My Journey with Tala - The Treatment Plan

Taking Tala into counseling means that I have answered two essential questions: “Do I want to work with this client? Am I capable to deal with her problem?” Accordingly, I need to state clearly the working alliance that incorporates mutual understanding of the following factors: goal, task and bond. All of these three components are essential for an effective working alliance, and a strong bond cannot compensate for a lack of agreement about the goals of counseling. 

Specific Treatment Problems & Target Behaviors:

a) Social Disinhibition: Tala feels shy and incapacitated in groups.

b) Unstable Personal Relationship: She was never able to sustain an on-going romantic relationship. She flirts inappropriately. Although she says she cares for her colleagues, she avoids contact with them. She feels lonely. 

c) Lack of empathy: Tala is unable to read “social signals” and pick up expressive cues about other people’s feelings and moods. She is bored by their activities and concerns and doesn’t care what they think, whether it’s about her or about topics of interest in their own lives. “I am living among strangers,” she explains, and she feels “like [she’s] in another country” where she can’t adapt to local customs or conventions.

d) Progressive loss of capacity to function at university. Her majors require a high level of attention to detail.

e) Endless pitiful internal monologue which affects her self-image even more.

The specific treatment goals are: (1) to restore Tala’s ability to function practically in the world; (2) to relieve the personal distress she feels at her lack of coping skills; (3) to restore her confidence and expertise in social environments and group contexts; (4) to improve her derogatory self-image; (5) to improve her own subjective impressions of the quality of her lived experience; and (6) to prevent her from having suicidal thoughts.

Dialectical behavior therapy (DBT), proven to be one of the most effective cures, focuses on the concept of mindfulness, or paying attention to the present emotion. DBT’s main goal is to teach skills on how to control strong emotions, reduce self-destructive thoughts and behaviors, manage melancholy and sadness, and improve relationships. In short, it seeks a balance between accepting the behavior and managing or changing it (Treating BPD, n.d). Treatment includes individual therapy sessions, skills training in a group setting, and phone coaching if needed. For DBT to be clinically effective, Tala must acquire a repertoire of emotion regulation skills. These include: (1) identifying and labeling emotions; (2) classifying obstacles to changing emotions; (3) reducing vulnerability to “emotion mind;” (4) increasing positive emotional events; (5) improving mindfulness to current emotions; (6) Having the courage to take opposite action; and (7) applying distress tolerance techniques (Linehan, 1993b, p. 84). I determined to concentrate on (1) - (3) and (5). 

           At our first session with Tala, I will introduce her to emotion regulation skills, which is the first step in Linehan’s approach. This skill includes observing and describing (a) the incident causing a certain emotion; (b) how the person interprets it with their mind; (c) how the person (subconsciously) experiences it; (d) its manifestations as behaviors; and (e) how it affects functioning (Linehan, 1993b, p. 84). At that moment, Tala might get offended as if she was accused that her emotions are bad. She will elaborate later on that she also feel disappointed and ashamed of herself for not being able to handle difficult situations or doing better at any task given to her or communicate with a strange person that she meets. This feeling might actually motivate her to act better next time. Tala never feels ok when she is embarrassed, and she will blame her family members and friends. I will help her detect the destructive emotion that led her to become angry and caused the conflict.

           After the emotions have been identified and labeled, both I and Tala will identify obstacles to change them. By deploying emotions, one can control other’s behavior and reinforce one’s own perceptions and interpretations of events, both of which are powerful inhibitors to emotional change (Linehan, 1993b, p. 85). We will focus on Tala’s communication skills and if she has ever felt misread by others because of mismatched nonverbal communication. Tala recalled a moment when she was happy in class; however, her classmates looked at her and asked why she is upset. She has also described a moment when she discovered that her mom had an appointment with the university administration: she automatically assumed that something urgent will happen so that her mom was asked to pass by. Instead, her mom was asking for the permission to organize a small birthday surprise to her daughter in class. Tala’s psychological state is highly affected by the emotions experienced. For example, she can experience anxiety due to the stress that she was living in her environment. This can be controlled by simple steps such as nutrition, getting enough sleep, and exercise. 

Increasing Mindfulness to Current Emotions: Being mindful of one’s emotions allows them to come up with hypothetical events that will help them foresee and anticipate the emotional response (Linehan, 1993b, p. 85). I will implement this strategy with Tala by exposing her to emotionally threatening situations, so that she would learn not to react in a visceral, negative way and, accordingly, prevent her from having suicidal thoughts. This will enable her to see that the situation was not as catastrophic as it seemed to her when her emotions were fully in control. The patient will acknowledge that such feelings exist for a reason: she will not get rid of them; however, she will experience them as they are. By practicing this, she can achieve better control of her emotions. She will gain self-confidence and boost her self-awareness in terms of acknowledging that she is beautiful no matter how her body is, which boosts her self-efficacy and the development of a more positive body image.

           While validating Tala’s suffering, I will ensure to help her take appropriate responsibility for her actions. She has definitely experienced trauma in the past, and she is blaming herself for it. The Effective therapy will help her realize that while she is not responsible for the neglect and abuse she experienced in childhood, she is currently responsible for controlling and preventing self-destructive patterns in the present. She will be asked to participate in a process of self-observation in order to grasp a better understanding of how internal motivations cause behaviors rather than them coming from “out of the blue” (Oldham, J.M., et al. 2001).

Decisions about whether and when to focus on trauma, if present, during treatment should be based on Tala’s agitation, stability, fragility, evidence of psychotic symptoms, and potential for self-harm or disruption of current vocational, family, or other roles. Working through the consequences of trauma will be done later during the treatment, after creating a more solid therapeutic alliance, achieving stabilization of the client’s symptoms, and establishing an understanding of Tala’s history and psychological structures. In a later phase of the treatment, we must focus on acknowledging, bearing, and putting into perspective the residue of the trauma that Tala had witnessed in her early life. This is a major component of a successful and effective psychotherapy. This process helps to reduce the unbidden, intrusive, and alien nature of traumatic memories and differentiates effects associated with the trauma from that elicited by current relationships (Oldham, J.M., et al. 2001).

Elaborating excessive interpretation very early in treatment may cause the patient to drop out of the therapy. One study of the psychoanalytic therapy of patients with BPD shows that these early interpretations can be seen as “high-risk, high-gain” phenomenon; i.e., although it might help construct a therapeutic alliance, it may also cause it to deteriorate. Therapists must use transference interpretation judiciously on the basis of their sense of the state of the alliance and the patient’s capacity to hear and reflect on observations about the therapeutic relationship. A number of empathic and kind comments may pave the way for a better transference interpretation. Other patients may be able to use transference interpretation effectively without this much preparatory work (Oldham, J.M., et al. 2001).

A pharmacological approach to the treatment of borderline personality disorder is based upon evidence that some personality dimensions of patients appear to be mediated by disregulation of neurotransmitter physiology and are responsive to medication.

Raising awareness about the disorder: At a certain point in treatment, Tala’s family members must be informed of all the progress (if any) that Tala has made so far; they should be familiarized with the diagnosis, including its expected course, responsiveness to treatment, and, when appropriate, pathogenic factors. Many patients with borderline personality disorder profit from ongoing education about self-care. It is also a good decision to involve the family members and educate them on the likely effect of the diagnosis and treatment (e.g., it may evoke undesirable reactions of guilt, anger, or defensiveness). Psychoeducation for families should be distinguished from family therapy, which is sometimes a desirable part of the treatment plan and sometimes not, depending on the patient’s history and status of current relationships (Oldham, J.M., et al. 2001).

To be continued...