Reply to Classmate Discussion post. Please make sure it has all three of the following:
_____ It is clear that you read the article on your own and did not rely on the posted summary
_____ Addresses points made in the classmates Implications discussion
_____ Brings up novel points that the classmate and other repliers have not mentioned. Needs to be
relevant or clinically-important, not just throwing in a tangential idea.
The classmates Post is below along with the reference for the article they are writing about:
A Dialectical Behavioral Formulation: The Case of Katrina
The response paper by McMain (2000) follows the case of a 25-year-old woman, Katrina, who is struggling with Borderline Personality Disorder. The article gives a thorough synopsis of Katrinas abusive upbringing and her suicidal behaviors, while also keeping a generalized perspective of DBT for clinicians to further use. Beyond the physical and sexual abuse Katrina endured, her brother being slapped for her actions is heartbreaking but revealing of manipulation, which is a common trait in BPD, to potentially be learned; Im sure if a behaviorist conceptualized Katrinas case, this would be a focus. The term dialectic accounts for the juxtaposition of both accepting your experience and changing your behavior. This makes sense considering so many people suffering with disorders commonly treated with DBT suffered from traumatic memories they must accept, while changing the maladaptive behaviors they use to cope. I was surprised at first an adaptive method for reminiscing on traumatic memories wasnt a strategy in DBT, for the way it is repeatedly mentioned in Katrinas cases. However, it is mentioned that addressing these memories was not the focus for the first 1-2 years of Katrinas therapy because she couldnt walk through them without completely breaking down. It sounds like addressing traumatic memories can be as intense as exposure therapy for those sensitive enough to it,
Before reading the case by McMain (2000), I had never thought about the link between growing up learning to suppress your emotions by putting on a smile amidst turmoil and facial motoric expression. In Katrinas case, it was difficult for even a skilled therapist to read how she was feeling because she had gotten so use to concealing her affect for the sake of avoiding conflict in her family. I found the summary of consequences for an invalidating environment to be particularly helpful to add to my practicum portfolio as Psycho Ed. Validating someone who has been invalidated their whole life by first explaining to them why being invalidated is such a harmful act by itself, let alone when paired with abuse and/or neglect, may be a very useful tactic.
Previously I assumed past suicidal attempts were a risk factor for suicide simply because the person may still
be feeling suicidal, or relapse on the suicidal behaviors. However, this case study highlighted for me the positively reinforcing attention & help that comes after a suicide attempt, which may prompt somebody like Katrina who grew up only getting help after presenting extremely concerning behaviors. The immediate consequence created such a strong reinforced behavior for a something as extreme as suicide. McMain (2000) goes as far as to even say hospitalization should be avoided for Katrina, and generally for clients with BPD, because it can reinforce their suicidality. The alternate solution of providing your phone contact anytime the client deems necessary for help is also concerning to me because of how much those with BPD tend to struggle with boundaries. It made me think Dr. Maceras solution of offering a surprise phone call check in may be more effective and appropriate for everyone involved. What do you think?
Naturally, while reading I was comparing the process of making a CBT case formulation, as we did in class, to one for DBT, as this article described (McMain, 2000). One of the major things I picked up on was the breakdown of classes of behavior that McMain (2000) referred to. Antecedents seem to be critical in determining the lethality or risk level of a suicidal behavior. Although I am grateful to even be getting a class on CBT intervention, reading this article made me realize how much I would benefit from a DBT course. From my understanding, DBT abides by the belief that psychopathology stems from and is maintained by emotional dysregulation, whereas for CBT, that is just apart of the equation; Cognitive distortions and contingencies are a focal point in CBT, as weve learned, whereas DBT has a stronger focus on managing the acute maladaptive behaviors. I think its very useful for us to become more familiar with DBT before going onto practicum because it is so heavily used for the known-to-be tough to treat clients, ranging from comorbidities of mood disorders, SUD, PTSD, and of course BPD. If treating high risk suicidal clients with a comorbid diagnosis like BPD and Bipolar II is anxiety provoking to you, you may be as relieved as I was scrolling through this page and seeing how much literature already exists, but then quickly overwhelmed on how to tackle it. It is extremely difficult to work with an individual who is a chronic serious suicide risk, who often presents as very competent, and who is difficult to engage in treatment. After mentioning the importance of consultation in DBT, McMain (2000) ended the case study with this, leaving me even more motivated to learn about how to effectively intervene with DBT.
Reference
McMain (2000). A dialectic behavioral formulation: The case of Katrina. Cognitive and Behavioral Practice, 7(4), 505-509. https://doi.org/10.1016/S1077-7229(00)80066-8.