Cognitive Behavioural Therapy (CBT) - Case Study Example

Cognitive Behavioural Therapy (CBT) This is an account of the ongoing psychotherapeutic intervention in the life of a patient named Karen, a 36-year old single unemployed woman, only recently identified as suffering from Borderline Personality Disorder (BPD) with a history of self-harm, numerous failed interpersonal relationships and suicidal behaviour. She is being treated by Dr Dierdra Banks, utilising dialectical behaviour therapy, a variant of Cognitive Behaviour Therapy (CBT). The processes and rationale for the interventions by Karen’s therapist is examined in some detail in this paper. Some information on Karen available to Dr Banks before undertaking psychotherapy is outlined below. Karen left her parental home at the age of 18 after graduating from high school and took up residence in lodgings in the neighbouring county. She found work as a waitress in a local diner. Just a few weeks after finding work, she married George whom she had met while at work. A very controlling and violent man, George dominated Karen in what seemed to be a repetition of the conditions under which Karen grew up. Her father had been violent and sexually abusive from the time she was six years old. As she grew older (13) her oldest brother continued the sexual abuse, until her other brother, nearer to her in age, put a stop to it. She was 16 at the time. George, her husband, would be nice to her on rare occasions, taking her out to dinner and dances, and would compliment her on her good looks. George proved to be a very jealous husband and forced her to give up work. She was virtually kept prisoner confined to the house. Even with the occasional beatings, and not knowing any better, she put up with it and appeared to accept the situation as ‘normal’. Unfortunately George died in an accident barely three years into their marriage. Karen was devastated. She had been totally dependent on him. He had created, as it were, both the centre and the boundaries of her universe. She was diagnosed a clinical depressive, and underwent psychiatric hospitalisation. Since then, over the past 15 years, until the time she came under the psychotherapeutic care of Dr Banks, she had been hospitalised at least on 10 more occasions. During that time she had been in the care of at least nine different psychotherapists, psychiatrists, social workers, and psychologists as an outpatient, one of whom was to abuse her sexually. Since her husband, George’s death, Karen’s love life had been a roller coaster affair involving fraught relationships with a number of men in succession. She was able to share rooms with another single girl who sought the help of a counsellor after an attempt by Karen at self-harm following a broken relationship. Cecily, the roommate had described this period as ‘two years of hell’. Karen would try to control Cecily’s movements on occasions whenever she felt abandoned by the man she was dating at the time. Most of these relationships were of the same abusive pattern with the men getting tired of Karen after a period of intense sexual activity. Before Karen came under the care of Dr Banks, she had been hospitalised after her third attempt at suicide by ‘taking an overdose of sedatives combined with alcohol’ (Attachment 1). On discharge from hospital Karen’s regular counsellor at the time had refused to continue seeing her and was discharged ‘into the local community mental health system, where she received once-a-month medication management and weekly group therapy’ (Attachment7). Until she was referred to Dr Dierdra Banks, her condition of borderline personality disorder had never been identified and documented. Karen was later able to describe this referral and the recognition of her psychiatric condition as “the break of a lifetime’. The Diagnostic and Statistical Manual of Mental Disorders 4th Edition, American Psychological Association (DSM-IV) (2000) provides the following Checklist as an aid to diagnosing Borderline Personality Disorder. A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adulthood and present, in a variety of contexts, as indicated by at least five of the following. Frantic attempts to avoid real or imagined abandonment. A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation. Identity disturbance markedly and persistently unstable self-image or sense of self. Impulsivity in at least two areas that are potentially self-damaging (for example, spending, sex, substance abuse, reckless driving, binge eating). Recurrent suicidal behaviour, gestures, or threats, or self-mutilating behaviour. Affective instability due to marked mood reactions. Chronic feelings of emptiness. Inappropriate intense anger or difficulty controlling anger. Transient stress-related paranoid ideas or severe dissociative symptoms. (Attachment 1) It is quite clear that Karen has in her adult life shown most of the above symptoms and it is strange that it had taken more than half her lifetime for someone to come up with the correct diagnosis of her psychiatric condition. Such a diagnosis, undertaken by Dr Banks was after a lengthy initial consultation where ‘Karen described her problems and history’ (Attachment7) whereby a basis for trust between client and therapist could be established. The first goal of therapy is to establish ground rules, boundaries, number and frequency of sessions, and in the case of CBT, the need for homework assignments. In other words, there is a great deal of pre-planning and “contract setting” involved. However, it is also essential that the patient is not overwhelmed with too much detail (Oldham, Gabbard, Goin, Gunderson, Soloff, Spiegel, Stone & Philips, 2001).Another consideration that may limit a client’s initial capacity to benefit from therapy, is the level of cognitive processing achieved in childhood. It is quite possible that Karen is still at the Piagetian preoperational level of cognitive processing. Dr Banks therefore may need to spend time with Karen to ‘drag the patient to the point where she can function using formal operations and so understand the consequences of her own behaviour’ (Attachment 11). The fact that Karen had worked in the past in secretarial positions (apart from waitressing) may give some indication as to her capacity to overcome such limitations. Cognitive therapy developed by Dr Aaron Beck and later cognitive behavioural therapy, were initially utilised for the treatment of depression, but has developed over the years to become the treatment of choice for a large number of psychiatric disorders including borderline personality disorder (Attachment 15). Not only have anxiety disorders been ‘treated effectively with cognitive therapy, but also substance abuse, borderline personality, paranoid delusional disorder, marital conflict and anger’ (Attachment 14). CBT focuses on changing thoughts and behaviour patterns that have become rigid and non-productive for the sufferers of psychiatric disorders. A variant of CBT is dialectical behaviour therapy, that Dr Banks specialises in, which ‘helps reduce destructive behaviours by teaching healthy ways to adapt to and cope with challenges and feelings of frustration and lack of power’ (WebMD, 2009). It is also slightly different from CBT in that its philosophical roots are in Hegelian dialectics where the strict logic of either/or is replaced by an acceptance in the form of both/and (Thesis + Antithesis = Synthesis). The therapist not only validates Karen’s self-hood but challenges behaviour which places that self at risk. The term ‘tough love’ is often used. Whereas intense emotions are rather neglected with CBT, DBT makes it the central issue. That may be disputed as in the statement: ‘Emotions and moods (e.g., anxiety, anger or depression) are often the target for work. Cognitive behavioural therapists have long argued that working with cold and detached forms of thinking are very limited in their effectiveness’ (Attachment 9). DBT focuses on everyday problems and unlike psychodynamic therapy (but like CBT) deals with the here and now. Another feature of DBT is that the patient would be asked to keep a record of issues important to her during the week by filling up diary cards as prompted by the therapist. Self-harming, suicidal behaviours and thoughts take priority followed by anything that would interfere with therapy itself (Koerner & Linehan (2000), (Linehan & Dimeff) (2001). This from of therapy appears most appropriate for Karen as she was beginning to feel that her previous treatment was only “maintaining [her] misery”;(Attachment 7) and was on the point of giving it up. DBT is the first therapy that has been experimentally demonstrated to be effective in treating BPD (Linehan, Heard, & Armstrong, 1993). DBT was developed by Dr Marsha Linehan, at the University of Washington, Seattle. ‘DBT was the first psychotherapy shown to be effective in treating BPD in controlled clinical trials – the most rigorous type of research. ... it has grown a large evidence base and is considered one of the best treatments in terms of documented success rates’ (Salters-Pedneault 2008). A patient’s progress is tracked closely by monitoring the use of learned skills and control of symptoms during the course of therapy. Salters-Pedneault (2008) lists the following as ‘covered in DBT skills training’. Mindfulness meditation skills (a ‘core skill’ to be discussed below) Interpersonal effectiveness skills (learning to assert oneself and mange conflict in relationships) Distress tolerance skills [learning to ‘accept and tolerate distress without doing anything that will make distress worse ... (e.g. self-harm)]’. Emotion regulation skills (‘learning to identify and manage emotional reactions)’. All these skills appear to be essential for Karen’s recovery through DBT. At the time that Karen presented herself for therapy with Dr Banks she had a history of having ’repeatedly engaged in frantic efforts to avoid abandonment, exhibited a pattern of unstable and intense interpersonal relationships, had a markedly unstable self-image, or sense of herself; engaged in recurrent suicidal behaviour and self-mutilation; her moods were unstable; she had chronic feelings of emptiness and frequently displayed inappropriate anger’. (Attachment 7). Given such a long catalogue of symptoms, the psychotherapeutic process could prove to be a lengthy one, of at least one year’s duration. Even with visible and tangible improvements after that length of time, there needs to be a gradual winding down with the frequency of sessions thinning out with continued self-efficacy shown by Karen. In Karen’s case, it is imperative that her therapist be aware of the need to renegotiate the therapeutic alliance as the therapy progresses in time (Attachment 8). Since Karen has suffered a great deal of childhood neglect and abuse, there has to be an empathetic validation of that mistreatment and consequent suffering. This helps Dr Banks establish a strong therapeutic alliance early in the process which is likely to be tested at intervals during therapy. If Karen has been prescribed medication while undergoing therapy, this has to be monitored, and should be discussed within the therapeutic framework established between patient and therapist. As trust develops between the two, Karen needs to be told explicitly about her condition, the diagnosis, the prognosis, and about self-care. The last category involves getting enough sleep, eating a balanced diet, regular exercise, avoiding drugs and alcohol, and not making precipitate life-changing decisions. She may also need to be provided with a social support system of friends perhaps within the therapeutic community and group work. One thing that Dr Banks is expected to guard against is regression on Karen’s part to a totally dependant role expecting the therapist to take on a parenting role, which she was denied as a child. However, dialectical behaviour therapy allows for out of hours telephone contact with the therapist at times of crisis or despair. It has been observed that features of borderline personality disorder are heterogeneous. Although most patients classified as suffering from BPD display a commonality of symptoms, each have a unique history, as in the case of Karen, and Dr Banks needs to be flexible at different points in time as the therapy progresses. The emphasis on different aspects of Karen’s problems would change and the focus of therapy may move from self-care and safety, to relationships, or attempts to secure paid employment and other life-skills. APA Practice Guidelines (2001) notes that two ‘psychotherapeutic approaches have been shown to have efficacy in randomized controlled trials: psychoanalytic/psychodynamic therapy and dialectical behaviour therapy’. Their advice is that ‘the psychotherapist must emphasize the building of a strong therapeutic alliance with the patient to withstand the frequent affective storms within the treatment’. Specific goals need to be agreed upon. The common key features of the two therapies mentioned above are that they both share ‘1) weekly meetings with an individual therapist, 2) one or more weekly group sessions, and 3) meetings between therapists for consultation/supervision’ (Oldham, Gabbard, Goin, Gunderson, Soloff, Spiegel, Stone, & Phillips, 2001). It may be assumed that Dr Banks would have her own supervisor and that at some point she would institute group sessions for Karen to attend. There is a hierarchy of needs of the patient that therapists should consider. ‘For example, practitioners of dialectical behaviour therapy might consider suicidal behaviours first, followed by behaviours that interfere with therapy, and then behaviours that interfere with quality of life’(op.cit.). There are many tools in Dr Banks repertoire as a psychotherapist that she could employ with Karen as and when needed. These techniques may include, Modelling, Imitation, Behavioural rehearsal, Relaxation training, Activity scheduling, Assertiveness training, Communication training, Self-reward, and so on (Attachment 14). Mindfulness, an esoteric Eastern Buddhist/Hindu concept is one of the cornerstones of Dialectical Behaviour Therapy. Mindfulness is about living fully from moment to moment experiencing sights, sounds and emotions fully. It helps patients not to dodge unpleasant emotions and feelings, nor to allow them to dominate, but to accept and tolerate them from a detached perspective. Originally developed by Prof. Jon Kabat-Zinn of the University of Massachusetts Medical Center in 1979, Mindfulness-based Cognitive Therapy (MBCT) could well be the precursor of DBT (Jayasinghe, 2009). Kabat-Zinn (1994) defined mindfulness as ‘paying attention in a particular way: on purpose, in the present moment, and non-judgmentally’. Karen is most likely to benefit from such an orientation in therapy, perhaps more towards the end, rather than early in the therapeutic programme. As therapy progresses Karen will be enabled to develop a non-judgmental, non-evaluative attitude both to herself, her past, and the situation she is currently in. This does not mean she is approving or resigning herself to unsatisfactory events and emotions, but recognising their impact without avoiding or being overwhelmed. She can then discuss without fear with her therapist means of overcoming the negatives by utilising appropriate tools from a repertoire of those mentioned earlier. It is most likely that Karen will then begin to grow as a person capable of taking charge of her future life and move in a positive direction. Childhood trauma, as in the case of Karen, is said to be a universal feature of borderline personality disorder. This was the reason for her ‘affective instability, damaged self-image, relationship problems fear of abandonment, self-injurious behaviour and impulsiveness’ ((Oldham, Gabbard, Goin, Gunderson, Soloff, Spiegel, Stone & Phillips, 2001). Most of her life-problems will be seen by Dr Banks as ‘displaced responses to abusive early life experiences’ (op. cit.). Inappropriate behaviour may also surface during therapy. This is usually identified as ‘splitting’, seeing people as either totally bad or totally good, an ‘all or nothing’ response. The earlier positive reaction to Dr Banks offering her ‘the break of a lifetime’ could easily turn to its opposite. She could be idealised in one session and devalued in the next. But the therapist is aware of such reversals and is able to contain and help Karen to move forward in her recovery process without giving up. Here it is necessary to note the phenomenon of transference and counter-transference. This is where the patient will project onto the therapist her earlier problems with others in her life, especially those with whom she had close relationships. On the other hand, the therapist could also ascribe to Karen, unless she is very careful, issues from her previous experiences with others like Karen in her life. This is why therapists require supervision so that they can overcome such tendencies to follow blind alleys. Dr Banks may, almost certainly, get Karen to work through past painful, traumatic memories and cognitively restructure them through ‘grief work’, acknowledging and placing in perspective the ‘residue of traumatic experience’ (op. cit.). This helps Karen to distinguish between inappropriate and appropriate reactions to current situations and relationships. It also helps Karen to stop being vulnerable to re-victimisation as had happened to her in the past. There is the possibility of triggering hyperarousal during therapy and the therapist will take steps to calm her down without being intrusive. This often happens because patients like Karen blame themselves for the trauma they experienced at the hands of their parents and other adults around them when they as children, they were ‘unable to appreciate independent causation’ (op. cit.). It is also possible that they blame themselves to avoid re-experiencing the helplessness they felt at the time they were subjected to the trauma. The above is a hypothesised account of the type of intervention that would be undertaken by a qualified and trained psychotherapist like Dr Dierdra Banks. She has specialised in Dialectical Behaviour Therapy, which, as documented is, believed to be one of the best, if not the best, proven treatment, particularly for the type of mental disorder identified according to DSM IV criteria as Borderline Personality Disorder. It is not a ‘quick cure’. It can be long drawn out, possibly for over a year, with at least once a week sessions with the psychotherapist. Additionally, there could be a requirement for medication, even intermittently, to stabilise the patient’s condition. Supportive group therapy should also be offered, so as to consolidate gains made within individual therapy and provide social reinforcement ad reality testing. References Attachments 1 to 18 (10 references) + 8 References = 18 Borderline Personality Disorder – Treatment Overview; http://www.webmd.com/mental-health/tc/borderline-personality-disorder-treatment Retrieved 08/02/2010. Dialectical Behavior Therapy – An Introduction to Dialectical Behavior Therapy; http://bpd.about.com/od/tratments/a/IntroDBT.htm?p=1 Retrieved 10/02/2010. Jayasinghe, M. (2009) Mindfulness Meditation as Psychotherapy (pp 23-27) in Renditions, 30 Topical Essays, Outskirts Press Inc. Denver, CO, USA. Kabat-Zinn, J. (1994) Wherever You go, There You Are - Mindfulness Meditation in Everyday Life. Hyperion, New York. Linehan, M.M., & Dimeff, L., (2001) Dialectical Behavior Therapy in a nutshell, The California Psychologist 34 10-13. Koerner, K., Linehan, M.M. (2000) Research in dialectical behavior therapy for patients with borderline personality disorder. Psychiatric Clinics of North America 23 (1). Linehan, M.M., Heard, H.L., & Armstrong, H.E. (1993) Naturalistic follow-up of a behavioural treatment of chronically parasuicidal borderline patients. Archives of General Psychiatry, 50 971-974. Oldham, J.M., Gabbard, G.O., Goin, M.K., Gunderson, J., Soloff, P., Spiegel, D., Stone,M., Phillips, K.A., (Oct. 2001) Practice Guidelines for the Treatment of Borderline Personality Disorder – Working Group of Borderline Personality Disorder. www.psych.org Read More