528- Evidence Based Practice, Case Conceptualization, and Treatment Planning

Question 1

ADDRESSING model

Answer 1

Part of: Multicultural and evidence-based practice What: ADDRESSING is an acronym of cultural influences and client factors to be aware of in case conceptualization and treatment. Including these dimensions of identity on intake paperwork can help therapists understand the client more fully and develop more effective, culturally sensitive treatment plans.- AGE and Generational influences (dominant group: young and middle-aged adults; nondominant: children, older adults)- DEVELOPMENTAL Disability (disabled from birth)- DISABILITY (may have developed at any point in lifespan; dominant group: nondisabled people; nondominant: people with cognitive, intellectual, sensory, physical, and psychiatric disabilities)- RELIGION and spiritual orientation (dominant group: Christian and secular; nondominant: Muslims, Jews, Hindus, Buddhists, and other religions)- ETHNIC and racial identity (dominant group: European Americans; nondominant: Asian, South Asian, Latino, Pacific Islander, Middle Eastern, and multiracial people)- SOCIOECONOMIC status (dominant group: upper and middle class; nondominant: people of lower status by occupation, education, income, or inner-city or rural habitat)- SEXUAL ORIENTATION (dominant group: heterosexual; nondominant: people who identify as gay, lesbian, bisexual)- INDIGENOUS heritage (dominant group: European Americans; nondominant: American Indians, Inuit, Alaska Natives, Aboriginal Australians)- NATION of origin (dominant group: US-born Americans; nondominant: immigrants, refugees, international students)- GENDER (dominant group: men; nondominant: women and people who identify as transgender). It helps counselors examine their own biases and areas of inexperience.

Example: Sam is a new client who identifies as a cisgender, Jewish female. She is 68 years old. As her therapist does the initial interview, the therapist will want to gather information about how her Jewish heritage/faith and age are influencing her presenting problems, if at all.

Question 2

Adjunct treatment

Answer 2

Each intervention brings it’s own methods to the client’s healing and it’s typically conducted by different practitioners so distinguished from receiving double
psychotherapy. Adjunct treatment is a part of treatment planning that describes additional secondary interventions that are used in conjunction with a primary intervention with the goal of enhancing treatment effectiveness. They are considered during case conceptualization and throughout the treatment process and are a part of individualizing treatment to the client.

Question 3

Case conceptualization/formulation

Answer 3

Part of: effective counseling, evidence-based practice What: Case conceptualization is the process of gathering information about a client, using a framework typically derived from a combination of your preferred theoretical framework, the best evidence available, clinical experience, and patient factors, to organize the information in a way that allows you to develop an effective treatment plan. Why: Careful case conceptualization can guide treatment, enhance the therapeutic alliance, and help both clients and clinicians measure if counseling is progressing towards therapeutic goals. It provides an idiographic outlook and is flexible.

Clinical example: Jane presents with symptoms of depression including lethargy, anhedonia, weight gain, and frequent crying spells. Her clinician uses a biopsychosocial model to help with the process of case conceptualization. She finds that Jane’s family has a history of depression, that Jane recently moved and has not developed strong friendships in her new home, and often experiences self-shaming thoughts. All of these factors will help guide the clinician’s choices about how to best treat Jane’s symptoms.

Question 4

Client factors

Answer 4

Part of: case conceptualization, treatment planning, evidence-based practice What: Client factors are aspects related to the client that impact their presenting problem(s) and its presentation. Client factors include multicultural factors, previous experience with therapy, expectations about therapy and therapeutic outcomes, readiness to change, and preferences. Why: Considering client factors is critical in order to be an effective therapist and one of the three legs of evidence-based practice. They can influence all aspects of the therapy process including therapeutic alliance, treatment planning, case conceptualization.

Clinical example:

Question 5

Common factors

Answer 5

Part of: all therapeutic approaches Who: Jerome Frank What: Common factors are elements of all therapeutic approaches that have been demonstrated to impact the effectiveness of the therapeutic process. Some common factors include the therapeutic alliance, empathy, warm, unconditional positive regard, client resources, expectations. Why: In contrast to the view that the effectiveness of psychotherapy/counseling is best explained by specific or unique factors (notably, particular methods or procedures) that are suited to treat particular problems.

Clinical example:

Question 6

Efficacy vs. effectiveness research

Answer 6

Part of EBP used to describe two different types of research. Efficacy is typically clinical settings while effectiveness looks at how generalizable it is to the research. What: Efficacy research determines whether an intervention produces the expected result under ideal circumstances. Effectiveness trials (pragmatic trials) measure the degree of beneficial effect under “real world” clinical settings.

Clinical example:

Question 7

Empirically supported treatments

Answer 7

Part of: evidence-based practice; What: (EST) interventions that have been found to be efficacious for one or more psychological conditions. Prior to 90s, there were no specific guidelines regarding which treatments for which conditions. In 93, a task force was appointed by the APA to develop a set of criteria for, and provisional list of, ESTs. ESTs have a manualized protocol and are therapies that have demonstrated: (criteria for EST)-(a) superiority to a placebo in two or more methodologically rigorous controlled studies, or -(b) equivalence to a well-established treatment in several rigorous and independent controlled studies, or -(c) efficacy in a large series of single-case controlled designs (>9) They do not account for client factors, nonadherence, and clients with multiple disorders. Clinician expertise.

Question 8

Evidence based practice

Answer 8

Part of: clinical practice What: Based on the medical model of evidence-based practice, EBP includes the integration of the best available research with clinical expertise in the context of patient characteristics, culture, and preferences (the three stool legs). The rise of ESTs fueled a debate amongst the mental health field regarding the most effective way to treat patients. Why: Evidence-based practice seeks to incorporate aspects of effective treatment that don’t lend themselves to empirical research with our current knowledge of what specific treatments have been proven to work for specific disorders.

Clinical example:

Question 9

Failure to respond

Answer 9

Part of: clinical practice What: Failure to respond to treatment occurs when a client prematurely ends therapy, or the goals for therapy are not met. Unfortunately, it is common: 63% of patients with depression, 57% with GAD, and 46% with panic disorder did not improve during treatment with an EST in one study. Progress monitoring can help identify failure so that therapist can discuss with client and course-correct treatment which may include changing or discontinuing treatment, or referring to another treatment setting. If after repeated efforts to turn therapy around, the patient is not responding, the therapist must refer to another provider; it is not ethical to continue to provide a failing treatment indefinitely. Consultation with peers can help therapists in this process as it is a very difficult part of clinical decision making.

Clinical example:

Question 10

Informed consent for treatment

Answer 10

Part of: clinical practice What: A person’s voluntary consent to treatment. Before beginning treatment, a therapist is ethically and legally required to obtain informed consent from their client. In a formal informed consent process, a therapist:- provides an assessment, including a diagnosis and formulation, of the client’s condition.- recommends a treatment, describes it, and provides rationale for recommendation.- describes available treatment options.- obtains the client’s agreement to proceed with the recommended treatment plan or a compromise treatment plan. The client must be aware that they can also withdraw from treatment at anytime.

Clinical example:

Question 11

Practice guidelines

Answer 11

Part of: treatment planning/evidence based practice What: Practice guidelines are guidelines that tell us the best practice or gold standard of treatment based on evidence from research. For example, APA puts out guidelines for working with transgender clients, including the most up to date information on what is considered to be the best, most effective, ethical treatment up to this point. The guidelines assist in clinical decision-making.

Question 12

Precipitants of the problem

Answer 12

Part of: case conceptualization/clinical practice What: In a diathesis-stress model of psychopathology, a precipitant is the stressor that activates the diathesis (underlying mechanism that made the client susceptible to psychopathology). Precipitants and problems often overlap. They can be biological or psychological. Why: Identifying precipitants of the client’s problems is a key part of cognitive-behavioral case conceptualization. Allows therapists to test hypotheses regarding underlying mechanisms of problems.

Clinical example:

Question 13

Problem list

Answer 13

Part of: case conceptualization/clinical practice What: As part of the pretreatment and assessment, therapist creates the most comprehensive list possible of the clients problems to understand how they fit together, which are the top priorities for treatment, and which treatment might address multiple problems simultaneously, any problems that might destabilize the client, ones that can help solve other problems, as well as ones that have an easy fix. The problem list includes DSM diagnoses, as well as interpersonal, occupational, school, medical, financial, housing, legal, and leisure problems. The problem list should also include information about the severity of each problem, obtained through psychological assessment measure like the BDI when appropriate. The problem list is derived from multiple sources of information, including the clinical interview, assessment measure, structured interview protocols, and other treatment providers. Family members may be useful in this process when treating patients with certain disorders.

Question 14

Mechanisms of action

Answer 14

Part of: case conceptualization and evidence-based practice What: A mechanism of action is how a treatment affects a change for a particular client problem. Why: Knowing how treatments affect particular changes helps clinicians so that they can improve hypotheses and treatment planning. Why does a treatment work? Exposure works because it targets the underlying mechanism of avoidance.

Mechanism of action: These are the deeper processes by which psychotherapeutic change occurs. The mechanisms that cause and maintain the client’s problems must be identified to create mechanisms of action. These are generally the schemas and core beliefs a client has held for most if not all of their life. Therapy targets these mechanisms to create change at the deeper level. By targeting these mechanism, it allows change to occur.

Through a behavioral perspective, avoidance also tends to me a driving mechanism.

Example: SSRI’s mechanism of action are that they prevent re-uptake so there is more serotonin in the synaptic cleft.

Question 15

Nonadherence

Answer 15

Part of: Clinical practice What: the failure to carry out an action that has been agreed to or expected such as an intervention or a homework assignment outside of therapy. Nonadherence can occur on the part of the patient or the therapist. Traditionally has been ascribed of oppositional behavior but is now thought of as failure to communicate between clinician and client, etc. and instead just seen as limitations that prevent the client of following recommendations. Why: Nonadherence can slow down the therapeutic process or cause it to fail.

Question 16

Outcome measures

Answer 16

Part of: evidence-based practice What: measurable phenomena directly related to a patient’s treatment goals which generally include:- reducing symptoms- increasing positive emotions and behavior- and improving functioning Typically therapists collect outcome measures at the beginning and end of each session as well as over the long-term. Why: Monitoring and measuring patient outcomes allows therapists to assess if the treatment plan is working and make adjustments if it’s not. Provides an idiographic approach to treatment monitoring.

Outcome measures: These are assessments of the effectiveness of an intervention on the basis of measurements taken before, during, and after the intervention. The therapist will select outcome measures for each client based on the treatment goals. The goals generally involve reducing symptoms, increasing positive emotions and behavior, and improving functioning. The therapist will select a phenomenon to measure, determine whether to measure frequency, intensity or duration, then establish a scale for measuring this. You compare the results of this scale to the client’s scores of the previous week. This is important in progressing monitoring and provides an idiographic approach to monitoring treatment.

Question 17

Origins of mechanisms

Answer 17

Part of: Case conceptualization and evidence-based practice What: a hypothesis that offers an explanation about how a patient learned or acquired the mechanisms that are contributing to their symptoms. Origins can be environmental events, cultural factors, biological factors, or genetics. They differ from precipitants in that they are usually distant rather than recent. Why: Understanding the origins of mechanisms maintaining or creating a client’s problems helps therapists create complete case conceptualizations and develop more effective treatment plans. It also allows them to make connections between different items on a problem list.

Question 18

Spheres of influence

Answer 18

What: an assessment framework for case conceptualization within the biopsychosocial model; the goal is to assess all spheres of influence Used to explore how pts surroundings are influencing them Spheres of influence are factors that influence a client:- self- partner and children- extended family- friends, neighbors, acquaintances- employers, schools, coworkers- government and social networks- interactive network/service providers

Example: Jill reports that her husband is drinking heavily, and one of her children is waking up with night terrors multiple times a night. Her boss is caustic and sarcastic. She has a strong bond with her mother who lives out of state but she speaks to daily on the phone. In case conceptualization, Jill’s therapist should consider how all of these layers of influence are affecting Jill’s presenting problems and ability to cope. EXAMPLE: In order to assess a client’s friends, neighbors, & acquaintances as well as their extended family and partner & children spheres of influence, you might ask things like “How is your social support?” “What would your family say is your biggest struggle?” “Tell me about your work life.” All of these questions are working to uncover how each sphere of influence is affecting the client and the presenting problem.

Question 19

Therapy interfering behavior

Answer 19

Part of: clinical practice What: Therapy-interfering behaviors are those on the part of the client that undermine or even prevent therapy from progressing. These should be listed as second on the client’s problem list. Some such behaviors are repeated cancellations, consistently coming late, not doing homework frequently, blowing up at therapist repeatedly, lying to therapist, calling the therapist incessantly, and failing to take medications as prescribed. It is the therapist’s responsibility to do what is needed to protect the therapeutic relationship and cannot allow the client to act in ways that will destroy the relationship. The therapist can approach these behaviors int he same way she would all client problem behaviors. It is important to identify, conceptualize, and use in formulation to treat these behaviors. Discussing them with the client is vital to the therapeutic process.

Clinical example:

Question 20

Treatment goals

Answer 20

Part of: Case conceptualization and evidence-based practice What: Treatment goals are specific, measurable outcomes developed collaboratively by therapists and patients and monitored over the course of therapy. They provide information about how patients and therapists know if the treatment plan is effective. Good treatment goals are:- explicitly agreed upon by patients and therapists- focused on reducing symptoms and problems- focused on increases desired behaviors or outcomes- emotionally compelling to patients- realistic- measurable- specific- listed in order of priority. Good treatment goals are a means of identifying progress and adjusting treatment planning.

Clinical example:

Question 21

Treatment monitoring

Answer 21

Part of: Evidence-based practice What: the process of assessing whether or not progress is being made towards mutually agreed-upon treatment goals. Can be informal - therapist making observations about patients symptomology, mood, behaviors, etc. OR can be a more formal process of data collection that therapists use to assess progress and make adjustments to the treatment plan Formal treatment monitoring includes consistently tracking, over time, aspects of the process or outcome of therapy in writing or on a computer, using some sort of assessment tool.

Question 22

Treatment plan

Answer 22

Part of: Evidence-based practice and case conceptualization What: a comprehensive and formal agreement that details the mutually agreed-upon treatment goals, modality of treatment, frequency of therapy sessions, and any potential adjunct treatments. Typically treatment plans are developed in pretreatment and formally agreed to by the patient during the informed consent process and prior to therapy beginning. Why: developing a treatment plan helps clients better understand the process of therapy and sets expectations about their role in the process. It also allows for treatment monitoring so that the treatment plan can be adjusted as more information is divulged and the patient and therapist monitor whether treatment goals are being met.