Research Proposal on "Theory Therapy Levy, Meehan, Kelly, Reynoso, Weber"

Research Proposal 15 pages (4158 words) Sources: 10 Style: APA

[EXCERPT] . . . .

Theory Therapy

Levy, Meehan, Kelly, Reynoso, Weber, Clarkin, & Kernberg have developed an empirical research work that begins with a comprehensive explanation of the various aspects of the work. Change in Attachment Patterns and Reflective Function in a Randomized Control Trial of Transference-Focused Psychotherapy for Borderline Personality Disorder the work defines the psychological disorder, borderline personality disorder (BPD). BPD is a highly prevalent, chronic, and debilitating psychiatric problem characterized by a pattern of chaotic and self-defeating interpersonal relationships, emotional lability, poor impulse control, angry outbursts, frequent suicidality, and self-mutilation (Skodol et al., 2002). (2006, p. 1028) the work also states that the prevalence of BPD is significant in the general population (@1-2%) and the psychiatric population (@11%) with a higher percentage in inpatient, out patient, and long-term care psychiatric patients. (2006, p. 1028)

The work goes on to discuss the original inception of attachment theory, relying heavily on the original theorist associated with the various aspects of the theory, including how attachment is defined and measured. Attachment theory is based on the idea that individuals go through a period in childhood where attachment occurs at normal or abnormal levels and if tit occurs at abnormal (decreased0 levels then the child will be at greater risk for psychological disorders as an adult. (2006, p. 1028) the work describes reflective function as the ability of the individual to appropriately code and remember events that have occurred within their life, in those with BPD there is a significant impairment in the ability to do so, especially within close interpersonal relationships. (p. 1029) Thus the hypothesis goes that psychotherapy that focused specifically on reflective function skills is more effective than other types of psychotherapy on treating those with BPD. The work then goes on to describe the empirical nature of the work through a longitudinal review of the effectiveness of three different types of psychotherapy on BPD.

The authors attempt to prove that changes in the observed levels of attachment organization (scaled as: secure, preoccupied, dismissing, unresolved, and cannot classify) and reflective function (RF) are the expected mechanisms of change with regard to the development of psychotherapy sessions that are specifically geared toward individuals with BPD. The study ran over a 1-3-year period where individuals diagnosed with BPD participated in psychotherapy sessions that were tailored specifically to improve attachment organization and reflective function, to more normal levels. The specific types of psychotherapy used on the 90 randomized BPD diagnosed patients are transference-focused psychotherapy, dialectical behavior therapy, or a modified psychodynamic supportive psychotherapy. Each study group was then assessed utilizing the Adult Attachment Interview technique and the Reflective Function coding scale. According to the researchers after 12 consecutive months of psychotherapy there was a significant increase in the number of patients who were classified as secure with regard to their state of mind, among those who participated in TFP, while only limited improvements were seen in the other two test groups. TFP participants also showed significant improvement in narrative coherence and Reflective Function. None of the three groups showed significant improvements in the resolution of loss or trauma. The later finding was surprising, as it had been assumed that all these functions were interdependent, as loss and lack of resolution of trauma are significant but independent of one another in functional memory and present memory. "Findings suggest that 1 year of intensive TFP can increase patients' narrative coherence and RF." (2006, p.1027) the work stresses the need to seriously look at TFP treatment to see what it is specifically about the treatment type that is most effective for BPD patients and what is less effective to help create a more effective treatment plan for the relatively pervasive disorder and establish best practices for treatment, as it is associated with failed attachment in youth. (p. 1037)

Clarkin and Levy in a 2003 empirical study a Psychodynamic Treatment for Severe Personality Disorders: Issues in Treatment Development, test the development of a treatment manual for TFP on patients with BPD through a comprehensive look at its specific efficacy. The importance of the work is to describe in detail the nature of TFP and why when modified for BPD patients it is most effective. The work first describes TFP, then goes on to trace the development of the TFP manual and describes the specific goals of TFP as a treatment regimen:

The major goal of TFP is the development of integrated self and object representations, the modification of primitive defensive operations, and the resolution of identity diffusion that perpetuates the fragmentation of the patient's internal representational world. In this treatment, focusing on the transference is the primary vehicle for transforming primitive object representations (i.e., split, polarized) into more advanced ones (i.e., complex, differentiated, integrated). (p. 251)

The empirical aspect of the work describes the use of intensive TFP treatment on 17 of 32 patients in treatment for BPD with TFP, utilizing the model developed in the manual and taught specifically to the therapists in the trial. Psychodynamic changes are then detailed after patients have been exposed to a full year of treatment. The uniqueness of this study is in the fact that changes are addressed with both self report before and after assessments and the socio-dynamic aspects of real behavioral change for these individuals was assessed.

The major finding in this study is that patients with BPD who are treated with TFP showed marked reductions in emergency room visits, hospitalizations, days hospitalized, and increase in global functioning. The effect sizes were large and no less than those demonstrated for outpatient DBT, inpatient DBT, and a psychodynamic day treatment (Linehan et al., 1991; Bateman and Fonagy, 1999; Bohus et al., 2000). (p. 262)

The study is also significant in that it develops a before and after change assessment using MRI screenings. The work stresses that there are significant expected and unexpected changes for patients in the work and that such changes are demonstrative of the fact that a controlled TFP treatment plan is a highly effective and should be further developed.

Ryle & Fawkes in Multiplicity of Selves and Others: Cognitive Analytic Therapy discuss in case study format the much less prominent psychological disorder known as multiplicity. (2007) the work demonstrates the novel clinical use of cognitive Analytic therapy, by a novice clinician, on a single patient. The empirical work initially explains the normal development of multiplicity, as a product of children experiencing relationships that require varied social responses and adapting to those varied situations and then goes on to explain how such multiplicity can falter in situations of extreme depravity, stress or abuse. Abnormal multiplicity may result in the individual carrying, into adulthood a set of selves that are designed to protect the individual from painful and/or feared experiences, with or without amnesia of other selves. (p.166)

The work then describes the method of treatment, including standard length, supervision process and outcomes, for this single individual with abnormal multiplicity, associated with post traumatic stress that continued into his adult life. The individual is in fact being seen at age 70 as a result of conflict associated with an inability to allow a necessary change to occur in his life. Cognitive Analytic Therapy (CAT) over 16 weekly sessions is determined to be the treatment of choice. (p. 167) Cognitive Analytic Therapy is described comprehensively including the stages of the practice, reformulation, active therapy and termination phase. In reformulation stage the clinician travels through symptoms and concerns with the patient and begins to form a picture of the problems, while in the active therapy stage of the work the therapist attempts to build a map, with the help of the patient that allows the therapist to be knowledgeable of the whole of the self, which they then allow the individual to see, in diagram form and the tool is utilized for the purpose of illuminating the selves to one another, allowing the core self to face the reasons and cognitions that are experienced to shelter the core from fear of harm. Finally in the termination phase the clinician offers the patient reasonable alternatives to resolving concerns and issues without turning to negative multiplicity roles and closes the therapy with appropriate resolution of a therapeutic relationship. (pp. 167-173)

The case study format is particularly effective in this instance as levels of multiplicity, either abnormal or normal can be better understood and the individual, in a relatively rare state of psychological distress can help illuminate the process for the novice clinician. The work is instrumental in understanding how the self can and does create defenses that are particular to how the individual sees him or herself and how they interact in their social and emotional relationships as a result of the failure to integrate selves. The work is also strong in the sense that it stresses the concerns and barriers experienced by the clinician, as she attempts to gain true empathy with the individual and build an appropriate therapeutic relationship over a relatively short period of time, something that is frequently… READ MORE

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