Psychopathology and Clinical Problems

1
Psychopathology and Clinical Problems

• All observation must be for or against some view
  if it is to be of any service.
• Darwin

2
Arent treatment outcomes enough?

• Nathan Gorman (1998)
• Classified Studies
•    Type 1 Randomised, prospective clinical trial
• Type 2 As 1, but non-fatal design problems
•     Type 3 Clearly methodologically limited

3
Treatments that work
4
Treatments that work
5
Andrews, Corry, Oakley-Browne, and Shepherd
(2000)
6
Why UWA?

• Yates (1970)
• Psychodynamic psychologists may or may not make
  use of knowledge derived from experimental
  laboratory studies (or may rely on clinical
  judgment alone) whereas the behaviouristic
  psychologist will try to investigate and treat
  abnormal behaviour strictly on an experimental
  basis." (p. 3).

7
(No Transcript)
8
(No Transcript)
9
(No Transcript)
10
(No Transcript)
11
Why new things?
12
(No Transcript)
13
Schulte et al. (1992)
14
Emmelkamp et al. (1994)
15
Oliver Page (2002)
16
Scientists

• Weaknesses of Science
• Not applied
• Valid observation, not a valid criticism
• Criteria of Science
• New knowledge (Theory)
• How can we turn new knowledge into better
  treatments and get clinicians to use the best
  treatment for each client they see?

17
Robin Winkler (1985)

• The major threats stem from its very success in
  professional practice. There is a continuing
  demand from the profession to learn techniques
  without necessarily understanding or developing
  their theoretical and empirical foundations. The
  danger of such a demand is that behaviour
  modification becomes simply a technology defined
  by its procedures.
• (Winkler, 1985, p. 154)

18
Robin Winkler (1986)

• 1.  Theoretical link between discipline of
  psychology professional practice
• 2.   Improvement of standards by which
  interventions in professional practice are
  evaluated.
• 3.   Development of new, effective procedures for
  use in professional practice.

19
Young

• Reinventing your life
• I have come to believe that integrating On the
  other hand, I am opposed to combining
  haphazardly ... I believe that the eleven
  lifetraps provide that unifying framework (p
  xvi).

20
Young

• We do not believe that any one technique will
  be successful for all people. We believe that the
  most effective change approaches we believe
  that more people will be helped We strongly
  urge you to seek out approaches and therapists
  that combine we hope to be more successful
  we believe that it is usually a mistake to We
  feel that the best therapists we have a
  preference for integrative therapists (p. 343 and
  350).

21
(No Transcript)
22
Behavioral Activation

• Jacobson et al. (1996, 1998).
•          Behavioural Activation
•          BA Automatic Thoughts
•          BAAT Schema (CBT)

23
Combining Treatments

• Anger management
• Fava, et al. (1997)
• But Mattick, Peters, Clarke (1989)

24
Norcross et al. (1989)

• 29 say CBT is their orientation
• 29 say they are eclectic.
• What are they mixing?

25
Yellow Pages for Anxiety

• EFT
• REBT
• TFT
• Meditation
• EMDR

• Relaxation
• Counselling
• Hypnosis
• Cognitive Therapy
• Innovative Therapies

26
Case Formulation

• Source Page Stritzke (in prep.)

27
Definition

• hypothesis about the causes, precipitants, and
  maintaining influences of a persons
  psychological, interpersonal, and behavioral
  problems. A case formulation helps organize
  often complex and contradictory information about
  a person. It should serve as a blueprint guiding
  treatment, as a marker for change, as a structure
  for enabling the therapist to understand the
  patient better. A case formulation should also
  help the therapist anticipate therapy-interfering
  behaviors and experience greater empathy for the
  patient broadly, a psychotherapy case
  formulation also includes descriptive information
  on which the hypothesis is based and prescriptive
  recommendations that flow from the hypothesis
• (Eells, 1997 p. 2 italics in original).

28
Client Data (Problem, Context, History, etc.)
Theoretical and Empirical Literature
Clinical Training Experience
Assessment Case Formulation
Treatment Decision Measurement
Treatment Implementation Monitoring
Evaluation Dissemination
29
Behavioural Case Formulation Functional Analysis

• A functional analysis involves the identification
  of important, controllable, causal functional
  relationships applicable to a specified set of
  target behaviours for an individual client
  (Haynes OBrien, 1990).

30
A, B, C.

• A for Antecedents
• B for Behaviours
• C for Consequences (see.

31
(No Transcript)
32
AAntecedents

• The antecedencts are those variables which are
  both proximal in time and those which are more
  distal to the behaviour.
• Identification of the antecedents also separates
  the variables that were important in the origin
  of the problem as distinct from those which are
  involved in the maintenance of the problem.
• Antecedents can also be divided into those which
  are moderators or mediators. Moderators have a
  direct effect on the behaviour in question,
  whereas mediators serve to influence a
  relationship between two variables.

33
BBehaviours

• The second set of variables examined in a
  functional analysis is the behaviour itself.
• The behaviour can be described in terms of its
  frequency, duration, intensity, and topography
  (such as the typical and more unusual patterns).
• Behaviours can also be examined in terms of their
  temporal sequence, their history, and their
  relationships with other behaviours.

34
CConsequences

• Traditionally, consequences have been divided
  into four categories based upon whether the event
  is turned on or off, and whether the behaviour
  increases or decreases.
• When the onset of an event causes an increase in
  a behaviour, the event is said to be a positive
  reinforcer.
• When the onset of an event causes a decrease in
  behaviour, the event is called a punisher.
• When the offset of an event causes an increase in
  behaviour, the event is said to be a negative
  reinforcer.
• Finally, when the offset of an event causes a
  decrease in some behaviour, this is called
  response cost.

35
Categories of Responses
36
Applications

• These concepts have been applied in the area of
  developmental disabilities to understand the
  existence of many problem behavioural excesses,
  such as self-injurious behaviour.
• These three variables are
• (i) positive reinforcement
• (ii) negative reinforcement, and
• (iii) stimulation (Carr, 1977) or automatic
  reinforcement (Iwata, Vollmer, Zarcone, 1990).
• The third category of automatic reinforcement
  refers to the strengthening of behaviour by the
  consequences directly produced by a behaviour
  (e.g., rocking and rhythmic or repetitive
  behaviours).
• Technically, these behaviours could be explained
  in terms of the four types of reinformcement
  outlined, but the term is useful for describing
  situations where there do not appear to be any
  reinforcement being derived from the external
  environment. In the instances described, the
  sensory feedback itself appears to be
  reinforcing, so that when the sensory feedback is
  removed, the behaviour is extinguished (e.g.,
  Rincover, 1978).

37
(No Transcript)
38
Assessing a Behaviours Function

• indirect assessments - unstructured interviews or
  with the use of structured questionnaires (e.g.,
  ONeill, Horner, Albin, Storey, Sprague, 1990
  or the Motivation Assessment Scale by Durand
  Crimmins, 1988).
• analog assessments, in which artificial
  conditions are constructed to test hypotheses
  about the hypothesized reinforcers.
• a control condition can be contrasted with
  situations involving negative reinforcement,
  positive reinforcement, and automatic
  stimulation, and the influence upon the behaviour
  of the schedules of reinforcement can be
  measured. The results of such an assessment
  might identify the reinforcer controlling a given
  behaviour (e.g., Iwata, Dorsey, Slifer, Bauman,
  Richman, 1982).
• naturalistic assessments. That is, the behaviour
  is observed in its natural setting, and changes
  in the frequency and topography are measured as
  different contingencies occur (or are
  established).

39
Example

• Child with self-injurious behaviour.
• A 7-year-old boy, Sebastian, with severe
  intellectual disability came to the attention of
  the psychologist following referral by the
  teacher. Sebastian would engage in tantrums that
  involved screaming and self-injury.
• The psychologist began with an interview with the
  teacher to obtain a description of the problem
  behaviour.
• The teacher described that he would suddenly
  begin to scratch at his face and forearms,
  beginning by pinching and squeezing the skin,
  which could escalate into banging his head and
  face with his hands.

40
Example (Cont.)

• Antecedents
• Outbursts occurred infrequently during classtime,
  but most common during breaks and lunchtime.
• baseline data, recording the events that occurred
  during each break and then calculating the
  probability of the behaviours occurrence and
  nonoccurrence in a one minute interval.
• probability of self-injurious behaviour was more
  probable (i.e., 62) when the supervising teacher
  was attending to another child
• probability of self-injurious behaviour was less
  probable (i.e., 38) when the supervising teacher
  was only observing the other children or
  attending to Sebastian.
• Thus, a working hypothesis was formed that there
  was a relationship between the self-injurious
  behaviour and the perceived withdrawal of
  attention.
• Test an additional teacher was assigned at one
  break, who then spent the time ensuring that his
  attention was allocated to Sebastian. When this
  occurred, the probability of self-injurious
  behaviour dropped to 0, thus giving the
  psychologist confidence in the working hypothesis.

41
Cognitive Behavioural Case Formulation

• Persons (1989, 1993 Persons Tompkins, 1997)
• Extension includes an assessment of cognitive
  beliefs and attitudes (see J. Beck, 1995
  Freeman, 1992, Muran Segal, 1992, Turkat
  Maisto, 1985 for other examples).

42
Problem List

• Comprehensive, descriptive, concrete list of the
  presenting problem(s) and any other difficulties
  that the client may have. (analogous to the
  Behaviour of the ABC)

43
Core Beliefs

• Set of hypotheses about the cognitions or beliefs
  that could explain the origins or the maintenance
  of some or all the problems in the problem list.

44
Precipitants and Activating Situations

• Precipitants are analogous to the Antecedents
  within the ABC model of the functional analysis
• Activating situations are also antecedents, but
  refer to those that explain the problem more
  generally and explain the consistency across
  situations.

45
Working Hypothesis

• Unlike the functional analytic approach, Persons
  and Tompkins make no explicit statement about the
  consequences of a given behaviour, triggered by a
  particular precipitant, and mediated by a set of
  beliefs.
• Instead, clinician develops a theory that links
  the problems on the problem list, the core
  beliefs and the activating events and situations.

46
Finding an underlying mechanism

• Examine the problem list (common themes,
  behaviour)
• Examine automatic thoughts
• Study chief complaint and way phrased
• Find antecedents and consequences
• Use standardised measure (SCL)

47
Testing underlying mechanism

• How well does it account for the problems?
• Does clients report fit formulation?
• Test predictions that follow from mechanism
• Ask for clients reaction to formulation
• Success of treatment

48
Origins

• The psychologist then outlines early events that
  might explain the origin of core beliefs. These
  include predisposing variables, such as early
  experiences of parental loss or failure, that may
  set the stage for later pathology by creating
  expectations of abandonment or hopelessness.

49
Treatment Plan

• not a component of a case formulation, but they
  suggest that since a treatment plan will flow
  from the working hypothesis, it is an aid to good
  clinical practice to get into the habit of
  including the plan along side the hypothesis.

50
Predicted Obstacles to Treatment

• Finally, the psychologist is encouraged to
  explicitly use the problem list, core beliefs,
  and working hypothesis to identify predicted
  obstacles to treatment.
• These may refer to potential difficulties in the
  therapeutic relationship, compliance with
  treatment strategies, abilities understanding
  psychoeducation or interpretations of the
  problems, recruiting motivation, and so on.
• The psychologist can then identify ways to
  address these obstacles.

51
Analysis

• The strengths of Persons approach is that the
  mediational role of core beliefs is identified,
  the treatment plan and obstacles to its
  implementation are linked to the formulation.
• The chief weaknesses are that it fails to
  explicitly include the Consequences identified
  in a functional analysis and the origins are
  mentioned but not fully integrated into the
  working hypothesis.
• Finally, while the sequence (beginning with the
  problem list) might match the order in which
  clients present information, the sequence does
  not follow a theoretical order of problem
  development.

52
Page Stritzke (in prep.) The Seven Ps

• Thus, our preference is to use the headings of
• (i) Presenting Problems,
• (ii) Predisposing factors,
• (iii) Precipitating variables,
• (iv) Perpetuating cognitions and consequences,
• (v) Provisional conceptualization,
• (vi) Prescribed interventions, and
• (vii) Potential problems and client strengths.

53
Cognitive Behavioural Case Formulation Worksheet

• Presenting Problems
• 1. 2.
• 3. 4.
• 5. 6.
• 7. 8.
• Predisposing factors
• 1. 2.
• 3. 4.
• Precipitating variables
• 1. 2.
• 3. 4.
• Perpetuating cognitions and consequences
• Cognitions Behavioural Consequences
• Problem conceptualization
• Prescribed interventions
• 1. 2.