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
