Clinical experience

Question 1

Summarize clinical experience

Answer 1

-EBTs, differential dx, assessment across a variety of settings.
+CBT, Cog/Pers assessment at UCC
+PTSD assessments, some PE at VA
+DBT, CBT, ACT in outpatient clinic
+Assessment and behavioral intervention for sleep disorders at medical clinic
+Currently: USH inpatient providing ACT for psychosis

Question 2

Case that went well and how I knew

Answer 2

-SCHSAM
\+Summarize the case: BPD, MDD, cutting,
\+How it went well: 
--->Stayed alive
--->Client/provider relationship sound 
--->Committd to tx/willingness
--->Symptom reduction (outcome measures)
--->Target behaviors to increase/decrease
--->Values-consistent behavior

Question 3

Theoretical orientation: Case formulation

Answer 3

• Client’s idea of life worth living
• Biosocial processes over time that led to client’ss current presentation
• Barriers to client’s life worth living
• Consideration of culture/diversity

Question 4

Theoretical orientation: Barriers to client’s life worth living

Answer 4

• Skills deficits
• Maladaptive cognitions
• Problematic contingencies
• Problematic emotional avoidance strategies
• Motivation/committment
• Non-acceptance/self-invalidation
• Lack of clarity of values
• Environmental issues

Question 5

Theoretical orientation: Therapeutic approach

Answer 5

• Cognitive-behavioral
• Mindfulness-based
• Acceptance-based approaches
• TIBs

-What is the client’s idea of a life worth living, and using the abovementioned approaches to remove barriers

Question 6

Therapeutic style

Answer 6

• Collaborative, “we are in it together”
• Meet client where they are at and adapt accordingly
• Adherent to EBT w/ flexibility
• I am MYSELF (within the range of what works for client)
• –>Quirky, vulnerable, self-disclose (when clinically indicated and within ethical bounds)
• I like to use the room
• Offbeat, quirky style balanced with validation
• Relationship is KEY and use to help client

Question 7

Clinical strengths

Answer 7

• Attentive to interpersonal process
• Attentive to client non-verbal cues
• Confident in ability to engage with just about any presentation
• Very good with irreverence, off-beat style to keep the flow of therapy going
• Radically genuine
• Willing to stretch limits when clinically indicated

Question 8

Clinical weaknesses

Answer 8

• Sometimes my behavior in the room can be constrained by interpersonally challenging clients
• Need to be better at recognizing burn out
• Need to be better at prioritizing self-care
• Sometimes I take on too much (clinically)
• Can sometimes jump to problem solving too quickly when clients may need validation instead

Question 9

Difficult population

Answer 9

Treatment-resistant depression

• –>”Yeah, buts”
• –>Urge to engage in problem solving, “fix it” style

OCPD
—>Rigidity/inflexibility is challenging, especially in the context of low insight/willingness

Question 10

Why DBT/suicidal clients?

Answer 10

• Helping client through lowest of lows
• Develop a life worth living
• Model meaningful/healthy relationships
• Some of the most creative, sensitive, warm, and endearing clients you’ll ever meet
• It feels good to help someone save their own life

Question 11

Difficult assessment case

Answer 11

• Young adult male presenting with self-harm hx, lying, anger problems, and “hallucinations,” no hx of substance use or childhood history of negative/positive symptoms of schizophrenia
• Diagnostic question: BPD vs. Mood disorder w/ psychosis vs. schizoaffective disorder vs. schizotypal
• Ruled out Mood disorder w/ psychosis AND schizoaffective because absence of MDE/hypo-/manic episode.
• MMPI- Negative impression management, invalid response style
• After further exploration, it became clear that the hallucinations had function. E.g., would report to loved ones hallucinations to explain away ineffectve behavior or elicit support from others.
• Therefore, what initially looked like a psychosis in the presence of BPD features actually is just BPD
• Recommended TAU for BPD and ignoring hallucinations when possible, while teaching the px other effectvie ways for serving the function of hal.

Question 12

Difficult therapy case and how I handled it

Answer 12

• 30 yr old caucasian hetero male with BPD who engaged in problem behaviors which stemmed from marital issues
• Px would engage in problem behaviors whenever he perceived invalidation from his wife
• Was particularly affected when he perceived that he was doing much more at home to contribute that she was
• For a while, I used techniques to help client change the situation (i.e., interactions with wife), and also relied on other strategies to change the client’s thinking to become more helpful
• Client would leave session with coping strategies and skills to engage with wife, and then would come back and report that nothing had worked
• Client/me became quite polarized on change, which proved ineffective, given that we were trying to change a relationship dynamic with just one member of the dyad
• Therefore, tx approach changed to help client accept the things about his situation that he was willing to accept, change those things he could, coaching the client to convince his wife to do couples tx. In the mean time, therapy also became focused on changing other aspects of his life that he could control (e.g., work) to build a life worth living to help buffer marital difficulties