CEP Workbook Module 5 Management 1

Fraser Todd & Michelle Fowler 2013

This workshop is provided through the Mental Health Education Resource Centre and supported by the Canterbury District Health Board. It is one of a series of workshops designed to help practitioners and services improve their capability to work with people experiencing complicated and complex mental heath problems. The material presented in this workshop is drawn from Te Ariari o te Oranga (Todd 2010), though is updated here in several areas. Copyright is asserted by Fraser Todd over the content. It may be freely used with permission. The name Te Ariari o te Oranga means the dynamics of well -being. The name was coined by that staff ad students of Te Ngaru Learning Systems, was given to a series of bicultural training events on co-exiting and mental health and substance use problems (CEP) over the past decade, and given to the document Te Ariari o te Oranga: The Assessment and Management of Co-existing Mental Health and Substance Use Problems (Todd 2010) by Paraire Huata. As a term, it captures the practice and teaching of CEP in New Zealand where bicultural approaches are honoured.

Welcome to this Workshop

This workshop on Management of CEP is the first of two on management, and the fourth of six advanced workshops. The relevant section in Te Ariari o te Oranga is essential background reading and much of that content will not be repeated in the workshop.

The MHERC CEP Workshop Series

Workshop 1: 1a. Introduction to CEP for frontline staff 1b. Introduction to CEP for managers Workshop 2: Recovery and Wellbeing Workshop 3: Motivation and Engagement Workshop 4: Assessment Workshop 5: Management I Workshop 6: Management II Workshop 7: Integrated Care To attend workshops 2-7, it is expected that participants will have either attended module 1 OR completed a self-directed learning package based on Workshop 1. It is essential that they are conversant with the generic principles that will be the focus of Workshop 1.

Workshop Overview
Management Part One Phases/stages of treatment and stage of change for problems Structured and comprehensive management plan from formulation Address Trans-diagnostic/common factors Structure of sessions

Management Part Two Use of generic and specific strategies Clinical case management Combining evidence-based practices for different diagnosis and problem Withdrawal management

Learning Intentions
Participants will be provided with the opportunity to: Gain a broader knowledge of management planning for tangata whaiora presenting with CEP Be able to implement combining evidence-based practices for working with different presentations Be able to plan and implement structured sessions for working with people with CEP Have a broad understanding of withdrawal management in working with people with CEP

Te Whare o Tiki Management

In addition, we will aim to cover some of the management components of the CEP Skills Framework Te Whare o Tiki. Te Whare O Tiki has been produced by Matua Raki to provide guidance and direction for learning and practice development in CEP.
Management is the fifth domain of the skills set and includes the following skills at three levels of competence, foundation, capable and enhanced: 6.1 Integrated treatment approach for CEP 6.2 Relapse prevention Strategies (RP) 6.3 Harm reduction and self-harm reduction strategies 6.4 Mental health or CEP crisis 6.5 Assessment and management of intoxicated states

6.6 Management of acute and protracted withdrawal states 6.7 Pharmacological treatments for mental health and substance use disorders 6.8 Psychological treatments including talking therapies such as Motivational Interviewing, Cognitive Behavioural Therapy, Dialectical Behavioural Therapy, group, systemic and family therapy. 6.9 Physical treatments e.g. ECT, Transcutaneous Magnetic Stimulation 6.10 Self-help approaches 6.11 Pregnancy 6.12 Mental health, substance use and gambling disorders across the lifespan 6.13 Co-existing physical health conditions 6.15 Nicotine dependence 6.16 Legislative Requirements

Background Reading
Reading and knowledge to support this workshop can be found in the relevant chapters of Te Ariari o te Oranga. This workbook will include further information where there are updates to the content of Te Ariari.

Workshop Outline
Mihi and Introductions Housekeeping Workshop overview Review of last workshops action planning exercise Introductory Mindfulness Exercise From Formulation to Treatment Planning Working with Families Action Planning

Exercise 1: Mindfulness Introduction Instructions will be given in the workshop.

From Formulation to Treatment Planning

This first of two workshops on management of CEP focuses on the process of developing a comprehensive treatment plan based on the opinion, including diagnoses, problems and strengths, and the aetiological or causal formulation.

The Need for Structure

Senior practitioners will find moving from opinion to treatment relatively straightforward for many people they work with. Experience means they have internalized the process and will intuitively apply appropriate treatments to the problems they detect. While this is a very useful skill for much of their work, it does have an important weakness; pattern recognition is very useful for patterns you are familiar with but of limited value when the patterns are less familiar. Complex cases, as often found with CEP, frequently bring up issues at a level of thinking we are not familiar with or used to. At these times, our experience and intuitive pattern recognition approach fails us. Furthermore, because our usual approach has been internalized and become intuitive, we may lack a process for developing and effective treatment plan. It is in these circumstances that having a structure for developing a treatment plan can be very helpful. Further, when it comes to learning to work at an advanced level, the apprenticeship model often used in health care has limitations, especially in terms of the ability of a learner to identify the steps an expert takes when they are intuitive and implicit. The structure outlined below is not how an expert practitioner works. Rather it is one way we have found that helps students learn to become experts.

Steps for Developing a Treatment Plan from the Opinion

The process of developing a comprehensive treatment plan based on the history and mental state examination involves the following steps: 1.The Opinion Diagnoses Problems and strengths 4x4 grid 2. The Formulation Statement The 4x4 grid with factors entered into the grid is developed into four paragraphs that are then fed back to the tangata whaiora as a narrative. This serves several purposes including allowing negotiation and shared understanding of how the problems are seen and how they relate to a persons life experiences, raising key issues that will be a focus for treatment, and it is also a mechanism of healing and treatment in its own right. 3.Goal Identification and Setting From the opinion, the key diagnoses, problems, strengths, and factors from the 4x4 grid (especially the maintaining factors and strengths are identified as key goals for treatment. 4. Goal Planning Key goals are prioritised and staged or ordered using the early, middle, late and autonomy pha ses. 5. Treatment planning Treatments are matched to the key goals and organised using the phases of treatment.

Step 1: The Opinion: Rachels Diagnoses, Problems/Strengths and 4x4 grid

We have discussed this in previous workshops. To summarise, the opinion relating to Rachel is as follows:

Axis1
Major Depressive Disorder Post-traumatic stress disorder Alcohol dependence with physiological dependence Cannabis dependence with physiological dependence Nicotine dependence with physiological dependence

Problems and Strengths

Negative ruminations Hyper-arousal and intrusive memories from rape Impulsivity Avoidant coping style Stressful relationship with partner Stress of caring for young child Lack of assertiveness in relationships (dependent traits)

Rachels 4x4 Grid

The 4x4 grid for Rachel is on the following page. Use this to undertake Exercise 2. Rachels history, a list of some factors for the 4x4 grid and a list of transdiagnostic factors is included in the appendices if you need to refer to them though the information in the grid should be sufficient to allow you to develop a formulation statement.

Exercise 2: Formulation Statement

Get into small groups Appoint a scribe and a person to feedback Each group will be assigned one paragraph of the formulation statement to work on

Develop a formulation statement for Rachel, using the factors identified in the 4x4 grid. This is what you will actually feedback to Rachel for negotiation. 1. Pattern over time 1. Vulnerability (Predisposing) &Triggers (Precipitating) 3. Maintaining (Perpetuating) 4. Strengths (Protecting)

Feedback and Discussion

Rachel Formulation - Four Paragraphs

1. Pattern -----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------9

----------------------------------------------------------------------------------------------------- 2. Predisposing and Precipitating ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------3. Perpetuating ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------4. Protecting ------------------------------------------------------------------------------------------------------

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----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

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Below is the 4x4 grid for the aetiological formulation for Rachel we developed during the previous workshop. Vulnerability (Predisposing) Triggers (Precipitating)
Genetic predisposition (SUDS, social anxiety) Intoxication Hyper-arousal Depressogenic effects of alcohol Anxiolytic effects of alcohol Sleep Executive functioning Craving Avoidant coping style Rumination Intrusive memories Shame Automatic thoughts self-worth, control Flashbacks Dependent traits (re relationships Social withdrawal Limited social support networks Arguments with partner Choice of relationships Lack of love from family/partner/friends Lack of belonging (interpersonal niche Social niche?

Maintaining (Perpetuating)

Strengths (Protecting)
Alcohol (PTSD symptoms, anxiety) Physical health Past abstinence

Biological

Psychological

Attentional control Impulsivity negative urgency Hyper-vigilance Low self-efficacy Some dependent traits? Inability to accept love?

Daughters age triggering memories of abuse Rape Intrusive memories trigger mood & substance use Lowered mood Withdrawal?

Intelligent Has developed some self-efficacy re social work, daughter

Attachment anxious Mistrust of others

Arguments Finance Large groups

Social

Good social skills Daughter Striving Ability to love

Identity Disconnection from the world?

Hostility / inconsiderate actions = further disconnection

Spiritual

Family values Hope actively future- orientated Has some meaning and purpose in life around social connection Identity mother, nurture Developing spirituality (love identity, niche, role, connection)

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Step 2: Goal Identification and Setting

The key diagnoses, problems and strengths, and formulation factors will become the targets of treatment. Having too many goals is confusing and cumbersome, and having complicated or vague goals does not lead on to effective treatment. When these problems occur, they can be dealt with by a process of lumping and splitting. Lumping involves the brining together of several goals into one single overarching goal. For example, goals of treat sleep problems, low mood, poor memory, poor concentration etc leads to too many goals and could easily be lumped into treat the symptoms of major depression. One or two of these, if particularly problematic, might be identified as specific goals. Note that the particular problems have been specified in the opinion and can be drawn on from there when it comes to specific treatments. Splitting involves the dividing of a single big goal into several sub-parts of components. For example treat mental health is probably too vague to predict specific treatments. It could be split into goals of treating major depression, treating PTSD and treating substance use problems.

Exercise 3: Goal Identification and Setting

Get into small groups Appoint a scribe and a person to feedback

From the opinion, identify key goals for Rachels treatment

Make the goals specific, measurable, able to be achievement, realistic and timely (SMART)

Feedback and Discussion

Step 3: Goal Planning

The phases of treatment outlined in the table below are similar to the stages of Engagement, Persuasion, Active Treatment and Relapse Prevention but differ in that the Engagement-Persuasion Model was intended as a series of stages to address substance use in people already engagement in mental health treatment. The model below is suitable for people who are not in either mental health or addiction treatment and where addressing CEP is the expectation from the outset of treatment,

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and where there are acute needs beyond engagement. Thus Engagement begins in the early phase of treatment (and continues throughout), while enhancing motivation (persuasion) may begin in the early phase and continue into the middle phase, or begin in the middle phase depending on the acute needs of the tangata whaiora and the duration of the early phase. It is still important to address key addiction and mental health problems in a stage wise manner (following the Engagement Persuasion Model discussed in the next section) within the phases below.

Prioritising Goals
Give preference to: Urgent goals (involving safety, stabilisation) Serious problems Pivotal problems and trans-diagnostic factors from the formulation Easily Achieved Goals

Also consider: Favouring goals that are more internally motivated Goal conflict; - treatment v life goals - tangata whaiora v clinician goals Approach rather than avoidant goals Short term v distant goals - distant goals important for shaping treatment but short term more motivating

Most easily achieved goals for those with severe impairment: reduction in panic attacks other fears and anxieties increased assertiveness self-confidence

Least easily achieved goals for those with severe impairment: sleep problems pain reflecting on self and the future depressive symptoms

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Exercise 4: Goal Planning

Get into small groups Appoint a scribe and a person to feedback

Using the table outlining the key goals by the phases of treatment, identify the key goals for Rachel for each phase of treatment. Enter these in the empty table on the preceding page.

Feedback and Discussion

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Early involve key supports e.g. whnau/family if appropriate assess and manage safety issues comprehensive and integrated assessment and management plan including integrated formulation to integrate care appoint case manager stabilise acute crises, substance use, physical, social problems detox if appropriate culturally appropriate engagement processes and assessment address spiritual needs link with and involve other services as indicated engage whanau support enhance engagement & motivation initiate or adjust medication initial coping strategies to help manage crises

Middle monitoring and adjustment of medication active treatment of mental health and substance use problems including specific psychotherapies and social interventions specific whnau/family interventions maintain engagement and motivation increasing focus on steps to enhance well-being peer support groups continue to manage linkages with others involved relapse prevention re-culturation and increased ability to access cultural resources

Late

Autonomous Wellbeing Ensure community supports in place Clarify future access to services Fully transfer responsibility to tangata whaiora and family/whanau Transtiionto primary care

ongoing monitoring of treatment adherence ongoing work on relapse prevention further enance well-bieng & recovery enhancement of occupational and social skills increasing self-management of mental health and substance use problems strategies to enhance well-being Fully engage community supports

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Early

Middle

Late

Autonomous Wellbeing

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Step 4: Treatment Planning

Treating planning involves planning the general context of treatment and applying specific interventions to the selected goals. A useful structure for thinking about each phase of treatment is the 10-point format outlined below. For each phase of treatment consider the following (outlined further in Te Ariari) as well as specific 1. 2. 3. 4. 5. Setting Further information Treatment of medical condition Psychopharmacology Psychological interventions Psycho-education Motivation Deficits (disorders, problems) Well-being, recovery and strengths

The format of psychological interventions can be: Individual Group Self-directed (e.g. online treatment resources, books) The template below can be useful for organizing psychological interventions

Individual

Group

Self-directed

Psycho-education

Motivation

Diagnoses & Problems

Well-being, Recovery & Strengths

Whnau/family and social interventions Spiritual Interventions Education of tangata whaiora and whanau Social Needs Education/work/occupation Accommodation Finance 10. Self-help groups. 6. 7. 8. 9. On the next page is a template for helping organise interventions by phase of treatment

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Early

Middle

Late

Autonomous Well-being

1. Setting

2. Further information

3. Treatment of medical conditions

4. Psychopharmacology

5. Psychological

6. Family/whanau

7. Spiritual 8. Education of client/whanau

9. Social Needs

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10. Self-help

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Stage-wise Treatment of Psychological Problems

Stage-wise treatment means applying the appropriate interventions for the stage of treatment a person is at. Generally the following four stages are used: 1. Engagement 2. Persuasion 3. Active Treatment 4. Relapse Prevention To some extent these follow the phases of treatment, with engagement and then motivation being a key goals of early treatment, active treatment a key goal of the middle phase of treatment and relapse prevention a key strategy for later phases of treatment. In fact these stages overlap and motivation, for example, begins to be addressed before engagement is complete.

Exercise 5: Treatment Planning

Get into small groups Appoint a scribe and a person to feedback

Develop a treatment plan for Rachel for the early and middle phases of treatment.

Feedback and Discussion

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Working with Groups

Group interventions have the strongest evidence base for working with CEP of any intervention, alongside contingency management and residential CEP programmes. The information below is drawn from TIP 42 (to be included in final resources) and from Integrated Treatment for Dual Disorders (Mueser et al: an excellent resource which provides more detail than most on delivering specific interventions) TIP 42 (free download) http://store.samhsa.gov/product/TIP-42-Substance-Abuse-Treatment-for-Persons-With-Co-OccurringDisorders/SMA12-3992 Mueser, K.T., Noordsy, D.L., Drake, R.E., Fox, L. Integrated Treatment for Dual Disorders: A Guide to Effective Treatment. The Guildford Press, New York 2003. Amazon: http://www.amazon.com/Integrated-Treatment-Dual-DisordersEffective/dp/1572308508/ref=sr_1_1?ie=UTF8&qid=1377650696&sr=81&keywords=mueser+integrated+treatment $US48

General Principles of Group Work with CEP

Support attendance rather than performance in the group - tolerate variable participation from clients Avoid confrontation Encourage group interaction rather than facilitator views Reduce emotional intensity o Non-provocative topics Stronger direction from staff to help CEP patients maintain focus Shorter duration less than an hour 40 minutes optimal Allow a participant to leave early if not coping with the group Run regularly, no cancelations because of shorter duration Smaller group sizes due to patients having difficulty in social settings (2-4 participants is okay initially) Co-facilitation one facilitator may need to leave the group with an individual for Consider Peer facilitator Brief, simple, concrete and repetitive verbal participation from facilitators Affirmation of positives rather than disapproval or sanctions Negative behaviour should be addressed rapidly Use motivational techniques Set ground rules: One person speaking at a time No interruptions Be on time for the group Show respect - no name-calling or put-downs Let everyone who wishes to speak get a chance to do so No aggression or threats

Types of Groups by Phase and Stage of Treatment

Persuasion Groups
Persuasion groups are best suited to the early and middle phases of treatment to help participants understand how substance use affects their lives and their mental health problems, to build

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motivation to change substance use, to set goals for substance use reduction and to start acting towards these goals. Session Process Brief sessions with break Weekly No more than 10-12 participants and 2-4 is sufficient. Use motivational interviewing techniques Try to evoke information from the group rather than provide it. NB reasons to reduce substance use are much more legitimate when coming from participants Tolerate participants turning up intoxicated as long as they are not disruptive. Address the disruptive behaviour rather than the intoxication. Provide brief psycho-education around a specific topic Use role play, diagrams, mnemonics to aid understanding and recall Structure of Sessions First Session Reasons for group Introductions Guidelines and rules for group Wrap-up Subsequent Sessions Check in (10-15 minutes) Brief discussion a pre-selected topic initiated by facilitator or a participant (30-45 minutes) o Basic psycho-education about the effects of drugs, diagnoses, medication and side effects, interaction of drugs and mental heath o Values and well-being o Decisional balance o Consider a guest speaker e.g. peer support o Medication and adherence o Dealing with stress o Problem solving o Social problem solving o Pleasurable activities and behavioural activation NB the key is to build engagement, to go with the participants discussion and use opportunities to enhance motivation as they arise. Closing (5-10 minutes) o State that the session is about to close o Discuss topic for next session o Check if any participants are experiencing high levels of stress or increased symptoms, risk etc

Key Specific Topics Psycho-education Decisional balance Problem solving Social problem solving

Active Treatment Groups

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For tangata whaiora in the active treatment phases. Session Process Up to 90 minutes Facilitator is less motivational given that participants are already in the active treatment stages Can be slightly more confrontational (from other participants) as long as respect is maintained Structure of the Sessions Similar to persuasion groups though longer Specific Topics Further psycho-education Assertiveness Managing cravings Relaxation and mindfulness skills Drink/drug refusal skills Managing thoughts about substances Medication adherence Managing mental health symptoms Communication skills Social skills Social problem solving Coping with unpleasant feelings Pleasurable activities and behavioural activation Relapse prevention Further Readings: TIP 42 Mueser et al 2003 (above)

Working with Families

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As with group treatments, family interventions can occur at a number of levels of complexity. At the more basic level, family work can and should be carried out by practitioners without extensive family therapy experience. More sophisticated work requires specific skills sets and training. Also like group treatments, family interventions should be a routine part of CEP practice given their effectiveness. NB For women (men not studied), couple therapy for addiction is more effective than individual therapy, but most women prefer the latter.

Basic Family Interventions

Key Goals Increase familys understanding of CEP and specific problems of tangata whaiora Reduce stress in the family Reduce substance use and mental health symptoms of tangata whaiora Reduce the impact of substance use on other family members Increasing adherence of tangata whaiora Improved support tangata whaiora in the whanau Encourage the family and clinicians to work together in a common direction Optimise familys problem solving skills Muser 2013 Family education helps, but addition of problem solving and communication skills training helps even more Session Process Follow the engagement, persuasion, active treatment, relapse prevention process Use motivational interviewing techniques where appropriate Specific Topics Psycho-education Stress reduction Problem solving around specific family problems Social problem solving Limit setting and establishing an autonomy supportive environment Reduce the impact of substance use on other family members Encourage tangata whaiora to undertake positive activities Increasing adherence of tangata whaiora Family Problem Solving 1. 2. 3. 4. 5. 6. 7. 8. 9. Identify and define a problem Reframe as a positive goal Seek everyones opinion of the problem Think of/brain-storm possible solutions Evaluate each solution Select the best solution Try out the solution Evaluate Decide what to do next time

Social Problem Solving Apply the problem solving strategy above to difficult social interactions. 1. 2. 3. 4. 5. Identify and define a problem Reframe as a positive goal Seek everyones opinion of the problem Think of/brain-storm possible solutions Evaluate each solution

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6. 7. 8. 9.

Select the best solution Try out the solution Evaluate Decide what to do next time

Further Reading Kina Trust Family Inclusive Practice in the Addiction Field http://www.kinatrust.org.nz/myfiles/FIP.pdf Mueser et al 2003 (above) Copello, A., Templeton, A. Orford, J. Velleman, R. The 5-Step Method: Principles and Practice. Drugs: education, preventions and policy (2010) 17(S1):86-99 Copello, A. Orford, J. Velleman, R. Templeton, L. Krishnan, M. Methods for reducing alcohol and drug related family harm in non-specialist settings. Journal of Mental Health (2000); 9(3):329-343.

COPMIA (Children of People with Mental Illness and Addiction)

Basic resources as a guide to considering the needs of children of people with CEP can be accessed at: http://www.copmi.net.au

Action Plan
1. Before the next workshop, review the formulation you did on one of your clients after the assessment workshop, and review the treatment plan using the steps of goal setting, planning and treatment planning covered today.

Appendices
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1. Rachel Scenario 2. Common trans-diagnostic factors to consider 3. Menu of some factors for the 4x4 grid

Case Scenario - Rachel

Rachel is a 30-year-old European mother of a 5 year-old daughter who was referred to your service via the local Emergency Department after having taken an overdose of 15 Paracetamol tablets the previous night. Rachel stated that the overdose had been an impulsive action after drinking a bottle of wine and having an argument with her partner about finances. She stated that she was not trying to kill herself or that she was at risk of future overdose as she was very embarrassed at the outcome. She was reluctant to attend the appointment with your service, but did so under pressure from her partner who threatened to leave her unless she did something about her drinking and her moodiness. History of Presenting Problems Rachel described her mood as low but believed that this was normal for her. At times her mood is worse than usual for a few weeks with persistent sadness, lack of energy and motivation and diminished pleasure from things she usually enjoys. This occurs once every three months on average. At these times she finds life a struggle and has thoughts that she would be better off dead but has never actually developed the intent to kill herself. Problems with low mood have occurred off and on since she experienced a sexual assault (rape) at a party while severely intoxicated at the age of 18 years. Since then she has experienced frequent intrusive memories and ruminations related to the rape which has impacted on her intimate relationships, and experiences hyper-arousal much of the time though it is worse when socializing in larger groups. She denies any other significant mental health problems. Alcohol and Drug History Rachel started drinking alcohol with friends around the age of 14 years but having seen her fathers drinking did not drink regularly or to intoxication until after the sexual assault at age18 years. She started drinking to intoxication most weekend nights when socialising, and by the age of 20 years was drinking half to three quarters of a bottle of wine most evenings as well. Her alcohol use decreased when, at age 22 years she entered a relationship with the father of her daughter, and over the next few years she would drink occasionally when socializing but would have periods of several months at time without using alcohol. Her partner left her when she became pregnant and decided to keep the child. She stopped drinking when she became pregnant at aged 25 years and did not consume alcohol again until her daughter was a year old and she entered a new relationship with her current partner who also drinks heavily. For the past three years she has consumed a bottle of wine each night during the week, and up to three on Friday and Saturday nights if socializing. She acknowledges tolerance to alcohol and has tried to cut her drinking down in the past on several occasions without success. She also acknowledges that she gets argumentative with her partner when intoxicated on alcohol but denies other problems, and finds that it actually helps her to be calm in most situations.

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She has used cannabis on a daily basis since her mid teens and experiences craving, irritability and significant generalised anxiety when she goes without it for more than a few days, but find it helps her mood. Other than during her pregnancy, she has not had any significant periods of abstinence from cannabis. She has not used any other substances apart from tobacco, which she started smoking at 14. She currently smokes 50gms of tobacco a week and would like to stop, as it is very expensive. Other Relevant History Family History: Youngest of three siblings with an older sister and the eldest a brother. Her father died in a motor vehicle accident when Rachel was 22 years old. Father alcohol dependence. Paternal Grandfather alcohol dependence Brother convictions for assault and possession of cannabis, heavy cannabis user Mother social phobia, less problematic the last few years

Medical History: Nil of note No current medications Personal History: Rachel had a normal pregnancy, birth and early developmental milestones. She was an outgoing and happy toddler, over adventurous and exploratory. She attended six different primary schools due to her fathers frequent change in employment. At primary school she struggled academically with mathematics and reading but was otherwise intelligent, but frequently got into trouble for disobedience and being easily distracted. She was noted to have a short temper and be intolerant of discipline, talking back to teachers. She was sexually abused between on one occasion at the age of 5 by a friend of her fathers, and though she did not tell anyone, her older sister told their other she disliked him and their mother made sure he did not have access to the children. She was frequently truant from secondary school and noted to be irritable and argumentative when she did attend. Upon leaving school she worked in a range of waitressing, bar and sales jobs until becoming pregnant. Over the past two years she has taken several tertiary papers in social work and hopes to get a job in the future in community support. Her current relationship tends to involve frequent arguments though not violence. She has one or two friends whom she has know for ten years, but few other contacts she would consider more than acquaintances. Over the past 5 years she has had increasing contact with her mother, revolving around her daughter. Her siblings have lived in the United Kingdom for the last 7 or 8 years; she talks to her sister on skype once every few weeks, but has limited contact with her brother.

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Some Trans-diagnostic Factors: Genes Attention control Impulsivity Negative urgency Negative emotionality Cog/Attention bias Emotion regulation Rumination Perfectionism Coping (approach/avoid) Sleep Social context

Menu of Some Factors for the 4x4 Grid

Developmental Transitions
e.g. Eriksons Stages Birth 1 year 10 months 4 years 3-5 years 5-10 years Adolescence Young Adulthood 1st Adulthood (18-30) parenthood 2nd Adulthood (30-45) Maturity (65+) trust v mistrust autonomy v shame and self-doubt initiative v guilt industry v inferiority ego identity v role confusion intimacy v isolation generativity v stagnation or self-absorption career, marriage, midlife transition ego integrity v despair

Biological Factors

Genes In Utero effects alcohol and drug exposure, infection, trauma Birth hypoxia and trauma Infection Temperament novelty seeking, harm avoidance, Predisposition to psychiatric and medical illnesses Appearance Head Injury Stress, HPA axis, cortisol Substance use IQ Motor activation hyper-arousal, agitation and activation Pain

Fraser Todd 2013

Sleep issues Effortful control v Impulsivity - Impulsivity 1. response initiation 2. response inhibition 3. consequence insensitivity - Negative urgency also appears to be one way of conceptualizing one of the dimensions of impulsivity

Psychological Factors

Temperament and personality Temperament and Character (novelty seeking, reward dependence, harm avoidance, persistence, self-directedness, cooperativeness, self-transcendence Neuroticism Extraversion High Anxiety Emotion dysregulation Negative emotionality Situational stressors Impulsivity response initiation, response inhibition, consequence insensitivity Negative urgency Effortful control Rumination Overgeneralised autobiographical memory Loss and bereavement Unresolved grief Positive and negative reinforcement Motivation Cognitive maps and schema Core beliefs - underlying assumptions automatic thoughts Thinking errors Over generalisations Personalization All or nothing thinking Emotional reasoning Mind reading Perfectionism Overgeneralised autobiographical memory the tendency to remember general rather than specific historical events (avoidance), associated with abuse in childhood and appears to be a vulnerability factor for depression and a maintaining factor for PTSD Coping Resources (optimism, self-efficacy, self mastery, social skills) Processes approach or avoidance Specific strategies Skills Deficits Coping skills Problems solving skills Social skills Assertiveness Emotion regulation Anger management Parenting skills Dysfunctional self-talk

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Immature sense of self Unconscious dynamics Positive psychology Positive experiences engaging (flow) and meaningful experiences Positive thinking and optimism Character strengths and values Interests, abilities and accomplishments Positive relationships Enabling institutions

Social Factors

Marital relationship Family Parents Control and limit setting Under or overprotection Abuse; emotional, physical, sexual Intergenerational transmission; rules, customs, rituals, beliefs Dysfunctional communication Family roles Hierarchies Boundaries Individuation Enmeshment Emotional reactivity Disengagement Triangulation and scape-goating Social role Social networks Community Support Violence Poverty Stigma Work environment Environment Basic needs e.g. housing, clothing, food, transport, living spaces Relevant income levels and discrepancies

Spiritual Factors

Spiritual crisis, guilt, intolerance of others Self-transcendence Ecological worldview Search for meaning, purpose and fulfillment Acceptance of suffering Hope Altruism Connection with the sacred Experiences inner peace, wholeness, creativity and flow, mystical experiences, boundaries of the self Beliefs connectedness, meaning, calling, life after death, divine purpose, Activities prayer, meditation, communing with nature, nourishing the soul, creative spiritual expression (art, reading, writing etc)

Fraser Todd 2013

Cultural Considerations

Identity Acculturation Values Transgressions of sacred rules and spaces (Tapu) Curses and makutu

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