1

Psychology and Psychotherapy: Theory, Research and Practice (2019)

© 2019 The British Psychological Society
www.wileyonlinelibrary.com

Clinical efficacy of a combined acceptance and

commitment therapy, dialectical behavioural
therapy, and functional analytic psychotherapy
intervention in patients with borderline personality
disorder
Michel A. Reyes-Ortega1, Edgar M. Miranda2, Ana Fresan3,
Angelica N. Vargas4, Sandra C. Barragan5, Rebeca Robles
Garcıa6* and Ivan Arango2
1
Academic Coordination Department, Contextual Behavioral Science and Therapy
Institute, Mexico City, Mexico
2
Clinic of Borderline Personality Disorder, Directorate of Clinical Services, Ram on de
la Fuente Mu~ niz National Institute of Psychiatry, Mexico City, Mexico
3
Laboratory of Clinical Epidemiology, Sub-directorate of Clinical Research, Ram on de
la Fuente Mu~ niz National Institute of Psychiatry, Mexico City, Mexico
4
Coordination Department of Clinical Services, Contextual Behavioral Science and
Therapy Institute, Mexico City, Mexico
5
Grantholder of the National Council for Science and Technology (CONACYT) for a
project of the Ramon de la Fuente Mu~ niz National Institute of Psychiatry, Mexico City,
Mexico
6
Center of Research on Global Mental Health, Department of Innovation and Global
Health, Directorate of Epidemiological and Psychosocial Research, Ram on de la
Fuente Mu~ niz National Institute of Psychiatry, Mexico City, Mexico

Objective. Borderline personality disorder (BPD) consists of a persistent pattern of

instability in affective regulation, impulse control, interpersonal relationships, and self-
image. Although certain forms of psychotherapy are effective, their effects are small to
moderate. One of the strategies that have been proposed to improve interventions
involves integrating the therapeutic elements of different psychotherapy modalities from
a contextual behavioural perspective (ACT, DBT, and FAP).
Methods. Patients (n = 65) attending the BPD Clinic of the Instituto Nacional de
Psiquiatrıa Ram
on de la Fuente Mu~nız in Mexico City who agreed to participate in the
study were assigned to an ACT group (n = 22), a DBT group (n = 20), or a combined
ACT + DBT + FAP therapy group (n = 23). Patients were assessed at baseline and after

*Correspondence should be addressed to Rebeca Robles Garc
ıa, Center of Research on Global Mental Health, Department of
Innovation and Global Health, Directorate of Epidemiological and Psychosocial Research, Ram
on de la Fuente Mu~niz National
Institute of Psychiatry, Calzada M
exico-Xochimilco 101, Tlalpan 14370, Mexico City, Mexico (email: reberobles@imp.edu.mx).

DOI:10.1111/papt.12240
2 Michel A. Reyes-Ortega et al.

therapeutic trial on measures of BPD symptom severity, emotion dysregulation,

experiential avoidance, attachment, control over experiences, and awareness of stimuli.
Results. ANOVA analyses showed no differences between the three therapeutic
groups in baseline measures. Results of the MANOVA model showed significant
differences in most dependent measures over time but not between therapeutic groups.
Conclusions. Three modalities of brief, contextual behavioural therapy proved to be
useful in decreasing BPD symptom severity and emotional dysregulation, as well as
negative interpersonal attachment. These changes were related to the reduction of
experiential avoidance and the acquisition of mindfulness skills in all treatment groups,
which may explain why no differences between the three different intervention modalities
were observed.

Practitioner points

Brief adaptations of acceptance and commitment therapy and dialectical behavioural therapy are
effective interventions for BPD patients, in combined or isolated modalities, and with or without the
inclusion of functional analytic psychotherapy.

The reduction of experiential avoidance and the acquisition of mindfulness skills are related with the
diminution of BPD symptoms severity, including emotional dysregulation and negative interpersonal
attachment.

Borderline personality disorder (BPD) consists of a persistent pattern of instability in

affective regulation, impulse control, interpersonal relationships, repeated self-injuries,
and chronic suicidal tendencies (American Psychiatric Association, 2013; Leichsenring,
Leibing, Kruse, New, & Leweke, 2011) leading these patients to frequently seek mental
health services (Zanarini, Frankenburg, Hennen, & Silk, 2004), which are soon
discontinued, including psychotherapy (e.g., in the classic study by Gunderson et al.
(1989), 60 per cent of newly hospitalized BPD patients discontinued their psychotherapy
at 6 months).
Some forms of psychotherapy are effective for BPD symptoms and related problems.
Nonetheless, their effects are small to moderate (Cristea et al., 2017), and the need
remains to undertake more research to manage this condition, focusing on the
development and dissemination of interventions with better outcomes and greater cost-
effectiveness (Lieb, Zanarini, Schmahl, Linehan, & Bohus, 2004).
One of the strategies proposed to improve psychosocial interventions and ensure that
they can be delivered in less time without jeopardizing their effectiveness involves
integrating the therapeutic elements of various psychotherapy modalities that have
proved useful for managing the condition (Marquis & Wilber, 2008).
From a contextual behavioural perspective, ACT, DBT, and FAP are well-established
psychotherapies with theoretical consistency that can easily be integrated (Kanter, Tsai, &
Kohlenberg, 2010; Reyes-Ortega, 2017a). Although DBT has the largest and strongest
evidence base, many practitioners trained as clinical behaviour analysts adopt an
integrative approach using treatments such as ACT, DBT, and FAP when comprehensive
DBT is not feasible given the resources available at a particular clinical site (Reyes-Ortega,
Vargas, & Tena, 2015).
DBT (Linehan, 1993) conceptualizes BPD as an emotion regulation dysfunction
leading to behavioural, interpersonal, cognitive, and self-dysregulation problems. It is
currently the gold standard treatment for BPD and an effective treatment for the reduction
of self-injurious and suicidal behaviour in this population (Lieb & Stoffers, 2012). DBT, as
 Brief interventions for borderline personality disorder 3

originally conceived, is a comprehensive, one-year outpatient intervention designed to

lead to behavioural control and acceptable quality of life, through a set of service delivery
methods and continuous support from a professional team. This includes individual
psychotherapy, weekly group skills training (e.g., mindfulness, interpersonal effective-
ness, distress tolerance, and emotion regulation), and skills-coaching phone calls as
required. Linehan, Kanter, and Comtois (1999) articulated the distinction between
functions and service delivery methods to help early adopters implement DBT in new
settings and with new populations when the needs or constraints in the local setting
interfered with adopting standard DBT (Koerner, 2011).
At the same time, ACT targets experiential avoidance and cognitive fusion to support
functionally flexible behaviour and develop patterns of action consistent with personal
values (Hayes, 2004). From an ACT point of view, BPD symptoms and its attendant
emotional regulation difficulties involve a severe emotional inflexibility problem driven
by experiential avoidance and fusion with a negative conceptualized self (Morton & Shaw,
2012). In other words, ‘it is not the intense negative affects per se that are the problem, it is
the experiential avoidance (which tends to increase the intensity of negative experi-
ences), fusion with negative thoughts, and the unhelpful choices the person makes about
action – particularly actions that are against the individual’s core values.’ (Morton,
Snowdon, Gopold, & Guymer, 2012, pp. 528).
Self-harm and drug or alcohol abuse can be seen as experiential avoidance strategies
(Chapman, Gratz, & Brown, 2006). The distress intolerance and interpersonal ineffec-
tiveness present in many BPD patients can be seen as two types of values or dynamic
verbally constructed reinforcers; while an unstable sense of self-identity could be
addressed by another ACT tenet, the self-as-context, which is an experience of flexibility
and an adaptation to a constant change. Thus, patients could benefit from strategies
designed to facilitate present-moment awareness, acceptance of difficult emotions,
identification of values, and committed action on values (Morton et al., 2012).
In fact, available data on its efficacy show benefits in affective and posttraumatic stress
symptoms (Siang-Yang, 2011), interpersonal relationships (Morton & Shaw, 2012), and
quality of life of patients with BPD (Yust & Perez-Dıaz, 2012), while brief ACT-based
interventions have proved to be a valuable addition to usual treatments for people with
BPD symptoms in the public sector (Morton et al., 2012). However, distress tolerance,
crisis survival, emotion regulation, and interpersonal effectiveness are not directly
targeted in ACT treatments, and it has been suggested that their active treatment could
achieve the benefits of DBT and support ACT interventions when DBT is unavailable
(Gratz & Gunderson, 2006; Morton et al., 2012; Shearin & Linehan, 1992).
Lastly, FAP (Kohlenberg & Tsai, 1991) is an intervention based on the interpersonal
relationship that has also been tested in treating patients with BPD (Kanter et al., 2017).
From this perspective, BPD patients’ problematic interpersonal behaviours (such as
aggressive behaviours) will be displayed in the therapeutic relationship, and through a
differential, contingent response, the therapist could help the patient decrease or
eliminate problematic behaviours in session, which could be generalized to out-of-session
relationships (Busch, Callaghan, Kanter, Baruch, & Weeks, 2010).
FAP highlights the role of a self under public control in the development of BPD
(Kohlenberg & Tsai, 1991). This means that pervasive invalidation across the lifespan fails
to establish a perception of self defined by one’s private events, leading instead to a
perception of self-controlled by external cues such as other people’s opinions, which
leads to chronic experiences of emptiness, unstable identity, and serious problems with
self-regulation. Thus, by integrating FAP principles into behavioural treatments for BPD,
4 Michel A. Reyes-Ortega et al.

greater emphasis is placed on interpersonal functioning. The focus on strategies to work

on in vivo interpersonal skills difficulties as they arise within therapy may contribute to
changing attachment representations (conceptualized as a social-cognitive and affective
construct), which has been proposed as one of the primary mechanisms whereby patients
with BPD improve with psychotherapy (Levy et al., 2006).
However, current research does not support the treatment of BPD patients with FAP
techniques alone, but rather in combination with research-supported psychotherapies to
increase their effectiveness while the therapist acts as a social reinforcer to bring about
positive change in problematic interpersonal behaviours (Kanter et al., 2017), particu-
larly when this is combined with DBT strategies (Hopko & Hopko, 1999; Valero-Aguayo,
Ferro-Garcıa, Kohlenberg, & Tsai, 2011).
It is therefore possible to suggest that the incorporation of elements from these three
psychotherapy models will enable the development of a more effective intervention for
patients with BPD (Reyes-Ortega et al., 2015), although they may also have similar
impacts due to their shared processes (Reyes-Ortega, 2017b). Moreover, since these
psychotherapeutic processes are prolonged, it is also essential to develop and evaluate
brief versions of both single and combined interventions to meet the demand for care in
saturated public institutions, at least in low- and middle-income countries such as Mexico.
Implementing the study in a Mexican population could also be useful for obtaining data in
non-English speaking countries and determine the cultural relevance of third wave
approaches in treating BPD patients.
The overall aim of this open-label study was to test the clinical efficacy of a brief
combined ACT + DBT + FAP therapy by comparing it with brief versions of ACT or DBT
alone for treating Mexican patients with BPD. Each modality of treatment is described
below in the Methods section. In general terms, they focus on reducing experiential
avoidance (ACT), emotional dysregulation (DBT), and interpersonal problems (FAP).
Thus, the main hypotheses were that ACT + DBT + FAP would be more effective than
ACT alone in reducing the severity of BPD symptoms (including emotional dysregulation
and suicide risk), than DBT alone in decreasing experiential avoidance, and than both ACT
and DBT alone in improving interpersonal functioning, mainly due to the reduction of
hostile conflict resolution and the increase in positive attachment. It was also
hypothesized that the three interventions would have similar impacts on the development
of participants’ sense of control over their experiences and mindfulness skills.

Methods
Participants and procedures
Sixty-five patients attending a BPD Clinic were included in the study. Before patients were
invited to take part in the study, the Ethics Review Board of the local institution approved
the study protocol and materials. Participation was voluntary, and all patients gave written
informed consent after the study procedures had been fully explained.
A total of 22 patients were assigned to the ACT group, 20 received DBT, and 23 were
given combined ACT + DBT + FAP therapy. This was based on a sequential assignment
(first ACT alone, then DBT alone, then the combined intervention). All sessions were
videotaped for the assessment of treatment fidelity by two independent certified
psychotherapists using an ad hoc checklist based on the structured manuals of each
intervention to record the number of activities and strategies planned for each session,
and compute the corresponding percentage of compliance, which proved high in all
 Brief interventions for borderline personality disorder 5

groups (85–95% of the activities and strategies scheduled for each session were delivered
during the field trial by the therapists in charge of the groups). The inter-rater reliability
achieved in each group was very high (ACT Kappa = .90, DBT Kappa = .87,
ACT + DBT + FAP Kappa = .85; Calculations and interpretation of Cohen0 s kappa
coefficients based on procedures detailed by McHugh, 2012).
Clinical baseline information was obtained through a face-to-face interview with
patients. This interview was performed by one of the psychiatrists from the BPD Clinic,
and BPD diagnosis was confirmed through a structured interview. Patients were assessed
at baseline and after the therapeutic trial for borderline symptom severity, emotion
dysregulation, experiential avoidance, attachment, control over experiences, and
awareness of stimuli. All the scales used for the evaluation of these variables were
performed by two independent trained raters (a psychiatrist and a psychologist), who
were blind to the therapeutic intervention received by the patients.

Measures
The Structured Clinical Interview for DSM-IV Axis II Personality Disorders (SCID-II;
First, Gibbon, Spitzer, Williams, & Benjamin, 1996) was used to determine BPD diagnosis
in this study. It is a semi-structured interview comprising 119 items for a face-to-face
interview designed to generate personality disorders diagnoses. The Spanish version of
the instrument used in this study was translated and evaluated by Villar et al. (1995). In
their study, overall inter-rater agreement on the presence or absence of the various
diagnoses assessed was high (K = 0.85).
The Borderline Evaluation of Severity Over Time (BEST; Pfohl et al., 2009) is a 15-
item self-report instrument scored on a 5-point Likert scale designed to measure the
severity of the main symptoms of BPD patients. The scale comprises three subscales: (1)
Thoughts and Feelings (first eight items rated from 1 = None/Slight to 5 = Extreme),
including mood reactivity, identity disturbance, suicidal thoughts, unstable relationships,
and emptiness; (2) Behaviors-Negative (next four items rated from 1 = None/Slight to
5 = Extreme), evaluating self-harm behaviours; and (3) Positive Behaviors (final three
items rated from 5 = Almost Always to 1 = Almost Never). A Spanish version of the
instrument for the present study was created using the translation and back translation
process by two bilingual mental health professionals. In our sample, Cronbach’s alpha
was .80 for the total score, suggesting adequate internal consistency.
Emotion dysregulation was assessed through the Difficulties in Emotion Regulation
Scale (DERS; Gratz & Roemer, 2004), which has been used to measure fear of emotional
experience and feelings of loss of control over internal and behavioural expression. It is a
36-item questionnaire designed to evaluate six areas (emotional experience, difficulties in
maintaining goal-oriented behaviour, lack of emotional awareness, and lack of emotional
clarity) on a 5-point Likert scale with higher scores indicating more difficulties in
emotional regulation. Its version in Spanish (Marın-Tejeda, Robles-Garcıa, Gonzalez-
Forteza, & Andrade-Palos, 2012) used in the present study was reduced to 24 items
showing good internal consistency, with a Cronbach’s alpha of .93, and a test–retest
reliability of r = .88.
The Acceptance and Action Questionnaire-II (AAQ-II; Bond et al., 2011) assesses
experiential avoidance, including thoughts, emotions, past experiences, and psycholog-
ical inflexibility as attempts to modify its form, frequency, intensity, or situational
sensitivity, even though this is futile or interferes with valued actions. It is a 7-item, self-
report questionnaire scored on a 7-point Likert scale with higher scores indicating higher
6 Michel A. Reyes-Ortega et al.

experiential avoidance and lower scores reflecting psychological flexibility. The Mexican
version developed earlier by Patr on (2010) showed high internal consistency and a
Cronbach’s alpha of .89.
The Adult Attachment Questionnaire was used for the evaluation of interpersonal
attachment (Melero & Cantero, 2008). It comprises 40 items scored on a 6-point Likert
agreement scale that evaluates four main areas to determine secure or insecure
attachment: (1) low self-esteem, need for approval, and fear of rejection; (2) hostile
conflict resolution, rancour, and possessiveness; (3) expression of feelings and comfort
with relationships, and (4) emotional self-sufficiency and discomfort with intimacy. The
study attempted to develop and evaluate the original version of the instrument in Spanish,
showing that it is a valid measure for identifying individuals with secure or insecure
attachment, with all its subscales lying within an acceptable range of internal consistency
(Cronbach a from .68 for subscale 4 to .86 for subscale 1).
The Experiencing of Self Scale (Kanter, Parker, & Kohlenberg, 2001) is a 37-item self-
report Likert questionnaire designed to assess four main areas in relation to control over
experiences: (1) the experience of self; (2) the influence of other non-close persons on the
expression of needs, opinions, attitudes, and actions; (3) the influence of a close person on
the expression of needs, opinions, attitudes, and actions; and (4) creativity, sensitivity to
criticism, and dissociation. Higher scores reflect low control over experiences. The
translated version of the EOSS into Spanish used in this study (Valero-Aguayo, Ferro-
Garcıa, L
opez-Berm udez, & Selva-L
opez, 2014) shows high internal consistency (a = .94).
Lastly, the Five-Facet Mindfulness Questionnaire (FFMQ; Baer, Smith, Hopkins,
Krietemeyer, & Toney, 2006) was used to assess awareness of internal and external stimuli
by measuring the five facets of mindfulness: observing, describing, acting with awareness,
no judging of inner experience, and no reactivity to inner experience. It comprises 39 self-
report items scored on a 5-point Likert agreement scale. Its total score ranges from 39 to
195, with higher scores indicating greater mindfulness in everyday life. A Spanish version
of the instrument for this study was created through the translation and back translation
process by two bilingual mental health professionals. In our sample, Cronbach’s alpha
coefficients for all subscales were adequate: Observing: .80, Describing: .84, Acting with
awareness: .87, No reactivity: .69, and No judging: .83.

Modalities of treatment
The three treatment modalities were brief adaptations for patients with BPD, developed
by two authors of this study (MARO and ANV verified DBT, ACT, and FAP clinicians). All
treatments included an equivalent number of group and individual sessions (although for
ACT intervention alone, no priority of group over individual session is expected), as well
as daily practice of the skills learned in the session as homework.

Combined ACT + DBT + FAP treatment for BPD

Combined intervention included 18 group sessions and 16 individual sessions, which
incorporated the objectives and core strategies of ACT, DBT, and FAP adapted for
interpersonal problems (Maitland, Kanter, Manbeck, & Kuczynski, 2017; Reyes-Ortega &
Kanter, 2017). Group sessions were designed to present the treatment model; recognize
the characteristics of effective and ineffective emotional regulation strategies (including
experiential avoidance and the perception of self-controlled external cues, and their
personal costs); understand and practice various emotional crisis survival skills; identify
 Brief interventions for borderline personality disorder 7

personal and interpersonal values; encourage radical acceptance of emotions, as well as

cognitive and behavioural flexibility; implement problem-solving strategies as opposed to
engaging in rumination and worrying; learn basic communication skills, including the
expression of one’s own opinions and negotiation; adopt a compassionate attitude
towards others and enjoy spending time with them; and relapse prevention.
Group intervention strategies included psychoeducation, guided experience, practis-
ing mindfulness, lectures and exercises, behavioural activation, cognitive diffusion,
implementation of opposite and committed actions, identification of non-healthy
relationships and what can and cannot be changed in these relationships, effective
communication training, adopting the other person’s perspective, drawing up a relapse
prevention plan, and homework diaries and practice.
Individual sessions were designed to strengthen the skills practised in group sessions
and encourage patients to use what they had learned in order to direct their behaviour
towards a valued objective, as well as self-observation skills. The main therapeutic
strategies included behavioural analysis, the use of the between-session bridging sheet
(homework), the identification of parallels between the natural environment and in-
session behaviours, in vivo contingency management, problem-solving, and the
assignment of homework activities.

Brief ACT adaptation for patients with BPD

Acceptance and commitment therapy intervention included 18 group sessions and 16
individual sessions, using specific ACT techniques. The overarching goal of ACT is to
increase psychological flexibility. This implies the skills to live in the present moment and
to engage in behaviours that fit with the patient’s values. Psychological flexibility is
established through ACT processes. These processes were implemented in each group
and in individual sessions. These strategies included the following: Mindfulness, Creative
Hopelessness, Cognitive Defusion, Values Clarification, Committed Action, and the use of
the ACT Matrix (Polk, Schoendorff, Webster, & Olaz, 2016). BPD symptoms addressed by
ACT Matrix components included self-injurious behaviours, emotional dysregulation, and
experiential avoidance.
Group sessions were designed to present the treatment model, enable participants to
learn to recognize and name their emotions, identify personal values, accept the things
they cannot change, promote cognitive and behavioural flexibility, implement problem-
solving strategies, practice mindfulness to connect with the present moment, undertake
committed actions every week in keeping with their personal values, and relapse
prevention. Given that BPD patients generally maintain their internal experience (e.g.,
emotions and cognitions), which could lead them to emotional dysregulation, during the
intervention, it was important to focus on achieving patients’ involvement with their five
senses, which facilitates their connection with the present moment. At the same time,
individual sessions were designed to explore patients’ personal problems and strengthen
the skills learned in the group to promote their daily use.

DBT-Informed brief adaptation for patients with BPD

The Dialectical Behavioural Therapy-Informed brief intervention (DBT-I) included 18 group
and 16 individual sessions. Group skills sessions were designed to focus on enhancing
patients’ competences by teaching them DBT skills (Linehan, 2014). The group therapist
teaches the skills during the session and assigns homework so that they can practise the skills
8 Michel A. Reyes-Ortega et al.

in their everyday lives. The structure of group skills is divided into four modules that included
four sessions on Mindfulness, four sessions on Emotional Regulation, five sessions on Distress
Tolerance, and four sessions on Interpersonal Effectiveness.
Individual sessions were designed to examine the specific behaviours of participants
through chain analysis, in order to identify which behaviours the patient should increase
or decrease and then to follow-up in the interaction with other professional team
members in order for them to achieve their goals, and provide reinforcement and
feedback after the implementation of each step. No pre-treatment sessions were
necessary.
The intervention model also included a one-hour weekly consulting team meeting, as
well as telephone assistance for patients.

Statistical analysis
Firstly, all variables were tested for normality using skewness and kurtosis. Demographic
and baseline clinical variables were tested for differences between the therapeutic groups
with v2 or with analyses of variance (ANOVA). If any difference emerged between groups
(p ≤ .05), the corresponding variable(s) was/were included as covariate(s) in the
following analyses.
The three therapeutic groups were included in a repeated multivariate analysis of
variance (MANOVA) model of two measures to examine direction of changes (time effect)
among therapeutic groups (interaction effect) in terms of BPD symptom severity (including
suicidal risk), emotion dysregulation, experiential avoidance, interpersonal attachment,
control over experiences, and awareness of stimuli. We used a p value of .01 as statistically
significant for the MANOVA analyses due to the aim of testing the therapeutic efficacy of the
ACT + DBT + FAP intervention and to reduce Type I error. The effect size of comparisons
was estimated using partial eta squared (g2p ) and reference values for the interpretation of
.01 = small, .06 = medium, .14 = large (Cohen, 1988). All these analyses were performed
using the Statistical Package for the Social Sciences (SPSS), version 20.
Additionally, given that no differences emerged between therapeutic groups in total
scores of main outcome measures (BEST = BPD symptoms and DERS = emotional
dysregulation), tests of equivalency were carried out in the XLSTAT software, using the
TOST procedure for Welsh’s t-test for independent simples (with a prefixed p ≤ .05) and
equivalent bounds (Lakens, Scheel, & Isager, 2018), using the 90% confidence interval of
the mean score of changes (1 SD) in BEST (12.84) and DERS (20.5) as the minimal
effect that should be noticeable in our sample or Smallest Effect Size of Interest (SESOI).
Once again in SPSS, the Pearson correlation coefficient was calculated to determine the
linear association between the changes observed in symptom severity assessed with BEST,
and in emotion dysregulation together with the changes reported in experiential
avoidance (ESS total score) and the five facets of mindfulness across each treatment
condition. A p value of .01 or less was also defined as significant for this analysis.

Results
Patients
A total of 65 patients participated in the study. The vast majority were women (n = 61,
93.8%); and their mean age was 33.7 years (SD = 10.4). A higher percentage were single
(n = 45, 69.3%) and unemployed (n = 51, 78.5%) at the time of their recruitment in the
 Brief interventions for borderline personality disorder 9

study. Major depression was the comorbid diagnosis most frequently reported (n = 51,
78.5%) followed by dysthymia (n = 4, 6.2%) and eating disorders (n = 3, 4.6%). No
differences emerged between groups either in the main demographic variables or in
comorbid diagnosis (p > .05).

Clinical variables
The distribution of the main clinical variables assessed in the study showed acceptable
values of skewness and kurtosis. None of the values was excessively out of range
(skewness range 0.76 to 0.91 and kurtosis range 1.07 to 0.30). The ANOVA analyses
revealed no differences between the three therapeutic groups in the baseline assessment
of BPD symptom severity, emotion dysregulation, experiential avoidance, attachment,
control over experiences, or awareness of stimuli (p > .05). The mean values of these
variables are summarized in Table 1.
The assumption of equal covariance matrices according to Box’s test was not met
(Box’s M = 515.7, p = .03). Results of the MANOVA model showed significant
differences in most dependent measures over time (Wilk’s Lambda = .21, F = 10.3,
p < .001) but not between therapeutic groups (Wilk’s Lambda = .651, F = 0.67,
p = .89), or in an interaction effect time per group (Wilk’s Lambda = .57, F = 0.91,
p = .60).
Similar improvements with large size effects were observed in all therapeutic groups,
with a reduction of BPD symptom severity, emotion dysregulation, and experiential
avoidance, and an increase in psychological flexibility and mindfulness skills. Moreover,
two areas of interpersonal attachment showed significant improvements in the three
therapeutic groups: self-esteem and conflict resolution (Table 1).
A comparison of the 90% confidence interval of the mean score of the changes
observed in the BEST severity score and DERS emotion dysregulation with the TOST
interval fixed for the analysis (1 SD) shows that both assessments were equivalent
between the three therapeutic groups (BEST-ACT≃BEST-ACT + DBT + FAP: t(41) 3.90,
p ≤ .0001; BEST-DBT≃BEST-ACT + DBT + FAP: t(39) 4.37, p ≤ .0001; BEST-ACT≃B-
EST-DBT: t(38) 2.53, p = .008; DERS-ACT≃DERS-ACT + DBT + FAP: t(41) 2.95,
p = 003; DERS-DBT≃BEST-ACT + DBT + FAP: t(39) 3.95, p ≤ .001; DERS-ACT≃
DERS-DBT: t(38) 2.03, p = .02).
Mean changes towards a decrease in global symptom severity (BEST total mean change
score) and emotion dysregulation were significantly correlated with a decrease in
experiential avoidance in the three therapeutic groups. These associations were more
closely related to the BEST subscale Thoughts & Feelings in the three groups and with the
Positive Behaviors subscale for the ACT group (Table 2). Higher awareness in the
Describing subscale of the FFMQ was related to a decrease in symptom severity of the
BEST Thoughts & Feelings subscale, while higher FFMQ Nonreactivity was associated
with the three BEST symptom severity subscales.
In terms of mindfulness, for the three therapeutic groups, mean increases reported in
the facet ‘Acting with awareness’ were related to a decrease in emotion dysregulation. For
the DBT and ACT + DBT + FAP groups, increases in ‘Nonreactivity’, and increases in
‘Nonjudging’ for the ACT and ACT + DBT + FAP were also associated with a reduction in
emotion dysregulation. Only in the DBT group was a reduction in emotion regulation
associated with an increase in the mindfulness facet of Describing (Table 2).
10 Michel A. Reyes-Ortega et al.

Table 1. Clinical efficacy of the therapeutic interventions in patients with BPD

Statistics

Baseline* Final* Analysis* F df p g2p

Total scores
BEST
ACT 40.5 12.0 26.6 8.0 Group 0.8 2 .44 .02
DBT 43.9 9.7 27.6 10.9 Time 73.1 1 <.001 .54
ACT + DBT + FAP 42.2 10.9 31.3 11.0 Group 9 time 0.9 2 .39 .03
DERS
ACT 79.3 17.2 53.9 18.2 Group 0.1 2 .82 .006
DBT 85.1 23.9 53.9 17.7 Time 119.3 1 <.001 .65
ACT + DBT + FAP 81.0 16.9 54.4 17.8 Group 9 time 0.41 2 .66 .01
AAQ-II
ACT 48.0 10.5 34.3 11.8 Group 0.3 2 .71 .01
DBT 54.9 12.7 32.3 14.4 Time 93.6 1 <.001 .60
ACT + DBT + FAP 51.4 13.0 34.5 11.3 Group 9 time 1.9 2 .15 .06
Adult Attachment Questionnaire
Low self-esteem
ACT 52.6 14.0 38.0 10.7 Group 0.6 2 .51 .02
DBT 58.8 14.5 39.6 15.9 Time 69.6 1 <.001 .53
ACT + DBT + FAP 54.9 10.1 39.6 14.0 Group 9 time 0.5 2 .60 .01
Hostile conflict resolution
ACT 40.3 9.1 28.5 9.2 Group 1.5 2 .22 .04
DBT 45.2 14.6 32.8 11.7 Time 53.1 1 <.001 .46
ACT + DBT + FAP 39.0 9.4 31.5 8.8 Group 9 time 1.1 2 .31 .03
Expression of feelings
ACT 35.0 6.9 36.8 7.1 Group 0.5 2 .60 .01
DBT 35.2 9.3 39.6 7.4 Time 8.0 1 .06 .11
ACT + DBT + FAP 35.3 5.6 35.9 5.0 Group 9 time 1.8 2 .16 .05
Emotional self-sufficiency
ACT 22.1 5.9 19.2 5.5 Group 0.06 2 .93 .002
DBT 21.3 8.7 20.4 7.4 Time 3.0 1 .08 .04
ACT + DBT + FAP 21.6 5.4 20.9 5.5 Group 9 time 0.6 2 .51 .02
Experiencing of Self Scale
Experience of self
ACT 28.1 8.3 19.3 6.2 Group 0.5 2 .57 .01
DBT 30.2 8.5 20.8 6.5 Time 79.6 1 <.001 .56
ACT + DBT + FAP 27.6 5.1 20.4 5.6 Group 9 time 0.4 2 .62 .01
Influence of others
ACT 31.7 16.3 19.9 8.7 Group 0.5 2 .58 .01
DBT 36.1 19.0 20.2 10.4 Time 37.6 1 <.001 .38
ACT + DBT + FAP 30.0 14.8 19.5 8.6 Group 9 time 0.5 2 .56 .01
Influence of a close person
ACT 38.1 16.4 24.8 11.0 Group 0.2 2 .78 .008
DBT 42.2 18.7 25.8 13.0 Time 44.5 1 <.001 .42
ACT + DBT + FAP 38.1 13.3 26.9 11.4 Group 9 time 0.5 2 .59 .01
Sensitivity to criticism
ACT 37.8 10.7 29.5 6.1 Group 0.3 2 .69 .01
DBT 40.6 10.5 30.7 8.0 Time 57.1 1 <.001 .48

Continued
 Brief interventions for borderline personality disorder 11

Table 1. (Continued)

Statistics

Baseline* Final* Analysis* F df p g2p

ACT + DBT + FAP 38.6 9.1 29.7 8.1 Group 9 time 0.1 2 .85 .005
FFMQ Questionnaire
Observing
ACT 23.6 6.1 25.8 5.6 Group 1.6 2 .20 .05
DBT 24.7 9.3 28.0 8.0 Time 6.8 1 .01 .10
ACT + DBT + FAP 27.6 5.8 28.5 5.7 Group 9 time 0.7 2 .46 .02
Describing
ACT 23.6 6.0 25.4 5.5 Group 1.2 2 .30 .03
DBT 20.9 8.4 26.4 7.6 Time 11.9 1 .001 .16
ACT + DBT + FAP 25.3 6.9 27.5 7.2 Group 9 time 1.5 2 .22 .04
Acting with awareness
ACT 22.0 6.1 26.1 5.5 Group 1.8 2 .16 .05
DBT 17.1 8.0 24.0 7.0 Time 47.2 1 <.001 .43
ACT + DBT + FAP 19.9 7.0 26.3 7.6 Group 9 time 0.9 2 .37 .03
Nonreactivity
ACT 18.2 4.1 22.5 3.5 Group 0.4 2 .63 .01
DBT 17.8 5.8 23.2 6.2 Time 39.6 1 <.001 .39
ACT + DBT + FAP 17.0 3.4 22.0 4.3 Group 9 time 0.1 2 .86 .005
Nonjudging
ACT 18.7 5.8 27.3 7.5 Group 0.6 2 .50 .02
DBT 16.3 6.0 25.9 6.9 Time 66.1 1 <.001 .52
ACT + DBT + FAP 19.0 7.4 26.2 6.9 Group 9 time 0.4 2 .65 .01

Note. *Means and SD are reported.

Discussion
The principal aim of the present study was to evaluate a brief combined contextual
behavioural therapy (ACT + DBT + FAP) in terms of its effectiveness in reducing the
most frequent problems in patients with BPD, including emotional dysregulation,
negative self-image, and interpersonal dysfunction (American Psychiatric Association,
2013). This was in light of the available evidence from well-controlled clinical trials
regarding the efficacy of ACT, DBT, and FAP separately and together to achieve these
therapeutic goals (Gratz & Gunderson, 2006; Morton et al., 2012; Shearin & Linehan,
1992); and the recognition of the need for brief psychological treatment to provide the
necessary care for this population in saturated clinical contexts, such as public institutions
in developing countries such as Mexico.
The state of the art indicated that it was time to progress to the development,
evaluation, and dissemination of brief combined adaptations that would yield similar or
even better results, thereby incrementing their cost-effectiveness. The first step is an
open-label study like the present one that provides evidence to evaluate the need for
subsequent controlled confirmatory studies in the field.
According to our results, the three modalities of brief contextual behavioural therapy
were useful for decreasing BPD symptom severity, emotional dysregulation, and negative
interpersonal functioning, specifically in regard to hostile conflict resolution. This is in
line with Hayes, Villatte, Levin, and Hildebrant’s (2015) suggestion about the possibility
 12
Michel A. Reyes-Ortega et al.
Table 2. Association between mean changes in symptom severity and emotion dysregulation with experiential avoidance and mindfulness across treatment
conditions

Symptom severity (BEST), r (p) Emotion dysregulation (DERS), r (p)

ACT DBT ACT + DBT + FAP ACT DBT ACT + DBT + FAP

AAQ-II score .65 (.001) .60 (.004) .67 (<.001) .69 (<.001) .62 (.003) .64 (.001)
FFMQ-observing .24 (.28) .42 (.06) .16 (.45) .17 (.43) .14 (.53) .01 (.93)
FFMQ-describing .31 (.14) .36 (.11) .56 (.005) .44 (.03) .56 (.010) .51 (.012)
FFMQ-acting with awareness .37 (.08) .13 (.57) .51 (.013) .74 (<.001) .68 (.001) .71 (<.001)
FFMQ-Nonreactivity .04 (.84) .27 (.24) .80 (<.001) .31 (.15) .55 (.010) .56 (.005)
FFMQ-Nonjudging .46 (.02) .11 (.63) .42 (.04) .73 (<.001) .32 (.16) .60 (.002)

Note. Significative correlations in bold italic.

 Brief interventions for borderline personality disorder 13

that contextual behaviour therapies such as ACT, DBT, and FAP share similar mechanisms
and therefore have similar impacts. This study suggests that therapeutic changes were
related to the reduction of experiential avoidance (targeted in ACT interventions) and the
acquisition of mindfulness skills (also included in ACT interventions and DBT), which
explains why no differences were observed between the three different treatment
modalities (ACT alone, DBT alone, and ACT + DPT + FAP).
Thus, although DBT alone does not make a specific effort to reduce experiential
avoidance in the same way as ACT does, it is possible that its emphasis on radical
acceptance of emotions, validation, and mindfulness skills serves to reduce experiential
avoidance. Increases in psychological flexibility in all interventions can also be a
consequence of the constant practice of goal-oriented behaviour in distressing situations
and in response to challenging emotions. Additionally, all the interventions under study
include mindfulness techniques, and all of them showed similar effects in the acquisition
of these skills by the end of treatment.
Interestingly, although we hypothesize that the incorporation of FAP principles into
the intervention (ACT + DBT + FAP) will increase beneficial changes in interpersonal
functioning (Levy et al., 2006), the effect sizes (g2p ) of the combined intervention for the
two interpersonal dimensions modified (self-esteem and conflict resolution) were similar
to those observed with DBT and ACT alone (medium, according to Cohen, 1988). In DBT
alone, the strategies designed to achieve emotional regulation are expected to have a
beneficial impact on interpersonal functioning (Linehan, 1993); and in ACT alone,
interpersonal functioning might improve as a consequence of strategies intended to
facilitate present-moment awareness, acceptance of difficult emotions, identification of
values, and committed action on values (Morton & Shaw, 2012; Morton et al., 2012).
However, it is important to recognize that the interventions evaluated in this study are
brief adaptations to our context (e.g., in the case of DBT, using customized index cards
translated into Spanish and modified to use suitable examples for Mexican culture), which
were applied by clinicians previously certified by official institutions dedicated to training
in the use of ACT, DBT, and FAP, with at least five years’ experience in their
implementation with BPD patients. Thus, although these interventions might offer cost-
effective therapeutic options for Spanish-speaking and/or Latin American countries that
share cultural aspects, they do not represent gold standard ACT, DBT, or FAP
implementation (Hayes, Strosahl, & Wilson, 2012; Koerner, 2011; Kohlenberg & Tsai,
1991). Thus, the effectiveness of these brief interventions should be compared with the
original ones in future controlled studies in order to determine whether similar results
could be obtained in a more cost-effective way.
Future studies should also evaluate moderating mediating variables, including the
reduction of experiential avoidance and the acquisition and practice of mindful skills (to
confirm whether these variables that showed a relationship with beneficial changes in our
study are indeed a mechanism of therapeutic change). Neacsiu, Rizvi, and Linehan (2010)
demonstrated that DBT skills fully mediated the decrease in suicide attempts and
depression and the increase in anger management over time, indicating that increasing
skills use is a mechanism of change for suicidal behaviour, depression, and anger control.
Similarly, given our results, it is possible to hypothesize that the increase in functionally
flexible behaviours (vs. experiential avoidance) and specific mindfulness skills (such as
awareness, non-reactivity, and non-judging) are at least partially mediating the decrease in
global symptom severity and emotion dysregulation in BPD patients.
Finally, one of the main limitations is the non-randomized nature of the study. Although
the present design does not suffice to offset doubts about the equivalence of the analysed
14 Michel A. Reyes-Ortega et al.

groups, the fact that there were no baseline differences among them is promising at this
early stage of evidence for these treatments. Moreover, our results support the
undertaking of a controlled clinical trial in the near future.

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Received 27 March 2018; revised version received 13 May 2019