ACT and IPT Treatment Planning for Borderline Personality Disorder

Diagnosis

Jen is a 19-year-old female of mixed ethnic background. When asked about her therapeutic goals, she states that she wants to "get over" the physical abuse she experienced from her mother's ex-husband, her stepfather. In her third therapy session, she abruptly claims that she may not continue with therapy because she is just "therapist shopping."

Also in this session, Jen mentions for the first time that she works as an exotic dancer. She asks with a belligerent tone, "You don't have a problem with that, do you?" Without waiting for a response, Jen quickly defends herself: "I love my work. I make so much money. There is nothing else I can do to make this much money. All my friends work harder than I do but they make less than me! I not only pull in what I make from dancing and tips, but I also sell drugs out of my house — it's like the perfect job. And I am practically getting paid to get high or drunk or whatever. And there's no one telling me what to do or how late I can stay out. It's really a dream job for me."

When asked whether she is in any relationships, Jen laughs and says, "Um, yeah, I go home with at least half the guys I meet at the club. No relationship needed, no strings attached, no ball and chain for me."

Because of her unwillingness to commit to a therapist — evidenced by her avowed "therapist shopping" — her persistent self-destructive behavior such as high-risk sex, and her general recklessness, the most appropriate DSM-5 diagnosis for Jen at this time is Borderline Personality Disorder (BPD). This remains a tentative diagnosis until more can be learned about her. She may also be experiencing Post-Traumatic Stress Disorder, as she admits to having experienced systematic abuse from her stepfather.

Jen currently meets several of the criteria for Borderline Personality Disorder (APA, 2016). The first is self-direction issues: her goals, aspirations, and career plans center on exotic dancing and selling drugs, which is not a sustainable plan and reveals a troubled sense of identity and self-concept. Second, Jen exhibits impairments in interpersonal functioning with respect to intimacy. Her relationships can be described as "intense, unstable, and conflicted," likely rooted in her abusive childhood (APA, 2016). Furthermore, Koerner (2012) points out that childhood sexual abuse is a "prototypical invalidating environment related to borderline personality disorder," with invalidation as its cornerstone, leading to emotion dysregulation (p. 7).

Jen's negative affect has yet to be fully determined but should emerge if she chooses to continue therapy. She does appear to exhibit separation insecurity, fearing the loss of her autonomy — which is why she clings to her job as a source of freedom. As she puts it, "no one can tell me what to do." Although the therapist has not yet witnessed hostile behavior, this should be explored in future sessions. Jen has not yet admitted to having suicidal thoughts or having attempted suicide.

Jen's disinhibition, however, is evident. She has demonstrated relative impulsivity — taking strangers home from the club and shopping around for therapists. She also takes considerable risks in her work, engaging in unsafe sex and allowing men into her home while intoxicated, leaving herself extremely vulnerable. She also sells drugs from that home, which means these men could take further advantage of her by robbing her. Future sessions should reveal how long these patterns have persisted and whether they constitute chronic issues.

Client Characteristics and Intervening Variables

Jen has only recently begun to open up about her life. It will be important to learn more about her, including the current nature of her relationship with her mother, and whether she has friends or other relatives who serve as social supports. At present it is presumed that she has little interest in maintaining a relationship with her family of origin given her history of abuse.

Jen is becoming financially independent and takes pride in her work, but long-term stability seems unlikely given her current lifestyle. She is at legal risk because of her drug-dealing side business and may not be declaring all of her income.

Although Jen is of mixed ethnic background, she has not yet indicated what her upbringing was like or whether she holds any religious or spiritual values. She is single but engages in sex with multiple partners, and has not yet clarified whether she identifies as heterosexual or bisexual. She has not attended college. Therapy should help clarify whether she has had difficulties in school, whether she has underlying career ambitions, and whether she has meaningful social support systems.

Therapeutic Goals

Short-term goals begin with helping Jen commit to a course of therapy and to stop "therapist shopping," at least until she gives one of the recommended treatment approaches a fair try. Jen has also expressly asked to confront the issues surrounding her childhood abuse, and addressing that trauma will be an immediate therapeutic goal, as many of her current difficulties may be rooted in past trauma and in the need to develop adaptive cognitive schemas and coping mechanisms.

It will also be important to assess Jen's social support system by clarifying her relationships with her parents, relatives, friends, and any broader community. Additional short-term goals include helping Jen understand why she is taking serious risks that could result in personal harm — such as getting drunk with strangers and bringing them back to a home where she keeps significant amounts of cash. Because Jen may not fully appreciate the danger of these behaviors, addressing this will remain a priority in therapy until she becomes willing to consider change. Short-term goals will further include helping Jen clarify her fears around intimacy and attachment.

Long-term goals include supporting Jen in developing durable personal and career goals. Even if she insists that exotic dancing and drug dealing are viable paths, she needs to recognize that neither is sustainable. Eventually she will need to consider investing her earnings, starting a business, or returning to school to develop new skills. Jen should also examine her instability in personal relationships. The core long-term goal will be effective emotion regulation and self-awareness, enabling her to develop lasting coping mechanisms and strategies.

References

American Psychiatric Association (APA, 2016). Diagnostic and statistical manual of mental disorders. Retrieved from http://www.psi.uba.ar/academica/carrerasdegrado/psicologia/sitios_catedras/practicas_profesionales/820_clinica_tr_personalidad_psicosis/material/dsm.pdf

Baer, R. A. (2006). Mindfulness-based treatment approaches. London: Elsevier.

Hayes, S. C., & Lillis, J. (2012). Acceptance and commitment therapy. Washington, DC: APA.

Koerner, K. (2012). Doing dialectical behavior therapy. New York: Guilford Press.

Lazarus, S. A., Cheavens, J. S., Festa, F., & Rosenthal, M. Z. (2014). Interpersonal functioning in borderline personality disorder: A systematic review of behavioral and laboratory-based assessments. Clinical Psychology Review, 34(3), 193–205.

Morton, J., Snowdon, S., Gopold, M., & Guymer, E. (2012). Acceptance and commitment therapy group treatment for symptoms of borderline personality disorder: A public sector pilot study. Cognitive and Behavioral Practice, 19(4), 527–544.

Welch, S. S., Rizvi, S., & Dimidjian, S. (2006). Mindfulness in dialectical behavior therapy (DBT) for borderline personality disorder. In R. A. Baer (Ed.), Mindfulness-based treatment approaches. London: Elsevier.

Weissman, M. M., Markowitz, J. C., & Klerman, G. L. (2007). Clinician's quick guide to interpersonal psychotherapy. New York: Oxford University Press.