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Introduction

Cognitive behavioral therapy (CBT), is a form of psychotherapy that focuses on altering the client’s dysfunctional cognitive processes in order to alter behavior and initiate positive change in daily life. Cognitive behavioral therapy encourages people to discuss their emotions and beliefs. CBT helps link the individual’s problem behaviors and distress to the underlying patterns of thinking (Jones et al., 2012). According to Beck (1995), individuals with personality disorders utilize aggression, avoidance, resistance, dependence, and competitiveness in compulsive ways in order to solve problems.

Theory

Cognitive behavior therapy is the theory that we will use to construct our intervention plan. Based on Serena’s unique characteristics, we chose the cognitive behavioral therapy (CBT) theoretical approach due to the ample amount of evidence that supports it for several psychiatric diagnoses. Additionally this approach would work well with Serena’s diagnosis of borderline personality disorder and her developing personal characteristics of self awareness and insight. Since Serena does not yet have the ability to be mindful of her triggers, thoughts, and behaviors that are causing dysfunction in occupational performance, is why it would make her a good candidate for CBT treatment (Brown & Stoffel, 2011).

Using this theory, it will help Serena to understand how her beliefs and thoughts are limiting occupational performance and healthy relationships with others. It will assist her in uncovering and understanding beliefs about herself, others, and the world as a whole to begin changing internal cognitive processes. Finally, using the CBT theory, it will further help Serena in understanding how her psychological and emotional reactions trigger dysfunctional beliefs in order to become more mindful for future positive relationships.

Evidence

Leichsenring & Leibing, 2003 conducted a meta-analysis that examined the effectiveness of cognitive behavioral therapy (CBT) versus psychodynamic therapy for the treatment of personality disorders. The results showed an overall effect size for psychodynamic therapy compared to CBT. However, self-report measures indicated larger effect sizes for CBT than for psychodynamic therapy as compared to observer-rated measures. Gibbon et., 2010 conducted another meta-analysis that compared the effectiveness of eleven different psychological therapies, including CBT, for antisocial personality disorder. Results indicated that CBT plus standard maintenance was more efficacious compared to control treatment in terms of outpatients with antisocial personality disorder using cocaine and exiting the study early. The relative effectiveness of psychological treatments for borderline personality disorder, was also studied, which showed no differences between dialectical behavioral therapy and individual meeting treatments at six months, or in hospital admissions in the previous three months (Binks et al., 2009).

A cognitive behavioral therapy study conducted by Beck (1952) showed that after writing down the “persecutors”  and their manner of dress, facial expressions, general behavior, and demeanor,  the patient was able to exam the people he assumed to be involved with the government and gradually drop them all of the list. Benefits of this therapeutic intervention included patient exploration of their delusions and reduced distress of false belief. Similar benefits for were found by Chadwick P, Birchwood M (1994), as they used CBT to help patients have a better understanding of their experiences by normalizing symptoms with debatable content and explanation.

Case Study

Serena is a 35-year-old single Caucasian female. At a young age she showed symptoms including irritability, temper tantrums, and loneliness. Serena engaged in self-harm behaviors for the first time at age 14 while suffering with self-image. At age 21, Serena was addicted to drugs and admitted to a mental health ward where she was diagnosed with borderline personality disorder. Since her release from the ward, Serena still battles with emotional instability and poor interpersonal relationships. Presently, she lives in Tallahassee, Florida where she works an office job that entails duties such as data collection, answering phone calls, and managing files. Serena stated she does not like her job due to poor relationships she has with coworkers. She is a mom of three children, and is living in her house with her mother. Although she has a large family, they frequently do not understand her unpredictable “snaps” or emotional outbursts because she appears ‘normal’ on the outside. Consequently,she lacks a strong familial relationship and relationships with others.

Intervention Plan

Problem Statement

Serena is having negative interactions within work and relationships with coworkers secondary to cognitive distortions, including black and white thinking.

Long Term Goals

1. Serena will independently challenge her black and white distortions through hypothesis testing in 4 weeks for social participation.
2. Serena will independently challenge her black and white distortions by asking for positive and negative feedback about her ideas at work in 4 weeks for social participation.

Short Term Goals

1. Serena will increase her awareness of her black and white distortions for social participation with verbal cues within one week.
2. Serena will identify her thoughts of black and white distortions in a real world environment for social participation with verbal cues in two weeks.
3. Serena will self-monitor her frequency of behavior with associated thought and feeling for social participation with verbal cues in three weeks.

Intervention Format

Individual

Setting

Serena will meet with the occupational therapist individually at the therapy center for 60 minutes once a week.

Supplies

A journal to write down any distorted thoughts.

Agenda

• Meet with Serena and discuss her work week (10 min)
• Serena discusses what she wrote in her journal (10 min)
• Discuss the results of writing in the journal (5 min)
• Engage in cognitive retraining for black and white thinking (20 minutes)
• Provide a summary of the session (10 min)
• Discuss the homework for the next session (5 min)

Documentation

S: “Everyone at work hates me. My coworkers never find any of my ideas useful and I know it’s because no one likes me.”

O: Serena engaged in a one-hour session using CBT, focusing on distorted thinking. Serena discussed how her work week went. Once Serena finished addressing her feelings, she explained what she wrote in her journal and how writing in her journal made her feel. She engaged in black and white distortions 16 times in a 60-minute therapy session. Serena required 23 verbal cues that redirected her to address why she believed her thoughts were realistic. Client and therapist used a CBT approach and identified seven instances of black and white thinking and restructured her way of thinking.

A: Serena demonstrated confusion and lack of insight towards her distorted thinking during the beginning of her treatment session. Serena demonstrated improved awareness as the session progressed. Serena’s distorted thinking impacts her social participation through negative interactions of her work environment. She needs to continue with occupational therapy to identify her black and white thoughts in order to restructure them in a positive way.

P: Serena will attend occupational therapy once a week, for one hour sessions. During the next session, Serena will choose which homework activities to complete in order to address problem areas for work participation.

References

Beck AT. Successful outpatient psychotherapy of a chronic schizophrenic with a delusion based on borrowed guilt. Psychiatry. 1952;15(3):305–312.

Binks C, Fenton M, McCarthy L, Lee T, Adams CE, Duggan C. Psychological therapies for people with borderline personality disorder. Cochrane Database of Systematic Reviews. 2006; 1:CD005652.

Brown, C., & Stoffel, V. C. (2011). Occupational therapy in mental health: a vision for participation. Philadelphia, PA: F.A. Davis Co.

Chadwick P, Birchwood M: The omnipotence of voices: a cognitive approach to auditory hallucinations. Br J Psychiatry 1994; 164:190–201

Gibbon S, Duggan C, Stoffers J, Huband N, Völlm BA, Ferriter M, Lieb K. Psychological interventions for antisocial personality disorder (Review). Cochrane Database Systematic Reviews. 2010; 6:CD007668.

Leichsenring F, Leibing E. The effectiveness of psychodynamic therapy and cognitive behavior therapy in the treatment of personality disorders: a meta- analysis. The American Journal of Psychiatry. 2003; 160:1223–1232. [PubMed: 12832233]