Countering emotional behaviors in the treatment of borderline personality disorder.

Abstract

The purpose of the current study was to investigate the unique effects of a commonly used skill incorporated into treatment packages for borderline personality disorder (BPD), countering emotion-driven behavioral urges. Individuals with BPD (N = 8) participated in a single-case experimental design, specifically a multiple baseline, in which they were randomly assigned to complete a baseline assessment-only phase of 2 or 4 weeks. Participants then received four sessions of the countering emotional behaviors module from the unified protocol, followed by a 4-week follow-up phase. Throughout the duration of the study, daily data capture was used to assess real-time changes in the frequency of emotionally avoidant behaviors in response to emotional experiences. Symptoms of BPD, depression, and anxiety were also assessed. By follow-up, the majority of patients demonstrated a meaningful reduction (per single-case experimental design guidelines for evaluating improvements) in their use of avoidant behaviors. There was also preliminary evidence that encouraging participants to act counter to avoidant urges is associated with decreases in BPD, depression, and anxiety symptoms, as well as negative affectivity. The countering emotional behaviors skill from the unified protocol indeed engages its putative target of emotionally avoidant behavioral coping, indicating it is an active ingredient in multicomponent treatment packages for BPD, with implications for downstream clinical endpoints such as BPD and depressive and anxiety symptoms.

Dimensions of Skill Use in the Unified Protocol: Exploring Unique Effects on Anxiety and Depression

“…Behaviors 2) more frequently than one's personal average predicted decreases in depression but not anxiety, conceptually replicating a single-case experimental design with this skill (Sauer-Zavala et al, 2020). Alternative actions are similar to behavioral activation, which has repeatedly been shown to predict decreases in depression (Cuijpers et al, 2021;Webb et al, 2016), in that alternative actions allow patients to engage in activities they want to avoid but that may be important to them, promoting a sense of mastery or pleasure.…”

Dimensions of skill use in the unified protocol: Exploring unique effects on anxiety and depression.

“…That is, when targeting anxiety, therapists may be encouraged to focus on how frequently patients use their skills regardless of the skill(s) being practiced and utilize patient feedback about which skills they are willing to practice more frequently. By contrast, practicing alternative actions to avoidant urges (Countering Emotional Behaviors 2) more frequently than one's personal average predicted decreases in depression but not anxiety, conceptually replicating a single-case experimental design with this skill (Sauer-Zavala et al, 2020). Alternative actions similar to behavioral activation, which has repeatedly been shown to predict decreases in depression (Cuijpers et al, 2021;Webb et al, 2016), in that alternative actions allow patients to engage in activities that they want to avoid, but that may be important to them, promoting a sense of mastery or pleasure.…”

“…In an independent idiographic study of a woman with GAD and MDD, the mindfulness module of the UP led to increases in restlessness, the cognitive flexibility module was unrelated to changes in anxiety or depression, and the exposure module led to decreases in avoidance, procrastination, and concentration difficulties (Altman et al, 2020). Although researchers have tested experimental interventions of other UP skills (e.g., countering emotional behaviors; Sauer-Zavala, Wilner, et al, 2019; Sauer-Zavala et al, 2020), these relatively small studies make it difficult to draw strong conclusions about the unique effects of the full suite of UP skills.…”

Nomothetic and idiographic patterns of responses to emotions in borderline personality disorder.

“…Finally, these findings provide information about participants who did not respond to the intervention. Participant 8 (a nonresponder according to the main outcomes assessed; see Sauer-Zavala et al, 2020) was more likely to use problem-solving in response to anxiety and mindful acceptance in response to sadness, regardless of treatment phase or emotional intensity. These findings suggest that rigid strategy use, rather than maladaptive regulation strategy selection, may have contributed to poorer outcomes for this individual.…”

“…The current study is an exploratory secondary analysis of a 10 -12-week intervention-based, daily diary study assessing specific emotion regulation strategy use in individuals with BPD (Sauer-Zavala et al, 2020). Participants provided descriptive accounts of the prompting events for their emotions that were grouped into relevant categories and reported their experience of several discrete emotions (i.e., anger, sadness, anxiety, guilt/ shame).…”