Using Formulation to

Change Team Cultures

I am returning to the subject of psychological formulation after rather a lengthy gap, during which controversy about the forthcoming 5^th edition of DSM has continued to grow – sign the petition ‘Stop the Insanity’ at  www.dsm5response.com if you share others’ concerns about the creeping medicalisation of everyday life and the risks that it poses.

The problem, of course, is wider than DSM of any edition: as discussed in previous posts, it applies to any classification system that attempts the futile and ridiculous task of dividing human despair and emotional suffering into neat parcels and then labelling them as though they were a form of biological dysfunction. I have suggested that any real alternative needs to be based on the opposite principle  – that is, restoring meaning to madness – and that one vehicle for doing this is psychological formulation. In this post I will describe a particular use of formulation in more detail: team formulation, or the process of facilitating a group or team of staff to develop a shared formulation about a service user (Johnstone, 2013). I have trained teams across the UK in this approach, as well as implementing it within my current clinical job.

Combating and providing viable alternatives to the unevidenced and appallingly damaging biomedical model of mental distress requires a sophisticated strategy at all levels from individual work with service users to international campaigns. In my experience, team formulation works particularly well at the level of the multi-disciplinary team. UK clinical psychology guidelines also recommend it as ‘a powerful way of shifting cultures towards more psychosocial perspectives’ (Onyett 2007) My clinical work is within Adult Mental Health community and inpatient settings, and colleagues in the UK are also developing this approach in Learning Disability, Older Adult, Child and Adolescent, and Health specialities (Johnstone 2013)

Team formulation meetings can be conducted as a series of one-off discussions about particular service users, or preferably as a regular part of the weekly timetable, attended by all professionals. The 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.’ A typical format for a 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; re-visit the formulation and the plan as necessary. Wherever possible (bearing in mind factors like severe learning disability, dementia etc) a parallel version is developed with the service user and their key worker. (It should be noted that in the team version of the formulation 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. While these staff reactions urgently need formulating, for obvious reasons it may not be appropriate or helpful to share them directly with the service user.)

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 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.

A summary of the literature on team formulation suggests that it can have the following benefits (in addition to those claimed for individual formulation):

• 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 research confirms my own experience that this approach makes intuitive sense to and is widely welcomed by staff, who make comments in audits 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).

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 which has 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 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. It has been my consistent impression 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, they are getting more deeply entangled in the ‘mental patient’ role which invariably reinforces and compounds their original difficulties.

These staff feelings emerged as a strong theme in a qualitative study of team formulation by Hood (2009) 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’ (p.7.)

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 2009, pp 9-10.)

Team formulation isn’t always easy to implement. Tact and persistence are necessary to get everyone on board; the dynamics of the meetings can be tricky; it is hard to preserve the time on busy wards where other crises take priority; 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. We don’t yet have the data to show that a team formulation approach can reduce medication and admissions, promote recovery and so on. Nor do we currently know much about service user views and experiences of this approach. However, I have found that a pro-formulation stance can, 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 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 my next post I will discuss the necessary principles of an alternative to psychiatric diagnosis – an issue which is highly topical as we approach the publication date of DSM 5. In the meantime I welcome feedback and debate: @clinpsychLucy

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. 2^nd edn Hove, New York: Routledge.

Hood, N. (2009) The hidden solution? Staff experiences, views and understanding of the role of psychological formulation in multi-disciplinary teams. Unpublished doctoral thesis, Bristol Clinical Psychology Doctorate.

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.