Rafael Rabenstein
rafael@rabenstein.net
The insights gained from the behavioral and problem analysis are the basis of the (Functional, Hypothetical) Condition Model (Kanfer et al., 1991). This is considered the basis for further therapy planning and serves as orientation for therapists and patients. From this, further therapy steps are planned. These are working hypotheses and are used to create a comprehensible “Plausible Model” of the current problem.
Preceding conditions:
Bio-psycho-social conditions (Fig. ) are taken into account and recorded. In the context of clarifying antecedent conditions, family diseases/biological vulnerabilities are considered as well as social factors. It is not about a monocausal explanatory model, but about capturing the different factors that contribute to the emergence of current problems and crises. This can only ever be an approximation of a multifactorial event. It is important to provide patients with an explanation of the history of their development, which allows for changes. In terms of the vulnerability-stress model, we also speak here of vulnerabilities / vulnerabilities.
However, these vulnerabilities do not necessarily lead to psychological problems or crises. It is assumed that only when a situation exceeds the coping capacity of the affected symptoms occur.
Aspects of antecedent conditions:
- Temperament factors[1]
- Genetic factors
- Familial diseases
Unstable | ↔ | non-reactive |
dysthym | ↔ | optimistic |
anxious | ↔ | quiet |
compulsive | ↔ | deflectable |
passive | ↔ | aggressive |
irritable | ↔ | serene |
shy | ↔ | sociable |
Fig.: Temperament factors according to Young et al., 2004
- (Pre-)diseases of the patient
- Physical factors
- Socioeconomic status
- Schemes, rules, goals, plans
- Validating/invalidating environment
- Life Events
- Traumatization
Triggering conditions:
Capturing the triggers for the current crisis is particularly important for episodic conditions. It can be triggered by biological, social or psychological factors. Especially developmental tasks, i.e. so-called “life stage crises” offer a high potential to trigger crises. If individual skills and coping abilities are exceeded, symptoms can be signs of this “overload”. Often change and crises in social relationships are decisive for the beginning of a crisis. But also other factors that threaten the patient’s “self-concept” such as job loss/change, physical changes, etc.
Examples of triggering conditions:
- Separation or loss of attachment figures
- Developmental tasks such as adolescence, retirement, parenthood
- Physical changes such as menopause, accidents, etc.
- Change of life circumstances: flight, war, relocation, job change
- Social conditions: Debt, unemployment
- Social conflicts
- Amplifier loss
Sustaining Conditions:
In framing behavioral therapy, maintaining conditions play a crucial role. These conditions often have essential functionality for patients, although the concept of “disease as gain” should not be invoked here. Often functional aspects are the worse of 2 bad alternatives.
Here, reinforcers and operant conditions play a major role, especially short-term negative reinforcement. As an example, in addiction, consumption is a short-term improvement of the current state of mind, so it is negatively reinforced. In the long run, however, there are more disadvantages. However, if one wants to work therapeutically on substance use, one must teach the patient to use other strategies of emotion regulation instead of substance use.
Examples of functionalities/maintaining conditions:
- Interpersonal functionalities: regulation of relationships, avoidance of conflicts
- Avoidance of development tasks
- Emotion regulation
- Maladaptive coping: brooding, safety behavior
- Avoidance of negative emotions
- Safety behavior
- Plans/rules, schemes, modes
Models:
It different forms of representation of the conditional model and its factors. In more detail, some models are presented. Not every model is suitable for providing patients with a better understanding of their disease. But they serve as a guide for therapists
Bio-Psycho-Social Condition Model
Fig.: Bio-Psycho-Social Condition Model
Preceding Conditions-Predisposition:
Bio:
- Temperament
- Genetic factors
- Family history (diseases)
Psycho:
- Family rules
- Socialization: Life Chart, Life Events
- Binding style
- Plan analysis, schema analysis à macron analysis
Social:
- Socioeconomic status
Triggering conditions:
Bio:
- Diseases
- Accidents
Social:
- Changes in the way of life
- Relationship problems
- Job change/loss
Psycho:
- Overload and excessive demand
- Development tasks
Sustaining Conditions:
Bio:
- Self-care deficit
- comorbid physical diseases
Social:
- Social withdrawal
- Sick leave
Psycho:
- Safety and avoidance behavior
- Rumination, Ruminations
- Interpersonal functionality
- Proximity/distance regulation
- Failure to resolve competing approach and avoidance goals.
“SORC(K)” model:
Fig.: Condition model – SORC(K)
In addition to the simple condition model, a functional condition model can also take the form of a SORC model (Fig. ). Where here the “Situation – S” or Trigger can be seen as the Triggering Condition.
The O variable/organism variable establishes the preceding conditions here. The findings Vertical Behavioral Analysis and other predisposing factors are cited.
Under “Response” or “reaction”, i.e. “R-Variable”, the current problem situation, symptoms or mental illness is summed up.
The consequences, “C variable” are all maintaining factors. Both short and long term.
See example “Integrative model of depression development”:
S Triggering situation and life situation – Triggering conditions
- Life design:
- Relying on few sources for self-worth
- Environment is evaluated and used according to degree of usefulness for self-worth
- Relationships:
- Suppression of behaviors that lead to loss of key attachment figures.
Lead
- Manipulative shaping of social relationships (idealistic self-esteem dispenser).
- Avoiding distance and seeking closeness in existing relationships (showing too little aggression outwardly, is directed against own person)
- Trigger:
- Loss or absence of central reference persons
- No longer sufficient attention from caregivers
- Role Change
O Organism variable – antecedent conditions/predisposition.
- Confirmation from outside, too little self-efficiency, not being able to praise oneself
- Learning history: parents focus attention only on mistakes, positive is a predisposition self-evidence
- Restrictive rules of life: high performance standard, high moral standards
- Biological variables: genetic factors (e.g. from twin studies)
R Reaction – problem behavior
- Depression
K Consequences – Sustaining conditions
- Negative self-worth
- Social withdrawal/passivity
- Traumatic experiences of helplessness – fear of autonomy
- Dependence on others: feeling incapable alone, lack of self-efficiency,
Symbiotic relationships, no autonomy – dependence
Vulnerability-stress model (Falloon et al., 19984).
A cross-diagnosis and simple condition model for a wide range of disorders. It can be easily communicated and adapted to individual problem situations, and it is also well suited to pointing out starting points for change. Sustaining conditions can also be well explained.
Fig.: Vulnerability stress model
Fig.: shows the most common model for anxiety disorders. It also deals with the basic tension, i.e. the general stress level. Starting points here would be relaxation techniques and mindfulness exercises. Stressors only raise the stress level above the perception threshold when the general stress is high. The threshold of 70-75% is called panic threshold, subjective perception threshold or in DBT “point of no return” depending on the underlying problem. This threshold marks the takeover of the “alarm system”, i.e. the emotional reaction leads to an extreme stress, a panic attack, a, dissociative state or similar. Cognitive control is hardly possible in this state.
Fig.: Vulnerability-stress model incl. problem behavior
Fig.: shows the coping and problem-solving attempts. Since these are mostly maldadaptive strategies, the “problem behavior” is mostly shown here. Depending on the problem behavior, almost all disturbance models can be represented here with “negative” reinforcement in order to convey the understanding of one’s own maladaptive problem-solving attempts. This form of presentation is well applicable for a variety of disorders, but also across disorders.
Fig.: Simplified vulnerability-stress model
A simplified condition model can be seen in Fig. It is particularly suitable for disorders in which emotional vulnerability is part of the disorder genesis in the context of psychoses, bipolar disorders or borderline disorder.
Literature:
Caspar F (2007). Understanding relationships and problems – An introduction to psychotherapeutic plan analysis. Bern: Huber.
Bartling, G., Echelmeyer, L., Engberding, M. & Krause, R (2004). Problem Analysis in the Therapeutic Process, 5th ed. Stuttgart: Kohlhammer.
Falloon, IH, Boyd, JL, McGill, CW (1984). Family care of schizophrenia: A problem solving approach to the treatment of mental illness. New York: Guildford
Hautzinger M (2003). Cognitive behavioral therapy for depression. Weinheim: Beltz.
Kanfer FH, Reinecker H, Schmelzer D (1996). Self-management therapy. Berlin: Springer.
Margraf J, Schneider S (eds) (2000). Textbook of behavior therapy. Volume 1. Second completely revised and expanded edition. Berlin: Springer.
Parfy E, Schuch B, Lenz G (2016). Behavior therapy: Modern approaches to theory and practice, 2nd edition. Vienna: Facultas/UTB.
Wittchen, HU. (2011). Clinical Psychology & Psychotherapy. Berlin: Springer