Week 4 - Case Conceptualisation Flashcards
Case Conceptualisation (what is it/why we do it)
What do you THINK IS GOING ON???
- –A way of thinking about a case
- –A way of communicating about a case
- –A way of proceeding with a case
Guides the information-gathering of the intake interview
Organises information that can be complex and contradictory
Guides formulation of hypotheses of causes, precipitants and maintaining influences (Eells, 1997)
A psychological narrative or explanation for why the client has developed the presenting issues, and what keeps them going
Case formulation can be very powerful way of sharing information / perspectives with your client +> better understanding – both therapist and client
Case Conceptualisation
- as per (Eells, 1997)
“…a Hypothesis about the Causes, Precipitants, and Maintaining influences of a person’s psychological, interpersonal and behavioral problems. A case formulation helps to Organize often complex and contradictory information about a person. It should serve as a blueprint Guiding Treatment, as a Marker for Change, and as a Structure enabling the therapist to Understand the patient better.” (Eells, 1997, p. 2)
Case Conceptualisation
Explains What?
(what does it lead to and what does it include)
Explains –
- –Why symptoms emerge
- –How various factors shape symptom patterns
- –What relationship is between symptoms
is a broader clinical task than diagnosis
Leads to:
+> understanding
+> good treatment utility
+> has to be parsimonious – accounting for observed data with a relatively simple explanation
including diagnosis but also other factors & treatment
Tensions Inherent in Case Conceptualisation
Immediacy versus Comprehensiveness
Complexity versus Simplicity
Observation versus Organisation
Cultural sensitivity
—-Sim et al. (2005) – Case formulation in psychotherapy
Case conceptualisation
framework, dynamic, evidence
Conceptual framework yet allowing for flexibility
Dynamic and fluid => requiring generation and testing of hypotheses
Continual refinement and revision
Evidence-based - Therapy is not “a bag of tricks”
Case conceptualisation
Individual versus General Formulations
Formulation tailored to a specific individual’s life circumstances, needs, goals, thought patterns, etc
BUT must also rely on therapist’s knowledge about psychology and past experience with other individuals
Problematic if:
- -Trying to make the client “fit” a generalised formulation that really doesn’t fit
- –Over-individualise a formulation, neglecting knowledge of psychology and clinical experience
Nomothetic
theories
general theories that apply to all individuals or group of individuals
Idiographic
theories
theories that are applicable to a particular/specific case
Steps to Developing a Cognitive-Behavioural Conceptualisation
(Persons & Tompkins (2007) – Cognitive-behavioral case formulation)
- Develop a comprehensive problem list
- —Needs to be manageable length
- —Can group problems together - Assign DSM diagnosis
- —Provides a link to nomothetic formulation & empirically supported treatment - Select an “anchoring” diagnosis
- —Diagnosis that will be used to guide selection of a nomothetic template for the idiographic case conceptualisation
- —Can be chosen based on what accounts for the most problems or treatment goals
Steps to Developing a Cognitive-Behavioural Conceptualisation
(steps 4 & 5)
- Select a nomothetic formulation of the anchoring diagnosis
- —Evidence-based formulations
- —Select based on familiarity, acceptability to client, or what best fits the case - Individualise the template
- —Based on individual details of the client
Steps to Developing a Cognitive-Behavioural Conceptualisation
(steps 6 & 7)
- Propose hypotheses about the origins of the mechanisms
- —Based on details of client history - Describe precipitants of the current episode of illness or symptom exacerbation
- —Based on details of presenting problem
- —Keep mechanisms in mind
The 4 Ps Model
Predisposing factors
Precipitating Factors
Perpetuating factors
protective factors
Predisposing factors
Physical / psychosocial factors that may have affected the client in uterus / early life
Vulnerability
Precipitating factors
appear shortly before disorder & appear to have induced it
E.g., Psychological stressors; social changes; physical change
Perpetuating factors
prolong or maintain disorder after it has started
E.g., cognitions, behaviours, social circumstances
Protective Factors
Coping factors / strengths
Introduction to Treatment
Roles of the Scientist-Practitioner
As consumers of research findings
“How can I best assess/treat my clients”
As evaluators of their own interventions
“Am I effectively assessing/treating my clients?”
As researchers, producing new data
“How can I best assist you to effectively assess/treat your clients?”
Introduction to Treatment
The Scientist-Practitioner Gap
Clinicans as poor consumers of research vs Researchers as inept salespeople…?
Attempts to shift focus “real world” e.g., what works in clinical setting
Identification of empirically supported treatments; relationships & principles of change
Payoffs for clinicans & researchers in collaboration
Some Suggestions on being a Good Scientist-Practitioner
Adopt a “hypothesis-testing approach” - consider alternative hypotheses
Try to rely less on memory
Try to recognize personal biases
Try to get good quality information (e.g., assessment / questionnaires etc.)
Become an informed consumer of research literature
Methods of scientist practioner approach?
Methods
- Interviews
- Self-reports
- –Watch the psychometrics!
- Ratings by others
- Self-monitoring
- Direct observations
Approaches to Treatment Planning
Client Data (problem,context, history, etc)
- Theoretical & Emprical Literature
- Clinical Training & Experience
–Assessment & Case Formulation
- –Treatment Planning
- —–choosing an empirically supported treatment or set of empirically-supported therapeutic principles
—-Treatment Implementation and Monitoring
—–Evaluation and Accountability
Treatment Planning: Determining Appropriate Treatments
Client problem and treatment literature
- -Empirical research (particularly randomised controlled trials) outlining effective treatment approaches
- -Case studies
- -Theoretical discussions regarding treatment choice
Therapist skill or expertise
–Training, experience, current/previous supervision
Therapist preference
–Theoretical orientation
Client preference
–Impact on cooperation or compliance
Treatment Planning: Common Elements
Problem selection
–Effective treatment plan deals with only a few selected problems
Problem definition
- -How the problem exhibits itself in the patient
- -Helps maintain focus and provides a measurable outcome
Treatment Planning:
Prioritising Problems
Consider:
–What the patient identifies as most troublesome/primary reason for seeking help
–Degree and extent of impact on patient’s life
–Which problem/s must be dealt with first to resolve the central problem (identified in the case formulation)
–Ease and speed of problem resolution
Treatment Planning: Common Elements - Goal Development
Goal development
- -Can be global and long-term
- —Overall desired outcome of treatment
- -Can be more specific and short-term
- —Required to reach more global goal
- —Sometimes referred to as objectives
Characteristics:
- -Achievable/Realistic
- -Measurable
- -Stated in the positive (wherever possible)
Prioritising Goals/Objectives
Priorities of goals/objectives should mirror priorities assigned to problems
Might focus on a single goal/objective
OR
Can work toward achievement of two or more goals/objectives simultaneously
Treatment Planning: Common Elements
Intervention techniques and Flexibility
Intervention techniques
–Strategies that will move the client towards goal/objective
Flexibility
- -Changes in case formulation:
- –Evaluation of treatment plan
- –Possible modification of treatment plan
DUGAS model of GAD
see slide 57 for visual
Mood State & life events + intolerance of uncertainty
"What if?" Positive Beliefs About Worry Worry Anxiety Negative Problem Orientation Cognitive Avoidance
Definitions of Worry
“…a chain of thoughts and images, negatively affect-laden and relatively uncontrollable; it represents an attempt to engage in mental problem-solving on an issue whose outcome is uncertain but contains the possibility of one or more negative outcomes; consequently, worry relates closely to the fear process” (Borkevic, Robinson, Pruzinsky & DePree, 1983; p.10).
“…an anticipatory cognitive process involving repetitive, primarily verbal thoughts related to possible threatening outcomes and their potential consequences” Vasey & Daleiden, 1994; p.186).
Intolerance of uncertainty
definitions
Defined as a dispositional characteristic that stems from negative beliefs about uncertainty and its repercussions (Dugas & Robichaud, 2007)
Find uncertain situations stressful and upsetting, which then impacts on their ability to effectively cope (Laugesen, Dugan & Bukowski, 2003; Dugas & Robichaud, 2007).
Negative problem orientation
definitions
A set of dysfunctional cognitive beliefs whereby individuals appraise problems as threatening and unsolvable (D’zurilla & Nezu, 1999)
Individuals with an NPO frequently doubt their problem solving abilities and tend to become easily frustrated or pessimistic (Robichaud & Dugas, 2005).
Positive beliefs about worry
definitions
Revolve around the utility of worry as an important coping strategy (Wells, 1997)
Believe that worry may circumvent bad things from happening, help them to cope (Wells, 1997), minimize negative outcomes, and allow for the identification of solutions to problems (Freeston et al., 1994).
Cognitive avoidance
definitions
Refers to a number of automatic or purposeful strategies that lead to the avoidance or suppression of unwanted cognitive content
Although individuals engage in CA in an attempt to dampen unpleasant physiological arousal, it tends to result in the opposite effect, increasing worry and arousal (Dugas & Robichaud, 2007)
Prevents exposure and therefore habituation to unpleasant intrusions
Wells’ (cognitive) Model of GAD
see slide 63 for visual
Trigger
|
positive meta-beliefs activated (strategy section)
|
Type 1 Worry (eg, about something)
|
Negative meta-beliefs activated
|
Type 2 Worry (meta-worry)
(behaviour, thought control, emotion)
emotion feeds into and is fed by Type 1 worry as well.
Negative beliefs about worry
definition
Negative beliefs about worry revolve around the perceived negative impact and consequences of uncontrollable worry
Concern about the mental or physical harm associated with uncontrollable worry (Wells, 1995) and believe that their worry is dangerous (Penney, Mazmanian & Rudanycz, 2013).
