Colleagues Response week 10

The Assignment:

Read a selection of your colleagues' responses.

Respond to at least two of your colleagues by providing one alternative therapeutic approach. Explain why you suggest this alternative and support your suggestion with evidence-based literature and/or your own experiences with clients. Support your responses with evidence-based literature with at least two references in each colleague’s response with proper citation.

Colleagues' responses # 1

Based on the case study, the symptoms of the 15-year-old male suggestive of borderline personality disorder

Explanation of the Most Likely DSM-5 Diagnosis

The criteria for diagnosing borderline personality disorder is a pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity, beginning by early adulthood and present in a variety of contexts, as indicated by five or more of the following which are frantic efforts to avoid real or imagined abandonment, a pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation, identity disturbance  such as markedly and persistently unstable self-image or sense of self, impulsivity in at least two areas that are potentially self-damaging such as spending, sex, substance abuse, reckless driving, binge eating, recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior, affective instability due to a marked reactivity of mood such as intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days, chronic feelings of emptiness, inappropriate, intense anger or difficulty controlling anger such as frequent displays of temper, constant anger, recurrent physical fights, transient, stress-related paranoid ideation or severe dissociative symptoms.

The patient presents with symptoms suggestive of the borderline personality disorder as written in DSM-5. He had suicidal ideation when he cut his leg at the school and history of multiple self-harm behaviors which started almost 10 months ago. The explanation he gives is because his boyfriend abandons him. He showed intense anger outbursts and difficulty in controlling it at home towards his mother who is taking care of him and also has problems in maintaining interpersonal relationships with his peers. His thought contents are about his broken peer relationships also, he identifies himself as pansexual and dates a male peer. His mood is depressed. He has problem with sleep onset and with low self-esteem and low energy level.

Group Therapeutic Approaches that Might be Used.

According to Allenbach et al. (2018) use of immature defense mechanisms are empirically shown in individuals with borderline personality disorder (BPD) and they used higher proportions of action, borderline, disavowal, narcissistic, and hysteric defense mechanisms than healthy matched controls.  The most successful treatment for BPD is psychotherapies and most empirically supported psychotherapy is dialectal behavior therapy which is rooted in cognitive behavior therapy (CBT) and Zen Buddhism. The symptomatic improvement during DBT occurs mainly through mechanisms including the alteration of emotion regulation, the learning and use of skills, and the beneficial effects of the therapeutic alliance (Allenbach et al.,2018). The interventions used in DBT are validation, telephone coaching, and skills training such as mindfulness, interpersonal effectiveness, emotion regulation, and distress tolerance skills and self-esteem skills. Studies have suggested that skill use mediated the decrease of several symptoms such as suicide attempts and depression (Andreas et al., 2018). Another study showed that practicing the DBT skills and building an increased sense of self-efficacy may be important and partially independent treatment processes in dialectical behavior therapy (Barnicot, Gonzales, McCabe, & Priebe 2018)

Expected outcomes for the client based on these therapeutic approaches.

Barnicot, Gonzales, McCabe, & Priebe (2018) concluded that the study they conducted revealed that using the DBT skills was associated with a lower likelihood of subsequent dropout, and less often self-harmed. Research studies have shown that DBT in BPD and antisocial behavior has a positive impact with moderate to strong, statistically significant pre-to posttreatment reductions of several dysfunctional behaviors, including self-harm, verbal and physical aggression, and criminal offending (Andersson et al., 2020). 

Legal and ethical implications of counseling children and adolescent clients with psychiatric disorders.

There are four major ethical issues emerge when counselling children and adolescence. The counsellor competence, ability give informed consent to the treatment, confidentiality and child abuse reporting. It is not possible to borrow knowledge from adult psychopathology and apply to children and therefore it requires course work in child psychopathology and child counselling theory for those work with children (Lawrence &Kurpius 2000).

A minor can enter in to contract for treatment typically in three ways such as parent consent, involuntarily at a parent’s insistence, and by order of the juvenile court. Informed parental or guardian consent is needed for treatment to be court ordered and if not obtained, counsellors risk the possibility of being sued for battery, failure to gain consent, and child enticement. However, there are exceptions where the treatment does not require parental consent such as if the child is court ordered for treatment. But the parent may be informed of the treatment as soon as possible as per recommendations from American Bar associations. Also, a mature minor who is above the age of 16 who can understand the nature and consequence of the disease are also considered as exceptions (Lawrence &Kurpius 2000).

What to share and what not share with parents is one of the most difficult legal and ethical dilemmas in counselling children.  Involving the parents in the creation of mutually agreed on guidelines for guidelines for disclosure and motivating the minor client to disclose on his or her own are two positive strategies (Lawrence &Kurpius 2000).

Reporting child abuse and neglect are the important first step in protection of children and failure to do so constitute one of the most common breaches of the law and ethical standards (Lawrence &Kurpius 2000)

Colleagues' responses # 2

The most likely DSM-5 diagnosis for the client in the case study is Borderline Personality Disorder (BPD).  It is diagnosed by a pervasive pattern of instability of interpersonal relationships, self-image and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by 5 (or more) of the following: Frantic efforts to avoid real or imagined abandonment, pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation, identity disturbance: markedly and persistently unstable self-image or sense of self, impulsivity in at least 2 areas that are potentially self-damaging, recurrent suicidal behavior, gestures or threats, or self-mutilating behavior, affective instability due to a marked reactivity of mood, chronic feelings of emptiness, inappropriate, intense anger or difficulty controlling anger and transient, stress-related paranoid ideation or severe dissociative symptoms (What are the DSM-5 diagnostic criteria for borderline personality disorder (BPD)? 2019).

           Client in the case study engages in intentional recurrent self-injurious behavior by cutting and OD, which started 10 months ago. Patients with borderline personality disorder are frequently encountered in the emergency department, where they present following threatened suicide or a suicide attempt (Biskin & Paris, 2012). Persistent cutting as a way of regulating emotions is a characteristic feature of the disorder, as are recurrent overdoses related to stressful events (Biskin & Paris, 2012).

Client in the case study reports imagined abandonment by his boyfriend and mother when the mother states, “patient shuts her out or states that he does not have time to spend with her because she needs to finish his homework”. Patients with the disorder have described it as feeling as if “something is missing,” and it overlaps with hopelessness, isolation and loneliness, as well as some symptoms of depression (Biskin & Paris, 2012).

Client’s sexuality is also a factor in diagnosing BPD. Client reports being a pansexual. Being unable to define an identity on one’s own and instead being dependent on interpersonal relationships to define one’s identity, as well as frequent fluctuations or a sense of incoherence in one’s identity, are more strongly associated with borderline personality disorder than with typical adolescent identity issues (Biskin & Paris, 2012).

Client also reports markedly and persistently unstable self-image or sense of self and loss of interest is hobbies such as no longer attending rehearsals for the school band. Clinical experience suggests that, over time, some patients react to this fear by becoming socially isolated to protect themselves from potential abandonment (Biskin & Paris, 2012).

The treatment approach I would utilize is Dialectical Behavioral Therapy (DBT). Within DBT, “dialectical” refers to the integration of both acceptance and change as necessities for improvement (May, Richardi, & Barth, 2016). Dialectical behavior therapy aims to address the symptoms of BPD by replacing maladaptive behaviors with healthier coping skills, such as mindfulness, interpersonal effectiveness, emotion regulation, and distress tolerance (May, Richardi, & Barth, 2016).

As a PMHNP it is important to respect all clients and understand that confidentiality is important in all situations even in adolescents. The PMHNP must maintain confidentiality; however, ethics and the law may overlap; therefore, it may be necessary to seek legal consultation (Avasthi & Grover, 2009).