Team formulation Developments in Cwm Taf Julian Pitt/Lucy Johnstone Consultant clinical psychologists

What is a formulation? A formulation is the essential link between theory/evidence on the one hand, and intervention on the other ‘ Formulations can best be understood as hypotheses to be tested’ (Butler, 1998) It is a core skill in the training of both psychologists and psychiatrists. ‘…….at some level it all makes sense’ (Butler, 1998)

DCP Good practice guidelines on psychological formulation 2011

All formulations: Summarise the client’s core problems Are constructed jointly with the client, who describes their life experience and the sense they have made of it Suggest, on the basis of psychological theory, research and evidence, why the client has developed these difficulties, at this time and in these situations Are used to inform an individual intervention plan Are open to revision and re-formulation.

‘Jane’ Her parents had substance abuse problems She performed poorly at school She could not cope with her children There is marital conflict She was diagnosed with depression

Formulation drawn up with Jane “Your parents had significant problems with drink and drugs, and as a result you grew up feeling unloved and worthless. You were not encouraged to fulfil your potential at school, and took the only option that seemed to be available to you – marriage to the first person who seemed to show an interest in you. Although you love your children very much, your background means that you find it hard to cope with the emotional demands of parenting. Your husband offers little support, and you once again feel unloved and unwanted in your close relationships. It is hard for you to assert yourself or get what you need. With so many past feelings still unresolved, you feel overwhelmed and despairing and full of self-blame. Sometimes you feel as if there is no way out. At the same time, you have considerable strengths and determination, and want to make a better life for yourself and your children. “

Team formulation – a recent development Adopted in a couple of Trusts in England (Tees, Esk and Wear OA, Sussex AMH/OA) and attracting an increasing amount of attention as an innovative practice Regular weekly meetings facilitated by a psychologist, attended by as many team members as possible Clients can be ‘booked in’ for discussion and staff from other teams/agencies invited as appropriate Key worker prepares brief summary of personal and psychiatric history in advance

Simple format:  What is the current question or ‘stuck point’?  Team members develop a shared formulation, guided by the facilitator  The formulation is used as a basis for an intervention Facilitator writes it up and circulates for agreement  Added to the records  Review as necessary in future meetings Inform and include service user as much as possible (meet them beforehand, feed back afterwards, develop parallel formulation to feed into staff version)

Benefits of team formulation (Guidelines 2011) Consistency of 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) Supporting each other with complex clients Drawing on and valuing the expertise of all team members Reducing negative perceptions about service users Helping staff to manage risk Minimising disagreement and blame within teams Increasing team understanding, empathy and reflectiveness Raising staff morale Conveying messages to staff about hope for change

Training in team formulation Lucy Johnstone’s half day training package has been delivered to all CMHT staff (Taf Ely, Rhondda, Cynon and Merthyr); both AO teams: the Pinewood and rehab service Lucy has also done 3 training sessions to social care teams Lucy Johnstone has delivered a day’s training on facilitating team formulation meetings to local psychologists

Feedback from before and after training

Regular team formulation meetings now running in: All 4 CMHTS Both Assertive Outreach teams 2 locked rehabilitation units RGH inpatient wards There has been support and good participation from all disciplines.

Evaluation of staff views 100% of the participants felt that the meetings had helped to develop a shared team understanding of a client’s problems, strengths and difficulties; draw on the knowledge and skills from different professional backgrounds; generate new ideas about working with the client; develop an intervention plan; and improve risk management. Hollingworth and Johnstone 2014

‘ The meetings give me a sense of not being on my own… they have increased my confidence in working with other professions involved’ ‘Useful in planning a way forward which has given the client and professionals a sense of hope for future recovery’ ‘It felt as if the formulation helped to focus and make more rigorous many of the ideas that were already there amongst the care team’ ‘..enabling team members to deal with emotional difficulties entailed in dealing with challenging patients’ ‘Although I was not in complete agreement…. I was able to express my view and an agreement was reached by the team’

Taking the model further? Develop a fully validated staff questionnaire based on the initial evaluation Measure of changes in team climate Look at other outcome measures (admissions, use of medication, recovery indicators etc) Look at service user involvement in/experience of the process

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