Jen is a 19-year-old female of mixed ethnic background. When asked what her therapeutic goals are, Jen states that she wants to “get over” the physical abuse she was subjected to her from her mother’s ex-husband (her stepfather). In the third therapy session with Jen, she abruptly claims that she may not be continuing with therapy because she is just “therapist shopping.”
Also in this session, Jen mentioned 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?” Even though there was no response, Jen quickly defends herself, saying, “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 mean, 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 if 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.”
Diagnosis
Because of her unwillingness to commit to a therapist, evidence by her avowed “therapist shopping,” her persistent self-destructive behavior such as high-risk sex, and her general recklessness, the most appropriate DSM-V diagnosis for Jen at the moment will be Borderline Personality Disorder. However, this is a tentative diagnosis until more can be learned about Jen. She may also be experiencing Post-Traumatic Stress Disorder, as she admits experiencing systematic abuse from her stepfather.
Currently, Jen meets several of the criteria for Borderline Personality Disorder (APA, 2012). The first is her self-direction issues, as her goals, aspirations, and career plans are focused on exotic dancing and selling drugs, which is not a sustainable plan and reveals a warped sense of identity and self-concept. Second, Jen exhibits impairments in interpersonal functioning with regards to intimacy. Her relationships can be described as “intense, unstable, and conflicted,” likely rooted in her abusive childhood (APA, 2012). Furthermore, Koerner (2012) points out that childhood sexual abuse is a “prototypical invalidating environment related to borderline personality disorder,” which has as its cornerstone a history of invalidation, leading to emotion dysregulation (p. 7).
Jen’s negative affect has yet to be determined, but should emerge if she decides to continue therapy. She does seem to be exhibiting separation insecurity, in which she fears losing her autonomy, which is why she is clinging 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 witnessed her acting in a hostile way, this should be something to discover in future sessions. She has not yet admitted to having suicidal thoughts or having attempted suicide.
Jen’s disinhibition, however, is clear. She has proven herself to be relatively impulsive, taking home strangers from the club, shopping around for therapists. She also takes a lot of risks in her job, both with unsafe sex and without regard to her personal safety because she is getting drunk and allowing men into her house, where she is extremely vulnerable. She also sells drugs in that house, meaning that those men could actually take further advantage of her by robbing her. Future sessions should reveal how long these patterns have been going on in Jen’s life, and whether they are chronic issues.
Client Characteristics and Intervening Variables
The client has only recently started to open up about her life. It is important to find out more about her, such as the nature of her relationship with her mother now, and whether the client has friends or other relatives she can count on as social supports. Currently it is presumed that the client has no interest in maintaining a relationship with her family of origin given her history of abuse.
Jen is becoming financially independent and is proud of her work, but it is unlikely that she has long-term stability given her lifestyle. The client is at risk for legal problems because of her side business selling drugs, and she may not be declaring all of her income.
Although the client is of mixed ethnic background, she has not yet indicated what her upbringing was like, and if she has any religious or spiritual values. She is single but likes to have sex with multiple partners, and has not yet indicated if she is heterosexual or bisexual. She has not gone to college. Therapy should help clarify whether the client has had any troubles in school, whether she has underlying career ambitions, and whether she has social support systems.
Therapeutic Goals
Short-term goals begin with having Jen commit to a course of therapy, and to stop “therapy shopping,” at least until she gives one of the recommended treatment plans a try. Next, Jen has expressly asked that she confront the issues surrounding her childhood abuse, specifically experience with sexual abuse. This will be an immediate therapeutic goal because many of Jen’s problems may be rooted in this past trauma and her need to develop cognitive schemas and coping mechanisms. It will also be important to assess Jen’s social support system, clarifying her relationship with her parents, her relatives, her friends, and any community she may have. Also, short-term goals will help Jen to understand better why she is taking serious risks that could lead to personal harm, like getting drunk with total strangers and taking them back to her house, where they know she keeps a lot of cash. Because Jen may not realize how dangerous her behavior is, this will be considered a prevailing goal in therapy until she becomes willing to change. Short-term goals will also include helping Jen to clarify her intimacy and attachment fears.
Long-term goals include Jen’s own development of long-term career or personal goals. Even if she insists that exotic dancing and drug dealing are viable career paths, she does need to realize that these are not sustainable careers. Eventually she will need to think of a means to investing her money for the future, starting her own business, or returning to school to learn a new skill. Jen should also consider her instability in personal relationships. The core long-term goal for Jen will be effective emotion regulation and self-awareness, so that she can develop coping mechanisms and strategies.
Theoretical Orientations
The two theoretical orientations that will be applied to Jen include Acceptance Commitment Therapy (ACT) and Interpersonal Therapy (IPT). ACT relies on relational framing and mindfulness techniques. ACT has been shown to be significantly helpful in reducing the symptoms of borderline personality disorder and with emotion regulation specifically (Hayes & Lillis, 2012; Morton, Snowdon, Gopold & Guymer, 2012, p. 527). Interpersonal problems are an ongoing issue and “central area of difficulty” for those with borderline personality disorder (Lazarus, Cheavens, Festa & Rosenthal, 2014, p. 193). Therefore, interpersonal therapy is also recommended as a theoretical orientation for working with Jen. IPT is a “time-limited and specified psychotherapy” that was initially developed to treat patients with depressive incidents but it can be applied to other situations (Weissman, Markowitz & Klerman, 2007). The goal of IPT is to focus on goals rather than dwelling too much on the past, and tends to downplay personality disorders and instead consider what is going on with the client right now. IPT can be used to help Jen evaluate her current relationships and the emotional responses she has to stressful situations. Although IPT does not focus on personality, it has been adapted to treat borderline personality disorder (Weissman, Markowitz & Klerman, 2007). ACT and IPT can also be integrated with dialectical behavior therapy (DBT), which also relies on mindfulness (Koerner, 2012). In fact, DBT was developed specifically for DBT (Welch, Rizvi & Dimidjian, 2006). Jen will currently benefit more from IPT and ACT because of DBT’s reliance on group interactions that may be more useful for Jen later in therapy, after she works out the issues related to her abuse.
Because Jen is already aware of her childhood trauma as a root cause of her current problems, ACT should prove helpful. Also, Jen seems to have forestalled finding a sense of meaning and purpose, instead relishing in the immediate gratification of quick money and high stakes thrills found through the power she gains through her sexuality. It is as if Jen has transmuted the loss of power she experienced as a victim of sexual abuse, as she now makes money and has power precisely because of her sexuality. If Jen were to give up her risky sexual behavior, she needs to find new ways of generation personal power. She also needs to find value in her work beyond amassing money and wielding power, and ACT can be tremendously helpful for finding meaning and purpose in life.
Treatment Plan: IPT
Using IPT, Jen’s treatment plan would address both short-term and long-term goals. IPT tends to be structured around a specific time frame, which might offer Jen some solace and assistance in refraining from “therapist shopping” for a set period of time, rather than telling her that treatment lasts indefinitely. Generally, IPT will last for twelve weeks and have a beginning, middle, and ending phase, each of which is roughly equal in terms of number of sessions. The beginning phase will start with an interpersonal inventory. Starting with the inventory will show Jen that the therapist is committed to helping her work through her sexual trauma and not on manipulating Jen to change her line of work. Also at the beginning stage of the therapeutic process, the therapist will show Jen how her current lifestyle may be causing her some problems and will further assess Jen’s symptoms.
The middle phase of IPT will focus on the interpersonal deficits Jen has been experiencing, based on what she shares during the beginning phases. Jen has already indicated her desire to work through the trauma with her stepfather, so it is critical to find out if Jen also wishes to have a confrontation with her stepfather and her mother. In addition to addressing the challenges of her family of origin, the therapist can also shift attention to Jen’s social supports at work, and the risky sexual behavior. At this stage, the therapist may be able to work with Jen in a non-judgmental manner to see if indeed the rewards outweigh the risks of her current high-risk sexual activity. Each sexual encounter is an interpersonal relationship, but one that can potentially harm Jen. Ideally, Jen will come to realize on her own terms whether these shallow sexual relationships are serving her in some way. She needs to come up with the reasons why these interpersonal relationships are feeding her, and why she may be avoiding intimacy or friendship. During this stage, the therapist will also focus on other treatment goals, such as her relationship with her parents. When she is ready, Jen may be able to draw some connections between the powerlessness she felt with her abusive parents and the power she derives in her current position vis-a-vis men.
Finally, the IPT treatment plan will conclude with providing Jen with the tools she can bring into her daily life. The focus will be on Jen’s relationships: with her mom and stepdad, if she still needs or wants to be in relationships with them, with her friends, and with lovers. Most importantly, the IPT treatment plan will provide Jen with the tools she can use in her relationship with herself including emotion regulation. Jen’s long-term goals include the solidification of her social support, as well as constructing a cohesive life plan for herself. Her future depends on the relationships she forges today, which is how IPT can help.
Treatment Plan: ACT
Most of Jen’s short-term goals involve her becoming more aware in general: more aware of what her present behaviors are, what her current emotional responses are, and how she is currently dealing with the stress that lingers from her traumatic past. Encouraging Jen to commit to therapy is also a short-term goal. ACT can be used to help Jen become more aware of her commitment fears, her fear of abandonment, or her resistance to change. Jen seems uniquely afraid of being judged or being “told what to do,” and it is therefore important at this early stage to create a non-judgmental environment in which Jen can feel safe. Jen can be reminded in initial sessions of therapy that the goal will not be to make her quit her job and find new work, but to simply make her aware of what she is getting out of her work and whether it is providing her with a genuine sense of peace and satisfaction.
Also as part of achieving the client’s short-term goals will be an assessment of Jen’s readiness and willingness to change. She has already affirmed her commitment to her exotic dancing career. Therefore, short-term goals should be on helping Jen come to a realization of how her current pattern of low emotional risk but high stakes sexual encounters are serving her. Without telling Jen that the goal of therapy is to stop her behavior, the therapist can help her to contextualize it instead. Jen can learn how to be mindful throughout her day, noticing how she feels when she is dancing, and also during and after her sexual encounters. Before working on her long-term goals Jen can focus on the immediate cognitive reorientation from a state of unconscious reactions to a condition where she becomes aware and cognizant of her current coping mechanisms. Using metaphors and reframing, Jen can cease struggling or feeling guilty; for her defensiveness signals that guilt and rebellion may be connected with some cognitive dissonance. The dissonance will lead to Jen voluntarily shifting her awareness to the meaning she is locating in her dancing, her sexual relationships, and her lack of emotional intimacy.
To address Jen’s long-term goals, ACT can help Jen focus on both the relationships that haunt her from the past, and those that she needs to cultivate for the future. Jen will also be able to focus on her skills, traits, and desires for the future as she realizes that exotic dancing is not a long-term, sustainable career even if it does offer her a sense of temporary empowerment and the opportunity to earn money. The therapist can help Jen to develop a timeline for herself, perhaps showing Jen how she can save money she earns how through her dancing and even from her dealing drugs, using that money to invest in real estate or in pursuing a higher education. The focus should be on helping Jen to recognize that getting drunk and taking home strangers is asking for trouble; she could be putting herself and her money at risk. As Jen becomes more aware of how these encounters are doing more harm than good, she may gradually come to see herself differently and to cease using her job as an excuse for the far riskier behaviors she engages in after work. ACT will offer Jen the opportunity to cultivate a core set of values and guiding principles, so that she acts consciously in her life in ways that supports her immediate and long-range wellbeing.
References
American Psychiatric Association (APA, 2016). Retrieved online: 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, Kelly (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 Baer, R.A. (2006). 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.
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