4.

3 Severe Mental Health in Urban Context: Assignment 3 - Case Lisa

Adrian Fleckenstein - 454158

Antigoni Dasopoulou - 607849
Ayan Huseynova - 492770
Christopher Scharpf - 504531
Sophie Scheele - 606193

Lisa (25 years old) was referred to psychiatric care for the first time at the age of 13. In the
following years, Lisa was referred again and again to other institutions. Several times, the intake
led to a direct further referral because Lisa’s care needs did not match the expertise of the
institution. A number of treatments were started but terminated preliminarily because she did not
improve. Overall, Lisa has seen over a dozen of therapists, and received 6 diagnoses along the
way: Major Depressive Disorder, Social Anxiety Disorder, Autism Spectrum Disorder, Body
Dysmorphic Disorder, Conversion Disorder, Anorexia Nervosa restrictive type. Lisa regards
these diagnoses as ‘empty labels’. For her, all her problems can be traced back to the severe
alcohol abuse of her parents in her childhood. She wonders why there is no label for that.
Because Lisa has severe suicidal ideations, she is referred to a specialist GGZ institution.

1. Script 1
Psychologist Bernard conducted the intake interview and performed additional diagnostic
assessments. In a multidisciplinary team meeting, he reports his findings:

Original
Bernard: I have seen Lisa, 25 years old, who was referred for alleged suicidality (MEANING).
Dossier-information shows especially that she has been to a whole lot of institutions, but that so
far, she failed to succeed (HOPE) in every round of treatment. The frequent changes between
therapists and counsellors suggest that she is a difficult patient (IDENTITY). This is emphasized
by the termination letters of her therapists, who write that Lisa shows controlling and resistant
behavior, and that she criticizes diagnoses frequently (MEANING: what do the labels mean for
her?). In the intake interview, I saw a seasoned psychiatric patient, in which suicidal expressions
rather seem a way of getting attention (IDENTITY). Lisa cannot reflect well (IDENTITY: needs
to be a good patient?) on her own dysfunctional behavior (MEANING. Behavior stripped out of
context and pathologized), she is preoccupied with looking for causes in the past and in her
relational context (looks for MEANING). Therefore, I did additional personality style
assessment and indeed, she is a Borderliner (IDENTITY: whole identity is merged with
diagnosis). Since she appears to be treatment resistant on the other diagnostic domains, I
suggest taking one last shot (little HOPE) at treatment focused on her personality. My idea is to
put her on weekly cognitive behavioural therapy, focused on teaching her to see her
surroundings less in black-and-white(MEANING). I shall also refer her to our psychiatrist to
start her on mood stabilisers (RESPONSIBILITY: all her personal responsibility is taken away
from her, it seems like the therapist is the expert and knows what to do without listening to her
own story + “teaching”- Treatment as something done by the clinician to the patient).

Improved
Bernard: I have seen Lisa, 25 years old, who was referred to us because she scored quite high on
the suicidal risk assessment. Of course, the suicidality needs to be taken seriously, and I will ask
her for her actual attitude towards suicidal ideation.
Apart from this, dossier-information says that she has been admitted to several treatments before,
but she didn’t seem to benefit from them, suggesting that perhaps an alternative approach is
needed.
In the termination letters, two therapists stated that she couldn’t see herself in the diagnoses,
which is why it might be useful to do a case formulation instead, enquiring about her biography,
existential challenges, contextual-interactional functioning, mental processes and biological
influences. Classification can still be done, however, only as a stimulation to the more
comprehensive case formulation.
I also asked her to fill out some personality style assessments, and from those it seemed like she
had some symptoms of borderline personality disorder (BPD), such as instability in self-image
and affect. It is too early to draw conclusions upon this finding, but it might be valuable to
discuss the symptoms with her and see how she relates to them and if they can help her build a
more coherent picture of her current problems.
By asking her about her own interpretation of her symptoms and how she attaches meaning to
them, we might be able to get more insights into her actual problems and goals, we might be able
to better assist her on her own path towards personal recovery.
A possibility would be to try another therapy that looks at her complaints within the context of
her past and present socio-cultural environment and also assesses potential personal as well as
environmental resources that could help her to manage her current problems. (Her personality
characteristics and her childhood experiences, as well as possible traumas into account, in order
to get a deeper insight into her presenting problems and hopefully a more effective treatment for
her. )
My specific idea would be to first do some cognitive behavioural therapy exercises to identify
current maladaptive beliefs, in order to make sure that she feels better about herself soon, and so
to decrease possible suicidal ideation. Then, it might help to try a more psychodynamic approach
or dialectical behavioral therapy (DBT), which would allow space for her curiosity to look into
possible causes for her symptoms. In the following session, I will ask her what she needs from
me, and will discuss with her whether she might find my idea helpful. [to colleagues:] Do you
have any other suggestions on how to see or approach her symptoms?

Justification
 Original Improved
Hope 1. She failed 1. Apart from this, dossier-
to succeed information says that she has
2. Difficult been admitted to several
patient treatments before, but she
3. One last didn’t seem to benefit from
shot them
2. suggesting that perhaps an
alternative approach is
needed.
3. A possibility would be to
try another therapy that
looks at her complaints
within the context of her past
and present socio-cultural
environment and also
assesses potential personal
as well as environmental
resources that could help her
to manage her current
problems.
Identity 1. She is a 1. Apart from this, dossier-
difficult information says that she has
patient been admitted to several
2. Lisa cannot treatments before, but she
reflect well didn’t seem to benefit from
3. She is a them
seasoned 2. That she couldn’t see
psychiatric herself in the diagnoses
patient who 3. Suicidality needs to be
Justification
1. Hope: By saying that she
didn’t seem to benefit from
them, it is suggested that the
therapies just didn’t suit her
as an individual, whereas
another new approach might
work. This can increase hope
in her that future treatments
that are adapted to her might
work.
2. Hope: The failure of the
treatments is not her fault,
and therefore not predictive
of future treatments. Instead,
it is the treatments that failed
and another approach might
work for her, which can
increase hope.
3. Hope: “One last shot” puts
a lot of pressure on Lisa to
succeed in this very last
treatment, and it seems very
pessimistic, the opposite of
hope. By offering another
treatment that fits her needs,
without qualifying it as the
last treatment, Lisa can see
this therapy as more hopeful.
1. This makes it seem like
she is difficult, wrong,
unable to improve. By
acknowledging that the
treatments didn’t work, it is
pointed out that the
treatments were inadequate
for her personality, rather
than the other way around.
 uses taken seriously 2. It is not that she is not able
suicidality to 4. it seemed like she had to do something, she actively
get attention some symptoms of reflects and decides that she
4. She is a borderline personality cannot see herself in the
Borderliner disorder (BPD) diagnoses. This way, her
disapproval of the diagnoses
is shown as her opinion, and
not part of a disability in her
character.
3. This way, suicidality is
taken seriously, and it is not
assigned to her ego craving
attention.
4. Here, it is emphasized that
she has some symptoms that
might be part of BPD, but it
is made clear that she seems
to have these symptoms and
that they are not part of her
personality, or even that they
prove a personality disorder.

Meaning 1. Referred for 1. Referred for suicidal 1. “Alleged” implies that the
alleged ideation and behavior patient potentially “made it
suicidality 2. She doesn't feel up”, thus undermining the
2. Criticizes comfortable with critical issue of self-harm.
diagnoses diagnostic labels suggested 2. It is important for a patient
frequently previously to identify and feel
3. 3. Behaviour that comfortable with their
Dysfunctional causes persistent distress in diagnostic labels.
Behaviour patient’s occupational and 3. Use of the word
4. Looking for social life “dysfunctional” can be
causes in the 4. Patient tries to stripped out of context and
past and in her understand her can lead to pathologization
relational symptomatology by active and further stigmatization of
context reflecting on her past the disorder.
experiences 4. Reduces the negative
connotation in regards to her
actions.
 Responsibility 1. She failed 1. Previously suggested
to succeed treatments were not
2. My idea is particularly effective in
to put her… addressing her mental 2. It is crucial to give the
(also to start well-being.
her) 2. The patient will be
described different lines
of potential treatment and
will be asked about her
feeling regarding them as
well as whether she feels
comfortable continuing
with the line of treatment
suggested by the
psychiatrist
1. Reduces the unnecessary
burden of responsibility
from the patient.
patient room for thought
instead of forcefully
putting her on certain
therapy and/or
medication. Most
importantly, it is the
patient's choice to decide
whether she wants to
continue with the
treatment or not.

2. Script 2

Original

Subsequently, Bernard shares his findings and treatment plan with Lisa:

Bernard: Based on our previous conversation and the questionnaires you scored, it appears that
you have a Borderline Personality Disorder (IDENTITY: Can be very stigmatizing to put this
label on the patient/MEANING: Transforming personal story into illness ideology language
strips the content of meaning by obscuring it into psychological symptoms) → could discuss the
symptoms with her, ask whether she sees herself in it/ could ask whether she sees herself in the
diagnosis).

Lisa: What? I did not come here to receive yet another label. I already have six diagnoses. What
does this mean, that I now also have a personality disorder?

Justification: She expresses that she is looking for the meaning behind her symptoms.

Bernard: The Borderline Personality Disorder is defined in DSM-V as a persistent pattern

(HOPE: persistent/unable to change) of unstable interpersonal relationships, self-image and
affects (IDENTITY: relationship at center of identity & unstable self-image).
Lisa: I don’t understand this. I know I have several problems, but why is it necessary to keep
putting new labels on it? How does that help me?
….

Bernard: Well, by giving you the correct diagnosis, we have the expertise to advise you the right
treatment. (RESPONSIBILITY: what do you think would be helpful for you?)

Lisa: So, what would you consider the right treatment?

Bernard: In your case, the right treatment is cognitive behavioural therapy, focused on your
distrust in relation to other people and on your treatment resistance (HOPE: treatment
resistance sounds like there is really little chance that she’s going to get better). Hopefully, that
will give you a more positive attitude towards your surroundings, and also towards yourself.

Lisa: What do you mean with a more positive attitude towards my surroundings? In our last
conversation I told you that my surroundings are very troubled. A lot of my problems started
with the alcohol abuse of my parents, but I am never allowed to talk about that. (DIRECT
MEANING: this is what happened. Helps her to understand her situation and make sense of it).

Bernard: At a certain point, you have to learn to focus on the here-and-now. What keeps
happening in your personal relationships, and also with people like me who try to help you with
your problems, that you are very suspicious. That does not help you forward. At some point you
have to stop hiding behind your past.

Lisa: You call it suspicion, but for me it is self-protection. I have learned in the past that not
every person is trustworthy. (IDENTITY)

Bernard: When you say ‘self-protection’, you basically say ‘I am being threatened’. It’s exactly
those dysfunctional ideas that you have to start working on.

Lisa: So when I would work on my ‘dysfunctional ideas’ in therapy, then I can recover from this
personality disorder, and all the other problems that I came here for?

Bernard: Personality disorders are disorders that are grown into your personality structure
(identity). You cannot ‘recover’ from your own personality (HOPE: need to keep going with this
forever), you will bear that with you your entire life (IDENTITY). Fortunately, we see that with
cognitive behavioural therapy, we can teach Borderliners to approach the world a bit less black-
and-white (MEANING: what meaning do I give to the world/do I want to change that?).
Lisa: I don’t know about this cognitive behavioural therapy. It sounds like something I have
already tried so many times.

Bernard: Try to approach it a bit more optimistic this time. Don’t let your resistance get the
better of you.

Lisa: I find it hard though, that after all those other diagnoses, now all the sudden I have to see
myself as a person with a borderline personality disorder.

Bernard: Well, we will give you psycho-education about this disorder and how you can
recognize the symptoms. Also, I will refer you to our affiliated psychiatrist to start you on mood
stabilizing medication (responsibility). This may help a bit with getting you out of your rigid
world views and hopefully open you up for a somewhat more positive outlook on the world
(MEANING: how she should look at the world).

Improved

Bernard: Hello Lisa, so I had another talk with my team, and among other things, we also talked
about all your previous diagnoses and that you generally see them as empty labels, not capturing
your experiences with the alcohol abuse of your parents and all that this meant for you. Thus, I’d
like to briefly address that: In general, modern mental health services work with diagnostic
classification according to these diagnostic manuals, which is due to the nature of modern
psychological science, where the testing of the efficacy of treatments is based on diagnoses
according to such manuals. Here at our clinic however, we understand that these diagnoses are
just one way of interpreting somebody’s experiences of mental suffering. Nevertheless, we still
need to make them receive reimbursement for your treatment. Furthermore, we use them to as a
stimulation to understand what you are going through. One of the questionnaires that I asked you
to fill out last time suggest that you have some tendencies that can be described as borderline
personality disorder, which is defined as a persistent pattern of unstable interpersonal
relationships, self-image, and affect. I’d be curious to hear whether you can relate to this, and,
given what we discussed about your past including the negative experiences you made with your
parents abusing alcohol, if you do relate to these patterns, what you think why you might have
them?

Lisa: I understand about the diagnoses, and yes I do recognize these patterns. Regarding the
instable relationships, it is just that I, in the past, have so often tried to trust other people,
including my parents, and have been let down or hurt again and again and again. I so want to
love others and have positive relationships, but with after all these negative experiences I have
made, this is just difficult to me. In terms of the self-image, I just feel like I sometimes just have
a hard time sometimes seeing me positively, because I with all the abuse I experienced, I feel
that it has to do something with me. And yeah, the constant unpredictability in my family home
where things could switch from being loving towards potentially seriously dangerous just
triggered very different emotions in very rapid succession in me, and I still feel that way today.
But I just wonder what I can do about it?

Bernard: I understand and indeed these circumstances which you describe are very difficult to
deal with. What I am wondering is, what are things that help yourself?

Lisa: Hmm, let me think… So I work at a café as a waitress. I tried to do a training to become a
hotel manageress but with all the distress I experience I did not manage to follow through with it.
But working is doable for me and it gives me a bit of a break from all the emotional pain that I
experience, as when I work, my mind is busy with what I do there and all the suffering is in the
background for a couple hours. Also it gives me a good feeling that I feel that I can provide for
myself. Aside from that, I really love to sing sometimes, because I feel that it makes it possible
for me to let out all the pain that I experience, which gives me some relief. Oh and also during
my past stays in clinics I made a couple good friends who understand me well because they went
through similar things in the past and it always feels good to talk to them. I wish I could live
together with one of them, because my current roommates seem to not like me because they
don’t understand why I am often in such a bad mood.

Bernard: Ah, so you’re a hard-working waitress and also a singer! That’s great that you found
all these things that help you. It is not easy to live with having experienced such difficult things,
and I see it as impressive that you are nevertheless always looking for ways to make the best out
of it anyways. I really encourage you to keep doing these things, and together I’d suggest that
together, aside from looking how we can give some direct relief to the distressing thoughts and
emotions that you experience, we also look for ways that you can give these things that help you
even more room in your life.

Lisa: That sounds great, but, after what you said earlier, I just feel like there’s little hope for me.
I mean, you said regarding the borderline patterns, that these are persistent. So does that mean
that I will always have to live with that? I can’t imagine living like that for my entire life.

Bernard: The fact that we have noticed some characteristics that are involved in the borderline
disorder doesn’t mean that this disorder defines you. You can live a meaningful, satisfying life
even though you have these symptoms. Hence, we are going to build a therapeutic relationship in
which you could feel free to talk about your traumas and discover your strengths, values,
motives.

Lisa: Since I was never allowed to talk about my past experiences, this sounds relieving for me
but I am still confused about how to work on this problem.
Bernard: I totally understand you. Therapy seems really complicated at the beginning, however
as the time goes by you will feel a sense of balance. It is also fundamental to actively participate
in the formation of this process since our therapy sessions are going to be based on self-
responsibility, empowerment and hope.

Lisa: I am more than willing to start the therapeutic process and be able to talk to someone.

Bernard: At this point I want to make clear that we are going to explore and understand your
needs, unique experiences and give meaning to them. Also, we will focus on older and most
recent experiences and feelings in order to understand the underlying issues of the problem. Then
we are going to focus on your strengths and explore the things that give you a sense of
fulfillment.

Lisa: That sounds interesting for me and I am curious about the process but I am still wondering
If I could completely recover after the therapy sessions.

Bernard: I can’t predict the results, this is not the aim of the process. To be precise, we are not
going to focus on the removal of the symptoms since these symptoms have a specific meaning
and it's a way to respond to the painful experiences. However, from my experience I have
noticed that patients who feel safe and free in a therapeutic environment have good outcomes.
Another important aspect that we have to define is the therapeutic treatment that we have to
choose. Personally, I suggest using some skills and techniques from CBT therapy but also we are
going to be based on psychoanalysis as well. What do you think?

Lisa: Sounds good, I heard that CBT focuses on restructuring, however I would also like to
include psychoanalysis approach sessions where we can talk about my childhood experiences, in
order for me to really understand how they are still impacting me.

Bernard: I can understand that you can be pessimistic since you are not satisfied from your
previous attempts for recovery but try to keep in mind that it’s difficult to find the suitable
therapeutic process. It is not your fault, the circumstances are really important,and also keep in
mind that you can alter your life and give it the meaning you want.

Lisa: That sounds helpful for me.

Bernard: Glad to hear that, so we will start to work with the aforementioned approaches and we
will reshape the process according to your needs. Through this therapeutic relationship which
will be dynamic and flexible we aim to achieve personal balance, empower your strengths,
redefine your values and live a more meaningful life.
Justification

Previously Alternative Justification

Hope You cannot recover Even though you have Clinicians should
from your own some symptoms these promote hope, be
personality don’t define your careful with the way
personality that they use the
language, and support
the individuals to
explore their unique
characteristics instead
of focusing on their
symptoms

Identity 1. In addition to 1. You have these 1. Recovery task

your previous diagnoses, but in 1: Developing
diagnoses you addition you are a a positive
also have hard-working identity. The
bordereline waitress, a singer, me-it
and a good friend difference.
(am caring) Personal
identity (I am
caring, a
singer, a
waitress, a
good friend)
& Social
identity (a
waitress, a
good friend) +
recovery task
2, framing the
mental illness

Meaning 1. You have 1. This just one way 1. Translating

Borderline of interpreting personal
experience. Can experience
patient relate to into illness
this? How does ideology
she find meaning? language
 strips
experience of
its meaning,
locates disease
inside
individual,
neglecting
context.
Mental health
diagnosis not
an explanation
but an
interpretation
+ Belgian
superior
health council:
Diagnosis can
still be used
but only as
broad
syndrome
stimulating
diagnostic
formulation

Responsibility 1. Borderline 1. What are personal 1. Avoid

diagnosis, we resources? What problems
give you this are environmental caused by sole
treatment resources/stressors focus on
? What do you do deficiencies
to help yourself? and
undermining
characteristics
of person
mentioned in
mismatch 3
(Slade chapter
2): Also
enquire about
personal
resources,
environmental
influences.
What are you
doing to help
yourself?