module 11 Integrating psychological assessment with tx planning and decision making Flashcards
describe various approaches to treatment planning
Might focus on different aspects eg;
1. Focus on TYPE OF THERAPY OR THE THERAPEUTIC APPROACH;
2.Focus on the DIAGNOSIS OR PARTICULAR PROBLEM;
(differential therapeutics)
3.Focus on CLIENT CHARACTERISTICS
Once therapy type and condition have been considered, a further 10% of variance in therapy effectiveness is attributed to client individual factors.
Just matching client/clinician ethnicity etc does not effect therapy outcome, but acknowledging clients’ preferences does positively effect outcome
Therapists who tend to value a high level of autonomy best matched with client who has high need for attachment and dependence, and therapist who is highly orientated to attachment and dependency better results with client who is highly self sufficient and autonomous.
Ideally, all areas would be addressed ie “what tx, by whom, for this individual with that specific problem and under what circumstances”.
Unfortunately, there is also a requirement for cost-effectiveness in considerations.
identify different treatment options based on the client’s presenting problem
2
INTERVENTION OPTIONS
- Treatment-includes therapy, interventions and medications.
- Placement-ie where will tx occur? in patient/out-patient, near/far, daily/weekly etc etc
- Further Evaluation-recognise when own skills are insufficient and refer to other experts as required.
- Alterations to client’s environment eg installing stove time-outs after set time, reminders for medications, altering learning environment, laptop for learning, note taker aide etc, ridding home of alcohol, etc
- Education and self-help
- Other - anything else. eg recommendation to give up driver’s license etc
Clinical decision-making factors
- Case Formulation
- Understanding the problem
- The problem context
- Treatment-specific client characteristics eg.CBT can be effective for patient with externalising coping style whereas a suportive self-directed method often more effective for those with an internalising coping style (better able to self-reflect).
Also note that suspicious clients have less therapy success, despite genuine warmth and empathy from therapist.
A therapy type or style which matches client’s expectations/needs is also more likely to be successful.
Systematic Treatment Selection approach
A system which attempts to consider all the multiple factors which affect a client and their tx and outcomes, as well as which therapies are most likely effective and empirically recognised;
VARIABLE and its TX CONSIDERATIONS
1. Functional impairment; Restrictiveness (in/outpatient)
Intensity (duration/frequency)
Medical or psychosocial intervention
Px
Urgency
2. Social Support; Cog behav vs relationship enhancemt
Duration of tx
Psychosocial vs medical
Possible group intervention
3. Problem complexity/chronicity; Narrow symptom focus vs
resolution of thematic unresolved conflict
4. Coping style; Behavioural symptom approach vs
internal insight approach
5. Resistance; Supportive non directive vs paradoxical vs
structured & directive
6. Subjective distress; Increase vs decrease arousal
7. State of change; Differentiate short term tx goals/targets
Supportive vs insight vs cog behav
notes
Those therapies which tend to be applicable for very narrow set of issues or particular issues, are likely to be more effective than those which can be broadly applied to a range of dx’s/issues. eg.systematic desensitization/hypnosis for phobia.
When condition, appropriateness/skill of therapy/therapist and client factors are considered, success or otherwise of therapy can be accurately predicted 90% of the time.
There are a few exceptions, but generally speaking, having a specific DSM dx, is not always useful in determining best therapy type.
Major depression tends to respond better to medications, but mild/moderate might be served equally by medications or therapy. More severe symptoms in Depression such as high number of vegetative symptoms (eg. fatigue, insomnia, loss of appetite) is better indicator likely need medications. Also more severe symptoms in schizophrenia or bipolar also likely then need medications.
High degree of psychiatric symptoms plus high levels of somatic symptoms likely to indicate poor px.
BASIC-ID
One method of taking into consideration certain factors, in order to aid a diagnostic/treatment plan.
BASIC-ID=Behaviours, Affects, Sensory experiences, Imagery, Cognitions, Interpersonal relationships & need for Drugs.
stages of change
Some also believe that the therapeutic plan may vary with which stage of change to client is in, and thus this also needs to be considered. Plus, might have multiple problems, and be at different state of change for each. Can also move in and out of states.
Stages of change are;
PRECONTEMPLATION-mostly unaware of need/potential for change (others are aware change needed). May have external pressure to change, but client has not internalized (accepted/recognised) this, thus change is unlikely. when client in the state, need to work hard to improve their understanding awareness.
CONTEMPLATION-aware of problem but not yet committed to change
PREPARATION-more committed to change but not sure how best to go about it. Minor behavioural experimental changes may occur.
For both contemplation and preparation stages work with client to explore their preferences and/or goals.
ACTION-with much time and effort, clients actually change environment, thoughts, behaviours. Change happens only with personal commitment. Others can see the change.
Implement specific strategies to change behaviours/ cognitions.
How successful the change is, is somewhat dependent upon the previous preparatory stages.
MAINTENANCE-work to consolidate and prevent relapse. consider how relapse is most likely to occur and formulate counter strategies.
case formulation
case formulation is a way of assembling all the case data in a “narrative” of what is going on for the client in their own particular context. It is described using the therapist’s own interpretations of what might be contributing, exacerbating etc etc. Somewhat variable, but usually includes;
a) description of symptoms
b)predisposing vulnerabilities
c)stressors/events/environmental factors which led to the issue
d)a hypothesised causal mechanism which links all factors together in an explanation of why and how the problem is maintained.
There are many MODELS for how to do the case formulation. These models include:
1.DIATHESIS-STRESS MODEL
Categorizes findings into diatheses (which factors individual contributes to the problem), stressors (what has happened or is happening), and outcome (problems/symptoms).
2. DEVELOPMENTAL MODEL
developmental mismatch b/n clients level of functioning and the environmental/life demands that client finds themselves requiring. Based on understandings of normative developmental trajectories.
3. COMMON FUNCTION MODEL
Links factors together by finding a common reason for all of them. eg all might serve to distance client from meaningful relationships etc. This then is successful, and gets reinforced etc etc.
4. COMPLEX MODEL
might start as per one of the other models, but adds in added layers of understanding. Recognizes that some factors may also then become a diathesis/stressor/reinforcing factor for further problems.
By going through process of case formulation, one can then logically formulate a tx plan which not only targets alleviation of symptoms, but also seeks to address those factors which are contributing to maintaining the problem etc.
diagnosis
Can be detrimental to have an inaccurate dx. Dx is useful to give prognostic info but there are many individual/cultural factors which may contribute to variability of outcome. Some argue that dx is less important than the consideration of individual factors. Some argue that a dx can be harmful in terms of client then “ giving up” etc.
functional impairment
assess extent to which problem impacts social, occupational or intrapersonal requirements.
May be assessed using various methods/tests as applicable. Assess risk of suicide. eg Beck Depression Index
Also often use Minnesota Multiphasic Personality Inventory which raises high concerns if any elevations for paranoia, schizophrenia, hypomania, etc. Sometimes use eg Millon Clinical Multiaxial Inventory, which raises concerns if severe personality pathology or severe syndrome scales.
Usually greater severity/concern for Schizophrenia, major depression, personality disorders, severe disorders or multiple disorders.
Degree of functional impairment (or risk) obviously determines intensity of tx eg inpatient, outpatient frequent, or out patient non frequent etc.
In general, these require greater intensity of tx:
1. More serious dx (eg borderline personality disorder)
2. poor pre-morbid functioning
3. external stressor does not seem to be main perpetuating factor
4. age 25-50 years
5. the assessment that change will require considerable time
6. exploratory and insight-orientated therapy
7. low levels of social support
In general, these require lesser levels of support:
1. an acute problem (eg adjustment disorder, brief psychotic disorder)
2. external stressor seems primary cause
3. good premorbid functioning
4. symptom-orientated focus of tx, or a crisis intervention
5. expect change to be achieved quickly
6. structured/directive and active interventions
7. children or older adults
8. high levels of social support
For complex and severe levels of functional impairment, will need to work on most debilitating first.
Complex or chronic issues
Chronic problems or those which are complex, are much harder to tx (worse px). Some examples of complex problems are where have repeatedly had unsuitable partners, dependent/independent conflicts or passive-aggressive relationships with authority figures.
Complex issues more likely related to personal unseen issues.
Indicators that likely have a complex problem;
1. Behavioural themes are repeated across unrelated (apparently) situations
2. Behaviours are ritualized efforts to resolve underlying interpersonal or dynamic conflicts
3. interactions seem more related to past relationships than present
4. The repetitive behaviours result in suffering rather than gratification
5. problems are symbolic expressions of underlying conflict
Complex problems more likely to respond to broad tx’s aiming to resolve long-standing conflicts and changing patterns of interpersonal relationships. Techniques may include;
1. group/family therapy exploring response patterns
2. cathartic discharge
3. enacting opposite patterns to how client normally behaves
4. exploring thematic patterns to relationships/nehaviour
5. interpreting the transferance
6. interpreting resistance
7. dialectical behavior therapy or interpersonal therapy.
Subjective distress
degree to which person experiences their problems. Moderate level of distress useful in promoting change (as always too little or too much is not helpful…). Treatment indications on subjective distress relate to whether a particular level of arousal should be increased/decreased.
Higher levels of distress may be indicated by:
1. motor agitation
2. emotional arouslal
3. poor concentration
4. quaverous voice
5. activation of ANS
6. hyperventilation
7. hypervigilance
8.excitation
9.intense feelings
Physiological arousal /anxiety may be dampened with the following techniques;
1. progressive muscle relaxation
2, physical relaxation with hypnosis help
3. guided imagery
4. biofeedback
5.aerobic exercise
6.graded exposure
More cognitive/social anxiety may be dampened with the following techniques;
1. meditation
2. reassurance
3. emotional support
4. cathartic discharge
5. supportively challenging dysfunctional cognitions
6. time management
7. thought stopping
Pharmacology has its benefits but is an aid to brain being in state to learn more appropriate behaviours/cognitions and should be weaned if possible
coping style
There is a continuum of coping style-at the 2 extremes are Internalizers and externalizers
EXTERNALIZER; are impulsive, blame problems on external factors, (eg bad luck, fate, others). Tend not to have good self insight.Indicators that are likely an externalizer are:
1. Blame others for problems
2. Paranoia
3.Low frustration tolerance
4. extroversion
5. unsocialized aggression
6. manipulation of others
7. distraction through stimulation seeking
8. somatization with a focus of seeking secondary gains
Tend to do poorly with therapies aimed at increasing insight. Do better with therapies which focus on specific behaviours or symptoms or skills building. Therapies better suited to Externalizers include;
1. social skills enhancement
2. assertiveness training
3. group interventions
4. anger management
5. graded exposure
6. reinforcement
7. contingency contracting
8. behavioural contracting
9. questioning dysfunctional beliefs
10. practicing alternate thinking
11. stimulus control
12. thought stopping
13. counterconditioning
14. relaxation
INTERNALIZERS; tend to blame themselves for problems and worry they are inadequate. Tend to experience more distress over problems and more likely to seek to understand them. Internalizers tend to;
1. Introversion
2. Intellectualization
3. emotions are either constricted or over-controlled
4. minimize difficulties
5. social withdrawal
6. somatization with symptoms related to activation of ANS
Tend to respond better to these therapies;
1. insight-orientated interventions
2. therapist-directed imagery
3. direct instruction
4. outside reading (bibliotherapy)
5. interpreting transferance reactions
6. interpreting resistance
7. meditation
8. two-chair work
social support
level of strong family or friend support network and /or steady work.
Loosely assessed by;
1. extent to which client feels trusted and respected by people in their life
2.extent and quality of people client can confide in
3. level of experienced loneliness
4. extent to which client feels abandoned by family/friends
5. extent to which client feels part of their family/network of friends
6. number of friends client has common interests with.
Not merely numbers but quality of contacts.
If have less social support, expect therapy will need to be longer, may require medication, might benefit from a supportive group intervention, less likely to have response from therapies trying to enhance relationships, more likely to respond to cognitive behavioural therapy.
