Brian: Treatment Plan

At the beginning of and throughout treatment, ongoing assessment/manage-

ment of Brian’s risk for suicidality and implementation of containment strategies
are needed. Relatedly, harm risk evaluation (related to his alcohol abuse) and
harm reduction strategies are introduced early in treatment. In parallel, motiva-
tional interviewing (MI) modules are included to increase Brian’s commitment
to and engagement in treatment. Next, BA interventions are introduced to in-
crease the rate of pleasurable events in Brian’s day-to-day life. His maladap-
tive cognitions (e.g., preoperational thinking, external locus of control, lack of
perceived functionality) and destructive interpersonal behaviors (e.g., discon-
nection from his environment, avoidance, and hostility) will also be targeted
with CBASP interventions to increase his perceived functionality, internal locus
of control, and connection with his environment. Behavioral skills training will
address deficits in interpersonal effectiveness (e.g., communication and asser-
tiveness skills) and reduce reliance on alcohol-based coping strategies. Lastly,
emotion regulation/tolerance strategies will address his anger dyscontrol and
poor stress management skills.
 Anne: Case Formulation

Similar to Brian, Anne’s current depressive episode was triggered by the loss of
her romantic relationship with Peter, her primary/only social support system.
Several interactive mediators maintain her current depression, including her
dysfunctional cognitive style, which is marked by self-criticism/self- loathing,
poor sense of self, lack of perceived functionality, low self-efficacy,
preoperational thinking style, emotional/avoidant coping, and unremittent
negative affectivity (emotional lability and emotion dysregulation problems
related to her borderline personality disorder [BPD]). Skill deficits compound
her problematic cognitive-affective functioning, including paucity of self-
affirming skills and ineffective emotion-regulation skills. Anne’s dysfunctional
approach to her interpersonal environment, namely, her pattern of dependence
and/or avoidance, maintains her social isolation and scarcity of positive events
in her life.
In regards to etiology, Anne has a biological vulnerability for emotional
dysregulation and depression. She also experienced childhood adversity (i.e.,
her parents’ emotional unavailability, her mother’s excessive control and poor
modeling of emotional regulation, and her brother’s abuse), which is likely to
have led to several negative outcomes, including disruptions in her attachment
experiences (with concomitant emotion regulation problems), acquisition of
maladaptive interpersonal need expectancies (i.e., viewing her environ- ment
as emotionally unavailable and/or threatening), and a resulting schema of the
self as vulnerable and unimportant/unlovable. The early onset of her emotion
dysregulation problems is likely to have derailed Anne’s cognitive- emotional
development and to have fostered her interpersonally avoidant/de- pendent
approach—all of which may have contributed to her BPD. In turn, thechallenges
of this debilitating disorder may have compounded her maladaptivecoping (i.e.,
drugs, nonsuicidal self-injury [NSSI]).
Interpersonally, Anne’s transitional attachment to deviant peers failed to pro-
vide her with corrective/healing interpersonal experiences or adaptive coping
skills. Similarly, as an emerging adult, her involvement in a number of “inti-
macy avoidant” brief relationships with mismatched partners did not pro- vide
affirming or relationship-building experiences. On the contrary, they
undermined her interpersonal maturation and compounded her negative view
of the self. Anne’s relationship with Peter was also not a healing experience, due
to her limited resources and Peter’s own inability to provide stable support. In
fact, Anne’s maladaptive coping with her abortion and Peter’s lack of enduring
support during that difficult time undermined the dyadic bond. The concur-
rent derailment in Anne’s educational pursuits (her only area of competency)
further compounded her distress. Peter’s progressive emotional distancing
is likely to have increased Anne’s attachment anxiety and fueled her use of “hyperactivating
strategies” (i.e., controlling, overdependence, enmeshment, intimacy-sabotaging affairs, suicide
attempt) as a dysfunctional attempt to re-gain proximity and support (cf. Mikulincer & Shaver, 2005).
The ensuing dys- functional dyadic cycle of abandonment and reconnection compounded Anne’s
emotion regulation problems and led to the end of the relationship. This signif-icant stressor further
eroded Anne’s connection with her environment and herability to cope, thus precipitating her current
depressive episode.