Case Conceptualization
When Sara was between six and ten years old, her older brother sexually abused her. Sara’s mother did not believe Sara and emotionally distanced herself from her daughter. As a result, Sara developed a fear of being abandoned, thinking that “everyone will leave me” and “others hate me.” In relationships, Sara experienced great distress during breakups, and she has engaged in self-harm. Recently, these issues have been exacerbated by her being laid off and her husband rekindling his relationship with his daughter from the previous marriage. Now, Sara engages in self-harm and suspects that her husband wants to leave her.
Currently, Sara’s knowledge and acceptance of the problem allow the client to work on their relationship and be receptive to the therapist’s advice. Sara appears to be a smart, capable woman who is currently unemployed due to the company’s restructuring. She does not seem to think about her job performance in a negative way. In attachments, Sara’s core belief is that her partner will abandon her – an end of a relationship appears devastating, which led to Sara attempting suicide before. Her automatic thought of the husband’s infidelity may be tied to her being abandoned by her family (classical conditioning).
The present symptoms and signs suggest a borderline personality disorder (BPD) and a strong fear of abandonment, and the chosen strategy is Cognitive Behavioral Therapy (CBT). This condition is characterized by strong emotional responses, fear of abandonment, intense anger, paranoid ideations, self-mutilating behavior, and chronic feelings of emptiness (American Psychiatric Association [APA], 2013).
The Goal for Treatment and Intervention
In CBT for BPD, one of the specialized approaches is dialectical behavior therapy (DBT). According to Cattane et al. (2017), sexual abuse and abandonment in childhood often manifest in the development of BPD. Thus, the main goal of DBT for Sara is to address her emotional dysregulation and coping mechanisms (anger, jealousy, and self-harm). This goal includes smaller aims – Sara needs to learn to navigate relationships with her husband and his daughter and recognize how her jealousy affects the relationship. One of the objectives is to avoid unhealthy coping actions (self-harm) and replace them with self-affirmation and mindfulness (Cancrini & De Gregorio, 2018).
The approach of DBT is chosen as one of the highly researched strategies for clients with BPD. The goal of emotional regulation seems to be the most important since Sara’s jealousy and her anger toward David’s daughter seem to be at the center of the couple’s conflict. Sara experiences intense anger that she cannot control, and jealousy that leads her to disrupt David’s work. The proposed intervention would be performed individually with the client to maximize her openness about her feelings about her husband and his child. The sessions should include mindfulness exercises, cognitive restructuring, and change behavior practices.
Multicultural Factors and Environmental Issues
DBT is a type of CBT that focuses on the person’s emotions at the moment, teaching individuals to cope with distress and regulate responses. According to Niedtfeld et al. (2017), DBT has also been successful in helping persons overcome their need to self-harm. Thus, this particular subtype is chosen for the client’s specific issues. The strength of this strategy is its attention to the present – during sessions, the client will use her current relationships to understand her emotions. She will also learn to regulate them using exercises that she will be able to use outside of the office. However, as DBT requires the client to accept that a behavior change is necessary, it may be unhelpful if the client is not responsive.
The client’s cultural background may be a barrier to the program’s effectiveness. As Castellanos et al. (2019) find, DBT can be highly effective for Hispanic individuals if treatment content is adjusted to reflect the client’s values and traditions. For example, her relationship with family and religion may be explored to see their importance. In regards to environmental issues, the client’s current unemployment and her support network can be addressed. Sara’s layoff had a great impact on her mental health and relationship. It is possible to consider how financial issues may occupy her mind, lowering the effect of therapy.
Therapeutic Relationship
A therapeutic relationship is vital for CBT; however, it is also essential to establish strong boundaries when working with clients with issues of emotional dysregulation. For example, the balance between quiet responses and positive, empathetic responses is crucial not to discomfort the client (Kazantzis et al., 2018). Moreover, in initial sessions, it is necessary to allow the client to express her emotions to establish a bond and see the potential for future case formulation.
A potential barrier lies in Sara’s belief that therapy is the “last resort.” This has to be overcome through discussion and attentiveness to the client’s needs. My experience with CBT and my specialization in working with adults can be helpful in this case. I am aware of people’s common resistance behaviors, and I can use this knowledge to address Sara’s use of therapy to engage her in DBT and mindfulness.
References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). American Psychiatric Publishing.
Cancrini, L., & De Gregorio, F. R. (2018). Borderline personality disorder storyboard from the systemic family therapist’s perspective. In R. Pereira & J. L. Linares (Eds.), Clinical interventions in systemic couple and family therapy (pp. 15-29). Springer.
Castellanos, R., Spinel, M. Y., Phan, V., Orengo-Aguayo, R., Humphreys, K. L., & Flory, K. (2019). A systematic review and meta-analysis of cultural adaptations of mindfulness-based interventions for Hispanic populations. Mindfulness, 1-16.
Cattane, N., Rossi, R., Lanfredi, M., & Cattaneo, A. (2017). Borderline personality disorder and childhood trauma: Exploring the affected biological systems and mechanisms. BMC Psychiatry, 17(221), 1-14.
Kazantzis, N., Dattilio, F. M., McGinn, L. K., Newman, C. F., Persons, J. B., & Radomsky, A. S. (2018). Defining the role and function of the therapeutic relationship in cognitive behavioral therapy: A modified Delphi panel. International Journal of Cognitive Therapy, 11(2), 158-183.
Niedtfeld, I., Schmitt, R., Winter, D., Bohus, M., Schmahl, C., & Herpertz, S. C. (2017). Pain-mediated affect regulation is reduced after dialectical behavior therapy in borderline personality disorder: A longitudinal fMRI study. Social Cognitive and Affective Neuroscience, 12(5), 739-747.