1. Summarise your case study – the key facts.
“Thabo”, is a 50-year-old male with a diagnosis of Borderline personality disorder (BPD) who presented for therapy due to his depression and isolation. He describes experiencing high level of distress and anger on a daily basis. During these periods he describes having problems in controlling his emotions and impulses, which creates problems with friends and family. He has never been married and he has never been in a long-term relationship due to what he describes as long history of emotional dysregulation, perceived rejection and abandonment by previous partners. Thabo has a prejudicial childhood with child sexual abuse and emotional abuse by his father from the ages of 10 years to 15 years and his mother was not present in his childhood due to substance abuse. Thabo has had numerous hospital presentation with suicide ideations, suicide gestures and deliberate self-harm by cutting usually in the context of conflict with partners and family and friends. Thabo has chronic suicide ideations and tends to self-harm almost on a daily basis. Thabo has a history of binge drinking when in crises but denies any history of illicit drug use. Thabo’s willingness to engage in therapy was driven by the desire to change his life. He expressed his need of overcoming his emotional problems, finding purpose in his life and building better relationships. Having accepted his diagnosis and having an understanding of what BPD is Thabo displayed a self-awareness that showed that he was ready to engage in therapy. (Gunderson, et al.2003) states that maintaining first line treatment for BPD such as psychotherapy is practical and effective choice permitting the best way to improve the BPD symptoms.
2. Summarise the therapeutic intervention you used and why you chose that intervention – what and why.
Borderline personality disorder (BPD) is characterized by extreme sensitivity to perceived interpersonal slights, an unstable sense of self, intense and volatile emotionality and impulsive behaviours that are often self-destructive (Gunderson, et al.2018).Dialectical behaviour therapy (DBT) which is referred to as “talk therapy” was used as therapy for Thabo .DBT is a form of cognitive therapy that focuses of the role of cognition which refers to thoughts and beliefs ,behaviours, or actions in the development of treatment intended to help reduce the symptoms of BPD Shipherd, & Salters-Pedneault, (2017). Do acceptance and mindfulness moderate the relationship between maladaptive beliefs and posttraumatic distress?
The core problem in BPD is emotion dysregulation which is a result of biological factors and emotional unstable childhood environment, the focus of DBT is helping the client learn and apply skills that will decrease emotional and unhealthy attempts to cope with strong emotions by letting one experience, recognise and accept these emotions (Katsakou.C.2014) hence leading to change in harmful behaviours. Individual therapy was used where Thabo had one on one sessions. The goal of individual sessions is to help clients use the skills learned in group to reduce target behaviours such as suicidality, self-harm, use of substances, and so on (Van Dijk,2013). Goals were set and specific changes that Thabo wanted to change in his life were outlined.
The first stage of therapy was the pre-treatment stage where Thabo was assisted in modifying any beliefs that he had and the expectation about therapy were discussed. Assessment of Thabo was done and psychoeducation about his condition was discussed. most therapeutic errors are based on faulty assessment, which leads to an inaccurate understanding of the behaviour and why it’s happening (Adelufosi et al,2017). Commitment to therapy was obtained from Thabo and specific goals set.
Stage 2 involved focusing on behaviours that posed a direct threat to Thabo’s safety and stability. These behaviours are identified by Thabo through mindfulness meditation skills this focuses on Thabo learning to observe, describe and participate in all experiences including thoughts, sensations, emotions and things that are happening externally in the environment without judging these as good or bad (Salters-Padneaulters ,2018). Development of healthy coping strategies was done with Thabo where his hobbies and interests were used to develop these. Thabo was able to list his interests and made a list of using these as distraction techniques for when he was having negative thoughts. He was encouraged to use these when at home if he felt unsafe of was emotionally upset. These are coping strategies aimed at reducing suicide thoughts, behaviours that destabilise and are self-distractive and also address poor coping strategies although Reddy and Vijay (2017) state that DBT when compared to other structured therapies does not fare well with regard to core features of borderline personality disorder except showing equivalence with regard to improvement in suicide attempts. Coping skill training sessions are used to educate BPD clients on skills that they can incorporate daily (A Doyle,2015). This provides structure for Thabo who has problems with emotional dysregulation, Van Dijk (2018) describes emotional dysregulation as emotional reaction is usually more intense than warranted by the situation, and it takes them longer than the average person to recover from that reaction and to return to their emotional baseline. A behaviour tracking sheet was provided for Thabo and this allows Thabo to identify behaviours that interfere with life, therapy and quality of life. Skills training is interwoven throughout this process, so we weren’t simply analyzing the behaviour without trying to do anything about it. Completing a thorough analysis of a target behaviour is the first step in problem solving or stopping a target behaviour this was done by going through the behaviour sheet helped identify behaviours that were undesirable and discussions were done about how Thabo would address these. Positive reinforcement was done by complementing and acknowledging use of health coping strategies while in crisis. Thabo was encouraged to repeat positive behaviours as reinforcing a behaviour is somehow making it more likely that the behaviour will occur again(J.Gomez et al ,2017 ). Once targeted behaviours were under control Thabo proceeded to the next phase of treatment. Reddy and Vijay (2017) state that unlike cognitive behavioural therapy (CBT) which has a near-complete integration of its component cognitive and behavioural theories, DBT lacks such a good fit between the behavioural and dialectic theories because of their radically different philosophical presuppositions.
The third stage in the treatment was dealing with Post Traumatic stress. It has been found that many individuals with PTSD also exhibit BPD, and conversely, a diagnosis of PTSD is quite common among people with BPD.The trauma becomes the focus and exposure therapy is used to emotionally process past traumas as these contribute to ongoing pain and problem behaviours if left unresolved ( M ,Tull ,2017 ).Negative emotions leading to poor coping strategies were explored and acknowledged and then new behaviours that could be implemented were discussed and Thabo was encouraged to practice these.Choi-Kain et al (2018) reports that focuses on exposure with anti-dissociation skills, emotional regulation regarding shame and guilt, and acceptance on the trauma and the feelings a patient has surrounding it assists the client to move on from the trauma.
The last stage is increasing self-respect and achieving individual goals. This focused on helping Thabo work on trusting, valuing and respecting himself. Focus was also done on generalising the skills learnt in therapy with the aim that Thabo would utilise them for the rest of his life. Wunsch, E.-M., Kliem, S., Kröger, C. (2014) state that in this stage, the goal of treatment is for the client to move from a sense of incompleteness towards a life that involves an ongoing capacity for experiences of joy and freedom.
Telephone coaching was also used during therapy as a means to help Thabo when he was struggling in-between session. It was arranged from the start of the therapy that he would call during working hours and that he had to call after attempting to use agreed upon coping strategies. The aim of phone coaching was discussed with Thabo and pointed out that these will be brief lasting 5-10 minutes and that they will be to briefly discuss the crisis and help through the crisis and the details of the crisis can be discussed on the next session. Rizvi and Oliveira describe telephone coaching as a treatment mode in Dialectical Behaviour Therapy (DBT) that is designed to help clients generalize skills, prevent suicidal behaviours, and repair therapeutic ruptures DBT phone coaching is focused on providing clients with in-the-moment coaching on how to use skills to effectively cope with difficult situations that arise in their everyday lives.
Frequent workshops are conducted regarding DBT skills training for staff and having attended most of these to enhance my skills in conducting therapy for patients. On line training was also another way used to enhance DBT skills. Continuous reading of new researches and evidenced based evidence to keep up to date with new treatment methods was done constantly. Reddy and Vijay (2017) state that DBT needs therapists who are highly qualified (many studies by Linehan had doctoral-level professionals) and who have to be under regular supervision by attending 2-h consultation team meeting every week for learning skills and supervision. This presents problems with dissemination and resource usage, especially in non-academic centres, community, and resource-poor settings like India. Shenk (2015) states that if one part of the human environment is endangered by the patient’s intensity, there is always another, who can help both the patient and the other staff member, this is why the therapist needs supervision sessions either in groups with their colleagues or individually so as to share any challenges that they face and explore treatment options they can try.
It was noted that Thabo had fewer emergency department presentations towards the end of his DBT sessions which was an indication that there was significant improvement. Studies represent the creative application of DBT skills training as a means of improving global functioning by reducing dysfunctional behaviours, results from trials that utilize a naturalistic study design provide important data for program evaluation, but are more limited in terms of the reliability of conclusions that we can draw about treatment efficacy. Although Thabo has shown significant improvement in his mental state, social life and has developed appropriate coping strategies it is not certain that his improvement will be a lifelong improvement and that he would not relapse. Valentine and Bankoff (2014) state that future research would benefit from more precise measurements. For example, studies should use outcome measures that are sensitive to change over time, incorporate process measures that have been used or validated in other treatment modalities, measure therapist adherence to the treatment in a reliable and valid manner, and employ standardized assessments of skills use and skills acquisition.With phone coaching it was also noted that Thabo had reduced self harming behaviours and also towards the end of therapy Thabo Mede less and less calls for crisis support.
There were numerous ethical dilemmas that were faced during therapy due to the challenging and complex nature of clients with borderline personality disorder.Discussing with Thabo about the increase in suicide risk when therapy is underway and Thabo has to deal with past conflict that lead to emotional distress.Ethically,disclosure risk demonstrates respect for the patient and may result in increased trust. On the other hand, disclosing might be harmful to the patient (e Howel,2013). Having disclosed this helped Thabo to prepare for the emotional challenges that he had to face and coping strategies were put in place for him to utilise.Putting in place boundaries for telephone coaching was another ethical challenge that was faced as people with broaderline personality disorder tend to view boundaries as abandonment as they have faced this on numerous occasions.With Thabo explanations were given for the phone sessions to be within business hours and that if he called there may be a time period that he would have to wait before he received a call back.The need to put these boundaries in place were aimed at avoiding creating dependency and try and encourage independent coping strategies.The strategies used for telephone consultation are designed to minimise reinforcement of parasuicidal behaviors,for that reason, patients are told at the beginning of therapy that they are expected to call their individual therapist before engaging in parasuicidal behavior. In addition, the patient is not allowed to call the therapist for 24 hours after engaging in parasuicidal behaviour unless there are life-threatening injuries. The 24-hour rule is meant to encourage patients to seek help from the therapist at earlier stages of a crisis while the therapist can still offer assistance and not after the patient has already chosen maladaptive behaviors.Thabo was warned against abusing the phone coaching as this is one of the risks that occurs.Guilford (1993) states that patients who abuse the telephone conversations, this becomes a therapy-interfering behaviour that is addressed during individual therapy sessions. Patient confidentiality was another ethical dilemma that was faced as at times it was necessary to ventilate to colleagues as it is taxing emotionally when dealing with people with borderline personality disorder.This was done through supervision where 1:1 sessions occurs between colleague and colleague to allow shared ideas and new based evidence practice.It helped when Thabo attempted suicide due to situational crisis in his personal life and guilt was prominent Roiff (2014) states that this avoids wrongly transfer a patient in response to guilt therapist should seek out assistance from trusted colleagues to help sort out these feelings and questions.