NUR 7620 Module 4 Group Therapy Case: Dialectical Behavior Therapy for Self-Harm Example

Four Skills, One Year: Dialectical Behavior Therapy Groups for a 24-Year-Old Nursing Assistant Who Cuts When She Feels Abandoned

Student Name

M.S. in Nursing, Psychiatric Mental Health Nurse Practitioner, Thomas Edison State University

NUR-7620: Family System Psychopathology and Psychotherapeutics Across the Lifespan

Mentor Name

Month Day, Year

Four Skills, One Year: Dialectical Behavior Therapy Groups for a 24-Year-Old Nursing Assistant Who Cuts When She Feels Abandoned

A Year of Crises

Dana, an invented patient, is 24 and works as a nursing assistant at a nursing home in Camden. Over the past year she has cut her forearms about a dozen times, usually after an argument with her boyfriend or a sense that a coworker disliked her, and has been to the emergency department three times, once after taking extra doses of her antidepressant. She describes feeling empty, swinging from adoring people to hating them and panicking at the thought of being left. She meets criteria for borderline personality disorder. She is not using drugs, drinks rarely and wants help, though she has dropped out of two therapies after a few sessions because she felt judged. This paper plans group-based treatment for her.

What Dialectical Behavior Therapy Is

Marsha Linehan built DBT in the 1980s and 1990s for women whose borderline personality disorder came with years of suicidal crises. Its central idea is the balance, or dialectic, between acceptance and change: the therapist accepts the patient as she is while pushing for new behavior. The standard program has four parts. Weekly skills groups, usually about two and a half hours, teach mindfulness, distress tolerance, emotion regulation and interpersonal effectiveness. Weekly individual therapy addresses the patient's own behaviors in order of priority, starting with self-harm. Phone coaching helps the patient use skills between sessions. A consultation team supports the therapists. The group is where most skills are learned, which makes DBT a group therapy as much as an individual one.

The Evidence

Linehan et al. (2006) enrolled 101 women with the disorder who had recently tried to kill themselves or hurt themselves, and assigned them at random to DBT or to experienced community therapists whom colleagues had nominated as especially skilled. Across one treatment year and one follow-up year, the DBT group made about half as many suicide attempts, spent fewer nights in hospital for suicidal thinking, came to psychiatric emergency rooms less often and stayed in treatment more often. Because the comparison group received expert therapy, the results suggest that DBT's specific features, not just good therapy, made the difference.

McMain et al. (2009) set DBT against general psychiatric management, a manual-guided approach in the hands of psychiatrists who know the disorder well, in 180 Toronto patients. After a year, both groups improved substantially on self-harm, emergency visits, symptoms, depression and functioning, and there were no significant differences between them. Storebø et al. (2020), reviewing 75 trials of psychotherapies for borderline personality disorder for Cochrane, found that psychotherapy reduced symptom severity compared with usual care by a clinically meaningful amount, with DBT and mentalization-based treatment the most studied.

Why DBT for Dana

Three features of Dana's history point toward DBT. Her self-harm is frequent and dangerous, and DBT's hierarchy puts life-threatening behavior first. She has left two therapies because she felt judged, and DBT's emphasis on validation addresses that directly. And the local community mental health center runs a DBT program with an opening in its next skills group. General psychiatric management would be a reasonable alternative if DBT were not available.

The Year Ahead

Dana begins with four pretreatment sessions in which she and her individual therapist agree on goals, chiefly stopping self-harm and keeping her job, and she commits to a year of treatment. She joins a skills group of eight members that meets on Tuesday evenings. The group cycles through the four modules over about six months and then repeats them. In mindfulness, she learns to observe and describe her emotions without acting on them. In distress tolerance, she learns crisis skills, such as cold water on her face and paced breathing, to use instead of cutting. In emotion regulation, she learns to identify emotions and reduce her vulnerability through sleep and regular meals. In interpersonal effectiveness, she practices asking for what she needs without threatening to leave or begging others to stay.

Each week she completes a diary card recording urges to self-harm, emotions and skills used. In individual sessions, every episode of self-harm is analyzed step by step to find where a skill could have interrupted it. She can call her therapist for brief coaching before acting on an urge, not after.

Phone coaching follows a firm rule that surprises many patients: calls come before self-harm, not after it. If she has already cut, she is asked to wait a day before calling, so that the contact rewards reaching out early rather than reaching out in crisis.

The group itself has rules that make it safe. Members do not discuss the details of self-harm in group, so no one is triggered or taught new methods; they arrive on time, complete homework and contact each other outside group only in ways that do not involve harm. Dana worries that she will be the "worst" member; the group leaders explain that every member joined for the same reasons and that the group teaches skills rather than asking anyone to share their history.

The PMHNP's Role

The psychiatric nurse practitioner manages Dana's medication alongside DBT. Because she took extra antidepressant doses during a crisis, prescriptions are limited to small supplies. No medication treats borderline personality disorder itself, so medication targets specific symptoms such as depression, and the nurse practitioner avoids benzodiazepines, which can worsen impulsivity. The prescriber coordinates with the DBT team so that crisis responses are consistent.

Measuring Progress

The diary cards provide weekly counts of self-harm and urges. Emergency visits and hospitalizations are tracked, and a borderline symptom scale is completed every three months. Her own goals, keeping her job and having one argument without cutting, are reviewed monthly.

Conclusion

DBT is a structured, year-long program built around skills groups, individual therapy, coaching and a team. Trials show it reduces suicide attempts and crises compared with expert therapy, while a well-structured psychiatric approach can do as well. For Dana, whose self-harm is frequent and who has left therapies that felt judgmental, DBT's priorities and its validating stance make it the right fit, with medication used cautiously alongside it.

References

Linehan, M. M., Comtois, K. A., Murray, A. M., Brown, M. Z., Gallop, R. J., Heard, H. L., Korslund, K. E., Tutek, D. A., Reynolds, S. K., & Lindenboim, N. (2006). Two-year randomized controlled trial and follow-up of dialectical behavior therapy vs therapy by experts for suicidal behaviors and borderline personality disorder. Archives of General Psychiatry, 63(7), 757-766. https://doi.org/10.1001/archpsyc.63.7.757

McMain, S. F., Links, P. S., Gnam, W. H., Guimond, T., Cardish, R. J., Korman, L., & Streiner, D. L. (2009). A randomized trial of dialectical behavior therapy versus general psychiatric management for borderline personality disorder. American Journal of Psychiatry, 166(12), 1365-1374. https://doi.org/10.1176/appi.ajp.2009.09010039

Storebø, O. J., Stoffers-Winterling, J. M., Völlm, B. A., Kongerslev, M. T., Mattivi, J. T., Jørgensen, M. S., Faltinsen, E., Todorovac, A., Sales, C. P., Callesen, H. E., Lieb, K., & Simonsen, E. (2020). Psychological therapies for people with borderline personality disorder. Cochrane Database of Systematic Reviews, 2020(5), Article CD012955. https://doi.org/10.1002/14651858.CD012955.pub2