Individualising treatment

Heterogeneous conditions call for multifaceted treatments that can be delivered flexibly, depending on the individual. In a climate of evidence-based, often manualised treatments, this represents a challenge. Davison (1998) points out that empirically supported manualised treatments do not take account of patient variability. Can an evidence base be reconciled with individualised treatment? Over 20 years ago, Liberman (1981) outlined a framework for doing just that. Liberman described a modular approach to the treatment of depression where, because of the complexity of the condition, a broad spectrum, multicomponent approach to treatment is needed. Crucially, although many factors are involved in causing and maintaining depression, not all factors contribute equally to all patients. As not everyone has all factors equally, a broad-spectrum approach is "intrusive and encumbers the patient with many interventions, some of which may not be necessary or applicable" (Liberman, 1981, p. 241). A modular approach consists of an array of treatment strategies that are selected after a careful assessment of the individual patient's needs. The modules for each condition would be specified and determined in advance on the basis of empirical evidence. Some modules may be more primary. For example, Liberman suggests that all depressed patients start with a problem-solving module and move beyond that to modules that match their particular problems if needed. Interestingly, the same idea of starting with problem solving has recently been advocated for suicidal behaviour (Hawton & van Heeringen, 2000). Treatment for suicidal behaviour would have modules for tackling poor problemsolving skills, hopelessness or lack of future positivity, and so on. A similar approach has been described by Evans et al. (1999), but without the explicit feature of selective targeting of different modules for different individuals. The modular approach provides a framework for containing the diversity of interventions needed to approach a heterogeneous population such as suicide attempters.

In fact, although not fully specified by Liberman (1981), a modular approach provides a framework for a full scientist-practitioner programme. The initial, research-based steps would consist of establishing the characteristics of those with the particular condition. In the case of suicidal behaviour, much progress has been made in respect to this. Therapeutic strategies to target those particular deficits would then be developed and evaluated for effectiveness. At the level of clinical application, each patient would be assessed on each characteristic, and the module would be selected according to assessment outcome. Evaluation would include the target behaviour (suicidal behaviour) but also the specific focus of the treatment module that is delivered (such as hopelessness or lack of positive future thinking). In the case of suicidal behaviour, some of this work has already been done (e.g., Linehan, 1993), but there is a need to develop intervention strategies that specifically target hopelessness or lack of positive future thinking. This may focus on formulating positive goals but is particularly likely to need strategies to help individuals to form plans to achieve positive goals. Vincent et al. (in press) found that parasuicide patients had less difficulty in thinking of goals than they had in thinking of plans to achieve those goals.

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