discussion #5 disease

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Assessment & Conceptualization in Chronic Illness Interventions:

An Overview

+ Biopsychosocial Model for Conceptualizing Chronic Illness

n  Biological and psychological/sociocultural factors play a role in chronic illness presentation and management; as such, an integrative conceptualization model is needed in order to execute treatment strategies that are comprehensive and effective

n  Biopsychosocial assessment strategies and formulations lead to treatment plans that combine biological and psychosocial treatment strategies

n  The biospychosocial conceptualization model is particularly effective for difficult or treatment resistant cases in which medical and psychiatic conditions co-exist

+ Biopsychosocial Model

n  The biopsychosocial model can best be described as:

“A HOLISTIC perspective for understanding and explaining the INTERFACING biological and social forces that influence health, illness, and well-being” (Engel, 1977)*

n  The goal of using this model is to achieve a multidimensional conceptualization of an individual’s presenting problem that can elucidate the use of comprehensive treatment strategies.

n  These are more powerful than those that can be devised by the use of a simple psychological, biological, or social conceptualization.

Engel, G. (1977, April 8). The need for a new medical model: A Challenge to biomedical science. Science, 196, 129-136.

+ Overview

n  From a biopsychosocial perspective, the assessment and conceptualization process involves: n  1). The articulation of biological, psychological, and social influences

on health and wellness n  2). The recognition that the goal of biopsychosocial interventions is to

achieve the integration of the chronic medical condition as part of an individual’s healthy sense of self

n  3). The realization that patients have their own subjective views of their illness (illness representation/explanatory model) that impacts their treatment adherence, and that patients and therapists need to work collaboratively to construct realistic models of illness representation that promote wellness

n  4). The commitment to conducting a comprehensive assessment that allows us to understand a patient’s behavior patterns

n  5). The recognition of the importance of establishing a strong therapeutic alliance based on a collaborative bond in which patients and clinicians work together to establish and achieve therapeutic goals

n  6). The understanding that treatments need to be individually tailored to a patient’s needs, and such, need to incorporate the use of multiple theories and treatment modalities.

+ Assessment n  The goal of a biopsychosocial assessment is to determine the

function of patient behaviors that predict their responsiveness to treatment

n  It involves the investigation and understanding of two core patient characteristics: n  1). Treatment Readiness: The patient’s motivation to engage in

treatment and their interest and ability to work collaboratively with the clinician to meet therapeutic goals. A patient’s readiness is also influenced by psychosocial factors that may promote or hinder treatment adherence.

n  2). Explanatory Model/Illness Representation: A patient’s own interpretation of his symptoms or disease process. In some cases a patient’s illness representation may contain misinformation or misattributions that may need to be addressed.

+ Assessment in Practice n  A biopsychosocial assessment usually occurs in the context

of a semi-structured interview process that elicits information about a patient’s illness and its context, the patient’s perceptions of the cause of the illness, their view of the disease progression and impact on their quality of life, and their readiness for change.

n  The assessment should naturally lead to a conceptualization process that informs the development of a treatment plan that is specific, realistic, and contains a sequence of attainable goals that is created in an effort to maximize treatment success

+ Key Assessment Factors

Thirteen Key Markers in a Comprehensive Assessment (Sperry, 2006)

1. Disease progression and impact of illness on functioning

2. Illness representation/explanatory model

3. Adequacy of health behaviors and exposure history

4. Early parental bond and adverse childhood experiences

5. Personal schemas and family narratives

6. Personality style/dynamics/disorder

7. Family competence level and style

8. Religious and spiritual beliefs

9. Patient resources and self-capacities

10. Readiness for treatment capacity and for self-management

11. Adequacy of treatment relationship with previous providers

12. Alignment between clinician-patient explanatory models and treatment goals

13. Phase of illness

+ Conceptualization n  Case Conceptualization consists of:

n  1. Diagnostic Formulation: A cross-sectional descriptive

statement about the nature and the severity of a patient’s psychiatric presentation

n  2. Clinical Formulation: Offers the rationale for the development and maintenance of the symptoms and behavior patterns. It is the integration of all aspects of a patient’s and links the diagnostic and treatment formulations.

n  Treatment Formulation: It is a “blueprint” of the treatment interventions and provides the treatment goals, treatment plan, and interventions in relation to educated predictions about the course and potential outcomes of treatment.

+ Clinician vs. Patient Conceptualization

n  Parallel to the three aspects of a comprehensive clinician conceptualization, patients have their own case formulation as follows:

Clinician Patient

Diagnostic Formulation Description of presenting problem/ concern, symptomatic distress and degree of life functioning impairment

Clinical Formulation A patient’s own explanatory model or illness representation

Treatment Formulation A patient’s expectations for treatment

* Similarities in the therapist’s and patient’s conceptualization are generally linked to greater treatment adherence and treatment effectiveness.

+ The Pattern Analysis Framework

Predisposing Factors

Perpetuating Factors

Presentation Factors & Relational Response

Factors

Precipitating Factors

Pattern Analysis is the process of examining the interrelationship among the individual and systemic dynamics that determine predictable ways of thinking,

feeling, acting and coping in the face of stressful circumstances