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Acceptance and Commitment Therapy Group Treatment for Symptoms of

Borderline Personality Disorder: A Public Sector Pilot Study

Article in Cognitive and Behavioral Practice · November 2012

DOI: 10.1016/[Link].2012.03.005

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Cognitive and Behavioral Practice 19 (2012) 527-544

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1
Contains Video

Acceptance and Commitment Therapy Group Treatment for Symptoms of

Borderline Personality Disorder: A Public Sector Pilot Study
Jane Morton
Sharon Snowdon
Michelle Gopold
Elise Guymer
Spectrum – the Personality Disorder Service for Victoria

A pilot study of a brief group-based Acceptance and Commitment Therapy (ACT) intervention (12 two-hour sessions) was conducted
with clients of public mental health services meeting four or more criteria for borderline personality disorder (BPD). Participants were
randomly assigned to receive the ACT group intervention in addition to their current treatment (ACT + TAU; N = 21) or to continue
with treatment as usual alone (TAU; N = 20). There was significantly more improvement from baseline for the ACT + TAU condition
than the TAU condition on the primary outcome variable—self-rated BPD symptoms. The ACT + TAU gain was both clinically and
statistically significant. The ACT + TAU condition also had significantly more positive change on anxiety and hopelessness, and on the
following ACT consistent process variables: psychological flexibility, emotion regulation skills, mindfulness, and fear of emotions. For all
but anxiety, the improvements for the ACT + TAU condition were significant, while the TAU condition had no significant changes on
any measure. Follow-up was possible for only a small number of participants. The improvements gained by the ACT + TAU participants
were maintained except for fear of emotions. Anxiety continued to improve, becoming significantly different from baseline at follow-up.
Examination of mediators found that psychological flexibility, emotion regulation skills and mindfulness, but not less fear of emotions,
mediated BPD symptoms. Psychological flexibility and emotion regulation skills also mediated hopelessness. There is a need for a larger
trial, for comparison with other established treatments for BPD, and for conducting a trial of a longer intervention. Nonetheless, this
pilot study suggests that a brief group-based ACT intervention may be a valuable addition to TAU for people with BPD symptoms in the
public sector.

B ORDERLINE personality disorder (BPD) is a condition

characterized by pervasive affective, cognitive, behav-
ioral, and interpersonal difficulties, and is often associated
dissociation, transient psychosislike symptoms; American
Psychiatric Association, 2000). There have been consider-
able advances in the treatment of this disorder over the last
with marked disability (Lieb, Zanarini, Schmahl, Linehan, two decades and there is now evidence for the efficacy of
& Bohus, 2004). BPD is characterized by difficult feelings several therapies for BPD. These include Dialectical
(intense and fluctuating negative emotions), problematic Behavior Therapy (DBT; Linehan, 1993), Mentalization
behaviors (angry outbursts, acting in potentially self- Based Therapy (Bateman & Fonagy, 1999), Transference-
damaging ways on impulse, deliberate self-harm, and/or Focused Psychotherapy (Clarkin, Kernberg, & Yeomans,
frantic efforts to avoid abandonment), unstable and intense 1999), and Schema Therapy (Giesen-Bloo et al., 2006).
interpersonal relationships and/or disturbances in the Group therapies for BPD symptoms are less resource
sense of self (unstable self-image, feelings of emptiness, intensive and have also shown promise (Monroe-Blum &
Marziali, 1995; Soler et al., 2009; Wood, Trainor, Rothwell,
Moore, & Harrington, 2001), as have group treatments
1
added to treatment as usual (TAU) (Blum, Pfohl, St. John,
Video patients/clients are portrayed by actors.
Monahan, & Black, 2002; Blum et al., 2008; Gratz &
Gunderson, 2006). Although ACT is proving to be an
Keywords: Acceptance and Commitment Therapy; mediation; bor-
effective treatment for a range of disorders (see Twohig,
derline personality disorder; treatment; group therapy
2012-this issue), there have been no published reports of
1077-7229/11/527-544$1.00/0 successful trials of ACT for BPD, other than a group
© 2012 Association for Behavioral and Cognitive Therapies. treatment which included ACT interventions by Gratz
Published by Elsevier Ltd. All rights reserved. and Gunderson.
528 Morton et al.

In Gratz and Gunderson's (2006) study, the addition of treatment in addition to treatment as usual (ACT + TAU
only 14 sessions of group treatment to TAU had positive condition) would experience (a) significant reductions in
effects on self-harm, BPD symptoms, anxiety, and mood. BPD symptoms, and (b) improvements in anxiety,
The treatment was based on the role of experiential depression, stress, and (c) improvements in hopelessness,
avoidance and emotion dysfunction in BPD and sought to compared with participants who received TAU only (TAU
teach more adaptive ways to respond to emotions. condition).
Elements of a number of therapies, including DBT, A further aim of the study was to investigate the role of
emotion-focused psychotherapy (Greenberg, 2002), tra- possible mediators in any improvements in the above
ditional behavior therapy, and ACT, were included. outcome variables. If BPD symptoms are manifestations of
Although there was no mediation analysis included in experiential avoidance, fusion with negative thoughts,
the study, the authors noted that the six group sessions difficulties with present moment awareness, and impul-
focusing on ACT content “generated the most enthusi- sive action contrary to personal values, then psychological
asm from clients during and after treatment, and appear flexibility, mindfulness, less fear of emotions, and skills for
[ed] to be the basis of much of the observed improve- dealing with strong emotion would be expected to
ments” (Gratz & Gunderson, p. 33). mediate outcome in successful ACT treatment.
The symptoms of BPD can be seen as having a similar
functional analysis to other disorders successfully treated Method
by means of ACT (Twohig, 2012-this issue), and as Recruitment, Screening, and Condition Allocation
possibly benefitting from treatment aiming to increase Potential participants were recruited via referrals from
present-moment awareness, increase acceptance of diffi- public mental health services to Spectrum. Trained
cult emotions, facilitate identification of values, and research assistants assessed those referred using the
increase committed action on values. From the perspec- schizophrenia, posttraumatic stress disorder, anxiety
tive of ACT, it is not intense negative affects per se that are disorders, affective disorders, and drug and alcohol
the problem, it is experiential avoidance (which tends to disorders scales of the Structured Clinical Interview for
increase the intensity of the negative experiences), fusion DSM-IV Axis I disorders (SCID-I; First, Spitzer, Gibbon, &
with negative thoughts, and the unhelpful choices the Williams, 1997) and the BPD scale of the Structured
person makes about action—particularly actions that are Clinical Interview for DSM-IV Axis II Disorders (SCID-II;
against the individual's core values. Self-harm and drug or First, Gibbon, Spitzer, Williams, & Benjamin, 1997). All
alcohol abuse can be seen as experiential avoidance potential participants then had a clinical interview with
strategies (Chapman, Gratz, & Brown, 2006; Strosahl, one of the group leaders. Consistent with the ACT view
2004). There is some research supporting the view that that there are other multiproblem clients with similar
BPD symptom severity is related to experiential avoidance difficulties to those with a DSM-IV diagnosis of BPD,
(Chapman, Specht, & Cellucci, 2005), and that BPD groups were open to clients with four or more of the nine
symptom severity is more strongly related to experiential BPD DSM-IV criteria. Although the current categorical
avoidance than to emotion dysregulation, or difficulties diagnostic system requires five criteria, it is widely
with distress tolerance (Iverson, Follette, Pistorello, & recognized that the disorder is better considered as on a
Fruzzetti, 2011). Higher levels of experiential avoidance dimension of severity (Trull, Widiger, Lynam, & Costa,
have been found to be associated with less likelihood of 2003). The presence of four or more symptoms of BPD
improvement in depression for those with BPD (Berking, for those accepted into the study was supported by the
Neacsiu, Comtois, & Linehan, 2009). referring clinician, the SCID assessment, and the clinical
The current study is a report on a pilot of a brief ACT interview.
outpatient group treatment to supplement TAU within Inclusion criteria were (a) four or more criteria of
public sector mental health services. The study was BPD; (b) a registered client of a public sector adult
conducted by staff of a specialist public sector mental mental health service (c) agreement from the public
health service in Victoria, Australia (Spectrum). The sector service to arrange an inpatient admission or crisis
group protocol was developed based on 10 years of team visit if required; and (d) any kind of regular contact
experience in providing residential and outpatient (at least once in 2 weeks) with a public or private sector
treatment for people with a diagnosis of BPD. Initially clinician, not necessarily for therapy. Both males and
Spectrum's group treatment was based on DBT, then a females were included, although the number of males
combination of DBT and ACT, and more recently “Wise referred was small (see Table 1 and Figure 1).
Choices,” based on ACT alone, the outpatient group Exclusion criteria were (a) current positive or negative
treatment which is the subject of this study. psychotic symptoms other than reactive psychotic symptoms
It was hypothesized that participants randomly associated with BPD; (b) a significant risk of violent and/or
assigned to receive 12 sessions of outpatient ACT group threatening behavior to other participants; (c) intellectual
 ACT Group Treatment for BPD Symptoms 529

Table 1
Demographic and Clinical Characteristics of Participants by Condition (N = 41)

ACT + TAU (n = 21) TAU (n = 20)

Age mean = 35.6 (SD = 9.33) mean = 34.0 (SD = 9.02)
(Range 19–52) (Range 21–54)
Gender: Female 90.5% (n = 19) 95% (n = 19)
Marital status: Single 52.4% (n = 11) 45.0% (n = 9)
Unemployed 71.4% (n = 15) 70.0% (n = 14)
Education:
Did not complete high school 14.3% (n = 3) 45.0% (n = 9)
Completed high school 38.1% (n = 8) 30.0% (n = 6)
Some tertiary/ has degree 47.6% (n = 10) 25.0% (n = 5)
Severe childhood trauma /deprivation 95.0% A (n = 19) 94.1% B (n = 16)
PTSD past or present 94.7% C(n = 18) 64.7% B (n = 11)
Admission in past 3 months 47.6% (n = 10) 42.1% A (n = 8)
More than 10 lifetime admissions 42.8% (n = 9) 31.6% A (n = 6)
Number of BPD criteria mean = 6.0 (SD = 1.34) mean = 6.5 (SD = 1.64)
Primary Axis I diagnosis:
Major Depressive Disorder 66.7% (n = 14) 50.0% (n = 10)
Bipolar Disorder 19.0% (n = 4) 25.0% (n = 5)
Schizoaffective Disorder 0% (n = 0) 5.0% (n = 1)
Panic Disorder 0% (n = 0) 5.0% (n = 1)
Depression - other 0% (n = 0) 5.0% (n = 1)
Age first self-harm mean = 18.5 (SD = 9.51) mean = 18.4 (SD = 11.6)
Suicide attempt in lifetime 85.7% (n = 18) 85.0% (n = 17)
Suicide attempt past year 47.6% (n = 10) 45.0% (n = 9)
Self-harm frequency in past 3 mos. mean = 9.1 (SD = 21.9) mean = 18.5 (SD = 30.5)
Violence last year 14.3% (n = 3) 35.0% (n = 7)
Current alcohol dependence 25.0% A (n = 5) 20.0% (n = 4)
Current substance dependence 20.0% A (n = 4) 15.0% (n = 3)
A
Missing data/refused to answer = 1.
B
Missing data/refused to answer = 3.
C
Missing data/refused to answer = 2.

disability, cognitive impairment, or difficulty speaking Available participants at each location were random-
English, severe enough to interfere with participation. ized to ACT + TAU or TAU, after stratification of the
There were no exclusion criteria based on gender, level of sample based on the presence or absence of two or more
suicidality, lethality of recent suicide/self-harm attempts, self-harm episodes in the last year. This stratification of
history of aggression towards others, drug abuse, or the sample was done in order to ensure equal base rates
presence of bipolar disorder. A recent history of self-harm across the conditions, as recent self-harm was not a
was not required, and the study was thus open to six criterion of inclusion in the trial. This resulted in four
participants who had not self-harmed in the last year, ACT groups in four locations, each with 4 to 6
including three clients who had never self-harmed. For participants.
clients with a history of violence, an assessment of the
person's likely risk to other group members was made by an
experienced clinician at the screening interview and no one Participants
was excluded on this basis. Demographic and clinical characteristics of partici-
All participants provided written informed consent. pants in each condition are provided in Table 1. Twenty-
Groups were run at four locations across Melbourne. one participants (19 females and 2 males) were assigned
Three of these were in predominantly lower socio- to the ACT + TAU condition, and 20 (19 females and 1
economic status (SES) areas and one in a middle SES male) to the TAU condition. Information on session
area. Figure 1 shows the flow of participants. Forty-seven attendance and completion of questionnaires is provided
clients were screened and 6 were excluded, leaving 41 in Figure 1.
clients who had been recruited by the time that the The participants manifested a high level of social
groups were scheduled to commence. disadvantage, early trauma, and psychiatric disturbance
530 Morton et al.

47 screened for eligibility

(43 females, 4 males)

6 excluded
1 probable schizophrenia
3 did not complete screening
2 met less than 4 BPD criteria

41 randomized
(38 females, 3 males)

21 allocated to ACT+ TAU 20 allocated to TAU

(19 females, 2 males) (19 females, 1 male)

14 attended seven or more sessions (mean of 10) 14 provided end -point

and provided end-point questionnaires questionnaires
2 attended seven or more sessions (mean of 9.5) 4 were not contactable for end-
but did not provide end-point questionnaires point questionnaires
2 attended the first six sessions and provided end- 2 refused to provide end-point
point questionnaires questionnaires
2 attended six sessions irregularly and provided
end-point questionnaires
1 discontinued after four sessions and was not
contactable for end-point questionnaires

10 provided follow -up questionnaires

8 did not return questionnaires
3 were not sent questionnaires (previously
uncontactable or previously refused)

Figure 1. Consort diagram of flow of participants in the study.

(see Table 1). Forty-six percent had made a suicide Statistical tests were conducted to determine whether
attempt in the last year. Although clients with only four those who were assigned to a condition but did not
criteria of BPD were accepted into the study, only three of provide two data points (n = 9) differed from the other
the ACT + TAU clients and two of the TAU clients had less participants (n = 32). No statistically significant differences
than five criteria, and the average number of criteria met were found on any of the initial questionnaire scores or
was 6.0 for ACT + TAU and 6.5 for TAU. on any demographic variables (all p N .05).
The ACT + TAU and TAU conditions did not differ
significantly (p N .05) on any of the demographic and
clinical characteristics listed in Table 1, except for PTSD, ACT Group Treatment
with the ACT + TAU condition more likely to meet the The ACT groups, Wise Choices, ran for 2 hours with a
criteria for a diagnosis of present or past PTSD, χ 2(1) = 10-minute break after 1 hour. The groups had a
6.17, p = .010. However, there was no significant difference psychoeducational format, with participants sitting at a
in the proportion of participants reporting severe trauma table and taking notes. Group norms limited the intensity
and/or deprivation on clinical interview (95% of ACT + of the presentation of potentially “triggering” material,
TAU, 94% of TAU). Also, 7 of the 12 participants who did allowing the mention of self-harm urges and acts, and
not receive a diagnosis of PTSD due to not reporting a trauma, in broad outline, but not allowing detailed
trauma in the SCID-I interview with a research assistant accounts, that other participants may find overwhelming.
described histories of severe trauma and/or deprivation Each session commenced with a brief check-in, a review of
on clinical interview, and a further 3 refused to answer home practice and a brief (1 to 5 minutes) mindfulness
questions about trauma and deprivation in both the practice, such as mindfully eating a raisin, mindful
clinical interview and the SCID-I. exploration of an object using the five senses, mindful
 ACT Group Treatment for BPD Symptoms 531

Video 1. Group discussion of the avoidance loop.

walking, or a body scan. The majority of these were brief Many participants had initial difficulties with values
versions of the mindfulness exercises described in Segal, awareness (see Video 2). In order to moderate shame and
Williams, and Teasdale (2002). distress about not living up to the values that were
The intervention included all components of standard identified, there was a focus on identifying small ways in
ACT treatment, although “self as context” was covered only which participants were already acting on their values (see
indirectly through the experience of brief mindfulness Video 3). If a group member found it difficult to identify
exercises, including “leaves on a stream” (Hayes, 2005, pp actions in line with values, the group leaders would assist
76–77). Colorful handouts summarizing key points in with comments such as “I think you are showing courage
pictures and simple jargon-free language were distributed. right now by sharing your values with the group.” Video 3
The ACT metaphor “passengers on the bus” (Hayes, also illustrates a simple defusion technique used to help
Strosahl, & Wilson, 1999, pp. 157–158) was used as a participants defuse from self-critical thoughts about
central theme throughout most of the sessions. This values — writing the words on the whiteboard enclosed
metaphor talks about the pressure from “difficult passen- by quotation marks as an aid to “just noticing” the thought as
gers” (thoughts and feelings) on the “driver” of one's “life a “bunch of words.” Initially some group members identified
bus” to turn off from the path of values-based action and a range of socially acceptable roles or family obligations as
take what appears to be an easier road, based on efforts to values. Group members were assisted to distinguish values
avoid aversive internal experiences. 2 from “shoulds” by noticing the vitality that is associated with
A range of defusion techniques were taught, including acting according to values (see Video 4).
“just noticing” thoughts and “letting them be there like a A particularly helpful values awareness technique in-
radio in the background.” Emotions skills training focused volved using a negative description of someone a group
on noticing the bodily experience of various emotions, member did not approve of to form hypotheses about values
describing bodily experiences (“if it had a color, what color (see Video 5). For example, if a participant said, “My case
would that be? If it had a shape . . .”) and on mindfulness manager doesn't listen to me or care about me,” then the
and acceptance strategies (e.g., “make space for it, allow it group leader might ask, “So maybe you value listening to and
to be there”). There was an emphasis on the value of caring about others?” If the participant was not comfortable
emotions as part of a full, rich, and meaningful life. with a positive description of a value, then the negatively
worded value “not someone who doesn't listen or care,” or
“not like my case manager,” was used, along with ongoing
2
Video 1 shows group members exploring an example of
efforts to find a positive wording.
experiential avoidance using the “avoidance loop,” a diagram based There was considerable emphasis on identifying
on the “passengers on the bus” metaphor. “choice points” for action, when difficult thoughts and
532 Morton et al.

Video 2. Group members may find discussing values difficult.

Video 3. Values as small steps in a valued direction.

 ACT Group Treatment for BPD Symptoms 533

Video 4. Exploring the difference between values and “shoulds.”

feelings are triggered and there is a temptation to take commenced, the decision was made to use only the ACT
action (such as self-harm, drug use, an angry outburst or components. Some of the groups included content similar to
social withdrawal) that is inconsistent with one's values. DBT groups, but these were modified to ensure ACT
Participants were taught that no matter what difficult consistency. One of these was a DBT group exercise that
thoughts or emotions arise, there is always the option to teaches mindfulness of pleasurable sensory experiences as a
choose to take action in line with values, or to do nothing. self-soothing technique (Linehan, 1993). This same exercise
They were encouraged to make changes in their actions was used, but with an emphasis on pleasurable experience as
and to live according to their values, rather than part of a full, rich, and meaningful life rather than as way of
attempting to change thoughts or emotions. coping with distress. Participants were encouraged to “just
Sessions concluded with discussion of ideas for home notice” difficult thoughts—such as, “I deserve punishment
practice, including planning small steps in a valued not pleasure” or “I can't enjoy anything”—and to mindfully
direction (see Video 6). In line with an emphasis on refocus on the object. If the exercise triggered painful
making wise choices, home practice was encouraged but feelings, such as sadness, participants were encouraged to
optional. Home practice was discussed as “experiments” “make space” for these, but not be turned aside from a path
that would help participants clarify what was truly of self-compassion and self-care—including pleasurable
important to them and identify difficult thoughts and experiences. Also included were two interpersonal skills
feelings that arose as obstacles to values-based action so practice sessions, one on reaching out to others and one on
that these could be worked on in group. negotiation skills. These were presented in the context of
The outpatient ACT groups evolved from earlier residen- participants’ relationship values (for example, reaching out
tial treatment groups that had contained elements of both to others, giving and receiving affection, fairness, justice),
ACT and DBT. However, when the outpatient groups rather than as “interpersonal effectiveness” (DBT). The
534 Morton et al.

Video 5. Values awareness exercise – a person I don't approve of.

exercises were used as opportunities to practice mindfulness services, and typically consisted of low-key supportive
and acceptance strategies for difficult thoughts and feelings contacts, medication management, with in-patient admis-
arising in interpersonal relating and to notice how experi- sions and crisis contacts if required. Contact with a
ential avoidance tends to interfere with values-based action in clinician at least once every 2 weeks was required. In the
relationships. 12 weeks prior to intake into the study, 29 participants
Clinicians were instructed not to include any CBT (71%) saw both a medical and a nonmedical clinician, 11
change strategies such as cognitive challenge. Efforts were participants (27%) saw only nonmedical clinicians, and 1
made to ensure treatment fidelity via review of group participant (2%) saw only a medical practitioner. The
materials by ACT trainer Russ Harris and via consultation average number of appointments per month was six,
and supervision sessions, which included discussion typically consisting of weekly to monthly medication
framed by the ACT Competencies Checklist (Luoma, reviews with a public sector psychiatrist or registrar, or a
Hayes, & Walser, 2007). An outline of the 12 sessions is local general practitioner, and weekly to monthly
provided in Table 2. A copy of the treatment manual, appointments with a local public sector mental health
including the handouts and group session outlines service, usually for what was described as case manage-
(Morton & Shaw, 2012) is available from Spectrum. ment. Eleven participants (27% of the total) described
the service they received as therapy or counseling, rather
than case management or medication review. In addition
Treatment as Usual to medication review and case management, 5 partici-
All participants in the study continued with TAU, pants (12%) saw a public sector sexual assault service
which was provided mostly by public mental health clinician, 4 (10%) saw an alcohol and drugs service, or
 ACT Group Treatment for BPD Symptoms 535

Video 6. Planning a small step in a valued direction.

attended Alcoholics Anonymous, and 6 (15%) received reliable diagnoses for Axis I disorders (Zanarini et al.,
visits from family support agencies. 2000) and Axis II disorders (Maffei et al., 1997).

BPD Symptoms
Data Collection The Borderline Evaluation of Severity over Time (BEST;
ACT + TAU participants completed self-report measures Pfohl & Blum, 1997) is a brief self-report measure of degree
before the first session, at the completion of the series of of impairment on BPD criteria over the past month, which
groups 13 weeks later and at follow-up 13 weeks after the was developed to assess outcomes for the STEPPS program
final group session. TAU participants continued in their (Blum et al., 2002). BPD-specific symptom severity is assessed
usual treatment while on a waiting list to commence group across three domains: negative thoughts and feelings,
treatment. They completed self-report measures at the start negative behaviors, and positive behaviors, which have a
of the waiting list period and at the end of the waiting list possible range from 8 to 40, 4 to 20, and 3 to 15, respectively,
period 13 weeks later. Attempts were made to contact all with higher scores indicating greater severity. The BEST
participants to complete questionnaires. Composite is an aggregate score that ranges from 12 to 72.
The measure was sensitive to change, had good internal
consistency (Cronbach α=0.86), moderate test-retest reli-
Measures ability, and adequate convergent and discriminant validity
Diagnosis (Pfohl et al., 2009). Although normative data have not been
As described above, selected DSM-IV, Axis I and Axis II published, Gratz and Gunderson (2006) referred to a group
diagnoses were obtained using the SCID-I and the SCID-II, of non-PD outpatients with a mean BEST Composite score of
respectively. These semistructured instruments provide 21.5 (SD= 7.83).
536 Morton et al.

Table 2
Overview of Group Sessions

1. Introduction to ACT and mindfulness: introductions; group norms; foundations of Acceptance and Commitment Therapy; introduction to
mindfulness practice —mindful exploration of an object; “passengers on the bus” metaphor.
2. Avoidance and values: further exploration of “passengers on the bus” metaphor, identifying difficult “passengers” (thoughts and
feelings); the “avoidance cycle” (short-term relief, long-term life constriction); preliminary work on identifying values.
3. Willingness and acceptance: attempts to fight with or avoid pain lead to additional suffering; willingness —“tug of war with a monster”
exercise; experimenting with different ways of relating to painful experiences; willingness metaphors.
4. Awareness of thoughts: how the mind works; noticing judgments (“good cup–bad cup” exercise); defusion exercises including “milk,
milk, milk” and “bad news radio.”
5. Mindfulness of pleasure: exploring pleasurable sensations via the five senses while noticing difficult thoughts and feelings that may
arise and “making space” for these. Pleasure as part of a full, rich, and meaningful life.
6. Emotion awareness and acceptance: practicing acceptance strategies with emotions, body sensations, and urges. Strategies for acting in
line with personal values, or doing nothing, even when emotions are strong.
7. Health issues: exploring values and experiential avoidance related to health.
8. Acting on relationship values—reaching out: in-session practice of giving and receiving compliments, and conversation skills. Practicing
awareness and acceptance of difficult thoughts and feelings that arise, while continuing to act on values.
9. Acting on relationship values in conflictual situations: practice of assertiveness and negotiation skills.
10. Choice points: noticing “choice points”; further exploration of values; planning a small step in a valued direction; discussion of likely
internal obstacles (difficult thought and feelings).
11. Obstacles: review of the planned small step; exploration of difficult thoughts and feelings that arose; practice of mindfulness and
acceptance strategies.
12. Review and celebration.
Note. Many versions of classic ACT exercises have been published, for example in Hayes et al. (1999), Hayes (2005), and Follette and Pistorello
(2007). However, nearly all the exercises used were adapted somewhat to suit the needs of people with BPD symptoms and new exercises
were devised. Hence, the best guide is the treatment manual, Morton and Shaw (2012) which is available from Spectrum via the website www.
[Link].

Depression, Anxiety, and Stress Richardson reliabilities ranging from 0.87 to 0.93 across
The Depression Anxiety Stress Scale (DASS; S. H. clinical and nonclinical samples, adequate test-retest reliabil-
Lovibond & P. F. Lovibond, 1995) is a 42-item questionnaire ity of 0.69, as well as satisfactory concurrent and discriminant
that measures depression, anxiety, and stress. Internal validity (Beck & Steer; Beck, Steer, Beck, & Newman, 1993).
consistencies ranged from 0.89 to 0.96 and test-retest
reliabilities ranged from 0.71 to 0.81 (Brown, Chorpita, Psychological Flexibility
Korotitsch, & Barlow, 1997). The scales also have adequate The Acceptance and Action Questionnaire (AAQ;
construct and discriminant validity (Antony, Bieling, Cox, Hayes et al., 2004) was developed as a tool to assess
Enns, & Swinson, 1998; Brown et al., 1997; P. F. Lovibond & experiential avoidance of difficult thoughts and emotions
S. H. Lovibond, 1995). This study used a 21-item version of and readiness to take action based on values. Despite its
the DASS, which is comparable to the 42-item version, with popularity and good convergent validity, there had been
internal consistencies from .87 to .94 (Antony et al., 1998). inconsistent findings on the factor structure and issues with
Scores on subscales of the 21-item version are multiplied by comprehension on some items. This study used a 10-item
two and so range from 0 to 42, with distributions found to be version of the AAQ-II, which was being developed to
highly positively skewed in a large nonclinical sample address these issues. The AAQ-II 10-item version was found
(Henry & Crawford, 2005). Suggested cutoffs for normal, to have a good internal consistency of 0.83 and a 3-month
mild, moderate, severe, extremely severe for depression are test-retest reliability of .80, as well as adequate convergent,
(9, 13, 20, 27, 42), for anxiety (7, 9, 14, 19, 42), and for stress discriminant, and concurrent validity. The mean of a
(14, 18, 25, 33, 42) (P. F. Lovibond & S. H. Lovibond, 1995). normative sample was 50.7 (SD = 9.19; Frank Bond, personal
communication, August 2007). Range of scores is from 10
Hopelessness to 70, with higher scores indicating greater psychological
The Beck Hopelessness Scale (BHS; Beck & Steer, 1988) flexibility. Recently the AAQ-II has been revised to a 7-item
is a 20-item checklist that assesses negative attitudes about the scale with a single factor structure (Bond et al., 2011).
future. The range of scores is from 0 to 20, with higher scores
reflecting a more pessimistic outlook. Scores of 9 or more Mindfulness Skills
were associated with an 11 times higher suicide rate than The Five Factor Mindfulness Questionnaire (FFMQ;
scores of 8 or below (Beck, Brown, Berchick, Stewart, & Steer, Baer, Smith, Hopkins, Krietemeyer, & Toney, 2006) is a 39-
1990). The scale has high internal consistency with Kuder- item 5-point Likert scale measured on five facets: observing,
 ACT Group Treatment for BPD Symptoms 537

describing, acting with awareness, nonjudging of inner obtained outcomes and missingness for participants with
experience, and nonreactivity towards inner experience. missing data, somewhat reducing the analytic problem
Scores range from 39 to 195 with higher scores indicating presented by missing data. Compound symmetry covari-
more mindfulness in daily life. Internal consistencies for the ance matrices were used as they were found to provide
five facets (which all loaded significantly onto the overall better model fit with fewer parameters than unstructured
mindfulness construct) ranged from 0.75 to 0.91. Adequate matrices as determined by the restricted log likelihood.
convergent and discriminant validity have been shown for Main fixed effects were condition (ACT + TAU vs. TAU)
the five facets (Baer et al., 2006). For a normative sample of and time, with Condition × Time as the interaction factor,
undergraduates the mean was 126 (SD = 13.8; Van Dam, and participants as the random factor within time.
Earleywine, & Danoff-Burg, 2009). Denominator degrees of freedom for the fixed effects test
statistics were based on the Satterthwaite approximation.
Fear of Emotions
Repeated measures ANOVAs using only observed data, and
The Affective Control Scale (ACS; Williams, Chambless,
thus including only 18 of the ACT + TAU participants and
& Ahrens, 1997) is a 42-item, 7-point Likert, self-report
14 of the TAU participants, were run for comparison
measure assessing fear of emotions, fear of acting
purposes. These resulted in the same conclusions as those
inappropriately when experiencing high levels of emotion,
obtained using mixed model procedures.
and attempts to control emotional experience. It was
Analysis of outcome measures at baseline indicated no
developed to test the view that fear of emotion is a common
significant between-condition differences (all ps N 0.05).
factor in a range of disorders including generalized anxiety
Effect sizes (Cohen's d) were calculated by the method
disorder (Roemer, Salters, Raffa, & Orsillo, 2005) and
suggested for repeated measures and multilevel designs
panic disorder (Smits, Powers, Cho, & Telch, 2004). Items
by Rosenthal and Rosnow (1991) and were interpreted
include fear of anxiety, fear of depression, fear of anger,
using the commonly used guidelines proposed by Cohen
and fear of positive emotions, with higher scores indicating
(1992: .2–.49 = small, .5–.79 = moderate, .8 or more =
more fear. The ACS total score has good internal
large). Clinical significance of the observed treatment
consistency (Cronbach α = .94), 2-week test-retest reliability
effects for the primary outcome variable (BEST Compos-
of 0.78, and good convergent and discriminant validity
ite), for those participants with both pre and post data
(Berg, Shapiro, Chambless, & Ahrens, 1998; Williams et al.,
points, was evaluated using the two criteria proposed by
1997). The possible range is from 1 to 7, with higher scores
Jacobson and Truax (1991): that the change in score was
indicating more fear. The mean for a female undergrad-
statistically reliable (|Reliable Change Index (RCI)| N 1.96)
uate sample was 3.4 (SD = 0.78; Williams et al.).
and that the score at the end of treatment was more likely
Emotion Regulation to be from a nonclinical distribution than from the
The Difficulties in Emotion Regulation Scale (DERS; clinical distribution defined by initial scores.
Gratz & Roemer, 2004) is a 36-item, 5-point Likert measure
that assesses difficulties with strong emotions. Items
included nonacceptance of negative emotions, inability to Changes in Symptoms
engage in goal-directed behaviors when experiencing Primary Outcome Variable
negative emotions, difficulties controlling impulsive behav- Means and standard deviations of observed scores are
iors when experiencing negative emotions, limited access to shown in Table 3. The BEST Composite interaction
emotion-regulation strategies perceived as effective, lack of between treatment condition and time was significant
emotional awareness, and lack of emotional clarity. The [estimate = 9.71, SE = 4.21, t(32.5) = 2.30, p = .028, 95% CI:
DERS has been found to have high internal consistency 1.13, 18.28, d = .81], with a significant and large improve-
(Cronbach α = .93), test-retest reliability of 0.88 over a 4- to ment in the ACT + TAU mean [estimate = − 11.52, SE = 2.75,
8-week period, and adequate convergent and predictive t(30.8) = − 4.18, p = .000, 95% CI: -17.14, -5.90, d = .99] and
validity. Scores can range from 36 to 180, with higher scores no significant change in the TAU mean [estimate = −1.80,
indicating poorer functioning. The mean in a sample of SE = 3.19, t(33.8) = − .57, p = .575, 95% CI: -8.28, -4.67,
undergraduate students was 78 (SD= 20.7; Gratz & Roemer, d = .15] (See Figure 2.) The power to detect this significant
2004). and large interaction effect was only 0.62, reflecting the
small sample size. The ACT + TAU mean moved from 2.9
Results to 1.4 standard deviations away from the mean for a
The primary outcome measure was the BEST Composite sample of outpatients without a personality disorder
and all other measures were secondary. Scores were (referred to in Gratz & Gunderson, 2006). Further,
analyzed using mixed model procedures (Raudenbush & 29.4% of the ACT + TAU condition met both clinical
Bryk, 2001), which allowed for all available data to be used significance criteria for the BEST Composite after
in the analyses. This approach takes into account the treatment compared with none of the TAU condition.
538 Morton et al.

Table 3
Means and Standard Deviations of Observed Scores

ACT Group + TAU (n = 21, follow-up n = 10) TAU (n = 20)

Measure Pre-Mean (SD) Post-Mean (SD) Follow-up Mean (SD) Pre- Mean (SD) Post- Mean (SD)
BEST Composite 44.57 32.76 30.60 49.80 47.42
(11.16) (12.47) (11.95) (12.35) (11.00)
BEST BPD Thoughts and Feelings 27.00 20.47 18.40 29.90 28.67
(7.73) (9.45) (9.07) (7.52) (7.76)
BEST BPD Negative Behaviors 11.33 7.12 7.20 12.25 10.83
(3.58) (2.18) (2.82) (4.98) (4.22)
BEST BPD Positive Behaviors 8.76 9.82 10.00 7.35 7.08
(2.62) (2.88) (2.00) (3.18) (3.06)
DASS Stress 28.48 26.55 22.22 30.3 31.57
(10.04) (11.58) (11.93) (10.16) (9.93)
DASS Anxiety 23.33 19.67 14.67 24.20 26.28
(9.34) (11.02) (13.23) (11.76) (8.33)
DASS Depression 31.52 22.67 16.00 33.70 31.00
(10.86) (14.73) (14.21) (8.74) (8.51)
BHS 14.40 9.70 7.50 15.70 16.43
(4.87) (6.34) (5.38) (3.58) (3.69)
AAQ-II 24.10 35.3 37.0 22.55 23.1
(9.29) (10.8) (6.3) (8.32) (7.1)
DERS Total 131.76 113.04 104.76 134.42 140.04
(25.15) (17.64) (20.52) (19.45) (20.88)
FFMQ Total 96.52 108.81 111.54 92.15 90.87
(23.01) (19.11) (19.11) (20.81) (20.67)
ACS Total 4.86 4.35 4.47 4.93 5.08
(.74) (.65) (.77) (.68) (.56)
Note. BEST= Borderline Evaluation of Severity Over Time; DASS = Depression Anxiety Stress Scale; BHS =Beck Hopelessness Scale; AAQ-II=
Acceptance and Action Questionnaire–II; DERS = Difficulties in Emotion Regulation Scale; FFMQ= Five Factor Mindfulness Questionnaire;
ACS = Affective Control Scale.

BPD Symptoms
Depression, Anxiety, and Stress
The condition interactions with time for the subscales
The condition interactions with time for both the
of BPD Thoughts and Feelings [estimate = 6.54, SE = 2.72,
DASS Depression subscale and the DASS Stress subscales
t(32.4) = 2.41, p = .022, 95% CI: 1.01, 12.07, d = .85]
were nonsignificant [Depression estimate = 6.51, SE = 3.93,
and BPD Negative Behaviors were also significant
t(34.6) = 1.66, p = .107, 95% CI: -1.47, 14.49, d = .56; Stress:
[estimate = 2.87, SE = 1.38, t(30.5) = 2.08, p = .046, 95%
estimate = 4.20, SE = 4.16, t(36.1) = 1.01, p = .319, 95% CI:
CI: .05, 5.69, d = .75]. For both subscales there were
-4.23, 12.64, d = .34]. The condition interaction with time
significant and large effect sizes for the ACT + TAU
for the DASS Anxiety subscale was significant [esti-
condition [BPD Thoughts and Feelings estimate = − 6.60,
mate = 7.90, SE = 3.36, t(32.0) = 2.35, p = .025, 95% CI:
SE = 1.77, t(30.9) = − 3.72, p = .001, 95% CI: -10.21, -2.98,
1.04, 14.74, d = .83] with the mean for the ACT + TAU
d = .88; BPD Negative Behaviors estimate = − 3.98, SE = .90,
condition improving nonsignificantly with a small effect
t(28.8) = − 4.42, 95% CI: -5.82, -2.14, p = .000, d = 1.05], but
size [estimate = − 3.92, SE = 2.24, t(30.9) = −1.74, p = .091,
no significant change for the TAU condition [BPD
95% CI: -8.50, .662, d = .41] and the TAU condition
Thoughts and Feelings estimate = −.05, SE = 2.05, t(33.6) =
actually deteriorating nonsignificantly with a small effect
−.03, p = .979, 95% CI: -4.24, 4.13, d = .01; BPD Negative
size [estimate = 3.98, SE = 2.50, t(32.9) = 1.59, p = .121, 95%
Behaviors estimate = − 1.11, SE = 1.04, t(31.8) = − 1.06,
CI: -1.11, 9.07, d = .41].
p = .296, 95% CI: -3.23, 1.02, d = .29]. However, for the
other BEST subscale, Positive Behaviors, the condition Hopelessness
interaction with time was not significant [estimate = − .75, There was a significant condition interaction with time
SE = 1.21, t(29.3) = − .61, p = .544, 95% CI: -3.23, 1.74, effect for the BHS [estimate = 5.55, SE = 1.87, t(33.7) = 2.96,
d = .23]. p = .006, 95% CI: 1.74, 9.36, d = 1.02], with the ACT + TAU
 ACT Group Treatment for BPD Symptoms 539

55 deviations from the mean for a sample of female un-

dergraduates (Gratz & Roemer, 2004).
50 Mindfulness
The FFMQ Total condition interaction with time was
45 significant [estimate = − 12.62, SE = 5.50, t(32.6) = − 2.29,
p = .028, 95% CI: -23.82, -1.42, d = .80] with a significant
ACT+TAU increase with moderate effect size for the ACT + TAU
40
TAU condition [estimate = 12.30, SE = 3.71, t(32.1) = 3.31,
p = .002, 95% CI: 4.74, 19.87, d = .79] and no significant
35 change for the TAU condition [estimate = − .31, SE = 4.06,
t(33.1) = − .08, p = .939, 95% CI: -8.58, 7.94, d = .02]. The
ACT + TAU mean moved from 2.1 to 1.3 standard
30
deviations from the mean for a sample of undergraduates
(Van Dam, Earleywine, & Danoff-Burg, 2009).
25
Pre Post Follow-up Fear of Emotions
The ACS Total condition interaction with time was
Figure 2. Means of observed BEST Composite scores over time. significant [estimate = .71, SE = .21, t(30.5) = 3.33, p = .002,
95% CI: .27, 1.16, d = 1.20] with significant improvement
condition improving significantly with large effect size and moderate effect size for the ACT + TAU condition
[estimate = − 4.93, SE = 1.27, t(32.7) = − 3.88, p = .000, 95% [estimate = −.54, SE = .15, t(30.1) = − 3.63, p = .001, 95% CI:
CI: -7.51, -2.35, d = .91] and no change for the TAU -.84, -.23, d = .89] and no significant change for the TAU
condition [estimate = .62, SE = 1.38, t(34.5) = .45, p = .656, condition [estimate = .18, SE = .16, t(30.9) = 1.15, p = .258,
95% CI: -2.18, 3.42, d = .11]. The ACT + TAU mean moved 95% CI: -.14, .50, d = .30]. The ACT + TAU mean moved
from 2.6 to 1.6 standard deviations from the mean for a from 2.0 to 1.3 standard deviations from the mean for a
sample of university undergraduates (Holden & Fekken, sample of undergraduates (Williams et al., 1997).
1988).

Follow-up
Changes in ACT Process Variables Three months after the end of treatment, follow-up of
Psychological Flexibility the ACT + TAU condition resulted in data from 10 of the
The AAQ-II condition interaction with time was 21 participants, despite an effort to contact and request
significant [estimate = − 9.88, SE = 3.60, t(30.6) = − 2.74, questionnaires from all participants. No statistically
p = .010, 95% CI: -17.23, -2.52, d = .99]. The ACT + TAU significant differences were found on any of the initial
condition showed a significant improvement in psycho- questionnaire scores or on any demographic variables
logical flexibility with a large effect size [estimate = 10.24, between those who provided follow-up data and those
SE = 2.44, t(29.7) = 4.19, p = .000, 95% CI: 5.25, 15.22, who did not (all p N .05). Mixed model procedures were
d = .98] while the TAU condition had no significant used for the three times (baseline, post, and follow-up) for
change [estimate = .37, SE = 2.65, t(31.4) = .139, p = .891, only the ACT + TAU condition. The mean scores at follow-
95% CI: -5.04, 5.77, d = .04]. The ACT + TAU mean moved up remained significantly different from baseline scores
from 2.9 to 1.7 standard deviations from the mean for a for the following: overall BPD symptoms [estimate =
nonclinical sample (Frank Bond, personal communica- −12.88, SE = 3.22, t(30.4) = − 4.00, p = .000, 95% CI: -19.46,
tion, August 2007). -6.30, d = 1.11] (see Figure 2); BPD thoughts and feelings
[estimate = − 8.56, SE = 1.95, t(28.73) = − 4.40, p = .000,
Emotion Regulation 95% CI: -12.55, -4.58, d = 1.24]; BPD negative behaviors
The DERS total score condition interaction with time [estimate = −3.78, SE = .918, t(31.58) = −4.12 p = .000, 95%
was significant [estimate = 23.94, SE = 8.48, t(33.0) = 2.82, CI: -5.65, -1.91, d = 1.13]; hopelessness [estimate = − 7.09,
p = .008, 95% CI: 6.69, 41.20, d = .98] with significant SE = 1.75, t(29.25) = −4.06, p = .000, 95% CI: -10.66, -3.52,
improvement and moderate effect size for the ACT + TAU d = 1.12]; psychological flexibility [estimate = 12.61,
condition [estimate = − 19.17, SE = 5.68, t(31.8) = − 3.38, SE = 2.80, t(26.22) = 4.50, p = .000, 95% CI: 6.85, 18.37,
p = .002, 95% CI: -30.74, -7.60, d = .78] and no significant d = 1.26]; emotion regulation skills [estimate = − 25.75,
change for the TAU condition [estimate = 4.77, SE = 6.30, SE = 7.28, t(30.00) = − 3.54, p = .001, 95% CI: -40.63,
t(34.1) = .76, p = .454, 95% CI: -8.03, 17.57, d = .19]. The -10.85, d = .96]; and mindfulness [estimate = 10.79, SE = 4.79,
ACT + TAU mean moved from 2.7 to 1.7 standard t(28.75) = 2.25, p = .032, 95% CI: .99, 20.58, d = .63]. However,
540 Morton et al.

fear of emotions [estimate = −.37, SE = .19, t(25.29) = −1.98, Table 4

p = .059, 95% CI: -.76, .01, d = .58] was no longer significant at Correlations
follow-up. Mean anxiety continued to improve to become BEST BHS AAQ-II DERS FFMQ
significantly different from baseline at follow-up [estimate = Composite Total Total
−7.68, SE = 2.85, t(28.8) = −2.69, p = .012, 95% CI: -13.52, BHS .669**
-1.85, d = .78]. AAQ -II −.718** −.765**
DERS Total .759** .751** − .776**
FFMQ Total −.555** −.615** .672** −.772**
Mediation Analysis ACS Total .520** .460* − .689** .717** −.738**
The method used in the present study involved boot- Note. BHS = Beck Hopelessness Scale; AAQ-II = Acceptance and
strapping to approximate distributions of products. It is Action Questionnaire–II; DERS = Difficulties in Emotion Regulation
recommended by Preacher and Hayes (2004), Shrout and Scale; FFMQ = Five Factor Mindfulness Questionnaire; ACS =
Affective Control Scale.
Bolger (2002) and Mackinnon, Lockwood, and Williams
** 0.01 level (2-tailed).
(2004) to avoid distribution issues, especially for small * 0.05 level (2-tailed).
samples. SPSS syntax provided by Preacher and Hayes
(2004) allowed for the construction of accelerated, bias-
corrected confidence intervals. The number of bootstrap for the ACS Total (point estimate = −4.96; 95% CI: -12.36,
samples was set at 1,000 and the confidence interval to 95%. 1.62). Thus, the effects were mediated by the AAQ-II, DERS
The independent variable in the mediation analysis was Total, and FFMQ Total, but not the ACS Total.
treatment condition—coded as 0 for the TAU only In order to examine the relative contribution of these
condition and 1 for the ACT + TAU condition. The post mediators (AAQ-II, DERS Total, FFMQ Total) for overall
scores for both mediating and outcome variables were used, BPD symptoms (BEST Composite), they were entered
and so conclusions that improvement in mediators into a multiple mediation model. The total effect of the
preceded improvement in outcome were precluded. The ACT + TAU condition on BPD symptoms was significant,
analysis was conducted without imputation of missing c = −14.67, t(26) = − 3.17, p = .004, and the direct effect was
values, which would be complex due to the need to reflect not, c´ = −2.07, t(26) = −.46, p = .647. Hence, the mediators
group effects and covariance among measures in the together mediated the effect of the ACT + TAU condition
imputation. The sample size ranged from 27 to 32 as on BPD symptoms. The total indirect effect through the
participants were more cooperative with some scales than three mediators was significant (point estimate = − 13.04;
others. 95% CI: -24.06, -4.16). The calculation of the indirect
The usual conventions for paths was followed, with a effects for each mediator revealed that only DERS Total
for paths from condition to mediator, b for paths from was a significant mediator (point estimate = − 29.39; 95%
mediator to outcome, c for total effect, c´ for direct effect CI: -29.39, -2.21). That is, with DERS Total in the multiple
(that is, after adjustment for the mediators), and ab for mediation model, there were no significant additional
the total indirect effect (through the mediators). Medi- contributions by the AAQ-II or FFMQ Total.
ation analysis was conducted for the variables that were To further understand the contribution of DERS in the
found above to have both a significant interaction with improvement of BPD symptoms for the ACT + TAU
time effect and also for which the ACT + TAU condition condition, a multiple mediation analysis was conducted
improved significantly at posttreatment. Correlations using the DERS subscales (emotion nonacceptance,
between these variables are presented in Table 4. goal-directed difficulties, impulse dyscontrol, emotion
First, potential mediators (AAQ-II, DERS Total, FFMQ nonawareness, lack of strategies, and lack of clarity). The
Total, ACS Total) for overall BPD symptoms (BEST total effect was significant, c = −14.65, t(27) = −3.26, p = .003,
Composite) were investigated individually. The total and the direct effect was not, c´ = .06, t(27) = .01, p = .990.
effect of the ACT + TAU condition on BPD symptoms The total indirect effect through the six mediators was
was significant, c = − 14.65, t(27) = − 3.27, p = .003, but the significant (point estimate = −15.23; 95% CI: -24.96, -5.66).
direct effect was not significant after accounting the AAQ-II, The only subscale that was a significant mediator was
c´ = −5.48, t(27) = −1.26, p = .219; the DERS Total, c´ = −3.91, impulse dyscontrol (point estimate = −7.55; 95% CI: -16.34,
t(27) = −.92, p = .365; the FFMQ Total, c´ = −9.68, t(26) = -1.94). Emotion nonacceptance (point estimate = −1.83;
−2.02, p = .055; or the ACS Total, c´ = −8.29, t(25) = −1.56, 95% CI: -8.37, .84), goal-directed difficulties (point
p = .132. The indirect effect, as assessed by the ab cross- estimate = −1.82; 95% CI: -.73, 13.90), emotion nonaware-
product, was significant for the AAQ-II (point estimate = ness (point estimate = .30; 95% CI: -4.83, 6.75), lack of
−9.56, 95% CI: -17.89, -2.78); the DERS Total (point strategies (point estimate = −5.57; 95% CI: -17.26, 5.30), and
estimate = −10.74; 95% CI: -20.11, -4.11); and the FFMQ lack of clarity (point estimate = −2.41; 95% CI: -11.87, 1.80)
Total (point estimate = −5.04; 95% CI: -12.31, -.31); but not were all nonsignificant.
 ACT Group Treatment for BPD Symptoms 541

Potential mediators (AAQ-II, DERS Total, FFMQ thoughts and feelings, BPD negative behaviors, and
Total, ACS Total) for hopelessness as measured by the hopelessness. For each of these, there were significant
BHS were also investigated individually. The total effect of and large improvements for the ACT + TAU condition. In
the ACT + TAU condition on hopelessness was significant, contrast, participants in the TAU condition who received
c = −7.04, t(27) = − 3.66, p = .001. The direct effect was not 3 months of TAU from local mental health and community
significant after accounting the AAQ-II, c´ = −3.12, t(27) = services and general practitioners showed no significant
− 1.92, p = .065, or the DERS Total, c´ = −2.25, t(27) = changes on any of the outcome variables. There was also a
− 1.21, p = .237. However, the direct effect was significant significantly better change for the ACT + TAU condition on
after accounting the FFMQ Total, c´ = − 4.35, t(29) = −2.29, anxiety, due to a nonsignificant improvement in anxiety
p = .030, or the ACS Total, c´ = −5.02, t(28) = − 2.15, p = .040. symptoms for the ACT + TAU condition, and a nonsignif-
The indirect effect as assessed by the ab cross-product was icant deterioration for the TAU condition. Almost a third
significant for the AAQ-II (point estimate = −3.91, 95% CI: (29%) of participants showed clinically significant change
-6.57, -1.45); the DERS Total (point estimate = − 4.87; 95% on overall BPD symptoms compared with none of the TAU
CI: -8.40, -2.10); and the FFMQ Total (point estimate = condition.
− 2.62; 95% CI: -5.19, -.18); but not for the ACS Total There were not significantly better outcomes on the
(point estimate = − 1.73; 95% CI: -4.24, .59). Thus, the stress and depression subscales of the DASS despite
effects were mediated by the AAQ-II, DERS Total, and significantly better outcomes in BPD thoughts and feelings
FFMQ Total, but not the ACS Total. (BEST subscale) and hopelessness (BHS). The DASS and
In the multiple mediation model (AAQ-II, DERS Total, the BPD thoughts and feelings subscale have different
FFMQ Total), the total effect of the ACT + TAU treatment content. Three of the eight BPD thoughts and feelings
on hopelessness was significant, c = −6.84, t(29) = −3.48, items refer to major swings in mood, and the other items
p = .002, and the direct effect was not, c´ = −1.41, t(29) = −.78, assess anger, feelings of emptiness, fears of abandonment,
p = .443. Hence, the mediators together mediated the effect and other emotional states not mentioned in the DASS.
of the ACT + TAU condition on hopelessness. The total The ACT + TAU intervention appears to have had a greater
indirect effect through the three mediators was significant impact on BPD symptoms and hopelessness than on distress
(point estimate = −5.58; 95% CI: -9.37, -2.29). Both AAQ-II more broadly. This is perhaps not surprising given that ACT
(point estimate = −1.98; 95% CI: -4.97, -.14) and DERS Total stresses pursuit of values based action and “taking your
(point estimate = −3.60, 95% CI: -4.97, -.21) were significant difficult thoughts and feelings with you” rather than
mediators, while FFMQ Total was not (point estimate = .00, reduction of distress as such.
95% CI: -2.22, 2.64). Thus, with AAQ-II and DERS Total in The ACT + TAU treatment also produced significantly
the multiple mediation model, there was no additional better change than TAU on the following ACT-related
contribution by FFMQ Total. process variables: psychological flexibility (AAQ-II), emo-
The DERS subscales were investigated as mediators of tion regulation skills (DERS), mindfulness (FFMQ), and
improvement in hopelessness. The total effect was signifi- fear of emotion (ACS). For each of these, there were
cant, c = −7.04, t(30) = −3.66, p = .001, and the direct effect statistically significant improvements with medium to large
was not, c´ = −1.56, t(27) = −.72, p = .475. The total indirect effect sizes for the ACT + TAU condition, which contrasted
effect through the six mediators was significant (point with no significant improvements on any of these measures
estimate = −5.89; 95% CI: -9.74, -1.09). The only subscale that for the TAU condition, consistent with the expectation that
was a significant mediator was lack of strategies (point the ACT + TAU treatment would affect these processes
estimate = −3.56; 95% CI: -7.66, -.06). Emotion nonaccep- while TAU would not.
tance (point estimate = −.03; 95% CI: -1.13, 1.35), goal- Follow-up of the ACT + TAU participants showed that all
directed difficulties (point estimate = −.06; 95% CI: -4.84, improvements were maintained, except for the reduction in
.77), emotion nonawareness (point estimate= −2.24; 95% fear of emotion, which was no longer significantly different
CI: -6.26, .04), impulse dyscontrol (point estimate = −1.32; from baseline at follow-up. Anxiety (DASS) continued to
95% CI: -5.05, 2.20), and lack of clarity (point estimate = 1.33; improve, becoming significantly different from baseline by
95% CI: -.68, 4.09) were all nonsignificant. follow-up. However, follow-up numbers were small.
Of the ACT-related process variables measured in this
Discussion study, psychological flexibility (AAQ-II), emotion skills
The results suggested that a brief 12-session ACT group (DERS), and mindfulness (FFMQ) were all mediators for
may be a valuable addition to TAU for public mental health BPD symptoms, providing support for the view that the
clients with symptoms of BPD. The ACT groups were well observed improvements in BPD symptoms were associated
attended with few dropouts. The addition of the ACT group with these processes. When they were entered into a
to TAU led to significantly better change than TAU alone multiple mediation model for BPD symptoms, only
for the following symptoms: overall BPD symptoms, BPD emotion skills (DERS) mediated. A separate mediation
542 Morton et al.

analysis including only the subscales of the DERS suggested support may not be effective, or that the better results for
that less tendency to act in unhelpful ways in the presence ACT + TAU were a nonspecific result of the additional
of strong negative effect (low impulse dyscontrol) was the treatment hours. Also, the ACT groups were delivered by
strongest contributor in the mediation. The definition of experienced staff who specialized in group treatment of
BPD includes considerable emphasis on self-destructive people with severe personality disorders. It is possible that it
impulsive action, so the apparent importance of this was not the ACT content of the groups that resulted in the
subscale may in part reflect how the disorder is defined. improvements, but rather access to specialist treatment, or
From the point of view of ACT, a reduction in impulsive acts access to a systematized treatment.
that are against the individual's values, and, conversely, A further weakness is the small sample size of the study.
increased action in a direction consistent with values would Some of the outcomes, where differences between the
be regarded as important targets of therapy regardless of conditions were not significant despite large effect sizes,
diagnostic category. may have reached significance given higher power from
As expected, more positive scores on psychological larger numbers. Another limitation was the numbers that
flexibility (AAQ-II) and emotion skills (DERS) were also were lost, particularly from the TAU condition and from
found to mediate a more subjective and less behavior-based the ACT + TAU condition at follow-up, despite efforts to
outcome measure, namely hopelessness. Once again, when retain contact. Although a mixed model analysis was used,
the two mediators were used in a multiple mediation model, the amount of data available for modeling was limited.
only the DERS mediated. In the case of hopelessness, the Nonetheless, both the mixed model analysis and the
strategies subscale of the DERS was found to be the strongest repeated measures ANOVAs produced the same statistical
contributor in the mediation. Items in this subscale refer to conclusions, lending support for the robustness of the
confidence that strong emotions will pass rather than results.
overwhelm one. Mindfulness skills (FFMQ) were not The study was able to provide some preliminary data on
found to mediate hopelessness, and it may be that learning ACT processes that may mediate changes in BPD symptoms
emotion acceptance skills is more important for reducing and hopelessness. However, all measures were self-report
hopelessness than mindfulness training more generally. and there is a need for a study including ratings by others or
Although there was a significant reduction in fear of objective measures. The researchers gathered little infor-
emotions (ACS), this was not found to be a mediator of BPD mation on several potentially important ACT process
symptoms or hopelessness. Scores on the ACS were strongly mediators: fusion with unhelpful thoughts, awareness of
correlated with scores for psychological flexibility (AAQ-II) values, and committed (valued based) action. Inclusion of
and emotion dysregulation (DERS) but less strongly with such measures in future studies may give a different picture
BPD symptoms (BEST) and hopelessness (BHS). Unlike of the ACT processes that are important for outcomes.
the AAQ-II and the DERS, the ACS includes items Notwithstanding these cautions, clinically significant
measuring fear of positive emotions, and it may thus be change for clients in a public sector setting was obtained
tapping different processes. Also, fear of emotions differs with a brief intervention. The intervention produced
somewhat from the postulated core ACT process, increased improvement for clients with high levels of initial
psychological flexibility, and it is possible that, at least in symptoms, including depression, suicidality and hopeless-
some cases, reduced BPD symptoms and/or reduced ness, and multiple diagnoses. The lack of improvement
hopelessness were associated with increased psychological on any measure after 3 months of treatment for the
flexibility (reduced experiential avoidance), but not with participants on the waiting list, who were receiving only
reduced fear of emotions. TAU, underlines the importance of developing supple-
The study was a small trial, conducted in a standard mentary treatments that can be delivered within the
public sector treatment setting, with as few exclusion limited resources of the public sector.
criteria as possible in order to maximize applicability to a Further research needs to be conducted to attempt to
broad range of clinical settings and to “multiproblem” replicate the results obtained in this small sample, to
clients. However, it has a number of weaknesses and compare the ACT group with other group treatments, and
limitations. The trial was conducted using only 12 sessions to ascertain whether outcomes are improved with longer
of treatment, in order to avoid a period of longer than treatment. There is also a need to explore whether the
12 weeks on a TAU waiting list. However, the ACT + TAU treatment can be effectively conducted by clinicians from
participants still suffered considerable disability and distress outside a specialist service.
at the end of the 12 sessions of treatment and it is clear that
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Practice, 19, 499–507 (this issue). Available online 25 April 2012

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