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Dialectical Behaviour Therapy for Personality Disorder Case Study

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Updated: Sep 9th, 2021

The rationale for Dialectical Behaviour Therapy

Terri is a 39-year-old woman who is seeking assistance because of her history of self-harm behaviors and suicidal thoughts and actions, periods of depression, and anxiety. Analyzing Terri’s case, the signs to pay attention to include her lack of confidence observed since the woman’s childhood, suicidal activities, episodes of depression, and her dissatisfaction with life. Additionally, Terri demonstrates stable behaviors associated with developing her career but has thoughts about changing it. She is unable to build close relationships with people, and she also fears criticism. Thus, Terri’s personality can be characterized by switching moods, focusing on negative aspects in her life, having an inadequate self-image, impulsive and suicidal actions, unstable relationships with her family and partners, and feelings of emptiness. These signs are associated with a borderline personality disorder, and the evidence-based therapeutic intervention for this disorder is dialectical behavior therapy (DBT).

The application of DBT for Terri’s case can be explained with reference to discussing the origins of her current psychological state. DBT was specifically developed as the variant of cognitive behavioral therapy to address the problems of individuals suffering from such symptoms as self-harm, suicidal behavior, and depression (May, Richardi, and Barth 2016). In the context of DBT, individuals are trained to develop their interpersonal effectiveness, mindfulness, emotion regulation, and distress tolerance skills (DeCou, Comtois, and Landes 2019). The causes of Terri’s inability to build stable relationships with other people are problems with asserting her needs based on her childhood experience of living with an abusive and critical mother. Terri lacks self-confidence, developed in a relationship with an abusive partner. Currently, she is not satisfied with her relationship, and she also lacks friends. Thus, Terri needs to develop interpersonal effectiveness skills to learn how to manage her relationships with people in the context of DBT.

Terri assesses situations in her life and her roles, focusing on negative thoughts. Consequently, she tends to blame herself for not realizing her potential. The focus on mindfulness as part of the therapy will help her to become aware of all experiences in her life while accepting them without judging (McMain et al., 2017). She will learn how to feel and react to different situations without feeling guilty. Terri experiences problems with managing emotions, and she often feels depressed and dissatisfied. The development of emotion regulation skills in the context of DBT will contribute to her psychological state. Furthermore, Terri needs assistance in how to manage stress and crises in her life to avoid self-harm and suicidal activities. For these purposes, the development of distress tolerance skills is required.

DBT is selected as appropriate for the case of Terri because of the dialectical component. Thus, it is important for Terri to focus on acceptance of her traits and behaviors and demonstrate how certain reactions can be positively changed for her. Positive changes are possible with reference to developing emotional regulation and interpersonal effectiveness (Jobes, Au, and Siegelman 2015). Terri will benefit from participating in DBT and will address her current problem.

Specific Details of Applying Dialectical Behaviour Therapy

The choice of DBT is supported by the analysis of Terri’s problems related to the areas of emotional regulation, interpersonal relations, distress management, and mindfulness. DBT for Terri should include participation in individual treatment, a skills training group, as well as phone coaching (Reddy and Vijay 2017). Individual treatment will be divided into four stages typical of DBT and adapted according to Terri’s needs: coping with life-threatening behaviors and specific therapy-interfering behaviors, improving the quality of life, and acquiring new skills. During skills training in a group, Terri will develop her skills in communicating with other people (Rudge, Feigenbaum, and Fonagy 2017). Before starting therapy sessions, it is important to establish rapport with Terri with the help of ensuring her that the therapist accepts her personality and her right to act in this or that manner. Terri should be encouraged to discuss her problems and change behaviors that influence her life negatively.

Addressing with Life-Threatening Behaviours

Currently, Terri is suffering from infected self-harm injuries, and she attempted to commit suicide at the age of 30. The woman can suffer from the crisis typical of middle-aged people when she tries to understand her achievements and contribution as an individual. In order to address these forms of suicidal behaviors, it is necessary to set goals for the therapy with a focus on avoiding self-harm injuries and suicidal thoughts and actions in the future. Terry should be proposed to complete diary cards to focus on her emotions and feelings every day (Barnicot et al., 2016). These cards will be discussed during weekly sessions.

In the context of distress tolerance training, Terri should learn how to cope with stress caused by her interactions with her mother, partner, or other situations with the help of certain techniques and practices. They include choosing positive and enjoyable activities to focus on, comparing the personal situation with worse cases in other people’s lives, relaxation, praying, meditation, and taking days off (Dunster-Page et al., 2017). If Terry notices suicidal thoughts, she needs to call her therapist and share her ideas as well as discuss the problem in the context of phone coaching.

Addressing Therapy-Interfering Behaviours

The therapist is expected to respect Terri’s needs and interests during DBT and motivate her to attend all planned sessions. If Terri demonstrates therapy-interfering behaviors, such as lateness, non-attendance, lying, non-collaboration, and passivity, the therapist should communicate with the woman and ask her to reveal true reasons for her behavior without judging her. Terri should be encouraged to share what current events, feelings, and emotions prevent her from participating in DBT and following the therapist’s recommendations.

Improving the Quality of Life

Terry needs to improve the quality of her life while coping with destructive thoughts about her potential and career. She also needs to change her relationships with her mother and sister and improve relationships with her partner, overcoming the problem of lacking physical intimacy. In the context of developing mindfulness skills, Terri should practice accepting her past and current life situations without judging her behavior. She is expected to learn how to avoid discussing her life as a failure or fearing mistakes. Terri also needs to practice mindfulness meditations to address and prevent painful and negative thoughts about her life and potential (Berk et al., 2019). These techniques will help Terri accept her personality as an individual who achieved successes in her life, received education, and was valued by bosses.

If mindfulness is associated with the component of acceptance, the next step in dialectical behavior therapy is the change with the help of emotional regulation. Terri should be taught how to recognize and name her emotions and then asked to complete diary cards describing her daily feelings and experiences in terms of associated emotions. Then, Terri and the therapist will discuss these emotions, and unwanted emotions will be replaced by opposite emotions (Roscoe et al., 2016). As a result, Terri will learn how to regulate her emotions associated with thinking about her career, personal life, and relationships with the family to change them into positive ones. The focus is on increasing Terri’s self-esteem and changing her vision of her potential as a personality.

Acquiring New Skills

Referring to Terri’s case, it is possible to state that she lacks skills in communication, self-management, and the development of close relationships. Terri needs to be educated on how to care about herself with the help of daily routines, relaxation and meditation techniques, sports activities, work-and-life balance, sleep, and a healthy diet. As a result, Terri will learn to focus on her needs and desires and become more energetic (Barnicot et al., 2016; Sinnaeve et al., 2018). To enhance communication skills and abilities in developing close relationships, Terri is recommended to participate in the skills training group.

Skills Training Group

In weekly group sessions, Terri will interact with other people to practice her communication skills, trust, leadership, and self-confidence. The woman will focus more on acceptance of her behaviors and changing them through learning distress tolerance, interpersonal effectiveness, mindfulness, and emotion regulation in a group of other people with similar problems. Thus, Terri will be taught how to deal with crises with the help of such techniques as radical acceptance and self-soothing (McMain et al., 2017). Terri will develop her interpersonal effectiveness with the help of learning how to interact with people she does not like or is afraid of. She will focus on developing her self-respect, being fair, saying “no,” and focusing on her values.

Mindfulness can also be trained in the context of group teachings. Thus, Terri will learn how to remain concentrated on her current life rather than fearing possible failures in the future or remembering painful experiences from the past. The woman will be educated on how to cope with her worries and focus on her current emotions while accepting them (May, Richardi, and Barth 2016). It will also be possible to develop her skills in emotion regulation through learning techniques of controlling and changing negative emotions.

Reflective Account

After presenting the details of therapy for Terri, it is also necessary to evaluate the effectiveness of the proposed DBT in terms of its advantages and disadvantages for the client. The strengths of DBT while being applied to the case of this 39-year-old woman are in the effectiveness of this intervention to cope with suicidal behaviors as a therapy priority. Suicidal and self-harm behaviors are addressed by therapists at the first stage of implementing DBT that allows for minimizing risks for a client and stabilizing the emotional state (Reddy and Vijay 2017). From this perspective, DBT is usually viewed as one of the most effective therapies to help clients with a history of self-injuries and suicidal behaviors.

One more strength of DBT to be applied to Terri’s case is associated with its complex and dialectical character. Terri receives opportunities to work with all problematic areas in her life related to her self-image, depression, and relationships to change current visions and emotions to positive ones. Terri will not only accept her emotions without feeling guilty for them and perceiving her life and behavior as a failure, but she will also change destructive emotions to improve her quality of life. DBT can be discussed as fitting the client’s needs, and the use of individual therapy and group meetings will be beneficial for Terri to improve her psychological state and develop the required skills.

Limitations of DBT that should be taken into account while working with the woman include the length of therapy, costs, and complexity. Usually, DBT sessions are conducted for one year and more, and the barrier is that a client needs to be highly motivated to attend a therapist and group classes each week (Carmel, Rose, and Fruzzetti 2014). It is important to guarantee that Terri is encouraged to participate in these sessions. Furthermore, the necessity of receiving assistance from a therapist for a long time is associated with significant expenses. Terri has a good job position now, but any changes in her career affecting her income can lead to ceasing DBT sessions. In addition, the need for both individual and group forms of therapy can be regarded by the client as a challenge, and the therapist should motivate Terri to participate in all variants of the therapy.

A client and a therapist have specific roles and responsibilities associated with their involvement in DBT. The responsibility of Terri is to be oriented towards cooperation with the therapist to receive positive outcomes, she needs to have high motivation. Furthermore, the client should not be late for sessions and should not avoid visiting the therapist or group meetings. The role of the therapist is to accentuate acceptance, support, and the necessity of collaboration. The therapist practicing DBT is sensitive, responsive, empathetic, and supportive (Rudge, Feigenbaum, and Fonagy 2017). Being focused on the dialectical nature of therapy, the professional accentuates the acceptance of the client’s behaviors, views, and emotions, emphasizes their meaning using paradoxes, and tactfully stimulates the client to change inappropriate behaviors.

Reference List

Barnicot, K., Gonzalez, R., McCabe, R., and Priebe, S. (2016) ‘Skills Use and Common Treatment Processes in Dialectical Behaviour Therapy for Borderline Personality Disorder’. Journal of Behavior Therapy and Experimental Psychiatry 52, 147-156.

Berk, M. S., Starace, N. K., Black, V. P., and Avina, C. (2019) ‘Implementation of Dialectical Behavior Therapy with Suicidal and Self-Harming Adolescents in a Community Clinic’. Archives of Suicide Research 2, 1-20.

Carmel, A., Rose, M. L., and Fruzzetti, A. E. (2014) ‘Barriers and Solutions to Implementing Dialectical Behavior Therapy in a Public Behavioral Health System’. Administration and Policy in Mental Health and Mental Health Services Research 41 (5), 608-614.

DeCou, C. R., Comtois, K. A., and Landes, S. J. (2019) ‘Dialectical Behavior Therapy Is Effective for the Treatment of Suicidal Behavior: A Meta-Analysis’. Behavior Therapy 50 (1), 60-72.

Dunster-Page, C., Haddock, G., Wainwright, L., and Berry, K. (2017) ‘The Relationship Between Therapeutic Alliance and Patient’s Suicidal Thoughts, Self-Harming Behaviours and Suicide Attempts: A Systematic Review’. Journal of Affective Disorders 223, 165-174.

Jobes, D. A., Au, J. S., and Siegelman, A. (2015) ‘Psychological Approaches to Suicide Treatment and Prevention’. Current Treatment Options in Psychiatry 2 (4), 363-370.

May, J. M., Richardi, T. M., and Barth, K. S. (2016) ‘Dialectical Behavior Therapy as Treatment for Borderline Personality Disorder’. Mental Health Clinician 6 (2), 62-67.

McMain, S. F., Guimond, T., Barnhart, R., Habinski, L., and Streiner, D. L. (2017) ‘A Randomized Trial of Brief Dialectical Behaviour Therapy Skills Training in Suicidal Patients Suffering from Borderline Disorder’. Acta Psychiatrica Scandinavica 135 (2), 138-148.

Reddy, M. S., and Vijay, M. S. (2017) ‘Empirical Reality of Dialectical Behavioral Therapy in Borderline Personality’. Indian Journal of Psychological Medicine 39 (2), 105-108.

Roscoe, P., Petalas, M., Hastings, R., and Thomas, C. (2016) ‘Dialectical Behaviour Therapy in an Inpatient Unit for Women with a Learning Disability: Service Users’ Perspectives’. Journal of Intellectual Disabilities 20 (3), 263-280.

Rudge, S., Feigenbaum, J. D., and Fonagy, P. (2017) ‘Mechanisms of Change in Dialectical Behaviour Therapy and Cognitive Behaviour Therapy for Borderline Personality Disorder: A Critical Review of the Literature’. Journal of Mental Health 1, 1-11.

Sinnaeve, R., Van den Bosch, L. M., Hakkaart-van Roijen, L., and Vansteelandt, K. (2018) ‘Effectiveness of Step-Down Versus Outpatient Dialectical Behaviour Therapy for Patients with Severe Levels of Borderline Personality Disorder: A Pragmatic Randomized Controlled Trial’. Borderline Personality Disorder and Emotion Dysregulation 5 (1), 12-18.

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