Group Dialectic Behavioral Therapy for Borderline Personality Disorder in Early Adulthood
We are proposing a group designed to work with teens with a history of sexual abuse and whom have been diagnosed with borderline personality disorder (BPD). The teen years are important development stages for individuals, where they develop separation, identity, cognitive/emotive regulation, and self-image (Aronson & Kahn, 2004). This makes it a particularly important stage for the development of a healthy mentality. The effects of childhood trauma such as, sexual abuse, can have long lasting effects on the psyche which can interfere with this healthy mentality development (Rosenstein, Ellison, Walsh, Chelminski, Dalrymple, & Zimmerman, 2018). BPD is one of the most common conditions to encounter in a clinical setting and is prevalent in all cultures (Rosenstein et al, 2018). Borderline personality disorder is a condition characterized by unstable relationships, impulsive behavior, and fractious self-image (APA, 2014). This can result in a severe detriment to the lifestyle of the individuals and can lead to self-harming behavior up to and including suicide.
Borderline Personality Disorder and Sexual Abuse
Trauma during formative years can produce dramatic effects. Trauma can interfere in the identity separation producing separation anxiety, impeding the development of psychological identity, interfering with the generation of healthy self-image, and cognitive dysregulation. The similarity of these symptoms to those seen in BPD should make it no surprise that youthful sexual abuse is a common history for those with BPD. Borderline personality disorder can also be comorbid with other conditions such as PTSD, depressive or bipolar disorders, bulimia nervosa, substance abuse, adhd, and various personality disorders (APA, 2014). Helping those who have been the subject of sexual abuse and have developed borderline personality disorder early can be critical to improving the chances of a healthy development cognitively during these formative years.
There are several risk factors involved when working with teens and also working with those diagnosed with borderline personality disorder. First, there is a risk of attachment counter-transference for the counselor (Kress & Payola, 2018, p. 275). This can result due to the high levels of emotional content that can be shared during the sessions and the increased vulnerability of the clients. This can be particularly complicated when one considers the increased concerns of unstable attachment associated with borderline personality disorder. This can result in a counselor over identifying with a client, causing desires to protect the client by not forcing disclosure.
Secondly, the teenage years, and even the early adult years, are a time of developing emotional regulation, something which can be interfered with or delayed by trauma (Broderick and Blewitt, 2015). This emotional dysregulation is a common criteria of borderline personality disorder. This can cause of risk of acting out by members of the group in response to trauma. A negative response to this by a counselor can generate group hostility which can undermine the efficacy of the session.
Third, the subject population is selected for this group due to a history of sexual abuse. Depending on the developmental stage of the subject this can impair the understanding of sexual acting out (Broderick & Blewitt, 2015). Individuals in the group session can develop inappropriate sexual attentions and intentions. Counselors must be prepared to validate the sexual feelings of individuals in the session while providing education on proper sexual activity but also putting limits on the acting out during the sessions.
Fourth, those who have been the subject of sexual victimization can develop jointly a perspective of themselves as a victim and others as victimizers (Sue & Sue, 2016). This requires that the clients are introduced to the environment as being safe for them and the therapist as both professional and supportive to combat this perception.
Group therapy is cost effective and a preferred method for working with teenagers and young adults. Teens often develop strong social bonds and spend considerable time in social groups. This socialization can be interfered with by trauma and by borderline personality disorder. Group therapy is thus more consistent with the regular development of individuals in this stage and can help fulfill this social group dynamic and teach healthy socialization. Such groups can help reframe the events for the teen.
Group theory is intended as dialectical behavior therapy (DBT). DBT is in the cognitive behavioral school of thought and mainly works on the idea of identifying thought patterns which are demonstrated as being unhealthy for the client (Biskin, 2013). The facilitator then works at helping the client to develop new thought patterns through changing the behaviors associated with those thoughts, which will then help the client to operate in a healthier fashion. Skills development sessions would be part of the group and can include not just the client but, their immediate family and support group. Aspects of mentalization are also included in the session plans as research has demonstrated notable improvements in decreasing self harm behavior and improved
Borderline personality disorder, characterized by instability across relationships, identity, and emotional affect, is estimated to be in up to 2.7% of the general population according to Trull, Jahng, Tomko, Wood, & Sher (2010). Studies have found that BPD was significantly related to childhood abuse, be it physical, emotional, and/or sexual (Johnson, Cohen, Brown, Smailes, and Bernstein in Rosenstein et al, 2018) with up to 75% of a sample of women diagnosed with BPD reporting childhood sexual abuse (McFetridge, Milner, Gavin, and Levita, 2015). Trauma such as this can cause significant impact on development of a healthy mentality by impairing separation, identity generation, intimacy, self-image, and the formation of mature cognitive abilities per Aronson & Kahn (2004).
Dialectical behavioral therapy (DBT) is a very common therapy type utilized with teens/young adults diagnosed with BPD and focuses on a series of behavioral based interventions meant to train more positive habits. Studies have demonstrated that these behavioral skills practices prove effective in reducing self-harm, suicidality, and hospitalization (Biskin, 2013). BPD includes a decrease in the ability to mentalize or interpret the mental state of others, leading to relationship instability across numerous studies (Brune, Walden, Edel, & Dimaggio, 2016). Mentalization has been found to produce positive improvements in the symptom of BPD including decreasing the instance of self harm (Bo, Sharp, Beck, Pederson, Gondan, and Simonson, 2017). Combining mentalization practices with DBT has been demonstrated to decrease the tendency towards self harm habits over DBT alone in studies by Edel, Raaff, Dimaggio, Buckheim, & Brune (2017).
This group will be designed to reduce negative symptomatology of borderline personality disorder in clients. This will be gauged by improvements in self-awareness, stability to relationship factors, increases in empathy, and decreases in self-harming behavior. Much of this will be through testing measures such as the Diagnostic Interview for Borderlines-Revised to be used as a pre/post test measurement (Zanarini, Gunderson, Frankenburg, Chauncey, Ruocco, Laporte, Russell, Guttman, and Paris, 2012). Due to the length of this assessment a special session may be required for both pre and post testing. A briefer test such as the Mood Disorder Questionnaire may be applied at intervals during the group. This would provide a quick check in, though it’s reliance would be less than the full test. Success will be gauged by improved scores across these diagnostic tools after the group sessions have completed.
Subjective measures will also be included in the objective goals. This will be by self report diaries for each client. The clients will at different points during the group be requested to details their views and feelings of several factors in a journalistic style. These will be collected for each client and stored for use both as an evaluation medium for the counselor, but also as a gauge that the client will be able to observe towards the end of the group sessions to evaluate their own progress.
During the practical consideration of this group proposal, we will discuss some of the basic information of how the group will flow. This section will cover the screening procedures of how we will select our client, go over the informed consent, and cancellation policies. We will also discuss the group rules that will be established and the time, location, and frequency of the group meetings. Then following up with the discuss of any necessary community resources we may need in order to continue this group.
Screening is crucial for creating a well-organized group experience (Corey, Corey, & Corey, 2018). It is also very important for those that have been sexually abused and if the group member is ready to partake in group therapy. For this group, the members need to have been diagnosed with Borderline Personality disorder. Once we have individuals show interest in joining the group, they would need to administer a screening assessment in order to see where they are. The McLean screening instrument for borderline personality disorder is very useful in screening for BPD and even more so in younger ages (Zanarini, Vujanovic, Parachini, Boulanger, Frankenburg, & Hennen, 2003). Once the members have taken the assessment and it has been looked over, each individual would need to see if they would be a good fit for the group.
Having a private session between the potential member and leaders will allow the leaders to know if this individual will be a good fit (Corey, Corey, & Corey, 2018). The potential member will also be encouraged to ask or interview the leaders to make sure they are comfortable themselves with those leading the group (Corey, Corey, & Corey, 2018). The individual needs to have a one on one therapy with a counselor already established in order to be a part of the group. The group would need to be a diverse group in order to help dispel stereotypes and any misconception about each other (Corey, Corey, & Corey, 2018).
Once everyone has taken the assessment and has been interviewed, the group leaders would then see who a best fit. The member would also need feel comfortable in partaking in the group. They need to be ready to share and to face some very deep emotions. The final group will be made up of ages ranging from 18-27 years old with 10-12 members.
Informed consent will be discussed with each group member individually prior to the first meeting, but it will also be briefly mentioned at the beginning of each session as well. It is important that members are aware that informed consent is ongoing throughout the entire process (Corey, Corey, & Corey, 2018). It is important that the group members know what their rights to confidentiality and to know what the limits to confidentiality are.
It is important that the group member attends all of the scheduled group meetings. However, there may come a point when the group member cannot attend a meeting due to an illness or other emergency. With that said, the member will need to provide a 24-hour notice that they will not be attending the group meeting, if it is for an illness, they will need to provide a doctor’s note. If the group member fails to notify the group leaders, they will be given a warning. If the client has another no-show, no-call the therapeutic relationship will be terminated. Overall each member can have two absences if they provided a 24-hour notice and the correct documentation. It is important that the group member is present during this time not only for the group, but for themselves. Consistency is key in reaching their goals.
During the group therapy session there will be a few group rules that will need to be respected by not only the clients, but also by the group leaders. Here is the list of rules that will be established prior:
- Please be on time and you must stay for the entire session
- Everyone gets a turn if they are wanting to speak
- There will be no laughing at or making fun of other group members
- Confidentiality is respected
- Have respect for all group members
- Be present in listening to the group member that is speaking
- No cell phones during the group session
After these rules have been established in the first group session, the group leaders will ask the members if there should be any other additional rules they would like to have incorporated.
Time, Location, and Frequency of Meetings
With this group being focused more on the ages from 18-27, this meeting would be held at a local campus in town. We would use a classroom that is not being used or another area within in the college campus. The group sessions would be held on Saturday from 2:00pm-3:30pm for a 90-minute session. The group would meet for 12 weeks once a week. This would be a closed group and if a group member does not complete the group time there will be no new members until after the original group has finish their 12 weeks.
This group will be held in a college setting so it is important that we are also area of any resources that the college may offer. Since we would need an area for our group meetings this would be a resource that is needed. Another resource that would be beneficial would to get a list of any other support groups or activities, that is held either at the college campus or within the community for the members and provide it to them.
What Is To Be Addressed At Each Session
During this beginning stage of the group it is very important that the group members are aware of the group policies and procedures. This is the time with each individual will begin to introduce themselves and decide if they will begin to trust the other group members or not. This is a period that the members are exploring the limits of the group, what the expectations are, wondering if they will be accepted by others or not, and anxiety surrounding the new experience (Corey, Corey, & Corey, 2018). The outline for what would be discussed for the sessions from 1-4 would consist of :
- Introduction of each individual
- Establish any other additional rules
- Allow members to openly express any concerns they may have surrounding the group
- Begin encouraging individual to share their stories
During the middle phase the members will begin to either establish more trust with each other or still possibly sit back and listen. This will begin the time that we will dig deeper into some of the sexual abuse of those that are willing to share. Allow them to role play and to focus on the here and now. Begin working through some of those concerns or challenges that each member may be having. The outline for what would be discussed for the sessions from 4-9 would consist of :
- Have check-in at the beginning of each session
- Allow members to role play
- Encourage the need to dig deeper
- Focus on Here and Now areas
- Deepen trust and relationship with members and group leaders
- Discuss coping skills that will help each group member
- Teach relaxation techniques
- Put those new coping skills into practice
- Allowing time at the end of each session to discuss what the members took away from group that day.
When starting to enter the termination phase of the group, group leaders will start to make members aware of the group coming to an end. During this time, we would want to encourage members to start looking at contracts they would like to make for themselves and discuss any concerns they have leaving the group. This is a time we will look back and see what all we have learned from the group and decide how that can become a part of their new daily routines (Corey, Corey, & Corey, 2018).
The outline for what would be discussed for the sessions from 10-12 would consist of:
- Discuss what we have learn from this group
- What can they take away and apply to their life.
- Make contracts with themselves
- Take the final exit assessment during the 10th session and review it at the 11th.
- Discuss any concerns the members may have about the group ending
- Discuss any issues with the other group members or group leaders that was not resolved prior.
- Provide members with information for support groups, activities, and other beneficial resources
Planned Strategies and Interventions
There are a number of techniques that shall be used throughout the group session. First, relaxation exercises will be taught early on beginning with the first sessions. This will also be encouraged as homework between sessions to assist with any anxiety issues. Group sessions will begin with a check-in period. This will allow for the facilitators to evaluate the state of all the participants and allow those participants to inform on the status of any homework they were assigned during the previous session.
After this check in period will be a short reflection period when examination of issues related to the abuse and BPD will be discussed to enhance understanding and to act as a framework for the behavioral skills. Following this reflection period will be skills development, practicing new coping strategies and methods which are designed to leach a healthier mindset and habits while replacing those which cause the clients’ distress. Finally the sessions will conclude with a wrap up period. This section will allow the group members to discuss and absorb what they have learned during the session and express plans for the following week until the next session.
Diversity and the Group Setting
Diversity is considered differences in race, gender, culture, religion, sexual orientation as well as other identifying differences. It is recognized as important and necessary for group counseling. Multicultural diversity can give the group members different perspectives as a group and individually.. Race, ethnicity and culture must be considered when forming a group and the counselor must have proper training in multiculturalism and diversity. If these considerations are not taken, there can be problems within the groups dynamic. A working balance needs to be found between the differences and commonalities of a group in order to work together in a harmonious and civil manner.
Ending a group is a process that needs attention from the very beginning of the group. There are three things that will need early acknowledgment. The group members are looking back, looking forward, and saying goodbye.
Looking back is that, looking back over sessions to the group. Asking the question as to did the group meet their goals. Looking forward is to make a plan, gather the information and understand what the group was able to retain. Next, saying goodbye, is the termination can be predetermined or decided later as progression happens. As they progress they can look at prospective termination dates. Termination of a group can be a difficult time for members as they can experience separation anxiety and this can impede on their progress.
The members may experience stages of denial: They may forget about the group ending, or look towards reunions. Next stage is regression, which is going back to previous behaviors or to previous sessions where relationships were strained or dependant. The next stage is flight, it is when members can develop aggressive behaviours at each other, or any part of the therapeutic environment. Members have been known to leave in this stage. The final stage is reviewing, it is going over the experiences, what they have learned, what they are taking from the information gained within the group (Corey, Corey, & Corey, 2018).
Evaluation of the group experience (subjective)
An evaluation is necessary to understand the group experience as a whole. As with any situation, not every member of the group will have the same experiences. In order to comprehend what each group member gained from the group experience, an evaluation is a necessary tool upon completion or nearing completion of the group.
The results are important in order to see what is next for the client or what changes need to be make within the group counseling setting. How the group functions is directly related to the members involvement.
Evaluation of Measured Progress Towards Goals
Counselors use techniques to evaluate a group’s progress towards their goals individually and as a whole. In order to do so, they have developed a formal measure and tools that can be used. Understanding the effectivity of the group helps determine where changes or adjustments to the groups. If it’s not effective, then it would be a waste of time for the members. Through these measurements of progress, it is found that group counseling and individual therapy are effectively comparable in a variety of presenting issues (McRoberts, Burlingame, & Hoag, 1998).
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