Borderline personality disorder
Recurrent crises, NSSI, intense unstable relationships; three prior dropouts from individual therapy.
Presenting concern
Self-referred after a hospitalization for NSSI escalating to suicide attempt. Pattern of intense brief relationships, chronic emptiness, identity instability, impulsivity (spending, alcohol). Difficulty maintaining school enrollment.
History
Three prior therapy trials, each ending in rupture. Childhood emotional invalidation; no overt abuse but chronic minimization. Multiple ED visits for self-harm. No current substance use disorder.
- Active NSSI and prior attempt
- Therapy-interfering history
- Functional disruption (school)
- Limited current support
- Self-referring (motivation rising)
- Bright, capable when stable
- No active substance dependence
- Receptive to structure
Conceptualization across modalities
Biological emotion sensitivity + invalidating environment = chronic difficulty regulating emotions. Behaviors that look 'manipulative' are skill deficits — best available solutions to unbearable emotional states. NSSI provides immediate emotion regulation; relationships ricochet between idealization and fear of abandonment.
- Stage 1: behavioral control (NSSI, suicidality, therapy-interfering, quality-of-life)
- Skills training across all four modules
- Diary card tracking emotions, urges, behaviors, skills used
- Phone coaching for in-the-moment skill use
Difficulty mentalizing — holding her own and others' minds in mind — under affective arousal. Relationships collapse because intentions get attributed without checking. Treatment builds capacity to pause and consider mental states.
- Stance: not-knowing, curious about both her own and others' minds
- Slow down moments of relational rupture in session
- Identify pre-mentalizing modes (teleological, psychic equivalence)
- Build epistemic trust
Treatment plan
Pre-treatment (1–4)
Commitment, diary card, safety contracting, group enrollment.
Stage 1 (months 1–12)
Behavioral control via DBT individual + skills group + phone coaching.
Stage 2 (year 2+)
Process trauma and emotional inhibition, if criteria for stage 2 met.
Differential diagnosis
- Complex PTSD (chronic emotional invalidation overlaps significantly)
- Bipolar II (mood instability — distinguishable by duration and triggers)
- Substance-induced mood instability (ruled out at intake)
- ADHD with emotional dysregulation (consider given impulsivity)
Session arc
Orienting to DBT, diary card setup, life-worth-living commitment, safety contract, group enrollment.
Chain analyses on every NSSI; phone coaching for in-the-moment skills.
Lateness, missed sessions, threats to quit — addressed head-on with chain analysis.
School re-enrollment, relationship skills, emotion regulation skills consolidation.
Process invalidation history, emotional experiencing if criteria met.
BPD diagnosis carries significant stigma, especially for young women. Some clinicians refuse the label; others apply it punitively. Be transparent about why you're using it and what it predicts about treatment, not personality. Family-of-origin invalidation is often culturally normalized ('we don't do feelings in this family') — name the pattern without pathologizing the culture.
Three prior dropouts means you'll be tempted to walk on eggshells or, conversely, to over-confront. DBT's stance — change AND acceptance, behavior-focused without blame — is structurally protective. Use consultation team weekly; this is not a solo case.
Between-session work
- Daily diary card — emotions, urges, behaviors, skills used (non-negotiable)
- Skills group every week — missing 4 = dropped from individual
- Pros/cons card before any NSSI urge
- One opposite-action experiment per week
Common pitfalls
- Skipping the diary card — DBT collapses without it
- Therapist solo-managing a Stage 1 case without consultation team
- Moving to Stage 2 before behavioral control is stable (predictably triggers regression)
- Reading rupture as 'manipulation' rather than skill deficit
- "What's the function of each NSSI episode this week — emotion regulation, communication, or punishment?"
- "Am I reinforcing therapy-interfering behavior by adjusting around it?"
- "When is the right point to formally introduce Stage 2 criteria?"
NSSI reduced from weekly to one episode in 4 months by session 20. Completed pre-treatment without rupture — significant given history. Group attendance was the hardest commitment.