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1 Case Conceptualizations and Treatment Recommendations from a Recovery Perspective
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Case Conceptualizations
and Treatment
Recommendations from a
Recovery Perspective
What are the Precipitators of
this presentation?• When OMHSAS and the Children’s Bureau came to
review evaluations, they felt that the evaluations did not meet “Best Practice” guidelines for form or content,
lacked sufficient clinical detail, and often failed to
establish necessity of service other than using the phrase
“it is medically necessary”
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Precipitators Continued
• As per the Children’s Bureau, “specific psychologists
routinely supplying cookie-cutter evaluations, cutting and pasting portions of the evaluations or providing
fixed and duplicative recommendations regardless of
the child’s presenting issues, diagnosis or abilities.”
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We at VBH
Shared some of the Children’s Bureau and OMHSAS’
concerns around the evaluations so we began
brainstorming ways to address the issues
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So to address Concerns
• VBH-PA, counties, oversight, and stakeholders discussed ways to address this issue
• VBH-PA, the clinical advisory committee, and counties
developed a tool, based upon research, to capture
conceptualization aptitude
• OMHSAS recently approved the tool along with a pilot
project to improve the conceptualization practices
throughout the network
• The first step in the pilot project is today’s forum and discussion.
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Goals for Today’s Seminar
• To facilitate open communication around evaluation
writing and how to incorporate strong case conceptualizations
• To discuss prescribing practices to encourage strong
conceptualization
• To review the tool that will be piloted by VBH-PA to
encourage strong conceptualizations
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So what makes a good
Evaluation?
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The Format as Suggested in the
Guidelines for Best Practice in
Child and Adolescent Mental
Health • Identifying Information
• Reason for Referral
• Relevant Information
• Interview
• Discussion
• Diagnosis
• Recommendations
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According to DHS, Office of
Mental Health and Substance
Abuse Services• A Life Domain Format is suggested for psychiatric and
psychological evaluations
• The goals of the Life Domain Format for Psychiatric and
Psychological Evaluations are:
• To help the evaluator construct a strengths based interview
and written report
• To help the evaluator identify crisis situations
• To assist the evaluator in obtaining core information so that
the interagency team is free to promote a creative treatment
plan, rather than engage in recitation of past failure
• To assist the evaluator in recommending individualized
services and natural supports consistent with CASSP Principles
which support the child
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The goals of the Life Domain Format for
Psychiatric and Psychological Evaluations are:
• To create a comprehensive document that serves as a
baseline for future evaluations and as a source of reference
for subsequent review of the child’s progress over time
• To support inclusion of parents, caregivers and other team
members into the evaluation process
• To encourage participation by the psychiatric or
psychologist as an active member of the interagency and
treatment team, helping to achieve consensus regarding
needs, services, and monitoring progress
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According to OMHSAS guidelines,
characteristics of a quality evaluation
include a report that is:
• Comprehensive- Is all of the necessary information present?
• Organized- Does the report provide a cohesive story?
• Respectful- Are strengths and goals, not just problems identified within the report?
• Individualized- Is there a clear picture of the child/individual
that emerges with developmental progression and actual
experiences?
• Thoughtful- Do the recommendations go beyond the
prescription of medically necessary services into assistance
with linking the family and child to appropriate services and
resources?
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Recommendations for Clinical
Evaluations from American Psychiatric
Association
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What makes a good
conceptualization?
• The conceptualization will be anchored in a diagnosis
• The conceptualization will be evidence based and may include self reports
• Has a hypothesis that has good treatment utility and will assist in
guiding treatment planning
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Since the evaluation is the basis
for the treatment…• If the conceptualization is not strong and the
treatment recommendations are not clearly
delineated, this causes confusion for the family,
provider, and VBH-PA
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How will the impact prescriptions?
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Things that may be different…
• Increased emphasis on child/ family/ individual goals
• Is not built upon discreet periods of treatment but it is
ongoing and flexible
• Levels of care are prescribed not specific programs
• Emphasis on motivation, competence, and independence
• Person first language use will occur
• All services that an individual is to receive will be listed, with
amount, intensity, and duration, on the prescription
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What if these things are not
present? • VBH-PA will be utilizing more frequently the requests
for additional information. This process is outlined in
Appendix AA. – When VBH-PA requests additional information the prescriber and
member will receive a letter stating exactly what additional information is necessary prior to making a medical necessity determination
– The prescriber/ evaluator will have 14 days to provide the additional information to VBH-PA so that a determination may be made
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Case Conceptualization Tool
• In addition to requesting that all services be
present on a prescription, an additional evaluation
tool that will be piloted is the Case
Conceptualization Tool
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So how was this tool developed?
• This tool was developed through reviewing of the
literature on case conceptualization practices and
working with stakeholders, clinical advisory
committee, counties, and oversight to develop a tool that captured that essence of a quality
evaluation.
• This tool was based upon the material and
references listed on the Case Conceptualization
Tool
• The tool is 10 items that capture the essences of a
quality evaluation. The next slides go over each of
the questions on the tool
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Item
Yes = 1,
No = 0 Weight
1. Theoretical orientation is identified to explain behavior. Clinician
may elect to use a trans-theoretical model. 0.13
2. Major symptoms and/or problems are identifed 0.13
3. Predisposing factors are stated, including any of the following:
parental variables, genetic influences, physical factors affecting
behavior, developmental factors (including trauma related variables,
and learning and modeling) 0.13
4. Precipitating stressors are identified, including life events 0.05
5. Protective strengths are listed. The strengths of both the consumer
and family are clearly identified and a statement is made about how to
potentially use those strengths in treatment 0.13
6. Why the consumer is showing symptoms at this time is clearly indicated 0.05
7. Appropriate DSM diagnoses (latest version) is justified by
constellation of symptoms consumer is displaying 0.05
8. Roles and responsibilities for important figures (such as parents and
teachers) in the treatment are recommended 0.13
9. Based upon items above and available data, effective interventions
are identified 0.15
10. The appropriate level of care and types of services are prescribed
[based on evidence based practices (EBP) or EBP components] 0.05
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So what do each of these
questions mean?• 1. Theoretical orientation is identified to explain
behavior. Clinician may elect to use a trans-
theoretical model. – Is the theoretical orientation consistent throughout the
evaluation?• For example, if the evaluator is discussing behavioral interventions and
issues through a behavioral lens, is this consistent or does it suddenly shift
and there are references to psychodynamic theories to explain behaviors
• 2. Major symptoms and/or problems are identified– Are the symptoms and problems specifically stated in the
evaluation?• For example, if there is a situation where you believe that trauma is the
precipitator for current symptomology/ current constellation of symptoms
that are supportive of the current hypothesis this should be discussed
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So what do each of these
questions mean?
• 3. Predisposing factors are stated, including any of
the following: parental variables, genetic
influences, physical factors affecting behavior, developmental factors (including trauma related
variables, and learning and modeling)– Is the background information sufficient in describing the
predisposing factors in relation to this individual?• For example, if both parents have autistic spectrum disorder this would be
important information to include in the evaluation
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So what do each of these
questions mean?• 4. Precipitating stressors are identified, including life
events– Are there any changes in stressors that are impacting
treatment and what are past stressors?• For example, if the member started a different school and there is an
increase in specific behaviors, this would be important information to
include, including if know, what is it about the new situation that is causing
the increased stress
• 5. Protective strengths are listed. The strengths of
both the consumer and family are clearly identified
and a statement is made about how to potentially
use those strengths in treatment– Are the strengths of the family and member delineated in
the evaluation and how these strengths may be used in
treatment?• For example, if there is a strong emphasis on schooling this could be a
strength within the family and this may be a strong motivator for symptom
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• 6. Why the consumer is showing symptoms at this
time is clearly indicated– Further exploration of the “why now” question.
• For example, additional explanation of what it is about the new school that is
increasing behaviors at school, and according to the information gathered what
are those situations where the behaviors are more likely to occur
• 7. Appropriate DSM diagnoses (latest version) is
justified by constellation of symptoms consumer is
displaying– Make certain that the diagnosis is supported by the
symptoms• For example, after extensive discussion of significant traumatic events and
difficulty with sleep, intrusive thoughts, nightmares, difficulty leaving
preferred caregivers, hyperarousal, a diagnosis of PTSD would be
expected (or if not, some rational as to why this is not being considered at
this time)
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So what do each of these
questions mean?
So what do each of these
questions mean?• 8. Roles and responsibilities for important figures
(such as parents and teachers) in the treatment
are recommended– How are the parents/guardians involved in the process? If
the behaviors are occurring in a specific class, how will the
teacher be involved?• For example, the parents will be involved in learning to deliver consistent
reinforcers and punishment for child’s behavior
• 9. Based upon items above and available data,
effective interventions are identified– What do you believe is the most appropriate treatment for
this member, at this time, in the best dose, to assist him/her
in reaching his or her recovery goals?• For example, at this time family based mental health services are
recommended due to a high risk of placement to the member. It is
believed that family based mental health services are the most
appropriate at this time because the family is experiencing difficulty in
giving cohesive messages in parenting and instillation of values which is
resulting in high risk behaviors for the member
So what do each of these
questions mean?• 10. The appropriate level of care and types of
services are prescribed [based on evidence based
practices (EBP) or EBP components]– Do the prescribed levels of care “make sense” given the
constellation of symptoms?• For example, if a member has been diagnosed with PTSD an appropriate
level of care may be to prescribe trauma based therapy
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How will this tool be piloted in
VBH-PA’s network?• Each evaluator and/or agency will be sent the Case
Conceptualization Tool and it will be posted on the VBH-
PA website.
• The evaluators and agencies are strongly encouraged to
complete self-audits and send the evaluation and the
self audit to VBH-PA.
• The evaluations that are sent to VBH-PA will be scored on
the Case Conceptualization Tool by VBH-PA and
compared with the self-audit score
• The Evaluator will receive the Case Conceptualization
Tool score from VBH-PA.
• If there are discrepancies between the self-audit and the
VBH-PA score on the Case Conceptualization Tool the
evaluator will be offered a peer discussion to discuss the
discrepancies
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Why would you want to do the
self-audit? • At the present time, this is a pilot project
• If the pilot shows that the tool is capturing
sophistication of conceptualization, this tool will be
part of the annual review of evaluations
• In the future, as part of the annual review of
evaluations, the score on the tool would be utilized
to determine incentives and disincentives
• Therefore, as all evaluators may be subject to this
tool in the future, VBH-PA strongly suggests doing
self-audits at the present time to make certain that
there is congruency between your scoring of your
evaluations and VBH-PA scoring of your
evaluations
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Questions?
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References…
• Guidelines for Best Practice in Child and Adolescent Mental Health
Services
http://www.dpw.state.pa.us/ucmprd/groups/public/documents/m
anual/s_001583.pdf
• Welcome Recovery to Practice
www.samsha.gov/recoverytopractice
• Summer Therapeutic Activities Programs
• Children’s Bureau powerpoint- presentation November 5, 2013
• SAMSHA’s Working Definition of Recovery
• Cognitive Behavioral Case Formulation- Persons and Tompkins
• http://www.parecovery.org/index.shtml
• http://www.dshs.wa.gov/pdf/dbhr/mh/MHRecoveryLanguage0802
2010.pdf
• Practice Guidelines for the Psychiatric Evaluation of Adults
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