IAPT FOR OLDER ADULTS Module 5. Formulation and Goal setting
Aims of Day To recap on issues/learning from Day 1 To develop knowledge/strategies g for adapting current formulation/goal setting approaches where necessary To develop knowledge/competences for adapting current interventions where necessary To develop awareness of any considerations which may be needed d in managing endings with older adults
Timetable 9.30-10.00 Introductions and Recap from Day 1 10.00-11.00 Module 5. Formulation and Goal Setting 11.00-11.20 Break 11.20-12.30 Module 5. Formulation and Goal Setting 12.30-1.15 Lunch 1.15-2.30 Module 6 Basic interventions 2.30-2.50 Break 3.00-4.00 Module 7 Endings 4.00-4.30 Plenary and evaluation
Recap on Day Take a few minutes to recall 3 facts/reflections from Day 1 Join up with another person and share with each other Join up with another pair and share with them Be prepared to feedback from each group of 4 Learning points Any yparticular concerns or skill issues to address today
Recap - Key Screening Questions Do you take care of someone else? Are you having any treatment for health problems? Have you had a fall recently? Has anyone close to you died recently? Would you say you had more problems with your memory than most people?
Aims of Formulation and Goal Setting You will be able to formulate knowing Implications of cognitive changes for therapeutic work How to use a lifespan perspective p appropriately p When to include others such as family/carers How to incorporate sociocultural factors including cohort beliefs How to acknowledge the reality of difficulties experienced without being overwhelmed You will be able to goal set knowing How to use principles of Selection, Optimisation, & Compensation in setting goals and interventions Whether there are any differences in how to set realistic, relevant, achievable goals
Clinical Presentation Framework (James, 2010). Intellectual Status No impairment (i) Physical Health Status (ii) Fit & active Unwell & inactive (iii) High level impairment (iv)
Zone of Therapeutic Work Quadrant ii (physical impairment and cognitively intact). Premorbid Functional Abilities Limits imposed by pathology and physical impairment i Limits imposed by fears, thoughts ht and selflimiting actions Increasing loss of function Zone in which CBT can be used to reduce levels of disability and handicap
Implications of cognitive changes for therapeutic work (James, 2010) There is agreement that executive functioning declines with age (Executive dysfunction Edf) It is also affected by: Physical health (cardiac, diabetes, pain, infections) Sensory loss Medications Psychological disorders depression, anxiety, psychosis
Adaptations for Dealing with Edf 1 (James 2010) Poor concentration Rd Reduce complexity Fewer topics More feedback Pacing Breaks Poor Attention Short meaningful Agenda Diagrams Avoid distractions
Adaptations for Dealing with Edf 2 Memory Problems working Pacing memory +encoding and retrieval Repetition deficits. Overgeneralisation of autobiographical information Facilitate recall with context Avoid blame Use of therapy folder Interpersonal Difficulties may affect alliance/interpersonal homework tasks Recognize signs (slow, inconsistent, unmotivated) Prepare and rehearse within session Rationale and components will need time
Adaptations for Dealing with Edf3 Poor problem solving harder to define problems, goals and plan Lack of motivation inability to engage in effortful strategies Break down goals Scaffolding Behavioural experiments Acknowledge Therapist role Meaningful tasks Acknowledge smallest gains Detailed explanations including expectations
Adaptations for Dealing with Edf 4 Lack of awareness of Provide some Edf over critical of explanation for origin of self, negative deficits comparisons with old self Self regulation of emotions sudden mood shifts/impulsivity Conceptualise as part of affective state Tk Take precautions with ih anger
Specific Strategies for enhancing therapeutic relationship Clarify how the client wishes to be addressed and how he/she wishes to address you Remember important details of individual s life history Be open to feedback and willing to gently confront any issues in the therapeutic relationship Give clients credit for specific accomplishments, but avoid generic compliments Elicit feedback in every session
Comprehensive Conceptualisation Framework (Laidlaw, Thompson & Gallagher-Thompson, 2004) Cognitive Therapy Early experience Importance of Cohort Value systems Self-sufficiency Grin & bear it Penny saved is a penny earned Role Investments/Transitions Validation of life through achievements or personal growth Core Beliefs Activating Events Conditional Beliefs Compensatory Strategies Negative Automatic Thoughts - View of self - View of world - View of future Depression Thoughts Feelings Behaviour Physiology Intergenerational Linkages Familial Spiritual/Religious Formal care agencies Socio-cultural context Ageism and attitudes to ageing Internalisations of ageism Therapist values & beliefs Health Status Presence and Impact of comorbid physical conditions
Comprehensive Conceptualisation Framework (Laidlaw, Thompson & Gallagher-Thompson, 2004) This diathesis stress model includes five further aspects of particular relevance Intergenerational Linkages (networks, supports, tensions) Sociocultural Context (identity, culture, class, politics) Transitions in role (e.g. retirement, bereavement) Cohort beliefs ( how views ageing, psychological problems, interventions, services) Health status and understanding of this Understanding all of the above also central to a collaborative therapeutic relationship
Mini- formulations (Charlesworth and Reichelt 2004) Short mini-linear formulations comprehensible if not comprehensive LINEAR CHAINS EVENT APPRAISAL EMOTIONAL RESPONSES Where event covers both external and internal experiences e.g. life events, actions, own thoughts, sensations and feelings
Mini- Cycles (Charlesworth and Reichelt 2004) Shared formulations can be facilitated t via 2 and 3 element mini cycles e.g. FEEL LOW NEGATIVE THOUGHTS- FEEL WORSE FEEL PAIN DEPRESSION PAIN WORSE These can be used as part of socializing to model and once understood clearly can be developed further
Formulation How you might use a life long perspective depends on Whether the problems are life long Whether they have been triggered by pre-existing vulnerabilities Age-appropriate p reaction to loss of positives in a previously resilient individual
Exercise :Mr Jones/ Mrs Cooper/Miss Davey In smallgroups identify one person to play the patient. The others assess with a focus on gathering information about the five areas of the Comprehensive Conceptualisation Framework. Each therapist to take turns to ask about a particular area. Think about using some of the strategies identified to compensate for Edf Under what circumstances might you consider including family members/carers?
Goal Setting Goal setting principles are as for all adults Also should incorporate the principles of Selection Optimisation i i and Compensation theory (Baltes &Baltes) Selection restricting areas and focus on to those where success is most likely Optimisation enhancing available resources to maximise functioning Compensation compensating for identified deficits in functioning with specific strategies All three should be present
Exercise Using the same example but swapping roles, identify one goal to work on and try to develop an intervention plan using the concept of Selection, Optimisation and Compensation. Discuss how you might do this first then try it out in role play. What is different to goal setting with adults of working age?
Revisiting the Aims Implications of cognitive changes for therapeutic work How to use a lifespan perspective appropriately When to include others such as family/carers How to incorporate sociocultural factors including cohort beliefs How to acknowledge the reality of difficulties experienced without being overwhelmed You will be able to goal set knowing How to use principles of Selection, Optimisation, & Compensation in setting ggoals and interventions Differences in how to set realistic, relevant, achievable goals