case conceptualisation, formulation and session management

Dr George Varvatsoulias

Basics prior to case conceptualisation

Case-conceptualisation or caseformulation?

Conceptualisation: Making sense of the condition together with the client Formulation: Working collaboratively on agreed SMART goals and Interventions Case-conceptualisation: Rationale for the condition, personalised understanding of the condition to the clients needs Case-formulation: Setting goals in the short-term so these to be advanced in the long-term via appropriate methodology/CBT interventions

Skills in use from caseconceptualisation

Explanation of the conceptualisation rationale to the client Description of current problem(s) History of the problem(s): Early experiences/critical incidents Key maintaining processes and hypotheses keeping the problem(s) going Helping the client understand cognitive and functional ABC models

Individualised picture of skills (1)

Problem description in the here and now a. Cognitions b. Emotions Affects c. Behaviour(s) d. Physiological changes or bodily symptoms Problem description in the past a. Predisposing factors (Why me?) b. Precipitating factors (Why now?)

Individualised picture of skills (2)

Triggers and modifying factors a. Triggers: What factors make the problem more or less likely to occur b. Modifiers: What contextual factors make the difference to how severe the problem is when it does occur c. Intensifiers: Size, speed, proximity, sound(s)

Individualised picture of skills (3)

Many factors can operate as triggers or modifiers a. Situational variables (situations, objects, places) b. Social/interpersonal variables (self and others) c. Cognitive variables [topics of thought related to trigger(s)] d. Behavioural variables (occurrence during the presence of activities with or without others)

Individualised picture of skills (4)

e. Physiological variables (changes in the body and their effect to the problem) f. Affective variables (do existing mental conditions worsen the problem? Locus of control) Consequences a. What is the impact of the problem in ones life? b. How salient others respond to ones problem? c. Coping strategies that have tried and their effect on ones problem d. Is the person under the influence of substances to cope with the problem?

Maintaining processes (1)

Safety behaviours

Maintaining processes (2)

Escape/Avoidance

Maintaining processes (3)

Reduction of activity

Maintaining processes (4)

Catastrophic misinterpretation

Maintaining processes (5)

Self-fulfilling prophecies

Maintaining processes (6)

Scanning or hyper-vigilance

Maintaining processes (7)

Performance anxiety

Maintaining processes (8)

Fear of fear

Anxiety (Originally arising from any cause)

Aversive anxiety symptoms (Anxiety symptoms experienced as extremely threatening, unpleasant, intolerable)

Anticipatory fear of becoming anxious

Maintaining processes (9)

Perfectionism
Negative personal beliefs I am worthless, useless, I am not competent or capable

Impossible to achieve standards Always see self as failing

High standards for self I can conceal my uselessness, if I do everything perfectly, always succeed, etc.

Maintaining processes (10)

Short-term reward

9-box formulation for a depressed client

An example of case formulation in written form (a)

Early experiences You told me you come from a family with strict religious values; that your father was a dominant figure and that he was easily becoming angry at you. Critical incidents In your childhood whilst living with family you werent allowed to say your opinion freely. During your school and university years when teachers were asking questions you did not answer them and though you were trying grades from assignments were

An example of case formulation in written form (b)

Event what happened You were referred to me by your parish priest because of depressive elements in your behaviour. The reason you came to see me was that you were asked to make a presentation at school where you are working as a teacher and you didnt. Thoughts that came to your mind after that event Your thoughts at the time were I will fail 08/10, I will be humiliated 07/10. You have also imagined that colleagues will ask you questions you wont be able to answer 07/10 and that they will laugh at you 08/10.

An example of case formulation in written form (c)

Physical and emotional sensations What you have physically felt were mouth numbness and heart pounding. Emotionally you have felt distressed 08/10, in low mood 09/10, sad 09/10, helpless 08/10 and lonely 08/10. What you did-behaviours What you said to your colleagues was you had to write students reports. In saying so you left the room and you went to write these reports. After you did what you said you felt relieved 09/10 that you didnt do the

An example of case formulation in written form (d)

Core beliefs In exploring a bit further what you thought about yourself you told me you believe you are nothing 09/10, that you are worthless 09/10, that you dont mean anything 8/10, that others wont notice you because they will consider you as being useless 09/10.

Rule for living To compensate for such beliefs you expressed the rule If I dont show others how capable I am I feel unimportant 08/10. During every session you completed the Patients Health Questionnaire with scores between 15 and 18 out of 27 (moderately severe depression), the Becks questionnaire for depression with scores between 25 and 26 out of 63 (moderate depression) and the Hopelessness Depression Symptom Questionnaire with scores between 38 and 42 out of 96 (moderately severe depression). In all three questionnaires you were identified suffering from moderately severe depression, which is a clinical component of unipolar major depression.

An example of case formulation in written form (e)

Interventions-Cognitions domain Cognitive restructuring: modifying irrational thoughts via debating. SMART discussed and agreed: Better knowledge acquisition on the subject-matter Irene teaches at school Feelings domain Developing coping strategies to reduce negative emotional responses. SMART Goal discussed and agreed: Walking in the park Behavioural domain Weekly activity scheduling: keeping activities well-planned and scheduled on a weekly basis. SMART Goal discussed and agreed: Activity planner presentation before colleagues every week

Possible problems during assessment (1)

Problems for the practitioner 1. Difficulty in gathering information to be used for formulation 2. Replacing wrong with correct questions, such as open and not closed ones, as to eliciting and elaborating information provided by clients 3. To be careful of persistent and irrelevant areas of questions

Possible problems during assessment (2)

Problems for the client 1. The client has become so used to the problem that he/she no longer notices the factors in viewed to be assessed 2. Avoidance or safety behaviours, one of most common is the client to jump from one topic to another 3. Difficulty in reporting thoughts and emotions. The expression I feel... many times refer to thoughts and not emotions

Possible problems in making formulations

Effect is not purpose (Behaviours and consequences do not necessarily refer to intentions) Censoring the formulation (Formulation is a collaborative process and every information provided from the client is respectfully recorded) Spaghetti junction (Teaming out information with other information when they are relevant or similar) Tunnel vision (Idiosyncratic formulation in terms of supporting and refuting hypotheses

Formulations need to make sense

The hot cross bun perspective

Behaviours

Thoughts

Physiology

Emotions

Core beliefs and schemata should be:

1.

2.
3.

Targeted because they are fundamental parts found deeper than NATs (Negative Automatic Thoughts) or behaviour(s) Modified so that to be altered Controlled in terms of their connection with others and the world (environment)

The process of assessment

Session management (1)

a. b. c. d. e. f.

g.
h. i.

Assessment phase: Gather information Analyse information using CBT theory Develop/modify hypotheses about important processes Initial tentative ideas about formulation Possible need to modify formulation Discuss with client and modify as necessary Agreed Formulation Treatment plans Note further information acquired during treatment

Session management (2)

Session management (3)