Theory Therapy Levy, Meehan, Kelly,

¶ … 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 asked of clinicians.

Kellogg & Young in Schema Therapy for Borderline Personality Disorder offer a comprehensive explanation of the use of Schema Therapy for patients with BPD, by first explaining the disorder and how it is particularly prime for the use of schema therapy as the disorder itself and the behavior and emotions exhibited from it can be seen as an individual traversing through a short list of schemas and are reflective of the childhood origins of BPD. The modes of BPD are described by the authors as consisting of the angry and impulsive child mode, the detached protector mode, the punitive parent mode and lastly the healthy adult mode. According to the authors if these modes are lacking in integration and emotions cannot be traversed across each, or if the modes are significantly unbalanced they become schemas that override normal adult behavior. The particulars of Schema Therapy are then described after a brief explanation of other modes of treatment, particularly simple cognitive therapy, which is not abandoned but used in a systematic manner to help educate the patient of the need for change and restructuring of behavior. The Schema Therapy used is described by the authors through a stepped system including; (1) limited reparenting, (2) experiential imagery and dialogue work, (3) cognitive restructuring and education, and (4) behavioral pattern breaking, all in three phases of treatment; (1) bonding and emotional regulation, (2) schema mode change, and (3) development of autonomy. (pp. 444-456) the only empirical aspect of the work is that which describes ongoing research associated with schema therapy, most of which are case study works that include but are not limited to BPD. (p. 457)

Clarkin, Levy, Lenzenweger, & Kernberg in Evaluating Three Treatments for Borderline Personality Disorder: A Multiwave Study provide a comparative study of three varied treatments for BPD in a multiwave study. The three forms of outpatient treatment evaluated are; dialectical behavior therapy, transference-focused psychotherapy, and a dynamic supportive treatment. In the empirical study 90 patients with BPD were randomly assigned to the three varied treatment plans and all received medication if it was indicated. The subjects were subjected to pre-study evaluations and were also evaluated at 4-month intervals during the year long study period. The factors assessed during evaluation were: suicidal behavior, aggression, impulsivity, anxiety, depression, and social adjustment, all in a multiwave study design. Results of treatment, over the year were as follows; " Individual growth curve analysis revealed that patients in all three treatment groups showed significant positive change in depression, anxiety, global functioning, and social adjustment across 1 year of treatment. Both transference-focused psychotherapy and dialectical behavior therapy were significantly associated with improvement in suicidality. Only transference-focused psychotherapy and supportive treatment were associated with improvement in anger. Transference- focused psychotherapy and supportive treatment were each associated with improvement in facets of impulsivity. Only transference-focused psychotherapy was significantly predictive of change in irritability and verbal and direct assault." (p. 922) the conclusions of the researchers were that though all three variations of structured treatments seem to be effective and the 12-month BPD period were affective for patients each was affective in different ways and that each should be evaluated specifically for its strengths and weaknesses with regard to BPD, a very difficult disorder to treat. Overall the researchers found that transference-focused psychotherapy was the most effective across the most dimensions, of those evaluated in this study and they call for additional research.

Van Kessel, Lambie & Stewart in the Impact of Brief Planned Admissions on Inpatient Mental Health Unit Utilisation for People With a Diagnosis of Borderline Personality Disorder provide empirical research not on a particular treatment for BPD but on a treatment regimen that stresses the decreased utilization of long inpatient stays for individuals with BPD. (2007) BPD is acknowledged as one of the most pervasive and difficult disorders to treat and one that is significant in resource utilization for inpatient alternatives in treatment. These long periods of inpatient treatment are disruptive for the individual, in his or her life and tax the system significantly. In the work the authors evaluate the utilization of brief planned inpatient treatment phases and stress that such plans tend to decrease the utilization of inpatient facilities significantly for such patients. Two groups of inpatient patients were studied comparatively to see if over a long period of time their utilization of inpatient treatment was decreased if they either did or did not experience brief planned admissions. There was significant differences in the long-term with regard to the randomized groups. Given that the decrease in inpatient stays over a year of care was 75% lower for the test group the researchers support the fact that this treatment protocol is appropriate and may have significant implications for how effective inpatient treatment, of any kind is for individuals. Quality of life might also be said to be improved when such patients can plan and implement inpatient care, allowing them the opportunity to see forward to a time of greater emphasis on therapy and structure their personal and professional lives accordingly. The research also supports the fact that structured care is most effective with BPD, in both treatment regimens and therapeutic interventions and may be a result of the need for structured care in other areas of treatment as a result of the BPD dynamic. (p. 93)

Sherry, Lyddon & Henson in Adult Attachment and Developmental Personality Styles: An Empirical Study develop a comprehensive empirical research study regarding the development of particular personality styles/disorders in correlation to the attachment theory protocols. (2007) According to the researchers the development of personality in both the normal and abnormal states are in many ways associated with the environmental developmental aspects of ones life, though there is a clear sense of genetics the environment plays and important role. Dysfunction in childhood environments has been strongly linked with devastating and nominal personality styles that can and often do disrupt how an individual behaves as an adult but most importantly how negatively or positively he or she views him or herself and others and therefore how they interact as adults. The work first defines attachment theory through the varied research and theorists as it has evolved over the years to help explain both normal and abnormal patterns of attachment and how these patterns help determine personality in both normal and abnormal ways. Participation in the empirical study was among 277 undergraduates, rather than clinically presenting patients. Attachment styles among these individuals are then evaluated, using three varied attachment instruments and grouped according to both normal and abnormal scales and difficulties. The three instruments used are: "Relationship Scales Questionnaire (RSQ," Griffin & Bartholomew, 1994b). Attachment in adulthood was assessed using the RSQ. The RSQ is a short, 30-item instrument that draws from Hazan and Shaver's (1987) attachment measure, Bartholomew and Horowitz's (1991) Relationship Questionnaire, and Collins and Read's (1990) Adult Attachment Scale." (p. 337) the work provides a baseline of "normal" individuals with regard to adult attachment and justifies the idea that such attachment is demonstrative of both normal and abnormal personality development. Among the "normal" population the researchers were able to find evidence of specific personality styles that could be considered detrimental to an individual's adult view of self and others; Dependent Personality Style, Avoidant Personality Style, Paranoid Personality Style, Borderline Personality Style, Schizotypal Personality Style, Schizoid Personality Style, Histrionic Personality Style. Among all these personality styles, excluding the histrionic personality style, the researchers found that all those who did not exhibit one of these difficult patterns or styles shared a single characteristic, i.e. secure attachment.

The findings from this study have at least three important implications for counseling. First, it is important to note that many of the personality styles accounted for in the analysis displayed a negative view of self. This finding might serve to guide counselors in the counseling process, noting that a negative core sense of self is fundamental to the presenting dysfunction. In addition to using cognitive behavioral strategies supported in the literature for this population constructing a therapeutic alliance that facilitates the client's exploration into her or his ability to appropriately elicit need-meeting responses from the counselor may prove beneficial. With this approach, it is hoped that learning new interpersonal behaviors will generalize to the client's relationships outside of counseling and gradually begin to facilitate the development of a more positive sense of self. An example of an attachment theory approach to the treatment of borderline personality is outlined by Sherry (2007).

2007, p. 337)

The work demonstrates that those therapies that specifically utilize new emotional, healthy and appropriate attachments are the most likely to be effective in the clinical setting, among both a "normal" and disorder diagnosed population.

Pickover in Breaking the Cycle: a Cclinical Example of Disrupting an Insecure Attachment System provides the reader with a clinical case study style empirical demonstration of how one might develop a system that effectively breaks a developing system of insecure attachment, in a child. (2002) it is not unusual for theorists and clinicians to face the idea of prevention, Pickover in fact provides the basis for the development of a system of counseling for children at risk for developing insecure attachment, and therefore increased risk of adult psychological disorders. The behavioral interventions are secondary to the application of attachment theory as a basis for intervention in the work. After a period of relationship building as well as the performance of the collection of all the perfunctory historical data on the patient the intervention seems relatively simple the councilor, in short replaced primary attachment with a more secure pattern of attachment with a stranger, in this case the counselor.

The weekly therapy session involved giving John positive feedback focusing on a continued positive interaction, including helping John improve his schoolwork. After three weeks of the intervention, the mental health counselor could spend 10 minutes reviewing math or writing, while John held his attention to the subject. He continued to seek attention and engage in negative behavior patterns, but had taken small steps toward taking more responsibility for his behavior. Five weeks later, John's grades improved dramatically and he began to appropriately negotiate for rewards. (Pickover, 2002, p. 358)