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CASE

PRESENTATION
PRESENTED BY- NAVNITA BOSE
IIND YEAR M.PHIL TRAINEE
DEPARTMENT OF CLINICAL PSYCHOLOGY
INSTITUTE OF PSYCHIATRY
KOLKATA
CHAIRPERSON- MS. DOYEL GHOSH

PURPOSE OF THE
PRESENTATION
Discussion on management plan

SOCIO DEMOGRAPHIC DETAILS


NAME: S.M.
SEX/GENDER: Female
AGE: 16 years
Marital status: married (not

registered)
Mother tongue: Bengali

Education: studying in

10th standard
Occupation: student
Religion and caste: Hindu
Residence: sub-urban
Family type: extended

Cont..
Family size: 4 Adults: 2
Income:
Income sources: 1. Father
Patients income: nil

INFORMANTS:
Name: S. M. and B.M.

Relationship with the child: Biological father and paternal

grand-mother

Duration of relationship: Since birth

Information provided was consistent and adequate. It was

corroborated.

PRESENTING COMPLAINTS:
1. Disturbed interpersonal relationship
2. Acts of deliberate self-harm
3. Episodes of running away from home
4. Impulsivity
5. Multiple Suicidal attempt
6. Low Mood

From
adolescence

HISTORY OF PRESENT ILLNESS:


Onset: insidious
Course: continuous
Progress: fluctuating
Client was apparently maintaining well 2 years back.

Since last 2 years, she has been in a relationship with a


neighborhood boy. They had a stable relationship and
used to call each other quite often, which at times used

CONT.
As reported by the informant, client used to mistrust this boy often

resulting in frequent arguments between the two. Such arguments would


made the client upset and she used to be distressed about it. However,
they were continuing with their relationship inspite of these arguments.
One day, she suddenly went with her boyfriend to one of his relatives

(MALDA) without informing to anyone. Next day, they came back and
went straight to the boys family as the client feared that her father
would not allow her in.

CONT..
Her father was called to the boys house but her father initially

refused to let her in. Then they were taken to the nearby police
station, after which her father allowed her back. This incident
deteriorated the relationship between the two families, but the
client and the boy continued their relationship.
Then she went back to her hostel. During this time, her father

started receiving complaints about clients behavior from her school


that she calls a million times to her boyfriend.

CONT..
Her boyfriend stated that during this time, she once

slashed her wrist due to arguments between them.


Another example of her running away from home
includes when after coming back in one such vacation,
she asked her father to give her phone as she wanted to
call her boyfriend. Her father refused and told her to go
to anywhere she wanted to. Next day she went to her
friends house and stayed for one entire day without

Meanwhile during last December 2014, when she came back

from her hostel in vacation, she met another boy living in the
neighborhood. This boy was her younger brothers friend. Client
got friendly to him and they started interacting well. She herself
mentioned this to her boyfriend. These interactions used to
make the clients boyfriend angry and he used to repeatedly
ask the client to stop interacting with him. However, ignoring
his boyfriends opinion, client continued talking with this boy.

CONT..
This made her boyfriend upset and he decided to end their

relationship. He discontinued talking to her. This made the client


angry and to make him more jealous, she started hanging around
with this second boy. After a few days, this boy proposed the client.
According to the client, she thought that this would make her
boyfriend more jealous and she accepted his proposal. During this
time, clients father also started behaving rudely with her as he did
not like this second boy and his daughter hanging around with her.

CONT..
This often led to a series of arguments in the house and often

hitting the client which made the client more upset. Previously,
she was upset because even after accepting this boys
proposal, her previous boyfriend did not approach her to
amend things. Such situation continued for around 4-5 days
and on the sixth day, she eloped with the second boy and
married him in temple. However, client denied this marriage
episode while taking the history.

CONT..
According to the client, she did this mainly to make his

previous boyfriend jealous and also she was angry with her
family and she wanted to teach them a lesson.
Within few hours, her father brought her back with the help of

the police. Her father took her to her paternal uncles house
from where she was taken for psychiatric help the following
day.

CONT..
After having the medicines for two days, she felt somewhat better and

her paternal aunty said that there is no need to take the medicines more.
However, medicines were kept with her only. After two days, she

consumed ten tablets of Escitalopram of 10 mg each with her morning


tea. She asked her maid for more sugar, and after she went, client mixed
the tablets and had the tea. She reported that all the above mentioned
events have made her life miserable and she did not want to live
anymore.

CONT..
After that she was taken to hospital and next day, she was

brought to the Institute Of Psychiatry OPD.


All these problems are creating significant distress in her

functioning life due to which she has come to seek treatment.

BIOLOGICAL FUNCTIONS:

SLEEP: unchanged
APPETITE: decreased
SEXUAL INTEREST AND ACTIVITY: not elicited
ENERGY: unchanged.

NEGATIVE HISTORY:
No significant brain injury, no episodes of fit, history not suggestive of

reduced level of consciousness


History not suggestive of pervasive elevated mood, stealing, setting up of

fire, and big talks


History not suggestive of presence of any pervasive firm, unshakable belief
History not suggestive of false perception which is not a sensory distortion

or a misinterpretation, but which occurs at the same time as real perceptions


History not suggestive of consumption of substance

TREATMENT HISTORY:
Treatment done at INSTITUTE OF PSYCHIATRY (IOP)
January 2015- May 2015
Tab Olanzapine 5 mg x---------x-------I
Effects: improvement in mood symptoms
Side effects: weight gain
Compliance was good

PAST ILLNESS:
Past history not suggestive of any significant medical or

psychiatric illness

FAMILY HISTORY:

FAMILY INTERACTION PATTERN:


Communication: direct
Leadership: democratic
Decision making: mostly father
Role: inadequate by father as he cannot spend much time with the

family
Family rituals: none reported
Cohesiveness: low
Family burden: financial problem
Expressed emotion: sometimes warmth, sometimes hostility and

critical comments

FAMILY HISTORY OF PSYCHIATRIC


ILLNESS:
Mother: suicide due to family problems, burnt herself, client

was 6-7 years old, she witnessed the accident, clients mother
had features such as suspecting her husband as having extramarital affair, had a clinging behavior towards clients father,
acts of deliberate self-harm present before her marriage
providing an impression Borderline Personality Disorder
Father: alcohol dependence

PERSONAL HISTORY:
BIRTH AND DEVELOPMENTAL HISTORY:
Full term, caesarian delivery with attainment of developmental

milestones within normal limits


CHILDHOOD DISORDERS:

None reported

PARENTS AND HOME ATMOSPHERE IN CHILDHOOD AND ADOLESCENCE:

As her mother was having strangled relationship with her in-laws,

whenever client used to talk to her paternal uncles and aunties,


her mother used to hit her, and scold her. During infancy, client
witnessed many family feuds in which her father often used to hit
her mother. After her mothers death, she was brought up by her
paternal uncle and aunty who used to live in the same house at
that time. Later they got separated due to financial problem.
They never criticized client or her younger brother after her
mothers death but previously sometimes used to criticize them.

CONT..
After her mothers death, they often showered more love and care in

order to compensate for her mother. When she was in 4 th standard, she
was sent to hostel as his father was having a tough time a she was not
able to give his children time and used to be sad about her wife
untimely death. Client reported that she liked staying at hostel but
missed her family very much. She was often more cared than her
brother so that she would not think that her brother is cared more and
had a poor equation with her brother.
HOME ATMOSPHERE: Dysfunctional

SCHOLASTIC AND EXTRACURRICULAR ACTIVITIES:


Highest grade completed: 9th standard
Academic performance: below average
Reason for discontinuation: NA
Peer relationships: cordial
Any disciplinary problems: complaints regarding calling often
Hobbies,

interests and extracurricular activities: drawing,

playing phone games

INTERPERSONAL RELATIONS AND SOCIAL ACTIVITIES:


Had few peers, likes socializing but with selected people
OCCUPATIONAL HISTORY: NA
MENSTRUAL HISTORY:
Menarche: 12 years
Date of last menstrual cycle: 21st November 2014
Periods: regular
Duration: 3-7 days
Any associated physical/psychological symptoms: stomach

ache

SEXUAL HISTORY:
She acquired sexual knowledge from friends at the age of 13

years. She denied masturbation and any sexual experience.


Attitude towards sexual knowledge was guarded.
MARITAL HISTORY:
She had an unregistered marriage at the age of 16 years with

consent. But she denied, when enquired.

HABITS AND ADDICTION:


She consumed 2-3 times alcohol with the second boy as

alleged by the informant. However, it was uncorroborated by


self. She is non-vegetarian.
LEGAL HISTORY:
Two times she got involved with police as mentioned in the

history.

GENERAL TEMPERAMENT:
From childhood, client was stubborn and often refused to obey

elders. However, she was not quick tempered and was easily
manageable. She is sensitive to criticism. If anyone would go
against her wish, she would think that everyone is bad. She
liked to share household responsibility, and likes socializing.

MENTAL STATUS EXAMINATION (MSE):


Consciousness was present
Client appeared to be well kempt and tidy with mesomorphic

body built. She was in contact with the surroundings and


maintained eye- contact. Rapport was easily established with
cooperative attitude towards the examiner.
Her motor behavior was normal.
Speech was audible with normal reaction time, normal speed,

normal fluctuations, spontaneous ease, and normal productivity,


relevant, coherent and goal-directed.

COGNITIVE FUNCTIONS:
Orientation:

Time

Intact

Place

Intact

Person

Intact

Date

Intact

Day

Intact

Month

Intact

Year

Intact
OVERALL IMPRESSION: INTACT

ATTENTION AND CONCENTRATION:


Attention being easily aroused and sustained. (Was able to do

100-7, complete sequence)


MEMORY:
OVERALL IMPRESSION: INTACT

Memory:
REMOTE

RECENT
IMMEDIATE

Own birth year: 23rd Apr 1999


Brothers birth year: 27th Jan
2001
Independence year: 1947
1st prime minister of India :
Jawahar Lal Nehru
Dinner: could answer
Breakfast: could answer
DF: 5
DB: 3
Word recall: 4 out of 4

ABSTRACTION:
SIMILARITIE

Aam- kola

Dutoi fruit

harmonium-

dutoi

tabla

korte

Nachte na janle

kore
Jara nachte pare

uthon beka

na bakide theke,

tader mone hoye

PROVERB

uthon
nachte

gaan
sahajjo

beka

bole

parena,

GENERAL INTELLIGENCE:
INFORMATION

Current

CM:

Mamta

Banerjee,

CALCULATION

Ramayan: Valmiki
Cost of 2 pencils is .5 paisa, how many
pencils can be bought by 20 paise? 8
153- 75= 78

COMPREHENSION
VOCABULARY

COOK FOOD: HOJOM HOAR JONNO


Shahosi: jara bhoye paye na
Hingsha- 2to friend, ek jon er kache sob
ache, eta dekhe onno jon chay k amaro
hok, etai hingsha
COMMENT: AVERAGE

JUDGMENT:
PERSONAL

Adequate general appearance

SOCIAL

Cooperative

behaviour

with

Intact

the

satisfactory

Fire in the house: jol diye nebhabo, fire-

satisfactory

clinician
TEST

brigade k dakbo
Envelope: letter box a dhele debo

LOBE FUNCTION:
Was able to do alternate sequence
Was able to draw clock

Her subjective affect was kokhono besi keu chechaye to

matha kharap hoye with objective affect being depressed


quality, shallow depth, adequate in range, appropriate to
thought, communicable and reactive to stimulus.

THOUGHT:
Stream: normal
Form: normal
Possession: no abnormality detected
Content: normal

Her insight to her problem was amar or sathe

friengship kora tai bhool hoye geche, na korle ei sob


hoto na GRADE V INTELLECTUAL INSIGHT

DIAGNOSTIC FORMULATION:
Indexed client, S.M., female, 16 years old, married(unregistered), Bengali,

studying in 10th standard, Hindu,, hailing from sub-urban domicile, with


middle socio-economic-status, extended family, presenting with the chief
complaints of unstable interpersonal relationships, acts of deliberate selfharm, impulsivity, low

mood, suicidal attempts from adolescence with

insidious onset, continuous course and deteriorating progress; with


inadequate role played by father, critical comments and hostility in
expressed emotions, suicide and borderline personality disorder in
mother, alcohol dependency in father with dysfunctional childhood home
atmosphere, occasional intake of alcohol, difficult temperament,

with MSE revealing well kempt and tidy appearance, mesomorphic body-

built, in contact with the surroundings in contact with the surroundings,


maintained

eye-

contact,

rapport

being

easily

established

with

cooperative attitude towards the examiner, with normal motor behaviour ,


audible speech with normal reaction time, normal speed, normal
fluctuations,

spontaneous

ease,

and

normal

productivity,

relevant,

coherent and goal-directed with intact orientation, attention being easily


aroused

and

abstraction,

sustained
average

with

general

intact

memory

intellectual

functions,

abilities

with

conceptual
satisfactory

personal, social and test judgment, objective affect being depressed in


quality, with shallow

depth, adequate range, appropriate to thought,

communicable and normal reactivity to stimulus, Grade iv insight.

TEST ADMINISTERED:
Temperament-character Inventory (TCI)
Thematic Apperception Test (TAT)

FINDINGS:
TCI:

TEMPERAMEN
T DOMAINS

PERECTILE
RANK

IMPLICATION

Novelty seeking
Harm avoidance
Reward
dependence
Persistence

75
85
50

High
Very high
Average

35

Very low

CHARACTER

PERCENTILE RANK

IMPLICATION

DOMAINS
Self- directedness
Cooperativeness
Transcendence

39.7
39.9
46.5

Very low
Very low
Average

TCI findings suggest that the client tends to be insecure and doubtful even in situations that do not worry
other people. She tends to be inhibited and shy in most social situations and feel easily fatigued. As a
consequence, she needs more reassurance and encouragement than most other and is unusually sensitive
to criticism. She also tends to be impulsive leading to fickleness in relationships and instability in efforts.

Low self-directedness and cooperativeness is suggestive of

characterological deficits. She appears to be ineffective and


poorly integrated when not conforming to the direction of a
mature leader. She seems to be lacking an internal locus of
control, making to difficult for her to define and pursue ling
term goals. She can also be described as intolerant and
opportunistic and tends to be inconsiderate of others rights or
feelings

TAT:
Environment
Non-nurturant, supportive,
mistrustful

SELF
Ambivalent (mostly
inadequate)
NEEDS
Counteraction, defendance,
harmavoidance

AUTHORITY FIGURES
Same sex: dominating
Opp. Sex: nurturant

NEEDS
Autonomy,
aggression, intraaggression
CONFLICT
Autonomy vs

compliance
Rejection vs

affiliation
Adequacy vs lack

ANXIETY
Being dominated, loss of
love

DEFENSES
Regression, rationalisation,
projection

PSYCHOPATHOLOGY
FORMULATION:
BIO-PSYCHO-SOCIAL MODEL

Mother: impression of
BPD
Father: substance
abuse

High novelty seeking,


harm avoidance,

Self
Insecure self
Childhood trauma
Mothers suicide,
going to hostel

Early childhood
experience
Invalidation of
emotion, maternal
neglect,

External locus of control,


(characterological deficits) n for
affiliation, aggression,
intraagression

Father not spending


much time, critical
comments from
younger brother

Arguments with
boyfriend, isolated
by relatives

Distress, frustration, impulsive acting out,


demanding behaviour, suicidal attempts

FINAL DIAGNOSIS:
ICD 10
F60.31; Emotionally Unstable Personality Disorder - Borderline

Type

POINTS IN FAVOUR
AGAINST
Impulsivity
Lack of self-control
Acts of self-harm, suicidal attempts
Emotional instability

POINTS IN

PROGNOSTIC FACTORS:
GOOD PROGNOSTIC FACTOR
Average intelligence
Motivation to know about causes
Female gender
Good compliance
warmth

BAD PROGNOSTIC FACTORS


Biological loading
Impulsivity
Repeated suicidal attempts
Family history
Brutalized early environment

Absence of narcisstic features

Woollcott, P. (1985). Prognostic indicators in the psychotherapy of


borderline patients. American journal of psychotherapy.

MANAGEMANT PLAN:
Locus of the therapy process: Hospital based set up with one

individual
Focus of the therapy process:
Short term goal:
Engagement in therapy process
Establishing empathetic relationship with the client
Understanding clients interpersonal environment
Psychoeducation
Improving adjustability

Long term :
Improving skills for better interpersonal functioning
Increasing perceived social support
Improving control over emotions
Enhancing problem solving skills
Enhancing coping skills
Modus of the therapy process: Dialectical Behavior

Therapy

RATIONAL FOR DIALECTICAL BEHAVIOUR THERAPY:


Dialectical Behavior Therapy (DBT) is a comprehensive treatment
program whose ultimate goal is to aid patients in their efforts to build a
life worth living.
Dialectical behavior therapy (DBT), an empirically supported treatment
for adult women diagnosed with borderline personality disorder (BPD),
has been increasingly adapted for use with adolescents across a variety
of settings. An article by Kristen A. Woodberry and Ellen J. Popenoe at
the Maine Medical Center, describes a community-based application of
DBT principles and strategies for adolescents and their families.

It is the first study of DBT with suicidal and self-injuring

adolescents to provide parent as well as adolescent reports of


change. The consistency of these effects with those of other
preliminary studies of adolescent DBT suggests that this model is
indeed feasible within a naturalistic community treatment setting
and may have benefits for families as well as adolescents.
DBT is based on Biosocial Theory. The main tenet of biosocial

theory is that the core disorder in BPD is Emotional dysregulation.


It is the outcome of biological dysregulation, environmental
context, and transaction between the two during development.

As with respect to emotional dysregulation, in the present case it

has been observed that early experiences of the client includes


mothers tendency to react inappropriately (clinging behaviour
with clients father, conflicts with in-laws, suicide with client
present in the vicinity) which has contributed to the clients high
emotional vulnerability. This tendency of mother (over-reacting
to situations) and going to hostel at a very young age where her
emotional needs got unsatisfied (client reported of missing her
family after going there, and wanting to come back), created an
invalidating environment (environmental context) for her.

Moreover, the differences in emotions expressed i.e. what she

experienced and what she saw with other children of her


family (initially, client had a joint family) and of hostel
intensified her emotional vulnerability.
According to the theory of DBT, the invalidating environment

contributes to emotional dysregulation by failing to teach the


child to label and modulate arousal, to tolerate distress, or to
trust her own emotional responses as valid interpretations of

It has also been advocated that emotion regulation difficulties

interfere with a stable sense of self and with normal emotional


expression. Without such capabilities, it is understandable that
borderline individual develop chaotic relationship (Linehan, 1993)
which is also the case with the present client.
Therefore, with DBT present client will be helped to understand

and develop the skill to fully accept her and her world as they are
in the moment through four skills modules; 2 of which emphasize
change and 2 emphasize acceptance and to stand still instead of
running away, to work to understand why her life is so hard.

INTERVENTION:
SESSION 1ST:
Case history was taken.
Mental Status Examination was done.
Due to the suicidal attempt the previous night, she was directly

referred from emergency to Institute Of Psychiatry and was getting


drowsy as the session progressed. Hence, first session was not
conducted further.
Informants were advised to keep a close watch and not to allow her

to take medicines by self.

SESSION 2ND:
History was re-clarified from the client and the informant (father and paternal

grandmother
Cost-and-benefit analysis for the self-harming behavior was done for suicidal

behavior
Subjective unit of distress (SUD) was rated to be 9 and BDI score was found to

be 34 (severe level of subjective depression).


Client was explained what is psychotherapy and its purpose.
Client was also asked about her expectations from the therapy
It was also emphasized that therapy would involve a collaborative process

which required the active participation of the client. The role of homework in
Dialectical Behavior Therapy was also explained

FEEDBACK FROM THE CLIENT:


Client expressed willingness to contribute, understood most of the

concepts discussed.
did not any express any difficulty with the concepts and appeared

motivated
Her guardians were also very motivated especially her father
He also enquired whether it would be right to send her back to

hostel. After mutual discussion with the client, the father and the
supervisor, it was agreed upon that at present it would be better for
the client to stay with her family only .

THERAPISTS REFLECTION:
Therapist was concerned as she was feeling that whether the
client has really understood the role of psychotherapy in the
treatment or whether the therapist was able to explain the
client properly about the therapeutic process. Presence of a
suicide attempt made the therapist more cautious about how to
proceed in the therapist. However, therapist was feeling glad
about the therapeutic alliance which was established.

SESSION 3rd:
Client was asked to go through her nature of problems as self-

harming behavior and difficulty in interpersonal relationship was


becoming a frequent problem for the client.
Socratic-questioning was applied for insightgeneration.
Different modules of DBT were explained briefly and with respect to

her current situation, EMOTION REGULATION SKILLS was targeted


first Model for describing emotions was explained to the client.

MODEL FOR DESCRIBING EMOTIONS:


Linehan, 1993

Goals of emotion regulation training were introduced i.e.


Understand emotions you experience
Reduce emotional vulnerability
Decrease emotional suffering
Client was asked to do above assigned homework and to keep

a record of it in the diary.

FEEDBACK FROM THE CLIENT:


Client reported that although she has understood the concepts

and somewhere could relate with them, how much she will be
able to carry out in the perfect manner, is doubtful.
But she assured that she will try to practice them. After

practicing with few examples with the therapist, client


reported that she has understood the concepts more properly.

THERAPISTS REFLECTION:
Therapist was somewhat relieved that she was able to make

the client motivated and could make her understand the


nature of the assigned task and its requirement. But
somewhere, she was worrying about has the client really
understood

the

fact

behind

the

homework

requirement. Anyhow, therapist hoped for the best.

and

its

SESSION 4th:
Homework done.
Have reunited with first boyfriend and was very happy about

that.
Her father was not very happy as he feared that something

negative can happen if they again go through breakup.

She also reported that her father is being severely strict with
her and does not talk with her properly.

Role playing was done with both, the father and the client.

Further in the session, two kinds of emotions were explained


one due to events in ones environment
other due to ones thoughts, actions and feelings.
The role of emotions in peoples life was explained with the

theory of emotion (emotions come and go. They are like waves
in the sea. Most emotions only last from seconds to minutes).
Client was explained about the prompting events (inside and

outside) and how one emotion can prompt the other emotion.
Examples were elicited from the client.

Client was adviced to think up different events and

interpretations that set off different emotions. Therapist also


acted as an additional participant to help with different
interpretations. Client came up with:
Client: amake kichu fol kine deyo.
Father: ki-ki fol kinbo?
Client: jeta khushi without looking at her father.
Father: etar ki mane hoye. Tor jonno eto kichu korchi, thik kore

bolteo paris na. takiye j kotha bolte hoye setao Janis na.

Client felt sad and thought that may be her father did not

forgive her for her past deed and was indeed angry with her.
He does not like her anymore
Therapists interpretation: may be your father was undergoing

some stress at work, which he displaced on you.


Such discussions helped the client to understand that a single

event can have different interpretations leading to the arousal


of different emotions.

SESSION 5TH
Review was done.
Client reported of having difficulty understanding the previous

concepts
Re-explanation was done.
Homework done by her was not adequate but was not given

much importance as the client had already informed that she


was having difficulty with the concepts.
New concepts such as diverting attention can lead to quitting

of negative feelings, how sensing ones body can help with


emotional regulation was explained.
How emotions involve action urges was explained.
Instances were drawn from the client.

Client: jokhon khub raag hoye, tokhon mone hoye j suicide

kori, be chup hoye jai


The point that meaning of emotions vary from time to time

and from person to person was explained.


Eg. kokhono tumi rege giye kando, ar kokhno dukkho peye.

Jar upore rege jao, tar uprei hoyeto pore khub bhalo laga
ashe.
Role play was done again with an example of the past event.
Homework was assigned for the day (to go through the

concepts and maintain emotion diary)


SUD=50

FEEDBACK FROM THE CLIENT:


Client liked the role-play section and reported to enjoy that.

When asked what was enjoyable in this, she replied that she
was unable discuss her points with her father due to his
behavior and mostly thought her father did not understand
her. After the role play she was able to understand her fathers
position somehow and was glad about that.

THERAPISTS REFLECTION:
Therapist was happy the way therapy was going and was already

aware that every time the client would not do the homework. However,
therapist still worried about her impulsive behavior and was concerned
as to where her impulsiveness would lead to. As improvement in
Borderline personality disorder was rather difficult and was thinking
that whatever the improvement was, it was at very shallow level.
However, therapist reminded herself that she should not devalue the
clients efforts and should encourage herself and the client.

SESSION 6th:
Client had done a suicidal attempt by taking overdose of olanzapine

(10 tablets of 5 mg each).


The reason for suicide was that she had a quarrel with her boyfriend

over visiting her that why he is not visiting her from last few days.
That agenda for the session was not continued and was again pros

and cons were discussed with her.


Cue identification was done.
Father was very much distressed about the situation and was again

feeling despaired. He was also very angry at the client and wanted
her to call off the relationship.

Father was reminded about the clients problems and was asked

to keep patience.
No homework was assigned.

FEEDBACK FROM THE CLIENT:

Client appeared very casual about the reason as to why she

attempted suicide. Initially she said that she is not able to


remember that but after returning back on the topic, she
remembered the reason. Client appeared very quiet for the
session and reported of feeling guilty about her act. She was also
feeling upset about her fathers changed behavior towards her.

THERAPISTS REFLECTION:
Therapist was disappointed with the clients behavior and felt that she

was not able to help the client properly. Therapist was more
disappointed with herself and did not know how to proceed further. She
was helped by her supervisor in realizing the fact that such instances
will be more common in future and she should be able to handle such
situations, and not getting disheartened by them. Therapist realized
that she not get overly emotional and should go ahead with an
optimistic outlook to the future, hoping for the best but also prepared
for the worst.

SESSION 7th:
Review was done.
Client was feeling guilty about her behavior and was upset

due to her fathers behavior towards her


Father was allowed to ventilate and was explained about the

consequences that have the chances to occur due to his


behaviour.
Father appeared as hopeless but assured the therapist that he

will do his best.

Both were allowed to ventilate.


Client was explained as how important it is to communicate

her feelings to the respective person.


In the homework it was assigned that whenever and whatever

she felt about any particular person, she should communicate


them to that person. If it was not possible at the peak time,
she may write it somewhere and then after the situation
calms, was asked to convey.
Client agreed and homework was assigned.
SUD= 70

Joint conversation with Client and father regarding the suicide

attempt.
Father expressed concern, worry, and anger on daughter.

FEEDBACK FROM THE CLIENT:


Client

reported

that

she

was

feeling

better

after

the

conversation with her father as at home he either was not


listening to her or was replying very rudely. She thanked the
therapist for the conversation and assured the therapist that
she will do the assigned homework.

THERAPISTS REFLECTION:
Therapist was worried about the clients fathers behavior and

its possible after effects on the client. Therapists also felt


that it was obvious for any parent to feel like this after such
events. However, therapist was somewhere assured that since
her father had brought her again for treatment and was
patience

enough

to

listen

the

importance

of

family

environment in the treatment and etiology of BPD, her father


would try to improve or have a control over her behavior.

SESSION 8th:
Review was done
Client did not do the homework as she had gone to her relatives house.
However, she reported about the improvement in the fathers behavior.
Previous topics were discussed again.
Clients was asked to do the homework and come for the next session.

THERAPISTS REFLECTION:
Therapist was disappointed and was worried that if the same

continues, there are more crisis periods coming in the near


future.

SESSION 9th:
Review was done
Homework done.
Client reported the she felt the urge to attempt suicide after having

arguments her boyfriend. She was alone at home and could easily have
attempted it. But instead called up her father and went to him. By
doing so she felt better.
She also reported that she could distract herself before her arguments

reach peak, either by switching off her phone or by going to another


room.
She was also glad about her improving relationship with her father and

also reported that father has decided to bring a TV for her.

She was able to identify the cues (sensing emotion) and then could

distract herself.
PLEASE MASTER was introduced.
TREAT PHYSICAL ILLNESS
BALANCE EATING
AVOID MOOD ALTERING DRUGS
BALANCE SLEEP
GET EXERCISE
BUILD MASTERY

Increasing positive emotions were suggested.


SHORT-TERM POSITIVE EMOTIONS

LONG-TERM POSITIVE EMOTIONS

Watching favourite soaps

Concentrating on studies

Talking to her boyfriend

Improving relationship with father

Visiting her relatives

Eating ice-cream

Homework was assigned.

FEEDBACK FROM THE CLIENT:


Client reported of feeling better that she was able to control

her urge of attempting suicide and that his father also


appreciated that instead of going that way, she called up her
father. But father was concerned as why she would even think
like that. Does this means that she is learning nothing by
coming to the sessions? However, inspite of being worried, he
appreciated the client and became more alert towards the
client.

THERAPISTS REFLECTION:
Therapist was happy that the client was able to utilize the

skills learned in the session to real life situation. It was


somewhat relieving that the therapy was really progressing.
However, therapist reminded herself that she should not be
very much satisfied as emotion regulation takes some time to
sink in and the beginning may have started but there is still a
long way to go.

SESSION 10TH:
Review was done.
Client had done the homework and was happy with the way things

were going in her life.


Emotion diary was discussed.
Clients boyfriend had also come with her to the session.
Boyfriend reported that although there has been some improvement

with the client but her demanding behavior has increased and
sometimes the client refuses to understand his situation.

Client reported that sometimes she does this deliberately to

annoy him and sometimes she does so because she feel angry.
Client had also brought her family album to share her good

memories with the therapist.


Facing emotions were explained to the client and was adviced to

practice Review of the whole module emotional regulation was


done.
SUD = 40
Next focus : INTERPERSONAL EFFECTIVENESS

FEEDBACK FROM THE CLIENT:


Client reported that she was feeling much better than she

used to and by writing in the emotion diary, she felt relieved.


She was also very happy about her fathers behavior. Although
she missed her friends and school, she preferred staying her.
The only thing she would like to be changed that her father
spending more time with her. As with the skills taught in the
session, she was able to practice them at home in some
instances.

THERAPISTS REFLECTION:
Therapist felt that although the client reported of improvement,

she mainly focused on home environment. According to her


boyfriends verbatim, she was still having difficulty. Therapist
thought that whether accepting her demands and in order to
make a comfortable environment for her, is her demanding
behavior was getting reinforced? Thus, therapist thought to
introduce INTERPERSONAL EFFECTIVENESS in the next session as
when she will again start her schooling, she may be able to cope
with her schoolmates in an effective way.

SESSION 11th:
Client reported that she got hold of medicines one day in

between the sessions and called up his father to inform him. She
sensed him tensed and replied by laughing that dont worry, I
will not consume them.
Client was praised for her behavior and related it to her

improving coping abilities.


Homework was reviewed.
Interpersonal effectiveness was started.

Client was briefed about the module and balancing priorities

and demands was discussed. Beginning and end of a time


period was explained as how during the timeline of an
individual, implosive behaviors can lead to an early end of the
life.
Building mastery and self-respect explained.
Cheer leading statements were discussed.
Homework was assigned to monitor her behavior and utilize

the skills taught in session in the real life.

FEEDBACK FROM THE CLIENT:


Client was happy that she could control her behavior and not

use the situation to her advantage.

THERAPISTS REFLECTION:
Therapist was happy the way the therapy was progressing and

hoped that it continue the same way.

SESSION 12th:
Review was done.
Client did not do the homework as she got admission in a coaching

center (long term positive change) and was busy with her homework
there.
Client was adviced to do the homework in the next session, however,

disappointment was expressed by the therapist over the clients


behavior regarding the homework.
Client reported that an incident have occurred at her coaching. One of

the student proposed her, and on rejecting his proposal the boy did
slash his wrist.

Through questioning, both of the client and the therapist was

able to reach to the point that it was through clients paying


attention to the boy by attending his phone calls , the boy
must have thought that the client has feelings for him.
Client was feeling disappointed about her behavior.
Practicing

interpersonal
effectiveness
exercises
were
suggested such as while talking to someone, changing the
topic; asking for change without buying anything from the
respective shop.

Above exercises were assigned as the homework.


SUD = 30

FEEDBACK FROM THE CLIENT:


Client was happy that her father had trusted her enough to let her in

a coaching center and was happy that she was again involved with
something. However, she was afraid about the incident occurred at
school and said that she will try and keep a check on her behavior.
THERAPISTS REFLECTION:
Therapist was happy that the client could relate to her part of

mistake but she was worried that how much she will be able to keep
a check on her behavior in future. And if such incidents keep on
occurring then, it will be not be good for the client.

FUTURE PLANS:
Mindfulness training
Distress tolerance training

THANKYOU..