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Introduction

Cognitive Orientation to Daily Occupational Performance (CO-OP) is a meta-cognitive approach to solving daily occupational performance problems, which focuses on cognition and skill acquisition. CO-OP encourages individuals to regulate their own behaviors through first setting a goal, making a plan, doing the plan, and finally checking if the plan was successful (Dawson, et al., 2013).

According to the fifth edition of the Diagnostic and Statistical Manual of Mental Illnesses (DSM-5), impulsive behaviors are a hallmark of borderline personality disorder. These individuals often find themselves struggling to manage impulsive behaviors like reckless spending, which is a problem behavior that can be addressed using a CO-OP approach.

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 because of the ample amount of evidence that supports it for several psychiatric diagnoses. Additionally, this theory would work well with Serena’s diagnosis of borderline personality disorder because of developing personal characteristics such as impulsivity. Serena does not have the ability to be mindful of her triggers, thoughts, and behaviors which are causing dysfunction in occupational performance. Consequently, this 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. Additionally, it will assist her in understanding beliefs about herself, others, and the world as a whole to begin changing internal cognitive processes.

Evidence

As of now, there are limited studies that have examined the link between CO-OP intervention and symptom change in borderline personality disorder (BPD). However, there is evidence to support other metacognitive approaches in decreasing deficits with individuals who have BPD.

Evidence describes that individuals with borderline personality disorder will experience impairments in metacognitive capacity, specifically the ability to understand and incorporate ideas about themselves. Consequently, they will have difficulties adapting with psychological challenges. Vohs & Leonhardt (2016), conducted a study with Carter, a female with a diagnosis of borderline personality disorder who presently lives in a long-term institutional setting. She has all typical symptoms of borderline personality disorder and has been hospitalized over 80 times due to self-harm. Carter received 14 months of metacognitive reflection and insight therapy (MERIT). Using MERIT,  this approach would help Carter identify her mental state in daily life events so she may better respond to future challenges. MERIT includes eight important processes which are attending to the client’s agenda, presence of the therapist’s thought in dialogue, eliciting narrative episodes, defining a psychological problem, discussing interpersonal processes, evaluating progress, stimulating reflective acts about self and others, and stimulating the use of knowledge about self and others. The results from the study concluded that Carter had increased stable interpersonal relationships with family and peers, decreased emotional dysregulation, and a decrease in impulsivity. Additionally, self-harm behaviors were not present for more than 9 months. Overall, this study demonstrated improved symptomatology of BPD and provided meaningful clinical gains using a metacognitive approach.

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, impulsivity,  and poor interpersonal relationships. She is a mom of three children, and is living in her mother’s house due to poor money management skills.

Intervention Plan

Problem Statement

Serena’s difficulty with money management skills are secondary to poor impulse control from distorted thinking.

Long Term Goals

1. Serena will be able to grocery shop independently without overspending in 20 weeks for meal preparation activities.
2. Serena will be able to apply CO-OP problem solving strategies independently on an untrained task within 20 weeks to improve independence in complex IADLs.

Short Term Goals

1. Serena will be able to grocery shop with items listed on her grocery list independently without overspending in 10 weeks.
2. Serena will verbalize the co-op process with 100% accuracy without assistance in 3 sessions in order to participate in meal preparation activities.
3. Serena will implement CO-OP strategies with verbal and gestural cues on a trained task within 5 weeks for meal preparation activities.

Intervention Format

Individual

Setting

Serena will meet with the occupational therapist individually at the grocery store twice a week for 30 minutes.

Supplies

N/A

Agenda

• Meet with Serena at the grocery store and review her shopping list (5 min)
• Discuss CO-OP strategies related to her grocery shopping (10 min)
• Engage in grocery shopping and identify prioritized items (10 min)
• Discuss the homework for the following session (5 min)

Documentation

S: Serena mentioned she lives at home with her mother. She said “living with my mom has been helpful, anytime I don’t have enough money for my groceries she lends me money”. She also mentioned living with her mom allows her to buy anything she pleases, even if she doesn’t need it, because her mom will pay for the rest.

O: Serena engaged in a 30-minute CO-OP based session at the grocery store. Serena applied CO-OP strategies to engage in grocery shopping. She required 8 verbal cues and 3 gestural cues to complete grocery shopping as she was choosing to buy items that were not on her grocery list. Serena was able to verbalize why certain items that she wanted to buy were not of equal importance in comparison to the pre-selected items on the grocery list.

A: Serena greatly benefited from verbalizations to enhance her problem solving abilities. Serena shows impairments with impulsivity which interferes with her ability to engage in high-level decision making. The CO-OP approach benefited Serena by slowing her cognitive processes so she could evaluate her choices instead of making quick and impulsive decisions.  Serena has the insight into her impulsivity and understands how her quick impulsive decisions negatively impact her money management skills. Serena would benefit from future OT to apply CO-OP to money management in all areas of spending.

P: Serena will attend occupational therapy twice a week for 30 minute sessions. During the next session Serena will create new strategies to enhance her problem solving abilities with money management in other spending areas.

References

Dawson, D. R., Gaya, A., Hunt, A., Levine, B., Lemsky, C., & Polatajko, H. J. (2009). Using the cognitive orientation to occupational performance (CO-OP) with adults with executive dysfunction following traumatic brain injury. Canadian Journal of Occupational Therapy, 76(2), 115-127.

Vohs, J., & Leonhardt, B. (2016). Metacognitive Reflection and Insight Therapy for Borderline Personality Disorder: A Case Illustration of an Individual in a Long Term Institutional Setting. Journal Of Contemporary Psychotherapy, 46(4), 255-264. doi:10.1007/s10879-016-9335-6