CH4
Intro
• Treatment planning is like problem solving and decision-making
- Problem solving involves coming up with different approaches
- Decision making involves using rules to make selections among available alternatives
• Done collaboratively
Ch4
Initial steps in developing a collaborative plan for therapy
• Eg characteristics of target behaviour, characteristics of the client, social-environmental factors
• Reaching consensus on the goals of therapy
- Goals of therapy: content focus of therapy, target behaviours , best intervention
- For clients who pp in CBT useful to discuss up front the focu on current behaviours
- And the rationale for this emphasis
- More likely to accept the behavioural targets if they know their rationale
- Therapists should focus on the development of behaviours and less on the elimination of behaviours
- Lessens the frequency of the problem area and creates greater flexibility for responding
- Therapist attempts to facilitate the clients personal freedom
• Prioritising Problem Areas
CH4
Prioritizing Problem Areas
- Linehans described the Dialectical Behaviour Therapy (DBT): outlined a schema for prioritising behaviours during therapy sessions
- 4 stages
1. Life threatening behaviours
2. Therapy interfering behaviours
3. Quality of life interfering behaviours
4. Behavioural skills to increase - If the Stage 1 treatment targets are addressed, go to stage 2 targets
CH4
Deciding which interventions to select
• EST ??? is most applicable for clients with a specific problem
- Otherwise you have to combine the components of EST
- Many problem areas don’t have an EST
- When this is the case there are 4 options for the therapist
1. Don’t treat client
2. Refer to another therapist
3. Use a collection of techniques of EST
4. Employ evidence- based cognitive and behavioural principles in the development of a clients formulation
• Behavioural case formulation and treatment planning are principle-driven rather than protocol drive
Next two principle driven case formulations are both idiographic
CH4
1st approach- The role of functional analysis in the selection of interventions
• Functional analysis is ideal to identify the sequence of events that precede and follow problem behaviour
• First client and therapist identify links between antecedents and problem behaviours
• Second look for alternative response
• Evaluating the functional similarity of different forms of problematic behaviour
- Functional response classes consist of o group of behaviour that, although different, share functional relatedness as they often influences by similar environmental variables
- This awareness can help pinpoint the core processes that maintain the occurrence of problem behavioral patterns
Ch4
2nd Approach: The role of functional analysis in the selection of intervention
• More individual for the client, more considerate of the clients needs and goals
- Compared to the EST approach more flexible
• First therapist performs an assessment within a given area
• Arter this treatment approach is constructed by assembling modules that are relevant to the clients needs and with between therapeutic activities as the glue that holds the modules together
• The client only receives those components that are most appropriate for him
Ch4
Some general intervention guidelines
• Interventions for behaviors maintained by positive reinforcement.
- These problem behaviors are often addressed by interventions changing the environment.
- Therapy here includes learning to be more effective through ones behavior and to enhance behavioral skills.
• Interventions to target unhelpful thinking patterns
- Intervention focuses on developing awareness of bringing behavior more in line with goals and values and changing thinking patterns.
• Interventions to target emotional difficulties
- For people who experience anxiety, exposure-based therapies can be helpful. When clients focus on the past or future or when they wish to increase self-acceptance, mindfulness interventions are useful.
CH4
Developing a framework for a course therapy
• Deciding which therapy modes to use
- In DBT there are 4 primary treatment modalities
1. Individual outpatient therapy (focus on problem areas)
2. Skills training group
3. Telephone consultations
4. Case consultation meetings (analogous to supervision meetings)
Ch4
Discussing therapy plan with the client
- When a therapist provides a rationale he can promote a clients’ optimism about the therpy
- Next are two primary areas the therapist will review with the client before therapy
CH4
1st area: Discussing the therapy rationale
- When client accepts the treatment rationale, associated with more therapeutic benefits
- Client is more optimistic whne they know the therapeutic approaches are widely tested and have been effective
CH4
2nd area: Discussing between-session activities as an integral part of therapy
• CBT interventions typically involve between-session activities carried out by the client, such as self monitoring and questionnaires
Ch4
Establishing a motivation change and securing a commitment for action
• The associated level of distress with motivation for change is often a U function- Too much, too less decrease in motivation
• A strategy for facilitating motivation is motivational interviewing
- Non-confrontational and emphatic approach for discussing the effects and consequences of the problem behaviour and exploring the benefits of change
- Components of this approach include: Feedback for problem behaviour, teaching problem-solving strategies
• Low motivation for therpy is sometimes associated with psychological disorders and then a medication consultation can be necessary
• Also treatment contracts
1. Promote motivation for change
2. It’s a reminder for therapy options
3. Can provide a framework for crisis resolution
CH4
Potential obstacles to effective therapy
• Following case formulation
- Ask client if they perceive obstacle
- Examine if the client anticipates other obstacles
- Invite clients to brainstorm on how the obstacle should be addressed
- Then can be translated into goals
CH4
Procedure for evaluating the effectiveness of therapy
• Ideally therapy goals should be measurable so you can see if there is progress being made
• Process of evaluating the therapy’s effectiveness, include the selection of an assessment framework and appropriate dependent measures
• For most clients the A-B of A-B-C schema is most effective
- A= baseline
- B= Intevention phase
- C= Period after investigation
• Nelson and Hayes provided guidelines to evaluate therapy efficacy
- measures should assess primary behaviors targeted in therapy, measures should occur frequently and if possible before treatment
- Data obtained should be graphed and regularly reviewed
Lec
Two phases in Behaviour Therapy
• Step 1
- understanding behaviour: analysing, hypothesisbased
• Step 2
- changing behaviour: interventions
Lec
Assessment in behaviour therapy
- Broadly surveying problem areas
- Narrowing down to focal assessment
- Choosing behavioural pattterns to target
- Continuous evaluation during treatment
- Post-treatment assessment of behavioural patterns (+ follow-up?)
• Make use of questionnaires, interviews, observation, self-monitoring
Lec
Assessment in Behavioural therapy
- Problem behaviour (incl frequency and severity)
- Antecedents (precipitating events)
- Consequences
- Learning histories
- Coping behaviours
- Functioning (social, family, work, school, financial)
- Relation between problem behaviours and values or goals
- Clients’ idea on problem behaviour
• Make use of questionnaires, interviews, observations, self-monitoring
Lec
Topographical analysis
• Very specific description of a specific situation, including antecedents, target behaviour and consequences; “video”
Lec
Functional analysis
- Clarifying the context and function of target behaviour
- Identifying eliciting factors (antecedents) + reinforcements and punishments (consequences) that contribute to a person’s maladaptive behaviors
Lec
Behavioural Case formulation (steps)
- the problem list,
- situational determinants (antecedents and consequences)
- hypothesized origins
- the working hypothesis
- sharing and exploring the formulation with the client.
- the treatment plans
- establishing a motivation for change and securing a commitment for action
- Potential obstacles to effective therapy, and
- procedures for evaluating the effectiveness of therapy
- Also: “holistic theory”: interrelated problem areas
Lec
All assessments together
• Provide clues for choosing interventions
- Empirically supported treatments
- Considerations based on individual behavioural case formulation
Lec
How to select the problem to work on?
• Start with the referral problem?
- Benefits: fits in with patient (motivation), does not overcharge the system, concrete, it may directly solve problems in the functioning of the patient, as first start (gaining confidence in tackling problems, possibly later address other (social) issues)
• Problematic value (e.g. life threatening)
• Changeability (treatment effectiveness through research, evidence based)
• Concrete problem
• Key position in the causal structure (holistic theory)
Lec
Antecedents
• Discriminative stimuli (Sd)
- Events or situations that elicit the behaviour and predict reinforcement or punishment (also called: precipitating events)
• Establishing operations (EO)
- Factors changing the reinforcing or punishing properties of other environmental events
- E.g.: hunger, thirst, negative mood
- Also: verbal rules (e.g. if-then statements, demands, moral rules)
- Motivational operations
Lec
Contingency management
Managing the relation between the antecedents, target behaviour and consequences
-
1 Intro33
-
2 Exposure42
-
Cl Conditioning and Exposure16
-
4 Parent training35
-
5 PTSD and EMDR28
-
6 Cog Interventions21
-
7 Psychosis24
-
8 Beh interventions and Eating dis27
-
9 Beh activation/actvity scheduling27
-
10 Cog interventions: beh exp21
-
11 Schema focused therapies37
-
12 3.Wave (Mindfulness, MBCT, ACT)0
-
13 Critical CBT0
-
14 3.Wave Pt.20
-
Slimstampen0
