Clinical Supervision

This week we focus on group therapy paying special attention to children and adolescents.  Children and adolescents have different needs when it comes to therapy.  The therapy should be tailored to the child’s developmental level and should be delivered within the here and now.  With that in mind, we will review the case study, “I feel like I’m going crazy” and offer treatment options that are evidence based.

The case study presents a Native American child that is 15 years old.  He lives with his single mom who works a lot and is not home often.  He has been inflicting self harm for about 10 months by cutting with a razor. The client reports problems with sleep onset, low self-esteem, low energy level, and previous suicide attempts. He reports feelings of abandonment from his boyfriend and a recent loss of friendships.  He also reports that he identifies as a pansexual and has been dating a male peer for two months.  The client’s chief complaint is, “I am feeling like I’m going crazy!”.

The client needs further assessment and evaluation to rule out major depressive disorder (MDD), borderline personality disorder (BPD), and other potential personality and anxiety disorders. At this assessment the client is denying any suicidal ideation.  With that, the most appropriate diagnosis is nonsuicidal self injury (NSSI). NSSI is a behavior that includes cutting, burning, scratching, hair pulling, hitting, head banging, and interfering with wound healing (Hornor, 2016). NSSI has a close relationship with borderline personality disorder.  However, the DSM-5 allowed for NSSI to stand alone as its own diagnosis.  This was the first time NSSI was not tied to the diagnosis of BPD as a symptom only. NSSI is also differentiated from suicidal behavior disorder in the DSM-5.

According to the DSM-5 the criteria for NSSI are: five days of self harming in the last year, patient self harm actions are unlikely to result in death, the client engages in self harm to resolve an interpersonal difficulty, the behavior is not sanctioned such as tattoos or piercings, the self harm interferes with clients academics, the self harm did not occur during an acute manic or psychotic episode nor while on or withdrawing from substances (American Psychiatric Association [APA], 2015). The client meets the diagnostic criteria to make this diagnosis.  The clients behaviors appear to surround feelings of abandonment, and low self esteem, The client has been cutting for 10 months and has scarring.  The client was unable to attend class one day due to bleeding.  Additionally, the client does not appear psychotic or manic on current assessment.  If the clients suicide attempts had been related to the cutting then a diagnosis of suicidal behavior disorder may be appropriate.  The gold standard is to assess for suicidal ideation before, during, and after diagnosis of NSSI (Plener et al., 2016).

Treatment for NSSI should be outpatient if possible to minimize impaired functioning.  Mentalization based treatment (MBT) and dialectical behavior therapy (DBT) are both recommended for the treatment of NSSI (Plener et al., 2016).  While evidence is lacking in regards to adolescents and much more research is needed, these approaches have shown improvement in symptoms and have been found effective with adults.  MBT focuses on secure attachment through the clients’ capacity to mentalize.  Basically the client should learn to think about thinking in that they are attempting to understand how the mental state of oneself directly affects overt behaviors.  DBT has an interesting focus on opposites occurring at the same time and both being truthful (Dbt 101: What Does ‘Dialectical’ Even Mean?, n.d.).  For example, I can love my sister very much, AND be very angry with her for not calling me for a month.  These are seemingly opposing facts, but both are truthful at the same time.  Through these dialectics the client and therapist look for acceptance and change. With either or both treatments I would expect outcomes that show symptom reduction from NSSI.  Clients may want to also consider individual therapy.  It is also important to note that medications are not recommended for this client (Plener et al., 2016).

Ethical concerns are ever present when working with children and families.  In regard to NSSI it is important for the therapist to check their biases at the door and approach treatment nonjudgementally.  NSSI has been shown to evoke intense emotion from counselors often evoking enough fear that the therapist may want to enter into a “safety contract” right away prior to giving the client substitute coping skills.  Additionally, therapists may find themselves lecturing clients that self harm, ultimately reducing the therapeutic alliance (Whisenhunt et al., 2016).

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