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Portfolio Including Thesis ADELINE ANN CRAWFORD a Portfolio Portfolio including Thesis Volume I of 2 ADELINE ANN CRAWFORD A portfolio submittedin partial fulfilment of the requirements of the University of Hertfordshire for the degreeof Doctor of Clinical Psychology including a Thesis entitled: Brain Injury and the Experience of Caring: Intrapersonal Aspects from a Personal Construct Perspective The programme of study was carried out in the Department of Psychology, University of Hertfordshire August 2006 TEXT BOUND INTO THE SPINE Contents PageNumber Written ExerciseI 2 Written Exercise 2 24 Small Scale Service Related Project 45 LiteratureReview 69 Thesis Title Page 90 Thesis Contents 91 Dedication 95 Abstract 96 Introduction 97 Method 119 Results 133 Discussion 159 References 177 Acknowledgements 196 Appendices 197 Critical Review 232 I Written Exercise 1 Critically evaluate the concept of "dual diagnosis" and argue its degree of relevance to treatment planning. Introduction To critically evaluate the concept of dual diagnosis, that is two comorbid or simultaneously existing psychiatric disorders (Mueser et at., 2001), the unitary concept of diagnosis must be critically analysed. The concept of diagnosis forms the basis of the contemporary medical model (Kroese and Holmes, 2001), although systems of classification have been in existence since classical times (Gross and Mcllveen, 1996). Diagnosis has several explicit purposes including aiding research; summarising information; and guiding treatment (Nurcombe, 2000). To explore the concept of psychiatric diagnosis, the categorical diagnostic framework of the Diagnostic and Statistical Manual (DSM) (American Psychiatric Association, 2000) will be the exemplar analysed. This system of diagnosis is multi-axial, involving assessmenton five axes all of which map on to different kinds of information that ought to enable the assessorto plan treatment (ibid. ). Attention will be focused on Clinical Disorders on Axis I, and Personality Disorders on Axis II. "Axis I is for reporting all the various disorders or conditions in the Classification except for the Personality Disorders and Mental retardation... "(American Psychiatric Association, 2000: 27). On Axis II, DSM- IV lists 10 separatepersonality disorders, grouped into three separateclusters based on descriptive similarities: Cluster A (an odd or eccentric pattern); Cluster B (dramatic, emotional or erratic); Cluster C (anxious and fearful) (Parker and Barret, 2000). Personality Disorders comprise, "... an enduring pattern of inner experience and behaviour that deviates markedly from the expectations of the individual's culture and is manifested in at least two of the following areas: cognition, affectivity, interpersonal functioning or impulse control. " (American Psychiatric Association, 1994; cited in Parker and Barrett, 2000: 1). Furthermore the "enduring pattern" must be "inflexible and pervasive", "stable over time", and have an "onset in adolescenceor early adulthood" (ibid. ). A client with a dual diagnosis may be diagnosed with two disorders on the same axis or one from Axis I and one from Axis II. form Psychological treatment planning based on a diagnostic system can take the of a manual-based approach, in which an empirically supported standard treatment programme is developed for a diagnosis from a particular therapeutic standpoint drawing on core elements of the diagnostic criteria. For example, Fairburn (1997) describes the cognitive- behavioural manual-based approach to Bulimia Nervosa (BN) in which a structured twenty behavioural session outpatient programme addresses central diagnostic criteria such as body compensation to binge eating, and self-perception as being evaluated in terms of 3 shape and weight. Thus, treatment planning based on a diagnostic system can be found to have its proponents, but it may not necessarily be appropriate for clients with a dual diagnosis. Moreover, not all forms of therapy accept diagnosis as compatible with their model (Bozarth, 1998), and, from a Person-Centred standpoint, treatment planning would be philosophically incompatible with an approach based on diagnostic criteria (Merry, 1999). An alternative method of psychological treatment planning can be found in a case formulation-based approach. According to Butler (1998: 1), "the process of clinical formulation remains the lynch pin that holds theory and practice together. ", and, while formulations can be constructed from disparate psychological theoretical models (Horowitz, 1997), a formulation essentially comprises: "(1) A hypothesisabout the relationship among various problems of the individual; (2) Hypotheses about the aetiology of the aforementioned difficulties; (3) Predictions about the patient's future behaviour. " (Turkat, 1990: 17; cited in Bruch, 1998a). Thus, a formulation is not a treatment procedure, per se, but a means to understanding the client and all his problems, permitting the selection and design of treatment based on each individual case (Adams, 1996; cited in Bruch, 1998a). A formulation is also a dynamic entity that can be altered throughout therapy as the therapist develops a greater understanding of the case (Butler, 1998), and can include aspects of the therapeutic process, such as the therapeutic relationship (Bruch, 1998b). for While the proposed intentions of a diagnostic system appear to be beneficial the individual's psychological well-being (Nurcombe, 2000), including treatment planning, the benefits reality is that the concept of diagnosis does not always provide the intended and, indeed, can be found to be theoretically flawed. Moreover, while socio-cultural themes debates have had an impact on the utility of the diagnostic concept, methodological and the criticisms abound for single and dual diagnoses; all of these factors ultimately affect relevanceof a dual diagnosisfor treatmentplanning. Unitary Diagnosis& Manual-BasedTreatment Multi-disciplinary teams provide the environment in which many psychologists currently work. In such a setting, a collection of people with disparate professional backgrounds need to find a common language in which to communicate regarding clients. One of the 4 strengths of a diagnostic system of classification is that it provides a shared nomenclature (American Psychiatric Association, 2000) for such communications. Thus, this diagnostic system can provide a "meaningful lexicon" to aid case-formulation (Parker and Barrett, 2000: 8) by multiple professionals; this would of course equally apply to clients who have a dual diagnosis. Furthermore, as no one therapeutic model, including cognitive, interpersonal, neurochemical, and psychodynamic, has greater empirical support than another to explain presenting disorders, (Widiger and Clark, 2000), a categorical diagnosis can provide an understanding accessible to all professionals from which treatment can be planned. However, it must be noted that while no one therapeutic model may have been proved superior to explain disorder, Persons (1989) argues that psychiatric diagnoses are merely descriptions of symptom clusters and are not underlying explanatory aetiological mechanisms. Moreover, while manual-based treatment has been planned for certain unitary diagnoses from a variety of theoretical standpoints (Fairbum, 1997; Ryle et al., 1997), not all diagnoses have had a manual-based approach developed, with manual-based approaches currently dominating only the cognitive-behavioural literature, thus limiting their potential role in treatment planning. Furthermore, clients with "complex disorders and enduring symptoms", such as those with a dual diagnosis, have not tended to be addressedby manual-based approaches as a single therapy is evaluated in a narrowly defined clinical research group (Guthrie, 2000: 132), thus not only denying an empirical understanding of for treatment planning for this group, but limiting the external validity of the findings clinical, rather than research, participants. When randomised clinical trials have been undertaken in clients with a dual diagnosis, such as Linehan et al. 's (1999) study on substance-abusingwomen with Borderline Personality Disorder (BPD), a standardised diagnosis manual-based treatment was not utilized and the Axis I disorder was the only evaluated at outcome. DiagnosticConstruct Properties As one of the design aims of the DSM is as an aid to research, it can also provide a structure from which scientist-practitioner psychologists can build their research, ultimately informing their clinical practice and treatment planning. The most recent version of the Diagnostic and Statistical Manual, DSM-IV-TR (American Psychiatric Association, 2000), is the most research-driven and empirically grounded version so far (ibid. ) and, thus, ought to provide an empirically robust platform for research. However, Widiger and Clark (2000) have criticised it for inadequate pilot testing, Mullen et al. (1999) have questioned the reliability of personality disorder diagnoses, and Tyrer (2000) has expressed doubts over the validity of the DSM as the diagnostic categories have been founded on clinical judgement. Thus, the diagnostic categories may be insufficiently theory-driven, and, indeed, are merely reflecting behavioural descriptions based on observations (Clark et al., 1997); in the case of a dual diagnosis, this may just result in a large objective symptom profile without an understanding of the problems and goals of the individual. For example, two clients with dual diagnoses of BPD and BN may have very different problems they wish to address
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