CLINICAL CASEFORMULATION CLINICAL CASEFORMULATION

Felícitas Kort

Psychology Projects Coordinator Clinical Management Consultants FREEDOM FROM FEAR

PSYCHOTHERAPY AS A FORMULATION

HYPOTHESIS

* Formulation *Treatment based in the formulation

*Monitor progress of treatment to proof the hypothesis

PSYCHOTHERAPY AS A FORMULATION

HYPOTHESIS

* Formulation *Treatment based in the formulation

*Monitor progress of treatment to proof the hypothesis

FORMULATIONOF A CLINICAL CASE*

FORMULATIONOF A CLINICAL CASE*

A frequent situation: the patient presents difficulties with a particularproblem

The question asked by the mental healthspecialist: What is the best for this patient at the present

moment ?

*Case formulation helps select the appropriate strategies

THE ANSWER TO THIS QUESTION REQUIRES AN:

THE ANSWER TO THIS QUESTION REQUIRES AN:

Evaluation

A develpment of a hypothesis of the case

Use the formulation to guide the intervention

An evaluation of the progress so as to observe the response of the intervention

EMPIRICAL TREATMENT OF A CASE

EMPIRICAL TREATMENT OF A CASE

1 EVALUATION

2 FORMULATION OF THE CASE

(HYPOTHESIS) 3 TREATMENT

MONITOR THE PROGRESS OF EACH

SESSION a) If it is positive continue

b)If it is inadequate:

EVALUATE AGAIN, OFFER ANOTHER HYPOTHESIS

AND PLAN OF TREATMENT

MONITOR THE PROGRESS OF EACH

SESSION a) If it is positive continue

b)If it is inadequate:

EVALUATE AGAIN, OFFER ANOTHER HYPOTHESIS

AND PLAN OF TREATMENT

FUNCTIONAL ANALYSIS OF PROBLEM BEHAVIORS

FUNCTIONAL ANALYSIS OF PROBLEM BEHAVIORS

ASK THE FOLLOWING QUESTION :

WHAT IS THE FUNCTION OF THIS BEHAVIOR ?

YOU NEED A HYPOTHESIS

YOU NEED THE DETAILS

A FUNCTIONAL ANALYSIS IN THE TREATMENT OF SUICIDAL BEHAVIOR

A FUNCTIONAL ANALYSIS IN THE TREATMENT OF SUICIDAL BEHAVIOR

FORMULATION : suicidal behaviors serve as a function of allowing the person to go to the hospital and find relief to the problems which are overwhelming, therefore

a)calls for attention b) escapes the problems

FUNCTIONAL TREATMENT: teaches skills which are more appropiate to problem solving

FORMULATION OF THE TREATMENT FOR SUICIDAL

BEHAVIOR

FORMULATION OF THE TREATMENT FOR SUICIDAL

BEHAVIORFORMULATION: suicidal behaviors are

caused by beliefs such as “since I am suffering so intensely this suffering will never pass” (hopelessness)

BEHAVIORAL AND COGNITIVE TREATMENT : Register thoughts and schedules of the activities to change thoughts and restructure new beliefs

FUNCTIONAL ANALYSIS OF PROBLEM BEHAVIORS

FUNCTIONAL ANALYSIS OF PROBLEM BEHAVIORS

ANTECEDENTS ( Signal or stimulus behavior ) BEHAVIORS CONSEQUENCES (If it influences the behavior or not, if it repeats itself or not

THE FORMULATION OF A CLINICAL CASE PRESENTS

THREE LEVELS :

THE FORMULATION OF A CLINICAL CASE PRESENTS

THREE LEVELS :

A situation

A psychiatric/psychological disorder or problem

A specific case

Examples of unuseful goals of treatment

Examples of unuseful goals of treatment

* “We would like to have a more loving relationship among each other”

* “I would like to get out of this rut I am in ”

* “I would like to feel better with myself ”

Examples of effective ways to reduce symptoms

Examples of effective ways to reduce symptoms

Reduce the symptoms of depression tolower levels

Reduce anxiety symptoms to lower levels

Eliminate panic attacks

Reduce worries ½ hr a day or less

Elements based in empirical evidence

Elements based in empirical evidence

Backup your results with latest research findings

Theoretical hypothesis

Ideografic evaluation

CASE FORMULATION :A DEFINITION

CASE FORMULATION :A DEFINITION

The formulation of a case is a hypothesis of the problems of the patient

The function of the formulation is to develop a plan to treat the problems

First we want to know where to guide the intervention and

Second understand it

EMPIRICAL EVIDENCE: AN INDIVIDUAL CASE

EMPIRICAL EVIDENCE: AN INDIVIDUAL CASE

Problem list Treatment plan

Objetives Measures Strategies

Progress follow up

Problem HierarchyProblem HierarchyCase formulation

Probability of certainty

Its impact in daily functioning

Its impact in social impact

OBJECTIVESOBJECTIVES

Short term : sub-goals motivate more

Concrete and specific

Measurements

CREATING OBJECTIVESCREATING OBJECTIVES

Evaluate a typical day vs. an ideal day :

Identify a goal associated with the main

problem

Identify if the patient achieved the goal

OBJECTIVESOBJECTIVES

TREATMENT DATE : ----------- PHASE I

OBJECTIVES 1.____________________________________ 2._____________________________________

3._____________________________________

CRITERIA FOR MEASUREMENT CRITERIA FOR MEASUREMENT

Aplicability

Acceptable and friendly

Validity and confiability

Sensitive to change

QUESTIONS TO BE ASKEDWHEN YOU CHOOSE MEASURES

QUESTIONS TO BE ASKEDWHEN YOU CHOOSE MEASURES

1. How can I use these data ?

2. How frequently should I measure?

3. What is the expectative of change ?

4. Should I include other significative

persons in the evaluation?

5. Should I measure only the symptoms associated with the problem or general measures ?

6. Can I design my own measures ?

TREATMENT STRATEGIES TREATMENT STRATEGIES

The more specific the better

Treatment manuals

Evidenced based protocols

The more specific the better

Treatment manuals

Evidenced based protocols

REVIEW OF PROGRESSREVIEW OF PROGRESS

“If there is not a pattern which measures behaviors

it is quite difficult to judge how the progress is

coming along and whether the capabilities are

developed at their best” Bandura & Schunk (1981)

“If there is not a pattern which measures behaviors

it is quite difficult to judge how the progress is

coming along and whether the capabilities are

developed at their best” Bandura & Schunk (1981)

TOOLS NEEDED FOR THE CHARTSTOOLS NEEDED FOR THE CHARTS

Microsoft Excel

Paper and pencil

Charts previously prepared

Microsoft Excel

Paper and pencil

Charts previously prepared

REVIEW OF PROGRESS Stage 1

REVIEW OF PROGRESS Stage 1

Goals

Potencially modify the treatment plan

Continue to another stage of treatment

Termination of behavior and cognitive therapy

Goals

Potencially modify the treatment plan

Continue to another stage of treatment

Termination of behavior and cognitive therapy

INITIATING A NEW STAGE INTREATMENT

INITIATING A NEW STAGE INTREATMENT

When the goals have been fulfilled

New issues arise

Share the results with the patient

When the goals have been fulfilled

New issues arise

Share the results with the patient

BIOPSYCHOSOCIAL REVIEWBIOPSYCHOSOCIAL REVIEW

Clinical crisis Healthy behaviors

Self-destructive behaviors Risk behaviors

Family funcioning Culture and spirituality

Ocupational School & Community functioning

Clinical crisis Healthy behaviors

Self-destructive behaviors Risk behaviors

Family funcioning Culture and spirituality

Ocupational School & Community functioning