Experiencing psychological formulation: a qualitative study of service user perspectives

Context: Formulation is considered a core skill for clinical psychologists (Division of Clinical Psychology, 2011) and is a central component in most therapeutic approaches. There is no universally agreed definition of formulation, and the purpose and use varies depending on the theoretical perspective taken. The definition used in the Division of Clinical Psychology Good Practice Guidelines (2011) is ‘formulation summarises and integrates a broad range of biopsychosocial causal factors. It is based on personal meaning and constructed collaboratively with service users and teams’. There is debate around the validity and reliability of formulation as an intervention; however, an alternative recommended way to explore formulation is to understand its usefulness, particularly whether it is felt to be useful to the service user. To date, research into service user experience of formulation is lacking. Aim: This thesis portfolio aimed to understand the service user perspective on, and experience of, psychological formulation and operationalise the factors that impact on this, with the hope that this knowledge will help to improve the overall experience of formulation. Design: The project is presented in a thesis portfolio format combining two main research papers; the systematic review explored service user experience of formulation developed with a psychologist as part of the therapy process. The qualitative empirical paper used Thematic Analysis to explore formulation developed with member of the Multi-disciplinary Team (MDT), who has not been psychologically trained, as part of the care co-ordination role, within a community mental health service. Results: The systematic review developed an initial four-phased process of formulation that service users progress through iteratively and in a non-linear fashion. The experience of each phase and overall formulation process were impacted by specific factors. The empirical paper identified six themes describing the service user experience of formulation with a non-psychologically trained member of the MDT and factors that impacted upon it. Conclusion: Findings are provided tentatively, and further research is required to develop findings from both papers. However, the findings from this thesis portfolio add to the literature base around service user experience of formulation and identifies potential factors that may inform clinical practice and service delivery

‘Momma bear wants to protect’: Vicarious parenting in practitioners working with disturbed and traumatised children

Practitioners working with disturbed and neglected children and young people face many practical and personal challenges, including countertransference and secondary trauma reactions. One under-explored area is the practitioner requirement to negotiate with children’s parents and to process feelings towards both parents and children. We explore the experiences of female counsellors and psychologists working with children and young adults in the UK mental health care sector, using an inductive thematic analysis. While participants spoke positively about their vocation and satisfaction gained from acting as an agent of change in young peoples’ lives, they also related highly intense emotional work and traumatic accounts, using powerful metaphors to convey the impact of hearing and processing stories, indicating vicarious trauma effects and a strong parental invocation in therapists, including maternal feelings toward some children (“vicarious parenting.”). Some parents were cast as potentially harming a child and obstructing the professional’s work. Our paper fleshes out vicarious parenting as a particular form of countertransference

Perceptual decisions regarding object manipulation are selectively impaired in apraxia or when tDCS is applied over the left IPL

This study evaluated whether apraxia can be understood as due to impaired motor representations or motor imagery necessary for appropriate object-use, imitation, and pantomime. The causal role of the left inferior parietal lobe (IPL), which is heavily implicated in apraxia, is also evaluated. These processes are appraised in light of the proposed ventro-dorsal sub-stream of the classic two visual pathway model, where perceptual information from the ventral stream and the dorsal action stream are integrated and essential for object manipulation. Using a task assessing object-use perception, stroke patients with apraxia demonstrated a selective deficit during perceptual decisions reliant on the integration of visible and known object properties to select the appropriate grasp for object-use. This deficit increased with apraxia severity. A dissociation was evident in these patients showing intact non-motoric perceptual decisions regarding the functional semantic relationship between two objects in the absence of the actor (e.g. how a hammer hits a nail). Converging evidence was found using a modified version of the same task in a neuromodulation study that directly targeted the left IPL in healthy participants using transcranial direct current stimulation (tDCS). Application of inhibitory stimulation over the left IPL reduced performance during perceptual decisions regarding object manipulation whilst performance was unaffected during functional semantic decisions. Excitatory stimulation of the left IPL did not affect performance in either task. Combined, these results suggest that the left inferior parietal lobe is critical for motor imagery, and that apraxia may be caused by an inability to use internal motor representations of object manipulation. These results are discussed in terms of motoric and non-motoric perceptual processes and the proposal of an additional ventro-dorsal sub-stream within the dorsal and ventral visual pathways model

Inter-individual variability in current direction for common tDCS montages

The direction of applied electric current relative to the cortical surface is a key determinant of transcranial direct current stimulation (tDCS) effects. Inter-individual differences in anatomy affect the consistency of current direction at a cortical target, likely leading to inter-individual variability in current direction. However, the degree of this variability remains undetermined. Using current flow modelling (CFM), we quantified the inter-individual variability in tDCS current direction at a cortical target (left primary motor cortex, M1). Three montages targeting M1 using circular electrodes were compared: PA-tDCS directed current perpendicular to the central sulcus in a posterior-anterior direction relative to M1, ML-tDCS directed current parallel to the central sulcus in a medio-lateral direction, and conventional-tDCS applied electrodes over M1 and the contralateral forehead. In 50 healthy brain scans from the Human Connectome Project, we extracted current direction and intensity from the gray matter surface in the sulcal bank (M1BANK) and gyral crown (M1CROWN), and neighbouring primary somatosensory cortex (S1BANK and S1CROWN). Results confirmed substantial inter-individual variability in current direction (50%-150%) across all montages. Radial inward current produced by PA-tDCS was predominantly located in M1BANK, whereas for conventional-tDCS it was clustered in M1CROWN. The predominantly radial inward current in functionally distinct subregions of M1 raises the testable hypothesis that PA-tDCS and conventional-tDCS modulate cortical excitability through different mechanisms. We show that electrode locations can be used to closely approximate current direction in M1 and precentral gyrus, providing a landmark-based method for tDCS application to address the hypothesis without the need for MRI. By contrast, ML-tDCS current was more tangentially oriented, which is associated with little somatic polarization. Substantial inter-individual variability in current direction likely contributes to variable neuromodulation effects reported for these protocols, emphasising the need for individualised electrode montages, including the control of current direction

The impact of brain lesions on tDCS-induced electric fields

Transcranial direct current stimulation (tDCS) can enhance motor and language rehabilitation after stroke. Though brain lesions distort tDCS-induced electric field (E-field), systematic accounts remain limited. Using electric field modelling, we investigated the effect of 630 synthetic lesions on E-field magnitude in the region of interest (ROI). Models were conducted for two tDCS montages targeting either primary motor cortex (M1) or Broca's area (BA44). Absolute E-field magnitude in the ROI differed by up to 42% compared to the non-lesioned brain depending on lesion size, lesion-ROI distance, and lesion conductivity value. Lesion location determined the sign of this difference: lesions in-line with the predominant direction of current increased E-field magnitude in the ROI, whereas lesions located in the opposite direction decreased E-field magnitude. We further explored how individualised tDCS can control lesion-induced effects on E-field. Lesions affected the individualised electrode configuration needed to maximise E-field magnitude in the ROI, but this effect was negligible when prioritising the maximisation of radial inward current. Lesions distorting tDCS-induced E-field, is likely to exacerbate inter-individual variability in E-field magnitude. Individualising electrode configuration and stimulator output can minimise lesion-induced variability but requires improved estimates of lesion conductivity. Individualised tDCS is critical to overcome E-field variability in lesioned brains

Development of a tool to predict organised team performance in process execution

The paper describes the development of a tool to predict the success of a team executing a process. It is expected to be used by systems engineers in initial stages of systems design, when concepts are still fluid, including the team(s) who are expected to be operators within the system. Currently, the tool is undergoing verification and validation; to date, the tool predicts well and shows promise. An unexpected finding is that the tool creates a good argument for Human Factors Integration in projects

PEAT- a tool to predict team performance in systems

The paper describes the development of a tool to predict the success of a team in executing a process. It is expected to be used by systems engineers in initial stages of systems design, when concepts are still fluid, including the structure of the team(s) who are expected to be operators within the system. Currently, the tool is undergoing verification and validation; to date, the tool predicts fairly well and shows promise

Predicting the performance of teams in systems

The paper describes the development of a tool to predict the success of a team executing a system process. It is expected to be used by systems engineers in initial stages of systems design, when concepts are still fluid, including the team(s) who are expected to be operators within the system. Currently, the tool is undergoing verification and validation; to date, the tool predicts well and shows promise. An unexpected finding is that the tool creates an a priori case for Human Factors Integration in projects, to reduce the probability of substandard operational performance