Treatment Planning

1
Treatment Planning

• Matching and Case Formulation

2
Problems with Diagnosis

• Diagnostic systems in mental health have
  traditionally been based on
• Presence and frequency of symptoms
• Social significance interpersonal effects
• Specificity of symptomatic responses to drugs
• Ignore empirical information about patient
  characteristics and traits (coping style,
  resistance, conflicts, etc.)

3
Problems with Diagnosis

• Beutler et al. (1999)
• Failure of matching a consequence of over
  reliance on a diagnostic system
• Criticise psychologists for not relying upon
  empirically derived dimensions of personality and
  prediction in constructing formulations of
  clients and interventions
• Problem Activation approach
• Problem Development or Problem Resolution
  approach

4
Treatment Matching

• (Beutler Clarkin, 1990)

5
(No Transcript)
6
Functional Impairment

• Degree of impairment caused by a condition
  (typically, the impairment that can be observed
  Strupp et al., 1997)
• Not same construct as subjective distress
• Impairment and distress confounded in the concept
  of problem severity
• Measured using the GAF

7
Functional Impairment

• Impairment negatively related to improvement and
  some claimed it is the single best predictor of a
  negative treatment outcome (McClellan et al.,
  1983)
• Clients with a high degree of impairment improve
  to a greater degree with longer and more
  intensive treatment (Shapiro, et al., 1994)
• Impairment is a predictor of relapse (Brown
  Barlow, 1995)

8
Functional Impairment

• Impairment may help in making treatment choices
• Impairment may be mediator of differential
  effects attributed to psychosocial treatments
• Unimpaired object relations absence of comorbid
  personality disorders (Joyce Piper, 1996 Woody
  et al., 1984) predicted success with dynamic
  therapy
• Kadden et al. (1989) patients with sociopathic
  personality traits responded better to CBT than
  insight-oriented psychotherapy

9
Subjective Distress

• Measured by Spielberger and Beck scales
• Subjective state of well-being that is
  problem-dependent, but poorly correlated with
  objective measures of impairment
• Measure of improvement
• Motivator for attending and remaining in
  treatment (Frank Frank, 1991)
• While high impairment retards change, moderate to
  high distress correlates positively with
  improvement (Lambert, 1994)

10
Readiness for Change

• Prochaska et al. (1992)
• Progress through therapy is function of how well
  intervention method fits patients position along
  a progressive series of stages reflecting
  personal efforts to change
• Five stages are measures with Stages of Change
  Questionnaire (Prochaska, et al., 1988)

11
Readiness for Change

• Stages of Change
• Pre-contemplation
• Contemplation
• Preparation
• Action
• Maintenance / Relapse

12
Readiness for Change

• Hypotheses
• More advanced stages of change associated with a
  greater likelihood of improvement
• Stage of readiness served as an indicator for use
  of specific therapeutic interventions
• Patients with little readiness responded better
  to techniques aimed to enhance motivation and
  encourage contemplation
• Patients at action phase did not show predicted
  benefits from CT (Project MATCH, 1997)

13
Problem Complexity

• Problems complicated by personality disorders,
  chronicity, entrenched interpersonal or
  conflictual patterns
• Measured with MMPI
• Behavioural interventions more effective with
  problems that are situational and reactive
  (Knight-Law, et al., 1988)
• CBT less effective with more complicated clients
  (Fairburn et al., 1993)
• But, Wilson (1996) nothing any better to date

14
Reactance/Resistance

• Trait-like resistance
• indicator of poor prognosis and is a mediator of
  differential treatment response (Arkowitz, 1991)
• Measured by the Therapeutic Reactance Scale (TRS
  Dowd, et al., 1991)
• Reactant individuals prefer settings that allowed
  them to exercise personal initiative and freedom
• react poorly if controlled or directed

15
Reactance/Resistance

• Horvath and Goheen (1990)
• reactant individuals responded well to
  paradoxical interventions, whereas less reactant
  individuals lost the goals once treatment stopped

16
Social Support

• Perceived social support is a predictor of
  treatment success among people with depression
  (and exceeds that predicted by objective social
  support Hooley Teasdale, 1989)
• Depressed patients with poor social support
  continued to benefit from treatment
• Those with good social support reached asymptote
  quickly
• E.g., Family Environment Scale

17
Coping Styles

• Measured by EPQ, NEO, MMPI, and MCMI
• Barber Muenz (1996)
• Depressed patients responded best to treatments
  that were opposite to their usual coping style
• CBT more effective with patients who preferred
  externalising coping strategies
• IPT more effective with patients who preferred
  internalising coping strategies
• Tasca et al. (1994)
• Externalisers preferred process-oriented
  therapies
• Internalisers preferred CBT

18
Assessment Protocol for Treatment Planning
19
Predicting Outcome

• Hooke Page (in press)
• Affective
• Neurotic

20
.57
DASS Anxiety Pre-Treatment
DASS Anxiety Post-Treatment
GAF Pre-Treatment
-.16
.54
DASS Depression Pre-Treatment
DASS Depression Pre-Treatment
Locus of Control Pre-Treatment
.12
DASS Stress Pre-Treatment
.44
DASS Stress Post-Treatment
Self-Esteem Pre-Treatment
-.18
21
DASS Anxiety Pre-Treatment
.35
DASS Anxiety Post-Treatment
Self-Esteem Pre-Treatment
-.25
.53
DASS Depression Pre-Treatment
DASS Depression Pre-Treatment
.35
DASS Stress Pre-Treatment
DASS Stress Post-Treatment
Self-Esteem Pre-Treatment
-.31
22
(No Transcript)
23
(No Transcript)
24
Functional Analysis

• A Case Formulation Approach

25
Functional Analysis Introduction

• Diagnosis comes out of a structuralist
  epistemology
• DSM taxonomic system grounded in the assumption
  that symptoms covary into syndromes because of
  some unmeasured and underlying causal variable
• Psychologists are sympathetic towards it because
  behaviours have knowable causes

26
Functional Analysis Introduction

• Case formulation approach comes out of a
  different epistemology
• It is functional
• Aim is not to know the causal processes but to
  predict behaviour and understand the conditions
  under which it occurs
• Pragmatism is attractive to a psychologist

27
Functional Relationships

• Functional relationships imply covariance
• May be
• Causal
• Correlational
• Controllable
• Important
• Probabilistic (rather than deterministic)

28
Functional Relationships A Practical Perspective

• A functional analysis involves the identification
  of
• Important
• Controllable
• Causal
• Functional relationships applicable to a
  specified set of target behaviours for an
  individual

29
Possible Relationships

• Linear or non-linear
• Single or multiple pathways
• Weighted and unweighted pathways
• Ceiling and floor effects
• Thresholds
• Temporal variations
• Mediators versus moderators
• Originators versus maintainers
• Direct and indirect effects

30
Case Example (Turkat Maisto, 1985)

• Ms R was a 22-year old, but overweight female.
  Insulin-dependent diabetic was referred because
  of her difficulty adhering to her diabetic regime
• More concerned about being overweight, rather
  than her attitude to diabetes

31
Case Example

• Eating
• Drinking
• Work Difficulties
• Financial problems
• Family dependence
• No husband

• Boredom
• Appearance
• Selfishness
• Daydreaming
• Lack of planning
• Non-compliance

32
What Do You Do in a Functional Analysis?

• Antecedents
• Behaviours
• Consequences

33
What do you do in a functional analysis?

• Antecedents
• Distal and proximal factors
• Originating and maintaining factors
• Moderators and mediators

34
What do you do in a functional analysis?

• Behaviours
• Physiology, cognition, action
• Frequency
• Intensity
• Topography (typical and unusual patterns)
• Duration
• Temporal sequence
• History
• Relationships with other behaviours

35
What do you do in a functional analysis?

• Consequences
• Onset of event that causes decrease in behaviour
  (punisher)
• Offset of event that causes increase in behaviour
  (negative reinforcement)
• Onset of event that causes increase in behaviour
  (positive reinforcement)
• Offset of event that causes decrease in behaviour
  (response cost)
• Emotional, behavioural, cognitive, physiological,
  relational, motivational, etc