Psychology

Over the years, there have been diverse studies carried out on personality disorders. Research is meant to expand the literature base for diagnosis and treatment of various such disorders. Personality disorders refer to the exhibition of behavioral inconsistencies amongst individuals which then alters their personalities. Basically, they are mental illnesses which result to the impairment of ones overall function. In general, personality disorders are accompanied with such similar symptoms like antisocial, narcissistic and histrionic personalities. However, the many kinds of personality disorders possess some unique symptoms. This paper will focus on borderline personality disorder. In addition the discussions will provide an analysis of two treatment theories with reference to a given case study. Research has shifted to treatment methods for personality disorders and this study will put into practice both cognitive therapy and dialectical behavior therapy.

As Gunderson and Links (2008) indicate, diagnosis procedures for borderline personality disorders have gradually developed from one criterion to another. One main characteristic of patients with this disorder is the history of unbalanced interpersonal relationships. They are obsessively trying to see the world as black and white and as a result they destabilize when there are any gray areas. This disorder is considered as an extensive pattern of impulsive and unstable behavior. Normally it affects individuals from early adulthood.  Adolf Stern coined the term borderline in reference to such patients bordering between psychotic and neurotic tendencies.

Borderline personality disorder is highly dominant in females and can be diagnosed from adolescence. However at this age it may prove to be difficult diagnosing such symptoms like impulsiveness, mood inconsistencies and other behaviors as borderline symptoms. It is when these symptoms occur past early adulthood that the possibility of a borderline diagnosis can be examined. DSM- IV has stipulated various symptoms which are mandatory for the positive diagnosis of borderline personality disorder. Dobbert explores such symptoms to include an individuals frenzied efforts to avoid abandonment, either real or imagined. They also have distorted images of themselves. Impulsive behavior is commonplace especially when it concerns such scenarios like sex, substance abuse and binge eating. Such individuals also exhibit suicidal tendencies and extreme cases of depression. Symptoms are quite expansive with others being, paranoia, intense anger and disturbing feelings of emptiness.

There are no identifiable causation factors for borderline personality disorder. However, there has been research suggesting neurological and biological factors to be highly responsible for its occurrence. Most patients experiencing this disorder share a history of abusive and neglectful childhoods often resulting to trauma. From such developmental inadequacies, individuals experience feelings of ineptitude and self hatred. It is from then that borderline has been perceived to emerge (Grohol, 2007).

Treatment for borderline personality disorder involves psychiatric therapy. Most patients seek help from therapists as a way of creating more interpersonal relationships. Effective treatment is challenging due to this factor. Such patients may end up intensifying their disorder when they do not get empathy from their therapists. Cognitive therapy and dialectical behavior therapy have been used to treat borderline personality disorder. They both make use of different perspectives but dialectical behavior therapy has been known to be effective in treating patients with suicidal tendencies. There are no medical treatments for the disorder but drugs are useful in suppressing some of the symptoms in order to ease discomfort.

Karen indeed does suffer from borderline personality disorder. Her behaviors are in tandem with the symptoms described in DSM- IV. A look at Karens past showcases evidence of trauma and childhood suffering in the hands of her family. Having been sexually abused by both her brother and father at such an early age and also physically abused by both of her parents Karen has been subjected to feelings of emptiness. More so, this same abuse continued when she got married to George. Karen has had an immense fear of abandonment which often prompts her to become suicidal. According to the American Psychiatric Association (1994), such individuals may result to cutting following feelings of abandonment. Karen also experiences intense feelings of emptiness and despair. The fact that she has been in so many sexual relationships indicate a frantic effort to eliminate her feelings of emptiness. In essence, she believes that having such intense relationships will prevent abandonment. When faced with the prospects of abandonment, Karen becomes very angry like she did when Gary left her. It is at this time that she started cutting. Constant periods of depression are also characteristic of Karen who rarely feels loved. She also became obsessive of her roommate because she feared Cecily would also abandon her.

Cognitive therapy is one form of treatment for borderline personality disorder. This therapy focuses on the cognition dysfunctions which contribute to the development of various individual responses (Livesley, 2001, p. 377). At its core is the concept of schemas are said to regulate the occurrence of thoughts, images and free associations. These schemas can be present at particular times and absent at others which explains the change of moods by patients with personality disorders. In addition, they can also be triggered by certain things or environmental cues. These schemas are what aid individuals in interpreting and understanding themselves. However, when there are dysfunctional schemas individuals are unable to do this and become vulnerable to personality disorders. Cognitive therapy aims at limiting such harmful schemas in order to alter the patients perceptions of themselves.

Beck et al, (2004) presents a cognitive treatment approach with emphasizes on the role early schemas have played in the development of psychological dysfunctions exhibited by individuals with personality disorders. Cognitive therapy programs are used to determine how individuals process information and the responses which follow. Ones innate tendencies are assumed to have been constructed at childhood and various belief systems are developed. For borderline personality disorders these belief systems have been reinforced for a long period of time. Dependent and paranoid assumptions are often the target of cognitive therapy. Therapists aim at correcting these processing dysfunctions with intense and lengthy periods of therapy.

Cognitive techniques used during therapy include the unraveling of underlying schemas. Patients are guided on how to best understand themselves. Clarifying the different schemas allows patients to gain more control and lessen their confusion. In order to accomplish this patients are encouraged to keep records of their thoughts, feelings and reactions which the therapist uses to show them how their various behaviors come about. Also traumatizing childhood experiences are reinterpreted during therapy. It is possible that as adults, individuals are better placed to understand and create perceptions of incidences which they may have misinterpreted as children. Through careful discussions patients can explore why they have felt abandoned and understand that it was not due to their deficiencies. Arntz and Weertman (1999) applaud the use of specific restrictive techniques as successful treatment for borderline personality disorder. This technique rebuilding of a patients childhood experiences especially those which were of sexual and physical abusive natures. Initially patients are expected to imagine such past scenes as they did as children. Then they imagine it with an adults perspective and at the end they imagine intervening in those experiences and helping the child. Thereon, the child is able to get help from the adult patient.

Jennings (2008) illustrates the efficacy of cognitive therapy by studying the influence of patients attitudes on the outcomes of treatment. The study was carried out among twenty eight patients who had completed cognitive therapy sessions for a year. Findings from this study indicated that effectiveness of cognitive therapy treatment improved when patients perceived treatment as an expectation of getting better. This insinuates that therapists under a cognitive therapy setting should aim at creating positive environments which imply a consequence of improvement.
Cognitive therapy has been known to be effective but is also laden by some limitations. For its effectiveness this form of therapy requires highly motivated patients and consistency in therapy. However, research has shown that majority of borderline disorder patients end up terminating therapy sessions before they are well. Also their impulsive nature may inhibit therapy regiments when patients fail to attend treatment sessions constantly. Another limitation involves the fact that it is difficult to translate various research perspectives into clinical treatment practices. Despite this, Turner (2001) displays studies where cognitive therapy has worked and attributes this to long durations of therapy. It is evident that success of this therapy is determined by many variables.

Unlike cognitive therapy, dialectical behavior therapy incorporates environmental elements as causation factors of borderline personality disorder. Apart from the biological disorder which emanates from brain defects environmental disorders are seen as those experience which have attributed to an individuals emotional instability. As a result, individuals have emotional difficulties which emanate from both the vulnerabilities and lack of ample emotional regulatory skills. The assumption that the regulation system is disordered lessens the influence of various problematic behaviors on borderline personality disorder. This model of therapy uses these assumptions to create treatment strategies aimed at altering the emotional regulation systems capabilities.

Linehan (1997) explains that dialectical behavioral therapy focuses on patient change. Successful treatment will aim at enhancing their capabilities for behavior and individual regulation. Motivational enhancements are also encouraged through the reinforcement of good behaviors and the non reinforcement of emotions or beliefs which may inhibit treatment. In essence, this therapy devotes itself to developing some specific skills. An individual is taught how to elevate their interpersonal effectiveness when dealing with problematic situations. This will lead to the decline of environmental factors which often trigger bad emotions and behaviors. Other skills reflected in Linehan (2003) are aimed at helping individuals tolerate distressing situations until solutions are forthcoming. Mindful practice also contributes in allowing the patient to experience emotions healthily as opposed to being inhibitive.

Dialectical behavior therapy has been used especially in reducing self harm incidences in borderline personality disordered individuals. Together with skills training and functional analysis this therapy has shown tremendous effectiveness in various studies. Bateman and Fonagy (2004) refer to such one successful research study. Patients with borderline personal disorder were exposed to dialectical behavior therapy while other women were assigned as a control group. Those in the control group were seen to be more prone to suicide attempts, spend longer durations as in patient treatments and terminate their therapy assignments. After six months the patients showed less display of suicidal behaviors.

Linehan et al (1991) evaluated the effectiveness of dialectical behavior therapy in a group of borderline personality disorder patients. In this specific study, the patients were engaged in chronic parasuicidal behaviors. After one year of treatment patients with this disorder were related to patients receiving treatment as usual. Those in the dialectical behavioral therapy recorded significant changes in reference to their suicide tendencies. These incidences had declined in both time and nature of occurrence.

Verheul et al (2003), also shows evidence of the effectiveness of dialectical behavior therapy in a Dutch research study. Results of the study indicated better levels of retention in the use of this therapy. Self harmful behaviors also reduced greatly amongst the borderline disorder patients. One common characteristic shared by both cognitive therapy and dialectical behavior therapy is that they all emphasize the role played by treatment durations in predicting effectiveness. In all research studies positive results were experienced in instances when treatment took place for a long time. Clarkin et al (2007) establishes that in comparison to other forms of therapy, dialectical behavior therapy does have its own unique strengths as do the others. This claim can be ascertained in Paris (2005) where three studies on the impact of dialectical behavioral therapy treatment on borderline personality disorder were all observed to be highly effective. In a study involving veteran women over 90 of the patients stayed in therapy for at least one year and the results indicated reduced self harm behavior. A replication of this study in a clinical inpatient set up also recorded similar results of high efficacy.

Dialectical behavior therapy will be effective for treating Karen. Treatment will involve helping Karen develop skills to regulate her emotions which will result to a reduction of the symptoms she is currently experiencing. Individual therapy will be vital in enhancing Karens motivation for therapy. With a lengthy initial interaction the first session will allow Karen to relate her problems which will be helpful in developing treatment strategies. A strong alliance builds a strong foundation for the treatment and prevents future problems. Karen has been having suicidal and self damaging experiences which are prompted by her feelings of abandonment. The initial stage of treatment will emphasize on the decline of these behaviors. Other areas of concern include those behaviors which interfere with therapy or Karens quality of life.   It will be crucial to help her in formulating skills for suppressing negative responses when she is faced with conflicting episodes. The elimination of these negative behaviors will also be dependent on the increment of behavioral skills.

Therapy will also involve trying to heighten Karens ability to cope with post traumatic disorder indicators. Having faced childhood physical and sexual abuse, it will take Karen relating her past experiences for her to establish a healthy mechanism for dealing and resolving traumatizing emotions effectively. After the initial stage therapy will then focus on achieving normalcy in both happiness and sadness in Karens life. Karen will adapt skills of establishing when she is meant to be happy and when sadness is warranted. Therapy sessions will involve engaging her on the problems she has been experiencing on her day to day life experiences. It will be crucial to ensure that Karen recognizes the various roles she has played in contributing to her disorder. Instilling a sense of importance will help Karen in dealing with her past experiences of abuse from her family and friends. Eventually when Karen has gained complete joy and acceptance she will be able to resolve her emotional issues realistically. Meditation during therapy will be used in developing Karens mindfulness skills. This will in turn allow her to balance her emotions, thoughts and applying reason when dealing with all kinds of environments. A reasonable mind makes for rational thinking and responses.

Similar to the research studies mentioned in the previous discussion, Karens suicidal attempts and her cutting behavior will decrease gradually especially in the one year of treatment. Karen will have gained the ability to detach her negative childhood experiences from her personal image and sense of completeness. Harnessing her feelings of self worth will ensure that she does not continue to engage in harmful relationships with others. This treatment is expected to be highly effective in reducing Karens suicidal and self harm tendencies. Verheul et al (2003) supports this claim in a research study where after being subjected to dialectical behavior treatment after one year, patients self-mutilating behaviors diminished gradually.

In the treatment of Karens personality disorder, it will be crucial to establish a trusting relationship. However, it will need to be carefully monitored in order to prevent Karens overreliance on the therapist. As a therapist, perceiving Karen positively and accepting her behaviors while still trying to assist her will be very important in the treatment process. Paris, further asserts that in research studies conducted patients recorded reduced suicidal behavior when therapists perceived them more positively.

It will be vital after the individual therapy to subject Karen to group therapy with other patients experiencing the same disorder. As Dulit et al (2007) asserts group therapy creates a support system for the patients. Thus Karen can have peers to grow and nurture particular skills together and with such a supportive environment the shame she experiences in respect to her behavior will be eliminated. Other than these group sessions, the use of phone conversations will be used in monitoring Karens response to various emotions. This distance from the therapy setting will prompt Karen to put to use skills learned during therapy in the coping of various emotionally disturbing situation. The therapy sessions will continue for one year with the integration of both individual and group therapy sessions. Evaluation of Karens skills and effectiveness of treatment will be carried out after every three months. This will indicate areas which need improvement and where progress has been achieved.

Cognitive therapy may have proved to be ineffective due to its lack of integrating behavioral concepts during treatment. While Karen may engage in restructuring her past thinking processes she will not have developed solid skills and capabilities to maintain her new status. The restrictive technique could have been used to help Karen reinterpret those instances when she was sexually and physically abused. However, due to the many occurrences of such incidences it might lead to further deterioration of her condition. Actually, the skills developed during dialectical behavior therapy are ample to ensure positive change in how Karen creates and develops her schemas. Skills provide a far more permanent solution of developing beneficial belief systems.

Borderline personality disorder affects an individuals quality of life dismally and treatment must be instigated during the early identifiable stages. Both cognitive and dialectical behavior therapies possess their own treatment strengths and can be applied under distinct circumstances. Cognitive therapy is instrumental in correcting cognitive dysfunctions which have contributed to how borderline personality disorder patients think of themselves. In order to achieve this it is vital to engage in long term therapy as the treatment process is long. This counteractively provides a challenge for the cognitive theory. Also, permanence of learned belief systems is often exposed to many uncontrollable factors which impede the treatment process.

On the other hand, dialectical behavior therapy offers a better treatment option especially for borderline personality disorder. The strengths of this therapy are mainly entailed in the core elements of skills development. When patients are driven to develop new ways of thinking and regulating their emotional behaviors it becomes easier to handle future problems. Eventually, the learned skills become permanent habits often resulting to healing. Karen was abused at a very early age and there was no room in her life to develop vital skills necessary for emotional stability. In addition to reconciling her with the past, this therapy will also equip her with the instruments needed to turn a new leaf. Verheul et al (2003) asserts the effectiveness of dialectical behavior therapy in a study done on women in The Netherlands. The women receiving this therapy had a higher retention rate for therapy in comparison with the control group. This was attributed to the skills learned and the objective relationship developed between patients and the therapist.

The above case study analysis has captured a comparison of two treatment therapies for borderline perspective disorder. Comparison has been done through the display of distinctive elements of cognitive therapy and dialectical behavior therapy. Drawing from past research, it has been established that both treatment therapies hold certain levels of authenticity in practice. Dialectical behavior therapy studies have reflected effectiveness in borderline personality disorder treatment especially in the reduction of suicidal and other self damage behaviors. It has also become evident that effectiveness of both therapies is dependent on many factors. For one, a patients motivational levels will depict how well they can handle treatment and their involvement levels. Other factors are external influences from the surrounding community and the therapists treatment approaches and methods.

Effectiveness of both therapies relies on the balance between both cognitive and behavioral changes. As such, cognitive therapy fails in respect to engaging behavior change in its approach. Cognitive behavior therapy has been built on cognitive therapy and provides better treatment prospects. Continued research is being done in the field of psychotherapy in such of better and more effective treatment therapies. In recent and previous research, dialectical behavior therapy has been established as a superior and highly effective psychotherapy treatment. Beck et al indicate that most studies have shown that patients receiving dialectical behavioral therapy were seen to have not existing self harm behaviors. However the challenge of transferring field studies to clinical practice has not yet been addressed. Clinical practice holds the ideal basis for evaluating the efficiency of various treatment therapies. It is therefore crucial to close this existing gap. A more directed and collective approach to research which involves clinical interactions with patients is best suited to achieve this.