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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.
Summary
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.
References
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.
