Formulation and Intervention

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Formulation and Intervention
PREP Prevention and Recovery of Early
Psychosis

• Kate Hardy, Clin.Psych.D
• Post Doctoral Fellow
• Prodromal Assessment, Research and Treatment Team
  (PART), UCSF
• Kate.Hardy_at_ucsf.edu

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Objectives

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

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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 clients situation

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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

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• Stress Bucket

Interpersonal Stress Feel lonely Only make
friends over the Internet, not in person
Adapted from UNSW Counseling Services Carver et
al., 1989
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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

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Morrisons (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)

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

• Psychoeducation
• Normalization

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Psychoeducation

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

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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

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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

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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

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

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Normalization intrusive thoughts

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

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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