Week 4 - Case Conceptualisation

Question 1

Case Conceptualisation
(what is it/why we do it)

Answer 1

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

Question 2

Case Conceptualisation

- as per (Eells, 1997)

Answer 2

“…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)

Question 3

Case Conceptualisation
Explains What?
(what does it lead to and what does it include)

Answer 3

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

Question 4

Tensions Inherent in Case Conceptualisation

Answer 4

Immediacy versus Comprehensiveness

Complexity versus Simplicity

Observation versus Organisation

Cultural sensitivity

—-Sim et al. (2005) – Case formulation in psychotherapy

Question 5

Case conceptualisation

framework, dynamic, evidence

Answer 5

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”

Question 6

Case conceptualisation

Individual versus General Formulations

Answer 6

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

Question 7

Nomothetic

theories

Answer 7

general theories that apply to all individuals or group of individuals

Question 8

Idiographic

theories

Answer 8

theories that are applicable to a particular/specific case

Question 9

Steps to Developing a Cognitive-Behavioural Conceptualisation

(Persons & Tompkins (2007) – Cognitive-behavioral case formulation)

Answer 9

1. Develop a comprehensive problem list
   - —Needs to be manageable length
   - —Can group problems together
2. Assign DSM diagnosis
   - —Provides a link to nomothetic formulation & empirically supported treatment
3. 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

Question 10

Steps to Developing a Cognitive-Behavioural Conceptualisation

(steps 4 & 5)

Answer 10

4. Select a nomothetic formulation of the anchoring diagnosis
   - —Evidence-based formulations
   - —Select based on familiarity, acceptability to client, or what best fits the case
5. Individualise the template
   - —Based on individual details of the client

Question 11

Steps to Developing a Cognitive-Behavioural Conceptualisation

(steps 6 & 7)

Answer 11

6. Propose hypotheses about the origins of the mechanisms
   - —Based on details of client history
7. Describe precipitants of the current episode of illness or symptom exacerbation
   - —Based on details of presenting problem
   - —Keep mechanisms in mind

Question 12

The 4 Ps Model

Answer 12

Predisposing factors

Precipitating Factors

Perpetuating factors

protective factors

Question 13

Predisposing factors

Answer 13

Physical / psychosocial factors that may have affected the client in uterus / early life

Vulnerability

Question 14

Precipitating factors

Answer 14

appear shortly before disorder & appear to have induced it

E.g., Psychological stressors; social changes; physical change

Question 15

Perpetuating factors

Answer 15

prolong or maintain disorder after it has started

E.g., cognitions, behaviours, social circumstances

Question 16

Protective Factors

Answer 16

Coping factors / strengths

Question 17

Introduction to Treatment

Roles of the Scientist-Practitioner

Answer 17

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?”

Question 18

Introduction to Treatment

The Scientist-Practitioner Gap

Answer 18

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

Question 19

Some Suggestions on being a Good Scientist-Practitioner

Answer 19

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

Question 20

Methods of scientist practioner approach?

Answer 20

Methods

• Interviews
• Self-reports
• –Watch the psychometrics!
• Ratings by others
• Self-monitoring
• Direct observations

Question 21

Approaches to Treatment Planning

Answer 21

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

Question 22

Treatment Planning: Determining Appropriate Treatments

Answer 22

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

Question 23

Treatment Planning: Common Elements

Answer 23

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

Question 24

Treatment Planning:

Prioritising Problems

Answer 24

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

Question 25

Treatment Planning: Common Elements - Goal Development

Answer 25

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)

Question 26

Prioritising Goals/Objectives

Answer 26

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

Question 27

Treatment Planning: Common Elements | Intervention techniques and Flexibility

Answer 27

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

Question 28

DUGAS model of GAD | see slide 57 for visual

Answer 28

Mood State & life events + intolerance of uncertainty ``` "What if?" Positive Beliefs About Worry Worry Anxiety Negative Problem Orientation Cognitive Avoidance ```

Question 29

Definitions of Worry

Answer 29

"…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).

Question 30

Intolerance of uncertainty definitions

Answer 30

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).

Question 31

Negative problem orientation definitions

Answer 31

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).

Question 32

Positive beliefs about worry definitions

Answer 32

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).

Question 33

Cognitive avoidance definitions

Answer 33

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

Question 34

Wells' (cognitive) Model of GAD | see slide 63 for visual

Answer 34

``` 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.

Question 35

Negative beliefs about worry definition

Answer 35

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).