Problem solving, case formulation and policy formulation

On W2tQ this year, and possibly in a previous paper, or conference presentation, I've stated that the nursing process is basically a problem solving algorithm. Nothing profound there of course. 

'Problem solving' is a developmental threshold and an evolutionary skill obvious in humans, with learning passed on across generations. Evidence of problem solving in animals and nature is becoming increasingly apparent; with examples over recent decades of problems solved not witnessed before.

In healthcare, and psychotherapy more specifically, we shift to case formulation. Again a step-wise process to arise at a sufficiently complete rationale for therapy. Ideally, this extends beyond the individual. As an parent, grandparent, guardian, teacher, supervisor ... teaches a child so therapy is an opportunity for learning and, it must be added, unlearning.

Returning to (and passing on):

Hague, R., & Harrop, M. (2007). Comparative Government and Politics (7th ed.). New York, NY: Palgrave Macmillan.

Chapter 18 (pp.377-395) concerns 'Public Policy'. Clearly, here there is a shift from the individual to the collective, population and citizenry. The chapter's second page on 'Initiation and Formulation' quickly provides a flowchart 'Figure 18.1 Stages of the policy process'. Box 18.1 informs readers about 'Rational and incremental models and policy-making' (p.380):

'The key contrast between the two models is this. The rational model views policy formulation as emerging from a systematic search for the most efficient means of achieving defined goals. By contrast, the incremental model sees policy as emerging from a compromise between actors who have goals which are ill-defined or even contradictory. Where the rational model seeks the best policy in theory, an incremental framework seeks out a practical policy acceptable to all the interests involved.' p.380.

The book highlights Simon (1983) as a source for the rational or synoptic model:

 

Simon H.A. (1983) Reason in human affairs. Oxford: Basil Blackwell.

Plus, for the incremental model:

Lindblom, C.E. 1979. Still muddling, not yet through. Public Administration Review 39: 517–526.

If needed, online, you will find accounts and diagrams on problem solving, the nursing process, case formulation and policy formulation. That's quite a family is it not? 

While not referred to as explicitly today, the nursing process (now routinized) should address parity and integrate care across mental and physical health. The individual (person, patient) should be assessed and care planned with their social and community context taken into account. Collaboration in care should help assure that this is indeed the case. The nursing process in the sociological domain acknowledges the role of parents, guardians, and families as informal carers. The social care sector can also be represented and further the objectives of a more open and integrated care community as per the local situation. While not added to the sciences domain; case formulation should also factor in the physical and political. 

Politically, are all instances of problem solving, and formulation recognised for their importance and influence on outcomes and effectiveness, economy, efficiency (another 'box' p.357), plus efficacy? Are services politically afforded the resources, as defined across the domains of Hodges' model required to deliver, improve and change (achieve sustainability, educational, preventive)? 

The elephant here of course are the determinantS. Ultimately, all these forms of problem solving should be at 'home' in the political domain, but they are rarely there. It is not just the practitioner who can make the difference - be the difference.

Enough of l-implementation

Policy needs to be fit for 21st century purposes, and not hollowed-out but allowed out - beyond the legislative walls where it can make a real difference.

individual

|

INTERPERSONAL : SCIENCES

humanistic -------------------------------------------  mechanistic

SOCIOLOGY : POLITICAL

|

group-population

Nursing process Case  formulation	Nursing process
Nursing process Case  formulation	Policy formulation

    

See also: https://herbertsimonsociety.org/

 'nursing process' : 'case formulation'

Case formulation - Theory and Practice

 Still sorting papers, I've discovered copies of slides from the COPE course University of Manchester on Case Formulation by John McGovern.

An original purpose for Hodges' model is to help bridge the theory-practice gap.

The slides include -

• content: ingredients - preliminary formulation
• a means of understanding an individual's problems and distress in line with cognitive behavioural theory
• hypothesis to explain acquisition, and maintenance of problem
• not piecemeal

ROLE OF CASE FORMULATIONS

Bridge between theory and practice

a flexible tool for guidance

an explanatory framework to share with the patient

How types of formulation can be related to situations (Hodges' model is situated) - inference chain.

Comprehensive formulation - reflects the template that supports data gathering

inc. core beliefs - conditional beliefs

Questions for Preliminary Formulation

Main Ingredients - includes social support/relationships/employment/finances

(so this touches on determinants)

Choosing Treatment Targets

group exercise and summary

ii from Learning Health Systems journal - to case studies

Returning to this journal, reference #47 -

MacQuarrie C. Holistic designs. Encyclopedia of Case Study Research.Thousand Oaks, CA: SAGE; 2010:442-443.

In -

From “Invented here” to “Use it everywhere!”: A Learning health system from bottom and/or top?

Christian Colldén, Andreas Hellström

- led me to (with my emphasis) 

Encyclopedia of case study research/edited by Albert J. Mills, Gabrielle Durepos, and Elden Wiebe. London: SAGE Publications Ltd. 2010.

"Case study methodology can be a rich source for understanding the multiple structures that support and sustain organizational life and business units. Its strengths are in its ability to gain an insider’s viewpoint during the research process, the more in-depth and nuanced findings based on that, and in its flexibility in using different methods. Its challenges are in the theoretical framework and in the development of concepts based on empirical findings. When these are taken into account, fruitful and nuanced research results are possible, and through the study it is possible to gain an overall and holistic picture of the research object." p.76.

"To reach the intended effect for the learners, these teaching cases must fulfill certain conditions and prerequisites. For this, Bernd Weitz proposes three essential criteria: exemplarity, clearness, and practical orientation.

Exemplarity means that the study must exemplify not just an arbitrary and subjective case, but also one that is objective, unique, or representative. Clearness requires that cases are not trivial; on the contrary, they have to make use of all possible and appropriate alternatives of illustration for a comprehensive understanding. This demands holism, traceability, visualization, and supplementation with additional information. The last point, practical orientation, aims for the highest integration of theory and practice for an integrated learning process." p.77.

    (And many other sources.)

Hodges' model provides a portal. As a frame, not just one type of portal but several including information (portal). A portal that can function as a learning health system. Could this in combination with health literacy* even be extended to represent a definition of self-care? Long identified as a research approach for Hodges' model, case studies are the logical fit. If they were not, then the whole clinical, nursing, healthcare rationale for the model would be lost. A clinical, medical, health care episode begins as a result of case-ness being achieved. In the case that follows in practice, we are looking to assure person-centered care in the midst of criteria, processes, (gate-keeping) thresholds that are inherently service-centred and possibly also influenced by targets and a series of constraints.

"Case studies of the elderly tend to embrace normativism. If health, as in naturalism, amounts to preserving the organic functional ability to make species-typical contributions to survival and reproduction, then health can be objectively and statistically determined—that is, subjects’ perceptions or awareness are not relevant. But if a normative evaluation of the person’s body and mind is a necessary element in the care of the elderly, then case studies are necessary." p.127.

Demographics, and intergenerational factors, plus the (probable) rise of appeals to transdisciplinarity^ means that for policy, governance and assurance case studies and mixed-methods will increase in research.

The orientation of Hodges' model is also inevitably practical and hence pragmatic.

I have only scratched the surface here, and probably not in the most itchy of spots (Encyclopedia and not the only one).

More to follow ... and if you have observations, advice I'd be pleased to hear from you.

*All the literacies and schools of informatics.
^Such are the problems we face.

See also: Contents: Learning Health Systems,6,3, July 2022

Happy New Year: Nostradamus c/o Al Stewart

"A Man for All Seasons" ...
"A Woman ... and other gender identities ..."
"A Child ..."
"A model ..."

"A model for Past, Present, Future"

A series of Frames - Janus-like view:

Pre-morbid, Diagnosis, Prognosis ...

Clinical and Case -
Assessment
Planning
Formulation
Evaluation
Engagement

individual

|

INTERPERSONAL : SCIENCES

humanistic ----------------------------------------------- mechanistic

SOCIOLOGY : POLITICAL

|

group - population

Nostradamus - Al Stewart
From the Album: Past, Present, Future

Thought, Formulation, Thresholds and Coherence

individual

|

INTERPERSONAL : SCIENCES

humanistic --------------------------------------- mechanistic

SOCIOLOGY : POLITICAL

|

group

"The paradigms that guide our clinical thinking are necessary. They afford us, at a minimum, the comfort (and the benefits) of being in error, rather than thrashing about in confusion. And .... they provide us with the necessary consistency, coherence and vision. ...."  (Dumont, 1993, p. 203)	Dumont: "All that is visible must grow beyond itself, and extend into the realm of the invisible." TRON
Or: "All that is invisible must grow beyond itself, and extend into the realm of the visible."

Dumont, F. (1993). Inferential heuristics in clinical problem formulation: Selective review of their strengths and weaknesses. Professional Psychology: Research and Practice, 24, 196–205.

Dumont is cited in:

Vertue, F., & Haig, B. (2008). An abductive perspective on clinical reasoning and case formulation. Journal of Clinical Psychology, 64(9), 1046-68.

Hodges' model - draft paper on case formulation informed by Rainforth and Laurenson (2014)

The following is from a literature review by Rainforth, M., & Laurenson, M. (2014) for a draft paper on Hodges' model and case formulation [CF]. They do not refer to diagrams, but two models are included and the role of modelling. The paper is supportive for Hodges' model within mental health, forensic care and supervision more generally.

Crowe et al. (2008) suggest an advantage of CF is its ability to create understanding of service user needs regardless of their diagnostic classification. Thus an emphasis on the link between training provision, training outcomes and treatment plans is needed so practitioners understand the frameworks for conceptualizing mental distress whilst also being able to recognize the expertise of the service user in CF development.
...
A goal of the person-specific evaluation of CF is the development of an intra-individual statistical prediction model for actuarial prediction tailored to the specific issues and life circumstances. The essence of CF is its ability to provide shared understanding of a person’s presenting problems through theoretical explanation of assumed causes and maintaining factors, so appropriate interventions can be utilized (p.208).

Rainforth, M., & Laurenson, M. (2014). A literature review of Case Formulation to inform Mental Health practice: Case formulation in mental health practice. Journal of Psychiatric and Mental Health Nursing, 21(3), 206–213. http://doi.org/10.1111/jpm.12069

"Index Case": Do we need a new form..? ( cas index, Indexfall, caso índice, 指數情況, الحالة الدالة, सूचकांक के मामले ... )

index case

nounMEDICINE

noun: index case; plural noun: index cases

1. the first identified case in a group of related cases of a particular communicable or heritable disease.

Source: Google (and translations)

Hodges' model can map the first identified case of any disease, but just as medicine can turn a crisis around - we need a new form of 'index case'.

In healthcare we spend a lot of time managing 'caseness' and for a population casenesses. While triage is concerned quite rightly with prioritization, safety, efficiency, it also seeks to deny people caseness through gate-keeping. Alternately, for those diagnosed and meeting criteria, services then seek to assess when they are better - on the other side...

A new index case is required to respond to demographic, socioeconomic and environmental pressures. Talk, action and outcomes must be about well-being, sustainable health, strengths, health literacy self-care and recovery.

Hodges' model can facilitate this change in care philosophy, perspective and the concurrent focus of disease AND health.

Consider:

For how long how we espoused person-centered care?

Health is where the person resides*.

So often disease fragments identity, memory, the person, relationships, even the whole community...

Disease is a matter for our humanity.

Hodges' model can be the index case for a person's health and well-being and how they maintain, maximize this status. This might even help us define person-centeredness. A care indices.

Being person-centered should be a index-phenomena that takes cognizance of history where this is available.
This should - must be the index case?

*taken-4-grantedness

Pigeonholes and a Matrix 4 Care

The structure of Hodges' model is 

not an invitation to pigeonhole. 

It is an equation: a matrix for care. 

What is done in one quadrant, 

needs to be counter-balanced 

in the other care domains. 

The operations here are not mathematical,

 but reflective, reflexive and ideally communicative.

Pushing the envelope: Reflections in mind, health and social care ...

Hodges' model can do 'envelopes', but it's first form is as an aide-mémoire. In this way it helps facilitate reflection, reflective practice and more besides.	Envelopes are just a start, the germ of ideas. Hodges' model needs to be evidence based - can you assist?
If you need to share your reflections as case formulations, care plans, or evaluations; the model can help to engage with patients, clients, carers, staff and residents...	Amid healthcare's legacy issue which is achieving integrated, person-centred and holistic care, Hodges' model can help the practitioner assure integrity on several levels (6Cs).

Original image source:
http://www.strengthweekly.com/2014/10/02/new-blue-towel/envelope-back/

Papers in process, book reviews and volcanoes

There are three papers currently in process. There is some good and bad news; plus some similarity with volcanoes. This is in the sense of active, dormant and extinct.

The papers are - with no prizes for guessing the common feature:

1. The Scope of Nursing and Hodges' model
2. Case Formulation (Conceptualization), Diagrams and Hodges' model
3. Recovery and Hodges' model

Two papers are active, that's Case Formulation and Recovery. On the stove is Recovery and it's cookin. I've two co-authors providing invaluable input.

I've just read Terry Marks-Tarlow's Clinical Intuition in Psychotherapy The Neurobiology of Embodied Response and a review will follow my recommending this book right now.

There's a review copy of another book in the post that I believe can inform the recovery paper:

Values-Based Commissioning of Health and Social Care (thanks CUP)

I'm sure the concept of values-based commissioning is a gift to Hodges' model and the recovery paper. A theme to return to on W2tQ. The paper includes the Recovery STAR and relates this to Hodges' model.

The case formulation effort is with my co-author, and after a meeting in Manchester one early evening may incorporate risk formulation too.

The good news is none of these projects are extinct. The first nursing scope paper was rejected. The nursing scope paper is dormant, but is stirring following the symposium on person centredness in nursing early in May 2013.

There are two other books to get to grips with and a project that is in danger of extinction. The sight of Vesuvius next month may help: shift matters.

Papers, case formulation and hyperbole

I am enjoying a three night break in Keswick where it is dry, windy and chilly. Invigorating for all that.

In between taking in the hills and the atmospherics of the skies I am working on completing the revision to the - scope of nursing - paper. There is still a paragraph to lose to reduce the length for the target journal.

The case formulation and h2cm paper is taking shape too - 5,000 words. I am sure the ongoing advice and thoughts of my co-author on the scope effort is making a difference. As a result the case formulation paper will be in final draft form soon. Then I'll seek some feedback from a CBT therapist before trying to locate a journalistic home. Here's a snippet from the draft:

... If the talking therapies are specialised forms of conversation then we should also be able see case formulation as being on a continuum, derived from narratives that can include extreme case formulation, and hyperbole (Norrick, 2004). The specific therapies discussed here [cognitive behavioural therapy and cognitive analytical therapy] are concerned with overstatement and exaggeration in thought not just speech. Things may be said in everyday speech that are rhetorical and not necessarily indicative of deeply held core, dysfunctional beliefs. ...

Norrick, N.R. (2004). Hyperbole, extreme case formulation. Journal of Pragmatics 36. 1727–1739.

I receive regular reminders about a part time PhD application that remains incomplete. So I will address this too (and check other opportunities) over the next few days.

Post on a new laptop and a socio-technical-existential addiction to follow ....

Dialectics in therapy, case formulation, h2cm and a tree

Kuyken et al. (2009) propose three dialectics that are useful in an evaluation of their model for case conceptualization, these are:

Released today - 28th Jan 2013

nomothetic – idiopathic; 
simple – complex; 
and subjective – objective.

This act of identifying polarities can be described as a diagrammatic formulation in itself.

These dialectics and many others can be readily incorporated into h2cm: for example;

socio – technical,
macro – micro.
...

Kuyken, W., Padesky, C., Dudley, R. (2009). Collaborative case conceptualization. New York, The Guilford Press.

Update on new papers: 1. Case formulation & 2. Scope of Nursing

At present, with the support of a co-author, I am editing a paper on Hodges' model and the scope of nursing. The text some 6000 words was submitted to a journal last April and rejected, but as ever feedback is golden and the comments are being used to revise. The referees have set a challenge as amongst several points I tease out where the inherent theoretical perspectives lie in Hodges' model and how their identification within h2cm helps to define the scope of nursing.

Another paper in final draft - 4400 words - concerns the model and case formulation. At last I've arrived at this topic. Hodges' model is basically a simple drawing with care concepts superimposed. Cognitive behavioural therapy [CBT] and cognitive analytical therapy [CAT] make use of case formulation and CAT utilizes what are called sequential diagrammatic formulations.

The old website pages were written rather on the fly. They almost comprise a 'to-do-list' of thoughts and findings to revisit and check. Of two old pages one dealt with possible ideas and sources that might inform the structure of Hodges' model; the other page theory.

On the latter page I learned of SDRs - the sequential diagrammatic reformulations used in CAT and related this to the care domains of h2cm -

It feels good to be able to address this theme at long last.

In just over a week I'm looking f/w to a three day break in the Lakes. Weather permitting some  walking and a few runs, a bike ride, writing and Drupal - which I have put down of late...

Case formulation and Reflection in Hodges' model

Case formulation is a process in which I believe Hodges’ model can be used. Johnstone and Dallos (2006) help conjoin case formulation with an original purpose of Hodges’ model, that of supporting reflective practice, as follows:

Formulation and reflective practice. The notion of reflective practice is becoming increasingly important in all therapeutic traditions; that is, the necessity of being aware of one’s own feelings and reactions as a therapist as well as one’s own position in terms of professional status, gender, class, ethnicity and so on, and how these impact upon the therapeutic process. How might these ideas be taken on board in formation? What kind of biases is formulation open to, and how can we minimise them? p.2.

There are of course many concepts mentioned above that are key in staging a therapeutic interaction. As a series of conjoined conceptual spaces Hodges’ model provides a stage were reflections can be made personally, professionally and therapeutically moving to the development of formulations that are shared with clients.

Johnstone, Dallos and contributors also describe the issue of integrative formulation an aspect also of relevance to further study of Hodges' model.

Johnstone L., Dallos, R., (Eds.) (2006). Formulation in Psychology and Psychotherapy: Making Sense of People's Problems, Routledge, Oxford.

Journeys of work and socio-technical kinds

It has been a very busy and taxing week with preparation for a job interview on Thursday. On this occasion I did very well with the presentation, but I really need to get myself sorted when it comes to anticipating and answering the questions....

Note to self: How many times!!! Read the job & person spec Dopey! You don't have to empathise (even if it helps) you're not@work - you're seeking work - be ready to answer the questions.

Interview panels need more, much more - so next time... As it happens I understand that no appointment was made. Although very disappointed I learned an awful lot*. There may be news of another opportunity this week, which would actually be a preparatory step along where I believe I am heading....? Fingers x'd anyway. I'm really looking forward to next time: with both eyes wide open.

14 May I received feedback on the socio-technical chapter proposal, but until now I've not had time to take a peek (nerves too!). It seems the editors and publishers consider the draft 'definitely publishable' which is another great step forward. One negative comment highlighted the fact that the introduction to Hodges' model has been published previously. This introduction does work - it is history. I will acknowledge this in the text and the references. The need to produce new introductory material is (still) on my to-do-list. If you would like to add this to your td-list please let me know.

After the interview I visited Tate Modern (which closed at 6pm sadly) and the National Portrait Gallery - which reminded me of the draft scripts still awaiting mic's attention (apparently podcast 1 with notes, summary slides and questions has been downloaded 345 times).

I'm making the required changes to the chapter (deadline 6th June), then I can think about the next effort. Already raised on W2tQ case formulation is one possibility with some notes and references gathered. This week's experience made me wonder about the way terms like e-Health, telehealth and telecare are defined and the very fact of their being defined. ...

Just to note also - the BCS magazine 'ITNow' features ethics within ICT and includes a short but interesting item on caring systems.

This weekend I'll also try and post an update on my Drupal efforts.

Best wishes Discovery!

*Aim to prove that one of these days... ;-)