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Introduction

Motivational interviewing is a therapeutic conversation used in the profession of healthcare to help people overcome their ambivalence by strengthening the their own motivation to change from what they hear themselves say (Rollnick, Miller, & Butler, 2008). There are many behaviors individuals with borderline personality disorder may need or want to change (American Psychiatric Association, 2013). These behaviors include:

• Suicidal, gestures, threats, or self mutilating behaviors
• Mood instability
• Impulsivity
• Unstable and intense relationships
• Chronic feelings of emptiness

Motivational Interviewing requires high-quality listening (Rollnick, Miller, & Butler, 2008) and can be used by Occupational therapy practitioners to guide people with borderline personality disorder engage in adaptive behaviors and have a healthier positive life.

Theory

The transtheoretical model assesses an individual’s readiness to engage in a healthier behavior through the stages of change (Prochaska, Redding, & Evers, 2008). Occupational therapy practitioners should begin by understanding why the individual wants to change and come up with an intervention to help him or her move from one stage to the next at the desired pace.

Evidence:

Evidence describes the role of family physicians in identifying and treating personality disorders. The paper notes that pharmacology is not the only treatment for these patients and various types of therapy such as motivational interviewing are necessary in treating patients with personality disorders. This paper also gives a step by step guide with an example on how to conduct and implement motivational interviewing (Angstman & Rasmussen, 2011).

Additional research investigates the use of integrated therapy methods, which include motivational interviewing as one of its components, to see if there is an association between personality disorder characteristics and treatment outcomes in people with co-occurring alcohol misuse and depression. The study found that integrated therapy (which uses motivational interviewing) was more effective than single-focused therapy for individuals with higher personality disorder cluster scores (McCarter et al., 2016).

McMurran et al (2010) describes the problem of personality disorder patients dropping out and not finishing their therapy. It then describes the use of motivational interviewing as a possible solution to decreasing the dropout rates. The study was a randomized controlled trial with one group receiving motivational interviewing in attempt to reduce the dropout rate.

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. In addition to recovering from bulimia, she also was drinking alcohol daily at the age of 18. 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 self-harm behaviors. When she feels stressed or has an emotional outburst she self-mutilates her skin. Presently, she lives in Tallahassee, Florida where she works at 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, they do not visit often her home often and lack a strong familial relationship.

Intervention Plan

Problem Statement

Serena engages in self-mutilating behavior which is negatively impacting her health and well-being in daily life.

Outcomes

Long Term Goals

1. Serena will move from precontemplation to maintenance related to self-mutilating behaviors by 3 months to promote health and well-being in daily life.

Short Term Goals

1. Serena will identify the pros and cons of her self-mutilating behaviors by 2 weeks to promote health and well-being in daily life.
2. Serena will increase her awareness of impact from self-mutilating behaviors by 2 weeks to promote health and well-being in daily life.

The following amount of goals were indicated for this client according to the amount of permissible visits, setting, and readiness of change determined by the transtheoretical model.

Intervention Format

Individual

Setting

Serena will meet with the occupational therapist individually at the student health clinic for 30 minutes once a week.

Supplies

None

Agenda

• Meet Serena & develop rapport (5 min)
• Assess Serena’s readiness for change (2 min)
• Engage in motivational interviewing of self-mutilating behaviors (18 minutes)
  • Potential open-ended questions
    • “What brings you here today?”
    • “Tell me what a typical day for you looks like?”
    • “That sounds really stressful, tell me what you do in a stressful situation?”
  • Provide affirmations
    • “It took a lot for you to come today, I appreciate you being here.”
    • “Your mom must really love you if she is concerned about your self-mutilating behaviors.”
    • “You’re a capable mother/daughter.”
  • Provide reflections
    • “You think your self-mutilating behavior doesn’t affect your ability to take care of your children.”
    • “You are noticing your mother is very concerned about your health.”
    • “It sounds like you don’t agree with your mother about the severity of your self-mutilating behaviors.”
  • Provide a summary of the discussion (5 min)

SOAP Note

S: “My mom recommended I talk to somebody because she’s worried I cannot take care of my children. She saw me cutting myself in the bathroom and thinks I’m at risk for suicide. I don’t really see the issue with my cutting.”

O: Client participated in a 30-minute session focusing on self-harm behaviors using a motivational interviewing approach. Client reported she cuts herself in the bathroom 2-3 times a week when presented with stressful situations. Client demonstrated intense emotions of depressed mood and sadness when discussing her self-harm behaviors throughout the week. Client reports she was not aware of her problem of self harm and did not discuss with others her pattern of harmful behaviors. Client reported at the end of the session that she is receptive and aware to her pattern of harmful behavior and would like to understand why she engages in them.

A: Client presents with self-harming behaviors impacting her health and well-being in daily life. Client presented in pre-contemplation stage of change, however advanced to contemplation during the discussion. Client would continue to benefit from skilled OT services to assist client in continuing her awareness of harmful behaviors so she may adapt healthy lifestyle patterns to be a successful mom.

P: Continue with motivational interviewing approach to develop adaptive coping strategies and routines. Evaluate progressive new habits and continue to refine. Serena will have occupational therapy twice a week for 30 minutes.

References

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

Angstman, K. B., & Rasmussen, N. H. (2011). Personality disorders: review and clinical application in daily practice. American family physician, 84(11), 1253.

McCarter, K. L., Halpin, S. A., Baker, A. L., Kay-Lambkin, F. J., Lewin, T. J., Thornton, L. K., … & Kelly, B. J. (2016). Associations between personality disorder characteristics and treatment outcomes in people with co-occurring alcohol misuse and depression. BMC psychiatry, 16(1), 210.

McMurran, M., Cox, W. M., Coupe, S., Whitham, D., & Hedges, L. (2010). The addition of a goal-based motivational interview to standardised treatment as usual to reduce dropouts in a service for patients with personality disorder: a feasibility study. Trials, 11(1), 98.

Prochaska, J. O., Redding, C. A., & Evers, K. E. (2008). The Transtheoretical Model and Stages of Change. In K. Glanz, B. K. Rimer, & K. Viswanath (Eds.), Health Behavior and Health Education: Theory, Research, and Practice. San Francisco, CA: Jossey-Bass.

Rollnick, S., Miller, W. R., & Butler, C. (2008). Motivationals Interviewing in Healthcare: Helping Patients Change Behavior. American Journal of Pharmaceutical Education (Vol. 73). http://doi.org/10.1111/j.1465-3362.2009.00073.x