Problem Work, Pattern Work

@#In this Unit we describe the first 2 types of intervention arising out of the extended consultation. In Problem work, the basic idea is to determine whether the patient’s behavior is a maladaptive response to antecedent stimuli, or the result of cognitive bias. We use counter-conditioning and contingency management to deal with maladaptive response. We use cognitive therapy to trace cognitive distortions that give rise to NATs and take steps to counter them. The problem approach is integrated as Cognitive Behavioral Therapy. The SMART solution to problems is deployed when there is no maladaptive behavior or cognitive bias at play. In pattern work, the salient life experiences of the patient which are selectively stored as narratives are examined. Such narratives may reflect a negative life pattern of thought and feeling. This is the problem-saturated story. Patients can be helped to change their pattern of thought and feeling and thus store their life experiences as preferred positive stories. The 4Rs – Re-membering, Re-framing, Re-authoring and Re-telling – help us to construct the new stories. When we do this consistently, the pattern work creates present and future stories of hope for the sufferer.

The 4Ps of Formulation & Intervention

@#The next step after the biopsychosocial information is collected from the extended history, extended examination, and extended investigation is the formulation of the 4P factors related to the patient’s problems (Predisposing, Perpetuating, Precipitating, and Protective factors). In this 4P formulation, attention is paid to the genogram, time-line, ROADS of the family, and the patient’s readiness to change. In certain situations, SBAR tool (Situation, Background, Assessment, Recommendation) may be needed to help get a better clarity of the situation and issues. Formulation helps us to be strategic in our psychosocial management.

The Extended Investigation

@#The aim of the extended investigation is to probe the mind for specific situations or issues that may help unravel the patient’s problem. The tool used is the mnemonic of CAR-ACE (clarifications, assumptions, reasons, alternatives, consequences, and relational experiencing). This disciplined inquiry brings information about feelings and thinking into the open, relating to the situation at hand. This is often used in problem work when troublesome situations are identified. It is used to uncover the Negative Automatic Thoughts arising from cognitive distortions that triggered the emotions. It is also used in pattern work to investigate the salient situations linked by themes into stories. The themes and stories can then be investigated for consistency and context.

The Extended Examination

@#The mind may be examined by using reflective communication which is also known as active listening. We pay attention to the modes, phases and channels of communication; the purposeful use of unusual grammar forms; and we also create discrepancies to destabilize the patient’s mind to get past his conscious mind and seek a deeper unguarded response from him or her. In the reflective communication, we validate, track and pace the patient’s thoughts, emotions and behavior. We express affirmation, empathy and sympathy and connection with the patient by use of mirroring, modelling and metaphors. Reflective communication skillfully used, helps the doctor to examine and understand the patient’s mind, and it also helps the patient to gain insight to his problem.