This study evaluates psychology-led formulation sessions within an assessment and treatment service. Five staff members completed interviews exploring their experiences of formulation and their perception of its usefulness to clients. Results suggested that they perceived formulation to be beneficial on a number of levels for themselves and their practice but were uncertain about the tangible benefits for clients

Casares, P.

Irving Quinn, G.

Jones, F.

Unadkat, S.

English

Canterbury Research and Theses Environment

Canterbury Christ Church University’s repository of research outputshttp://create.canterbury.ac.ukPlease cite this publication as follows: Unadkat, S., Irving Quinn, G., Jones, F. W. and Casares, P. (2015) Staff experiences of formulating within a team setting. Clinical Psychology Forum (Extended Online Edition), 275. pp. 85-88. ISSN 1757-2142. Link to official URL (if available):This version is made available in accordance with publishers’ policies. All material made available by CReaTE is protected by intellectual property law, including copyright law. Any use made of the contents should comply with the relevant law.Contact: create.library@canterbury.ac.ukStaff experiences of formulating within a team setting  Shreena Unadkat, Trainee Clinical Psychologist, Salomons Centre for Applied Psychology; shree_u@hotmail.com; Twitter: @SuperEgo_Shree;   Gillian Irving Quinn, Clinical Psychologist, Sussex Partnership NHS Foundation Trust;   Fergal Jones, Senior lecturer, Salomons Centre for Applied Psychology, Canterbury Christ Church University;   Philippa Casares, Consultant Clinical Psychologist, Sussex Partnership NHS Foundation Trust   in Clinical Psychology Forum (Extended Online Edition) 275 – November 2015 Abstract  This study evaluates psychology-led formulation sessions within an assessment and treatment service. Five staff members completed interviews exploring their experiences of formulation and their perception of its usefulness to clients. Results suggested that they perceived formulation to be beneficial on a number of levels for themselves and their practice but were uncertain about the tangible benefits for clients.  As part of a major service re-organisation, Sussex Partnership Trust set up a project to integrate formulation within all its assessment and treatment teams (Casares & Johnstone, this issue). Formulation leads in each locality were encouraged to set up regular team formulation meetings to allow multidisciplinary discussion of complex or longer-term service users. To date, eight of the assessment and treatment services have implemented such meetings, and the remaining one is about to do so. This service evaluation investigates staff experiences of the formulation meetings within one team. An exploratory, qualitative stance was taken. The aims were to discover: 1. What were the main staff motivations for bringing a client to formulation? 2. How did staff members experience the sessions? 3. What influence did staff perceive formulation to have on their practice and clients?  Method Participants Participants were staff members in a newly formed secondary care adult mental health community assessment and treatment service, who had attended at least one formulation session in the preceding six months. They were recruited via information sheets, distributed and explained at a clinical team meeting. Five staff members responded to the invitation to participate out of a pool of fifteen potential participants. Of the five, four were female and one was male, and all were of white British ethnicity. The group comprised of two community psychiatric nurses, two occupational therapists and one support worker. Age and socioeconomic data were not collected.  Design The study used a qualitative design with semistructured interviews. Interviews began with general questions about how the participants found the meetings. Further questions were developed based on the ‘Purposes of a formulation’ section of the Division of Clinical Psychology’s Good Practice Guidelines on the Use of Psychological Formulation (2011, p.8). Questions were left open in order to allow both positive and negative answers. Participants were also asked about areas that formulation meetings missed and ways in which the process could be improved. Prior to the main data collection, the interview schedule was piloted on two team members to check face validity. Feedback led to adjustments to the wording of the questions to ensure openness and good coverage of potential effects of the sessions on client working.  Procedure Participants were informed that the study was fully anonymised and that data recorded would be stored securely. It was made explicit that participation was voluntary and informed consent was sought. Face-to-face interviews were carried out by the first author and recorded on a digital recorder. Participants were asked to focus on one client that they had discussed at a formulation session. The interviews were transcribed and the researcher analysed the data using thematic analysis (Braun & Clarke, 2006). Themes were cross-checked by the second and third authors for validity.  Results The seven main themes are described under the headings below, along with twenty-one subthemes, which are indicated in bold.   Wanting a way out of frustration and being stuck Participants described feeling a sense of difficulty about their work with the client before taking the decision to attend a formulation meeting. Every participant reported themselves, the client or the team as feeling ‘stuck’. This was described in terms of a ‘…lack of change’, a feeling of ‘…not knowing what to do’ or of ‘…going round in circles’.   The majority of participants also reported feeling frustrated about their progress or work: ‘A definite sense of frustration about the situation, about where it was going’. Complexity of the client or client group was another theme. All participants noted the complexity of the clients’ presentation, history or relationship with the service: ‘We deal with very complex clients here.’   The majority of participants expressed a hope that the formulation session would relieve these ‘stuck’ feelings and promote change. Participants stated: ‘I’d hoped to find some clarity, I think; just a sort of way forward’ and ‘…there was a hope, I guess, that going along [to the formulation meeting] would help to relieve some of the stuckness I was feeling’.  Validation and affirmation All participants expressed a positive sense of reassurance and recognition from the formulation sessions. This included a sense of validation of difficult feelings around their clients. This was described in various ways, such as: ‘…[formulation] made me feel like I wasn’t useless, or doing something wrong for feeling so frustrated’, ‘…it’s validating that… you are doing all right, that you are ok at this’.  Participants also expressed a sense of affirmation of the work that they were carrying out, commenting that: ‘…just to hear them say “actually I would probably be doing the same” is affirming and useful’ and ‘…when I was explaining it all to [the psychologist] I actually realised it did make sense really’.   There was also mention of a growing recognition of the service and one’s own limitations. Participants reported that ‘…sometimes it’s also about having someone not just say what had already been tried, but also what we couldn’t try anymore of’ and ‘…it was a much firmer stance than I expected from a psychologist, for them to say “actually, maybe they don’t need to know that, maybe it’s not good for them to have that”’.  Stopping and thinking Participants reported a sense of slowing down of their thinking, describing ‘…a real shift, from reacting to reflecting’. This was noted as a distinct process from usual team practice: ‘Things can get quite rushed around here, so having that space to slow things right down took some getting used to. I think it was good in the end.’  Participants described the difference between the solution-focused approach of the team and the exploratory nature of formulation. This solution versus exploration was seen as useful aspect of the sessions: ‘I think we all naturally rush around to get a solution, you know, and I’m not sure that is always the best thing. We can forget to really think about things.’  Getting a different perspective Another theme was of having an alternative perspective on the client’s issues, aided by an objective outsider. The theme of an external perspective was common, with participants stating: ‘…to get an external perspective, an objective one. That was helpful.’ And: ‘…when you’ve known someone for a long time, you get stuck asking the same sorts of questions in the same sorts of patterns. Sometimes it takes an extra person outside of it to really look for things’.  All participants commented on the placing of the client within the wider context of their lives, histories, and their relationships with the team. Similarly, staff were encouraged to think about themselves in the wider context, with one participant noting ‘…it does just help to put the whole thing in context really, looking at it all as part of the system [we] are all a part of.’  Participants also discussed the benefit of having multiple viewpoints in the room and thinking from a multidisciplinary angle more effectively: ‘Just being able to hear from different disciplines, that helped to mix things up a bit.’ An additional reported benefit was the ability to share the case with the team (either by sharing risk burden or knowledge of the client). One participant stated: ‘I was managing the risk alone every time I saw the client, so sharing that with the team became a good process for me.’  Increased understanding All participants reported an increased understanding of their clients’ issues. This was often expressed as a ‘…deeper and more thorough’ understanding of how the client’s history ‘…linked to the way they are presenting right now’.  The formulation sessions also highlighted gaps in understanding. The sessions ‘… showed us what we didn’t know really’ and ‘… left [me] with more questions than answers’. This prompted the staff member to seek out further information.   Having protected time The theme of ‘time’ was apparent. All participants referenced the idea of having ‘protected’ or ‘ring fenced’ time as one of the most ‘…useful things about… formulation sessions’. One participant stated: ‘It’s a good development in the service, using some protected time to think this way.’ Formulation meetings were seen as a different use of time to the everyday practice of the team: ‘It’s a really different use of time. In our other meetings we go through things quickly and have a lot to cover.’  Impact on clinical practice The majority of participants felt that they gained new strategies to work with the client, stating: ‘…it gave me a bit of a different way of looking at him after that; I guess I approached him differently’; ‘…there was a new strategy in my head, I suppose, more than anything’; and ‘…we came up with lots of new ideas about the client as a whole, lots of new ideas that were generated changed the way I thought about it.’  Some participants also commented on the passing on of validation, ideas, and containment to the client. One staff member stated that: ‘…it’s easier to be honest with clients and to contain them’.  Although participants noted new strategies and the passing on of benefits to clients, they struggled to name these when asked explicitly about the direct benefit to clients: ‘I suppose we might have thought about it differently, but overall things stayed much the same’; ‘I didn’t change a huge amount about the way I was working with the client – although I did refer them on’; and ‘It didn’t change the client’s pathway after the session.’ One participant also expressed dissatisfaction with the lack of a clear action plan at the end of the session, noting that: ‘I normally get a decision by the end of the meeting.’  Discussion Overall, staff gave overwhelmingly positive feedback about their experience of formulation meetings. The main perceived benefits seemed to be the recognition and validation of their work, the opportunity to slow down and think about clients in a deeper way, and increased understanding of the clients’ issues. Although staff reported that they had new ideas and strategies to try, they struggled to identify more tangible benefits for the clients and impact on practice. This may reflect the very ‘stuck’ nature of the clients whom staff chose to discuss, or perhaps a hope that formulation would resolve the challenging issues with which they were faced. The comments may indicate a need for concrete action plans at the end of meetings or further meetings in which staff can identify progress and change in practice.  The results support guidance on the purpose and uses of formulation as described in the Good Practice Guidelines on the Use of Psychological Formulation (DCP, 2011). The themes are consistent with reported benefits such as noticing gaps in knowledge, troubleshooting, helping the staff member to feel contained, helping staff to manage risk, increasing team understanding, empathy and reflectiveness, drawing on and valuing the expertise of all team members, gathering key information, and raising staff morale. The findings are also in line with the results of another recent evaluation of staff experiences of formulation meetings (Hollingworth & Johnstone, 2014).  The data suggest that keeping protected time around formulation meetings is of great importance, as this provides the space and ability to think and react in a different way. Providing containment, validation and peer support may in the longer term help to protect against the ‘burnout’ that is common in secondary care mental health staff (Prosser et al., 1999), which ultimately leads to poorer treatment outcomes for clients (Lasalvia et al., 2009). Further research into this is needed.  Limitations of study Participants were aware that the interviewer was a psychologist and that the results would be fed back to the psychologists who facilitated the formulation meetings. They may have withheld negative feedback for this reason. Questions were left open to allow for negative feedback; however, this was not specifically asked about. The sample size for the interviews was small, and participants were self-selecting and may have been those who felt most positively about the meetings. Further questions might have helped to ascertain whether positive effects were due to formulation specifically, or due to the general space for discussion. Qualitative methodology recognises that the researcher’s own values and biases may affect the research (Ratner, 2002). These issues were discussed in supervision prior to interviewing as a measure to reduce this risk.  Implications for future research This service evaluation took an exploratory stance. The themes identified would benefit from further exploration: specifically, the perceptions staff have of how formulation influences their practice and client outcomes. A larger scale study may be able to test the presence of these themes in practice, and may wish to relate them to staff satisfaction and client outcome.  References Braun, V. & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative Research in Psychology, 3, 77–101.  Division of Clinical Psychology (2011). Good practice guidelines on the use of psychological formulation. Leicester: British Psychological Society.  Hollingworth, P. & Johnstone, L. (2014). Team formulation: What are the staff views? Clinical Psychology Forum, 257(5), 28-34.  Lasalvia, A., Bonetto, C., Bertani, M., Bissoli, S., Cristofalo, D., Marrella, G. & Ruggeri, M. (2009). Influence of perceived organisational factors on job burnout: Survey of community mental health staff. British Journal of Psychiatry, 195, 537–544.  Prosser, D., Johnson, S., Kuipers, E., Dunn, G., Szmukler, G., Reid, Y., Bebbington, P. & Thornicroft, G. (1999). Mental health, ‘burnout’ and job satisfaction in a longitudinal study of mental health staff. Social Psychiatry and Psychiatric Epidemiology, 34, 295–300.  Ratner, C. (2002). Subjectivity and objectivity in qualitative methodology. Forum: Qualitative Social Research, 3(3). Retrieved from www.qualitativeresearch. net/index.php/fqs/article/view/829/1801 

Staff experiences of formulating within a team setting

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Staff experiences of formulating within a team setting

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