CASE PRESENTATIONPRESENTED BY- NAVNITA BOSEIIND YEAR M.PHIL TRAINEEDEPARTMENT OF CLINICAL PSYCHOLOGYINSTITUTE OF PSYCHIATRYKOLKATA

CHAIRPERSON- MS. DOYEL GHOSH

PURPOSE OF THE PRESENTATIONDiscussion on management planSOCIO DEMOGRAPHIC DETAILSNAME: S.M.SEX/GENDER: FemaleAGE: 16 yearsMarital status: married (not registered)Mother tongue: Bengali

Education: studying in 10th standardOccupation: studentReligion and caste: HinduResidence: sub-urbanFamily type: extended

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

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:

Disturbed interpersonal relationshipActs of deliberate self-harmEpisodes of running away from homeImpulsivity Multiple Suicidal attemptLow Mood

From adolescenceHISTORY OF PRESENT ILLNESS:Onset: insidiousCourse: continuousProgress: fluctuatingClient 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 to irritate her father. 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 informing to her father.

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 elicitedENERGY: unchanged.

NEGATIVE HISTORY:

No significant brain injury, no episodes of fit, history not suggestive of reduced level of consciousnessHistory not suggestive of pervasive elevated mood, stealing, setting up of fire, and big talksHistory not suggestive of presence of any pervasive firm, unshakable beliefHistory not suggestive of false perception which is not a sensory distortion or a misinterpretation, but which occurs at the same time as real perceptionsHistory not suggestive of consumption of substance

TREATMENT HISTORY:

Treatment done at INSTITUTE OF PSYCHIATRY (IOP)January 2015- May 2015Tab Olanzapine 5 mg x---------x-------I Effects: improvement in mood symptomsSide effects: weight gainCompliance was good

PAST ILLNESS:

Past history not suggestive of any significant medical or psychiatric illness

FAMILY HISTORY:

FAMILY INTERACTION PATTERN:

Communication: directLeadership: democraticDecision making: mostly fatherRole: inadequate by father as he cannot spend much time with the family Family rituals: none reportedCohesiveness: lowFamily burden: financial problemExpressed 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 extra-marital affair, had a clinging behavior towards clients father, acts of deliberate self-harm present before her marriage providing an impression Borderline Personality DisorderFather: alcohol dependencePERSONAL HISTORY:

BIRTH AND DEVELOPMENTAL HISTORY: Full term, caesarian delivery with attainment of developmental milestones within normal limitsCHILDHOOD 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 4th 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 standardAcademic performance: below averageReason for discontinuation: NAPeer relationships: cordialAny disciplinary problems: complaints regarding calling oftenHobbies, interests and extracurricular activities: drawing, playing phone gamesINTERPERSONAL RELATIONS AND SOCIAL ACTIVITIES:Had few peers, likes socializing but with selected peopleOCCUPATIONAL HISTORY: NAMENSTRUAL HISTORY:Menarche: 12 yearsDate of last menstrual cycle: 21st November 2014Periods: regularDuration: 3-7 daysAny 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 presentClient 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 IntactPlace IntactPersonIntact DateIntactDayIntactMonthIntactYearIntactOVERALL IMPRESSION: INTACT ATTENTION AND CONCENTRATION:

Attention being easily aroused and sustained. (Was able to do 100-7, complete sequence)MEMORY:OVERALL IMPRESSION: INTACT

Memory:REMOTEOwn birth year: 23rd Apr 1999Brothers birth year: 27th Jan 2001

Independence year: 19471st prime minister of India : Jawahar Lal NehruRECENTDinner: could answerBreakfast: could answerIMMEDIATEDF: 5DB: 3Word recall: 4 out of 4ABSTRACTION:SIMILARITIESAam- kolaharmonium-tablaDutoi fruitdutoi gaan korte sahajjo korePROVERBNachte na janle uthon bekaJara nachte pare na bakide theke, tader mone hoye uthon beka bole nachte parena, ojuhat dayeOVERALL IMPRESSION:CONCEPTUAL:GENERAL INTELLIGENCE:

INFORMATIONCurrent CM: Mamta Banerjee, Ramayan: ValmikiCALCULATIONCost of 2 pencils is .5 paisa, how many pencils can be bought by 20 paise? 8153- 75= 78COMPREHENSIONCOOK FOOD: HOJOM HOAR JONNOVOCABULARYShahosi: jara bhoye paye na Hingsha- 2to friend, ek jon er kache sob ache, eta dekhe onno jon chay k amaro hok, etai hingshaCOMMENT: AVERAGEJUDGMENT:

PERSONAL Adequate general appearanceIntact SOCIAL Cooperative behaviour with the cliniciansatisfactoryTEST Fire in the house: jol diye nebhabo, fire-brigade k dakboEnvelope: letter box a dhele debosatisfactoryLOBE FUNCTION: Was able to do alternate sequenceWas 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: normalForm: normalPossession: no abnormality detectedContent: normalHer 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 self-harm, 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 sustained with intact memory functions, conceptual abstraction, average general intellectual abilities with 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:

TEMPERAMENT DOMAINSPERECTILE RANK

IMPLICATIONNovelty seeking75HighHarm avoidance85Very highReward dependence50AveragePersistence 35Very low

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.

CHARACTER DOMAINSPERCENTILE RANKIMPLICATIONSelf- directedness39.7Very low Cooperativeness39.9Very lowTranscendence 46.5AverageLow 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 feelingsTAT:

EnvironmentNon-nurturant, supportive, mistrustfulSELFAmbivalent (mostly inadequate)NEEDSCounteraction, defendance, harmavoidance

AUTHORITY FIGURESSame sex: dominatingOpp. Sex: nurturant

CONFLICTAutonomy vs complianceRejection vs affiliationAdequacy vs lackNEEDSAutonomy, aggression, intra-aggression

ANXIETYBeing dominated, loss of loveDEFENSESRegression, rationalisation, projection PSYCHOPATHOLOGY FORMULATION:

BIO-PSYCHO-SOCIAL MODELMother: impression of BPDFather: substance abuseEarly childhood experienceInvalidation of emotion, maternal neglect,SelfInsecure selfChildhood traumaMothers suicide, going to hostelHigh novelty seeking, harm avoidance,External locus of control, (characterological deficits) n for affiliation, aggression, intraagression

Father not spending much time, critical comments from younger brotherArguments with boyfriend, isolated by relativesDistress, frustration, impulsive acting out, demanding behaviour, suicidal attempts

FINAL DIAGNOSIS:ICD 10 F60.31; Emotionally Unstable Personality Disorder - Borderline Type POINTS IN FAVOUR POINTS IN AGAINSTImpulsivityLack of self-controlActs of self-harm, suicidal attemptsEmotional instabilityPROGNOSTIC FACTORS:

GOOD PROGNOSTIC FACTOR BAD PROGNOSTIC FACTORSAverage intelligence Biological loadingMotivation to know about causes ImpulsivityFemale gender Repeated suicidal attemptsGood compliance Family history warmth Brutalized early environmentAbsence of narcisstic featuresWoollcott, 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 individualFocus of the therapy process: Short term goal:Engagement in therapy processEstablishing empathetic relationship with the clientUnderstanding clients interpersonal environment Psychoeducation Improving adjustability

Long term :

Improving skills for better interpersonal functioningIncreasing perceived social support Improving control over emotionsEnhancing problem solving skillsEnhancing coping skillsModus 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 events.

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 grandmotherCost-and-benefit analysis for the self-harming behavior was done for suicidal behaviorSubjective 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 motivatedHer 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 experienceReduce emotional vulnerabilityDecrease emotional sufferingClient 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 and its requirement. Anyhow, therapist hoped for the best.

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 explainedone 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 anymoreTherapists 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 jaiThe 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 doneClient 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 doneHomework 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 ILLNESSBALANCE EATINGAVOID MOOD ALTERING DRUGSBALANCE SLEEPGET EXERCISEBUILD MASTERY

Increasing positive emotions were suggested.

Homework was assigned.

SHORT-TERM POSITIVE EMOTIONSLONG-TERM POSITIVE EMOTIONSWatching favourite soapsConcentrating on studiesTalking to her boyfriendImproving relationship with fatherVisiting her relativesEating ice-creamFEEDBACK 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 = 40Next focus : INTERPERSONAL EFFECTIVENESSFEEDBACK 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 trainingDistress tolerance training

THANKYOU..