Adult Treatment Planner

Objectives and Interventions

• Discuss openly the history of difficulties that have led to seeking treatment.
  • Assess the client's experiences of distress and disability, identifying behaviors (e.g., parasuicidal acts, angry outbursts, overattachment), affect (e.g., mood swings, emotional overreactions, painful emptiness), and cognitions (e.g., biases such as dichotomous thinking, overgeneralization, catastrophizing) that will become the targets of therapy.
  • Explore the client's history of abuse and/or abandonment particularly in childhood years.
  • Validate the client's distress and difficulties as understandable given his/her particular circumstances, thoughts, and feelings.
• Verbalize an accurate and reasonable understanding of the process of therapy and what the therapeutic goals are.
  • Orient the client to dialectical behavior therapy (DBT), highlighting its multiple facets (e.g., support, collaboration, challenge, problem-solving, skill-building) and discuss dialectical/biosocial view of borderline personality, emphasizing constitutional and social influences on its features (see Cognitive-Behavioral Treatment of Borderline Personality by Linehan).
  • Throughout therapy, ask the client to read selected sections of books or manuals that reinforce therapeutic interventions (e.g., Skills Training Manual for Treating BPD by Linehan).
• Verbalize a decision to work collaboratively with the therapist toward the therapeutic goals.
  • Solicit from the client an agreement to work collaboratively within the parameters of the DBT approach to overcome the behaviors, emotions, and cognitions that have been identified as causing problems in his/her life.
• Verbalize any history of self-mutilative and suicidal urges and behavior.
  • Probe the nature and history of the client's self-mutilating behavior.
  • Assess the client's suicidal gestures as to triggers, frequency, seriousness, secondary gain, and onset.
  • Arrange for hospitalization, as necessary, when the client is judged to be harmful to self.
  • Provide the client with an emergency helpline telephone number that is available 24 hours a day.
• Promise to initiate contact with the therapist or helpline if experiencing a strong urge to engage in self-harmful behavior.
  • Interpret the client's self-mutilation as an expression of the rage and helplessness that could not be expressed as a child victim of emotional abandonment or abuse; express the expectation that the client will control the urge for self-mutilation.
  • Elicit a promise (as part of a self-mutilation and suicide prevention contract) from the client that he/she will initiate contact with the therapist or a helpline if a suicidal urge becomes strong and before any self-injurious behavior occurs; throughout the therapy process consistently assess the strength of the client's suicide potential.
• Reduce actions that interfere with participating in therapy.
  • Continuously monitor, confront, and problem-solve client actions that threaten to interfere with the continuation of therapy such as missing appointments, noncompliance, and/or abruptly leaving therapy.
• Cooperate with an evaluation by a physician for psychotropic medication and take medication, if prescribed.
  • Assess the client's need for medication (e.g., selective serotonin reuptake inhibitors) and arrange for prescription if appropriate.
  • Monitor and evaluate the client's psychotropic medication prescription compliance and the effectiveness of the medication on his/her level of functioning.
• Reduce the frequency of maladaptive behaviors, thoughts, and feelings that interfere with attaining a reasonable quality of life.
  • Use validation, dialectical strategies (e.g., metaphor, devil's advocate), and problem-solving strategies (e.g., behavioral and solution analysis, cognitive restructuring, skills training, exposure) to help the client manage, reduce, or stabilize maladaptive behaviors (e.g., angry outbursts, binge drinking, abusive relationships, high-risk sex, uncontrolled spending), thoughts (e.g., all-or-nothing thinking, catastrophizing, personalizing), and feelings (e.g., rage, hopelessness, abandonment; see Cognitive-Behavioral Treatment of Borderline Personality by Linehan).
• Participate in a group (preferably) or individual personal skills development course.
  • Conduct group or individual skills training tailored to the client's identified problem behavioral patterns (e.g., assertiveness for abusive relationships, cognitive strategies for identifying and controlling financial, sexual, and other impulsivity).
  • Use behavioral strategies to teach identified skills (e.g., instruction, modeling, advising), strengthen them (e.g., role-playing, exposure exercises), and facilitate incorporation into the client's everyday life (e.g., homework assignments).
• Verbalize a decreased emotional response to previous or current posttraumatic stress.
  • After adaptive behavioral patterns and emotional regulation skills are evident, work with the client on remembering and accepting the facts of previous trauma, reducing denial and increasing insight into its effects, reducing maladaptive emotional and/or behavioral responses to trauma-related stimuli, and reducing self-blame.
• Identify, challenge, and replace biased, fearful self-talk with reality-based, positive self-talk.
  • Explore the client's schema and self-talk that mediate his/her trauma-related and other fears; identify and challenge biases; assist him/her in generating thoughts that correct for the negative biases and build confidence.
  • Assign the client a homework exercise in which he/she identifies fearful self-talk and creates reality-based alternatives; review and reinforce success, providing corrective feedback for failure (see "Journal and Replace Self-Defeating Thoughts" in Adult Psychotherapy Homework Planner, 2nd ed. by Jongsma, or "Daily Record of Dysfunctional Thoughts" in Cognitive Therapy of Depression by Beck, Rush, Shaw, and Emery).
  • Reinforce the client's positive, reality-based cognitive messages that enhance self-confidence and increase adaptive action.
• Participate in imaginal and/or in vivo exposure to trauma-related memories until talking or thinking about the trauma does not cause marked distress.
  • Direct and assist the client in constructing a hierarchy of feared and avoided trauma-related stimuli.
  • Direct imaginal exposure to the trauma in session by having the client describe a chosen traumatic experience at an increasing, but client-chosen level of detail; integrate cognitive restructuring and repeat until associated anxiety reduces and stabilizes; record the session and have the client listen to it between sessions (see "Share the Painful Memory" in Adult Psychotherapy Homework Planner, 2nd ed. by Jongsma, and Posttraumatic Stress Disorder by Resick and Calhoun); review and reinforce progress, problem-solve obstacles.
  • Assign the client a homework exercise in which he/she does an exposure exercise and records responses or listens to a recording of an in-session exposure (see Posttraumatic Stress Disorder by Resick and Calhoun); review and reinforce progress, problem-solve obstacles.
• Verbalize a sense of self-respect that is not dependent on others' opinions.
  • Help the client to value, believe, and trust in his/her evaluations of himself/herself, others, and situations and to examine them nondefensively and independent of others' opinions in a manner that builds self-reliance but does not isolate the client from others.
• Engage in practices that help enhance a sustained sense of joy.
  • Facilitate the client's personal growth by helping him/her choose experiences that strengthen self-awareness, personal values, and appreciation of life (e.g., insight-oriented therapy, spiritual practices, other relevant life experiences).