Mindfulness in personality disorders: Interview with Azucena García Palacios

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  Azucena Garcia Palacios is Professor of Psychopathology at the University Jaume I of Castellón, and member of the research group Labpsitec (www.labpsitec.es) where she specialized in the use of new technologies for psychological wellbeing. She trained in dialectical behavior therapy in Seattle, USA, with the group Marsha Linehan.  She is currently the principal investigator in a research project on adaptation of that therapy to the Spanish population with patients diagnosed with eating disorder and borderline personality disorder.

In the advanced training course organized by AMyS, about mindfulness and clinical practice, She has taught the module on mindfulness and personality disorders. From a simple, clear and worthy of highlight transparency, has been bringing the complex world of patients with these disorders, the great difficulties involved in their treatment, and the great contribution to achieve an improvement in the quality of life of these through the application of the therapeutic program of dialectical behavioral therapy program that has shown it in all its steps and which has managed to involve all that we have heard.

AMyS.- Could we say that to date, effective psychotherapeutic interventions in general, with this type of disorder, have been scarce?

A.G.– Until a few years ago, the truth is yes.I think in the last 20 years begin to appear programs and in the last 10, new studies appear. Studies with rigor and control and realize that you can treat these patients and can improve. What happens is that when compared with studies conducted in other disorders, those made with these disorders are still scarce.

AMyS.-What is the meeting point between Mindfulness and dialectical behavioral therapy, such interventions? How Mindfulness practice is incorporated into the dialectical behavior therapy?

A.G.– For the DBT, Mindfulness is essential, in the sense that changing the focus of a therapy based on the change, made a therapy based on the Acceptance more Change, a way to reach Acceptance is the Mindfulness and the only way to get the change is Acceptance.Therefore, in the DBT, I repeat, Mindfulness is essential.

AMyS. -What contributions brings the dialectical behavior therapy for the treatment of these disorders compared to more traditional therapies of court cognitive behavioral?

A.G. -The Most important is the concept of Acceptance.Why? Because these patients have a tendency to be escaping from their experiences. To escape from their experiences, when you apply a cognitive behavioral classical therapy, for example, want to do a cognitive discussion or a behavioral technique does not work well, because they themselves are not able to identify their problems, therefore, it needs to be done previous work of awareness of those aspects that need to be changed. This is the contribution of DBT compared to conventional therapies.

AMyS.- People with these disorders are very reluctant to undergo psychotherapy, and among the initiated, there are many dropouts.It seems to be the motivation is very low. How it arises from dialectical-behavioral therapy treatment adherence?

A.G. -I think that neglect, is about 30%, which compared with abandonment in other disorders is high, but when compared with normal rates of abandonment of these patients, which sometimes exceeds 60%, then, DBT has managed to improve this percentage.Two aspects are key: 1. The program itself provides a structure to the patient and the patient is comfortable in that structure, and 2. Which it is a program that is designed specifically for what happens to those problems, not a consequence of his illness such as an eating disorder, but to work the problem of personality. Moreover , the work done Linehan therapy to be very careful to validate the patient and validate their difficulties and from there , start working, to build change, makes the patient feel comfortable and want to return to following the session.

AMyS.- You mean, that is the design of the treatment itself that creates its adherence to treatment?

A.G. -So it is, is what creates the accession, the treatment itself.All treatment, of course.

AMyS.- Being a disorder beginning in adolescence or early adulthood, we understand that prevention can not be done this disorder and therefore its treatment?

A.G.– That’s an interesting aspect because if we focus on Linehan model, it is clear that if he had intervened before the development of the disorder was consolidated surely could have been prevented.And that job try to teach the child to accept and regulate their emotions, to identify experiences, to become aware of them (mindfulness) etc. Thus it would help those children who have difficulty in emotional intensity or are more impulsive. Teach them to be regulated, not tell them they have to regulate or chastise them for they know not regulated, but teach them to learn to do.

AMyS.– That ‘s what you were talking before the types of families that may favor the development of this disorder.

A.G. – That’s. This involves working with families and children, which could also be addressed in the children ‘s clinic or from education in schools.It is a field that is not developed and should be done. They could prevent very serious problems. And then there are all the costs to society, medical expenses, etc. That is a line that is not yet developed but is basic.

AMyS.– Mindfulness practice may be in any case contraindicated for any specific disorder, especially for example at the limit or disorder schizoid personality?

A.G.- More than a kind, I would say at some point.When a borderline patient is in crisis, you can not start working on Mindfulness, because at that time, give focus on the present moment maybe it is too aversive, can have counterproductive effects, but I think you can always work with a limit or a schizoid with Mindfulness.We must find the time.

AMyS.– On the other hand, it seems that Mindfulness help with the dissociation that occurs in these subjects…

A.G..- When they are dissociated or in crisis, it is difficult, but what you can do is work Mindfulness when they are not differentiated.Progressive practice is having an effect on dissociation, which decreases. But to work at the time they are dissociated it is very difficult (we’re talking severe dissociative episodes), what to do is work when they are not, so that instead of using the mechanism of dissociation to escape from the experiences , be aware of them, ie, the Mindfulness makes them reconcile with the experiences.Then, no longer you have, so to speak, the need to escape through dissociation.

AMyS.-There ‘s empirical evidence demonstrating the efficacy of such interventions over others, in personality disorders?Specifically which ones?

A.G.-There have been no studies comparing the programs, what we do know is that the DBT is the treatment program that has greater empirical support.There are other therapeutic programs, such as mentalizing therapy, Young’s therapy schemes , among others, who have studies and also offer good results. What happens is that the DBT takes longer and has and 9 controlled clinical trials supporting its effectiveness…

AMyS.- There are interventions with this model and Mindfulness in antisocial personality disorders?With what results? I think I read some article about experimental treatments in prisons.

A.G.–  If there is any study. In any case, when the DBT applied to these patients it is necessary to adapt since the DBT is highly targeted to patients with serious emotional dysregulation. I think that the DBT could be applied to antisocial disorder, but making changes.

AMyS.– Maybe we should distinguish the antisocial disorder of psychopathy.

A.G.– Exactly, I think the core of psychopathy does not respond well to this model.

AMyS.- Developed addictive behaviors in people with a personality disorder are also susceptible to this type of intervention?

A.G.-  Yes. In fact, these studies we have mentioned there are some that have been made to people with BPD and substance dependence (eg heroin addiction) and has served them well.

AMyS.- In general, psychoactive drugs can be dispensed with this type of intervention?

A.G. -Today for today, depends on the severity, but it is true that anti-impulsive and mood regulators drugs are often an important aid for patients.It is true that some patients who are medicated remain very impulsive behaviors, so it appears that pharmacological interventions alone will not get very good results. It seems more effective to use a combination treatment…

AMyS.- Being permanent personality traits what is the goal of therapy?It can be considered completed treatment?

A.G.– The objective personality disorders, psychotherapy is to improve the overall level of functioning.Linehan said a very nice phrase “have a life worth living”, have what others have. Surely always be people who will be vulnerable to suffer from depression or emotional problems or interpersonal problems, but they have to be able to put life goals, take satisfaction from that. This is to improve the overall functioning, to quality of life, always thinking that we can not speak of healing, and that these features will still be there, what we will do is modulate. Moreover, it is nice to think, and thus from the DBT think, “who are we to turn an emotionally intense person into someone completely controlled or rational.” Perhaps a more appropriate target leverage that emotional intensity to direct their life goals to something that has to do with their personality traits.

AMyS.- How important is training the therapist in these skills?Is it convenient teamwork or the program may apply for an individual therapist?

A.G. Therapists training is done in many ways.For example, from United States, for teams from outside the country, for example, Spanish teams who wanted to offer training in DBT intensive program. Comes a team of therapists, providing teams with a minimum of 4 people of the same team. For a week they receive intensive training in DBT, learning the basics of therapy and techniques. They return to their workplace, and work with the DBT model for 6 months. Then they return to receive a week training. They also have to present a case study and a plan for implementation of DBT in clinical center. That’s the way they do training for people coming from outside. More advanced courses are also offered. The training center is called Behavioraltech. On their website is information on training provision and the DBT: www.behavioraltech.org

AMyS.–  And on limiting work it a therapist at a private clinic…

A.G. From the DBT it is always required teamwork.We must also say that the DBT is designed for serious disorders. It is true that if you’re working with patients with borderline personality traits that show no risk impulsive behaviors, DBT can be applied from an individual perspective, but always that gravity is not a concern.

AMyS.- Before closing, is there anything you want to add to all that has been said?

A.G.  No. Just to thank you for your interest. Amys encourage you to continue with this kind of experience because I think it is essential and the importance of Mindfulness in DBT think you have to highlight it . We always talk about DBT as a complex program that is including DBT and this course has been very interesting because what it does is highlight the important role of the Mindfulness in this therapy.

AMyS.- Thank you, it has been a very interesting interview and sincerely appreciate your cooperation and teachings.