CLINICAL CASE FORMULATION 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

FORMULATION OF A CLINICAL CASE* A frequent situation: the patient presents difficulties with a particular problem The question asked by the mental health specialist: 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: 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 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

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 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: 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 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 : A situation A psychiatric/psychological disorder or problem A specific case

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 Reduce the symptoms of depression to lower levels Reduce anxiety symptoms to lower levels Eliminate panic attacks Reduce worries ½ hr a day or less

Elements based in empirical evidence Backup your results with latest research findings Theoretical hypothesis Ideografic evaluation

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 Problem list Treatment plan Objetives Measures Strategies Progress follow up

Problem Hierarchy Case formulation Probability of certainty Its impact in daily functioning Its impact in social impact

OBJECTIVES Short term : sub-goals motivate more Concrete and specific Measurements

CREATING OBJECTIVES Evaluate a typical day vs. an ideal day : Identify a goal associated with the main problem Identify if the patient achieved the goal

OBJECTIVES TREATMENT DATE : PHASE I OBJECTIVES 1.____________________________________ 2._____________________________________ 3._____________________________________

CRITERIA FOR MEASUREMENT Aplicability Acceptable and friendly Validity and confiability Sensitive to change

QUESTIONS TO BE ASKED WHEN 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 The more specific the better Treatment manuals Evidenced based protocols The more specific the better Treatment manuals Evidenced based protocols

REVIEW 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 CHARTS Microsoft Excel Paper and pencil Charts previously prepared Microsoft Excel Paper and pencil Charts previously prepared

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 IN TREATMENT 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 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