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Introduction

Dialectical Behavioral Therapy (DBT) is a cognitive behavioral treatment created by Marsha Linehan. DBT would be a good intervention strategy to implement for borderline personality disorder for our client Marshall (Brown & Stoffel, 2011). The evidence, which will be discussed later in this chapter, widely supports the use of DBT therapy for borderline personality disorder.

DBT focuses on 5 functions that serve as the objectives or aims of the therapy. The functions consist of 1) enhancing capabilities with DBT skills training, 2) enhancing motivation with individual therapy, 3) ensuring generalization with coaching, 4) structuring the environment with case management, and 5) supporting therapists with the DBT consultation team (“What is Dialectical Behavior Therapy (DBT)?”, 2017).

1) Enhance Capabilities with DBT Skills Training encompasses skills training that is frequently taught in a classroom format where group leaders teach the skills and assign homework. The homework is an aid for the client to manage everyday life. The class meets weekly for 2.5 hours sessions that last a duration of 24 weeks. The curriculum is usually repeated to create a 1-year program. Briefer schedules have been created for different populations and settings. Mindfulness focuses on awareness and being present in the moment. Distress tolerance focuses on how to tolerate pain (not change it). Interpersonal effectiveness focuses on how to express needs and decline requests while maintaining self-respect with others. Emotion regulation focuses on changing emotions that you want to change. 2) Enhance Motivation with Individual Therapy encompasses individual therapy which is focused on increasing motivation and aiding clients in applying the skills to challenges in their life. Therapy takes place once a week and is provided concurrently with DBT skills training (“What is Dialectical Behavior Therapy (DBT)?”, 2017). 3) Ensure Generalization with Coaching which utilizes telephone coaching to provide in-the-moment support. Clients can call their individual therapist to receive coaching during times of stress. 4) Structure the Environment with Case Management encompasses case management strategies that aid the client in managing their life in their  physical and social environments. The therapist aids the client in applying dialectical, validation, and problem-solving strategies, which teach the client to be their own case manager. 5) Support Therapists with the DBT Consultation Team this component includes the DBT consultation team which is composed of those who provide DBT, individual therapists, skills training group leaders, and case managers. The consultation team aids DBT providers. The consultation team helps the therapist stay competent and motivated in order to ensure that the therapist is capable of providing the best treatment. It can be envisioned as therapy for the therapist. This approach is unique and highly valuable when treating individuals with severe disorders so that the team can manage burnout and share knowledge effectively (“What is Dialectical Behavior Therapy (DBT)?”, 2017).

Theory

Cognitive behavior therapy is the theory that we will use to construct our intervention plan. DBT was derived from CBT. Based on Marshall’s unique characteristics we chose the CBT theoretical approach because of the ample amount of evidence that supports CBT with borderline personality disorder and Marshall’s personal characteristic of self awareness and insight. Marshall’s ability to be mindful of the triggers, thoughts, and behaviors that can cause dysfunction in his occupational performance make him a good candidate for a type of CBT treatment known as Dialectical Behavior Therapy (DBT) (Brown & Stoffel, 2011).

DBT was constructed in order to help individuals who experience mood disorders, self-harm, suicidal ideation, and substance abuse. In therapy, DBT targets the individual’s most damaging symptoms first such as life threatening symptoms, therapy interfering symptoms, symptoms affecting quality of life, and finally skill acquisition. Thus, the critical components of cognition and behavior that DBT strives to improve have a marked similarity to the symptoms experienced in BPD such as, instability in mood, self mutilation, impulsivity, and substance abuse (Butcher, Hooley, & Mineka, 2011). DBT emphasizes individual psychotherapy and group skills training to aid in an individual’s development of a life worth living. A focus is placed on skill training that includes mindfulness, emotion regulation, distress tolerance, and interpersonal effectiveness. These skills help the individual manage challenges that may arise in everyday life and thus maximize occupational performance (“What is Dialectical Behavior Therapy (DBT)?”, 2017).

Evidence

Barley et al, exhibited a study at an homogeneous, several month day borderline personality disorder (BPD) unit that focused on highlighting distress tolerance skills and touched on mindfulness and interpersonal effectiveness through Dialectical Behavior Therapy (DBT) therapy.  According to the study, repetition has been proven to be most effective and leads to the process of generalization of learned techniques. DBT techniques in this study, resulted in lowered para suicidal rates for the 14 months while receiving services, compared to 19 months prior treatment. Also, when compared to a general psychiatric unit in the same hospital, scores from those patients not receiving DBT stayed the same throughout (Barley et al., 1993).

According to Horan & Fox (2016),  participants in their study felt that the WRAP helped them reduce psychiatric symptoms. Also, it kept them from the hospital. They could recognize that they were feeling bad and were able to call someone for help (for instance a nurse). Participants who had used this tool in a group found it beneficial because they were able to socialize with others and they did not feel alone. Also, identifying triggers and warning signs helped participants when they felt they were becoming unwell. The WRAP helped the participants in stay organized in their recovery. Participants had recommendations about the WRAP such as offering it to individuals early on in therapy. They also agree it should be done various times. Although some found the experience of the wrap more positively than others, all participants recommended it to others. One participant even went as far as to mention that it could even be given to people who did not have mental illness (Horan & Fox, 2016).

Case Study

Brandon Marshall is an American football wide receiver for the New York Giants (“Brandon Marshall”, 2017). He is 33 years old and was diagnosed in 2010 with Borderline Personality Disorder. Marshall has stated that he always knew that there was something wrong, but he did not know what it was or if he could receive help. Since being diagnosed, Marshall founded PROJECT 375. The organization raises awareness of mental illness, offers resources for people to seek help, and strives to decrease the stigma surrounding mental health diagnosis (“Who We Are”, 2016). Although aware of his personality disorder and symptoms, Brandon still frequently engages in self harm behaviors.

Intervention Plan

Problem Statement

Brandon engages in self-mutilating behavior due to emotional dysregulation which is negatively impacting his health and well-being in daily life.

Long Term Goals

1. Brandon will write a list of pro’s and con’s before making any major decisions in topics regarding family, career or finances in order to reduce impulsivity and promote mindful decisions for the next two months.
2. Brandon will implement his acquired emotional regulation techniques by playing a football game with no incident of fines or suspension due to violation and misconduct of NFL standards towards teammates in order to improve overall job performance.

Short Term Goals

1. Brandon will identify the pros and cons of his self-mutilating behaviors by 2 weeks to promote health and well-being in daily life.
2. Brandon will identify 2 negative coping mechanisms and 2 positive coping mechanisms in 1 week for health management.
3. Brandon will recognize incoming anger or anxiety and implement a relaxation technique such as deep breathing once a day to improve emotional regulation for improved health management.

Intervention Format

Individual

Setting

Brandon will meet with the occupational therapist individually at the therapy center for 30 minutes twice a week.

Supplies

A video of Brandon from a football game where he performed well in.

Agenda

• Meet Brandon & develop rapport (5 min)
• Analyze and discuss Brandon’s Beck’s Inventory Score (2 min)
• Engage in dialectical behavior therapy of life threatening behaviors (18 minutes)
  • Brandon will make a list of things that make him happy, including his football career.
  • He will watch a highlight of a football game where he performed well.
  • He will then write out positives about himself observed during the game.
• Provide a summary of the discussion and talk interest in completing the WRAP as a homework assignment at home. (5 min)

Documentation

S: “I told the world that I went to Mclean Hospital for 3 months that I was diagnosed with Borderline Personality Disorder. I didn’t know what to expect but immediately I began to see healing in other people’s lives around me. Although, I still struggle with self-harm behaviors today.”

O: Client participated in a 30-minute session focusing on self-harm behaviors using a dialectical behavioral approach. Client reports he is aware of his self harming behavior and expresses that he wants to change. While watching a highlight of a football game where Brandon performed well in, he wrote down positive characteristics about himself. At the end of the session, client expressed that the WRAP would be a good tool to identify stressful triggers that could be causing his self harming behavior.

A: Client’s self-harming behaviors are impacting his health and well-being in daily life. Watching a highlight of his football career incorporates his passion for football and works on mindfulness. This allows him to learn to be in the moment and be aware of the more positive factors in his life. Client would continue to benefit from skilled OT services to assist him in increasing his awareness of harmful behaviors in order to adapt a healthy lifestyle for participation in daily life.

P: Client expressed interest in completely a WRAP. Next session will focus on discussing his triggers, which he will identify in the WRAP activity. Marshall will attend occupational therapy 2 times a week for 30-minute sessions.

References

A timeline of Marshall’s off-field problems. (2012, March 15). Retrieved November 01, 2017, from http://www.espn.com/blog/chicago/bears/post/_/id/4675509/a-timeline-of-marshall%E2%80%99s-off-field-problems

American Psychiatric Association. (2013, May). DSM-5 Diagnostic Classification. Retrieved November 16, 2017, from http://dsm.psychiatryonline.org/doi/full/10.1176/appi.books.9780890425596.x00DiagnosticClassification

Barley, W., S. B., & E. P. (1993). Development of an inpatient cognitive-behavioral treatment program for borderline personalitydisorder. Journal of Personality Disorders ,7, 232-240. Retrieved November 09, 2017.

Bohus, M., Haaf, B., Simms, T., Limberger, M. F., Schmahl, C., Unckel, C.,Linehan, M. M. (2004). Effectiveness of inpatient dialectical behavioral therapy for borderline personality disorder: a controlled trial. Behaviour Research and Therapy,42(5), 487-499. doi:10.1016/s0005-7967(03)00174-8

Brandon Marshall. (2017). Retrieved November 01, 2017, from http://www.espn.com/nfl/player/_/id/9705/brandon-marshall

Bring Change To Mind. (2015, January 21). Retrieved November 01, 2017, from https://www.youtube.com/watch?v=dccpIU3bPj8

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

Butcher, J. N., Hooley, J. M., & Mineka, S. (2011). Abnormal psychology: core concepts (2nd ed.). Boston, MA: Pearson.

Carollo, K. (2011, August 01). NFL Star Brandon Marshall Has Borderline Personality Disorder. Retrieved November 01, 2017, from

Flagg, C. S. (2012, March 21). Brandon Marshall, Borderline Personality Disorder and how you can be more aware. Retrieved November 17, 2017, from http://www.chicagonow.com/as-i-see-it/2012/03/brandon-marshall-borderline-personality-disorder-and-how-you-can-be-moreware/

Greer, S., & Bagley, C, R. (1971). Effect of psychiatric intervention in attempted suicide: A Controlled study. British Medical Journal, 1,310-312.

Jackson-Koku, G. (2016, February 15). Beck Depression Inventory | Occupational Medicine | Oxford Academic. Retrieved October 06, 2017, from https://academic.oup.com/occmed/article-abstract/66/2/174/2750566/Beck-Depression-Inventory

Jaslow, R. (2011, August 01). Borderline personality disorder blamed for Brandon Marshall’s troubles. Retrieved November 01, 2017, from https://www.cbsnews.com/news/borderline-personality-disorder-blamed-for-brandon-marshalls-troubles/

Lee S, Harris M (2010) The development of an effective occupational therapy assessment and treatment pathway for women with a diagnosis of borderline personality disorder in an inpatient setting: implementing the Model of Human Occupation. British Journal of Occupational Therapy, 73(11), 559-563.DOI: 10.4276/030802210X12892992239396

Swenson, C. R., Sanderson, C., Dulit, R. A., & Linehan, M. M. (2001). The Application of Dialectical Behavioral Therapy for patients with borderline personality disorder on inpatient units. Psychiatric Quarterly,72(4), 307-324. Retrieved November 10, 2017, from http://eds.a.ebscohost.com.ezproxy.fiu.edu/eds/pdfviewer/pdfviewer?vid=2&sid=b9bf731d-0525-4ef2-9253-23ad0a95c46e%40sessionmgr4009

What is Dialectical Behavior Therapy (DBT)? (2017). Retrieved November 21, 2017, from https://behavioraltech.org/resources/faqs/dialectical-behavior-therapy-dbt/

Who We Are. (2016). Retrieved November 01, 2017, from https://project375.org/who-we-are/