Therapy in a Nutshell: For Emotional Dysregulation

Presenting Issues

Zee* came in with severely depressive symptoms, including ideas and attempts to self-harm. They also mentioned experience of panic attacks and severe anxiety that tends to become stronger around the evening, after which they usually begin to feel desperate for relief or symptom reduction in some way owing to a deep sense of unsafety in their body. This led them on to self-harm, further guilt and other distressing emotions that kept certain self-sabotaging patterns going with no break or rest.

Background Information

In the intake session, they mentioned having received multiple clinical diagnoses by various health professionals, including ADHD, borderline personality disorder, bipolar disorder – most of which relate generally to a difficulty in managing one’s own emotions, and the resulting impulsivity in one’s behaviour. The coping mechanisms that Zee seemingly had access to were mostly self-harming and sabotaging in nature, making the need for exploring healthier and supportive options for nervous system and emotional regulating a potential lead to follow.

Assessment

The client came into therapy in a state of ongoing crisis, exhibiting severe symptoms of depression and anxiety. A high degree of emotional lability (rapid, exaggerated changes to one’s emotional state, that can look like intense mood swings) was also observed.

Treatment Plan

Goals

1. Zee chose to work with the very present physical/physiological concerns of overwhelm and distress (and the specific patterns in which they were coming up). She also felt the need to work on leaning first into ‘less unhealthy’ ways of coping, and steadily moving towards creating a list of progressively and relatively healthier alternatives.

Intervention Strategies

1. Slowly and deliberately incorporating various grounding and orientation techniques to help the client feel more present and regulated within each session.
2. Usage of cognitive-behavioural techniques mixed in (based on the client’s preferences and past affinity) to specifically help in working with building a list of coping responses for various situations they were likely to enter into. These alternatives were presented in an order of relative healthiness to relative unhealthiness. This gradual exploration of the rationale behind each alternative’s inclusion provided further ground to Zee’s sense of Self and agency.
3. Use of Somatic orientation and Nature-based imagery were employed as and when needed to stabilize the functionality of the nervous system. Techniques within the Somatic Experiencing (or SE^TM) framework helped reduce the possibility of retraumatization while making more space for better regulation.

Frequency and Duration

Weekly therapy sessions for the first 6 months, a break of about 10 months, then bi-weekly session work from the last 2 months, and continuing.

Results

1. Starting with feeling disconnected and overwhelmed around thoughts of self-harm, Zee moved slowly to co-regulate differently with their therapist over time as the trauma-focused work allowed for them to experience and stay longer with the previously traumatized parts of themselves that had been waiting to feel more of safety in the body.
2. They came into the realization that without this safety, their body had been stuck in a sense of urgency and desperation that was not based off of anything specifically current, but seemed real to them anyway.
3. An important shift occurred after exploration and discussion of their support system(s) - what was absent, what was present, and in which directions they would prefer to be supported differently from what was accessible currently.
4. Over time, they learned different ways of regulation that worked well enough for them to experience more connection with their body, more of joy and essentially, more of life.