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Similar to The use of the transdiagnostic themes and the severity and complexity of their impact to assist in the allocation to clinical interventions
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The use of the transdiagnostic themes and the severity and complexity of their impact to assist in the allocation to clinical interventions
- 1. The use of the transdiagnostic themes and the severity and complexity of their impact to assist in the allocation to clinical interventions Dr Patrick G Gwyer CPsychol CSci AFBPsS SMARTER-life-GROWTH Slide 1 2018 Conference on Transdiagnostic Approaches to Mental Health Challenges Medical Research Council Cognition and Brain Sciences Unit, University of Cambridge 17-18 September 2018
- 2. SMARTER-life-GROWTH Slide 2 What do we mean by Severity and Complexity? Level of complexity Levelofseverity Petrified Terrified Panic Frightened Fearful Alarmed Afraid Scared Fretful Anxious Worried Uneasy At the more intense (severe) end of the continuum, other areas of life are more likely to be impacted. For example, if feeling fearful, a person may become more avoidant of social situations and so may become socially isolated. This could impact their mood and make the situation more difficult to resolve (i.e. more complex) as now fearfulness and depression need to be addressed At the lower end of the continuum, the person is able to function without impairment or impact in other areas. Thus the complexity of the problem faced is lower. .
- 3. Initial identification of themes and conclusion • 1993 to 1996 – “Transfunctional tendencies” (Cambridge - Unit for Research in Applied Psychology, 1944) • 2005 to 2010 Crisis Resolution Home Treatment, Assertive Outreach, Acute & Intensive Psychiatric Units • A range of varying presentations with common themes • As with the previous example of anxiety, these varying presentations and themes can be placed on a complexity*severity dual continuum. • Placement on the continuum can be used to allocate intervention • 2010 to 2015 Creation and use of a Departmental allocation matrix Wellbeing is a continuum that can be matched to a stepped staging framework based on Severity, Complexity and Risk regardless of diagnostic label. SMARTER-life-GROWTH Slide 3
- 4. SMARTER-life-GROWTH Slide 4 Practitioner assessment
- 5. Complexity Overall Presentation Severity upon functioning. Overall presentation Mild impact upon functioning Moderate impact upon functioning Severe impact upon functioning Low Signpost appropriate agency Watchful waiting Bibliotherapy CCBT /Course Counselling CBT EMDR CCBT/Course CBT CAT EMDR Medium CCBT/Course Counselling EMDR CBT Counselling CBT EMDR CAT CBT Schema / CAT EMDR High Counselling CBT EMDR Schema / CAT CBT Schema / CAT DBT CBT Schema / CAT DBT SMARTER-life-GROWTH Slide 5 Assessment outcome. Presence of risk [Harm to self or others, from exploitation &/or neglect] indicated by red shading. Severity*Complexity matrix used in a clinical setting (MDT: Nurses, Counsellors, Clinical/Counselling/Assistant Psychologists) Risk in red (lighter shading represents “lower” assessed risk)
- 6. Further exploration • 2014 Incorporation of Positive Psychology and Coaching to Clinical approaches – less stigmatizing • 2015 Thematic Analysis of notes (Inpatient, CMHT, Primary care, Supervision, Private work) • 2016 Sub sample of notes used for MSc dissertation (https://www.researchgate.net/publication/312210095_An_exploration_into_Positive_Psychology_and_Clinical_Psychology) • Transdiagnostic themes to help allocation to the Severity, Complexity and Risk matrix SMARTER-life-GROWTH Slide 6
- 7. SMARTER-life-GROWTH Slide 7 Severity*Complexity matrix used to place Positive Psychology, Wellbeing coaching, Peer support and Clinical approaches Allocation to PP, Coaching, Peer support, Lay counselling or Skilled helper (blue shading) following appropriate assessment (Severity, Complexity & Risk) Complexity Overall Presentation Severity upon functioning. Overall presentation Mild impact upon functioning Moderate impact upon functioning Severe impact upon functioning Low Signpost appropriate agency Watchful waiting Bibliotherapy CCBT /Course Positive Psychology Wellbeing coaching Peer support “Lay counselling/Skilled helpers" Counselling CBT EMDR CCBT /Course Positive Psychology Wellbeing coaching "Lay counselling/Skilled helpers" CBT CAT EMDR Medium CCBT/Course Counselling EMDR CBT Positive Psychology Wellbeing coaching "Lay counselling/Skilled helpers" Counselling CBT EMDR CAT CBT Schema / CAT EMDR High Counselling CBT EMDR Schema / CAT CBT Schema / CAT DBT CBT Schema / CAT DBT
- 8. SMARTER-life-GROWTH Slide 8 Themes identified (focus of intervention can be on one or many themes)
- 9. SMARTER-life-GROWTH Slide 9 Example questions from collaborative measure (based on themes identified)
- 10. Use of themes 1 • Provide a baseline for pre and post assessment and session-by-session monitoring • Identifies areas to focus upon and informs the severity*complexity matrix. Risk assessed separately • Use as outcome measure (reasonably well correlated to CORE-OM) SMARTER-life-GROWTH Slide 10 SMARTER-life-GROWTH Slide 10 Clinical Outcomes in Routine Evaluation Outcome Measure (CORE) 34 Severity&Complexityof PresentationEvaluation(SCOPE) r = +0.58 Commonthemesscore
- 11. Use of themes 2 • Creation of collaborative, diagnostic free formulation, based upon individual’s whole experience • Creates Specific and Measurable goal directed actions (SMARTER-life-GROWTH). Wellbeing goals – increase the helpful, decrease the unhelpful and include things that make life meaningful (the things that you Love and are passionate about, are Interested and curious in, while being Fair, kind and compassionate to yourself and others, and Engaged and connected to what you do and who you are) • Combines the parts and the whole • Helps increase individual’s self monitoring and self awareness of their wellbeing – the parts and the whole • Use as a mindfulness exercise (similar to body scan) SMARTER-life-GROWTH Slide 11
- 12. Theoretical underpinnings: A transdiagnostic approach needs an Integrative approach that links theory, evidence, and technique SMARTER-life-GROWTH Slide 12
- 13. Different approaches • Acceptance & Commitment Therapy - Hayes • BioPsychoSocialSpiritual - Engel • Cognitive Analytic Therapy - Ryle • Cognitive Behavioural Therapy - Beck, Ellis, Padesky • Compassion based - Gilbert, Neff • Dialectical Behavior Therapy - Linehan • Gestalt - Perls • Holons - Koestler • Humanistic - Rogers • Meaning (Logo) - Frankl • Mindfulness - Kabat-Zinn • Personal Construct - Kelly • Positive Psychology - Seligman • Schema - Young • Time Perspective Therapy - Zimbardo SMARTER-life-GROWTH Slide 13 Connected through the common factors • Ability to regulate emotions • Collaboration towards agreed goals • Enhancing self-compassion, acceptance, forgiveness and kindness • Explanation for current difficulties and a solution for resolving • Improve interpersonal relationships • Modelling • Non-judgemental acceptance, understanding and empathy • Normalisation of experience • Possibility of alternative perceptions and actions • Provision of hope • The helping relationship (Therapeutic working alliance / Reparative / developmentally needed / Person-to-person/ Transpersonal) (Bergin, Clarkson, Frank, Garfield, Grencavage, Lambert, Lazarus, Luborsky, Rogers, Rosenzweig, Norcross)
- 14. SMARTER-life-GROWTH Slide 14 The whole remains in the background providing the context for the parts.Emotions Actions Thoughts Body sensations Anticipation of Outcomes (Future) Current experience (Present) Past experiences Interpretations of experiences Creation, Utilization, Depletion of Biological, Psychological, Social, Spiritual Resource Capital Mindful Awareness Reflection Insight Action The area of intervention (the part) has moved to the foreground and is the focus of current attention. The other parts create the background (the whole) to the part. Maintaining a healthy diet and activity The reciprocal connection between the parts, mean that change in one, leads to change in others. The constructive nature of memory means that past, current and future experiences alter recollection. The event is fixed but the meaning, recollection and impact is flexible. Meaning and emotional impact of experiences alter.
- 15. SMARTER-life-GROWTH Slide 15 Confusion to …. Clarity ….
- 16. SMARTER-life-GROWTH Slide 16 Childhood trauma (all names changed for confidentiality)
- 18. SMARTER-life-GROWTH Slide 18 Low mood and anxiety
- 20. SMARTER-life-GROWTH Slide 20 Emotions Actions Thoughts Body sensations Anticipation of Outcomes (Future) Current experience (Present) Past experiences Interpretations of experiences Creation, Utilization, Depletion of Biological, Psychological, Social, Spiritual Resource Capital Mindful Awareness Reflection Insight Action Insight based (top down) Skills based (bottom up)
- 21. Sample data (n = 27) SMARTER-life-GROWTH Slide 21 SMARTER-life-GROWTH 200 . . . . . . . . . . 190 . . . . . . . . . . 180 . . . . . . . . . . 170 . . . . . . . . . . 160 . . . . . . . . . . 150 . . . . . . . . . . 140 . . . . . . . . . . 130 . . . . . . . . . . 120 . . . . . . . . . . 110 . . . . . . . . . . 100 . . . . . . . . . . 90 . . . . . . . . . . 80 . . . . . . . . . . 70 . . . . . . . . . . 60 . . . . . . . . . . 50 . . . . . . . . . . 40 . . . . . . . . . . 30 . . . . . . . . . . 20 . . . . . . . . . . 10 . . . . . . . . . . 0 . . . . . . . . . . Assessment Baseline Session 1 Session 2 Session 3 Session 4 Session 5 Session 6 Session 7 Session 8 Follow up
- 22. Areas currently being addressed • A eight week group is being run to explore effectiveness of approach in group setting • No comparison group • Participants • Clients who were willing and motivated • Realistic but confounding presentations • One therapist • Experimenter effects • Practitioner and therapeutic approach confounded SMARTER-life-GROWTH Slide 22
- 23. Thank you for your time and attention Questions SMARTER-life-GROWTH Slide 23 Contact details Email: drpatgwyer@gmail.com Website: drpatrickgwyer.com LinkedIn: https://www.linkedin.com/in/drpatgwyer/
Editor's Notes
- McGorry, P. D., Hickie, I. B., Yung, A. R., Pantelis, C., & Jackson, H. J. (2006). Clinical staging of psychiatric disorders: a heuristic framework for choosing earlier, safer and more effective interventions. Australian and New Zealand Journal of Psychiatry, 40(8), 616-622.
- McGorry, P. D., Hickie, I. B., Yung, A. R., Pantelis, C., & Jackson, H. J. (2006). Clinical staging of psychiatric disorders: a heuristic framework for choosing earlier, safer and more effective interventions. Australian and New Zealand Journal of Psychiatry, 40(8), 616-622.
- Include the things that you love and are passionate about? What are you really interested and curious about in life? How fair, kind and compassionate are you to yourself or others when things don’t go to plan? How connected and engaged you are you to what you do?
- Gestalts / Holons in a holarchy) Schiller, D., Monfils, M. H., Raio, C. M., Johnson, D. C., LeDoux, J. E., & Phelps, E. A. (2010). Preventing the return of fear in humans using reconsolidation update mechanisms. Nature, 463(7277), 49. memories essentially had to be neurally rewritten every time they were recalled