The case being analyzed this week deals with a 36-year-old single, unemployed female who is believed to be suffering from a condition known as borderline personality disorder. But what is borderline personality disorder (BPD)? BPD is often characterized by unpredictable, unbalanced and erratic behavior, moods, and relationships (Gorenstein & Comer, 2015; Sneed et al., 2012). People with this condition often find that they cannot appropriately regulate their emotions, maintain healthy and positive interpersonal relationships, they have a poor self-image, suffer from severe, unhinged mood swings, impulsivity, and are just overall really unstable. The severity of the instability often leads patients to engage in many self-destructive behaviors, such as self-inflicted injuries, promiscuity, and even suicidal behavior (Sneed et al., 2012). Nevertheless, while difficult, this condition is treatable.
To begin, it is important to garner an understanding of the patient and her background. The patient, Karen, is a single, unemployed 36-year-old who was recently admitted to a medical center for purposely overdosing on sedatives, which she consumed with alcohol. Karen has a fairly lengthy history of self-inflicted injuries and suicide attempts. She also has a history of substance use, with her alcohol and drug use varying greatly depending on her relationship status. Typically, when Karen is in a relationship, she feels more positive about life, as if it somehow holds more significance and purpose. However, at the minutest indication of trouble/problems within the relationship, it triggers profound emotional suffering (Gorenstein & Comer, 2015). But what led to this sort of dysfunction? Karen has a background that is riddled with abuse. Though they looked stable and happy on the outside, her family was severely violent and abusive. Her father both physically and sexually abused her, with the sexual abuse beginning when she was the ripe age of six. Additionally, one of her older brothers, John, also began sexually abusing her weekly from the time she was six until her other older brother put a stop to it when she was 18. To add insult to injury, when Karen tried to tell her mother what was happening to her, her mother lashed out verbally and physically. When Karen moved away after graduation, she met a man at her place of employment, began dating him, and then they were married a few weeks later. Her husband, though kind in the beginning, soon turned accusatory, controlling, and abusive. He often beat her for merely thinking she might have deceived him about something. At this point in time, Karen found it tremendously challenging to judge her life with her husband. Though she hated being abused, she did not know whether or not she actually deserved this treatment, or even if she could find anyone that might treat her better. Luckily, she only had to endure the abuse three years, as her husband was killed in an accident 3 years into their marriage (Gorenstein & Comer, 2015). This, however, through Karen into severely uncharted territory and left her in complete confusion and devastation, which ultimately led to her psychological decline.
In terms of theoretical orientation(s), dialectical behavioral therapy is part of the cognitive-behavioral orientation; however, there are also biological and social-environmental underpinnings as well. Each of Dr. Banks’ proposed interventions are largely targeted to shift both maladaptive behaviors and thought processes to more typical, healthy behaviors and thought processes. To achieve this, Dr. Banks will work in stages (Gorenstein & Comer, 2015). The interventions that Dr. Banks is proposing, include: Outlining the process of DBT, having Karen promise that she will go to group behavioral skills training, as well as individual psychotherapy, and requiring that Karen engage in imaginal exposure to trauma so that her memories no longer trigger prominent distress (Moten, 2014).
Originally established by Marsha Lineham, dialectical behavioral therapy (DBT) is a socio-psychological treatment designed for patients with borderline personality disorder (Rizvi et al., 2013). This form of therapy encompasses four treatment approaches that are intended to deal with five primary functions. These five primary functions include: enhancing motivation to change, improving capabilities, and generalizing client gains to larger environments, shaping environments to reinforce those gains, and increasing therapists’ impetus and expertise (Rizvi et al., 2013, p. 74). The aforementioned four approaches to therapy include individual therapy, group skills training, discussions between client and therapist outside of therapy session as deemed necessary, and team conferences among therapists (Rizvi et al., 2013). Moreover, DBT is driven by three predominant theories, which are biosocial theory, behavioral theory, and dialectical philosophy (Rizvi et al., 2013).
In terms of the pretreatment stage, Dr. Banks primary goal is to have the client, Karen, commit to undergo therapy for a specified duration. Dr. Banks believed this was crucial to Karen’s overall treatment course because of the frequency with which borderline patients impulsively and prematurely terminate therapy on the basis of past discouraging experiences. To establish the trust for such a commitment, Dr. Banks met with Karen for two full sessions to get her history in an effort to garner a more profound awareness and understanding of Karen’s personal experiences. This ultimately allowed Karen to see that Dr. Banks was truly invested in helping her get better (Gorenstein & Comer, 2015). Moreover, Dr. Banks also went over the principles and techniques of DBT with Karen, which Karen found quite impressive and helped make the decision to commit to therapy for at least 6 months. Dr. Banks explicated to Karen that the therapy was intended to help Karen learn more efficacious ways to deal and cope with her emotions, which would eventually help alleviate some of the adverse behaviors exhibited by Karen due to her poor emotional regulation.
Like numerous other therapists who specialize in utilizing DBT, Dr. Banks generally administers treatment on two fronts. The two fronts that Dr. Banks revealed to Karen and explained would be part of her treatment include behavioral skills training groups and individual psychotherapy. The purpose of the behavioral skills training groups is to help Karen cultivate necessary behavioral skills. Individual psychotherapy is intended to assist Karen in focusing on what is taking place at the moment and helping her through times of crisis, as well as managing Karen in the appliance of her new behavioral skills (Gorenstein & Comer, 2015).
As mentioned previously, there are three primary stages of DBT, along with a pre-treatment stage. In this section, the second and third stages of treatment will be discussed. The second stage of treatment in DBT involves reducing distress due to past traumas. For Karen, this stage focused largely on helping her prevail over persistent feelings of anguish due to her past traumas of abuse, particularly the sexual abuse she suffered (Gorenstein & Comer, 2015). This was done through a type of exposure therapy, where Karen was required to talk about her abuse experiences in general terms over and over. As she did this, Karen became less distressed when recounting her abuse and subsequently began to give more details as time progressed. Even when Karen was recalling the abuse in great detail, over time even the most detailed of explanations produced mild upset. This exposure therapy was later applied to other traumatic experiences/memories and had alike outcomes (Gorenstein & Comer, 2015). The third stage of treatment in DBT is concentrating on longer-term issues. For Karen, this meant focusing on the procurement of better self-respect and attaining social, career, and interpersonal objectives (Gorenstein & Comer, 2015). Luckily, with the advances Karen had been making throughout the first and second stages of the treatment course, achieving these goals was happening naturally. Therefore, during this stage of therapy, Dr. Banks and Karen focused largely on solidifying all the progress Karen had been making, and was continuing to make (Gorenstein & Comer, 2015).
As the consulting clinical psychologist on this case, I would recommend that Dr. Banks and Karen utilize video teleconferencing (VTC) between sessions. VTC can be accessed from any smartphone device and allows for real-time communication between patients and their providers regardless of where either party is located (Luxton et al., 2011). As long as there is a wireless signal, VTC should be manageable/accessible. I believe this would be a beneficial e-therapy tool in Karen’s case, as it allows her to directly and visually connect to Dr. Banks in times of crisis, and subsequently enables Dr. Banks to better gauge Karen’s emotional state via seeing and hearing. This ability to see and hear the patient will ultimately allow Dr. Banks to come up with an effective way to regulate Karen and guide her through her crisis and get her back on track. However, while telecommunication is a convenient tool and becoming more integrated within the medical and mental health realm(s), it should be noted that there are possible ethical concerns and liabilities that must be considered and addressed sufficiently. As with any form of therapy, a patient’s right to confidentiality and having their information safeguarded is something that must be addressed at to outset. Thus, informed consent should be obtained in both instances of in-patient therapy and outpatient-telehealth therapy. Some liabilities would include liability for negligence and abandonment (Miller, 2006). There is ground for a liability for negligence when a provider fails to provide services that should have been delivered and this negligence leads to harm or injury to the patient. However, in order to prove such injury or harm, the patient must illustrate severe damage or extreme and disgraceful conduct of the provider (Miller, 2006). Additionally, all parties should be trained in utilizing the technology with which they plan on use for e-therapy sessions. In addition to negligence, liability for abandonment could be an issue in the event that a provider one-sidedly terminates the relationship with the patient, or the liaison is ended without proper or reasonable notice when continued assistance was needed (Miller, 2006). To avoid such liabilities, all parties should be knowledgeable in the use of telehealth and a disclaimer should be signed before the outset of e-therapy.
When it comes to the effectiveness of the treatment interventions implemented by Dr. Banks, it would appear that they are quite efficacious in helping Karen function on a more normal level, rather than the sort of erratic pendulum she was traversing prior to getting proper treatment. DBT is evidenced in many studies to provide positive outcomes for patients with BPD, but many studies also include patients with comorbid PTSD. Although PTSD was not mentioned in this case with Karen, it is likely that she could possibly be suffering from BPD and PTSD. Many studies show significant positive change rates in symptoms of PTSD and BPD; such as, suicide attempts, non-suicidal self-injury (NSSI), psychological distress, and other BPD symptoms through the implementation of DBT (Andreasson, 2016;Boritz, Barnhart, & McMain, 2016). Though it should be noted that DBT is not the only therapeutic intervention that has showed promising results. In the case of Karen, we see that DBT interventions prove extremely efficacious. Though at first hesitant about behavioral skill training groups, Karen began to make great progress in terms of acquiring mastery in particular skill areas, and becoming comfortable and grateful for the support the groups was providing her. Additionally, she got great satisfaction out of being a support system to others like her (Gorenstein & Comer, 2015). Karen began to learn how to regulate her emotions and emotional reactions in such a way that her ability to distinguish what she was feeling and why she was feeling it became easier for her to voice not only in therapy settings, but in her interpersonal relationships as well. Moreover, Karen learned coping-strategies that ultimately allowed her to stop self-harming and reduced her use of alcohol consumption during times of crisis (Gorenstein & Comer, 2015). In the end, and over the course of a couple of years, Karen was able to regain control over her mental and emotional state through the utilization of DBT and individual psychotherapy, so much in fact that she is holding down and part-time job and going to college successfully (Gorenstein & Comer, 2015).
Finally, and in conclusion, three additional treatment intervention that would be applicable in Karen’s case include: Schema-focused therapy (SFT), mentalization-based therapy (MTB), and manual-assisted cognitive therapy (MACT). SFT may be beneficial in helping Karen further overcome maladaptive schemas she developed during her early childhood experiences. This was a time where she was physically and sexually abused, often being called names like “whore” and having the “devil” beat out of her. These schemas developed early on have likely contributed to some of Karen’s maladaptive behaviors and emotional responses; thus, a primary goal of SFT is to help the patient assume the Healthy Adult Mode, demonstrated by the clinician, in an effort to regulate both behavioral and emotional patterns so that conveying their emotions and needs becomes easier and more socially appropriate (Sneed et al., 2012). Mentalization-based therapy endeavors to help patients make sense of their own actions and those of others. This therapy understands that there is an inhibition in mentalization in BPD patients, which often results in problematic interpersonal relationships with others. MBT is not meant to focus on relationship patterns, rather it endeavors concentrate on the way patients consider, sense/experience, and comprehend their interpersonal experiences (Sneed et al., 2012). This would be important in Karen’s case, as she has a history of poor interpersonal relationships and experiences, which often times have led to her use of self-mutilation. This form of therapy often uses art and writing to help with personal expression. Lastly, manual-assisted cognitive therapy would be a great addition to the already established interventions. MACT consists of six therapy sessions wherein patients concentrate on reading self-healing and educational material. Each therapy session is designed around a chapter from the reading material, and such material goes over topics of behavioral and/or functional evaluation of parasuicidal episodes, problem-solving approaches, emotion regulation tactics, and the controlling of negative thoughts and substance utilization. Additionally, this intervention helps with coming up with effective plans for avoiding relapse (Sneed et al., 2012). Each of these additional interventions could benefit Karen by enabling her to live her life in the best way possible for herself and her condition, through educating her on how to manage distress, emotional dysregulation, risky behaviors, and interpersonal relationships.
References
Andreasson, K., Krogh, J., Wenneberg, C., Jessen, H. L., Krakauer, K., Gluud, C., & ... Nordentoft, M. (2016). Effectiveness of dialectical behavior therapy versus collaborative assessment and management of suicidality treatment for reduction of self‐harm in adults with borderline personality traits and disorder—A randomized observer‐blinded clinical trial. Depression And Anxiety, 33(6), 520-530. doi:10.1002/da.22472
Boritz, T., Barnhart, R., & McMain, S. F. (2016). The influence of posttraumatic stress disorder on treatment outcomes of patients with borderline personality disorder. Journal Of Personality Disorders, 30(3), 395-407. doi:10.1521/pedi_2015_29_207
Gorenstein, E. E., & Comer, R. J. (2015). Case studies in abnormal psychology (2nd ed.). New York, NY: Worth Publishers.
Luxton, D. D., McCann, R. A., Bush, N. E., Mishkind, M. C., & Reger, G. M. (2011). mHealth for mental health: Integrating smartphone technology in behavioral healthcare. Professional Psychology: Research and Practice, 42(6), 505-512. doi:10.1037/a0024485
Miller, T. W. (2006). Telehealth issues in consulting psychology practice. Consulting Psychology Journal: Practice and Research, 58(2), 82-90. doi:10.1037/1065-9293.58.2.82
Moten, S. (2014). PSY650 Week four treatment plan📷📷 [PDF]. College of Health. Ashford University: San Diego CA.
Rizvi, S. L., Steffel, L. M., & Carson-Wong, A. (2013). An overview of dialectical behavior therapy for professional psychologists. Professional Psychology: Research and Practice, 44(2), 73-80. doi:10.1037/a0029808
Sneed, J. R., Fertuck, E. A., Kanellopoulos, D., & Culang-Reinlieb, M. E. (2012). Borderline personality disorder. In P. Sturmey & M. Hersen (Series Eds.), Handbook of evidence-based practice in clinical psychology: Vol. 2. Adult disorders. (pp. 507-529) [E-book]. Hoboken, N.J.: John Wiley & Sons.
�@���
Comments