Treatment Strategies for Each Class of Targets

Decreasing Self-Injurious Behaviors

Several strategies were implemented to address parasuicidal drug use. C. N. attended a DBT skills training group to learn to tolerate her intense guilt and rage. Problem-solving chain analyses like the one outlined earlier were used in individual therapy to identify points at which various coping skills could be employed. These were primarily from the Distress Tolerance and Emotion Regulation modules. For example, C. N. found that leaving the situation and engaging in intense exercise and holding ice in her hand were both strategies that reduced her rage, as did writing down her feelings. To regulate lower levels of emotion, she found that a mindful focus on her breathing, knitting, watching television, and telling herself, "Let it go," were all successful distractors and ways of calming herself, at least temporarily. She also agreed to dispose of her stash of pills to avoid ease of access in a crisis.

Treatment also involved generating a list of statements to challenge the automatic thoughts "I'm a loser," and "I'm just like my mother," which often directly preceded self-injury according to C. N.'s chain analyses.

C. N. also reported that her drug use was often motivated by her desire to hurt herself to make her boyfriend feel bad and thereby punish him. Therefore, individual therapy also focused on C. N.'s use of the assertiveness skills she was learning in the Interpersonal Effectiveness module of the DBT skills group, to express better her needs and her feelings of disappointment or anger when these were not met. Cognitive restructuring work also focused on whether hurting her boyfriend actually led to any substantive positive outcomes for her, even if it might have felt satisfying momentarily, or whether, as in the previous example, it simply resulted in C. N. feeling bad about herself and further damaging the relationship.

Decreasing Therapy-Interfering Behaviors

As C. N.'s self-injurious behavior decreased, the therapeutic target became reduction of her therapy-interfering behaviors of lateness and noncompli-ance with completing the diary card. She was frequently very late for therapy sessions. She revealed that she was also habitually late for work. Further examination revealed that whereas she budgeted her time quite effectively, she demonstrated an inability to say "no" to others' requests that she help them. Therefore, the interpersonal effectiveness skills she was learning in the group were employed to reduce this deficit. These same skills were applied to the many situations in which C. N. received unwanted sexual attention or contact. Over time, she became quite skillful at saying "no" to unreasonable demands of others. Learning to set appropriate limits also served to reduce conflict and to regulate emotion associated with her family's demands of her.

Regarding completion of the diary card, C. N. remained noncompliant for several months. When asked why she had not completed it, C. N. stated that she had forgotten, or that she had left it at home. She also wanted to avoid thinking about her problematic anger and substance use due to shame associated with this behavior. When the therapist requested that she complete the diary card in session, C. N. did so. The therapist highlighted that because session time was taken up with completion of diary card, there was not time to attend to many quality-of-life-related items on the agenda for the session. On occasions when C. N. did complete the diary card beforehand, the therapist reinforced this behavior with praise and by allotted that time to discussion of items on C. N.'s agenda. Whereas C. N. continued to complete the diary card in session sometimes, incidences of daily completion of the diary card increased.

Decreasing Quality-of-Life-Interfering Behaviors

As her self-injurious and therapy-interfering behaviors gradually decreased, more therapy time could be devoted to C. N.'s serious quality-of-life-interfering behaviors. A major one was her total involvement in the drug community. She was strongly encouraged to build a friendship network outside of this subculture to support her commitment not to abuse drugs. Interpersonal effectiveness skills were employed to assist her in asking acquaintances to socialize with her. In addition, a typical day involved going to work, exercising, eating dinner, and going to bed. C. N. often commented that she dreaded each day and looked forward to nothing. In keeping with the overarching treatment goal of building a life worth living, she was strongly encouraged to engage in daily pleasant activities and to be mindful of any positive emotions they occasioned, just in that moment, without worrying about whether she deserved it, whether it was going to last, and so forth (i.e., combining a traditional CT strategy with the use of mindfulness skills she learned in the DBT group). In addition, C. N. decided to adopt a pet, which gave her much joy and a feeling of mastery in taking good care of it.

C. N. also often became overwhelmed and dropped all of her responsibilities, missing work and therapy sessions as a result of severe emotional dysregulation and associated depression. Treatment involved encouraging her to focus on endurance by being kind to herself and planning minibreaks throughout the day in order to avoid burnout. The skill of opposite action

(discussed in the Emotion Regulation module), in this case, behavioral activation, a skill commonly used in cognitive-behavioral therapy for depression, helped combat C. N.'s feelings of inertia, lethargy, and hopelessness when she felt depressed and compelled to stay in bed all day.

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