Biopsychosocial Assessment: A Case Study

Tuesday, January 11, 2022 2:57:19 AM

Biopsychosocial Assessment: A Case Study



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Intake and Assessment Role-Play Part 1 - Referral and Presenting Problems

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Social Justice Goals in Social Work. Diagnosis in Social Work. Treatment Planning in Social Work. Managing Therapeutic Relationships. Case Management in Social Work. See practice tests for:. Researchers have traditionally distinguished between specific and non-specific treatment effects. The specific treatment effect refers to the amount of improvement that is attributable to the unique features of a particular treatment. The non-specific treatment effect refers to the amount of improvement that is attributable to features that are common to all or most well-conducted therapies.

In RCTs of pharmacological interventions the main contrast is always between the active drug and a placebo. The placebo controls for the non-specific effects of seeing a competent clinician, having one's symptoms consistently monitored, receiving a plausible treatment rationale and taking a tablet. The comparison between active drug and placebo is therefore only an index of the specific treatment effect attributable to a particular chemical. As most chemicals have side effects, some of which are severe, it is generally accepted that a drug must show a specific effect in order to warrant its use.

However, it is important to note that service users are likely to show substantially greater improvements than implied by the active drug versus placebo effect size because giving a placebo also produces a further non-specific benefit. In RCTs of psychological interventions the focus is less exclusively on establishing specific treatment effects. Commonly the control condition is a waitlist. In this case, the observed difference between the treatment and the control condition will be the sum of the relevant non-specific and specific effects. As psychological interventions are generally thought to have few side effects, it seems reasonable for researchers to have a primary interest in determining whether the treatment has any beneficial effects compared with no treatment.

However, it is also important that evaluations of psychological interventions attempt to determine whether the treatment has specific effects as this gives us greater confidence in knowing exactly which procedures therapists should be taught in order to replicate the results that the treatment has obtained in RCTs. If a psychological intervention is known to have a specific effect, it is clear that therapists need to be trained to deliver the procedures that characterise that treatment. If a treatment has only been shown to have a non-specific effect people should be informed and it should not usually be offered in a publicly funded system.

In social anxiety disorder it seems highly plausible that part of the improvement that is observed in treatment is simply due to the non-specific effect of meeting someone who is initially a stranger while talking about one's emotions and numerous embarrassing topics. In other words, almost all interventions for social anxiety disorder involve a substantial amount of potentially beneficial exposure to feared social situations.

How does one determine whether a psychological intervention has a specific effect? Essentially one needs to demonstrate that the treatment is superior to an alternative treatment that includes most of the features that are common to various psychological interventions such as seeing a warm and empathic therapist on a regular basis, having an opportunity to talk about one's problems, receiving encouragement to overcome the problems, receiving a treatment that seems to be based on a sensible rationale and having one's symptoms measured regularly.

RCTs approach this requirement in one of three ways, each of which has strengths and weaknesses. In the second approach, the alternative treatment might be something that is used routinely in clinical practice and is considered by some to be an active intervention but it turns out to be less effective than the psychological intervention under investigation, despite involving a similar amount of therapist contact. In the third approach, the psychological intervention is compared with pill placebo, which controls the many non-specific factors but often fails to fully control for therapist contact time because this is usually less in a medication-based treatment.

The fact that RCTs of medications almost always only focus on assessing specific treatment effects, whereas RCTs of psychological intervention may focus on assessing specific, non-specific or both types of effect, means that caution needs to be exercised when comparing the findings of such evaluations. In an ideal world, it should be possible to obtain an estimate of the effectiveness of each type of treatment against controls for specific effects as well as the overall benefit of treatment compared with no treatment. The network meta-analysis NMA that underpins this guideline attempts to provide such information by inferring how medications would fair against no treatment even though most RCTs of medication use placebo controls and do not include a waitlist no treatment control see Chapter 3 for further information about the NMA.

The next section outlines the different psychological and pharmacological interventions that have been tested for efficacy in social anxiety disorder. The first RCTs of psychological interventions for social anxiety disorder used two variants of this approach systematic desensitisation and flooding and obtained modest improvements. However, in anxiety disorders in general imaginal exposure treatment soon became superseded by treatments that involved confronting the feared stimulus in real life. This review had a substantial effect on treatment development work in all anxiety disorders. Subsequent behavioural and cognitive behavioural interventions for social anxiety disorder have therefore focused on techniques that involve real life confrontation with social situations, to a greater or lesser extent.

Exposure in vivo is based on the assumption that avoidance of feared situations is one of the primary maintaining factors for social anxiety. The treatment involves constructing a hierarchy of feared situations from least to most feared and encouraging the person to repeatedly expose themselves to the situations, starting with less fear-provoking situations and moving up to more difficult situations as confidence develops. Exposure exercises involve confrontation with real-life social situations through role plays and out of office exercises within therapy sessions and through systematic homework assignments. Many people with social anxiety disorder find that they cannot completely avoid feared social situations and they tend to try to cope by holding back for example, by not talking about themselves, staying quiet or being on the edge of a group or otherwise avoiding within the situation.

For this reason, exposure therapists devote a considerable amount of time to identifying subtle, within-situation patterns of avoidance safety-seeking behaviours and encouraging the person to do the opposite during therapy. Applied relaxation is a specialised form of relaxation training that aims to teach people how to be able to relax in common social situations. Starting with training in traditional progressive muscle relaxation, the treatment takes individuals through a series of steps that enables them to relax on cue in everyday situations.

The final stage of the treatment involves intensive practice in using the relaxation techniques in real life social situations. Social skills training is based on the assumption that people are anxious in social situations partly because they are deficient in their social behavioural repertoires and need to enhance these repertoires in order to behave successfully and realise positive outcomes in their interactions with others. The treatment involves systematic training in non-verbal social skills for example, increased eye contact, friendly attentive posture, and so on and verbal social skills for example, how to start a conversation, how to give others positive feedback, how to ask questions that promote conversation, and so on.

The skills that are identified with the therapist are usually repeatedly practiced through role plays in therapy sessions as well as in homework assignments. Research has generally failed to support the assumption that people with social anxiety disorder do not know how to behave in social situations. In particular, there is very little evidence that they show social skills deficits when they are not anxious. Any deficits in performance seem to be largely restricted to situations in which they are anxious, which suggests that they are an anxiety response rather than an indication of a lack of knowledge.

Nevertheless, social skills therapists argue that practising relevant skills when anxious is a useful technique for promoting confidence in social situations. Cognitive restructuring is a technique that is included in a variety of multicomponent therapies and has also occasionally been used on its own, although this has usually been as part of a research evaluation assessing the value of different components of a more complex intervention. The therapist works with the person to identify the key fearful thoughts that they experience in anxiety-provoking social situations, as well as some of the general beliefs about social interactions that might trigger those thoughts. To facilitate this process, they regularly complete thought records, which are discussed with therapists in the treatment sessions.

Some practitioners argue that it is not essential that they fully believe a rational response before they start rehearsing it in fear-provoking situations Marks, Cognitive behavioural interventions encompass various well-recognised and manualised approaches including cognitive behavioural therapy CBT. However, most cognitive behavioural interventions involve exposure in vivo and cognitive restructuring. In recent years, research studies have identified several processes that appear to maintain social anxiety in addition to avoidance behaviour. These include self-focused attention, distorted self-imagery and the adverse effects of safety-seeking behaviours, including the way they change other people's behaviour. CBT can be delivered in either an individual or group format.

When it is delivered in a group format, other members of the group are often recruited for role plays and exposure exercises. Sessions tend to last 2 to 2. When CBT is delivered in an individual format, therapists may need to identify other individuals who can sometimes join therapy sessions for role plays. Cognitive therapy CT developed by Clark and Wells is based on a model of the maintenance of social anxiety disorder that places particular emphasis on: a the negative beliefs that individuals with social anxiety hold about themselves and social interactions; b negative self-imagery; and c the problematic cognitive and behavioural processes that occur in social situations self-focused attention, safety-seeking behaviours.

A distinctive form of CT that specifically targets the maintenance factors specified in the model has developed. The procedures used in the treatment overlap with some of the procedures used in more recent CBT programmes, therefore CT can validly be considered to be a variant of CBT. However, it is distinguished from many CBT programmes for social anxiety disorder by the fact that it takes a somewhat different approach to exposure with less emphasis on repetition and more on maximising disconfirmatory evidence and it does not use thought records.

Instead, the key components of treatment are: developing an individual version of Clark and Wells' model using the service user's own thoughts, images and behaviours; an experiential exercise in which self-focused attention and safety behaviours are manipulated in order to demonstrate their adverse effects; video and still photography feedback to correct distorted negative self-images; training in externally focused non-evaluative attention; behavioural experiments in which the person tests specific predictions about what will happen in social situations when they drop their safety behaviours; discrimination training and memory rescripting for dealing with memories of past social trauma.

The treatment is usually delivered on an individual basis. However, there is a need for the therapist to be able to call on other people to participate in within-session role plays. It is common for the therapist and the person with social anxiety disorder to also leave the office to conduct behavioural experiments in the real world during therapy sessions. This is easier to do if sessions are for 90 minutes, rather than the usual 50 minutes. Interpersonal psychotherapy IPT was originally developed as a treatment for depression but was modified by Lipsitz and colleagues for use in social anxiety disorder. Treatment is framed within a broad biopsychosocial perspective in which temperamental predisposition interacts with early and later life experiences to initiate and maintain social anxiety disorder.

There are three phases to the treatment. In the first phase, the person is encouraged to see social anxiety disorder as an illness that has to be coped with, rather than as a sign of weakness or deficiency. In the second phase, the therapist works with the person to address specific interpersonal problems particularly in the areas of role transition and role disputes, but sometimes also grief. Role plays encouraging the expression of feelings and accurate communication are emphasised. People are also encouraged to build a social network comprising close and trusting relationships.

In the last phase, the therapist and the person review progress, address ending of the therapeutic relationship, and prepare for challenging situations and experiences in the future. Sessions are typically 50 to 60 minutes of individual treatment. Psychodynamic psychotherapy sees the symptoms of social anxiety disorder as the result of core relationship conflicts predominately based on early experience. Therapy aims to help the person become aware of the link between conflicts and symptoms. The therapeutic relationship is a central vehicle for insight and change. Expressive interventions relate the symptoms of social anxiety disorder to the person's underlying core conflictual relationship theme.

Supportive interventions include suggestion, reassurance and encouragement. Clients are encouraged to expose themselves to feared social situations outside therapy sessions. By no means are these things clear indicators that someone is feeling suicidal, but many of them tend to be present when someone is experiencing this kind of issue. Although risk factors for being a danger to others can coincide with being a danger to self, there are other factors that are unique and should be reviewed, including:. When working with patients that may be a danger to themselves or others, it's good to have a long-term risk assessment prevention plan set up so you can review and determine if your patient may be dangerous.

This is also helpful in other instances in which you're being asked your professional opinion on the safety of your patient. Once you have answered these questions, you should be able to determine if your patient is low, moderate, or an extreme risk to themselves or others. Then you can note any mental illnesses that the patient is suffering from to make sure this is available. All right, let's take a moment or two to review.

When working with patients and trying to diagnose issues that may contribute to self-harm or harming others, it's important to know the primary risk factors , which remember are what they sound like: things that can increase danger and risks. These factors can come directly from the patient or indirectly from their environment. It's also very important to set up a long-term violence risk prevention plan, so you know how likely it is your patient could harm others or themselves. The contents of the Study. The Content is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition.

Never disregard professional medical advice or delay in seeking it because of something you have read on the Study. If you think you may have a medical emergency, call your doctor or immediately. Reliance on any information provided by Study. To unlock this lesson you must be a Study. Create your account. Already a member? Log In. Log in. Sign Up. Explore over 4, video courses. Lesson Transcript. Risk factors are a set of behavioral and social modifiers that can be reviewed to see if a patient may be a danger to themselves or others. This lesson reviews those factors and discusses long-term violence risk prevention plans. An error occurred trying to load this video. Try refreshing the page, or contact customer support. You must c C reate an account to continue watching.

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