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Clinical vignette

The first BCA described in the last chapter offers an opportunity to illustrate how a therapist and client may interweave multiple solutions for a single episode of behaviour. To enhance the clarity of the illustrations, we will present each solution analysis in the chronological order of its corresponding chain analysis, rather than in the order of solution generation in the session. Also, the solutions identified for the target behaviour represent a summary of the solutions generated over several analyses of similar episodes of the same behaviour.

In the first case described above, the therapist encouraged interpersonal effectiveness skills as a solution to increase the likelihood that the client’s husband would agree to spend time with her when she initially asks. Though his refusal to spend more time with her was not directly linked to her increased suicidality in this chain, the behavioural analysis did reveal a reinforcing link between the overdosing behaviour and the husband’s behaviour. One way to change this contingency was to increase the time with the husband in response to the client being interpersonally skilful. The judgements and anger that followed the husband’s departure were not key variables in this chain, but the therapist encouraged the client to become mindful whenever judgements occurred. Over time, the client also learned various emotion-regulation skills for the anger. Indeed, she eventually generated validating thoughts about her husband’s wish to spend time with his friends as a way to act opposite to her emotional urges.

In response to the loneliness, a common link across chains, the therapist and client generated a variety of solutions, some of which helped in the short term and others that created longer-term change. Initially, the client generated a list of distractions to cope with being alone. The use of these skills reduced the likelihood of the loneliness leading to intense anxiety in the moment, but they did not change the client’s general relationship to loneliness over time. The client also succeeded in changing the associations with being alone (the cue that prompted the loneliness) by learning to consider being alone as an opportunity to do things at home that her husband did not enjoy. This solution decreased the likelihood of loneliness, but again it did not change the experience of loneliness itself. Teaching the client how to experience the loneliness mindfully and how to develop a sense of connection to the universe at large proved the most effective solutions for the loneliness. Cognitive restructuring decreased the worry that the husband would not return but it had little impact on the “can’t cope” thoughts or the subsequent fear.

To treat the fear, which provided the primary motivation for the overdose, the therapist suggested a combination of mindfulness and emotion-regulation skills. This combination of both allowing and decreasing the fear seemed critical to reducing the overdosing. First, the client practised mindfully describing the “I can’t” thoughts and refocusing her attention on the task at hand. Next the client identified the action urges elicited by the anxiety (e.g. more “I can’t” thoughts, taking pills) and developed a plan to act opposite to these urges (e.g. asking, “What skills do I need to use?” and throwing away the pills). The therapist also encouraged the client to phone her for skills coaching. Longer-term solutions included implementing exposure procedures for the cue of loneliness and working on increasing mastery in other areas of her life.

If the client’s anxiety increased beyond a certain level or panic had begun, she would become cognitively dysregulated and require additional skills or adaptations of skills. Attending to Gottman’s tasks of emotion regulation and its corresponding cognitive requirements (Gottman & Katz, 1990), the therapist suggested that the client use grounding and distraction in response to high levels of fear and panic and then progress to the other solutions. Also, reviewing notes helped to overcome the memory problems associated with cognitive dysregulation. For example, during a session, the client could easily list negative consequences of self-harm as a way to inhibit her urges, but she had great difficulty recalling them while panicking. To solve this obstacle, she kept a detailed list of negative consequences in front of her medication.

To address the reinforcing consequences of the overdose, the therapist also employed contingency management. The treatment could not prevent overdosing from decreasing fear (thus the emphasis on treating the fear with other interventions), but it did succeed in changing the husband’s increased attention to his wife. Meeting with the client and husband together, the therapist developed a plan to change the husband’s behaviour such that he became more attentive when the client engaged in interpersonally skilful behaviour and less attentive when she engaged in suicidal behaviour.

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