Mental health articles

borderline personality disorder case study:

Case formulation

Ms H was a 26-year-old single woman. She presented with a history of self-harm including cutting her wrists and arms, overdosing on prescription medication, and stabbing herself in the abdomen. On more than one occasion these, and other harming behaviours, were intended to end her life. She had previously been seen by a clinical psychologist, but had dropped out of therapy after only a few sessions, and had not taken the opportunity for further therapy offered following hospital admissions following episodes of self-harm. She had few acquaintances, and no close friends, living on her own in a bedsit in a large town. She was unemployed at the time she was seen by a clinical psychologist.

Long-term antecedents

Ms H reported being sexually abused by her father as a young girl. This was originally denied by her family. Her mother initially did not acknowledge the reality of her claims of abuse. However, once this was acknowledged (after several months of abuse), her mother left the relationship bringing Ms H up alone (or in the company of a succession of uncaring and occasionally verbally and physically abusive ‘boyfriends’) from the age of 11 years. The relationship between Ms H and her mother was not good, and although she lived with her mother until the age of 19 years, she felt unloved and uncared for. She was often ignored, and at best tolerated; not loved or respected. However, she learned to keep a ‘good face’ on her experiences and hide any distress she may have felt. When she did express any distress she felt from her mother or her mother’s boyfriends’ behaviour, they only way she could gain attention was through engaging in extremes of behaviour. She learned that self-harming behaviour such as cutting would actually lead to her having some attention, although it was also related to subsequent confl ict and her being forced to leave home. Episodes of low mood, related to her poor self-esteem, memories of abuse and diffi culties in relationships would also form triggers to episodes of self-harm such as overdosing, with an intent if not to die, at least to provide a time out from the distress she was experiencing. She had a succession of short-term relationships with a number of men, each of which was typifi ed as stormy. She was claustrophobically needy, demanding her boyfriends’ full attention and becoming upset and threatening self-harm if they were away too long. These typically ended in a dramatic argument followed by her self-harming in some way. She was offered psychiatric treatment following two of these episodes, but chose not to take this up. However, on a third episode she agreed to see a psychiatric nurse before being referred to a clinical psychologist. However, she had only attended two sessions, saying she did not feel able to relate to the therapist.

Formulation

As a consequence of her early history, Ms H had low self-esteem and a strong sense of shame. She had not learned to tolerate or express negative emotions in a meaningful and appropriate way. Indeed, she had learned to express any negative emotion in a histrionic and overly expressive manner. When things were stressful in her life (for example, relationships failing), she felt extremely vulnerable and anxious and experienced high levels of negative affect. She had not learned to manage these emotions appropriately, and frequently did so by becoming overly reliant on support from anyone willing to provide it (usually her boyfriends), or, when this support was not available, she resorted to self-harm as a means of expressing distress, trying to manage this distress, and manipulating others (‘Stay with me or I will really hurt myself’). She found therapy challenging and distressing because it addressed issues she was unable to cope with effectively. She therefore dropped out or refused to engage in it.

Intervention

The intervention with Ms H lasted many months, and involved both individual and group sessions. The fi rst aim of treatment was to reduce her likelihood of self-harming. This involved identifying factors likely to precipitate self-harming, in order to understand and possibly avoid them happening, and learning skills including mindfulness and distraction techniques such as squeezing a ball in her hand to the point of pain to help her control her strong emotions in a more positive manner. In addition, she was taught interpersonal skills (including appropriate assertiveness and talking to people about her emotions) in order to learn to express any emotional distress in a more appropriate and acceptable manner. While these reduced the risk of self-harm, they did not entirely prevent some incidents. Nevertheless, Ms H reduced her self-harm signifi cantly. Once she was better able to monitor and manage her negative emotions, the therapist examined some of the inappropriate beliefs related to her shame and low self-esteem (‘It was my fault I was sexually abused’; ‘My parents did not love me, so I am unworthy of love’, etc.) using the Socratic approach of cognitive behaviour therapy. This was conducted carefully and slowly, and because the distress this process may evoke could potentially trigger self-harm, there was some debate between her therapist and the ward nursing team about whether Ms H should stay in hospital at this time. However, she and her therapist made a joint decision that she would not come into hospital, but that the therapist could be contacted at agreed times (not ‘randomly’ as this may increase dependency on the therapist) should contact be necessary. Ms H found this process stressful, but was able to confront some of her beliefs and she became less shamed and her episodes of low mood became less frequent. She was also able to develop appropriate (non-dependent) relationships with some members of the group sessions she attended. These became a source of long-term support and reinforced changes in her approach to others – in particular learning to become less dependent and demanding. Over a period of many months, Ms H became more independent and confi dent. She remained fragile, but was able to cope with diffi cult emotions without consistently harming herself (although this did not stop completely), and was able to use a number of coping mechanisms should this occur. She was able to develop supportive relationships with a number of people (all of whom themselves had a history of mental health problems). She was discharged after around one year of gradually decreasingly frequent sessions with her therapist and therapy group. However, she was given regular follow-up sessions every 3 – 4 months for some time longer to support her in her changes and, in particular, if she were to begin to experience more signifi cant problems in the future.

Tags: borderline personality disorder, case study, disorder, personality