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.
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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….....
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
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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