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Principles of Psychotherapy
Tracey Rogers
December 5, 2014
Psychotherapy Design
Karen, a 36-year old single Caucasian woman, has a history of childhood physical and
sexual abuse, along with self-harming behavior in adulthood. Her constant fear of abandonment,
history of unstable interpersonal relationships, frequent self-harming behavior, emotional
instability and lack of a stable self-image indicate that she has borderline personality disorder
(BPD).For our therapy with Karen, one of the approaches I would use is dialectical behavior
therapy (DBT). Another approach I would use is the mentalization-based treatment (MBT).
Study done by Harned et al.(2010) shows that dialectical behavior therapy is effective in
treating the life-threatening conditions of BPD. In this study, after a year of DBT, the BPD
patients’ suicide risk and recent self-injury rates decrease from 96.2% to 29.2%, which shows
that DBT is effective in reducing self-harming behavior. Considering Karen had recently been
hospitalized for two weeks for a suicide attempt, I think that DBT would be effective in her case.
Another study by Carter et al. (2010) shows that after 6 months of DBT compared to therapy as
usual and wait list for DBT, a significant improvement of the quality of life is seen in BPD
patients who received DBT. Due to these results, DBT would also be a helpful approach for
Karen in terms of improving her sense of worth and her interpersonal relationships. I think that
overall, DBT is a suitable approach for Karen’s case as she needs to work on reducing her self-
injurious behavior and improving the quality of her life.

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In DBT, the relationship between the therapist and the client is very important. A
collaboration between the two is crucial to the effectiveness of this approach. While working
with Karen, I will need to be highly engaged during the sessions, as that will be a way to show
her that I am not rejecting her and that her opinions are not dismissed like they have been in her
previous interactions (Bedics et al., 2013). I will also need to approach Karen’s feelings,
thoughts and actions with an open mind and a nonjudgmental attitude. As Karen has a tendency
to engage in self-injurious behavior when she feels that she is being rejected, I will need to
reassure her that I accept her as she is and that I am not judging her for her emotions or actions. I
will also need to balance validation and efforts for change as I interact with her. Considering that
her mother denied Karen’s experiences of molestation when she was younger, as an adult Karen
looks for validation from others when she experiences different situations and expresses
emotions. I think that I will need to reassure her that I believe her experiences and that her
reactions to the situations are normal. In doing so, I will be encouraging her to form a more
positive self-image of herself, which will be learned by modeling. Another factor in the client-
therapist relationship is the feeling of equality between the two, which empowers the patient
(O’Connell &Dowling, 2013). I think that will help Karen because she has mostly been in
significant relationships where she did not have much power or control, as with George, her
parents and the new partners that find her “needy”. Having more say in the therapy while
creating the agenda and setting goals would make her realize the capacity she has for thinking
and making decisions for herself.
Establishing therapy goals will be a collaborative process. However, due to Karen’s
suicidal attempts and self-injurious behavior, I will suggest that first step should be to reduce her
likelihood to harm herself. After the life-threatening behaviors are under control, we will focus

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on our behavior that interfere with the therapy. Karen will probably not be ready to open up
because in the past, she has been dismissed and abused by her mother and her ex-husband for
doing so. I will need to help her identify these moments when she holds back due to her past
experiences and remind her that this is a new experience and that she should not reflect her past
relationship problems onto a new relationship that is forming. I will also have to reassure her that
I will listen to her thoughts and emotions and I will not judge. After we successfully work out the
problems in our therapeutic relationship, we will start discussing what she finds most troubling
in her life. In her case, this might be the instability of her past romantic relationships and her lack
of friends. We will work on her modeling of the nature of our therapeutic relationship outside of
the therapy. We will make it a goal, if agreed, to start establishing healthier interpersonal
relationships and reducing emotional dependency on others. (Bedics et al., 2013)
The therapy will consist of weekly individual therapy and skills group training and phone
consultation in times of crisis as needed. Individual therapy sessions will start out with the
discussion of the diary card. The diary card is a way for the patient rate the level and frequency
of their urges(drug use, self harm, suicide), emotions(pain, sadness, shame, anger, fear),
substance use and positive(coping skills used) and negative actions(self-harm, lying) for the time
between the last therapy session and the current session. This will be a way to start every therapy
session in order to know what state Karen is in and how the therapy is going. It will also be
helpful for setting an agenda for the session and prioritize goals, such as reducing excessive self-
injurious behavior if the ratings are high as the first goal. Also, after every session, Karen will fill
out the same diary card and this way we will know whether the therapy is helpful or not. (Bedics
et al., 2013)

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Throughout therapy, I will be using problem solving and validation strategies, and
balancing the two with dialectics. Through problem solving, I will try to show Karen that her
problematic behavior, such as hurting herself, is an attempted solution to her problems. After
discussing the diary card at the beginning of the session, we will move on to a chain analysis of a
recent specific event, such as a recent suicide attempt. We will talk about events prior to the
incident, how she felt, what she thought and how she acted, as well as her feelings, thoughts and
actions after the suicide attempt. Following the chain analysis of the specific incident, we will
start thinking about the solutions to this event. In case of the attempted suicide, I will reinforce
using the coping skills she is learning in skills group training. I will also suggest that she consults
me over the phone during time of crisis rather than not talking to anyone. I will also encourage
openness to new experiences, reminding her that she is bringing in her feelings and thoughts
from her previous relationships into the current ones and not living the present. After the
solutions are discussed, I will remind her to commit to the solutions that we have agreed on and
to apply them whenever she encounters a problem similar to the one we have discussed. (Bedics
et al., 2013)
Validation will help form the relationship and will make Karen comfortable. I will need
to show her through validation that her emotions and thoughts make sense. My nonjudgmental
approach will give her confidence in her own thoughts and feelings. It will change her negative
self-view of herself due to the abusive relationships that she has been in. While offering
validation is great, I will need to use a dialectical technique that will incorporate change into the
validation. I will need to show her empathy about her experiences, but at the same time
encourage her to interpret incidents differently, making her realize what she is feeling is normal
but questioning her way of expressing her emotions. I may say things like “I understand that you

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felt lonely and you are right, anybody would feel the same way; but…” or “What could you have
done instead to express this emotion?” which would express both acceptance and encouragement
of change. (Bedics at el., 2013)
Karen will also be attending weekly skills group training. This training will have 4
modules: mindfulness, distress tolerance, emotion regulation and interpersonal effectiveness.
Mindfulness will help her focus on the here and now rather than thinking about her past abusive
relationships. Distress tolerance will help her handle difficult times without causing harm to
herself. Emotion regulation will help her identify her emotions and reduce the intensity of them.
Interpersonal effectiveness will increase her self-respect and help her identify abusive
relationships and make the decision of leaving those kinds of relationships.
The study of DBT is mainly done with female BPD patients. In the study done by Harned
et al.(2010), the population is self-injuring or suicidal women with BPD, half of whom also have
PTSD, that are between the ages of 18 and 45. The population of the study done by Carter et
al.(2010) is also women with BPD, who are between the ages of 18 and 65. The research and
application of DBT show that this approach is generally used with women with BPD who are
between 18 and 65. I think that if Karen was an adolescent younger than 18, I would not choose
to use DBT with her. It is not found to be any less effective with older patients, so if Karen was
older, I would still be able to use DBT with her. (O’Connell &Dowling, 2013)
Another approach I would use with Karen is mentalization-based treatment. As defined
by Eizirik and Fonagy(2009), metalization is “the capacity to make sense implicitly and
explicitly of oneself and others in terms of subjective states and mental processes, such as
desires, feelings and beliefs” (p. 2). It is known that childhood trauma can lead to the impairment
of the capacity to mentalize. (Eizirik& Fonagy, 2009, p. 2) The disruption of mentalization can

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then lead to adult psychopathology, such as BPD. (Choi-Kain& Gunderson, 2008, p. 1) A study
done by Banes et al. (2012) shows that patients with severe BPD show more improvements in
symptom distress(quality of life, general symptom distress, depression), social and interpersonal
functioning(interpersonal problems, interpersonal relations, social role functioning), and
personality pathology and functioning(borderline symptoms) after MBT for 18 months in
comparison to treatment as usual. (p.9) Another study, done by Bateman and Fonagy (2008),
shows that after treatment, patients in the MBT group compared to the treatment as usual group
have shown more improvements in the attempts of suicide, as only 23% attempted suicide at
least once compared to 74%. (p.3) Also, only 13% of the MBT group continued meeting the
diagnostic criteria for BPD compared to 87% of the treatment as usual group. (p.5) There were
improvements seen in unstable relationships and efforts to avoid abandonment as well. (p.6) In
this study, what really distinguished MBT from treatment as usual was that the positive effects of
treatment lasted longer and did not diminish over time, which is usually the case after therapy.
(p.6) Due to these improvements in self-injurious behavior, interpersonal relationships and
pathological symptoms, and given Karen’s history of suicide attempts, problematic relationships
and childhood abuse, I think that this would be a good approach for her.
The focus of our mentalization-based treatment will be the therapist-client relationship.
(Jorgensen sen et al., 2013, p. 4) During our sessions, I will be working collaboratively with
Karen to explore my feelings and thoughts as well as hers. (Bateman&Fonagy, 2008, p.2) This
will guide Karen to be more reflective on her own mental states.(Eizirik&Fonagy, 2009, p.3)
However, as BPD patients have a discontinuity of beliefs, feelings and desires, I will need to
keep in mind this while interacting with her. I will need to be accepting of the simultaneous
opposite views she may have within her belief system and work with both perspectives.

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(Bateman&Fonagy, 2004, p. 8) Through this, I will be modeling acceptance and understanding
of feelings and thoughts of oneself and others. Due to her attachment problems and fear of
abandonment, Karen might question my loyalty or get overly attached to me as we will form a
secure relationship. In that case, I will need to address her fear and explore why she thinks I will
stop the therapy or how this makes her feel. As she has been accused of being needy in the past, I
will focus on how that makes her feel and why she thinks her previous partners found her to be
needy.
The initial phase of our therapy will consist of the assessment process. The focus of the
assessment will be in the context of important relationships, as Karen’s mentalization capacity is
most likely impaired in relationships involving attachments. To work on improving
mentalization, I will need to map out Karen’s important interpersonal relationships and how
these relationships are related to the problematic behaviors, such as self-injury and “needy”
behaviors mentioned by previous partners. This assessment process will lead us to our diagnosis,
possible causes of BPD and therapy goals. Throughout therapy, I will take some time at the
beginning of our sessions to give Karen an assessment that will allow her to self-report her levels
of anxiety, social function and depressive symptoms (Jorgensen et al., 2013, p.9), which are
areas of improvement expected with MBT.
Our goal throughout the therapy will be to increase Karen’s capacity to mentalize. This
will mean that she will become more aware of her current mental states and that these states are
the drive behind her actions. She will be able to recognize that others’ behaviors are also driven
by their feelings and thoughts. (Ezirik&Fonagy, 2009, p. 2) The focus on our relationship will
give Karen an example of how to mentalize during interactions with others. Her awareness of her
own mental state and her analysis of my behavior in terms of my feelings and thoughts will help

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her practice her mentalization skills, which will help her become aware of her irrational beliefs
and improve her interpersonal relationships.
We will practice the mentalization process and address Karen’s self-injurious behavior
and her interpersonal problems in three dimensions: modes of functioning, objects and aspects.
The modes of functioning are divided as implicit and explicit. The implicit modes of functioning
are unconscious and automatic whereas the explicit ones are conscious and deliberately
exercised. I will use implicit mentalization by encouraging Karen to consciously focus on her
moment-to-moment feelings and thoughts in our weekly psychotherapy sessions. In order to
accomplish that, I will ask Karen to stop and pause to think about how she is feeling and why she
is feeling that way when she seems to not pay attention to her state of mind. Her homework will
be to continue this exercise outside of therapy when she has the urge to harm herself and when
she feels abandoned in a relationship. For explicit mentalization, she will attend weekly art
therapy and writing therapy. (Bales et al., 2012, p. 4) The second dimension, objects, is divided
as self and other. These two work together; imagining one’s own state of mind in a certain way
determines how one perceives the other’s state of mind and vice versa. In order to consider both
aspects, I will ask Karen to identify her own feelings and then encourage her to identify the
feelings and the thoughts that may be behind the actions of the other person. We will exercise
this in our therapeutic relationship, which then will help Karen carry it onto her interpersonal
relationships outside of therapy. The third dimension, aspects, involved in mentalization is
divided as cognitive and affective. The process of mentalization requires the exploration of both
thoughts and emotions. I will encourage Karen to think about her and others’ actions in terms
thoughts and emotions in order to understand the complex reason behind others’ behavior as well
as her own. (Choi-Kain& Gunderson, 2008, p. 2)

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In terms of diversity of this approach, it seems to me that there are limitations to the
populations that it can be used with. In the study done by Jorgensen et al.(2013), most patients
are women in their twenties and thirties and there is not enough evidence for its effectiveness for
younger or older women or males. (p.11) According to Bales et al.(2012), most studies on MBT
exclude most severe BPD patients with co-morbid substance use disorder, and paranoid or
antisocial personality disorders. (p.11) In their study, the only exclusions are patients with
schizophrenia and intellectual impairment and it is said that those with ASD and PPD seem to
have benefited from this approach just as much as the patients without co-morbid disorders. (p.
11) Due to these findings, if Karen had any co-morbid disorders or intellectual impairments, I
would not find this approach suitable. Although it is said in one study that co-morbid disorders
do not make a difference on the results of MBT for BPD patients, given the other studies that
argued the contrary, I would choose a different approach in case of co-morbidity.
For our therapy with Karen, I will start with DBT due to this approach’s strength of
reducing self-injurious behavior. I think that DBT is more appropriate to start with, as Karen was
hospitalized just 2 weeks ago due to a suicide attempt. Once Karen’s safety is established, I will
then continue with MBT, as it is found to have long-lasting effects. I also think that MBT will be
more effective in teaching Karen cognitive abilities that will be useful in her future interpersonal
relations. DBT seems to fall short on teaching the cognitive processes involved in improving the
quality of life. This can be because it is more focused on the modeling of how a healthy
relationship can be formed, but not teaching how the feelings and thoughts of oneself and others
affect behavior and form a healthy relationship. Although they are fairly similar in some aspects,
there are certain elements in MBT, such as the relationship between the therapist and the client
and the techniques, that I think will be more appropriate for Karen.

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I choose to use DBT as the starting approach in order to reduce Karen’s self-injurious
behavior. As she might not be able to adapt to the cognitive processes of mentalization right
away, I think DBT techniques can be useful in making her aware of the problem and prevent her
from harming herself further. Using the diary card assessment system, we can keep track of how
often she gets the urge to engage in this sort of behavior and help her use positive coping skills
when she notices the urges. Using the problem solving technique from DBT, I will bring to
Karen’s attention that she is looking for solutions to the problems in her life by engaging in the
problematic behavior of harming herself. We will also do a chain-analysis of the incidents of
self-injury by looking at the events that took place prior to the incident and exploring the feelings
and thoughts she had after the incident. After this phase of the therapy helps keep Karen’s self-
injurious behavior under control, we will start the mentalization practices and shift our focus to
her interpersonal relations.
I think that the therapist-client relationship formed in MBT is more useful for Karen than
the one formed in DBT. Both of these approaches promote a nonjudgmental and accepting
attitude. However, in DBT acceptance is used to comfort the patient and relieve her of the fear of
abandonment, whereas in MBT it is used to teach acceptance of oneself and others as a general
concept. In DBT, I would simply reassure Karen that I would not end our therapy and that her
reactions are normal, which would help her with her fears to a certain extent. However, in MBT,
I would explore our relationship by asking her why she has those fears of me abandoning her and
how that makes her feel. This would be more beneficial for her as she can use the same cognitive
processes for her other relationships in the future. It would also give her a higher sense of
control, as she would come to the realization that her fears are irrational by herself rather than me
reassuring her that I would not leave her. As she tends to get overly attached in close

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relationships, addressing this issue would also prevent her from getting more attached to me and
having a greater fear of abandonment.
I think that the techniques used in MBT will be more effective in helping Karen with her
interpersonal relationships. When I compare the problem solving and validation techniques of
DBT and the three dimensions of mentalization in MBT, I find the DBT techniques helpful for
building Karen’s trust and self-image but MBT seems to teach a life-long cognitive skill that can
be used to maintain this sense of trust and positive self-image in the long-run. Using implicit
mentalization techniques, Karen will learn to stop and pause to think about how she is feeling
and and why. She will also identify feelings and thoughts that may be behind the actions of
others. This will help her interpret her and others actions in terms of thoughts and feelings.
Practicing this in therapy and outside the therapy will help her internalize this process of pausing
considering what lies behind the actions will help her improve her interpersonal relationships.
While DBT is good for the first phase of the therapy, which is mainly ensuring Karen’s
safety and stabilizing her emotions, MBT will further this by changing her cognitive process and
her interactions with others.
Overall, I would like to use DBT as my first approach while building the relaionship with
Karen and addressing her self-injurious behavior. However, to move further in our therapy and to
make changes in Karen’s life in terms of how she sees herself and her interpersonal relations, I
will utilize the therapist-client relationship format and mentalization techniques in MBT, as I
find these to be more beneficial for Karen.

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References
Bales, D., van Beek, N., Smits, M., Willemsen, S., Busschbach, J. V., Verheul, R., & Andrea, H.
(2012). Treatment outcome of 18-month, day hospital mentalization-based treatment
(MBT) in patients with severe borderline personality disorder in the Netherlands. Journal
Of Personality Disorders, 26(4), 568-582. doi:10.1521/pedi.2012.26.4.568
Bateman, A. W., & Fonagy, P. (2004). Mentalization-Based Treatment of BPD. Journal Of
Personality Disorders,18(1), 36-51. doi:10.1521/pedi.18.1.36.32772
Bateman, A., & Fonagy, P. (2008). 8-year follow-up of patients treated for borderline personality
disorder: Mentalization-based treatment versus treatment as usual. The American Journal
Of Psychiatry, 165(5), 631-638. doi:10.1176/appi.ajp.2007.07040636
Bedics, J. D., Korslund, K. E., Sayrs, J. R., & McFarr, L. M. (2013). The observation of essential
clinical strategies during an individual session of dialectical behavior therapy.
Psychotherapy, 50(3), 454-457. doi:10.1037/a0032418
Carter, G. L., Willcox, C. H., Lewin, T. J., Conrad, A. M., & Bendit, N. (2010). Hunter DBT
project: Randomized controlled trial of dialectical behaviour therapy in women with
borderline personality disorder. Australian And New Zealand Journal Of
Psychiatry,44(2), 162-173. doi:10.3109/00048670903393621
Choi-Kain, L. W., & Gunderson, J. G. (2008). Mentalization: Ontogeny, assessment, and
application in the treatment of borderline personality disorder. The American Journal Of
Psychiatry, 165(9), 1127-1135. doi:10.1176/appi.ajp.2008.07081360
Eizirik, M., & Fonagy, P. (2009). Mentalization-based treatment for patients with borderline
personality disorder: An overview. Revista Brasileira De Psiquiatria, 31(1), 72-75.
doi:10.1590/S1516-44462009000100016

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Harned, M. S., Jackson, S. C., Comtois, K. A., & Linehan, M. M. (2010). Dialectical behavior
therapy as a precursor to PTSD treatment for suicidal and/or self-injuring women with
borderline personality disorder. Journal Of Traumatic Stress, 23(4), 421-429.
doi:10.1002/jts.20553
Jørgensen, C. R., Freund, C., Bøye, R., Jordet, H., Andersen, D., & Kjølbye, M. (2013).
Outcome of mentalization-based and supportive psychotherapy in patients with
borderline personality disorder: A randomized trial. Acta Psychiatrica Scandinavica,
127(4), 305-317. doi:10.1111/j.1600-0447.2012.01923.x
O'Connell, B. B., & Dowling, M. M. (2013). Dialectical behaviour therapy (dbt) in the treatment
of borderline personality disorder. Journal Of Psychiatric And Mental Health Nursing,
doi:10.1111/jpm.12116