PSY343 - 6. Case Formulation Flashcards
Case Formulation
Process for developing hypothesis about causes, precipitants + maintaining influences of person’s psychological, interpersonal + behavioural problems in context of that individual’s culture + environment
Case Formulation
pulling together ideas + hypothesis about problems + causes based on context
theoretical, but grounded on specific experience of client
individualized
explanatory: inferences based on history, biology, sociocultural influences
Case Formulation
currently operating: contingencies + reinforcements in environment
person’s psychology: how they process information
pieces of puzzle: guides diagnosis + approach
Case Formulation
psychodynamic: unconscious
cognitive: beliefs, disruptive thinking
behavioural: learning history + contingencies
depends on approach
heavy emphasis on cause, sometimes narrative
diff depending on orientation + theory
Case Formulation
Subject to revision as new information emerges, new problems develop, new insights gained
tentative - can never be sure why they have problem
Case Formulation
Involves aspects of process and content:
Process: clinician’s activities aimed at eliciting info required to develop formulation content (clinical interview)
ask questions - how i get the data
Case Formulation
Content: problems identified, diagnosis, explanation of problem - data
content will vary widely depending on which theory of psychotherapy + psychopathology clinician uses
Case Formulation
blueprint guiding treatment; tool to facilitate treatment planning
use it to determine how to treat
treatment is also tentative: changes based on preference + how well it’s working, case formulation
Tensions Inherent in Case Formulation
Immediacy vs Comprehensiveness
Balance betw goals of efficiently identifying what is needed to help client + getting all necessary information to help understand client’s situation
pragmatic: need to process lots of info naturally
Tensions Inherent in Case Formulation
more we make sense of it, better we can intervene
comprehensive: also need to take time to see what’s missing
ppl change over time, thinking + relationships change
get more info over time, but we need to start case formulation quickly
Tensions Inherent in Case Formulation
Complexity vs Simplicity: ppl are very complex
we can’t capture complexity
too complex - don’t know what to do with it
simplicity: too reductive - don’t grasp richness of person it’s gonna be useless
Tensions Inherent in Case Formulation
Balance betw goals of integrating multiple aspects of problem into meaningful presentation + keeping formulation clear + reliable
Tensions Inherent in Case Formulation
Therapist Bias vs Objectivity
Balance between managing therapist bias + relying on one’s personal experience to empathize with client
we all have bias
Tensions Inherent in Case Formulation
some can overpathologize based on degree of difference
some underpathologize - same as their experience
use my humanity to relate, but need to see other as seperate
Tensions Inherent in Case Formulation
Observation vs Inference
Balance between gathering descriptive evidence + forming conclusions based on this evidence
too much inferences can be bad
Tensions Inherent in Case Formulation
Individual vs General Formulations
rely on theoretical understanding of how ppl work
relying too much might mean we don’t see individual
if we look at individual too much, we miss years of research
Tensions Inherent in Case Formulation
Balance betw generating unique understanding of an individual with general knowledge about psychopathology + psychotherapy
Case Formulation in Psychotherapy Research
Value of case formulation is relative to its reliability + validity
reliability: extent clinicians agree on approximation of same case formulation
Case Formulation in Psychotherapy Research
validity: how likely is to accurately guide me to successful outcome or the course of treatment
Case Formulation in Psychotherapy Research
Persons (1991): “conceptual incompatibility” betw design of psychotherapy studies + models of psychotherapy evaluated in studies
seitz: consensus problem: looked at same case
Case Formulation in Psychotherapy Research
essay on precipitants, focal conflict, defence mechanisms, reasoning on interpretations
difficult to achieve any consensus
problem since it’s a research, scientific field
Case Formulation in Psychotherapy Research
more important that it guides me a therapist rather than objective therapy process
Revised approach to case formulation
big push toward identifying specific steps in formulation
Case Formulation in Psychotherapy Research
when we study therapy decontextualize, we talk about an artificial design
assessment + treatment are separate
process is what predicts outcome more than content of case formulation
Steps for Developing a Case Formulation
Step 1. Create Problem List – Describe full range of client’s problems
what they wanna focus on, doesn’t mean we disregard what they don’t wanna talk about, but it influences our formulation
Steps for Developing a Case Formulation
Signs + Symptoms: types of behaviours exhibited by client, complaints of distress, signs of disturbances observable to therapist + others, but not client
Steps for Developing a Case Formulation
signs: stressed, struggling in relationship
sign: observable to others, but client not related
symptom
Steps for Developing a Case Formulation
Problems in living: issues in self-functioning, social/interpersonal functioning, societal functioning
self-functioning: mood, identity, existential concern
interpersonal: relationships
societal: relates to larger society - war, poverty
Steps for Developing a Case Formulation
Step 2. Diagnose: Provide diagnosis for both practical requirements (i.e., billing) + future treatment planning
formal diagnoses
some base interventions on diagnoses
Steps for Developing a Case Formulation
Step 3. Develop explanatory hypothesis – therapist’s account of what is causing, maintaining, + precipitating client’s problems
Identify precipitants – triggers of symptoms + problems
anything that precedes episode when they seek treatment
Steps for Developing a Case Formulation
Identify origins – predisposing events, traumas, stressors, + risk factors inferred as causally related to development of client’s current problems
often emerges gradually
Steps for Developing a Case Formulation
development inferred to be causally related to development of issues
distal precipitant
direct: divorce, failing, death
contributing; established conditions that increase vulnerability to issues
Steps for Developing a Case Formulation
Identify resources – strengths client brings to therapy to facilitate recovery (internal + external)
internal - qualities, skills (hobbies)
external - strong social network, money
contributes to process
Steps for Developing a Case Formulation
Identify obstacles – aspects of client’s life that may interfere with treatment success
start planning on how to address them
Steps for Developing a Case Formulation
State core hypothesis – brief summary statement of central mechanism generating problems, based on specific theoretical approach
how it fits together
ideological understanding of person
Steps for Developing a Case Formulation
Step 4. Plan Treatment – explicit statement of how selected problems will be addressed in treatment
Identify treatment goals (process + outcome goals)
short term + long term goals
Steps for Developing a Case Formulation
goals: decrease anxiety, resolve conflict in relationships
plan: how do we do this? change contingencies/look at disruptive thoughts - depends on specific therapy
Steps for Developing a Case Formulation
outcome goals: reduce anxiety/avoidance
process goals: expose client to emotion
Plan interventions to address goals
explanatory hypothesis + creating process goals around it
Cultural Competence in Case Formulation
Culture: collection of ideas + values in individual + group behavior + that over time have acquired stabilizing power in personality + in society
• distinguishes groups along multiple dimensions
can include age, sexuality, gender, SES
Cultural Competence in Case Formulation
Cultural influences vary among people from similarcultural backgrounds
common mistake that ppl from similar cultural background are the same
Cultural Competence in Case Formulation
on paper looks the same, but how it effects 1 person is diff from another
it’s about the thought of considering culture
Cultural Competence in Case Formulation
Meta-analysis demonstrated that culturally adapted psychotherapy more effective than therapy not culturally adapted
Cultural Competence in Case Formulation
client at centre of case formulation; conceptualizes person
through sensitive understanding of his/her identity
begins with client at the centre, not the diagnosis, the protocols or treatment plan
understand person based on how they identify, not how i identify them
Cultural Competence in Case Formulation
ppl don’t fit well in specific categories
doesn’t privilege one cultural influence, but how intersections influence person’s formulation
Cultural Competence in Case Formulation
Hays’ (2007) ADDRESSING model of human diversity:
• Age
• Disability
• Religion
Cultural Competence in Case Formulation
- Ethnicity
- Social Class
- Sexual Orientation
Cultural Competence in Case Formulation
- Indigenous Origins
- National Origin
- Gender
Cultural Competence in Case Formulation
• Other dimensions: history of colonization, relationship status, size, attractiveness, trauma history, combat experience, etc.
all inform person’s identity
Cultural Competence in Case Formulation
Cultural factors intersect in multiplicity of ways: they are not additive, but dynamically related in ways unique to individual
sensitive to the fact that ppl’s identities are formed in multiple ways
Cultural Competence in Case Formulation
children of interracial couple
in sibling pairs - multiplicity of ways they can understand trajectory of developing identities
important to understand intersectionality + asking what aspects is important to them
Cultural Competence in Case Formulation
Therapists must understand their own biases, rather than operate from an assumption of “neutrality”
recognize/understand own biases + how they influence interpretions
Cultural Competence in Case Formulation
if one claims to be unbiased, shut down part that says i need to explore biases - it’s impossible to be completely unbiased
Cultural Competence in Case Formulation
Amending to common factors + relationship variables is a solution for culturally competent psychotherapy practice
when we get very narrow, we are more prone to miss individual differences
