Posted: August 6th, 2023

Therapeutic Communication and Cognitive Behavioral Therapy:

How would you use therapeutic communication and principles of cognitive behavioral therapy with the client?
Describe your assessment process. What are some likely co-morbid conditions? List one nursing diagnosis and an appropriate nursing intervention.
What interdisciplinary referrals might be appropriate? NUR2488 Module 07 Borderline Personality Disorder Case Study

S.is a 48-year-old divorced woman with one adult daughter and three grandchildren. She is currently working as an LPN part-time in a nursing home and works at a convenience store one or two days per week. She has had many jobs over the last 22 years, usually changing every one or two years to a new job. S notes that she has been called less often to work in the convenience store and worries that they don’t like her anymore. She reports being written up several times for arguing with customers. She also reports that she liked her supervisor at; first; she says, “Now I hate her; she’s trying to get me fired.” S. reports that she has tried to get full-time jobs five times in the last four years was hired for three but only lasted one or two weeks at each one.

S. reports that she is currently not talking to her daughter because “she is mean to me and she needs to apologize, or I won’t talk to her again.” She is upset that she hasn’t seen her three small grandchildren in about a year. She sends them presents and cards frequently that say “I still love you! Grandma” but hasn’t called them since she stopped talking to her daughter. She is considering reporting to the county that her daughter is keeping her grandchildren from her.

S. is very unhappy that she isn’t in a relationship. She was abused by her ex-husband and had a pattern of meeting and dating men who eventually abused her. She states that her last relationship was very good; the man was not abusive, and “I loved him very much.” The relationship ended for reasons that S. doesn’t understand. However, she does report many arguments that ended in “scenes,” such as her throwing chairs, stomping out of the house, making crank phone calls to his family, and calling the police with false reports. But S. also reports that she “couldn’t have loved him more, and I showed it.” She gives examples of going to her boyfriend’s place of work with flowers, buying him expensive presents, surprising him with tickets to Mexico at the last minute – she was very upset that he wasn’t willing to drop everything and go with her. S. reports asking him why he didn’t love her and what she was doing wrong regularly. When the boyfriend asked to break up, S. reported sitting outside his house for weeks, crying; she called his mother, called his boss, and called and texted him until he filed a restraining order. This occurred about four months ago.

S. admitted herself to the mental health unit when she felt suicidal. She reports that she had stopped her psychotherapy three months ago and stopped going to DBT. She also stopped her anti-depressant at that time, as she felt it wasn’t working, and missed her last two psychiatrist appointments.

Therapeutic Communication and Cognitive Behavioral Therapy:

As an experienced mental health professional, employing therapeutic communication and principles of Cognitive Behavioral Therapy (CBT) is paramount when working with a client like S. who presents with Borderline Personality Disorder (BPD) symptoms. To establish a strong therapeutic alliance and promote a conducive environment for healing, the use of empathetic, non-judgmental, and genuine communication is essential.

Empathy and Active Listening: Demonstrating empathy and active listening are fundamental components of therapeutic communication. By actively listening to S.’s concerns about her relationships, past abusive experiences, and recent difficulties at work, the therapist can validate her feelings and emotions. Validating her experiences will help her feel understood, leading to increased trust in the therapeutic process.

Reflective Responses: Utilizing reflective responses, the therapist can reiterate and paraphrase what S. shares during sessions. This technique fosters understanding and enables S. to explore her thoughts and emotions further. By reflecting her feelings and experiences back to her, the therapist can help her gain insights into her behavior and reactions.

Empowerment and Collaboration: Encouraging S. to actively participate in setting therapeutic goals and treatment plans is crucial. Collaboration empowers her and gives her a sense of control over her healing journey. Additionally, by incorporating her interests and preferences into the treatment process, she will be more motivated to engage in therapy.

Cognitive Behavioral Therapy (CBT) is particularly effective in treating BPD. It focuses on identifying and modifying maladaptive thought patterns and behaviors. For S., some of the key CBT interventions may include:

Identifying Cognitive Distortions: Helping S. recognize and challenge distorted thought patterns, such as all-or-nothing thinking or personalization, can assist her in developing a more balanced and rational perspective of her experiences.

Emotion Regulation Skills: Given S.’s emotional intensity and impulsivity, teaching her effective emotion regulation techniques can be beneficial. Mindfulness practices, grounding exercises, and deep-breathing techniques can help her manage overwhelming emotions more effectively.

Interpersonal Effectiveness: Addressing S.’s difficulties in relationships and providing her with communication and assertiveness skills can enhance her ability to interact positively with others, thus reducing conflict and improving social functioning.

Assessment Process:

During the initial assessment, it is vital to conduct a comprehensive evaluation to gain a clear understanding of S.’s mental health status, medical history, psychosocial factors, and current challenges. The assessment process should include:

Clinical Interviews: Conducting in-depth interviews with S. to gather information about her symptoms, past psychiatric treatments, life stressors, and family history of mental health issues.

Mental Status Examination: Performing a thorough mental status examination to assess S.’s appearance, behavior, thought processes, mood, affect, cognition, and insight.

Collateral Information: Obtaining collateral information from relevant sources, such as previous therapists, family members, or coworkers, can provide valuable insights into S.’s functioning in different settings.

Likely Co-morbid Conditions:

Individuals with Borderline Personality Disorder often experience co-occurring mental health conditions. Some potential co-morbidities for S. may include:

Major Depressive Disorder (MDD): S.’s history of stopping her antidepressant and experiencing suicidal ideation suggests the possibility of co-morbid MDD, warranting further assessment.

Post-Traumatic Stress Disorder (PTSD): Given her past history of abusive relationships, S. might be experiencing symptoms consistent with PTSD, such as intrusive memories and hyperarousal.

Nursing Diagnosis and Intervention:

Nursing Diagnosis: Risk for Self-Harm related to emotional dysregulation and suicidal ideation.

Nursing Intervention: Safety Monitoring and Crisis Intervention. Regularly assess S.’s emotional state and implement measures to ensure her safety. This may involve developing a safety plan, providing crisis intervention strategies, and educating her support network on recognizing warning signs.

Interdisciplinary Referrals:

Collaboration with other healthcare professionals is crucial for a comprehensive treatment approach. Appropriate interdisciplinary referrals for S. may include:

Psychiatrist: To reassess her medication needs and manage any co-occurring psychiatric conditions like depression or anxiety.

DBT Therapist: To resume Dialectical Behavioral Therapy and provide specialized treatment for BPD.

Social Worker/Counselor: To address psychosocial stressors and provide ongoing support.

Domestic Violence Support Group: To address her history of abusive relationships and foster a safe space for healing.

In conclusion, employing therapeutic communication and principles of Cognitive Behavioral Therapy are essential in the treatment of S., a client with Borderline Personality Disorder. A comprehensive assessment, identification of co-morbid conditions, and implementation of appropriate interventions, along with interdisciplinary referrals, will pave the way for her healing journey and overall well-being.

References:

Linehan, M. M. (2018). DBT skills training manual (2nd ed.). The Guilford Press.
Paris, J. (2016). The treatment of borderline personality disorder: Implications of research on diagnosis, etiology, and outcome. Annual Review of Clinical Psychology, 12, 427-453.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). American Psychiatric Publishing.
Bateman, A., & Fonagy, P. (2016). Mentalization-based treatment for personality disorders: A practical guide. Oxford University Press.