184

Psychology and Psychotherapy: Theory, Research and Practice (2011), 84, 184200 C 2010 The British Psychological Society

The British Psychological Society

www.wileyonlinelibrary.com

A feasibility study of mindfulness-based cognitive therapy for individuals with borderline personality disorder
Sandy Sachse1 , Saskia Keville1 and Janet Feigenbaum2
1 2

Department of Psychology, University of Hertfordshire, Hateld, UK Research Department of Clinical, Educational and Health Psychology, University College 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 intervention. 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 hoc analyses of treatment improvers (N = 9) identied changes in mindfulness and somatoform dissociation. 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 interventions including: dialectical behaviour therapy (DBT; Linehan, 1993), mindfulness-based stress
Correspondence should be addressed to Dr Janet Feigenbaum, Research Department of Clinical, Educational and Health Psychology, University College London, Gower Street, London WC1E 6BT, UK (e-mail: j.feigenbaum@ucl.ac.uk).
DOI:10.1348/147608310X516387

MBCT for borderline personality disorder

185

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 some psychiatric conditions (e.g., generalized anxiety disorder, binge eating disorder) with studies generally showing improvements on measures of anxiety and depression (e.g., Kabat-Zinn et 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 and feelings in order to break into vicious cycles of negative emotions and develop more adaptive ways of coping (Williams, Duggan, Crane, & Fennell, 2006; Williams & Swales, 2004). MBCT (Segal et al., 2002) was originally developed for clients with a history of recurrent depression and has been found to signicantly 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 training attentional control. Borderline personality disorder (BPD) is dened as a pervasive pattern of instability of interpersonal relationships, self image, and affects and marked impulsivity (American Psychiatric Association, 1994, p. 1250). Prominent models suggest that emotional dysregulation underpins the characteristic patterns of cognitive and behavioural dysregulation (Crowell, Beauchaine, & Linehan, 2009; Livesley, 2008; Reisch, Ebner-Priemer, Tschacher, Bohus, & Linehan, 2008). BPD frequently involves high rates of Axis-I comorbidity (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/or depression (Finucane & Mercer, 2006; Kenny & Williams, 2007; Ree & Craigie, 2007) with demonstrable improvements. The successful application of MBCT to clients at high risk of suicide (Barnhofer et al., 2007; Williams et al., 2006) and psychiatric in-patients (York, 2007) suggests that MBCT may also prove helpful to clients meeting BPD criteria. Further evidence suggests that decits 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: emotional regulation, interpersonal effectiveness, and distress tolerance. Underpinning these modules are core mindfulness skills (Feigenbaum, 2007; Linehan, 1993). Research is only beginning to explore the specic value of mindfulness for this client group. In a preliminary 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 demonstrable benets. The emotional dysregulation which characterizes BPD involves marked reactivity of mood and heightened emotional arousal (e.g., Linehan, 1993; Putnam & Silk, 2005; Rosenthal et al., 2008). Specic brain structures have been identied which may underlie the difculties typically experienced in BPD, namely prefrontal and temporo-limbic structures. Frontal lobe structures are associated with mechanisms of self-control and attention (also captured in the notion of executive function) and have been shown to play a central role in emotion regulation and impulsive behaviour (Dinn et al., 2004). In

186

Sandy Sachse et al.

line with this, Ruocco (2005), in a meta-analytic review of neuropsychological decits in BPD, concludes that compared to normal controls clients meeting BPD criteria show decits in attention and cognitive exibility (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 following therapeutic 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 in attentional 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 mediator factor in the relationship between anxiety and mindfulness ability. The concept of experiential avoidance may be particularly relevant in individuals with BPD. Hayes, Wilson, Gifford, Follette, and Strosahl (1996) note that clients meeting BPD criteria engage in a range of behaviours which share features with the experiential avoidance properties of addictive behaviour. Individuals with BPD have a tendency to avoid 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 conduct a 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. The secondary aim of the study was to explore the relevant outcomes which could be identied 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 employing within-subject and between-subject comparisons of a sample of participants meeting DSM-IV diagnostic criteria for BPD. Those who completed fewer than the minimum number of sessions (<4 sessions) were deemed non-treatment completers. The primary hypotheses were that MBCT-a would lead to an increase in mindfulness and that changes in mindfulness would lead to a decrease in clinical symptoms and experiential avoidance, and improved performance on attentional tasks.

Participants Participants in this study were recruited from a specialist personality disorder Inclusion criteria were a diagnosis of BPD as assessed using the Structured Interview for DSM-IV Axis II Personality Disorders (SCID-II; First, Gibbon, Williams, & Benjamin, 1997) undertaken by expert clinicians trained in the aged 1850, and uent in English. Exclusion criteria included a diagnosis of psychotic or bipolar disorder, head injury, and current daily substance abuse.

service. Clinical Spitzer, SCID-II, current

MBCT for borderline personality disorder

187

In this study, 30 clients initially agreed to participate. Four dropped out before attending the pre-intervention assessment. Thus, 26 participants were assessed preintervention. Four clients did not agree to be reassessed after dropping out of the intervention 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 < 4). Participants attended one of three consecutively run MBCT-a interventions. Posttreatment assessments were conducted within 1 month of the nal group session.

MBCT adaptations MBCT is a manualized programme, which aims to teach clients mindfulness and cognitive skills in a group setting (Segal et al., 2002). Clients attend an individual orientation session, followed by 8 weekly 2-h group sessions. Clients are provided with homework exercises, including guided and unguided mindfulness exercises for daily practice. The treatment manual used in this study was adapted from the original MBCT manual h) and changes (Segal et al., 2002). Adaptations included extended session lengths (2 1 2 to the range of mindfulness CDs provided. The main set of CDs (as outlined in the MBCT manual) was provided, however only one out of the four additional CDs from Series two of Jon Kabat-Zinns range was used, thus representing a more narrow range of choice in exercises. The mindfulness exercises in which there was no instruction (silence and bells) were excluded as they were considered to be potentially too difcult for this client group at this stage of their recovery. In addition, session 4, which focuses on psychoeducation for depression was extended to include discussion of experiences of anxiety and emotional distress in general, highlighting the similarities regarding negative thinking patterns and behavioural consequences across mood states. The adaptations to MBCT were discussed with several practitioners of MBCT including a developer of the treatment.

Measures Clinical outcome Mindfulness was measured using the Five-Facet Mindfulness Questionnaire (FFMQ; Baer, Smith, Hopkins, Krietemeyer, & Toney, 2006). The FFMQ is a 39-item self-report measure that provides ve subscales (observing, describing, acting with awareness, accepting without judgment, non-reactivity). The ve facets can be combined to yield a total score, which reects a global measure of mindfulness. Anxiety was measured using the StateTrait Anxiety Inventory (STAI; Spielberger, 1983). The STAI is a commonly used 40-item self-report measure assessing state and trait anxiety with good psychometric properties. Depression was measured using the Beck Depression Inventory 2nd Edition (BDI-II; Beck, Steer, & Brown, 1996). The BDI-II, a 21-item self-report measure of symptoms of depressive disorder, is used as a standard in clinical practice and has excellent psychometric properties. Cognitive dissociation was measured using the Dissociative Experience Scale 2nd Edition (DES-II; Carlson & Putnam, 1993). The DES-II is a 28-item self-report instrument which measures how frequently individuals experience cognitive dissociation. The DES has been shown to have high reliability and validity (Dubester & Braun, 1995).

188

Sandy Sachse et al.

The Somatoform Dissociation Questionnaire (SDQ-20; Nijenhuis, Spinhoven, van Dyck, van der Hart, & Vanderlinden, 1996) is a reliable and valid 20-item instrument, which measures how frequently individuals experience symptoms of physical dissociation (see Nijenhuis, Spinhoven, van Dyck, van der Hart, & Vanderlinden, 1998, for psychometric properties). Cut-off scores of 30 for the DES-II and 35 for SDQ-20 are typically used in clinical practice to identify individuals likely to be severely dissociative (Carlson & Putnam, 1993; Putnam et al., 1996). Barratt Impulsiveness Scale-11 (BIS-11; Patton, Stanford, & Barratt, 1995) is 30-item self-report questionnaire designed to measure an individuals tendency to be impatient and impulsive. A recent review has highlighted the good psychometric properties of the BIS-11 (Stanford, Mathias, Dougherty, Lake, Anderson, & Patton, 2009). There are no norms available for the BPD population, however scores of 74 and above are generally held to reect high levels of impulsivity (e.g., Moeller et al., 2001).

Attention The STROOP version employed in this study consists of two parts: in Part I individuals are asked to read the printed colour names and in Part II to state the colour in which each word is printed. The time taken to complete both parts of the STROOP provides a measure of speeded processing (e.g., Kunert, Druecke, Sass, & Herpertz, 2003). The difference between the times taken to complete the two parts is referred to as STROOP interference, providing a measure of selective attention (e.g., Kunert et al., 2003, Ruocco, 2005). The Trail Making Test (TMT) is a complex test of attention (Lezak, Howieson, & Loring, 2004; Tombaugh, 2004). Individuals are required to connect sequential numbers (Trial A) followed by connecting alternating letters and numbers (Trial B). The time difference between Part B and Part A provides a measure of executive functioning and sustained attention requiring the individual to hold two lines of information in working memory and alternate between them sequentially (also known as set shifting; Dinn et al., 2004; Ruocco, 2005).

Experiential avoidance Experiential avoidance was measured using the Acceptance and Action Questionnaire (AAQ; Hayes et al., 2004). The AAQ is a 22-item self-report instrument designed to measure degree of experiential avoidance (e.g., attempts to control thoughts or emotions) using a seven-point Likert scale. The AAQ is a relatively new measure and there is a lack of published data regarding norms or the interpretation of scores.

Statistical analyses Complete data sets were available for 22 participants. Whole sample analysis is a conservative test of the hypotheses as this includes data for participants who did not attend the group or did not complete the minimum effective dose (i.e., 4 out of 8 sessions) as dened by Teasdale et al. (2000). In order to ascertain changes in measures across time, non-parametric analyses of paired samples were used due to the small sample size. Given the exploratory nature of the study and small sample size, it was decided

MBCT for borderline personality disorder

189

not to use Bonferroni-corrected p values to enhance statistical power. To further gain statistical power, it was decided to raise the alpha level to 10%. Treatment effect sizes were calculated using Cohens d statistic (Cohen, 1988). Non-parametric correlations between individual gain scores (for each variable) and the number of sessions completed were executed to explore dosage effects.

Table 1. Frequencies (percentages or SDs) of demographic variables for the whole sample, treatment completers and non-completers

190

Sandy Sachse et al.

Reliable change analysis allows one to consider if a change is signicant taking into account both the population variance (standard deviation) and the reliability of the measure (Cronbachs alpha) (see Jacobson & Truax, 1991). A reliability of change index (RCI) was calculated for those differences identied in the whole sample or post hoc analyses of treatment improvers.

Results
The mean number of sessions attended by the whole group was 4.91 (SD = 2.49). The mean number of sessions attended by treatment completers (N = 16) was 6.19 (SD = 1.33) and for treatment non-completers was 1.50 (SD = 1.22). Demographic characteristics of all participants is shown in Table 1. Participants were predominantly female (86.4%), single (68.2%), and White British (86.4%). The mean age of participants was 39 years (SD = 7.5). This is representative of this client population (Lieb et al., 2004) and referrals received by the service. Of the sample, 81.8% were receiving another psychological treatment at the time of the study. Approximately, 73% of participants were prescribed psychotropic medication (primarily antidepressant), in line with reports in the literature (e.g., Lieb et al., 2004; Zanarini et al., 2004). There were no signicant differences between treatment completers and non-completers on any of these variables. Table 2 provides a breakdown of diagnostic information of the sample. The mean number of BPD criteria met on the SCID-II was 7.04 with a range of 59. Approximately 27% of participants had one or more comorbid Axis-II diagnoses, which is somewhat low compared to commonly reported comorbidity. All participants met criteria for at
Table 2. Frequencies (percentages and SDs) of psychiatric diagnoses and BPD severity for the whole sample, treatment completers and non-completers

MBCT for borderline personality disorder

191

least one Axis-I disorder with approximately 77% meeting criteria for major depressive disorder. Treatment completers and non-completers were comparable for BPD severity. Changes in mindfulness The initial hypothesis was that MBCT-a would increase mindfulness. Higher scores on the FFMQ indicate higher levels of mindfulness. The mean FFMQ score at pre-treatment was 103.27 (SD = 19.64) with a range from 60 to 153. The mean FFMQ score at posttreatment was 107.46 (SD = 22.95) with a range from 67 to 148. Recently published data showed a mean total score of 116.9 in a community sample and 124.34 in a student sample (Baer et al., 2008). Thus, the sample scored below a non-clinical population for mindfulness both before and after intervention. Based on a Wilcoxon signed ranks test, there was no signicant difference in mindfulness scores from pre- to post-treatment (Z = 0.92, p = .18) for the whole sample. Out of the total of 16 treatment completers, 9 participants (56%) showed an improvement in mindfulness on the FFMQ. Reliability of change analyses showed that the change in FFMQ was a signicant change (RCI = 18.4; observed change = 26). Selected demographic variables (Table 3) outcome measures (Table 4) were explored for differences between the improvers and non-improvers to investigate characteristics of participants which could identify individuals more likely to benet from MBCT-a.
Table 3. Descriptive statistics for participants who improved in mindfulness and participants who did not improve

Participants who improved in mindfulness did not differ in age or BPD severity compared to those who did not. However, those who did not improve had spent approximately ve times as long in some form of psychological therapy (Table 3). Participants who improved on the FFMQ had lower scores at pre-assessment compared to participants who did not improve (Table 4).

Clinical outcome Table 5 shows the descriptive statistics for the whole sample on the clinical outcome measures. Depression Higher scores on the BDI-II indicate greater levels of depressive symptomatology. The mean pre-treatment scores were 33.95 and post-treatment 31.09, indicating severe depressive symptomatology at both time points. Based on a Wilcoxon signed ranks test of the whole sample, no difference was observed in scores from pre- to post-treatment (Z = 1.20, p = .115). However, post hoc analysis exploring treatment completers showed a signicant reliable change (RCI = 6.6; mean improvement = 7.0).

192

Sandy Sachse et al.

Table 4. Median scores and standard deviations on outcome measures for treatment completers divided by improved and not improved on the FFMQ measure of mindfulness

MBCT for borderline personality disorder Table 5. Whole sample pre- and post-intervention scores on the clinical outcome measures

193

Anxiety Higher scores on the STAI indicate higher levels of state or trait anxiety. Based on a Wilcoxon signed ranks test, no signicant difference was observed pre- to post-treatment for state anxiety (Z = 0.035, p = .486). Scores fell at the 93rd percentile for males and 91st percentile for females and are comparable to scores found in psychiatric patients diagnosed with depression. Post hoc analysis exploring treatment completers showed no signicant change in state anxiety.

Dissociation On the DES-II and SDQ-20 higher scores indicate higher rates of dissociative symptoms. Based on a Wilcoxon signed ranks test, no signicant difference was observed in scores from pre- to post-treatment for the DES-II (Z = 0.89, p = .374) or the SDQ-20 (Z = 1.04, p = .297). Post hoc reliability of change analyses of the treatment improvers showed a signicant change for SDQ-20 (RCI = 5; observed change = 5) but no signicant change for the DES-II.

Impulsivity Higher scores on the BIS-11 indicate higher levels of impulsivity. Based on a Wilcoxon signed ranks test, no signicant difference was observed in scores from pre- to posttreatment (Z = 1.09, p = .138). Post hoc analysis exploring treatment completers showed no signicant change.

194

Sandy Sachse et al.

Attention Descriptive statistics for whole sample on the attentional measures are shown in Table 6. Performance on the STROOP and TMT was analysed using non-parametric tests due to abnormalities in the distribution of the data.
Table 6. Whole sample descriptive statistics for measures of attention

Trail Making Test The TMT data were analysed with the Wilcoxon Matched-Pairs Signed-Ranks Test. A signicant difference was observed in performance speed from pre- to post-treatment for Part A (Z = 1.89, p = .03) and a trend towards signicance on Part B (Z = 1.43, p = .077), representing a small effect size (Cohens d = .26).

STROOP The STROOP data were analysed with the Wilcoxon matched-pairs signed-ranks test. No signicant difference was observed in performance speed from pre- to post-treatment (Z = 0.55, p = .2905) for STROOP-I (Reading). However, for STROOP-II (Colour naming) (Z = 1.93, p = .0265) (medium effect size; Cohens d = .36) and STROOP interference (Z = 1.93, p = .0265) (medium effect size; Cohens d = .35) signicant differences were observed.

Experiential avoidance Experiential avoidance was measured using the AAQ. Higher scores on the AAQ reect higher levels of experiential avoidance. Scores range from 16 to 112 using the 16-item solution (Table 4). Based on a Wilcoxon signed ranks test, a signicant difference was

MBCT for borderline personality disorder

195

observed in scores from pre- to post-treatment (Z = 1.71, p = .044). This difference represents a small effect size (Cohens d = .19). However, post hoc analysis exploring treatment completers suggested this difference may not be reliable (RCI = 15.26). Dosage effects In order to explore relationships between outcome measures and the number of sessions attended by participants, gain scores for each clinical outcome measure were calculated by subtracting pre-treatment scores from post-treatment scores. Individual gain scores were then correlated with the number of sessions attended (dosage). Spearmans rho indicated no association between changes in FFMQ scores and dosage ( = .213, p = .170), for BDI-II scores and dosage ( = .218, p = .165), for DES-II scores and dosage ( = .015, p = .946), or for BIS-11 scores and dosage ( = .240, p = .1405). However, Spearmans rho indicated a weak but signicant negative association with changes in AAQ scores and dosage (r = .356, p = .05) representing a reduction in experiential avoidance post-treatment. Spearmans rho indicated a moderate negative association with changes in STAI-state scores and dosage ( = .418, p = .027). On the SDQ-20, Spearmans rho indicated a moderate but signicant negative association with changes in SDQ-20 scores and dosage ( = .473, p = .026).

Discussion
This pilot study represents the rst attempt to evaluate MBCT adapted for use with clients with a diagnosis of BPD using a range of clinical and theoretical outcome measures. As such we were primarily concerned with the feasibility of intervention and the identication of possible primary outcomes for a future larger study. This study suggests that it is possible to run an adapted MBCT programme with clients meeting BPD criteria in a clinical setting. Out of 22, 16 participants with BPD (78% retention; 22% drop-out) completed greater than half of the sessions offered, with the majority attending 2/3 of sessions. Compared to drop-out rates for other interventions for patients with BPD, this is good rate of retention. Drop-out rates for psychological interventions with clients with BPD vary in the literature from 15% for a 3-month DBT group (Soler et al., 2008), to 27% for schema-focused therapy (Giesen-Bloo et al., 2006), 37% for DBT (Verheul et al., 2003), to 51% for transference-focused therapy (Giesen-Bloo et al., 2006). Qualitative feedback of client satisfaction suggested that participants valued the intervention and experienced some person positive change as a result of attending. An intention to treat analysis did not identify signicant changes in any of the clinical variables, however a signicant change was identied on measures of attentional control, which is theoretically linked to mindfulness. Whole group analyses of attention using the TMT and the STROOP indicated signicant improvements in attentional control postintervention. These results are in line with reports of decits in attention and cognitive exibility in individuals meeting BPD criteria (Ruocco, 2005). Thus, the results suggest that although there is evidence of improvement in attentional control, this client group continue to be impaired compared to non-BPD individuals even after intervention. Future research will need to consider whether extending the intervention or modications to MBCT are needed to further enhance attentional control. Walsh et al. (2009) have suggested that levels of trait anxiety mediate attentional control and mindfulness ability.

196

Sandy Sachse et al.

In our sample participants scored highly on trait and state anxiety, thus potentially interfering with their capacity to benet from the intervention. This would suggest that targeting anxiety symptoms initially may enhance the outcome from MBCT provided at a later time. It is possible that more ecologically valid tests of attention relating to daily task and functioning could be used in future to determine the impact of MBCT on quality of life. Participants in this study scored high on experiential avoidance, supporting theories which conceptualize BPD as a diagnosis characterized by experiential avoidance (Hayes et al., 1996). A small but signicant improvement was shown on a measure of experiential avoidance, in line with predicted outcomes for a mindfulness-based intervention. Doseeffect analysis indicated that experiential avoidance reduces with number of sessions attended. Berking et al. (2009) have also used the AAQ and found that experiential avoidance reduces the impact of therapy on symptoms of depression. They conclude that experiential avoidance is an important target of therapy. This supports our ndings and suggests that it is important to continue to explore the usefulness of MBCT as part of a treatment plan for individuals with BPD. With respect to mindfulness as measured by the FFMQ, mean scores for the whole group at pre-test were approximately one standard deviation lower than that reported for the general population (Baer et al., 2008). This nding adds to accumulating evidence that participants with BPD tend to score lower on measures of mindfulness compared to the general public (e.g., Brown & Ryan, 2003). While there was no signicant effect of MBCT on mindfulness in the whole sample analysis, 56% of treatment completers showed a reliable improvement in mindfulness. This suggests that further analysis with a larger sample may be helpful in identifying the characteristics of those likely to benet from MBCT. In the whole sample or treatment completers analyses, no signicant differences were found between pre- and post-measures for depressive symptoms, state anxiety, dissociation, or impulsivity. However, treatment improvers (N = 9) showed reliable signicant change on measures of somatoform dissociation, and small effect sizes for state anxiety and cognitive dissociation, suggesting that with a larger sample size these effects might continue to be relevant. In addition, with the exception of Trait Anxiety, all other clinical measures showed a trend towards improvement supporting the development of a full size trial. When considering a dose effect (changes in relation to number of sessions attended), there were signicant improvements in state anxiety and somatoform dissociation linked to number of sessions attended. This could suggest that increasing the length of treatment for this client group may lead to more robust outcomes. As this was a feasibility pilot study no long-term follow-up was conducted. It may also be the case that changes in clinical symptoms may occur over time and that a follow-up of 6 months or more after treatment may reveal further changes in both mindfulness ability and clinical symptoms. In addition, it is not possible to conclude that the improvements would be sustained over time. A further limitation is the lack of a control group to consider whether the changes identied were due to the additional clinical attention provided to these individuals in the group. This study was not designed to evaluate the impact of MBCT separate from concurrent treatments. However, as 18/22 participants were receiving either CBT or DBT, both of which provide mindfulness and cognitive restructuring skills development in our programme, as this was a feasibility pilot we were interested in the added benet

MBCT for borderline personality disorder

197

of MBCT. Future studies will need to consider the impact of MBCT with or without concurrent treatments. It is possible that MBCT has a role in the treatment of BPD at certain stages in treatment. For example, with the original focus of MBCT on relapse prevention in depression, it may be that MBCT has a similar role to play in clients with BPD. Future research could evaluate the effectiveness of MBCT to reduce relapse rates once clients have completed current treatments and have been discharged.

Conclusion This study suggests that MBCT is a promising adjunct clinical intervention for those with BPD. Of those who offered MBCT, 70% completed greater than 50% of sessions offered. Although small and not statistically signicant with this limited sample size, those who improved in mindfulness showed improvements across all clinical measures. Larger efcacy trials of MBCT with BPD will need to consider a number of questions including: the impact of concurrent treatments, sustainability of improvements, treatment length, or symptom severity.

Acknowledgements
This project was funded by the University of Hertfordshire and by the Research and Development Department of North East London Foundation Trust. We wish to express our appreciation to Steve Davies for advice during the project; to Marion Bates, Josie Thomas, and Matthew Stainsby for co-facilitating the MBCT groups; and to Joerg Schulz for statistical advice.

References
American Psychiatric Association (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author. Baer, R. A. (2003). Mindfulness training as a clinical intervention: A conceptual and empirical review. Clinical Psychology: Science and Practice, 10, 125143. doi:10.1093/clipsy/bpg015 Baer, R. A., Smith, G. T., Hopkins, J., Krietemeyer, J., & Toney, L. (2006). Using self-report assessment methods to explore facets of mindfulness. Assessment , 13(1), 2745. doi:10.1177/ 1073191105283504 Baer, R. A., Smith, G. T., Lykins, E., Button, E. L. D., Krietemeyer, J., Sauer, S., . . . Williams, J. M. (2008). Construct Validity of the Five Facet Mindfulness Questionnaire in Meditating and Nonmeditating Samples. Assessment , 15, 329342. doi:10.1177/1073191107313003 Barnhofer, T., Duggan, D. S., Crane, C., Hepburn, S., Fennell, M. J. V., & Williams, J. M. (2007). Effects of meditation on frontal alpha-asymmetry in previously suicidal individuals. Neuroreport: For Rapid Communication of Neuroscience Research, 18(7), 709712. Beck, A. T., Steer, R. A., & Brown, G. K. (1996). Manual for Beck Depression Inventory II (BDI-II). San Antonio, TX: Psychology Corporation. Berking, M., Neacsiu, A., Comtois, K. A., & Linehan, M. M. (2009). The impact of experiential avoidance on the reduction of depression in treatment for borderline personality disorder. Behaviour Research and Therapy, 47(8), 663670. doi:10.1016/j.brat.2009.04.011 Bijttebier, P., & Vertommen, H. (1999). Coping strategies in relation to personality disorders. Personality and Individual Differences, 26 , 847856. doi:10.1016/S0191-8869(98)00187-1

198

Sandy Sachse et al.

Bishop, S. R., Lau, M., Shapiro, S., Carlson, L., Anderson, N. D., Carmody, J., . . . Devins, G. (2004). Mindfulness: A proposed operational denition. Clinical Psychology: Science and Practice, 11, 230241. doi:10.1093/clipsy/bph077 Brown, K. W., & Ryan, R. M. (2003). The benets of being present: Mindfulness and its role in psychological well-being. Journal of Personality and Social Psychology, 84, 822848. doi:10.1037/0022-3514.84.4.822 Carlson, E. B., & Putnam, F. W. (1993). An update on the Dissociative Experiences Scale. Dissocation: Progress in the Dissociative Disorders, 6 (1), 1627. Chambless, D. L., & Hollon, S. D. (1998). Dening empirically supported therapies. Journal of Consulting and Clinical Psychology, 66 (1), 718. doi:10.1037/0022-006X.66.1.7 Cohen, J. (1988). Statistical power analysis for the behavioral sciences (2nd ed.). Hillsdale, NJ: Erlbaum. Crowell, S. E., Beauchaine, T. P., & Linehan, M. M. (2009). A biosocial developmental model of borderline personality: Elaborating and extending Linehans theory. Psychological Bulletin, 135(3), 495510. doi:10.1037/a0015616 Dinn, W. M., Harris, C. L., Aycicegi, A., Greene, P. B., Kirkley, S. M., & Reilly, C. (2004). Neurocognitive function in borderline personality disorder. Progress in Neuro-psychopharmacology and Biological Psychiatry, 28, 329341. doi:10.1016/j.pnpbp.2003.10.012 Dubester, K. A., & Braun, B. G. (1995). Psychometric properties of the dissociative experiences scale. Journal of Nervous and Mental Disease, 183(4), 231235. doi:10.1097/ 00005053-199504000-00008 Feigenbaum, J. (2007). Dialectical behaviour therapy: An increasing evidence base. Journal of Mental Health, 16 (1), 5168. doi:10.1080/09638230601182094 Finucane, A., & Mercer, S. W. (2006). An exploratory mixed methods study of the acceptability and effectiveness of mindfulness-based cognitive therapy for patients with active depression and anxiety in primary care. BMC Psychiatry 2006/04/11 edition, 6 , 14. First, M. B., Gibbon, M., Spitzer, R. L., Williams, J. B. W., & Benjamin, L. S. (1997). Users guide for the Structured Clinical Interview for DSM-IV Axis II Personality Disorders (SCID-II). Washington, DC: American Psychiatric Association. Giesen-Bloo, J., van Dyck, R., Spinhoven, P., van Tilburg, W., Dirksen, C., van Asselt, T., . . . Arntz, A. (2006). Outpatient psychotherapy for borderline personality disorder: Randomized trial of schema-focused therapy vs transference-focused psychotherapy. Archives of General Psychiatry, 63(6), 649658. doi:10.1001/archpsyc.63.6.649 Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (1999). Acceptance and commitment therapy: An experiential approach to behavior change. New York: The Guildford Press. Hayes, S. C., Strosahl, K., Wilson, K. G., Bissett, R. T., Pistorelly, J., Toarmino, D., . . . Mccurry, S. M. (2004). Measuring experiential avoidance: A preliminary test of a working model. Psychological Record , 54, 553578. Hayes, S. C., Wilson, K. G., Gifford, E. V., Follette, V., & Strosahl, K. (1996). Experiential avoidance and behavioral disorders: A functional dimensional approach to diagnosis and treatment. Journal of Consulting and Clinical Psychology, 64(6), 11521168. doi:10.1037/0022-006X. 64.6.1152 Huss, D. B., & Baer, R. A. (2007). Acceptance and change: The integration of mindfulness-based cognitive therapy into ongoing dialectical behavior therapy in a case of borderline personality disorder with depression. Clinical Case Studies, 6 (1), 1733. doi:10.1177/1534650106290374 Jacobson, N. S., & Truax, P. (1991). Clinical signicance: A statistical approach to dening meaningful change in psychotherapy-research. Journal of Consulting and Clinical Psychology, 59, 1219. doi:10.1037/0022-006X.59.1.12 Kabat-Zinn, J. (1990). Full catastrophe living: Using the wisdom of your body and mind to face stress, pain and illness. New York: Dell Publishing. Kabat-Zinn, J., Massion, M. D., Kristeller, J., Peterson, L. G., Fletcher, K. E., Pbert, L., . . . Santorelli, S. F. (1992). Effectiveness of a meditation-based stress reduction program in the treatment of anxiety disorders. American Journal of Psychiatry, 149, 936943.

MBCT for borderline personality disorder

199

Kenny, M. A., & Williams, J. M. (2007). Treatment-resistant depressed patients show a good response to mindfulness-based cognitive therapy. Behaviour Research and Therapy, 45, 617 625. doi:10.1016/j.brat.2006.04.008 Kristeller, J., & Hallett, C. B. (1999). An exploratory study of a meditation-based intervention for binge eating disorder. Behavior Therapy, 32, 371390. Kruedelbach, N., McCormick, R. A., Schulz, S. C., & Grueneich, R. (1993). Impulsivity, coping styles and triggers for cravings in substance abusers with borderline personality disorder. Journal of Personality Disorder, 7, 214222. Kunert, H. J., Druecke, H. W., Sass, H., & Herpertz, S. C. (2003). Frontal lobe dysfunction in borderline personality disorders? Neuropsychological ndings. Journal of Personality Disorders, 17, 497509. doi:10.1521/pedi.17.6.497.25354 Lezak, M. D., Howieson, D. B., & Loring, D. W. (2004). Neuropsychological assessment (4th ed.). New York: Oxford University Press. Lieb, K., Zanarini, M. C., Schmahl, C., Linehan, M., & Bohus, M. (2004). Borderline personality disorder. Lancet , 364, 453461. doi:10.1016/S0140-6736(04)16770-6 Linehan, M. (1993). Cognitive-behavioral treatment of borderline personality disorder. New York: The Guildford Press. Livesley, J. (2008). Toward a genetically-informed model of borderline personality disorder. Journal of Personality Disorder, 22(10), 4271. doi:10.1521/pedi.2008.22.1.42 Ma, S. H., & Teasdale, J. D. (2004). Mindfulness-based cognitive therapy for depression: Replication and exploration of differential relapse prevention effects. Journal of Consulting and Clinical Psychology, 72(1), 3140. doi:10.1037/0022-006X.72.1.31 Moeller, F. G., Dougherty, D. M., Barratt, E. S., Schmitz, J. M., Swann, A. C., & Grabowski, J. (2001). The impact of impulsivity on cocaine use and retention in treatment. Journal of Substance Abuse Treatment , 21, 193198. doi:10.1016/S0740-5472(01)00202-1 Nijenhuis, E. R. S., Spinhoven, P., van Dyck, R., van der Hart, O., & Vanderlinden, J. (1996). The development and psychometric characteristics of the Somatoform Dissociation Questionnaire (SDQ-20). Journal of Nervous and Mental Disease, 184(11), 688694. doi:10.1097/ 00005053-199611000-00006 Nijenhuis, E. R. S., Spinhoven, P., van Dyck, R., van der Hart, O., & Vanderlinden, J. (1998). Psychometric characteristics of the somatoform dissociation questionnaire: A replication study. Psychotherapy and Psychosomatics, 67(1), 1723. doi:10.1159/000012254 Patton, J. H., Stanford, M. S., & Barratt, E. S. (1995). Factor structure of the Barratt impulsiveness scale. Journal of Clinical Psychology, 51, 768774. doi:10.1002/10974679(199511)51:6<768::AID-JCLP2270510607>3.0.CO;2-1 Putnam, F. W., Carlson, E. B., Ross, C. A., Anderson, G., Clark, P., Torem, M., . . . Braun, B. G. (1996). Patterns of dissociation in clinical and nonclinical samples. Journal of Nervous and Mental Disease, 184(11), 673679. doi:10.1097/00005053-199611000-00004 Putnam, K. M., & Silk, K. R. (2005). Emotion regulation and the development of borderline personality disorder. Development and Psychopathology, 17, 899925. doi:10.1017/ S0954579405050431 Ree, M. J., & Craigie, M. A. (2007). Outcomes following mindfulness-based cognitive therapy in a heterogenous sample of adult outpatients. Behaviour Change, 24(2), 7086. doi:10.1375/ bech.24.2.70 Reisch, T., Ebner-Priemer, U. W., Tschacher, W., Bohus, M., & Linehan, M. M. (2008). Sequences of emotions in patients with borderline personality disorder. Acta Psychiatrica Scandinavica, 118, 4248. doi:10.1111/j.1600-0447.2008.01222.x Rogers, R., & Kirkpatrick, T. (2005). Neuropsychology of borderline personality disorder. Psychiatry, 4(3), 3135. doi:10.1383/psyt.4.3.31.62441 Rosenthal, M. Z., Cheavens, J. S., Lejuez, C. W., & Lynch, T. R. (2005). Thought suppression mediates the relationship between negative affect and borderline personality disorder symptoms. Behaviour, Research and Therapy, 43, 11731185. doi:10.1016/j.brat.2004.08.006

200

Sandy Sachse et al.

Rosenthal, M. Z., Gratz, K. L., Kosson, D. S., Cheavens, J. S., Lejuez, C. W., & Lynch, T. R. (2008). Borderline personality disorder and emotional responding: A review of the research literature. Clinical Psychology Review, 28, 7591. doi:10.1016/j.cpr.2007.04.001 Ruocco, A. (2005). The neuropsychology of borderline personality disorder: A meta-analysis and review. Psychiatry Research, 137, 191202. doi:10.1016/j.psychres.2005.07.004 Schmertz, S. K., Anderson, P. L., & Robins, D. L. (2009). The relation between self-report mindfulness and performance on tasks of sustained attention. Journal of Psychopathology and Behavioral Assessment , 31, 6066. doi:10.1007/s10862-008-9086-0 Segal, Z. V., Williams, M., & Teasdale, J. D. (2002). Mindfulness-based cognitive therapy for depression: A new approach to preventing relapse. New York: The Guildford Press. Shapiro, S. L., Carlson, L. E., Astin, J. A., & Freedman, B. (2006). Mechanisms of mindfulness. Journal of Clinical Psychology, 62(3), 373386. doi:10.1002/jclp.20237 Soler, J., Trujols, J., Pascual, J. C., Portella, M. J., Barrachina, J., Campins, J., . . . P erez, V. (2008). Stages of change in dialectical behaviour therapy for borderline personality disorder. British Journal of Clinical Psychology, 47(4), 417426. doi:10.1348/014466508X314882 Spielberger, C. D. (1983). Manual for the StateTrait Anxiety Inventory (STAI). Palo Alto, CA: Consulting Psychologists Press. Stanford, M. S., Mathias, C. W., Dougherty, D. M., Lake, S. L., Anderson, N. E., & Patton, J. H. (2009). Fifty years of the Barrett Impulsivity Scale: An update and review. Personality and Individual Differences, 47(5), 385395. doi:10.1016/j.paid.2009.04.008 Teasdale, J. D., Segal, Z. V., Williams, J. M., Ridgeway, V., Soulsby, J., & Lau, M. (2000). Prevention of relapse/recurrence in major depression by mindfulness-based cognitive therapy. Journal of Consulting and Clinical Psychology, 68(4), 615623. doi:10.1037/0022-006X.68.4.615 Tombaugh, T. N. (2004). Trail Making Test A and B: Normative data stratied by age and education. Archives of Clinical Neuropsychology, 19, 203214. doi:10.1016/S0887-6177(03)00039-8 Verheul, R., Van den Bosch, L. M. C., Koeter, M. W. J., de ridder, M. A. J., Stijnen, T., & Van den Brink, W. (2003). Dialectical behaviour therapy for women with borderline personality disorder. Behaviour Research and Therapy, 43, 12311241. Walsh, J. J., Balint, M. G., Smolira, D. R., Frederickson, L. K., & Madsen, S. (2009). Predicting individual differences in mindfulness: The role of trait anxiety, attachment anxiety, and attentional control. Personality and Individual Differences, 46 , 9499. doi:10.1016/j.paid.2008.09.008 Williams, J. M., Duggan, D. S., Crane, C., & Fennell, M. J. V. (2006). Mindfulness-based cognitive therapy for prevention of recurrence of suicidal behavior. Journal of Clinical Psychology: In Session, 62(2), 201210. Williams, J. M. G., & Swales, M. (2004). The use of mindfulness-based approaches for suicidal patients. Archives of Suicide Research, 8, 315329. doi:10.1080/13811110490476671 Wupperman, P., Neumann, C. S., & Axelrod, S. R. (2008). Do decits in mindfulness underlie borderline personality features and core difculties?. Journal of Personality Disorders, 22(5), 466482. doi:10.1521/pedi.2008.22.5.466 Yen, S., Zlotnick, C., & Costello, E. (2002). Affect regulation in women with borderline personality disorder traits. Journal of Nervous and Mental Disease, 190, 693696. doi:10. 1097/00005053-200212000-00008 York, M. (2007). A qualitative study into the experience of individuals involved in a mindfulness group within an acute inpatient mental health unit. Journal of Psychiatric and Mental Health Nursing, 14, 603608. doi:10.1111/j.1365-2850.2007.01148.x Zanarini, M. C., Frankenburg, F. R., Hennen, J., Reich, D. B., & Silk, K. R. (2004). Axis I comorbidity in patients with borderline personality disorder: A follow-up and prediction of time to remission. American Journal of Psychiatry, 161, 21082114. doi:10.1176/appi.ajp.161.11.2108 Received 31 July 2009; revised version received 16 May 2010