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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.

Wednesday 30 October 2013

What Adults Need to Know about Pediatric Depression - Courtesy of Scientific American MIND

By Deborah Serani | October 9, 2013 |  

Research shows that children, even babies, experience depression1. The clinical term is called Pediatric Depression, and rates are higher now than ever before2. In the United States alone, evidence suggests that up to 1% of babies, 4 percent of preschool-aged children, 5 percent of school-aged children, and 11 percent of adolescents meet the criteria for major depression3.
According to American Association of Suicidology, Suicide is the 3rd leading cause of death in adolescents ages 15 to 24, and is the 6th leading cause of death in children ages 5 to144. Suicide is significantly linked to depression, so early diagnosis and treatment of Pediatric Depression is not just extremely important – it is life-saving.
History of Pediatric Depression
Pediatric Depression, has weathered a long journey for recognition. Only in the last twenty years has it been accepted by science as a real disorder. Prior to that, only a small group of individuals believed depression existed in children. The majority of others believed children were too cognitively and physically immature to experience depression.
Depression was first noted as an illness by ancient Greeks in 450 BC. Called melancholia, it was seen only seen in adults who displayed a cold and dry disposition – a diagnosis reflected from the theory of an imbalance of black bile in the body. The Father of Western Medicine, Hippocrates, wrote that melancholia involved an “aversion to food, despondency, sleeplessness, irritability, restlessness and fear5.” Though later in the 1st century Greek physician, Aretaeus of Cappadocia, described melancholy as having a relationship between mind and body, little changed in the view of melancholia for thousands of years6.
Things started changing in the 19th and 20th centuries when science began branching off from early Greek theories. Studies took a more serious look at how life experiences affected the symptom of melancholy in adults. Epic research by Robert Burton’s “Anatomy of Melancholy,” Henry Maudsley’s Physiology and Pathology of Mind and Sigmund Freud’s essay “On Mourning and Melancholia furthered the understanding of sadness and melancholy in adults, but also laid the groundwork for considering depression in children7.
The fields of neurology, psychology, psychiatry and pediatrics started tracking symptoms of longing, sadness and anxiety in children, which helped launch the official discipline of child psychiatry in 1920. Many pioneers like Melanie Klein, John Bowlby, Anna Freud, D.W. Winnicott, Rene Spitz, and Erick Erickson broadened the field of child depression, detailing theories on trauma, despair and melancholic reactions in children. But it would take almost a century more for science to truly root itself in the belief that children could, without a doubt, have depression.
The 21st century showed a rapid growth of clinical interest in mood disorders in children, influenced by advances in medical technology and the field of neurobiology joining forces with psychology and psychiatry. Evidenced based research studies started streaming in, each one validating aspects of pediatric depression, its symptoms, etiology and methods of treatment. Scientists agreed that though children had immature and underdeveloped affective (emotional) and cognitive (thinking) skills, depression was something they can experience. Children have mood changes, are capable of having negative thoughts, and tend to show depressive symptoms more behavioral ways. Examples like joyless facial responses, listless body posture, unresponsive eye gaze, slowed physical reactions and irritable or fussy mannerisms, just to name a few. Not only did studies confirm the existence of Pediatric Depression, but distinctive symptoms were seen in differing stages of childhood. These results widened the scope of understanding depression in children, and helped highlight that patterns of depression vary with a child’s age8.
So, the history of Pediatric Depression began with a steadfast “No way it could ever be” to a more thoughtful “Oh yes it can,” to a postmodern “and it’s intricately unique.” 9
Facts Every Adult Should Know
Depression in children is not a passing phase. It is a real illness that is clinically recognized and widely treated. Here are 10 myths every adult should know how to debunk.
1. Myth: Depression looks the same in children as it does in adults.
False. Children don’t have the verbal language or cognitive savvy to express the textures of depression. Instead, body symptoms like aches and pains, fatigue, and slowness present as can tearfulness, unrealistic feelings of guilt, isolation and irritability.
2. Myth: Good parents can always detect if their child is depressed.
False. Most children who suffer with depression keep their thoughts and feelings masked. The only way for parents to understand depression is to be aware of the age specific behaviors and symptoms. More importantly, depression is not a result of bad parenting.
3. Myth: Pediatric Depression will go away on its own.
False: A serious mental illness cannot be willed away or brushed aside with a change in attitude. Ignoring the problem doesn’t give it the slip either. Depression is serious, but treatable illness, with a success rates of upwards of 80% for children who receive intervention.
4. Myth: Talking about depression gives kids ideas and makes things worse.
False. Talking about depression with your child actually helps to reduce symptoms. Support and encouragement through open communication are significantly meaningful. This lets your child know he’s not alone, is loved and cared for.
5. Myth: The risk of suicide for children is greatly exaggerated.
False. Suicide is the 3rd leading cause of death in adolescents ages 15 to 24, and is the 6th leading cause of death in children ages 5 to14. Suicide is significantly linked to depression, so early diagnosis and treatment of Pediatric Depression is extremely important.
6. Myth: There are no proven treatments to treat Pediatric Depression.
False. Volumes of studies show that talk therapy treatments like play therapy, family therapy, and individual therapy offer significant improvements for children who experience depression. Upwards of 80% of children who receive treatment move into remission. The other 20% may require medication to help with their illness – and, though this is often a hot topic for controversy, there are evidenced based studies that support this as a treatment option.
7. Myth: Antidepressants will change a child’s personality.
False. Antidepressants normalize the ranges of moods in children who have a mood disorder – and will not change your child’s personality what-so-ever.
8. Myth: Once a child starts taking antidepressants, he is on it for the rest of his life.
False. The majority of children who take antidepressant medication will stop their prescription in a careful and modified manner when recovery from depression occurs. This clinical state of recovery takes about a year or so to achieve.
9. Myth: When a depressed child refuses help, there’s nothing parents can do.
False. If your child refuses to go to talk therapy or take medication, there are things you can do. You can seek therapy with a trained mental health specialist to learn how to help your child in spite of the fact that he won’t attend sessions. In a crisis situation, you can drive your child to the nearest hospital emergency room, or contact family, friends or the local police for assistance in getting him there.
10. Seriously depressed children CANNOT lead productive lives.
False: Many children with depression can grow up to live full, productive lives. In fact, many high profile people, including President Abraham Lincoln, Writer J.K. Rowlings, Artist Michelangelo, Actor Harrison Ford, Choreographer Alvin Ailey, Actress Courteney Cox, Entrepreneur Richard Branson, Prime Minister Winston Churchill, Rocker Bruce Springsteen and Baseballer Ken Griffey, Jr. have been very successful in their chosen professions – despite struggling with depression in their young lives.
What to Do Next
If you suspect that a child is struggling with depression, immediately contact a physician. Share your concerns and plan for a full medical evaluation to begin this diagnostic process. Once medical tests show no other reason for the fatigue, sadness, aches and pains that often come with depression, a mental health professional will evaluate further for this pediatric mood disorder.
Pediatric Depression is a serious, but treatable disorder. And there is great hope for healing when detected early.
1 abcNews, “One in Forty Babies Has Depression.” abcNews, accessed, January 25, 2013, http://abcnews.go.com/Health/OnCall/story?id=2640591&page=1
2 American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders: 5th Edition. Washington, D.C.: American Psychiatric Association, 2013.
3 Joan Luby et. al. “The Clinical Significant of Preschool Depression: Impairment in Functioning and Clinical Markers of the Disorder. Journal of Affective Disorders 112(2009):111–19.
4 Target News Service . “Depression Rates Triple Between the Ages of 12 and 15 Among Adolescent Girls.” Health Reference Center Academic, July 25, 2012.
5 Stanley Jackson. Melancholia and Depression: From Hippocratic to Modern Times. New Haven: Yale University Press, 1990.
6 Andreas Marnerous & Frederick Goodwin. Bipolar Disorders: Mixed States, Rapid Cycling and Atypical Forms. New York: Cambridge University Press, 2005.
7 Jennifer Radden. The Nature of Melancholy: From Aristotle to Kristeva. New York: Oxford University Press, 2002.
8 Ian Gotlib & Constance Hammen. Handbook of Depression. New York: Guilford Press, 2009.
9 Joan Luby et. al. “Preschool Major Depressive Disorder: Preliminary Validation for Developmentally Modified DSM-IV Criteria.” Journal of the American Academy of Child and Adolescent Psychiatry 41 (2002):928–37.
Deborah SeraniAbout the Author: Dr. Deborah Serani is a go-to media psychologist and an award-winning author. She is also an associate professor at Adelphi University where her research interests are in depression and trauma. Her new book Depression and Your Child: A Guide for Parents and Caregivers" is available online and in book stores. Follow on Twitter @DeborahSerani.

OVER ZEALOUS PSYCHIATRISTS - are diagnosing quirks as mental illnesses - Courtesy of the South China Times - 28th October 2013



Today it seems that almost everyone is certifiably mad. According to critics, amateur and professional psychiatrists are routinely guilty of "diagnostic inflation": turning normal people into mental patients with alphabet soup diagnoses. In a new book, America's Obsessives, author Joshua Kendall argues that many great people have been shaped by obsessive compulsive personality disorder.
Other widely applied questionable labels include disruptive mood disregulation disorder, which may mean nothing more than children's temper tantrums, and social anxiety disorder, which may be shyness. Thanks to psychiatric overreach, every quirk is judged a mental disease, especially if the US$300-billion-a-year pharmaceutical sector has a pill for it, the theory goes.
Meet florist Caren Ragan, who says she has taken every psychiatric test under the sun. Much mental health diagnosis is subjective, Ragan says.
Her mental health ordeal stemmed from declaring her intention to divorce her ex-husband who, at the start of a 10-year court battle, branded her "paranoid-delusional", she says. Six times during her ordeal, Ragan took one of the most commonly used personality tests in mental health: the Minnesota Multiphasic Personality Inventory.
Her answers were consistent, she says, but the diagnosis depended on the examiner. The verdict varied from "normal" to severe psychosis with paranoid delusions. "Which was pretty strange considering I worked, raised a family and volunteered at school and not one single person ever noticed this severe mental disorder," she says.
Ragan adds that she was prescribed several kinds of anti-depressants for real, related depression; all worked briefly before she decided she had no time to indulge in emotional problems, which are a luxury of rich countries, she says.
In the developed world, the mental health industry is booming. According to psychologist Carole Stovall, an expert in anxiety complaints such as post-traumatic stress disorder, mental health prescription rates have "skyrocketed".
Stovall is appalled that doctors prescribe psychotropic drugs to children as young as six months. "This is shameful. Clearly, society is over-prescribing," she says. True, she adds, careful medication can help a patient. But medication is often used "off-label", which can be detrimental. All medication has side effects, she says.
In fact, medication can make you crazy. According to the mental health watchdog the Citizens Commission on Human Rights, common and well-documented side effects of psychiatric drugs include mania, hallucinations, depersonalisation, suicidal ideation, psychosis, heart attack, stroke and sudden death.
The view that psychiatrists recklessly medicate first and ask questions later, pathologising normality, is fuelled by an oft-cited Canadian study. Children born in December, close to the cut-off date for entry into British Columbian schools, were 39 per cent more likely to be diagnosed with attention deficit hyperactivity disorder (ADHD) than children born 11 months earlier, the study found.
The University of British Columbia researchers deduced that younger students were diagnosed with ADHD because of their youth. The finding suggested that the education system is medicalising immaturity.
According to the leading critic of diagnostic inflation, Allen Frances, we can cope with plenty of pain because the brain is naturally resilient and self-healing - given time, people get through rough patches.
Newly invented conditions such as "major depressive disorder", which is grief in Frances' view, worsen a cruel mental health industry paradox: people desperately needing help wilt unaided while the "worried well" win the bulk of the treatment, often to their detriment, says the blurb for Frances' book, Saving Normal.
Defenders of labelling, including the influential clinical psychiatry professor Ronald Pies, contest that it draws flak for a suspect reason: society fears, misjudges and reviles mental illness, he claims.
According to City University of Hong Kong social scientist Daniel Wong, speaking in a 2011 BBC interview, mention of mental illness makes people think of danger and murderous violence. So, some of the doubt about diagnosis may stem from prejudice.
Therapist Peggy Tileston reckons that the psychiatric profession merits some credit.