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Commentary on The Case of "Sonia": Psychotherapy With a Complex, Difficult Patient
Grounded in the Integrated Psychotherapy Model of Héctor Fernández–Álvarez
The Case of "Sonia" Through the Lens of Dialectical Behavior Therapy
SARA GEISSER a,b AND SHIREEN L. RIZVI a
a
Graduate School of Applied and Professional Psychology, Rutgers—The State University of New Jersey
b Correspondence regarding this article should be addressed to Sara Geisser, PsyM, Graduate School of
Applied and Professional Psychology, Rutgers—The State University of New Jersey, 152 Frelinghuysen Road,
Piscataway, NJ. 08854
Email: [Link]@[Link]
_____________________________________________________________________________________________
ABSTRACT
Scherb (2014) describes the case of Sonia, a 44-year-old woman with severe and complex
presentation of borderline personality disorder, along with diagnoses of bipolar disorder,
trichotillomania, borderline intellectual functioning, and obesity. At the end of 10 years of
therapy with decreasing frequency, Sonia has made a dramatic recovery from almost all of her
presenting symptoms. Scherb's therapeutic approach was based on Fernández-Álvarez's
Integrative Psychotherapy Model, which incorporates behavioral, cognitive, and emotional
components. In this commentary we look at Sonia's psychopathology and treatment through the
lens of Dialectical Behavior Therapy, a highly developed treatment model that has shown
impressive success in treating individuals with borderline personality disorder and that also
combines behavioral, cognitive, and emotional components. A comparison of a DBT approach to
Sonia's case with the approach Scherb actually employed reveals many similarities in proposed
treatment strategies, as well as differences in the format and delivery of treatment.
Key words: borderline personality disorder; Dialectical Behavior Therapy; case formulation; case study;
clinical case study
____________________________________________________________________________
Elena Scherb (2014) describes the case of Sonia, a clinically complex client she treated
over the course of ten years at the AIGLE center in Buenos Aires, Argentina. Sonia participated
in a longitudinal research study run by Scherb designed to treat severe and multi-problem clients
with a history of hospitalization utilizing Héctor Fernández-Álvarez's (1992, 2001) Integrated
Psychotherapy Model. Sonia entered the treatment as a 45-year-old morbidly obese woman who
had problems managing her financial situation and her 18-year old mentally retarded son’s care.
Her family paid for Sonia’s apartment and her son’s care and, while they supported her
financially, Sonia’s relationship with her parents was marked by periods of conflict and fighting
followed by efforts to take over Sonia’s responsibilities and at times hospitalize her. Scherb’s
guiding model throughout treatment was the Integrated Psychotherapy Model, a model
promoting change through addressing dysfunctional schemas through a bio-psycho-social
perspective. Scherb and Sonia’s agreed-upon treatment plan included individual therapy, family
therapy, intensive case management and therapeutic coaching, and medication management, all
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occurring in different settings to help Sonia practice new behaviors in relevant settings such as
her work place and her parent’s house. Over the course of treatment, Scherb and Sonia focused
on restructuring Sonia’s beliefs about herself and her relationships with others, especially her
family, and made great progress in developing interpersonal skills and self-management skills.
Scherb’s conceptualization of Sonia’s case called for specific cognitive, behavioral, and
systemic interventions designed to address Sonia’s dysfunctional schemas. In this paper, we
provide an alternative perspective to conceptualizing Sonia’s treatment. Using Dialectical
Behavior Therapy (DBT; Linehan, 1993a, 1993b) we aim to identify problematic behavioral
patterns that underlie Sonia’s difficulties in functioning and systematically target these patterns
according to a hierarchy prioritizing behaviors that threaten Sonia’s life, treatment, and quality of
life. In this alternative case conceptualization, DBT will be used as the framework in
conceptualizing Sonia’s presenting problems, and the DBT structure and treatment strategies will
inform the development of Sonia’s DBT treatment plan.
DBT was originally developed by Marsha Linehan to treat women with suicidal
behaviors and BPD. Since its first implementation, DBT has gained strong empirical support
from randomized clinical trials (Lynch, Trost, Salsman, & Linehan, 2007). DBT has been
found to significantly reduce suicidal and self-injurious behaviors, decrease psychiatric
hospitalizations, decrease depression, and decrease dropout rates among participants as
compared with control groups (Linehan, Armstrong, Suarez, et al. 1991; Linehan, Comtois,
Murray, et al., 2006; Linehan, Heard, & Armstrong, 1993; Lynch et al., 2007). More recently,
DBT has been effectively applied to other diagnoses like substance dependence and eating
disorders as well as various treatment settings (Lynch et al., 2007).
DBT CASE FORMULATION
A strong case formulation in DBT in essential to inform the direction of treatment
(Koerner, 2007). After a thorough assessment of the client’s presenting problems and
psychological history, the first step in formulating a case is determining the client’s current level
of disorder which informs his or her stage of treatment (Linehan, 1993a). The different stages of
treatment determine which behaviors are targeted in treatment. Linehan has described five
different stages of treatment that progress from a “pretreatment stage” to Stage 4. In these stages,
clients first gain behavioral control to achieve a reasonable life expectancy; then work toward
reducing emotional desperation through targeting posttraumatic stress responses and
traumatizing emotional experiences; next work on increasing self-respect and solving problems
in living; and lastly work towards freedom to accept reality to address a sense of incompleteness
that might remain after the first three stages of treatment. For the purposes of this case, we will
describe the pretreatment stage and Stage 1.
The pre-treatment stage is the phase in which clients and therapists commit to treatment
and agree on goals to be worked on in therapy. The therapist describes the treatment and
highlights the importance of a collaborative relationship between client and therapist. The client
describes why she is seeking treatment at this time, and the therapist uses the biosocial theory as
a framework for discussing the etiology of the client’s dysregulated behaviors and emotions.
Additionally, any necessary risk assessment is completed during pretreatment, and a full history
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of suicidal behavior and self-injury is obtained. Pretreatment ends with the client committing to
giving up all suicidal and self-harming behaviors, and also committing to being a client in DBT
treatment. After commitment is obtained, the stages progress from Stage 1 in which the
overarching goal is to move a client from behavioral dyscontrol to behavioral control. Within
Stage 1 there is a hierarchy of behaviors to target, beginning with life-threatening behavior, then
treatment-interfering behavior, and lastly quality-of-life interfering behavior. The rationale
behind this hierarchy is related to DBT’s overarching goal of clients “building a life worth
living.” Clearly, individuals cannot build a life worth living if they are dead or are continuing to
threaten their life or safety with behaviors like suicide attempts and self-injury, and therefore this
category of behaviors is targeted first.
Next, any behaviors that interfere with therapy are targeted, under the assumption that
therapy cannot be effective if it is compromised by behaviors that interfere with treatment
progressing. After both life-threatening and therapy-interfering behaviors are decreased or
eliminated, the client and therapist address quality-of-life interfering behaviors. Under this
category falls many of the reasons why clients come to treatment—impulsive spending, fights
with significant others, substance use, depression, and a host of other behaviors that interfere
with the client’s quality of life. It is also important to note that stages of treatment are not
necessarily linear; in fact, it is quite common for clients to shift back and forth between pre-
treatment and Stage 1. When this occurs, time is spent recommitting to DBT treatment and the
goals agreed upon at the beginning of treatment.
The DBT stages of treatment provide the framework in which the treatment is conducted.
That is, the stage model and the treatment hierarchy dictate to the therapist what the targets of
treatment in any given session need to be. The “how” of DBT involves using the full set of DBT
strategies to help an individual move from a life of dyscontrol and overwhelming emotions to a
life of control, non-anguished emotional experiencing, and freedom from reality nonacceptance.
Although a full description of all the DBT strategies cannot be adequately presented within this
commentary, a brief description of the core strategies (behavioral problem solving, validation,
and dialectics) will be provided.
Behavioral problem-solving strategies are the vehicle of change within DBT. Problem-
solving is a two-stage process that first involves understanding the problem, then moves to
brainstorming and implementing alternative behaviors if the situation were to occur again. In
fact, many sessions are spent utilizing specific problem-solving strategies, like behavioral "chain
analysis" (a type of detailed functional analysis [Rizvi & Ritschel, in press]) and solution
analysis, to help the therapist and client first define and understand a problematic behavior, and
then assess and implement a plan for more adaptive behaviors. Additionally, DBT commitment
strategies are considered a part of behavioral problem solving, as they increase client motivation
and commitment to address problematic behaviors throughout therapy.
Validation, as defined by Linehan (1993a, 1997), is the communication to the client that
her responses in a given situation make sense and are understandable within her current life
context. Validation strategies are used in DBT to communicate acceptance and emphasize the
understandability of the client’s actions, thoughts, and feelings. Pushing a client to change her
behavior, emotions, and thoughts without acknowledging the “kernel of truth,” the piece that
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makes sense about their response given the individual’s history or current context, can isolate the
client and make them feel misunderstood and less motivated to change. Specific DBT validation
strategies include identifying, countering, and accepting “shoulds,” finding the “kernel of truth,”
and "cheerleading" the client by focusing on their capabilities and assuming that each client is
doing the best she can. Validation strategies are extremely important in DBT; they can increase
connectedness between the client and therapist, increase a therapist’s own empathic attitude, and
teach the client to trust and validate herself (Linehan, 1993a).
The “D” in DBT stands for dialectical, which originates from a dialectical philosophy
that views reality as a holistic and ever-changing process that is not stagnant but instead consists
of opposing views continually synthesizing and changing. Dialectics are inherent in all aspects
of DBT treatment; DBT therapists are aware of dialectical tensions that arise in treatment, and
dialectics are represented as a set of concrete strategies used by the therapist to teach and model
to the client the inherently dialectical nature of her own reality (Linehan, 1993a). Dialectics as a
core strategy aims to balance acceptance and change, which are each represented in the other
core strategies, behavioral problem solving and validation, respectively. The dialectical
strategies are used to highlight a tension that exists in the client’s life or within a therapy session.
These strategies are used to help the therapist hold both sides of a dialectic in order to avoid
getting into struggles in treatment in which the client and therapist each hold one side of a
dialectic and remain stuck in their own position.
CONCEPTUALIZING THE CASE OF SONIA
FROM A DBT FRAMEWORK
Based on Scherb’s description of Sonia upon entering treatment, we would view Sonia as
starting DBT treatment in either pre-treatment or Stage 1 of treatment. The differentiation would
be made based on whether Sonia is committed to participating in treatment, eliminating self-
harming and suicidal behaviors, and her agreement to goals developed by her and her therapist.
During Sonia and Scherb’s first sessions, Sonia seemed to vacillate between commitment to the
treatment and hesitancy to participate in parts of the treatment that involved other family
members. This is an example of how clients often revisit pre-treatment; Sonia’s lack of
participation in agreed-upon family meetings demonstrated a need for further orientation as to
why sessions with her family might be important in helping Sonia reach her treatment goals. To
elicit such a commitment, DBT therapists implement a number of strategies. These are designed
(a) to link current commitment to treatment and the client’s future goals, and (b) to highlight the
incompatibility of current dysfunctional behaviors with reaching those goals.
For example, DBT therapists often implement the strategy of “Devil’s Advocate.” This
instructs the therapist to take the opposite side of the argument for stopping dysfunctional
behaviors as a way to challenge the client to come up with her own reasons why stopping these
behaviors would benefit her. In Sonia’s case, Scherb might say something like, “Why would you
agree to not shout and scream during these family sessions when your family members are
blaming you and treating you like you are not a part of they family? Why not refuse to
participate in family sessions, or at least continue to yell at your family when you feel blamed?”
The hope in using this strategy is that Sonia would argue against the therapist and jump in with
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arguments for changing her current behaviors. She might point out that in order to avoid her
family from hospitalizing her, she needs to sit through family sessions without yelling at them,
and her willingness to participate in family sessions would increase the likelihood that her family
would continue to agree to pay for the treatment, which she wants to continue individually.
Treatment Targets
Goals of treatment in DBT are defined behaviorally in terms of behaviors to decrease and
behaviors to increase. The overarching goal for clients in DBT treatment, as described by
Linehan (1993a), is to increase dialectical behavior patterns and decrease extreme behaviors and
cognitions so they can respond to each moment with more balanced and integrated responses. In
Sonia’s case, some typical dialectical tensions that would be a focus in treatment include
independence versus dependence, emotional control versus emotional tolerance, and self-
efficacy versus help-seeking. Aside from these dialectical behavior targets, Sonia’s target
behaviors would be addressed in the following order according to the DBT hierarchy.
Life-Threatening Behaviors
Stage 1 of DBT treatment targets life-threatening behaviors, therapy-interfering
behaviors, and quality-of-life-interfering behaviors in that order. Sonia had been hospitalized
five times in her life, including twice in the three years prior to the beginning of her treatment,
and more information is necessary to determine whether any of the behaviors that resulted in her
hospitalizations would be categorized as life-threatening. Factors to consider include the
presence of suicidal thoughts or intent, and any intent to harm herself or others during violent
outbursts. The next behaviors to target are intentional self-injurious behaviors. Scherb
categorized Sonia’s trichotillomania as self-injury in her conceptualization of the case. In DBT,
the function of the hair pulling would need to be explicitly and concretely assessed in order to
determine if it is in fact self-injurious. That is, if Sonia pulled out her hair with the intent to
induce pain and punish herself, it would be considered self-injury; but if this behavior functioned
more as a way to reduce anxiety or other intense emotions, it would be more appropriately
conceptualized as a quality-of-life-interfering behavior.
Scherb also noted that Sonia was in a relationship with a man who was physically
aggressive and verbally abusive towards her, and she labeled her involvement in this relationship
as “self-injury… in a covert manner” (Scherb, 2014, p. 10). While it is apparent that Sonia’s
continued participation in this relationship resulted in Sonia being belittled and abused, that
behavior would be better categorized within a DBT framework as a quality-of-life-interfering
behavior. DBT, as all types of behavioral therapy, aims to functionally define problems, that is to
describe problems in terms of the specific behaviors that constitute them and the environmental
and experiential contingencies that appear from observational evidence to reinforce and
maintain those behaviors. The problem in labeling Sonia’s relationship as self-harm and using
the label of “self-harm” for a wide variety of behaviors that inadvertently harm an individual is
that it does not speak to the function of the behavior nor does it help to address the possible
contingencies that reinforce and maintain the behavior. The label “self-harm” is reserved in
DBT to mean any behavior that functions to purposely inflict physical harm to a person’s body.
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If the function of Sonia staying in this relationship was not to directly inflict physical harm onto
herself, but rather to serve some interpersonal function, it would not be labeled self-harm.
Therapy-Interfering Behaviors
While Scherb’s summary of Sonia’s treatment plan did not explicitly address treatment-
interfering behaviors as a specific target, it could be assumed that Sonia occasionally behaved in
a way that interfered in the treatment. The description that Scherb gave of Sonia yelling and
leaving during a family session is an example of a non-collaborative, therapy-interfering
behavior. In DBT, this behavior would be addressed as a target in the following session. Both a
chain analysis of what events, thoughts, and feelings led up to the problem behavior, as well as a
solution analysis of ways to intervene in the future before the problem behavior occurs again,
would be conducted in the next session with Sonia. Other therapy-interfering behaviors that
Sonia may have engaged in, given the information that Scherb shared in her treatment summary,
might have included Sonia’s willfulness to participate in skills practice with her therapeutic
coach or yelling during sessions. Some therapist-initiated, treatment-interfering behaviors that
Scherb herself may have engaged in include treating Sonia as fragile or failing to see the
dialectic around a particular issue in treatment. These are common therapist responses to clients
who express feeling helpless or conversely hold tightly onto their own agenda, and it can be
assumed that within ten years of treatment Scherb engaged in these behaviors at some point.
Quality-of-Life Interfering Behaviors
Many of Sonia’s presenting problems as outlined by Scherb’s problem list fall into this
category of behaviors to target. These targets include decreasing depressive symptoms,
decreasing financial dependence on her parents and increasing control over her own spending
and finances, increasing responsibility over her son’s care, decreasing anger and fights with her
parents, increasing social contact and supports, and increasing self-care as it relates to her
obesity. Addressing these target behaviors could both improve Sonia’s functioning as an
independent adult and also improve her quality of life by increasing positive events and
relationships as well as addressing her health concerns.
Biosocial Theory
A cornerstone of DBT case conceptualization is utilizing the biosocial theory to
understand how an individual’s biology and environment transact over time to contribute to the
client’s current maladaptive behavioral patterns. The biosocial theory is mapped onto each
client’s personal developmental history as a way to conceptualize the client’s current difficulties,
and it is also discussed with the client within the first few sessions as a way of communicating in
a non-pejorative fashion the therapist’s understanding of how the client developed maladaptive
behavioral patterns over time. The biosocial theory proposes that the transaction between
emotional vulnerability and an invalidating environment lead to the development of emotion
dysregulation and other characteristics associated with borderline personality disorder.
In the section labeled “Origin of Mechanisms,” Scherb describes the transaction between
Sonia’s inherent emotional vulnerability and her family’s invalidation of her emotions. Scherb
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(2014) describes Sonia as having an “emotionally sensitive disposition and modest cognitive
resources” (p. 9). In DBT, this is labeled “emotional vulnerability” and is described as a
biological predisposition to being highly sensitive to emotional stimuli, highly reactive to
emotional experiences, and having a slow return to emotional baseline. In Sonia’s case, the
invalidating environment might be defined by her parents’ failing to acknowledge her internal
emotional experience. A transactional process occurred between these two factors: Sonia’s
parents intermittently reinforced her escalated displays of emotion by first punishing these, then
reacting when she escalated her displays of emotion—bursting into tears and becoming violent—
by becoming overprotective and trying to fix Sonia’s problems. As noted by Scherb (2014),
“…this method of influencing the world was effective for Sonia” (p. 9), and therefore she missed
the opportunity to learn more effective ways to self-regulate. This resulted in Sonia’s deficit in
regulating her own emotions and behavior, as her parents swooped in to fix the problem each
time Sonia became more emotionally dysregulated.
COMPARISON OF SCHERB'S ACTUAL
TREATMENT TO A DBT APPROACH
Much of the Scherb’s treatment with Sonia is consistent with a DBT framework and
philosophy. Over the ten years that Scherb worked with Sonia, she shifted back and forth
between implementing strategies aimed at helping Sonia change her behaviors and helping Sonia
restructure her maladaptive schemas to increase acceptance. This flow between acceptance and
change is consistent with a dialectical approach to treatment. In Scherb’s description of the
treatment, it seems as if there was a balance between validating Sonia, especially in regards to
her feeling blamed and abandoned by her family members, and supporting her in making
changes such as acquiring a job.
Scherb states that a primary mechanism maintaining Sonia’s current problems is a
disturbance in emotion regulation. A DBT conceptualization would support this, as Linehan
(1993a) posits that symptoms associated with BPD primarily result from a deficit in emotion
regulation. One difference between a DBT approach compared to Scherb’s treatment, however,
might be DBT’s focus on behaviorally defining the problems that Sonia experiences as a result
of this emotion regulation deficit, whereas Scherb often defines Sonia’s problems in the context
of maladaptive schemas and core beliefs. DBT incorporates cognitive strategies, such as
cognitive modification or restructuring; however, behavioral theory is the underlying theoretical
basis for DBT and therefore problems are defined behaviorally, with an emphasis on
understanding problematic patterns as failures to regulate one’s emotions.
The order in which Scherb and Sonia worked toward certain treatment goals was similar
to the approach that a DBT therapist might take in individual therapy. In conjunction with the
target hierarchy, the goals of DBT therapy are first to acquire basic capacities and a reasonable
life expectancy, then to reduce PTSD symptoms, and lastly to increase self-respect and work
toward achieving individual goals (Linehan, 1993a). Scherb’s treatment with Sonia followed a
very similar path. The treatment began with helping Sonia gain some basic capacities; they
worked to increase her effectiveness in communicating with her family, helped her gain control
over her finances, and worked on reducing maladaptive behaviors like yelling at others when
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angry. Scherb (2014) notes that the first step in Sonia’s treatment was “…to find some aspect in
which Sonia could believe in herself (the beginning of self-esteem)” (p. 11). While increasing
self-esteem would not be the first goal in DBT treatment, the ways in which Scherb and Sonia
worked toward increasing mastery and self-esteem is still consistent with a behavioral approach.
Specifically, Scherb used contingency management strategies to shape Sonia towards desired
behaviors, like naturally rewarding Sonia’s progress by increasing her independence from her
therapeutic coach or rewarding her with vacations when she accomplished a treatment goal.
After Sonia made significant gains in basic capacities like getting a job and better
tolerating her emotions during family sessions, they moved on to reducing Sonia’s
interpretations of others’ behaviors as rejecting and abandoning. This helped to increase Sonia’s
sense of mastery as she reduced behaviors that distanced herself from others through a process
of challenging her negative interpretations of her family’s and coworkers’ behaviors. During the
final stages of Sonia’s treatment, Sonia accomplished two goals that previously interfered with
her quality of life: finding a more appropriate living situation for her son and beginning to treat
her obesity. From a DBT perspective, it is important to note that treatment targets are flexible
and subject to change with continuous assessment. For example, at the beginning of treatment,
Sonia’s living situation with her son may have been categorized as “quality-of-life-interfering.”
However, as time went on and their relationship became violent and the potential for harm
between Sonia and her son became more evident, the relationship may have been moved higher
up in the hierarchy of targets and addressed before other quality-of-life-interfering targets.
A number of other points about Scherb’s treatment in comparison to DBT treatment are
noteworthy. First, the focus on skills acquisition and generalization is seen as a great strength in
Sonia’s treatment from a DBT perspective. In DBT, one mode of treatment is a skills group, in
which clients are taught new skills—mindfulness, distress tolerance, emotion regulation, and
interpersonal effectiveness—and are asked to practice these skills to increase generalization of
these skills in their environment outside of treatment. Additionally, the individual therapist acts
as a skills coach as needed and is available by phone for the purpose of in-vivo skills coaching to
increase skills generalization in specific challenging situations. In Sonia’s case, she was
assigned a therapeutic coach who helped Sonia acquire new skills and practice them in various
contexts like work and at her parent’s home. While the mode of delivery of skills may be
different between the two approaches, the importance that Scherb placed on Sonia’s skill
development likely contributed significantly to Sonia’s continued progress throughout treatment.
DBT places great importance on skills acquisition and generalization to the extent that individual
therapists take time in sessions to model skillful behavior, are available outside of session for
skills coaching, and dedicate a mode of treatment entirely to skills acquisition. Sonia’s access to
a therapeutic coach, assuming their work was similar to a skills coach as described above, is
similar to the various modes of skills work done in DBT.
Some final points of comparison between the two treatment approaches have to do with
treatment efficiency and continued assessment. DBT is an outcome-oriented treatment; efficacy
of treatment is measured by the reduction of target behaviors like self-harm and hospitalization
and the increase of more skillful behaviors and positive outcomes like employment and
improved relationships. For this reason, client progress in DBT is assessed at regular intervals
by the use of a daily Diary Card and often more structured assessments at designated intervals
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throughout treatment. The use of the Diary Card determines the direction of treatment each
session and ensures that behaviors are being targeted according to the hierarchy. Regular
assessment allows the therapist to assess whether they are on track in terms of reaching their
treatment goals, and allows for changes to be made to the treatment plan as necessary. Scherb’s
monitoring of Sonia’s progress using the List of Problems and Behaviors Questionnaire
(LOPBQ) demonstrates that over the course of treatment Sonia made significant progress
towards her goals. In DBT, assessment procedures would ideally consider similar problematic
behaviors on a more frequent basis.
Continued assessment also impacts treatment efficiency, with the goal being to deliver a
treatment that is effective and also time-limited and cost-effective (Rizvi & Harned, 2013).
Little has been published about DBT beyond Stages 1 and 2 during which time behavioral
control is achieved, partly as a result of the time-limited nature of research studies and grant
funding. DBT treatment outside of a research setting is not confined to a 6-month or 12-month
course of treatment, and most DBT clinicians would agree that for clients with severe
psychopathology like Sonia’s, 12 months of treatment would not be sufficient.
However, a ten-year course of DBT treatment would likely not be favorable. Aside from
the costs of treatment, DBT’s overarching goal of “building a life worth living” would not
necessarily be in line with remaining in intensive therapy for 10 years. Rather, once Sonia
achieved certain treatment gains like maintaining a job, handling her own finances, and
eliminating hospitalizations she might be referred to a DBT-informed clinician in the community
for once-weekly psychotherapy rather than continuing to participate in a comprehensive DBT
program. In Scherb's (2014) case study, she presents a helpful Table 1, labeled "Sonia’s
Treatment Phases, Treatment Resources and Frequency Over Time." Summarizing the table,
Scherb states that Sonia’s contact with other treatment providers declined greatly by her fourth
year in treatment, leaving her with individual therapy once weekly and monthly family sessions.
This decrease in treatment intensity, and subsequent increase in other activities like going to
work and participating in hobbies, is a desirable outcome according to DBT.
CONCLUSION
Scherb’s execution of the Integrated Psychotherapy Model shares many similarities with
a DBT conceptualization and treatment approach for the case of Sonia. Both models emphasize
the need for a structured treatment plan to systematically address the numerous problems with
which Sonia presented to therapy. Scherb’s focus on helping Sonia change ineffective behavioral
patterns, acquire and generalize more skillful behaviors in various contexts outside of therapy,
and improve the quality of her life by targeting problems like her obesity is consistent with a
DBT approach. Some differences exist, however, in how Scherb formatted treatment as
compared to a DBT approach. For example, in our discussion above, we pointed out how DBT
takes a more behavioral and a more functional analytic approach to developing a case
formulation and treatment plan; a more formalized approach to focusing the therapy on different
stages; and more frequent monitoring of the client's progress, yielding the possibility of
improved treatment efficiency. Still, Scherb’s approach to treating Sonia resulted in the
reduction of many of Sonia’s problems over the course of treatment and contributed to a vast
improvement in Sonia’s quality of life.
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