elisei S, Anastasti S, Verdolini N. The continuum between bipolar disorder and borderline personality disorder. Psychiatr Danub. 2012;24:143–6.Google Scholar
  34. 34.
    • Morton J, Snowdon S, Gopold M, Guymer E. Acceptance and commitment therapy group treatment for symptoms of borderline personality disorder: a public sector pilot study. Cogn Behav Pract. 2012;19:527–44 Results from the direct application of full ACT model to patients with BPD using a 12-week group-based intervention model, and with promising results such as decreased symptoms of BPD.CrossRefGoogle Scholar
  35. 35.
    • Gratz KL, Gunderson JG. Preliminary data on an acceptance-based emotion regulation group intervention for deliberate self-harm among women with borderline personality disorder. Behav Therapy. 2006;37:25–35 Novel group-based DBT intervention specifically targeting emotion dysregulation with promising results like decreased self-harm, anecdotal patient preference for components of ACT.CrossRefGoogle Scholar
  36. 36.
    Bailey A, Mooney-Reh D, Parker L, Temelkovski S. Beyond the fragmented self: integrating acceptance and psychodynamic approaches in the treatment of borderline personality. In: Blackledge JT, Ciarrochi J, Deane FP, editors. Acceptance and commitment therapy: contemporary theory, research and practice. Bowen Hills, QLD: Australian Academic Press; 2009. p. 281–310.Google Scholar
  37. 37.
    Chapman A. Acceptance and mindfulness in behavior therapy: a comparison of dialectical behavior therapy and acceptance and commitment therapy. Int J Behav Consult Ther. 2006;2:308–13.CrossRefGoogle Scholar
  38. 38.
    Fossetti A, Vigorelli Porro F, Maffei C, Borroni S. Are the DSM-IV personality disorders related to mindfulness? An Italian study on clinical participants. J Clin Psychol. 2012;68:672–83.CrossRefGoogle Scholar
  39. 39.
    O’Toole SK, Diddy E, Kent M. Mindfulness and emotional well-being in women with borderline personality disorder. Mindfulness. 2012;3:117–23.CrossRefGoogle Scholar
  40. 40.
    Wupperman P, Neumann CS, Whitman JB, Axelrod SR. The role of mindfulness in borderline personality disorder features. J Nerv Ment Dis. 2009;197:766–71.PubMedCrossRefGoogle Scholar
  41. 41.
    Peters JR, Eisenlohr-Moul TA, Upton BT, Baer RA. Nonjudgment as a moderator of the relationship between present-centered awareness and borderline features: synergistic interactions in mindfulness assessment. Personal Individ Differ. 2013;55:24–8.CrossRefGoogle Scholar
  42. 42.
    Wupperman P, Neumann CS, Axelrod SR. Do deficits in mindfulness underlie borderline personality features and core difficulties? J Personal Disord. 2008;22:466–82.CrossRefGoogle Scholar
  43. 43.
    Mitchell R, Roberts R, Bartsch D, Sullican T. Changes in mindfulness facets in dialectical behavior therapy skills training group program for borderline personality disorder. Intervention Research. 2019;75:958–69.Google Scholar
  44. 44.
    Scheibner HJ, Spengler S, Kanske P, Roepke S, Bermpohl F. Behavioral assessment of mindfulness difficulties in borderline personality disorder. Mindfulness. 2016;7:1316–26.CrossRefGoogle Scholar
  45. 45.
    Selby EA, Fehling KB, Panza EA, Kranzler A. Rumination, mindfulness, and borderline personality disorder symptoms. Mindfulness. 2016;7:228–35.CrossRefGoogle Scholar
  46. 46.
    Soler J, Elices M, Pascual JC, Martín-Blanco A, Feliu-Soler A, Carmona C, et al. Effects of mindfulness training on different components of impulsivity in borderline personality disorder: results from a pilot randomized study. Borderline Personal Disord Emot Dysregul. 2016;3:1.PubMedPubMedCentralCrossRefGoogle Scholar
  47. 47.
    Elices M, Pascual JC, Portella MJ, Feliu-Soler A, Martín-Blanco A, Carmona C, et al. Impact of mindfulness training on borderline personality disorder: a randomized trial. Mindfulness. 2016;7:584–95.CrossRefGoogle Scholar
  48. 48.
    Feliu-Soler A, Pascual JC, Borràs X, Portella MJ, Martín-Blanco A, Armario A, et al. Effects of dialectical behaviour therapy—mindfulness training on emotional reactivity in borderline personality disorder: preliminary results. Clin Psychol Psyother. 2014;21:363–70.CrossRefGoogle Scholar
  49. 49.
    Soler J, Valdepérez A, Feliu-Soler A, Pascual JC, Portella MJ, Martín-Blanco A, et al. Effects of the dialectical behavioral therapy-mindfulness module on attention in patients with borderline personality disorder. Behav Res Ther. 2012;50:150–7.PubMedCrossRefGoogle Scholar
  50. 50.
    Baer RA, Smith GT, Hopkins J, Krietemeyer J, Toney L. Using self-report assessment methods to explore facets of mindfulness. Assessment. 2006;13:27–45.PubMedCrossRefGoogle Scholar
  51. 51.
    Jeffcoat T, Hayes SC, Szabo T. Development of the Reno Inventory of Self-Perspective: measuring self-as-context and perspective-taking. In: Jeffcoat T, chair. Continuing developments in measuring ACT processes. Proceedings of the symposium conducted at the Association for Contextual Behavioral Science World Conference 13, Berlin, Germany. 2015.Google Scholar
  52. 52.
    Zettle RD, Gird SR, Webster BK, Carrasquillo-Richardson N, Swails JA, Burdsal CA. The self-as-context scale: development and preliminary psychometric properties. J Contextual Behav Sci. 2018;10:64–74.CrossRefGoogle Scholar
  53. 53.
    Yu L, Norton S, Almarzooqi S, McCracken LM. Preliminary investigation of self-as-context in people with fibromyalgia. Br J Pain. 2017;11:134–43.PubMedPubMedCentralCrossRefGoogle Scholar
  54. 54.
    Richetin J, Preti E, Costantini G, de Panfilis C. The centrality of affective instability and identity in borderline personality disorder: evidence from network analysis. PLoS ONE, 12 (10). 2017. http://search.ebscohost.com.revproxy.brown.edu/login.aspx?direct=true&db=psyh&AN=2018-17369-001&site=ehost-live&scope=site. Accessed 25 May 2019.
  55. 55.
    Gillanders DT, Bolderston H, Bond FW, Dempster M, Flaxman PE, Campbell L, et al. The development and initial validation of the cognitive fusion questionnaire. Behav Ther. 2014;45:83–101.PubMedCrossRefGoogle Scholar
  56. 56.
    Herzberg KN, Sheppard SC, Forsyth JP, Credé M, Earleywine M, Eifert GH. The believability of Anxious Feelings and Thoughts Questionnaire (BAFT): a psychometric evaluation of cognitive fusion in a nonclinical and highly anxious community sample. Psychol Assess. 2012;24:877–91.PubMedCrossRefGoogle Scholar
  57. 57.
    Fresco DM, Segal ZV, Buis T, Kennedy S. Relationship of posttreatment decentering and cognitive reactivity to relapse in major depression. J Consult Clin Psychol. 2007;75:447–55.PubMedCrossRefGoogle Scholar
  58. 58.
    Naragon-Gainey K, DeMarree KG. Structure and validity of measures of decentering and defusion. Psychol Assess. 2017;29:935–54.PubMedCrossRefGoogle Scholar
  59. 59.
    Donald JN, Atkins PWB, Parker PD, Christie AM, Guo J. Cognitive defusion predicts more approach and less avoidance coping with stress, independent of threat and self-efficacy appraisals. J Pers. 2017;85:716–29.PubMedCrossRefGoogle Scholar
  60. 60.
    Mandavia A, Masuda A, Moore M, Mendoza H, Donati MR, Cohen LL. The application of a cognitive defusion technique to negative body image thoughts: a preliminary analogue investigation. J Contextual Behav Sci. 2015;4:86–95.CrossRefGoogle Scholar
  61. 61.
    Masuda A, Feinstein AB, Wendell JW, Sheehan ST. Cognitive defusion versus thought distraction: a clinical rationale, training, and experiential exercise in altering psychological impacts of negative self - referential thoughts. Behav Modif. 2010;34:520–38.PubMedCrossRefGoogle Scholar
  62. 62.
    Masuda A, Hayes SC, Sackett CF, Twohig MP. Cognitive defusion and self - relevant negative thoughts: examining the impact of a ninety year old technique. Behav Res Ther. 2004;42:477–85.PubMedCrossRefGoogle Scholar
  63. 63.
    Masuda A, Twohig MP, Stormo AR, Feinstein AB, Chou YY, Wendell JW. The effects of cognitive defusion and thought distraction on emotional discomfort and believability of negative self - referential thoughts. J Behav Ther Exp Psychiatry. 2010;41:11–7.PubMedCrossRefGoogle Scholar
  64. 64.
    Blackledge JT. Disrupting verbal processes: cognitive defusion in acceptance and commitment therapy and other mindfulness-based psychotherapies. Psychol Rec. 2007;57:555–76.CrossRefGoogle Scholar
  65. 65.
    Kramer U, Vaudroz C, Ruggeri O, Drapeau M. Biased thinking assessed by external observers in borderline personality disorder. Psychol Psychother Theory Res Pract. 2013;86:183–96.CrossRefGoogle Scholar
  66. 66.
    Bateman A, Fonagy P. Psychotherapy for borderline personality disorder: mentalization based treatment. Oxford, United Kingdon: Oxford University Press; 2004.CrossRefGoogle Scholar
  67. 67.
    Chapman AL, Dixon-Gordon KL, Walters KN. Experiential avoidance and emotion regulation in borderline personality disorder. Journal of Rational-Emotive and Cognitive Behavioral Therapy. 2011;29:35–52.CrossRefGoogle Scholar
  68. 68.
    Chawla N, Ostafin B. Experiential avoidance as a functional dimensional approach to psychopathology: an empirical review. J Clin Psychol. 2011;63:871–90.CrossRefGoogle Scholar
  69. 69.
    Bijttebier P, Vertommen H. Coping strategies in relation to personality disorders. Personal Individ Differ. 1999;26:847–56.CrossRefGoogle Scholar
  70. 70.
    Rüsch N, Hölzer A, Hermann C, Schramm E, Jacob GA, Bohus M, et al. Self-stigma in women with borderline personality disorder and women with social phobia. J Nerv Ment Dis. 2006;194:766–73.PubMedCrossRefGoogle Scholar
  71. 71.
    Iverson KM, Follette VM, Pistorello J, Fruzzetti AE. An investigation of experiential avoidance, emotion dysregulation, and distress tolerance in young adult outpatients with borderline personality disorder symptoms. Pers Disord. 2012;3:415–22.CrossRefGoogle Scholar
  72. 72.
    Sharp C, Kalpakci A, Mellick W, Venta A, Temple JR. First evidence of prospective relation between avoidance of internal states and borderline personality disorder features in adolescents. Eur Child Adolesc Psychiatry. 2015;24:283–90.PubMedCrossRefGoogle Scholar
  73. 73.
    Neacsiu AD, Lungu A, Harned MS, Rizvi SL, Linehan MM. Impact of dialectical behavior therapy versus community treatment by experts on emotional experience, expression, and acceptance in borderline personality disorder. Behav Res Ther. 2014;53:47–54.PubMedCrossRefGoogle Scholar
  74. 74.
    Berking M, Neacsiu A, Comtois KA, Linehan MM. The impact of experiential avoidance on the reduction of depression in treatment for borderline personality disorder. Behav Res Ther. 2009;47:663–70.PubMedPubMedCentralCrossRefGoogle Scholar
  75. 75.
    Krantz LH, McMain S, Kuo JR. The unique contribution of acceptance without judgment in predicting nonsuicidal self-injury after 20-weeks of dialectical behaviour therapy group skills training. Behav Res Ther. 2018;104:44–50.PubMedCrossRefGoogle Scholar
  76. 76.
    Bond FW, Hayes SC, Baer RA, Carpenter KM, Guenole N, Orcutt HK, et al. Preliminary psychometric properties of the Acceptance and Action Questionniare - II: a revised measure of psychological flexibility and experiential avoidance. Behav Ther. 2011;42:676–88.PubMedCrossRefGoogle Scholar
  77. 77.
    Dixon-Gordon KL, Turner BJ, Rosenthal MZ, Chapman AL. Emotion regulation in borderline personality disorder: an experimental investigation of the effects of instructed acceptance and suppression. Behav Ther. 2017;48:750–64.PubMedCrossRefGoogle Scholar
  78. 78.
    Chapman AL, Rosenthal MZ, Dixon-Gordon KL, Turner BJ, Kuppens P. Borderline personality disorder and the effects of instructed emotional avoidance or acceptance in daily life. J Personal Disord. 2017;31:483–502.CrossRefGoogle Scholar
  79. 79.
    • Morton J, Shaw L. Wise choices: acceptance and commitment therapy groups for people with borderline personality disorder. Melbourne: Australian Postgraduate Medicine; 2012. An acceptance and commitment therapy–based group treatment manual for borderline personality disorderGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  1. 1.Department of Psychiatry and Human BehaviorBrown Medical SchoolProvidenceUSA
  2. 2.Department of PsychiatryRhode Island HospitalProvidenceUSA

Personalised recommendations