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Thursday 31 October 2013

Using Psychological Formulation in Teams by Lucy Johnstone Courtesy of the DxSummit.org Website - September 2013

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Using Psychological Formulation in Teams
Lucy Johnstone       September 19, 2013     

In my first post I outlined the principles and practice of psychological formulation, which is one possible alternative to psychiatric diagnosis. I suggested that any genuine alternative needs to be based on the principle of restoring rather than obscuring (as diagnosis does) the meaning in madness. Formulation will already be a familiar idea to many; it is a core feature of mainstream therapies like CBT and psychodynamic (Johnstone and Dallos 2013.) The topic of this post is a particular use of formulation which makes it applicable to every service user whether or not they are in a position to benefit from individual therapy, and however extreme or long-standing their difficulties. It is known as team formulation, or the process of facilitating a group or team of staff to develop a shared formulation about a service user, and it is rapidly gaining a hold in mental health services in the UK, as well as in other settings such as Learning Disability, Older Adult, Child and Adolescent, and Health (Johnstone, 2013; Cole, 2013).
The most ambitious project to date comes from an Older Adult service in the north of England, where, over a 5 year period, the entire staff group, including the cleaners, has been trained in a team formulation model which is integrated into every aspect of the service, both inpatient and community (Dexter-Smith 2010.) I have trained many mental health teams in this approach, as well as introducing it within my current clinical job. The second edition of ‘Formulation in psychology and psychotherapy: making sense of people’s problems’ (Johnstone and Dallos 2013) includes a chapter on ‘Using formulation in teams’ which summarises practice and development in this area.
UK clinical psychology guidelines recommend team formulation as ‘a powerful way of shifting cultures towards more psychosocial perspectives’ (Onyett, 2007.) The team formulation approach is ideally implemented through meetings that are a standard part of the weekly timetable, attended by all professionals. Essentially, the aim is to facilitate a process of developing a formulation with the whole team, resulting in a shared team understanding that can be used as the basis for intervention and collaborative work with the service user and, as appropriate, their carers. A typical format for the meeting is: summarise the background information; identify the main current concerns or ‘stuck points’; develop the formulation in discussion with the team; outline possible ways forward based on the formulation; write up and circulate the formulation and intervention plan to all staff; re-visit the formulation and the plan as necessary.
It should be noted that in this version of formulation practice the main client is, in effect, the team, whose counter-transference feelings of stuckness, hopelessness, anger or despair are likely to have prompted the request for a discussion. In effect, a team formulation meeting is a type of supervision or consultation, and in the same way as with those activities, it may not always be appropriate or helpful to share the aspects that deal with strong staff reactions directly with the service user. However, careful thought needs to be given as to how to involve the service user as closely as possible. Wherever possible (bearing in mind factors like severe learning disability, dementia etc) a parallel formulation is developed with and for the service user, and the two versions feed back into and inform each other. Sometimes this is most appropriately done via a conversation, or series of conversations, with the service user rather than a written document.
The team formulation meeting needs a facilitator, usually but not necessarily a psychologist, whose role is to reflect, summarise, clarify, encourage creativity and free-thinking and ask questions, not provide ‘solutions.’ This simple but novel approach can, in my experience, be a powerful and effective means of harnessing the team’s clinical experience and intuitions, promoting psychosocial understandings, moving away from narrow diagnostic-based plans and encouraging all staff to take an active and valued part in care planning. In fact, lower status staff (health care assistants, support workers) often have more to contribute than the psychiatrists whose views typically dominate ward rounds and treatment discussions because of the former’s more intimate knowledge of the service users’ lives and circumstances. It is remarkable how rapidly a reasonably well-functioning team can, with a little guidance, come up with the outline of a psychological formulation.
Initial audits and evaluations of team formulation suggests that it can have the following benefits (in addition to those claimed for individual formulation listed in my previous post):
  • achieving a consistent team approach to intervention
  • helping team, service user and carers to work together
  • gathering key information in one place
  • generating new ways of thinking
  • dealing with core issues (not just crisis management)
  • understanding attachment styles in relation to the service as a whole
  • supporting each other with service users who are perceived as complex and   challenging
  • drawing on and valuing the expertise of all team members
  • challenging unfounded ‘myths’ or beliefs about service users
  • reducing negative staff perceptions of service users
  • processing staff counter-transference reactions
  • helping staff to manage risk
  • minimising disagreement and blame within the team
  • increasing team understanding, empathy and reflectiveness
  • raising staff morale
  • conveying meta-messages to staff about hope for positive change
(Division of Clinical Psychology, 2011, p.9.)
The limited amount of existing research confirms my own experience that this approach is widely welcomed by staff, who make comments such as ‘One of the most productive things on the ward’;’ ‘Makes me more tolerant, more patient, increases empathy’; ‘Afterwards the problems seemed understandable, something we could start to address’ (Summers, 2006, p. 342). However, we don’t yet have the data to show whether a team formulation approach can reduce medication and admissions, promote recovery, lead to more effective risk management, and so on. Nor do we currently know much about service user views and experiences of this approach. These are gaps that need filling.
As with all uses of formulation, its effectiveness depends on how it is done. Everyone has their own personal style, and I have found it helpful to include the following core aspects in team formulation:
  • Formulating the ‘symptoms’ and psychiatric diagnoses in psychosocial terms
  • Transference and counter-transference between service user and team
  • Attachment-based perspective on the way the service user interacts with the psychiatric service as a whole
  • Psychological framing of the impact of medical interventions (eg medication, sectioning, admission)
  • Awareness of social causal factors (eg poverty, unemployment)
  • Awareness of how the ‘mental patient’ role interacts with the difficulties
  • Possible role of trauma/abuse
  • Possible re-traumatising role of services
Clearly, the last two aspects are particularly controversial. In training, I make a point of introducing staff to recent research demonstrating the horrifying facts about the causal role of all types of trauma (Read and Bentall, 2012), particularly in so-called ‘psychosis’, where it is vitally important that we don’t simply stop formulating and apply a label instead.
This is the ‘Free Gift’ which I offer to teams in a light-hearted form with a very serious message:
Lucy’s one-size-fits-all formulation for long-term service users 
Service user X has unmet attachment needs and unresolved trauma from their early life. X tries to meet these through the psychiatric services, but fails, since services are not set up to do this. Still needy, but unable to achieve enough emotional security to move on, X ends up trading ‘symptoms’ for whatever psychiatric care is on offer. Staff are initially sympathetic but become increasingly frustrated at X’s lack of progress. The resulting dynamic may end up repeating X’s early experiences of neglect, rejection or abuse. Both parties become stuck, frustrated and demoralised in this vicious circle.
Of course it is important to say to teams that this is a systemic process, not a matter of individual malign intent. Nevertheless, professionals need to accept the reality of the damage that services can inflict. Perhaps surprisingly, I have yet to meet any single staff member, from psychiatrists downward, who has disagreed with this summary. In fact, it is invariably met with rueful acknowledgement of its accuracy. Nearly every team formulation that I have facilitated turns out to be a variation on this template.
A team formulation of ‘Jane’, the hypothetical client described in my previous post, might be based on helping the staff to see her difficulties as a response to trauma, not a symptom of ‘schizophrenia’. With this understanding they might feel less frustrated at her apparent lack of progress and less inclined to insist on medication that may make her feel powerless and out of control. Instead, they might try to support her by education about the impact of abuse and strategies for managing voices.
We need to remember that psychiatric staff of all disciplines are struggling with a daily experience of frustration and failure. They may not have a detailed critique of the biomedical model, or the confidence to express it if they do, but they cannot fail to notice that the great majority of people are not getting ‘better.’ On the contrary, service users are often getting more deeply entangled in the ‘mental patient’ role which reinforces and compounds their original difficulties. These staff feelings emerged as a strong theme in a qualitative study of team formulation by Hood et al (2013) in which mental health professionals made a number of comments along the lines of:
I think services now are full of people who wouldn’t be here if people had taken a little bit longer to think about what brought them to the service and how we can help them and be more proactive and help them to recover. I think we’re just stuffed full of people who’ve been given various diagnoses and medication and that hasn’t actually achieved that much’.
Part of the appeal of team formulation to staff lies in this sense of being trapped, as service users are, in a dysfunctional system. From this perspective, formulation can seem to professionals like a longed-for escape: ‘It really should be a bit more about formulation, formulation, formulation’ (Hood et al 2013.)
Challenges to implementing team formulation
Team formulation isn’t always easy to implement. At one level formulation, in the sense of trying to make sense of people’s thoughts, feelings and behaviour, is something we all do as human beings, which makes it easy for staff of all grades to understand and contribute to the process. Formulations are perhaps most acceptable if explained to staff as a more explicit and structured version of what they are already doing. At another level, pulling together the complex mixture of information, feelings and intuitions into a coherent, integrated, theory-based narrative that is acceptable to staff and service users is a sophisticated and demanding task. Tact and persistence are necessary to get everyone on board; it is hard to preserve the time in busy teams where other crises take priority; and the facilitator will be required to do quite a bit of chasing up and generally ensuring that the formulation does not simply get lost in the day-to-day pressures and crises of mental health work.
The dynamics of the meeting can be tricky. It often feels a bit like group therapy, with powerful counter-transference feelings of anger, frustration, stuckness or sadness being expressed. These need careful handling, as do the splits and disagreements that sometimes arise within the team, reflecting the service user’s own conflicts and dilemmas. This is crucial information that can be used to enhance our understanding of the service user rather than, as so often happens, simply being acted out through unintegrated, contradictory and sometimes punitive interventions, based on primitive formulations such as ‘She’s just doing it for attention’ or ‘He doesn’t want to get better.’
The major challenge is to encourage the translation of medical language and solutions into psychosocial terms. Direct opposition to diagnostic terms is counter-productive, but encouragement to think about the psychological meanings of ‘symptoms’ (‘So in his case, schizophrenia means hearing critical voices? What do they say? How might we understand that?’) does, in time, pay off. (I have described other useful strategies in Johnstone 2013.) A pro-formulation stance can thus, without directly challenging the diagnostic model, lead to a gradual erosion of narrow medical thinking as trauma becomes a subject that can be discussed more openly, the psychological impact of medication and coercive interventions starts to be recognised, and the team becomes increasingly sophisticated at translating ‘symptoms’ and ‘illnesses’ into understandable responses to life circumstances.
In summary, team formulation is a way of creating space for two crucially important activities that are routinely squeezed out of day-to-day teamwork: thinking and processing feelings. We need to attend to both the information, theory, research and clinical experience that underpins our work, and the feelings that we and the service user are struggling with. These two aspects can be integrated through the team formulation process and framed in terms of personal meaning to the service user. In this way, staff are supported to fulfil the core purpose of all mental health professionals, which is, as I argued in my first post, creating meaning out of chaos and despair.
Team formulation is not just a framework for more effective work with a series of individual service users, but a way of challenging and changing the whole model on which services are based. It puts back what psychiatry takes out, and restores meaning, agency and hope, for staff and service users.
Cole, S (2013) In L. Johnstone and R.Dallos (eds) Formulation in psychology and psychotherapy: making sense of people’s problems. 2nd edn Hove, New York: Routledge.
Dexter-Smith, S. (2010) Integrating psychological formulation into older people’s services – three years on. PSIGE Newsletter, 112, 8-22.
Division of Clinical Psychology (2011) Good Practice Guidelines on the Use of Psychological Formulation.  Leicester: The British Psychological Society.
Johnstone, L (2013) Using formulation in teams. In L. Johnstone and R.Dallos (eds) Formulation in psychology and psychotherapy: making sense of people’s problems. 2nd edn Hove, New York: Routledge.
Johnstone, L and Dallos, R (2013) (eds) Formulation in psychology and psychotherapy: making sense of people’s problems. 2nd edn Hove, New York: Routledge.
Hood, N., Johnstone, L. and Musa, M. (2013) The hidden solution? Staff experiences, views and understanding of the role of psychological formulation in multi-disciplinary teams. Journal of Critical Psychology, Counselling and Psychotherapy, 13, 2, 107-116.
Onyett, S. (2007). Working psychologically in teams. Leicester: The British Psychological Society.
Read, J. and Bentall, R.B. (2012) Negative childhood experiences and mental health: theoretical, clinical and primary prevention implications. British Journal of Psychiatry, 200: 89-91.
Summers, A. (2006). Psychological formulations in psychiatric care: staff views on their impact. Psychiatric Bulletin, 30, 341-343.
Acknowledgment: Parts of this article originally appeared on www.madinamerica.com, and are reproduced here with thanks.

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