Beutler Model of Treatment Planning

Question 1

What are the elements of the Beutler Model Coping Style?

Answer 1

A continuum

Externalising ————————– Internalising

“Externalisers” are people who generally:

• Blame others, events, bad luck, fate
• Actively try to avoid their problems
• More impulsive, manipulative, aggression risk

“Internalisers” are people who generally:

• Blame themselves – perceive poor skills/abilities
• Seek understanding and answers (risk of intellectualising)
• Constrict, repress, minimise, control

Question 2

What is the Beutler Model of Treatment Selection?

Answer 2

• Based on identification of relevant client characteristics
• Links approach to characteristics with evidence-based research.
• 6 client dimensions
• Functional Impairment; Social Support; Problem complexity/chronicity; Coping style; Resistance; Subjective distress
• Additional Problem-solving phase (based on stages of change)

Question 3

What are the 6 Client Dimensions of the Beutler Treatment Model?

Answer 3

1. Functional Impariment
2. Social Support
3. Problem complexity/chronicity
4. Coping style
5. Resistance
6. Subjective distress

Question 4

How does the current DSM-V rate current functioning?

Answer 4

Using the WHODAS

Question 5

What is the WHODAS and what does it stand for?

Answer 5

DSM-V rating of functional impairment

WHO Disability Assessment Schedule (WHODAS)

WHO (World Health Organisation)

Question 6

What is important to assess in Functional Impairment?

Answer 6

Does the concern interfere with the client’s ability to manage everyday social, occupational, interpersonal, other tasks?

What is the Severity of the impairment?

Higher severity likely to relate to:

• less ability to cope
• Poorer insight
• Chronicity of symptoms

Question 7

What other things are there to consider when assessing functional impairment?

Answer 7

Don’t rely solely on clients self-report of their distress by their level of functioning

A more objective assessment required, consider:

• Ability to function and interact with the interview
• Poor concentration and distractibility
• Number of area’s where functioning is impaired
• Higher scores on measures (e.g., BDI-II) suggest a higher degree of incapacity
• DSM-V – rate current functioning using WHODAS

Question 8

Wha are the High Level and Low Level criteria for Functional Impariment?

Answer 8

High level of functional impairment – may require hospitalisation to achieve stabilisation

• Intense in frequency and duration
• Benefits of medication
• Focus on the symptomatic areas of concern (e.g., neurovegative symptoms) – greater urgency to achieve

Mild-Moderate – suitable for outpatient treatment

• Moderate frequency and duration
• Focus can be directed towards long-term outcomes, which may change (i.e., less urgency)
• But do need to ensure other specific symptoms are addressed

•Both – ensure social supports to aid functioning

Question 9

What doesthe Beutler Model for Social Supports take into consideration?

Answer 9

What is the level of support from:

• family members
• Friends
• Employment

More than assessing the number – need to assess the quality

• Trusted & respected by others
• Sense of belonging to a family network
• Relatedness (i.e., sharing common interests)
• Availability – does not feel lonely or abandoned.

Question 10

What treatment approach would you use for High and Low Social Supports?

Answer 10

High social support

• Shorter treatment
• Focus on enhancing the quality of relationships

Low social support

• Longer treatment
• Benefit of group interventions
• Teaching of strategies to manage symptoms (e.g., CBT)

Question 11

Beutler Model Comlexity/Chronicity - what do you consider?

Answer 11

Underlying patterns in a person’s life that may/may not result in a degree of impairment

Related to internal unseen events – theoretically bound.

3 features:

• Several problem domains/diagnoses (comorbidity)
• Pervasive/recurrent patterns & themes of problem behaviours
• Presence of a personality disorder (or personality style that resembles a PD

Question 12

What would you consider are complex problems in the Beutler Model?

Answer 12

Complex Problem

• Repeated behavioural patterns across unrelated situations – leads to suffering
• Behaviours are attempting to resolve interpersonal or dynamic conflicts
• Interactions seem related to past relationship (rather than present)

Question 13

What would you consider are non - complex problems in the Beutler Model?

Answer 13

Non-complex problems

• Situation-specific & related to precipitating events
• Transient
• Related to inadequate knowledge of skills & use of prior learnt unbeneficial behavioural patterns to cope/manage

Question 14

What is the treatment approach in the Beutler model to High Levels and Low Levels of Complexity?

Answer 14

High problem complexity

• Longer-term treatment
• Resolve underlying conflicts through exploring patters of behaviour & relationships, interpreting transference
• Role-play work of beneficial responses to situations

Low problem complexity

• Targeting specific symptoms
• Targeting precipitants and perpetuating factors

Question 15

What is the Beutler Model treatment approach to Coping Styles?

Answer 15

High Externalisers

• Symptoms-orientated interventions (e.g., relaxation, cognitive restructuring)
• Specific techniques for building skills (e.g., social skills, anger management)

High Internalisers

• Develop insight (e.g., interpreting resistance and transference)
• Develop emotional awareness (e.g., mindfulness)

Question 16

Beutler Model Resistance …what is it all about?

Answer 16

• A defence against a perceived loss of control
• High resistance can result in person acting in opposite ways to that recommended
• Which can therefore increase symptoms and dysfunction
• Low resistance does not equal submissive

Question 17

What are the treatment approaches to Resistance high level and low level?

Answer 17

High Resistance

• Supportive approach
• Self-directed interventions (e.g., self-monitoring)
• Paradoxical techniques (e.g., symptoms exaggeration, prescribing no change)

Low Resistance

• Directive & Structured approach
• Multiple therapeutic interventions (e.g., CBT)

Question 18

What is Subjective Distress in the Beutler Model?

Answer 18

• Degree to which client experiences their problems
• Differs from ‘Functional Impairment’
• ‘Functional Impairment’ is more objective
• Subjective distress can be reactive to environmental events
• e.g., might feel a decrease in distress upon receiving some flowers; but this wouldn’t change their functional impairment
• Distress can change within each session

Question 19

What are the high and Low qualities of Subjective Distress?

Answer 19

High distress looks like:

• High emotional expression
• Hyperventilation
• Motor agitation
• Poor concentration
• Hypervigilance

Low distress looks like:

• Poor emotional investment in treatment
• Low energy
• Constricted/blunted affect
• Slow speech, monotone

Question 20

Subjective Distress and it’s relationship to therapy

Answer 20

High distress can be disruptive on therapy

• Difficulty processing information

Low distress can be disruptive on therapy

• Difficulty becoming engaged

Moderate distress can be useful

• Not too overwhelmed
• Motivates engagement in therapy
• More able to concentrate and perform interventions

Question 21

What is the Beutler model Treatment Aproach to

Subjective Distress?

Answer 21

High distress

• Immediate goal to reduce distress level
• Overall be supportive, structured and focused on enhancing relaxation.
• Pharmacotherapy may be useful in initial stages in conjunction with therapy.

Low distress

• Increase distress levels will help facilitate client to be more open to changing behaviour (e.g., discussing painful memories, looking at impact of current behaviour)

Question 22

What are the 5 stages of change?

Answer 22

Pre-contemplation – no intention of changing his or her behaviour. Many individuals in this stage are not even aware they have a problem.

Contemplation - aware that a problem exists and are thinking about it but have not yet made a commitment to take action.

Preparation - intend to change their behaviour but may not yet have begun to do so. This may be due to unsuccessful attempts in the past, or they may be delaying action until they get through a certain event/stressful period of time.

Action - where the individual modifies their behaviour to overcome the problem.

Maintenance - Been able to remain free of the behaviour for more than 6 months. Work to prevent relapse and consolidate the gains they have made.

Question 23

What is the Beutler treatment approach to the

Problem Solving Phase?

Answer 23

Precontemplation stage

• Building rapport; highlighting areas of life dissatisfaction

Contemplation & Preparation stage

• Explore interpersonal/behavioural patterns, pros & cons for changing, clarify life values and goals, explore possible strategies to change

Action stage

• Specific and concreate therapeutic techniques (e.g., CBT)

Maintenance stage

• Relapse prevention
• Social supports
• List of strengths, coping strategies

Question 24

Tips for Treatment Planning

Answer 24

Write a detailed treatment plan

• Help keep you on track
• Help you identify what elements are not working and modify accordingly
• Usually means your case formulation has changed (e.g., new underlying mechanism)

Example:

Week 2 – Provide education on cognitive theory; review a recent event and associated thinking; teach to identify automatic negative thinking; homework to record events & thoughts.

Question 25

Treatment Tips cont…

Answer 25

Consult a treatment manual

• Help provide a structure to approach
• Alleviate any anxiety (to a degree)
• May provide useful forms & handouts
• Tips for dealing with issues
• Remember: Each client is unique, be flexible!

Review with your Supervisor

Question 26

Which Problem do I treat first?

Answer 26

No one answer to this – each client is unique.

Consider

Is there a threat to life (i.e., suicidality)?

• Do any problems undermine the therapy itself (e.g., agoraphobia, untrusting etc)?
• What problem does the client want to address first?
• What is the most disruptive to the clients life/interfering most with functioning?
• Is there a problem that can be treated ‘quickly’?
• Is there a problem which might destabilise the client?
• Will treating 1 disorder result in another also remitting?

Question 27

Outline a Simple Session Agenda

Answer 27

1. Review & Update with client the past week
2. Review weekly task (i.e., homework)
3. Collaboratively agree on content of session
4. Conduct main session content (based on treatment plan)
5. Summarise session (inc. what client has learnt)
6. Assign new weekly task
7. Final check-in (questions, concerns, other issues to discuss)

Question 28

Outline FOUR factors you might take into consideration when planning a client’s psychological treatment

Answer 28

1. Functional Impairment - High/Low Hospitalisation or Outpatient
2. Chronicity/Complexity - Longer term treatment v’s argeting specidfic symptoms
3. Social Supports - High /Low whether group or individual
4. Coping Style-Externaliser/Internaliser
5. Resistance -High or Low depends on whether self directed or structured treatment
6. Subjective Stress - reduce or increase will affect motivation to participate in therapy