"Kathy" is a 32 year old female who has had 17 prior admissions to acute care psychiatric facilities for suicide attempts and self-mutilation. She reported hearing voices and losing periods of time for which she could not account.
Dissociative Identity Disorder, Post Traumatic Stress Disorder, Depression
Kathy was referred by her therapist for immediate admission for treatment of her self-mutilation, dissociative identity disorder, and post traumatic symptoms.
Barriers to Treatment
Kathy has been repeatedly self abusive by cutting her arms with razor blades, burning herself with cigarettes and masturbating with sharp objects.
According to her account, Kathy's childhood was characterized by two alcoholic parents who exhibited violence toward each other and Kathy. They divorced when Kathy was 5 and Kathy lived with her mother and a series of "stepfathers" who physically and sexually abused her. Kathy's mother confirmed much of this abuse in sessions with Kathy's therapist. Kathy was first hospitalized at age 13 following a Tylenol overdose. Shortly thereafter she refused to go to school and lived on the streets where she traded sex for food and shelter. Kathy was picked up by the juvenile authorities and spent the next 4 years in a residential program as a ward of the state.
Kathy's behavior improved with the structure; she completed high school and got a secretarial job. She married at age 20, but soon after began to have problems. Kathy's husband reported that she was extremely moody and would often become hysterical during sex. Kathy began having "flashbacks" of sexual abuse and became extremely depressed. She was hospitalized repeatedly during the next 10 years receiving diagnoses of schizo-affective disorder, bipolar mood disorder and borderline personality disorder.
Kathy had seen her current therapist for six months at the time of admission. A clinical interview conducted by this therapist revealed that Kathy often heard "mean voices in her head" and "children crying." Kathy reported that she cut on her arms and abdomen to "relieve the internal pressure and stop the bad feelings." Kathy said she frequently lost periods of time and would find herself in strange places not remembering how she got there. Upon request, the therapist was able to talk to an alter personality, Julie, who said that she helped Kathy during times of stress. Kathy's therapist requested admission to a Ross Institute program following an excerbation of self mutilatory behavior and threats of suicide.
Course of Treatment
An integrated team approach, consisting of psychiatrists, masters level therapists, case managers, direct care staff and Kathy, developed a master treatment plan which included individual and group psychotherapy. In individual therapy, Kathy and her therapist worked on identifying the alter personalities who were suicidal or self injurious, orienting them to the present, encouraging them to talk about their feelings and reframing them as positive and helpful. Kathy also worked with her therapist on problem solving and coping skills and practiced these new behaviors with peers on the unit. Kathy received a variety of specialized group therapies designed to address her defenses, anger and cognitive distortions. With these new skills she learned in the Trauma Program, she would not have to rely so much on dissociation as a coping strategy.
In groups, Kathy found safe ways to manage and discharge her anger and was able to talk openly about the difficulties her dissociative disorder created in her daily life. Cognitive distortions such as "I can hurt or kill the body and not die myself" and "It was my fault that I was abused" were recognized and corrected both in groups and in individual therapy. Education groups helped Kathy learn about her disorders and feel less isolated.
Through the course of treatment Kathy began to appreciate the protective role her dissocation played during childhood, and she began to accept her parts as parts of herself. She was able to partly revers her self-blame, and therefore be less depressed, suicidal and hopeless. Kathy was soon able to be discharged to the Trauma Day Program where she could practice her new skills in an outpatient setting.
Kathy was discharged to the Ross Institute Day Program, a partial program dedicated to the treatment of trauma disorders. Since Kathy was referred from another state, she was assisted in finding safe housing near the hospital. In the Day Program, Kathy was given many opportunities to practice her new coping skills and to learn effective strategies for independent living.
The above patient information is a composite of patients treated in the program.
"Lisa" is a 35 year old, single woman. She was admitted to the inpatient Trauma Program two weeks ago and is now considered stable enough for day treatment.
Axis I - Major Depression, Post Traumatic Stress Disorder
Axis II - Borderline Personality Disorder
Lisa was referred for treatment in the Day Program by her psychiatrist as a transition between the structure and safety of inpatient treatment and outpatient therapy at home.
Barriers to Treatment
Lisa is fragile and at risk for possible self injury. She is dependent upon external support, lacking in ego strength, and fears potential acting out during periods of stress.
Lisa was in outpatient treatment for six years. This is her fifth inpatient confinement. She was first diagnosed with major depression followed by bipolar mood disorder, then borderline personality disorder, before receiving the posttraumatic stress diagnosis two years ago. Lisa is quite dependent on her outpatient therapist who she sees three times per week, and who is becoming exhausted by the demands of treating this labile and needy patient.
Course of Treatment
An integrated team approach, consisting of the psychiatrist, masters level therapists, case manager, direct care staff and Lisa, developed a treatment plan which focused on correcting cognitive errors, building ego strength and emphasizing her responsibility for her own behavior. The patient received individual therapy three times per week and was able through that modality to improve her functioning to the point that she was ready for discharge. Self esteem was especially helped by group therapy, which improved Lisa's self confidence and problem solving abilities. Cognitive therapy groups helped Lisa recognize distortions in her thinking. Anger management groups helped Lisa learn to release her anger in healthy ways rather than to turn it inward. Life skills calss and trauma education group increased Lisa's knowledge of her defenses and coping strategies and improved her general level of functioning. The program's "no self harm" policy motivated Lisa to maintain her safety and built confidence in her ability to do so.
The Trauma Program's confrontive, yet supportive style, offered Lisa a chance to move from supervision to independence. It helped her find and use the strength within her to set and meet treatment goals and to begin setting and working toward real life goals. Lisa's outpatient therapist and psychiatrist were regularly informed of her progress. Upon her return home, Lisa was scheduled to see her outpatient therapist twice weekly. With the help of Trauma Program staff, limits were set on phone calls between therapy sessions. Lisa enrolled in college part-time and began working a few hours each week.
This information should NOT be used as a substitute for seeking professional medical diagnosis, treatment, and care.