Case Formulation: Person-Oriented Model

Introduction

• A focus group study concluded that more guidance is needed for case-oriented work.
• There is a need for guidelines to work more participatory, diversity-sensitive, and interdisciplinary.

Pathological Model vs Person-Oriented Model

• Pathological model: Diagnostics has a narrow view, is socially embedded, problem-oriented, and expert-driven; the client is reduced to their symptoms, and provides few guides for treatment.
• Person-oriented model: Problems are not only attributed to the person, the broader cultural embedding is considered, attention is paid to positive factors and resilience, reaching a shared understanding, and adjusted and achievable goals.

The Help Question Determines the Direction of Diagnostics

• Diagnostic processes often focus on classification, scaling, and advice, instead of a person-focused and solution-focused approach.

Focus of Case Formulation

• Case formulation aims to provide a shared understanding of the issues presented through a theoretical explanation of presumed causes and maintaining factors, in order to implement appropriate interventions.
• Descriptive component: The problems the person presents.
• Explanatory component: A theoretical explanation of presumed causes and maintaining factors.
• Prescriptive component: Prescribing suitable interventions.
  • These aspects are not separate but are a dynamic process that can be revised based on new information.

5 I Model

• Idiographic: Mapping information at the level of the unique client.
  • This involves the BioPsychoSocial model, with more concrete guidance.

7 P's

• Presentation complaint: Includes difficulties, worries, and problems of a biological, psychological, or socio-cultural nature, and potentially a classifying diagnosis.
  • Different perspectives within the client’s system are central.
• Predisposing: Factors that can create vulnerability in the long term; these are not always unchangeable.
• Precipitating: Short-term factors, stressors, or triggers.
• Perpetuating: Maintaining factors.
• Positive/Protective: Strengths, supporting factors, positive experiences, and exceptional situations.
  • These are essential for further progress.
• Persons: Relational and social network.
• Plans: The goals of the client and their expectations.
  • The 7Ps are further detailed as inspiration, not as a standard practice.

Integrative

• Integrative: An overview of important events, behaviors, internal experiences, or psychological processes to understand how and why complaints arise and are maintained.
• Theoretic basis is necessary to narrow a focus.
• There isn’t one right model, awareness of perspective is important
• A shift toward more integrative models helps, and requires knowledge and affinity with different models.
• An integrative image is a working hypothesis within a dynamic process, adjustable with new information.

Intervention-Oriented

• Case formulation is not an end in itself, it is tailored to the specific needs of the client.
• It is an important step in the care process, contributing to a relationship of trust, a corrective experience, and reduced stigma and guilt.
• It gives a sense of agency and hope, involving clients closely to increase motivation and involvement.

Interactive

Dialogue with the Team

• Team Formulation: The process in which a group of professionals develops a shared understanding of the client's difficulties through case formulation.
• This helps to develop a shared understanding of promoting and hindering factors, giving insight into the case and enabling effective crisis and resistance management.
• Bringing knowledge from different professionals stimulates reflexivity and reduces prejudice and bias.

How to Do This

• Team composition.
• Sufficient time for team formulation.
• Attention to the process.
• Keep the client in mind.

Dialogue with the Client

• A participative basic attitude includes authenticity, involvement, equality, openness, unconditional acceptance, positive attitude, professional proximity, reliability, and respect.
• A diversity-sensitive attitude: Openness, curiosity toward norms and values, and willingness to understand the meaning of behaviors, with readiness for open communication.
• Participation: Involving clients, listening to their voices, and giving them weight; the right of children and young people to participate in relevant matters, with adults giving serious consideration to their input.

Why Focus on Participation for the Client

• It's a right.
• It is motivating.
• It involves.
• It gives a sense of recognition.
• It gives a sense of self-determination and ownership.
• It supports self-development and the development of abilities.

Why Focus on Participation for the Helper

• Participation as a means, not an end.
• The client has valuable, unique expertise and information, crucial for truly addressing the request for help and understanding causal and maintaining factors.

How to Implement Participation

• Lundy Model: Participation is only possible if the client has space and an audience to express their voice and thus influence.
  • Space: A safe and inclusive space to form and express opinions.
  • Voice: Access to information and support to develop and express perspectives.
  • Audience: Opinions and ideas can be expressed to someone responsible to listen.
  • Influence: Perspectives are taken seriously, weighed, and acted upon.

Participation Ladder of Hart (Types of Participation)

• Fake Participation:
  • Buying off: Giving a client a diagnosis without allowing them to contribute.
  • Decoration: Inviting a client to an interview, without the opportunity to contribute.
  • Manipulation: Using only client statements that confirm the helper's hypothesis.
• Informing is the Basis:
  • Inform: Providing clear, understandable explanation about the diagnostic process.
  • Consult: Inviting the client to share their experiences and perspectives.
  • Advise: Client suggestions can influence the process, with the helper maintaining control.
  • Co-produce: Clients and helpers bring expertise and reach mutual insights.
  • (Co-)Decide: The client helps the decision-making process.
• Participation Continuum: Revised version of the participation ladder, its normative and not hierarchical
• Participation Wheel: Considering what a person needs and helping in the right way, this way can be different for everyone

Promoting Participation

• Focus on the help question.
• Use an inclusive and diversity-sensitive approach.
• Engage in a conversation regardless of age.
• Be open for feedback.
• Include partners as equals.
• Recognize client needs in participation.
• Identify and remove barriers to provide support.

Participation with Less VocalTarget Groups

• Sometimes diagnoses get asked for through Schools or guidance who are dealing with interactive problems. Make sure not to imply that it is simply placed on the person.
• Dont just simply listen to the people with guidance but also the person the guidance is about so you can get 2 perspectives.

Communication Plan

• Tell them what you see and explain what you do.
• Clearly explain (possibly aided by resources) who you are.
• Have guidelines of how the info you use get shared out.
• Basic rule: If they are there talk to the person and not about the person
• Important meetings/decisions should include the clients side on things
• Let the client respond in an appropriate way.
• Be watchful and take in personal feelings/views.

Trust Relationship

• Take your time with them! Do stuff clients like, it will help them.
• Even when a client doesn't know you, still listen and understand what they are going through.
• Pay attention to what client is saying/doing.

Enter an Interaction

• Sometimes people can find it hard to say it, try and bring it out of them.
• Key non-verbal interaction + communication.
• Watch out how you act.
• Viewing ≠ involving, being actively included.

Diversity Sensitive Get to Work

• Frequently examine social- group influences.
• Be interested about cultural distinctiveness, worth, and question actively.
• Respect the unique mindset of those who have a mental issue.
• Be clear on the use of translator options.

Introspective

• (Three methods of reasoning for gathering data, all shown on the graph include Inductive, Deductive and Abductive)

• Abductive reasoning helps develop logical with diagnostic data.

• The answer is never finished.

Shapes of Deviation

• Tunnel Vision: Focusing on one thing can lead to other aspects not getting shown.
• Verankeringseffect
• Confirming bias: Looking for info that agrees with your theory, while rejecting those against it
• Seeing/reading info for the first time has a large impact, negative stuff also is more remembered.

Reification

• Making diagnoses from just a couple of comments, instead to looking at all facts.

• Important to be aware of the matter.

Fragile Workflow Requires Quality Check

• Genuineness + Wide: Does the case agree with data?
• Accuracy + Sensitivity: Does the case match with the clients unique environment?
• Coherence/Consistency: Has the case been explained clear/understandable and accepted for others?
• Consequences: Does the method being used actually fit what the client says and the teams side?
• Handelingsgerichtheid/Achieveable: Does the case give enough good advice so problems can be averted where needed?

Quality Monitoring

• Good quality methods.
• Observation
• Training