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Introduction

Dialectical behavior therapy (DBT) puts an emphasis on emotional regulation through the integration of acceptance and change (Brown, 2012). An occupational therapist’s role in DBT is in the skills training portion of the therapy. In DBT, the client’s current emotional state is taken into account and the therapist will work in conjunction with the client to promote changes in skills, cognition, and behaviors.

Theory

The Cognitive behavioral therapy (CBT) suggests that negative thinking patterns adversely affect occupational performance. CBT suggests that replacing negative thinking to positive thinking will create more adaptive behavior patterns. (Brown, 2012).  Occupational therapy practitioners can approach treatment using CBT by having the client engage in expressive writing and relaxation therapy.

Evidence

A meta-analysis review found CBT to be a significantly effective intervention for homeless diagnosed with schizophrenia (O’Donnell & Schnakenberg, 2016) They focused on how maladaptive thoughts produce and maintain emotional distress and problematic behaviors.

Case Study

Fitzroy Frederick is a 37 year old homeless man living with schizophrenia in New York City.  He was provided housing and an employment opportunity in The Fountain House, a program designed to provide assistance to individuals with mental illness. Recently, Fitzroy has become confrontational and verbally aggressive with his roommates.  He has been observed yelling, swearing, and insulting other residents in The Fountain House, in addition to storming out.  Fitzroy is currently receiving psychotherapy services and was referred to an occupational therapist at The Fountain House for DBT skills training to address his verbally aggressive behaviors.

Intervention Plan

Problem Statement

Fitzroy demonstrates a lack of ability to regulate his emotions when engaging in conversation with his roommates. His lack of coping strategies and social skills limits his ability to engage in social relationships.

Long Term Goals

1. Fitzroy will respond to peers’ statements in a non-aggressive and socially appropriate way for 3 out of 5 opportunities during a group therapy session to improve his social participation within 4 weeks.
2. Fitzroy will exhibit improved emotional regulation by remaining in the therapy session 3 out of 5 times when confronted with disagreements by his peers to improve his social participation within 4 weeks.
3. Fitzroy will use no more than 3 foul language responses and/or insults in response to confrontation during the group therapy session with his peers to improve his social participation within 4 weeks.

Short Term Goals

1. Fitzroy will identify to the therapist 3 triggers that elicit aggression during conversations with his peers to improve self-awareness for social participation within 2 weeks.
2. Fitzroy will identify 2 alternative responses to his verbal aggression during a group therapy session with his peers to improve self-awareness for social participation within 2 weeks.

Intervention Format

Group session

Setting

Fitzroy will meet with the occupational therapist in a group session at the Fountain House for 30 minutes 2x a week.

Supplies

None

Agenda

• Meet group & develop rapport through group warm up exercise (5 min)
• Engage in skills training group session (20 minutes)
  • Discuss an opinion-based and controversial topic using effective DBT interpersonal skills
• Provide a summary of group discussion and skills acquired (5 min)

Documentation

S: “These people always argue with me. I get mad when I’m with them.”

O: Client completed a 30-minute group session focusing on emotional regulation approaches with the use of DBT skills training. Client demonstrated difficulty engaging in the opinion-based discussion as he responded inappropriately to his peers 3x by raising his voice and insulting group members. Client used 2 foul words directed at peers who disagreed with him during the discussion. When given a verbal cue to use an alternative response to his verbal aggression, client became frustrated and stormed out of the therapy group session.

A: Client’s inability to refrain from insulting his peers and using an alternative response to his verbal aggression indicates emotional dysregulation and poor social skills.

P: Continue with DBT interpersonal skills to increase appropriate socialization and emotional regulation. Continue to evaluate progress of aggressive outbursts and maladaptive reactions in social interactions. Client to see OT 2x/ weekly for 30 minutes each in group sessions.

References

Brown, C. (2012). Occupational therapy practice guidelines for adults with serious mental illness. Bethesda, MD: AOTA Press. ISBN-13: 978-1-56900-331-2

O’Donnell, B. F., & Schnakenberg Martin, A. M. (2016). Emerging Behavioral and Psychotherapeutic Interventions for Schizophrenia. Dusunen Adam: Journal Of Psychiatry & Neurological Sciences, 29(3), 189-201. doi:10.5350/DAJPN20162903001