a feasibility study of mindfulness-based cognitive

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Psychology and Psychotherapy: Theory, Research and Practice (2011), 84, 184200C2010 The British Psychological Society

The

British

Psychological

Society

www.wileyonlinelibrary.com

A feasibility study of mindfulness-based cognitivetherapy for individuals with borderline personalitydisorder

Sandy Sachse1, Saskia Keville1 and Janet Feigenbaum2

1

Department of Psychology, University of Hertfordshire, Hatfield, UK2Research Department of Clinical, Educational and Health Psychology, UniversityCollege London, UK

Objectives. Mindfulness-based cognitive therapy (MBCT) was originally developed to

prevent relapse in recurrent depression. More recently it has been applied to individuals

at high risk of suicide or currently suffering with anxiety and depression. The aim of

this study was to consider the feasibility of MBCT for individuals with a diagnosis of

borderline personality disorder (BPD).

Design. The design of the study was a repeated measures, quasi-experimental design

employing within-subject and between-subject comparisons of a sample of participants

with BPD. Based on previous studies and theoretical models of the effect of mindfulness

and of cognitive therapy, pre- and post-group measures of mindfulness, depression,

anxiety, dissociation, impulsivity, experiential avoidance, and attention were obtained.

Method. Participants attended an 8-week adapted MBCT (MBCT-a) group interven-

tion. A total of 22 participants were assessed pre- and post-intervention and were

subsequently divided for analysis into two groups: treatment completers (N = 16) and

non-completers (number of sessions attended < 4;N = 6).

Results. The study found that MBCT-a is acceptable to individuals with BPD. Using

intention to treat analyses, only attentional control improved. However,post hocanalyses

of treatment improvers (N = 9) identified changes in mindfulness and somatoformdissociation. A dose-effect analysis suggested a weak improvement in mindfulness,

experiential avoidance, state anxiety, and somatoform dissociation.

Conclusions. This study suggests that further exploration of MBCT for use with

individuals with BPD is merited. The study lends tentative support for attentional and

avoidance models of the effects of mindfulness.

Mindfulness-based interventions have attracted growing clinical interest and attention(Baer, 2003). Mindfulness has been incorporated into a number of interventionsincluding: dialectical behaviour therapy (DBT; Linehan, 1993), mindfulness-based stress

Correspondence should be addressed to Dr Janet Feigenbaum, Research Department of Clinical, Educational and HealthPsychology, University College London, Gower Street, London WC1E 6BT, UK (e-mail: [email protected]).

DOI:10.1348/147608310X516387


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reduction (MBSR; Kabat-Zinn, 1990), and mindfulness-based cognitive therapy (MBCT;Segal, Williams, & Teasdale, 2002).

MBSR has predominantly been applied to medical patient populations and somepsychiatric conditions (e.g., generalized anxiety disorder, binge eating disorder) with

studies generally showing improvements on measures of anxiety and depression (e.g.,

Kabat-Zinnet al., 1992; Kristeller & Hallett, 1999).MBCT combines techniques from cognitive therapy with intensive training in

mindfulness. Through educational and experiential group sessions and between session

mindfulness meditation practice participants learn about the nature of thoughts, feelings,and bodily sensations. Clients develop a different relationship with their thoughts andfeelings in order to break into vicious cycles of negative emotions and develop moreadaptive ways of coping (Williams, Duggan, Crane, & Fennell, 2006; Williams & Swales,

2004). MBCT (Segal et al., 2002) was originally developed for clients with a historyof recurrent depression and has been found to significantly reduce relapse rates (Ma& Teasdale, 2004; Teasdale et al., 2000). Barnhofer et al. (2007) have suggested that

the overarching goals of MBCT are to enhance emotion regulation through trainingattentional control.

Borderline personality disorder (BPD) is defined as a pervasive pattern of instabilityof interpersonal relationships, self image, and affects and marked impulsivity (AmericanPsychiatric Association, 1994, p. 1250). Prominent models suggest that emotional

dysregulation underpins the characteristic patterns of cognitive and behavioural dysreg-ulation (Crowell, Beauchaine, & Linehan, 2009; Livesley, 2008; Reisch, Ebner-Priemer,Tschacher, Bohus, & Linehan, 2008). BPD frequently involves high rates of Axis-Icomorbidity (Lieb, Zanarini, Schmahl, Linehan, & Bohus, 2004; Zanarini, Frankenburg,

Hennen, Reich, & Silk, 2004). Thus, models which address comorbid conditions may

prove valuable in the treatment packages of those with BPD.MBCT has been applied to individuals who currently suffer with anxiety and/ordepression (Finucane & Mercer, 2006; Kenny & Williams, 2007; Ree & Craigie, 2007)

with demonstrable improvements. The successful application of MBCT to clients at highrisk of suicide (Barnhoferet al., 2007; Williamset al., 2006) and psychiatric in-patients(York, 2007) suggests that MBCT may also prove helpful to clients meeting BPD criteria.Further evidence suggests that deficits in mindfulness skills may explain variability in

different BPD features (Wupperman, Neumann, & Axelrod, 2008).DBT is the most well-researched treatment for BPD (Lieb et al., 2004; Linehan,

1993). DBT is based on the cognitive behavioural therapy model and incorporates

a comprehensive, skills-based treatment package including modules on: emotionalregulation, interpersonal effectiveness, and distress tolerance. Underpinning thesemodules are core mindfulness skills (Feigenbaum, 2007; Linehan, 1993). Research isonly beginning to explore the specific value of mindfulness for this client group. In apreliminary consideration of the effectiveness of MBCT as an adjunct therapy, Huss and

Baer (2007) adapted MBCT for use during ongoing DBT in one client with demonstrablebenefits.

The emotional dysregulation which characterizes BPD involves marked reactivityof mood and heightened emotional arousal (e.g., Linehan, 1993; Putnam & Silk, 2005;Rosenthal et al., 2008). Specific brain structures have been identified which may underlie

the difficulties typically experienced in BPD, namely prefrontal and temporo-limbicstructures. Frontal lobe structures are associated with mechanisms of self-control andattention (also captured in the notion of executive function) and have been shown to

play a central role in emotion regulation and impulsive behaviour (Dinnet al., 2004). In


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line with this, Ruocco (2005), in a meta-analytic review of neuropsychological deficits inBPD, concludes that compared to normal controls clients meeting BPD criteria showdeficits in attention and cognitive flexibility (see also, Rogers & Kirkpatrick, 2005).It is suggested that impulsivity and emotional reactivity, leading to dysregulation, are

mediated by attentional mechanisms associated with frontal lobe functioning. Thus far,

studies do not appear to have investigated changes in measures of attention followingtherapeutic intervention in individuals with BPD.

Various mechanisms through which mindfulness exerts its positive effects have

been proposed including changes in attentional control (Bishop et al., 2004; Shapiro,Carlson, Astin, & Freedman, 2006) and reduced experiential avoidance (Hayes, Strohsal,& Wilson, 1999). Mixed results have been emerging looking at the role of mindfulness inattentional control. Schmertz, Anderson, and Robins (2009) obtained only partial support

for the relationship between sustained attention and mindfulness. Walsh, Balint, Smolira,Frederickson, and Madsen (2009) suggest that attentional control is a partial mediatorfactor in the relationship between anxiety and mindfulness ability.

The concept of experiential avoidance may be particularly relevant in individualswith BPD. Hayes, Wilson, Gifford, Follette, and Strosahl (1996) note that clients meetingBPD criteria engage in a range of behaviours which share features with the experientialavoidance properties of addictive behaviour. Individuals with BPD have a tendency toavoid unpleasant thoughts, emotions, sensations, and situations likely to elicit these

(Bijttebier & Vertommen, 1999; Kruedelbach, McCormick, Schulz, & Grueneich, 1993;Rosenthal, Cheavens, Lejuez, & Lynch, 2005; Yen, Zlotnick, & Costello, 2002).

The primary aim of the current study was to establish whether it is possible to conducta MBCT group adapted (MBCT-a) for individuals with a BPD diagnosis in everyday clinical

practice (Chambless & Hollon, 1998) and to explore its clinical effectiveness on a range

of clinical and neuropsychological measures theoretically linked to mindfulness. Thesecondary aim of the study was to explore the relevant outcomes which could beidentified as primary outcomes for a larger randomized control trial in future.

Method

Design

The design of the study was a repeated measures, quasi-experimental design employingwithin-subject and between-subject comparisons of a sample of participants meeting

DSM-IV diagnostic criteria for BPD. Those who completed fewer than the minimumnumber of sessions (


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In this study, 30 clients initially agreed to participate. Four dropped out beforeattending the pre-intervention assessment. Thus, 26 participants were assessed pre-intervention. Four clients did not agree to be reassessed after dropping out of theintervention and were removed from analyses. The total sample therefore consisted of

22 participants composed of 16 treatment completers (number of sessions attended

4; Teasdale et al., 2000) and 6 non-completers (number of sessions attended

a feasibility study of mindfulness-based cognitive

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