www.prepwellness.org formulation and intervention kate hardy, clin.psych.d post doctoral fellow...

www.prepwellness.org

Formulation and Intervention

Kate Hardy, Clin.Psych.DPost Doctoral FellowProdromal Assessment, Research and Treatment Team (PART), [email protected]

PREP Prevention and Recovery of Early Psychosis


Objectives

• Be able to formulate a client using the stress vulnerability model, linear model and Morrison’s Model of Psychosis

• Develop this formulation collaboratively • Use the formulation to identify where

intervention is required


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 client’s situation


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


Stress BucketIntrapersonal Stress

Poor diet (living on caffeine)Worrying about money

Academic StressMore assignments

Disagreement with teacherPoor results

Environmental StressRoommates often argue, I’m

caught in the middle and can’tfocus on my studies

Stress Level

Buffer Zone

Interpersonal StressFeel lonely

Only make friends over theInternet, not in person

Coping skillsCoping skills

UnhelpfulCoping

Adapted from UNSW Counseling Services & Carver et al., 1989


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


Morrison’s (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)


Theoretical Model


Client friendly version of the formulation

What happenedEvent /intrusion

How I make sense of it

Beliefs about yourselfand others

Life experiencesWhat do you do when thishappens

How does it make you feel


Back to the original triangle

How I make sense of it

What do you do when thishappens

How does it make you feel


Intervention

• Psychoeducation

• Normalization


Psychoeducation

• Should be based on case formulation

• Should be specific to the client and their concerns and needs

• Should incorporate strengths where possible


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


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


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


Normalization

Psychotic

Experiences

No experiences

Stress, Drugs, Trauma, Sleep deprivation Bereavement


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)


Normalization –

intrusive thoughts

• Provide information on the prevalence and types of intrusive thoughts

• Experiment with thought suppression


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

www.prepwellness.org formulation and intervention kate hardy, clin.psych.d post doctoral fellow...

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