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Case of Danielle Danielle is a 20-year-old woman with a history of bipolar disor
Case of Danielle Danielle is a 20-year-old woman with a history of bipolar disorder, non-suicidal self-injury (NSSI), and frequent marijuana use. Danielle is currently a sophomore in college, being seen twice per week in the college counseling center. She self-referred to counseling her freshman year following a course of partial hospitalization, intensive outpatient, and individual outpatient treatment for bipolar disorder throughout her junior and senior years in high school. NSSI History Danielle began cutting in ninth grade, though she cannot recall the precise onset or the rationale for her decision other than “my parents were getting divorced and I was just really fucked-up about the whole thing.” Over time she began to utilize NSSI to manage her affect, mood, and cognition. Danielle would carry a small sandwich bag in her backpack filled with shards of broken glass (she had broken an old juice glass). When she felt “out of control” she would go the bathroom, lock a stall, and cut her upper leg. Her family and friends never knew about her cutting as she would carefully cut areas that she could hide via clothing. Danielle’s NSSI increased to sometimes two times per day, almost every day of the week. However, Danielle also began to grow frustrated with her NSSI in her latter high school years into college. For example, Danielle does still engage in NSSI as of today, but after she does so, she experiences a negative reaction: It sucks. This used to make me feel in control. It helped me feel something. Now, it does nothing. Empty. I feel the pain of the cutting, but that’s it. Then, I feel guilty as shit afterwards for having cut. I keep going back to it, then it sucks, but I keep going back to it. Bipolar History Danielle struggled with depressed mood and manic-type episodes throughout her latter teen years. At the age of 18, she was formally diagnosed with bipolar disorder. Danielle experiences a few moderate to severe depressive episodes per year (typically lasting approximately three weeks). She also has experienced a few episodes of her clinicians deemed as mania. When manic, Danielle would act erratic, be irritable, and suffer from bouts of insomnia. Bipolar and NSSI Inter-relationship When depressed, Danielle also experiences suicidal ideation. The depth of her depression “scares” Danielle, so this is where she typically engages in NSSI to manage her emotions. Danielle has not cut in the past three months, but reports the idea comes to mind nearly every day—especially following a stressful event when already in a depressive episode: So, I got a “C-“ on a test. I knew it wasn’t going to go OK because I had been depressed past few weeks. My first damn thought was to go back to my room, find something sharp, and cut my leg. I even started walking back to the dorm, even though I had told a friend I’d meet her for lunch in 5 minutes. I got halfway to the dorm when I just sort of snapped out of it and thought what the hell am I doing? I didn’t cut, which I’m proud of, but the pull to do so was still nagging me all day and night. And that bothered me. I got depressed about wanting to cut. That just makes the pull to cut even stronger. Danielle and her counselor work on management of her depressive symptoms, processing her NSSI ideation and abstaining from NSSI acts, and recognizing developing potential manic symptoms. Danielle says the hardest part is “not wanting to cut, and not cutting when I do want to.” Questions to Consider: Please discuss how your conceptualization of this case would differ by comparing a stance where NSSI is seen as a co-occurring process addiction and where NSSI is NOT considered an addiction. Do you handle Danielle differently? If yes or no, please explain why. From a CBT or REBT perspective, how would you assist Danielle in managing her co-occurring NSSI and bipolar disorder (namely, the depressed mood)? Discuss Danielle’s NSSI using some of the recovery/relapse models discussed in Chapter 10.

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