Chapter 9. Email Tirades and Four Stepfathers: Alicia’s Case

9.1 Screen 1

Clinical Choices
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You must read each slide, and complete any questions on the slide, in sequence.
Antisocial Personality Disorder

1. Persons repeatedly disregard and violate the rights of other people in 3 or more of the following ways:
  a) Little or no adherence to social and legal norms.
  b) Deceitfulness.
  c) Impulsivity or poor planning.
  d) Irritability and hostility, marked by repeated fights.
  e) Careless disregard for safety of self or others.
  f) Failure to behave responsibly in the spheres of work or finances.
  g) No regret for hurting or mistreating others.
2. Persons are at least 18 years old, but showed signs of conduct disorder before they were 15 years old.
(Information from: APA, 2013)
Narcissistic Personality Disorder

1. By early adulthood, individual displays wide-ranging features of grandiosity, including need to be admired and inability to feel empathic.
2. Pattern features at least 5 of the following:
  a) Exaggerated sense of self-importance
  b) Repeated unrealistic fantasies of success, brilliance, beauty, or the like.
  c) Belief that one is "special" and in need of other special people or institutions
  d) Need for excessive admiration
  e) Repeated expectations of favorable treatment or compliance by others
  f) Propensity to take advantage of others
  g) Low empathy
  h) Frequent envy
  i) Displays of arrogance
(Information from: APA, 2013)
Borderline Personality Disorder

1. Individuals display pronounced, wide-ranging, unstable, and impulsive patterns in their relationships, sense of self, and emotions. Such patterns begin by the time they reach their mid-20s.
2. The individuals specifically exhibit at least 5 of the following symptoms:
  a) Desperate efforts to avoid perceived abandonment.
  b) Fluctuations between idealizing and denigrating family members, friends, and coworkers.
  c) Highly changeable self-concept.
  d) Self-damaging displays of impulsivity.
  e) Repeated self-mutilating or suicidal acts or gestures.
  f) Significant fluctuations in moods and emotions.
  g) Long-term sense of emptiness.
  h) Experiences of extreme and often uncontrollable anger.
  i) Periodic, short-term paranoid ideas or dissociation during times of stress.
(Information from: APA, 2013)
Histrionic Personality Disorder

1. By early adulthood, individual repeatedly displays extreme emotionality and attention seeking
2. Pattern features at least 5 of the following:
  a) Discomfort when not the center of attention
  b) Inappropriate sexual overtures or behavior
  c) Changeable and shallow emotions
  d) Repeated use of physical appearance to gain attention
  e) Speech that is scanty in detail and substance
  f) Overly dramatic and extreme expressions of emotion
  g) Excessive suggestibility
  h) Distorted sense of intimacy in relationships
(Information from: APA, 2013)
Tolerance

The adjustment that the brain and the body make to the regular use of certain drugs so that even larger doses are needed to achieve earlier effects.
Interview Notes

What brought you in?

- Just fired
- Keeps losing jobs
- Says coworkers caused problems
- Says not her fault
- Sent email about another coworker to coworkers & boss
- Harder to find job due to interpersonal problems and short-term jobs in job history
- Quick to get upset & angry

Other concerns

- Mood out of control, up and down
 • Feels happy one minute
 • Feels down the next minute
 • Admits to intense emotions
 • Mood swings wearing her down

Areas of life affected

- Trouble maintaining relationships
- Wants a best friend
- Gets too close too fast
- People avoid her as a result
- Her worst fear → rejection

How long?

- Since childhood
- Teased as kid
- Felt “awful”
- Few friends → none of them “fit in”
- Got into fights with her few friends
- When she tried to befriend “normal” people, they would rebuff her

Childhood

- Parents divorced when 2
- Lived with mom, sometimes grandma
- Dad would make promises and break them
 • She had trouble trusting him as a result
 • He didn’t pay child support
- Mom remarried 4 times → losers
- Mom never had a job for very long

Abuse?

- Sexually abused by stepfather at age 8
 • At age 9, he raped her
 • Went on for some time
 • Told mom → mom didn’t believe her
 • Started avoiding being alone with him

Relationship difficulties

- Has had boyfriends since age 14
- Feels great at start of relationship
- Gets anxious → “tests” guy
 • Sends text, times response
 • Rejects any excuse
- Feels relationship will end
 • Makes things up to stay in relationship
 • Self-harm and suicidal threats
 • Sends emails or leaves notes on car
 • Hard time controlling these behaviors

Hurt self?

- Started around 13 or 14
- Dug nails into arm
- Scratched arms and legs with paperclip
- Started cutting with razor
- Wore concealing clothing to hide scars → embarrassed
- Cutting makes her feel better

Other self-harm

- Not currently suicidal
- Binge eating
- Binge drinking
- Alternates with cutting
- Feels emotional → helps for a short time

Hurt others?

- Violent fight with 4th stepdad
- Threw chair through sliding glass door
- Stepfather kicked her out, mom didn’t intervene
- Unstable jobs & living situation ever since
Cluster A: Odd Personality Disorders

Personality disorders in which people display odd or eccentric behaviors that are similar to but not as extensive as those seen in schizophrenia, including suspiciousness, social withdrawal, peculiar ways of thinking, and isolation.
Obsession

Personality disorders in which people display odd or eccentric behaviors that are similar to but not as extensive as those seen in schizophrenia, including suspiciousness, social withdrawal, peculiar ways of thinking, and isolation.
Cluster B: Dramatic Personality Disorders

Personality disorders in which individuals exhibit behaviors that are so dramatic, emotional, or erratic that it is almost impossible for them to have satisfying relationships.
Cluster C: Anxious Personality Disorders

Personality disorders in which individuals typically display anxious and fearful behavior.
Psychoanalysis

A conversational treatment used by psychodynamic therapists that includes techniques such as free association, or letting the client talk about whatever comes to mind, and therapist interpretation, which involves giving insight and offering an opinion on patterns noticed in the client’s free association and other things such as dreams. A psychoanalyst would treat Alicia by seeing her 3-5 times per week for several years. Psychoanalysis is costly and it requires a large time commitment.
Interpersonal therapy

Interpersonal therapy focuses on problems in significant relationships in the patient’s life. Interpersonal therapists treat patients by focusing on their current relationships with the most important people in their lives. These people include partners and spouses, parents, children, and other close relatives. For Alicia, this would likely be her mother or her current boyfriend.
Dialectical Behavioral Therapy (DBT)

A therapy developed by Marsha Linehan, that consists of cognitive-behavioral techniques in combination with various emotional regulation, mindfulness, humanistic, and other techniques. DBT requires dedicated work with a trained DBT therapist via individual therapy, group skills training, the completion of “homework” between sessions to monitor emotional and behavioral symptoms, and phone coaching to help clients forgo self-harm when they feel overwhelmed. DBT involves getting to the root of the problematic thoughts about life events that have led a person to engage in self-harming behaviors. For Alicia, treatment would include individual therapy to address Alicia’s specific problems, group skills training to teach her better coping skills for when she feels overwhelmed, and phone coaching for when she feels like she may engage in self-harm behavior. Treatment would also include monitoring Alicia’s mood and other symptoms during the week as well as focusing on maladaptive behaviors to try to link Alicia’s symptoms directly to these harmful actions.
Medication

Medication involves taking a chemical agent prescribed by a medical doctor to address physical problems, such as infections, and alter brain chemistry, which subsequently alleviates psychological symptoms. A physician or a psychiatrist, who has a medical degree (MD), would be able to prescribe patients medication to treat, respectively, their physical and psychological symptoms. As a psychiatrist, you could prescribe a mood stabilizing medication for Alicia. This medication would help control Alicia’s mood swings and prevent future mood fluctuations. You would continue to meet with Alicia regularly to monitor her symptoms and to adjust the dose of her medication as necessary.

Author: Taryn A. Myers, Ph.D., Virginia Wesleyan College

A young woman talks on a phone while sitting in her cubicle in an office while the woman in another cubicle is working.

9.2 Screen 2

Please note: Clinical Choices allows you to enhance and test your understanding of the disorders and treatments covered in your textbook, in a simulated case study environment. It is not intended to replicate an actual intake interview or therapy session or provide training on therapeutic techniques. Clinical Choices is for educational purposes only and is not intended as a substitute for clinical training.

9.3 Screen 3

Get instructions for the interview
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The receptionist hands you the intake paperwork prior to your intake interview with your new client, Alicia, who self-referred for therapy after losing her job. Click on the button below to review the paperwork before you begin the interview.

New Client
Alicia: Case #10116

Psychological Clinic

Intake Paperwork

Client Name: Alicia

Age: 28 years old

Gender: Female

Ethnicity: Puerto Rican

Occupation: Unemployed

Current living situation: I live by myself

Why are you seeking services at our clinic?

I got fired for no reason! Every job someone I work with has it out for me. It’s like I don’t have any control and everyone in my life turns on me. No one wants to stay my friend, and I can’t find a good man. I really need someone who understands me and wants to help me. I need to take control of my life.

9.4 Screen 4

Begin the interview

On the following screens, you will ask Alicia a number of questions you would typically ask during the intake interview. As you conduct the interview with Alicia, begin to think about her symptoms, what her diagnosis might be, and later, what type of treatment might be most helpful to her. Click the “play” button below the illustration to hear Alicia’s responses to your questions. To read the transcript for these answers, click on the “transcript” button. Take notes in the box provided as you listen to Alicia’s responses.

9.5 Screen 5

What type of disorder does Alicia have?

“Hi Alicia. It’s good to meet you. What we are doing today is called an intake interview. I’m going to have you tell me what brought you here today, and I’m going to ask you some questions that I ask everyone who comes to the clinic. This information will tell me how best to help you. This may mean continuing to come to see me for therapy at this clinic, or it may involve referring you to another mental health professional or facility. Let’s start. Tell me about what brought you to the clinic today.”

Alicia expresses her concerns about her professional life during an intake interview in the clinic.

Transcript

Alicia: [agitated and oversharing] I just got fired! I keep getting fired. I just don’t get it. It’s not like it was my fault. My coworkers … always causing problems... Every time someone has it out for me. Like this most recent job – a girl I worked with complained about me, and BOOM … “You’re fired” [in “Donald Trump/Apprentice” style]! Or the job before that the nasty witch in the next cubicle asked me – get this! – to keep my voice down when speaking on the phone. [raising her voice] “How am I supposed to do my job if I can’t talk on the phone?” I say to her but she’s not sorry at all--the disrespect. She had no right. In school she would’ve got jumped for doing this to me. But HA! No apology, no nothing. So I go home and I think about it a little and it comes to me: let everybody know what she did. I emailed the supervisor and cc’d everyone! And then that supervisor took HER side and fired me from that job, too! He said it was “inappropriate” [you can almost hear her doing air quotes] – I think it was very “appropriate” – maybe even too nice. It’s hard to get a job when you have to work with idiots like that and you’ve only got short-term jobs on your record. And don’t get me started on my so-called friends and family!

Question 9.1

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Check Your Notes

What brought you in?

- Just fired
- Keeps losing jobs
- Says coworkers caused problems
- Says not her fault
- Sent email about another coworker to coworkers & boss
- Harder to find job due to interpersonal problems and short-term jobs in job history
- Quick to get upset & angry

Question 9.2

Which of the following symptoms of personality disorders does Alicia seem to be exhibiting based on her initial description of her problems at work? Check all that apply.

bI0LPa9lfHQ+dYqk Hostility
wCfH0QtRgXJ8o+c+ Self-criticism
bI0LPa9lfHQ+dYqk Blaming others
wCfH0QtRgXJ8o+c+ Grandiosity/egocentricity
bI0LPa9lfHQ+dYqk Impulsivity/recklessness
bI0LPa9lfHQ+dYqk Emotional instability
wCfH0QtRgXJ8o+c+ Depression/helplessness
wCfH0QtRgXJ8o+c+ Attention deficiencies
Table
Congratulations! Alicia is exhibiting hostility, impulsivity and recklessness, emotional instability and she is blaming others.
That’s not quite right. Alicia is exhibiting hostility, impulsivity and recklessness, emotional instability and she is blaming others.

Hint

Review your notes from the interview or listen to Alicia again to review her symptoms.

9.6 Screen 6

What else is going on with Alicia?

Question 9.3

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2
Correct.
Think about which of the clusters Alicia’s symptoms best fit. Remember that her symptoms include hostility, blaming others, impulsivity and recklessness, and emotional instability.
Incorrect.

Hint

Think about which of the clusters Alicia’s symptoms best fit. Remember that her symptoms include hostility, blaming others, impulsivity and recklessness, and emotional instability.

9.7 Screen 7

Ask Alicia the next question

“Wow, that sounds like a lot to deal with. Are there any other concerns you are having at this time?”

Alicia explains her mood fluctuations.

Transcript

Alicia: My mood. It goes up and down all the time-- it’s like all out of control. Any small thing can set me off. One moment I’m really happy, like everything is great. Like, I feel really, really good… On top of the world. And then … someone calls to change plans on me, and I feel like it’s all over.... Sometimes I just feel numb, like I can’t feel anything at all. That’s maybe the scariest time, because I mean, I have a big heart… I can’t feel just a little bit – but the ups and downs kind of wear me down after a while.

Question 9.4

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Check Your Notes

Other concerns

- Mood out of control, up and down

  • Feels happy one minute
  • Feels down the next minute
  • Admits to intense emotions
  • Mood swings wearing her down

9.8 Screen 8

Ask Alicia the next question

“How has your life been affected by everything that is going on?”

Alicia explains her concerns about relationships.

Transcript

Alicia: Um, let me think. I’m having trouble with my “friends,” too. That’s really hard for me, to try to keep people as friends long-term…finding someone who doesn’t let me down. I want a “best friend” in my life, someone I can go to with anything and share everything with. So when I meet someone I have something in common with or who wants to hang out with me, I get really excited that this person will be that “best friend” I’ve been looking for. So I hang out with her all the time and try to get close, learn her story right away. But it never works out, and then I’m all alone again. Like, one time in high school, there was this girl that I knew was going to be my best friend. We had really been bonding for like a whole week, so I gave her a “best friends” necklace. She just walked away. She started ignoring me, acting like she didn’t see me after that. [pauses, then with more intensity] It really, really sucks. It hurts so bad when people turn on you, reject you like that … but it keeps happening to me. [Brief pause; suddenly brightening] I’m glad I came to see you. Talking to you is totally going to help—I can tell.

Question 9.5

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Check Your Notes

Areas of life affected

- Trouble maintaining relationships
- Wants a best friend
- Gets too close too fast
- People avoid her as a result - Her worst fear → rejection

9.9 Screen 9

Ask Alicia the next question

“It sounds like you have been struggling for a while, at least since you were a teenager. How long have these issues been going on?”

Alicia continues her interview.

Transcript

Alicia: Even as a kid, I feel like my reactions were bigger than the other kids. My family—a lot of the time it was just Mamí and me-- we were poorer than everyone else, so I got teased a lot because I didn’t have “THE” clothes or the rich-kid toys. They had so much nice stuff, but I didn’t fit in because we didn’t have money. When they teased me I would feel awful, just awful. I had a few friends, I guess. They were like me – none of us fit in. We sort of stuck together because we had that in common, but then we’d get into fights. It got ugly. Whenever I’d try to get close to people, they would be friends with other people, not me, and I’d feel jealous. So yeah, I guess this has been going on my entire life.

Question 9.6

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Check Your Notes

How long?

- Since childhood
- Teased as kid
- Felt “awful”
- Few friends → none of them “fit in”
- Got into fights with her few friends
- When she tried to befriend “normal” people, they would rebuff her

9.10 Screen 10

Find out more about Alicia’s childhood

“Tell me about your childhood. What was it like growing up in your family?”

Alicia talks about her childhood in the interview.

Transcript

Alicia: [conversational tone like she’s talking to her best friend] Well, my parents got divorced when I was only 2. I lived with Mamí most of the time growing up, but sometimes I would live with my Abuela-- my grandma-- for a few months. My dad would contact us, but only when he felt like it. [Suddenly agitated and angry] He would call and promise he would pick me up for the weekend and take me someplace fun, like to the zoo, or to get ice cream. One time I was sitting on the front porch waiting for him for hours and I got so upset when he didn’t come. I would tell myself I wasn’t going to trust him again, he was garbage—not a man, but then he would apologize, be all sweet on the phone… [small, sad voice] and then not show up again. [suddenly resentful] He didn’t give us any child support, and Mamí never had a job for very long, so I wasn’t able to have nice things. Mamí remarried 4 times from the time I was 3 until I left home at 17. These guys were all losers—also garbage. I was never close to any of them.

Question 9.7

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Check Your Notes

Childhood

- Parents divorced when 2
- Lived with mom, sometimes grandma
- Dad would make promises and break them

  • She had trouble trusting him as a result
  • He didn’t pay child support

- Mom remarried 4 times → losers
- Mom never had a job for very long

Question 9.8

How could Alicia’s childhood have influenced what is happening to Alicia now? More than one answer could be correct. Select all that apply.

bI0LPa9lfHQ+dYqk Alicia’s father’s neglect could have led her to have difficulties trusting others.
bI0LPa9lfHQ+dYqk Alicia’s mother’s work history could have modeled Alicia’s current behavior at work.
wCfH0QtRgXJ8o+c+ Alicia’s time staying with her grandmother was likely a negative experience.
wCfH0QtRgXJ8o+c+ The fact that Alicia had four stepfathers meant she likely had a bad relationship with all of them.
Table
Congratulations! Alicia’s father’s inconsistent and neglectful behavior early in her childhood can certainly influence future relationships and the ability to trust others. Further, children learn by observing their parents, as Alicia observed her mother losing jobs.
That is not quite right. Alicia’s father’s inconsistent and neglectful behavior early in her childhood can certainly influence future relationships and the ability to trust others. Further, children learn by observing their parents, as Alicia observed her mother losing jobs.

Hint

Think about how the behavior of the most significant people in Alicia’s life may have influenced her.

9.11 Screen 11

Respond to Alicia

“Sometimes when people have childhood experiences like you are telling me you have had, people in their lives treated them poorly. Has anyone ever done anything to you to hurt you physically, or touched you in a way that was inappropriate or made you feel uncomfortable?”

Alicia continues her interview.

Transcript

Alicia: Um … [silent for a moment, then in a flat, matter-of-fact tone] … Yeah, actually. When I was 8, my second stepfather molested me. It started off as just touching me. It got worse and worse over time. Then when I was 9, he started raping me… I was so scared. I told no one—no best friend to talk to, like I told you. He said he would hurt me if I told anyone. I was so embarrassed. All I could think was why is this happening to me? What am I doing wrong? But finally I worked up the courage to tell my mom. I was sure she would throw him out of the house because she would be so mad. [pause] But Mamí didn’t believe me. She said I was making it up. So Mamí stayed with this molester, this garbage, … and I just tried to hide from him as much as I could. I would say I was doing some clubs and stuff after school, and sometimes I could make excuses to stay late after school, but mostly I hung out in the park near our building just so I didn’t have to be home alone with him. [Suddenly earnest, intimate] I haven’t told that to anyone since I tried to tell Mamí about it. I feel like you really GET me.

Question 9.9

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Check Your Notes

Abuse?

- Sexually abused by stepfather at age 8

  • At age 9, he raped her
  • Went on for some time
  • Told mom → mom didn’t believe her
  • Started avoiding being alone with him

Question 9.10

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
2
Correct.
Think about how this experience may be linked with other issues Alicia has told you about.
Incorrect.

Hint

Think about how this experience may be linked with other issues Alicia has told you about.

9.12 Screen 12

Ask Alicia the next question

“I really want to acknowledge how difficult it was for you to share that with me. Thank you for trusting me with this information so early in our relationship. What your stepfather did was wrong, and it must have been very difficult when your mother did not react the way you had hoped and remove your stepfather from your home. I want to let you know I believe you, and I will support you as you deal with this and your other issues. Many times when individuals have been sexually abused, they have difficulties with romantic relationships later in life. Have you found that to be the case?”

Alicia explains her difficulties in building relationships with others.

Transcript

Alicia: Yes, totally. I’ve had boyfriends since I was 14. When you like a guy and you can tell he’s into you it’s so great! I know he’s “the one” – every time, it feels that way--and I’m thinking about marriage and children and having a real family, you know? But then I start thinking… maybe he’s getting tired of me… maybe this won’t last. I worry that this guy is going to dump me like all the other guys before. Or I see him looking at a girl and I think he’s cheating on me and I can’t get it out of my head. I mean, all men are cheaters, but I think maybe this one will stay. So I’ll set up “tests” to make sure he really cares about me. Like, I’ll send him a text saying, “how could anyone love someone like me?” I wonder that all the time so why not ask? Then I’ll time how long it takes him to text back. If he doesn’t respond right away, I figure he’s already moving on … falling out of love with me and even if he gets back to me it’s like “you’re so hot, I’m into you” and then I know it’s all about sex and it’s not about me, loving ME. If he tries to give me some BS story like he was in a meeting, I know he’s lying and ignoring me. Nothing lasts. Every single time they start to drop hints they are going to break up with me. Then I get really scared. I’ll do anything to keep them with me. I’ll tell them my grandmother is about to die or that I just got a test back saying I have cancer, whatever I think will work. The last guy I dated—Justin—he was so perfect, really smart and hot. I told him I’d hurt myself if he left—I showed him a razor I had. It worked for a little while, but then he still left me. I felt frantic—like I wanted to kill myself for real. I tried to tell him—I sent emails, I left notes on his car. I thought anything would be better than hurting so much and I kept trying to reach him, to tell him, but he blocked me and…I was alone again.

Question 9.11

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Check Your Notes

Relationship difficulties

- Has had boyfriends since age 14
- Feels great at start of relationship
- Gets anxious → “tests” guy

  • Sends text, times response
  • Rejects any excuse

- Feels relationship will end

  • Makes things up to stay in relationship
  • Self-harm and suicidal threats
  • Sends emails or leaves notes on car
  • Hard time controlling these behaviors

9.13 Screen 13

Ask Alicia about this symptom

“You mentioned feeling like you want to kill yourself and sending your ex-boyfriends messages about that. Have you ever done anything to hurt yourself?”

Alicia shares the self-destructive behavior she exhibited in her childhood.

Transcript

Alicia: Yes. When I was probably 13 or 14, I figured out that when I was feeling really bad, I could feel a little better if I dug my fingernails into my arm as hard as I could and counted to ten. It started out sort of like a ritual and I’d wear long sleeve shirts to cover up the marks my nails would make. Then I started using a paperclip to scratch my arms, my legs, sometimes till they started bleeding. But then that felt like it wasn’t enough, so I started cutting myself with a razor. I would do it in places my clothes would cover so that no one else would know. I was – I am – embarrassed of the scars. I have to be careful what I wear out, but it was really hard NOT to cut myself after awhile. It just made me feel better—like I could handle things and be okay.

Question 9.12

Aw4Neimql6WiMoYbuJRsIoWYmUI0RI7zrHbz76SzMIbhWEDqh6ekegUlrs1Emw4+XZkUEXqAzYeD9ge9pFWce/4cOT0=

Check Your Notes

Hurt self?

- Started around 13 or 14
- Dug nails into arm
- Scratched arms and legs with paperclip
- Started cutting with razor
- Wore concealing clothing to hide scars → embarrassed
- Cutting makes her feel better

Question 9.13

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
2
Correct.
You want to find out more information related to what Alicia just told you.
Incorrect.

Hint

You want to find out more information related to what Alicia just told you.

9.14 Screen 14

Ask Alicia the next question

“You said that cutting yourself helped you to deal with your emotions when you were younger. Sometimes when people engage in patterns like this, they also use other ways to cope with their emotions, some of which might be harmful to them in different ways. They also sometimes think about killing themselves. What else have you tried to help you block out these overwhelming emotions? Do you currently feel like harming or killing yourself?”

Alicia continues with the interview.

Transcript

Alicia: No, not today [laughs ironically] I have you to thank for that—I can tell you’re going to make me feel better. But, okay, I’ve tried pretty much everything. I get so down and depressed and just…like you said… overwhelmed, you know? I’ll have these moments when I feel like I’m back in that room with my stepfather doing stuff to me – [pause, like she is back in that moment, zoned out] I’ll see him when he isn’t there, or I’ll feel him touching me when he’s not there, especially when I’m really stressed out. Eating a lot of food all at once seems to help a little. I’ll eat a lot in the middle of the night, standing over the kitchen counter. I tell myself I need to stop doing that because I’m going to gain weight, so I’ll stop for a few weeks but then when I stop eating, it’s like I still need something to help me feel okay. So I’ll drink – beer, whiskey, you name it – a lot all in one sitting. I know that’s not good, either, so every morning I wake up and I think “I’ll never do that again.” But then something happens and I get all out of control again, so I eat, or drink or [quickly, a little embarrassed] … I cut myself. Not for almost a month, though.

Question 9.14

Aw4Neimql6WiMoYbuJRsIoWYmUI0RI7zrHbz76SzMIbhWEDqh6ekegUlrs1Emw4+XZkUEXqAzYeD9ge9pFWce/4cOT0=

Check Your Notes

Other self-harm

- Not currently suicidal
- Binge eating
- Binge drinking
- Alternates with cutting
- Feels emotional → helps for a short time

Question 9.15

3UJSW2skNBumLwWRnPtfem1vNkt8Dc+vD8ojRRgSLXyOd7JAOuMx20o6hr9IYgSbtfmYNJ8nc9wMRvFgywESJJ2kzDczVxAmiKY7fwEQxrjbKPuqpoarPteGrQQx30x65807N17b6yToX/pD66tgiFeHRi4KmmKdjC7SHsx70sc2JiTXZHaYgtuxwePRPcYPSrZH/1zqN3fr1a4/GLl3x9Xp4seGgeCitXv9Vtu5irfUkdBupauWic1sZIHHih+dcKT0Iecvh6i46AQsn5/7552+CS7UjkF7/MhVrq+zX1TBmoqfWGG86I5TryRl7009E6o51amOQ0gaKO9vfG4BP7ooX5ilavRv4M0hLZezVxNAvbsB5b0SECKqAOr6k8fj9XbJ6eaGnpqIuRYK6F7+EtDr66+w00wAJUBtfdh2Dde4DU4B119/eatVOy1MMIg+tP7LgkR1Pbo0T+dUuUxWlf+jNbYEOgZigRJKvMJycgksQzRw1KfDphXXzJv9dbfYabqKLOWhoGLGWpegfk1R3ZmxvqOT76jKIe1KoWYjFUGomeMDW+jP6V03+E2dnrgbNgXOqDO/RmsCnvoeaBkx3fPnNb9I9DHSgTsbrcx57+etwWMvwPznlJDJQ0PTsTShgGZHHKcHrGGXtTYGW8QDeloi8Y6P/zfmxVAgB7c2U3tFGSfOI1i0CsYhQbv0nN8HCQWM0inUqKEnrEC5sEfXJ3XvchHkUFDokdDfZ35pZpyvTztfjESEYB30sZU5I3uK3/W6yk+KM7WQUjduMmKBvgls0Qf4nP64kLg0DNO9M4c9nmDRLmbSnYnJ9JSvDElzF7QZiHX9GtgUJySZrAENx96Acnp+tTHeyEgSBkGrz8TnP9+pz2PcOPqX7dxJQ3tzRGsd6HGPvGqQBx/3JyM930EU2Vy8ZSA2ylqIaNrgSxGxlvyRB0IsNuFqy9kyBzyNFcym2kBjIsMMKcCQux5dBhlYmodMM5H+yQWOuDMgPJjDX6IHP0HOcg0/85aMOZSIvgpcTQ==
2
Correct.
Think about how Alicia describes her feelings about these behaviors.
Incorrect.

Hint

Think about how Alicia describes her feelings about these behaviors.

9.15 Screen 15

Review Alicia’s symptoms

“You’ve talked about hurting yourself. Have you ever lashed out and hurt someone else?”

Alicia further explains her impulsive behavior.

Transcript

Alicia: Hmmm… I don’t know if this is what you are asking, but when I was 17, my 4th stepfather and I got into a huge fight. It started real small, but then I got really angry really fast. I got so mad I ended up throwing a chair through the sliding door onto the balcony. Then that jerk threw me out of the house, and Mamí did nothing to stop him! [pause] Ever since then, I’ve had to move a lot. I’ve lived with some of my boyfriends, but that never lasts. I even had to live in a homeless shelter for a couple of weeks. And that brings me back to my main problem, which is that I can’t hold down a job for very long, which makes it hard to pay rent. [Brightly, intimately] Can I just say, I feel like I can really TALK to you. I know you’re going to help me. I am so glad I’ll be coming to see you.

Question 9.16

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Check Your Notes

Hurt others?

- Violent fight with 4th stepdad
- Threw chair through sliding glass door
- Stepfather kicked her out, mom didn’t intervene
- Unstable jobs & living situation ever since

9.16 Screen 16

Review a similar case

Question 9.17

Which of the following symptoms is Alicia currently experiencing? Check all that apply. Use your interview notes to help you remember!

bI0LPa9lfHQ+dYqk Relationship problems
bI0LPa9lfHQ+dYqk Suspicious/distrustful
bI0LPa9lfHQ+dYqk Hostile
bI0LPa9lfHQ+dYqk Blames others
bI0LPa9lfHQ+dYqk Deceitful
bI0LPa9lfHQ+dYqk Controlling/manipulative
bI0LPa9lfHQ+dYqk Jealous
bI0LPa9lfHQ+dYqk Sensitive
wCfH0QtRgXJ8o+c+ Aloof/Isolated
bI0LPa9lfHQ+dYqk Self-absorbed
bI0LPa9lfHQ+dYqk Self-critical
bI0LPa9lfHQ+dYqk Impulsive/reckless
bI0LPa9lfHQ+dYqk Grandiose/egocentric
bI0LPa9lfHQ+dYqk Emotionally unstable
bI0LPa9lfHQ+dYqk Overly emotional
bI0LPa9lfHQ+dYqk Depressed/helpless
bI0LPa9lfHQ+dYqk Anxious/tense
bI0LPa9lfHQ+dYqk Cognitive/perceptual eccentricities
wCfH0QtRgXJ8o+c+ Attention deficiencies
wCfH0QtRgXJ8o+c+ Psychotic-like episodes
Table
Congratulations! Alicia is experiencing a number of symptoms characteristic of personality disorders, including problems with relationships, hostility, deceitfulness, blaming others, controlling and manipulative behavior, jealousy, sensitivity, self-absorption, self-criticism, impulsivity/recklessness, grandiosity, emotional instability, anxiety, and helplessness/depression. Alicia is also suspicious and distrustful, overly emotional, and exhibits cognitive and perceptual eccentricities.
That’s not quite right. Alicia is experiencing a number of symptoms characteristic of personality disorders, including problems with relationships, hostility, deceitfulness, blaming others, controlling and manipulative behavior, jealousy, sensitivity, self-absorption, self-criticism, impulsivity/recklessness, grandiosity, emotional instability, anxiety, and helplessness/depression. Alicia is also suspicious and distrustful, overly emotional, and exhibits cognitive and perceptual eccentricities.

Hint

Review your notes to remember all of the symptoms Alicia is showing.

9.17 Screen 17

Diagnose Alicia

From the File. You remember a former patient who shared symptoms similar to Alicia’s. You review this case to help you diagnose Alicia.

Question 9.18

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Both this patient and Alicia talk about difficulties in relationships as one of their primary problems. Alicia focuses more on her emotions being out of control, while the patient in the video focuses more on feeling as if she does not have a clear sense of self. Both of these are symptoms of the disorder that this patient and Alicia have in common.

9.18 Screen 18

Next Question

Question 9.19

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2
Correct.
Think about the following symptoms Alicia exhibits in making your choice: - Difficulties in relationships - Fear of abandonment, with dramatic measures taken if she thinks she will be abandoned - Self-harm behaviors
Incorrect.

Hint

Think about the following symptoms Alicia exhibits in making your choice:

- Difficulties in relationships
- Fear of abandonment, with dramatic measures taken if she thinks she will be abandoned
- Self-harm behaviors

9.19 Screen 19

Choose a treatment

Question 9.20

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Alicia exhibits many symptoms of borderline personality disorder. Her reactions to coworkers and her fight with her 4th stepfather show her extreme anger. She alternates between idealizing and denigrating the men with whom she has relationships. Her binge drinking and binge eating reveal potentially damaging impulsivity. Her mood is very unstable. She displays frantic efforts to avoid abandonment by using suicidal threats, and she exhibits self-mutilating behaviors, such as cutting. Her flashbacks of her stepfather abusing her show dissociative symptoms.

Question 9.21

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The sexual abuse Alicia suffered at the hands of her stepfather, her biological father’s abandonment, and her mother’s refusal to believe or stand up for Alicia would certainly affect the way she approaches relationships with other people. She learned early on to keep her secrets and her emotions hidden, which led to her trying to find other ways to express her emotions, such as cutting herself, binge eating, and drinking heavily.

9.20 Screen 20

Next Question

Question 9.22

BROvJODDWb7Be0sj3d5u3urJJz2ee/Uwbjv9NSssMyXQJqgrnqPO/TsND6iujSIJBr/Kv/rOv3bTDODyK0PYS3L/lAKV6GForyeTwo1Z/LHF/EvU84sRWyPcMrRu7bEEY3qvIBN5d3XJq3FJGeSPKEYHYnuFNNJ+H5kou9bVc0zSyoVGNDL87PETWUyhXkdx29eBBePxBYFzFNfnKypANO3GssiC4rHGlkdrlhLJIshXTcvFImZV+YPTbNZAvvdAoD3bMuiY+vthWKtOOal42vQhYoVrCwKejoDp+QHKYUNe5zPmHEBloX+gnR9s9qfO24zufy+qyCAIRXzsyU9eCIekNPbG3am1eIILfJc9tQOtgrUxxYoxW/T8I9I6nRUcWUIgrxu+vK8qzXg4YWBkFgpbMnTOdYnvZpDAeqElZs3S74mxkxYNog7ofCWrLWN4u+Z5YM63riTyn1fa30ivnXQ6GFVMyWx+Fy5Wah7JiFAGjNPPgwammg0VkoJLW+zypJWx+XLqe8+GtSpRSJWpBb9riaTQtxH8BFosSGvHU7DpCPbdjDsKukluY8KW6bj+aNl1RdqouhnYiklhly6Senoyl/2dANujbxkUociVvOj21X4KiyUkQ9CC/sgZnQtIUzcCzm2zeL3YzY3//NAGSkwT2A5zbPtwx6ZaTfHGI/UsNeBwhYE13jgzgOSa/TSLTeU3KKLgxrWSRHA9nd2A/HLZHVF3hsrmYCGsPIgAoRutI19aWdnIWglTKpdruchiLR8OS2lFoBZwkprhotERyDEKJGju7id39CVKKWpgpBVaAQ8Tnp+Jaryz9K1Hk3rV6Qen7S3WCOhukC6VVCV+oM9pf0a6Fqa6Kj+XY47kiAd7Uo1CY2fOw9ayZNkifMuUf4PBJpjjokQpp/9rtymDjYXbfvVnS9BRUAaCGx5AOVbHjTmwtNOTbhRDhdpRHRi5tgZYRKeIkkhaMnmHFOOem0f2IRBcC8tuXbDOrr7NOxh2Z13qolbbjN5omoKoMt81gfZmCYETRqWI3EZHNTfCo8NqwpTQmmivOhqlbHJbEwcpHW9JGXm/vZWT+1Olu2rC2igq/r8RgTut9hSMOKTFzx47+dfaPJTdJZ+MH9hgaAw2Gb5hmmbs/+85tmmmnt4oOt4zMExOVDx41oPxA5O7ul4mYX7mTtUdYVMfcmOlMzu8wyoorvoatYf8kj0LQ2iCnd33CWh7tcOLGnecDORv06tFdu+b7nzb44DehfgN3HJHbS4ctCxLvbbA5aqE0x4ZIvgxL/2BJhBaTyuKlrQWQ0wrSxW1OIvjNE3pEh6inDrrKc93v2HOCECTLs9hq+RQgxp+ImaIJh1esU7ZzausA+UUl2e/0d6qVf48iEIFw3WLdYJjsI+Wganf6omER1fBmWS70ofXJsDDMTr7epGcWqjKYdKZrikGkbqCxAkXGNtwKt9nNrOHoEW8iNPdVdOI8tPTSn+hjzkG2x61bI7Agf7r4zYVFJSV8zIz3ENaDul5DHNTnA1hnOj8wHbIi3gX0Zbo1D2tImW39INVEJoypw9BCEN6CWK6cZI2kHy5QIHSIAiLSRLi6FveTMtUIB6dk6Qmhk28DiALQE2gHwBGygl6x4ZPpUbpuNw+KdJ5tc/sz0zTsbBPtvDaTYZW9M1aUV+oVfg/WIOK6RMIMp0LWFA4DzATQ4Dm7e9lKXb0miDNKYlYA8NAfkKmaRrirQ+yUl1u/2aoAwNVLpacoIxzTro0q6JsNky3U5StgL6ciOSgarFVx1gTkQ0tXXbEPuIE8yDcFYT0s64YbBP666kgidFz0iMyzgw3MGTq9WTKKCzngUQmt19zljdCcjp8YkLihnA6vLuVaAVtBf8kMUQsSH4TKsz9Eyi51k9s0fyS2b1XtARyi9zN37lA6TuQoyYjUhlcDfiiqbF93pcILDaN0qzhcIrKc7OYDnGlUYg00Wq2Nwq8djVaLb/j9CisxUPrZbZJ43J0P8rGstURp/mHPgWmgaXnyjR7nFTOuaVFWc+E/SsnI5CP/VETRcrVCkwgDfYRWmKcmHLOc8JvHGdORacbKjS5YoA5b1KzrXT0nvoSiPq8o4P9eedCFKZaUMjrNiY1rCxHAyr9CO3GZpb5QYxX//mTmw/Xyak5SBckgRWsKXx7gO/Pb1GkNkHFEDKz9mcBBxq4ZfaN7DhOen2PApXkMad+qjkrEVjpLAhICiv1wOGa2cA37nbCuzZu4FaHPIUawT0A7tRSaQUCchtG2fvAtuAsDuyKInaY8Bz0jClA+5fZoSoAYPK2m9oSatBqYJ8hd7BZXNtyHp+BUxKBPO6/Wqcw3QrMpKgXA6jX0dsy3louDeVIUDBX+4GJX2jRV62PAV44T7EItRU80VmEM5ZUFpmJbhN90ikYqiI2JyM5TXKVwXglm6MjKNXabEDd7m2a3ih3em/DtYGgyFqV3SGSXyehdCIJs/rQiMCEZcW8hmRIFkEvbCZaARzgOp0sPP/O8KYCRSrw1dtVTD51ViD43JP98I1liZqahKBE4678d4jIjPp78+ODZo+lHPVnJPAIriula325F5AJQp0AS9eQISTIO2cwOmQm3x8FrSVPX2ttDQIsDGVoTTLo8/ZP5WtZym+4X1D3DyFyQcWQTcoULLr4E3Dn11QPb6zhB6YN5wz7HSMHk9b396SrCYub8EBKltemBOY8I98KSHmbhNp9zpBGE6DgiAi/fbyC9N4CYnBxcNy8GhBgd8zdl5y5wfH6Xyfn91YZeql1YkOon4diq6uznuTr+3jLd4yPE3L9GPDCs5grzUNzjAVUreFJ26ppQES8I30ihHKn1Zktgi7+qLhO5Flrq4c3Ws9zfE2Grv9AyGMlQ/rL4awDNF/h0vlbG06L0KEB7+qxn0Pujp9xBEZcBZ46/R0/RItcb0OPNqt4m+rJ71JKjcebAODLEj1tCXHpcsmPTICEildLhWectKXpEfyDCTUAC/7TJcaCUYjLvzUp2pEuhd4gcXECmWHVdC89aQiY5I57497WBZUwr3h0BMA4u1mqyMLDJIccBYvrSyFGTiuVgYMkJ7h6SXmIUj5mIS0w6tju/xdmeqPaF8C0PgznV4l9aya4q8w7MJHPwnXbxmXv8szNZNFwXFkye9C9lecrtkFIXTV1PnjaviCan2+5TZhe1twyS6fB1rFWy+a9AFQvDWyrtPtwwMJmNUwba9Pifn9ZruEBIMUKYhIBr0v4CJhPeUO3yYwRyKuTmw+2AcGuepGMSxv0M3LCQczuZdc/ZLF5n67pR+Y4UKw=
2
Correct.
In making your choice, think about which type of therapy has been shown to be very helpful in treating individuals with self-harm behaviors.
Incorrect.

Hint

In making your choice, think about which type of therapy has been shown to be very helpful in treating individuals with self-harm behaviors.

9.21 Screen 21

What happened to Alicia?

Question 9.23

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2
Correct.
Think about what you learned in your feedback so far.
Incorrect.

Hint

Think about what you learned in your feedback so far.

Question 9.24

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
2
Correct.
Think about how effective research has shown Dialectical Behavior Therapy to be.
Incorrect.

Hint

Think about how effective research has shown Dialectical Behavior Therapy to be.

9.22 Screen 22

Real World Application

EPILOGUE

Alicia looks happy at her job.

You are trained in DBT, so you begin treating Alicia individually and refer her to your practice’s skills training group. In the group, she meets other people who share her experience and learns valuable coping skills in the areas of mindfulness, emotion regulation, distress tolerance, and interpersonal communication. When she is feeling overwhelmed and she wants to cut herself, she calls you (as you have instructed her to do), and you coach her to try some of these skills she has learned instead of engaging in self-harm behaviors. The individual sessions are a longer road. Phase 1 of DBT, which entails focusing on getting her self-harm behaviors under control, takes you and Alicia two years to complete. During this time, Alicia repeats group skills training and works on figuring out when and why she self-harms to figure out how to stop from doing so in the future. Only then do you feel that Alicia has gained enough control of her self-harm behaviors to begin addressing the trauma of her stepfather’s sexual abuse.

After the difficult process of addressing this trauma and its related symptoms, you work with her on dealing with ordinary life problems like setting long-term goals, something she never allowed herself to consider previously. During the last stage of treatment, you work with Alicia on finding meaningfulness and connection in her life. Although it is a very long process with some slips along the way including trips to the ER and hospitalizations when she harms herself, Alicia eventually is able to hold down a steady job as an office manager at a doctor’s office. She feels more open to relationships and less worried about what will happen if the man she is dating leaves her or if she and a friend have a disagreement.

9.23 Screen 23

Real World Application

Watch the following video and answer the questions.

Question 9.25

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Alicia might be put off at first, especially since she, like many patients with Borderline PD, is very sensitive. She will likely put her therapist on a pedestal some times and think her therapist is the worst person in the world at other times, just like she does with every other person in her life. Eventually, Alicia will see the positive changes in her life as a result of engaging in DBT, such as engaging in self-harm behavior less and using her coping skills to help her feel more in control of her emotions and her life.

Question 9.26

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There is no right or wrong answer to this question, only your personal opinion.

In 2011, Dr. Marsha Linehan, the therapist who is doing therapy in this video, revealed in an interview with the New York Times that she herself had suffered from Borderline Personality Disorder as a teenager. In order to “treat” Dr. Linehan, doctors put her in a seclusion room, which had only a bed, a chair, and one window. They claimed that doing so would prevent her from attacking herself, as she had repeatedly cut and burned herself. Left alone in the seclusion room, she instead banged her head on the wall and floor to engage in self-harm. When she got out, she vowed to help others like herself. Many years later, she earned her Ph.D. in psychology and created D.B.T.

(Source: http://www.nytimes.com/2011/06/23/health/23lives.html?pagewanted=all&_r=2&)

Question 9.27

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There is no real right or wrong answer here, but the lack of knowledge and research about how to help people who engage in self-harm behaviors is the main reason. The doctors at that time thought that they were doing the best thing they could to help Linehan.

Question 9.28

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There is no right or wrong answer to this question, only your personal opinion.

Question 9.29

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There is no real right or wrong answer here, but there is a real stigma against psychologists who reveal that they themselves suffer from mental illness. Other psychologists may be less likely to take them seriously, and patients may question their ability to treat others with mental illness. Linehan was likely trying to reduce some of the stigma surrounding mental health diagnosis in particular and diagnosis of borderline personality disorder in particular when she revealed her diagnosis of BPD.