5/11/17. Youth Comprehensive Assessment & Case Formulation. Workshop Agenda. Background and Context

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1 The image part with relationship ID rid3 was not found in the file. Youth Comprehensive Assessment & Case Formulation Fraser Todd 2017 Workshop Agenda Housekeeping & Workshop overview Background and context The structure of the comprehensive assessment The Opinion and the formulation From Opinion to Treatment Planning Background and Context 1

2 The image part with relationship ID rid2 was not found in the file. The image part with relationship ID rid2 was not found in the file. nts/publications/te-ariari-o-te-orang-teariari pdf Three Dimensions of CEP Practice Person-focused care Well-being orientated care Spirit Walk the Talk Integrated care 1. Cultural Considerations 2. Well-being 3. Engagement 7 Key Principles 4. Motivation 7. Integrated Care 6. Management 5. Assessment Techniques 2

3 Te Ariari Matrix pre early middle late autonomy Cultural Considerations Wellbeing Engagement Motivation Assessment Incorporation of 7 Key Principles into goals and strategies during each phase of treatment Management Integrated Care Three Dimensions of CEP Practice Person-centred Pre-treatment Early Treatment Middle Treatment Late Treatment Autonomous Independence Integrated Techniques Wellbeing-orientated Person-centred Care 3

4 Person-centred Care: Tools & Strategies 1. Measure outcome by rating quality of life 2. Identify personal values 3. Identify strengths 4. Identify hopes, wellbeing & meaning 5. Niche - Personhood The image part with relationship ID rid2 was not found in the file. Walking the talk: Where the rubber meets the road Factor Intervention Quick & Simple Personal Values Values Card Sort Paper Values Card Sort Values Card Sort for Sz (Moyers & Zuckoff) Paper Values - Teens Paper Values Card Sort (Sz) Character Strengths VIA Signature Strengths Character Strengths 72 (Ogier-Price) Identify Wellbeing Identify Meaning & Purpose Quick and Simple Clinical Strategies Best Possible Selves Ex. Fast Forward Ex. Quality of Life Measure WHOQOL (NZ) WHOQOL-Bref WHOQOL & WOQOL-Bref WHOQOL 100 questions WHOQOL Bref 24 questions Validated in Australia and NZ Four Dimensions 1. Social 2. Psychological 3. Environmental 4. Physical 4

5 Wellbeing: Best Possible Selves Think about your best possible self at some point in the future say, in 5 years time. Imagine yourself after everything has gone as well as it possibly could. You have worked hard and succeeded at accomplishing all of your life Goals. Think of this as the realization of your own best potential. You are realistically identifying the best possible way that things might turn out in your life. Take a few moments to write down what this life would be like. Meaning: Fast Forward Exercise Fast-forward several years. You are retiring from your job and your workplace is having a celebration for you and have invited your family. Your boss and family members give a speech about your life both in work and as a person. Write down what you would like them to say about your life and your life s purpose. Optimism +ve Relationships Pleasure +ve Activities Character Strengths Pathways to Well-being Well-being Enabling Institutions etc Finances Accommodation Barriers to Well-being Unemployment Mental Illness Family tensions etc Substance Use Relationships 5

6 5/11/17 Scales and Interventions to Enhance Wellbeing Scales and Interventions to Enhance Wellbeing The Case of Josh 16 years-old Nga Puhi/Samoan/Pakeha Identifies New Zealander 6

7 Exercise: Josh s presentation Spend a few minutes looking over the handout material of the Case of Josh. Josh: Personal values &VIA Character Strengths Personal Values Exercise 1. Acceptance 2. Friendship 3. Independence 4. Family 5. Excitement Top Character Strengths: 1. Bravery 2. Humility 3. Perseverance 4. Teamwork 5. Forgiveness Josh: WHOQOL-Bref How would you rate your quality of life = 3/5 (Neither poor nor good How satisfied are you with your health = 2/5 (Dissatisfied) Domain 1: Physical Health 44 Domain 2: Psychological 19 Domain 3: Social relationships 6 Domain 4: Environment 13 (out of 100) norms around 70, sd s around

8 Josh: Wellbeing (Best Possible Self 5 years) Happy and content with himself Stable relationship Good job and car Healthy lifestyle Financially stable Lots of supportive friendships Physically active and healthy Sport touch Josh: Meaning and purpose (Fast forward exercise 5 years) Strong and principled Integrity Hard worker - dedicated Team player Brought people together But also a quiet leader Family man Fun to be around The Structure of the CA 8

9 Three Dimensions of CEP Practice Person-focused care Well-being orientated care Spirit Walk the Talk Integrated care 1. Cultural Considerations 2. Recovery & Well-being 3. Engagement 7 Key Principles 4. Motivation Techniques 7. Integrated Care 6. Management 5. Assessment The key to learning is structure 1. Information 2. Opinion 3. Management 4. Prognosis 5. Feedback 1. Information a. History what the tangata whaiora tells you b. Mental State Examination what you observe of the tangata whaiora during the interview c. Other sources of information other information available at the time of the assessment d. Summary 2. Opinion a. Diagnostic statement b. Problem orientated statement including strengths c. Aetiological formulation d. Risk assessment 3. Management a. Management goals b. Management plan 4. Prognosis (initial prediction of outcome) 5. Feedback and negotiation 9

10 Learning about the CA The nature of expertise More knowledge Details are connected to big picture Knowledge is chunked appropriately Connections between details lead to patterns Patterns associated with real life context (i.e. clinical practice) Knowledge retrieved more quickly Premature closure Common pitfalls Lack of structure or frameworks Lack of comprehensiveness and integration Lack of detail about diagnostic criteria Excessive focus on diagnosis at the expense of functioning Failure to control the interview Failure to corroborate information Failure to assess risk adequately 10

11 The Opinion and Formulation 1. Information a. History what the tangata whaiora tells you b. Mental State Examination what you observe of the tangata whaiora during the interview c. Other sources of information other information available at the time of the assessment d. Summary 2. Opinion a. Diagnostic statement b. Problem orientated statement including strengths c. Aetiological formulation d. Risk assessment 3. Management a. Management goals b. Management plan 4. Prognosis (initial prediction of outcome) 5. Feedback and negotiation Four Components of the Opinion Four perspectives given equal weight: 1. Diagnostic (nomothetic) 2. Individualised (idiographic) 3. Aetiological (causal) 4. Risk 11

12 Using DSM5 Josh: Diagnoses Major Depressive Episode Differential diagnosis: Bipolar disorder Substance induced mood disorder Cannabis use disorder Conduct Disorder Specific learning deficit Problems low mood/severe mood dysregulation Josh: Problems and strengths Strengths close relationship with mum past suicide attempt?moderate risk dyssocial peer group inability to control cannabis use disrupted education able sportsman cultural supports if decides to access them good social skills violent relationship with step-father anger control problems 3. Aetiological (Causal) Formulation 12

13 Why is the Formulation Important? Integrates multiple theoretical perspectives makes meaning of tangata whaiora s situation healing in its own right identifies important deeper factors that are important targets of treatment extends the clinician beyond commonly recognized patterns grows clinicians intuition transitions novice to expert assessor How Do You Do a Formulation? 1. Identify key explanatory factors from history 2. Draw a 4x4 grid 3. Label the grid Biological/psychological/social/spiritual Predisposing/precipitating/perpetuating/protecting 4.Enter factors in each box of the grid 5. Four paragraphs to make a narrative Pattern/Predisposing and precipitating/perpetuating/protecting The 4x4 Grid Predisposing (Vulnerability) Precipitating (Triggers) Perpetuating (Maintaining) Protecting (Strengths) Biological Psychological Social Spiritual 13

14 Choice of Factors Chose factors that predict treatments No right or placement in grid Speculative but evidence-informed Basic - use whatever models you are familiar with Advanced - use complex, evidence-informed models Four Paragraphs The image part with relationship ID rid2 was not found in the file. Pattern: Description of the patterns of the presentation e.g. chronic, relapsing, multi-problem self-sustaining system, intermittent etc The image part with relationship ID rid2 was not found in the file. Predisposing and Precipitating Factors: Perpetuating Factors: The image part with relationship ID rid2 was not found in the file. Protecting Factors: The image part with relationship ID rid2 was not found in the file. Exercise: Aetiological Formulation I In small groups From the information provided, develop a list of factors for the assigned boxes in the 4x4 grid for Josh Feedback and Discuss 14

15 Josh: 4x4 grid Predisposing (Vulnerability) Precipitating (Triggers) Perpetuating (Maintaining) Protecting (Strengths) Biological Psychological Social genetic - mood, addiction,. externalizing factor mixed mood - agitation chronic stress, high cortisol, physiological over-arousal PFC damage low self-esteem attachment - lack of trust, anxious attention problems, emotion dysregulation controlling violent step-father, racist comments bullying from step brothers pubertal changes? high school - socialization stress cannabis use (dependence) chronic stress, high cortisol, physiological over-arousal PFC damage mood instability poor coping skills - avoidant low mood & irritability, anger control problems -ve cognitive appraisals, (perfectionistic, goal driven) dysfunctional peer group invalidating environment limited emotional social supports cannabis use (supports mood) good social skills relationship with brother, mother Spiritual mothers emotional unvailability cultural disconnection identity problems - lack of secure identity lack of hope spiritual disconnectedness Exercise: Aetiological Formulation II In your small groups Using the information in the 4x4 grid, develop the assigned paragraph for the formulation. Feedback and Discuss Josh: Four paragraphs - pattern Josh has chronic self-sustaining pattern of mood, impulsivity, conduct problems & cannabis use 15

16 Josh: Four paragraphs Predisposing/preciptating There is a genetic predisposition to substance dependence, conduct problems and mood problems. His mothers depression, the stress of the parental separation and subsequent controlling and violent behaviour from his step father have led to trust issues in relationships, high levels of anger and poor self-esteem, which in turn has made him vulnerable to depression and antisocial behaviours. His frequent episodes of irritable, mixed mood heightens his anger. He has also failed to develop effective coping strategies, worsening the impact of his anger and impulsivity. Brought up by Pakeha parents & with frequent racist comments from his step-father, he lacks a secure sense of who he is increasing his vulnerability to depression and dyssocial activities. His problems appear to have begun around the start of secondary school, a time when the hormonal and psychological changes of puberty and the challenges of transitioning to high school are likely to have sparked the change in behaviour. Josh: Four paragraphs - perpetuating Many of the predisposing factors persist and maintain his problems. In particular, he continues to experience chronic stress, hyper-arousal, and depressed but unstable moods which maintain his cannabis use. Poor attentional control and negative urgency lead to impulsivity, and he lacks adaptive coping skills, choosing to avoid stress which in turn increases the stress he experiences over time. This worsens his mood and maintains cannabis use as a coping mechanism. He is attached to a dysfunctional peer group which encourages antisocial activities but does not provide significant emotional support. He is disconnected culturally and spiritually, lacks a sense of place to which he belongs and as a result has not developed a secure identity. Josh: Four paragraphs - strengths Josh has good social skills and a close relationship with his mother and brother. He is an able sportsman and has excellent cultural supports should he decide to access them. 16

17 Troubleshooting the formulation Reformulate Too many pieces: o identify overarching themes e.g. poor self-regulation, difficulty developing a stable identity, then o chunking and splitting Missing pieces: o look for underlying medical problems o un-identified stressor Pieces that don t fit: o Look for parental conflict, un-reported trauma o Corroborative objective informants From opinion to management planning 1. Information a. History what the tangata whaiora tells you b. Mental State Examination what you observe of the tangata whaiora during the interview c. Other sources of information other information available at the time of the assessment d. Summary 2. Opinion a. Diagnostic statement b. Problem orientated statement including strengths c. Aetiological formulation d. Risk assessment 3. Management a. Management goals b. Management plan 4. Prognosis (initial prediction of outcome) 5. Feedback and negotiation 17

18 Management Goals 1. Identify goals 2. Organise goals 3. Prioritise goals Identify goals Overarching goal improve quality of life and Identify key goals from the diagnoses, problems & strengths and the aetiological formulation Avoid having too many goals; 5-7 is optimal Use lumping/chunking and splitting Trying to state as positive or approach goals rather than negative or avoidance goals Organise goals Avoid having too many goals; 5-7 is optimal Use lumping/chunking and splitting Trying to state as positive or approach goals rather than negative or avoidance goals How will you know when the goal is achieved? (outcome measure) 18

19 Prioritise goals Prioritise issues that: are life threatening are de-stabilising e.g. substance use undermine therapeutic alliance e.g. hostility, avoidance most impairing quickly or easily addressed barriers to treatment most impairing Set goals for early, middle, late & independence stages Ease of goal achievement Most easily achieved goals for those with severe impairment: reduction in panic attacks reduction in other fears and anxieties increased assertiveness increased self-confidence Least easily achieved goals for those with severe impairment: sleep problems pain control reflecting on self and the future depressive symptoms Troubleshooting goal setting Reformulate Too many pieces: o identify overarching themes e.g. poor self-regulation, difficulty developing a stable identity, then o chunking and splitting Missing pieces: o look for underlying medical problems o un-identified stressor Pieces that don t fit: o Look for parental conflict, un-reported trauma o Corroborative objective informants 19

20 Exercise: Goal Identification In your small groups From the opinion, identify key goals for Josh s treatment Make the goals SMART (Specific, Measurable, Achievable, Realistic and Timely) Feedback and Discuss 1. Information a. History what the tangata whaiora tells you b. Mental State Examination what you observe of the tangata whaiora during the interview c. Other sources of information other information available at the time of the assessment d. Summary 2. Opinion a. Diagnostic statement b. Problem orientated statement including strengths c. Aetiological formulation d. Risk assessment 3. Management a. Management goals b. Management plan 4. Prognosis (initial prediction of outcome) 5. Feedback and negotiation Management Planning Develop potential interventions from goals and 10 point structure evidence based (from diagnosis) + individualised (from formulation) Adapt for acceptability to tangata whaiora and whanau Re-evaluate prioritisation of treatments (as for goals) Apply goals and treatments across phases of treatment 20

21 Management Planning 1. Setting 2. Further information 3. Treatment of medical condition 4. Psychopharmacology 5. Psychological interventions 6. Whānau/family and social interventions 7. Spiritual Interventions 8. Education of tangata whaiora and whanau 9. Social Needs Education/work/occupation Accommodation Finance 10. Self-help groups. Exercise: Management plan In your small groups From your management goals, develop a detailed management plan for Josh Feedback and Discuss Prognosis 1. The natural history of the condition/s 2. Factors that improve the natural history 3. Factors likely to worsen the natural course 4. Summary 21