Case Conceptualization

Relevant Developmental History

C. N. reported that in 1 year during middle childhood, her father died and a family member sexually abused her. She felt blamed by her family for encouraging the rape. Reactions to the sudden loss of her father were not processed, and she was not permitted to mention him ever again. She reported a lifelong history of both physical and emotional abuse from her mother and a family that often referred to her as "crazy" and "ill" due to her frequent emotional outbursts. She also reported several incidents of date rape during her late adolescence and early adulthood.

Self-Injurious Behaviors

C. N. had had a history of self-injurious drug use since her early teens. Her most common form of deliberate self-injury involved abusing large quantities of sedatives, which she obtained from her boyfriend. She engaged in risky drug use approximately once a month, usually with the desire to become numb. On occasion, she engaged in cutting her hand and hitting her leg with a pole. Other risky behaviors included reckless driving, sleeping overnight in a parking lot in a dangerous part of town, and walking alone along a highway late at night. All of these behaviors were considered intentionally or potentially self-injurious, and their reduction was the primary target of treatment in Stage 1.

Stage of Treatment and Target Hierarchy

Given that C. N. exhibited severe behavioral dysregulation, she was considered to be in treatment Stage 1. The primary targets, in descending order, were her self-injurious and risky behaviors, urges to engage in these behaviors, and suicidal ideation. The next level of targets included her lateness, missing sessions due to substance use, and noncompletion of the diary card. The third targeted area was behaviors that compromised her quality of life, such as anger, depression/misery, and lack of social support outside of a community of drug users. Treatment targets were tracked on her diary card.

Sample Behavioral Analysis

A representative chain analysis of events surrounding C. N.'s self-injury is as follows: Her mother made a demand with which C. N. did not want to comply and about which she then felt guilty. She then argued with her boyfriend, while he was drunk, about his failure to meet her needs and about his alcohol use. Because her boyfriend did not exhibit any reaction, C. N. first felt hurt, unacknowledged, and powerless, then intense rage. She was physically violent toward her boyfriend (punching his face, slamming his head into the ground, kicking him, purposely breaking his eyeglasses), and he did not fight back. She then felt intense guilt and told herself that she was just like her physically abusive mother. C. N. then took sedatives to escape her feelings of guilt. As a consequence, she then stayed in bed and missed several days of work due to fatigue and depression associated with drug use. Another consequence was that her boyfriend then spent time with her cleaning up and repairing objects in the house.

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