CONCEPTUALIZAREA CLINIC (CASE FORMULATION) N CBT

CE ESTE CONCEPTUALIZAREA CLINIC?

O descriere a tabloului clinic O explicaie teoretic asupra cauzelor i factorilor de meninere, cu rol informativ pentru intervenie

Elemente cheie: descrierea simptomelor, factori predisponzani (receni i distali), factori de meninere, factori protectori (puncte tari) i indicaii specifice pentru intervenie

TIPURI DE CONCEPTUALIZARE
Conceptualizare general ex. modelul stresvulnerabilitate Conceptualizare specific pe categoria de diagnostic pe situaia/problema specific (ex. modelul ABC)

MODELUL STRES-VULNERABILITATE

CONCEPTUALIZARE SPECIFIC FOBIE SOCIAL (CLARK & WELLS, 1995)

CONCEPTUALIZARE SPECIFIC

CONCEPTUALIZAREA (KUYKEN, PADESKY, & DUDLEY, 2009)

FUNCIILE CONCEPTUALIZRII
1) Sintetizeaz experiena clientului, teoria CBT i datele de cercetare 2) Normalizeaz reaciile clientului fa de tabloul clinic 3) Susine angajamentul clientului fa de tratament 4) Face ca problemele numeroase i complexe s fie mai uor de gestionat de client i terapeut 5) Ghideaz selecia, focalizarea i ordinea strategiilor de intervenie

FUNCIILE CONCEPTUALIZRII
6) Identific punctele tari i ntrete reziliena clientului 7) De cele mai multe ori sugereaz utilizarea unor intervenii eficiente 8) Anticipeaz problemele ce pot aprea n terapie 9) Ajut la ntelegerea lipsei de rspuns la terapie i sugereaz ci alternative 10) Faciliteaz procesul de supervizare (structurarea discursului)

PAI N FORMULAREA CONCEPTUALIZRII (PERSONS & TOMPKINS, 2007)

Obinei o list de probleme comprehensiv (5-8 probleme) Stabilii un diagnostic DSM (pe cele 5 axe) Selectai un diagnostic principal (responsabil de cele mai multe simptome/pe care se focalizeaz scopurile terapiei) Selectai modelul potrivit de conceptualizare pentru categoria general de diagnostic Individualizai acest model astfel nct s fie incluse problemele din list Propunei ipoteze despre originea mecanismelor psihologice Descriei factorii precipitani cureni

EXEMPLU
Example: Formulation of the Case of John John is a 37-year-old, single, second-generation Japanese American male who lives alone and is selfemployed as a web designer. John, who has hepatitis C, was referred by his nephrologist for treatment of depression and poor medical adherence. His chief complaint to the therapist was: My doctor says Im not getting better and its time for some new ideas. Johns therapist developed the following formulation of his case. The origins, mechanisms, and precipitants are identified in brackets [e.g., origins], and the problems are italicized. Caused by [origins] a likely biological vulnerability to anxiety (as evidenced by his mothers apparent social anxiety) and by rearing in a household in which (due to his mothers shyness and her difficulty adjusting to the American culture) there were few visitors and thus few models of easy social interaction, and in which his father was largely absent but when present often brutally critical and attacking, John developed [mechanisms] schemas of others as critical and rejecting, of himself as weak, weird, and helpless, and of the future as hopeless. These schemas, activated by [precipitants] his worsening medical problems and increasing pressure from his physician to comply with treatment recommendations, have exacerbated Johns social anxiety and passive, unassertive, and avoidant behaviors. Johns medical problems also trigger [precipitants] his schemas by causing physical symptoms (sweating, trembling, fatigue, and dizziness) that he fears others will notice and then think him as weird or weak. In addition, Johns social anxiety and unassertiveness worsen his noncompliance, because the symptoms block him from following some of his physicians recommendations (e.g., to attend a self -help group for hepatitis C) and even from participating fully in treatment-planning discussions with his physician. The noncompliance, of course, aggravates his medical condition and the symptoms he worries that others will notice. Johns views of himself as weak and of the future as hopeless, together with all his other problems, cause depression and suicidal thoughts and urges. John copes with distress through avoidance (which leads to social isolation that generates evidence to support his belief that others are rejecting and he is weird), and alcohol abuse (which exacerbates his liver disease, depression, and social isolation).

CONCEPTUALIZAREA CLINIC VALIDAT TIINIFIC

Este teoria subiacent validat tiinific? Procesul, impactul, utilitatea conceptualizrii (fidelitate i validitate)

CONCEPTUALIZAREA CBT VALIDAT TIINIFIC

Conceptualizrile CBT ofer descrieri acurate dar n multe cazuri teoriile explicative sunt insuficient explorate acest lucru se reflect n formularea conceptualizrii i n practic

Are conceptualizarea clinic validitate ? - oamenii utilizeaz n general scurtturi mentale (euristici) inclusiv n luarea deciziilor n mediul clinic Reprezentativitatea, disponibilitatea (ex. Informaii recente), ancorarea (organizarea informaiilor n jurul unei idei iniiale)

ARE CONCEPTUALIZAREA CBT FIDELITATE?

Practicienii CBT de obicei sunt de acord ntre ei n ceea ce privete descrierea simptomelor, dar acordul este moderat n ceea ce privete mecanismele etiopatogenetice

ARE CONCEPTUALIZAREA CBT VALIDITATE?

Date inconsistente legate de corespondena cu experiena subiectiv a pacientului mbuntete rezultatele terapiei? - Formularea individualizat a cazului (fa de prezentarea general, manualizat) nu aduce rezultate mai bune n terapie (ex. Emmelkamp et al., 1994) dar tratamentele indiviualizate au rezultate mai bune n timp (Jacobson et al., 1998)

RECOMANDRI PENTRU O CONCEPTUALIZARE EFICIENT

Generarea unor ipoteze provizorii i testarea lor continu A sta mai aproape de nivelul descriptiv al conceptualizrii; inferenele pot duce la idiosincrazii

Mai multe preri - crete nivelul de acord inter-evaluatori: grupuri de intervizare

Triangularea datelor (obinerea de informaii din mai multe surse) Atenie la euristici Urmrirea protocoalelor de intervenie

GHID PENTRU FORMULAREA UNOR CONCEPTUALIZRI CBT EFICIENTE

EXEMPLU CONCEPTUALIZAREA N TULBURRILE DE ANXIETATE

Conceptualizare a: Categoriei Tulburrii specifice Problemei specifice intr-un caz

CONCEPTUALIZAREA TULBURRILOR DE ANXIETATE (WELLS, 2007)

MODELUL COGNITIV AL TULBURRII DE PANIC (WELLS, 1997)