DBT Case Formulation

Consultant name: Luci

Treatment provider: Lic. Elsa Oviedo

Data and Background

1. Luci is 28 years old, she is single, without children, she lives alone, she is the only
daughter of her parents' union, and she also has x paternal siblings and xx maternal
siblings. She live alone. She has little contact with her parents and siblings, her mother
lives in Argentina and helps her financially, while her father lives in the same city. He
studies a degree in Mathematics, works as a teacher in a public school. The uncle
mother lives one week a month in the same house, for work reasons.
Regarding her support network, she has a small circle of friends (2 friends), the mother
is not considered due to the distance and absence in the consultant's life.
Furthermore, the therapist is considered a support in her network.
2. Self-harm since the age of 15, induced vomiting, promiscuity, suicidal ideation and
shopping compulsion.
Comorbidity: GAD, Depression (mild to moderate), BPD (Interpersonal relationship
problems, emotional dysregulation)
3. Previous treatments:
 At 10 years old (no details)
 He begins cognitive behavioral therapy XXXXXXXX, his reason for consultation
being: xx

Last event that occurred: argument with the uncle because he used his soap.
 A: problems at school, discomfort
 Activating situation: the guy used his soap
 Thought: He shouldn't have touched my soap, I can't stand it, he's taking
advantage of me. / Mom and my aunts are going to be angry with me and they
are going to believe that I am the worst person, that I am bad.
 Emotion: Anger – fear and guilt
 Behavior: discussion and self-harm , then communicates with the therapist
(sends photo)

4. Environmental Invalidation:
 Separation from parents at 4 years of age
 Mother's migration at 5 years
 Abandonment experienced by the patient
 Father's absence
 History of paternal depression according to the patient with probable
bipolarity.
 History of depression of the mother, maternal aunts of the consultant

Goals

a. Finish your Mathematics degree (you must have two subjects)

b. Form a family
c. Be a mother
 d. Have your own house
e. Economic independence

1. Treatment goals
- Disorder level: imminent threat

Alcohol consumption, promiscuity, reckless driving

- Disability:
Work problems, problems in your interpersonal relationships, family conflicts
- Severity:
High emotional distress (Level 1)
- Penetrability:
Family, work, personal, social, economic context
- Complexity:
Problems in work relationships (frequent fights with your restaurant officials),
conflictive relationships with your family, poor social support, impulsiveness,
promiscuity, alcohol consumption, comorbidities (GAD, depression)

Treatment Stages

Stage 1

They threaten life

Presents risky behaviors that threaten his life: self-harm (CASIS)

Interfere with therapy

Behaviors such as: absences, does not practice skills, difficulties respecting therapeutic limits,
does not use telephone coaching appropriately, communicates after having performed the
problem behavior

Interfere with quality of life

Alcohol consumption, self-induced vomiting, promiscuity

Stage 2

Residual disorders:

Generalized anxiety disorder

Feeling of not belonging:

Irritability, low tolerance for frustration, difficulties in problem solving and interpersonal
ineffectiveness

Experiential avoidance: Not observed

Analysis of the objectives

Stage 1

Behaviors

- CASIS
 - Doesn't do homework
- Inappropriate use of telephone coaching
- Absences
- alcohol consumption
- Self-induction of vomiting
- Risky sexual relations

Goals

- Reduce CASIS
- Increase task completion
- Use calls when necessary
- Strengthen commitment to treatment
- Decrease alcohol consumption
- Reduce self-induction of vomiting
- Reduce risky sexual relations

Stage 2

- Fights
- Avoidance of anxious situations
- Aggression to third parties

Goals

- Eradicate fights
- Increase interpersonal effectiveness skills
- Increase coping behaviors

Objective Behavior

- CASIS

Define the problem behavior

Topography: on the right leg with stylet; I don't need stitches, I bleed slightly; 4 cm cut.
Approximately

Frequency: once

Duration: less than a minute

Intensity: light

The chain was completed during the fourth treatment session

Complete the chain analysis according to the following:

a) The context of vulnerability in which the behavior occurred: irritability, work problems,
exhaustion, feelings of rejection, feelings of inferiority due to the sister's pregnancy.

b) The triggering event: mistake by an official of your company (he put too much salt in his
clients' food)

c) Using the following table, complete a chronologically detailed list of what happened from
the background to the problem behavior :
1. Label the links in the chain

- Actions of the consultant: she goes home without solving the problem and cuts herself
- Body sensations: agitation, tremors
- Cognitions: I can't stand it, I'm useless, everyone can but me
- Emotions: anger
- Environmental events:….

2. Complete a detailed list of what happened after the problem behavior. Include immediate
and long-term consequences:

Short-term consequences: relief from discomfort, physical pain, guilt

Long-term consequences: fights with your mother, shame, feelings of worthlessness,

depression

3. Highlight problematic links

Deficits in emotional regulation skills , interpersonal effectiveness, discomfort tolerance, and

basic awareness skills

Problematic emotion: anger

Dysfunctional cognitions: Catastrophic thoughts, I can't stand it, I'm useless

Examples of secondary objectives:

1) Emotional vulnerability: anger towards his uncle, anger towards his officials, anger
towards the therapist when she is online and does not respond, anger towards the
secretary of the school where she works.
2) Self-invalidation (not applicable)
3) Active passivity: frequently requires help from the therapist in analyzing the solution.
4) Apparent competence (not applicable)
5) Relentless crises: she self-flagellates, uncontrollable events generate impulsiveness in
her that leads her to cut herself

d) Identify intervention points and corresponding solutions. Specify the type of change
procedure and include a description of how the intervention was or will be implemented.

1) Basic awareness skills:

Goals:

- Reduce suffering and increase happiness

- Reduce pain, tension and stress

(Training the wise mind and what and how skills)

2) Emotional regulation skills:

Goals:

- Train the patient so that she can understand and name her emotions
- Understand what the adaptive and communication functions of emotions are
- Decrease the frequency of unwanted emotions, or stop them before they start or
change them when they have started
 - Reduce emotional vulnerability, increasing resilience
- Increase positive emotions
- Reduce emotional suffering in the face of painful emotions

3) Discomfort tolerance skills

Goals:

- Surviving crisis situations (Stop, Pros and Cons, Tip, Distraction, Self-Calm)
- Accept reality (Radical acceptance, Change the mind, Good disposition and
stubbornness, Half smile and open hands, Mindfulness of thoughts)

4) Interpersonal effectiveness skills

Goals:

- Train the patient in skills that allow her to be skilled at achieving what she wants and
needs from others.
- Getting him to actually say “NO”
- Help her build new relationships and end those that are destructive
- Create and maintain balance in relationships

5) Cognitive modification

Goals:

- Reinforce and validate the client's beliefs, expectations, rules and adaptive
interpretations, through cognitive restructuring and clarification of contingencies.

Chain from antecedents to problem behavior

Consequences that followed the problem behavior

Secondary objectives

1. Emotional vulnerability
2. Self-invalidation
3. active passivity
4. Apparent competition
5. Relentless crises

Evaluation of the consultant's skills

Mindfulness:
You use the skills daily, and when you use them they help you

Emotional regulation:

Does not use the skills frequently, only in moments of crisis with the help of the therapist

Discomfort tolerance:

Uses skills very infrequently, through distraction methods

Interpersonal effectiveness:

You try to use them on some occasions without obtaining the desired results, it is difficult for
you to implement them effectively

Self-management skills:

Has great difficulty learning self-control and self-direction skills

Treatment functions

Motivation

Emphasis is placed on the client's goals, obstacles to engaging in skillful behaviors are
identified. Positive reinforcers have been used in order to increase skilled behaviors and their
effective use. Difficulties in managing contingencies are identified to reduce behaviors that
affect the therapist's personal limits.

Increase capabilities

There is no skills training group, therefore, they are being developed according to the
possibilities (time, cost) in individual sessions

Generalization

The generalization of skills is carried out in individual sessions and through telephone
coaching.

Structure the environment

Environmental interventions have been carried out only in cases of crisis. The patient does not
have a support network in which validation skills can be intervened and taught.

Increase the motivation and capabilities of the therapist

Consulting team meetings have been held since September 2018, in which skills are practiced
between therapists, case management is worked on, and therapists are encouraged to talk
about their difficulties in relation to their personal and therapeutic limits.
Paula:

 Practice skills together

 Write if we don't find the Kelly Kell chapter (we found it, we'll let you know)
 Write down all theoretical doubts for the 2nd part of the training
 We can write to Paula if we have questions about the assignments.
 Program in DBT… a team project.. ask.. try to do it alone... how we would like
to do… skill groups or not… Who would be the coordinators or trainers...
individual therapists... The idea is to form a team... if they don't want to, they
work together... each one do an individual project... skills for adolescents.
 Case supervision questions. I am not being able to achieve this with the
patient, how do I do it?
 From the team… implementation questions… or how team meetings work
 Conceptualization of the team… how we do some part of the implementation
of the dbt program…
 Practice more how the team meeting works. Call in crisis. and skills
 More mentoring before part 2.
 Send the conceptualization of the dBT case and program. and the 3 questions
of the case and the dbt.
 Remember date for the 3rd supervision end of February or beginning of March