Formulation and Intervention Kate Hardy, Clin.Psych.D Post Doctoral Fellow Prodromal Assessment, Research and Treatment Team (PART), UCSF PREP Prevention and Recovery of Early Psychosis

Objectives Be able to formulate a client using the stress vulnerability model, linear model and Morrison’s Model of Psychosis Develop this formulation collaboratively Use the formulation to identify where intervention is required

What is a formulation? A way of organizing the information gathered through assessment Proposes links between current symptoms and early experiences Sets agenda for intervention Attempts to explain timing of onset and factors maintaining the symptoms Developed collaboratively Can enhance alliance by showing insight and interest into client’s situation

Stress Vulnerability Hypothesis Vulnerability from genetic factors/biological factors Stress factors from relationships, lifestyle, substance abuse etc –Low vulnerability plus high stress may equal mental health problems –High vulnerability plus low stress may equal mental health problems Can be used to challenge assumptions and catastrophic view of psychosis and sense of unpredictability

Stress Bucket Intrapersonal Stress Poor diet (living on caffeine) Worrying about money Academic Stress More assignments Disagreement with teacher Poor results Environmental Stress Roommates often argue, I’m caught in the middle and can’t focus on my studies Stress Level Buffer Zone Interpersonal Stress Feel lonely Only make friends over the Internet, not in person Coping skills Unhelpful Coping Adapted from UNSW Counseling Services & Carver et al., 1989

Linear Formulation Event – thought – feeling – behavior Useful in making sense of a behavior that otherwise may seem bizarre or not understandable Simple and may be tolerated when other more complex formulations are not Can identify level at which need to intervene

Morrison’s (2001) Model of Psychosis Positive symptoms are conceptualized as intrusions into awareness The interpretation, rather than the intrusion, causes distress and disability Symptoms are maintained by mood, arousal and mal-adaptive cognitive-behavioral responses (e.g. avoidance)

Theoretical Model

Client friendly version of the formulation What happened Event /intrusion How I make sense of it Beliefs about yourself and others Life experiences What do you do when this happens How does it make you feel

Back to the original triangle How I make sense of it What do you do when this happens How does it make you feel

Intervention Psychoeducation Normalization

Psychoeducation Should be based on case formulation Should be specific to the client and their concerns and needs Should incorporate strengths where possible

Psychoeducation Stress Vulnerability Model –Provides information on the relationship between stress and genetic risk factors Provide information about possible triggers and risk factors for the individual –Drugs, decreased sleep, increased workload etc. Dispel myths of psychosis and provide facts –Challenge negative media portrayals of psychosis –Provide facts about what we know about psychosis

Psychoeducation Can be associated with an increase in suicidal thinking and depression –Be aware of this and assess –Regular checks with the client to explore how they are hearing this information

Normalization Focus is on normalizing the experiences NOT dismissing them Again should be specific to the problems client presents with Consistent with the continuum hypothesis

Normalization Psychotic Experiences No experiences Stress, Drugs, Trauma, Sleep deprivation Bereavement

Normalization 5% of population hear voices (Tien 1991) People hear voices without coming into contact with mental health services (Romme and Escher 1989) 9% people hold delusional beliefs (van Os 2000) Common to see or hear loved one following bereavement (Grimby 1993)

Normalization – intrusive thoughts Provide information on the prevalence and types of intrusive thoughts Experiment with thought suppression

Normalization Should not minimize experiences or dismiss them Trying to decatastrophize Showing the client that they are having experiences that are more common than they (and many clinicians) realize