ACP-UK member Lucy Johnstone considers the relevance of the team formulation approach for the Reducing Restrictive Practice programme established by NHS Improvement and the Care Quality Commission in 2015 in response to a request by the Secretary of State (follow this link for post from ACP member giving consideration to wider context for the programme).

Team formulation: current models and practice

Team formulation is the process of facilitating a group or team of professionals to construct a shared understanding of a service user’s difficulties, which then forms the basis of the multidisciplinary team’s intervention plan. As with all formulations, it is open to revision as understandings evolve. This approach has grown in popularity over the past 10 years or so and is now a common feature of Adult Mental Health and other services, including inpatient settings (see Clinical Psychology Forum ‘Special edition: Team Formulation’ November 2015 for examples from different specialties; see also the summary in Johnstone, 2014.) Team formulation is a recommended approach in clinical psychology professional documents (e.g. Health Professions Council, 2009; Skinner and Toogood, 2010), and the Division of Clinical Psychology (DCP) has published Good Practice Guidelines covering both individual and team formulation (DCP 2011).

Team formulation may take a number of different formats and draw from various therapeutic approaches. The role of the facilitator, usually but not necessarily a clinical psychologist, is to reflect, summarise, clarify, encourage creativity and free-thinking and ask questions, not provide ‘solutions.’ Models for facilitating formulation meetings for the whole team, usually weekly, have been developed by Lake (2008) with Community Mental Health Teams; Whomsley (2009) in Assertive Outreach; Kennedy (2008) in an inpatient unit; Davenport (2002) and Summers (2006) and Berry, Barrowclough and Wearden (2009) in rehabilitation services; Martindale (2007) in an early intervention team and Johnstone (2014) in adult mental health. Some services aim to provide a formulation for every client (eg Kennedy, Smalley & Harris, 2003; Whomsley, 2009) while others use it only where particular queries or difficulties arise. The Older People’s service in Tees Esk and Wear Valleys NHS Foundation Trust (Dexter-Smith, 2010; Dexter-Smith, 2015) has the most thoroughly embedded team formulation approach; five community mental health teams (CMHTs), a young onset dementia team, care home liaison team, and four inpatient units (functional and organic) serving a population in the region of 107,600 people over 65 years of age, all of which implement formulation at all stages of the care pathway.

Team formulation can be seen as a type of staff consultation or supervision and as such is likely to focus on allowing space for understanding and processing staff feelings such as frustration, stuckness or hopelessness. For this reason, not all the content will be appropriate for direct sharing with the service user, although practices vary. Ideally, one-to-one formulation work proceeds in parallel with the team formulation, and both formulations feed into and inform each other.

Team formulation: potential benefits

As is the case with individual formulation, this is an under-researched area. However, clinical reports, audits and qualitative studies suggest that the team approach can have benefits in addition to those found in one-to-one formulation such as clarifying hypotheses, informing the intervention, predicting difficulties and so on. These are: achieving a consistent team approach to intervention; helping the team, service users, and caregivers 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 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; minimizing disagreement and blame within the team; increasing team understanding, empathy, and reflectiveness; raising staff morale; and conveying meta-messages to staff about hope for positive change (DCP, 2011, p. 9).

The most consistent finding is of positive staff responses: ‘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). Wainwright and Bergin’s (2010) evaluation also suggested that staff empathy, understanding and tolerance were increased. In an audit of the team formulation work of 3 psychologists based in Adult Mental Health inpatient and CMHT settings, staff rated team formulation as helpful or very helpful across all areas assessed (Hollingworth & Johnstone, 2014), with 100% of the 22 participants reporting 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. They made comments such as ‘Useful in planning a way forward which has given the client and professionals a sense of hope for future recovery’. Berry, Barrowclough and Wearden’s (2009) comparison of wards using and not using team formulation found improvements in staff-patient relationships and reduced staff burnout. Feedback interviews suggested that the intervention was acceptable, increased staff understanding and resulted in changes in practice.

Overall, clinicians also report that ‘Using formulations may help in shifting staff culture’ (Summers 2006.) ‘Taking formulation into a wider setting can be a powerful way of shifting cultures towards more psychosocial perspectives’ (Onyett, 2007).

There are also challenges. For example, further input may be necessary to ensure that plans for complex clients remain consistent in the face of ongoing daily pressures (Wainwright & Bergin, 2010), and that formulation time is not eroded by other crises and demands. Facilitation can be demanding, especially where the team is divided in its views, or where feelings of anger or hopelessness predominate, as is common with more complex presentations (Johnstone, 2014.) Transference and counter-transference reactions may therefore need to be a central focus of team formulation meetings, since if these are not sensitively addressed and explored, there is a risk of ‘…staff re-enacting punitive, withholding or abusive roles in relation to enraged, overwhelmed or helpless clients…The team can be split, with mistrust and misunderstanding between colleagues’ (Dunn & Parry, 1997.) Similarly, ‘Staff may inadvertently re-enact early patterns of abuse and become enmeshed in unhealthy, destructive interactions’ (Meadon & van Marle, 2008.) It is in these situations that inappropriate restrictive measures are most likely to be employed.

The DCP Good Practice Guidelines recommend that all formulations should be trauma-informed (Criterion ‘Considers the possible role of trauma and abuse’, DCP 2011, p. 29.) Since trauma-informed practice also emphasises the risk of re-traumatising service users, another essential criterion is ‘Considers possible role of interventions in compounding the difficulties’, DCP 2011, p.29.) Team formulation can thus be a powerful way of encouraging the adoption of this perspective (Johnstone et al, 2015.)

To be effective, team formulation ‘must be supported by influential members of the team’ (Lake, 2008) with all professionals on board (Casares & Johnstone, 2015; Dexter-Smith, 2015) since ‘formulation may have most to offer if embedded as the core business of the unit, with robust links to patient care planning and to staff training’ (Summers, 2006: 343.) Since team formulation demands a high degree of psychological sophistication and leadership, and is time-consuming to plan, facilitate, write up and disseminate, there are obvious implications for staffing (see Dexter-Smith 2015 for how one service has addressed this.)

Clearly, this is a promising approach which deserves further investigation, and a number of areas for future study have been suggested (Cole, Wood & Spendelow, 2015). However it should be noted that there is already extensive research into the psychological principles on which team formulation is typically based (e.g. attachment theory, developmental psychology, cognitive-behavioural therapy and so on.). It has also been pointed out that if formulation is defined as ‘the tool used by clinicians to relate theory to practice’ (Butler 1998) it can be seen as a way of operationalising the basic principles of evidence-based practice (Cole et al, 2015.)

Team formulation and reducing restrictive practice

Team formulation is an ideal vehicle for reducing restrictive practice on inpatient wards, since it can be expected to offer the following benefits to support the ‘Tools and Resources for Change’ in the Reducing Restrictive Practice programme.

• Team Formulation is a form of supervision for the whole team, in which feelings can be expressed, thoughts can be shared and the facilitator can introduce new ideas and concepts.
• Best practice team formulation is trauma-informed and is thus a powerful way of helping staff to understand the impact of trauma in service users’ lives and the way that services can unintentionally re-traumatise them. Thus, while it may not always be possible to avoid restrictive practices, staff will be more aware of the reasons for the behaviours that may trigger such responses; will have a space to explore less restrictive alternatives; and will be more alert to the risks of re-traumatisation.
• Team formulation can offer support to staff who are working in highly demanding environments, such that the team operates in a more cohesive way. This in turn makes it less likely that they will become burned out and act on inevitable feelings of exhaustion and frustration.
• A team formulation helps to construct an individual hypothesis that ensures other strategies, such as those recommended in the ‘Tools and resources for change’, are used appropriately and sensitively to meet a service user’s needs, not simply as a cookbook response.
• Team formulation can help to create cultural change towards more psychologically-informed environments in which staff feelings and counter-transference can be understood and processed, and space given for reflection on the likely impact of coercive interventions.
• Team formulation can help to suggest alternatives to restrictive practice where possible, and if it is unavoidable, can help to ensure such practices are carried out in a minimally traumatising way.
• Team formulation is a highly effective use of the time of more highly trained professionals, whose input will thus be influential beyond one to one interventions.

Lucy Johnstone
Consultant Clinical Psychologist

References

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Casares, P., & Johnstone, L. (2015). Integration of formulation in adult multidisciplinary services across a large NHS Foundation Trust – Phases 1 and 2: Training and integration. Clinical Psychology Forum, 275, 20-27.

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Division of Clinical Psychology (2011) Good Practice Guidelines on the Use of Psychological Formulation.  Leicester: The British Psychological Society.

Dunn, M. and Parry, G. (1997) A formulated care plan approach to caring for people with borderline personality disorder in a community mental health service setting, Clinical Psychology Forum 104, 19 –22.

Health Professions Council (2009). Standards of proficiency: Practitioner psychologists. London: Health Professions Council.

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Johnstone, L (2013). Using formulation in teams. In L. Johnstone & R. Dallos (Eds.), Formulation in psychology and psychotherapy: Making sense of people’s problems (2nd ed., pp. 216-242). London: Routledge.

Johnstone, L., Durrant, C., James, L., Lewis, H., Maybury, E., McCann, S.,Sandford, C. (2015). Team formulation developments in AMH services in South Wales. Clinical Psychology Forum, 275, 38-42.

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Whomsley, S. (2009). Team case formulation. In: C Cupitt (ed) Reaching Out: The Psychology of Assertive Outreach. London: Routledge.