DBT Treatment Plan

Treatment Plans

Diagnosis

F60.3 Borderline Personality Disorder F33.1 Major Depressive Disorder, recurrent, moderate

Presenting Problem

Pt is a 26 y/o female presenting with chronic emotional dysregulation, interpersonal volatility, and recurrent NSSI (superficial cutting on forearms) triggered by perceived abandonment. Reports worsening depressive symptoms, emptiness, and impulsive anger outbursts over the past 3 months following a relationship breakup. Currently prescribed lamotrigine (Lamictal®) 100 mg PO QHS and fluoxetine (Prozac®) 40 mg PO QAM.

Treatment Goals

The client reports their goal for treatment is "to stop hurting myself when I get overwhelmed and learn how to not ruin my relationships." In the short term, the client wants to eliminate self-harm behaviors and reduce daily emotional reactivity. The client and clinician collaboratively created the following goal: achieve behavioral control over self-destructive urges and build a life worth living through improved interpersonal stability over the next year. Progress will be assessed weekly via DBT diary cards, tracking urge intensity (0-5 scale) and skill utilization, alongside quarterly PHQ-9 and BSL-23 assessments. The client was offered and accepted a copy of the treatment plan.

Objectives

Leveraging the client's high motivation and artistic expressiveness, she will replace NSSI with adaptive distress tolerance skills when experiencing emotional distress rated ≥ 4/5, reducing self-harm episodes to zero per week as measured and tracked daily on her DBT diary card.

Chain analysis and Distress Tolerance skills training - Individual DBT and DBT Skills Group - Weekly - 15/09/2026 - 5 months

Conduct behavioral chain and solution analysis on NSSI urges; teach and rehearse TIPP, ACCEPTS, and self-soothing skills.

Individual DBT psychotherapy (60 mins) and DBT skills training group (90 mins), supplemented by between-session phone coaching PRN.

1x/week individual therapy; 1x/week group skills training.

15/09/2026 (5 months)

Utilizing her strong capacity for empathy, the client will decrease interpersonal conflict by applying emotion regulation and interpersonal effectiveness skills during relationship stressors, achieving a 50% reduction in verbal outbursts as logged weekly on her DBT diary card.

Mindfulness, Emotion Regulation, and Interpersonal Effectiveness training - Individual DBT and DBT Skills Group - Weekly - 15/09/2026 - 5 months

Instruct on DEAR MAN, GIVE, FAST, and Check the Facts; role-play assertive communication and opposite action during individual sessions.

Individual DBT psychotherapy and DBT skills training group.

1x/week individual therapy; 1x/week group skills training.

15/09/2026 (5 months)

Discharge Criteria/Planning

Pt will be ready for step-down to standard outpatient maintenance therapy upon achieving: 6 consecutive months free of NSSI and suicidal behaviors, consistent independent application of DBT skills during crises, BSL-23 score reduction by ≥ 50%, and stable functioning in occupational and social domains.

Additional Information

Strengths: High verbal intelligence, strong insight into triggers outside of acute distress, employed full-time, supportive sister (collateral contact: Sarah Miller, ROI on file). Barriers: History of therapy-interfering behaviors (late cancellations when feeling shame), black-and-white thinking. Safety Plan: Active Stanley-Brown safety plan in chart. Pt agrees to remove sharps from bathroom, utilize ice/cold water (TIPP skill) for acute urges, contact DBT therapist for phone coaching prior to acting on NSSI urges, or call 988 / present to nearest ED if safety cannot be maintained.

Prescribed Frequency of Treatment

Individual DBT session 1x/week, DBT Skills Group 1x/week, and psychiatric medication management 1x/month.