A psychological case formulation is an attempt to understand a patient’s difficulties through a set of hypotheses about what happens in his or her mind, and the links with present and past experience and actions. Formulations are central to some individual psychological therapies and have also been advocated within psychiatric care, where they may help team cohesion and satisfaction, and provide a ‘map’ to negotiate complex processes of care (Reference Alanen, Lehtinen, Aaltonen, Martindale, Bateman and CroweAlanen et al, 2000; Reference DavenportDavenport, 2002). However, evidence of the impact of formulations is limited and conflicting (Reference Chadwick, Williams and MacKenzieChadwick et al, 2003).
This article describes a qualitative study of staff views, aimed at developing understanding of benefits and limitations of using psychological formulations with patients with severe mental illness.
The study setting was one ward of a high-dependency rehabilitation service, where both the service and use of formulations have previously been described (Davenport et al, 2002). In 2003, 2-weekly ‘formulation meetings’ lasting approximately 90 min were instituted. These are open to all staff and are used to review the history, discuss individual staff experiences of the patient and generate ideas that might contribute to formulation. After each meeting, the therapist leading the meeting (either the team’s clinical psychologist or a specialist registrar training in psychoanalytic therapy) prepares or updates a written formulation in textual and diagrammatic form, sometimes with separate ‘mini-formulations’ focusing on particular aspects of interest. Formulations have been based on either a predominantly cognitive-behavioural or object relations theoretical framework. In some cases, all or part of the formulation is discussed with the patient.
Sample, data collection, analysis
Among the target population of all regular ward staff, a sample was selected, with the aim of achieving the maximum variation in response. Apart from one nurse on sick leave, everyone selected was interviewed using a semi-structured format covering participants’ experiences and views on using formulation. Interviews lasted up to 20 min and were performed by the author, who recorded responses in writing, where possible verbatim, and analysed these using a grounded theory-based methodology (Reference Miles and HubermanMiles & Huberman, 1994). This approach included generating categories through phrase-by-phrase analysis of data, using initial findings to shape sampling and exploration in later interviews, and refinement of emerging codes and hypotheses through an iterative process, with particular efforts to search for discrepant cases and alternative explanations.
A total of 25 staff were interviewed: 9 nurses, 11 support workers, 2 doctors, an occupational therapist, a social worker and a drama therapist.
Professionally trained staff were more likely to attend formulation meetings and read written formulations; 10 out of 12 had done both, whereas among 11 support workers and 2 students, only 6 had attended formulation meetings and only one had read a written formulation.
‘One of the most productive things on the ward…. a richness which you don’t pick up from the notes or (the patient).’
Everyone who had participated in using formulations made predominantly positive comments. Those who had not participated attributed this to lack of awareness or opportunity, and expressed interest.
Most participants said they could see few or no drawbacks. The most frequently suggested was the potentially limited impact on care (four mentions).
‘They could be more productive… need to guide care plans more.’
Some saw problems in incomplete information or excessive emphasis on speculative suggestions (three mentions).
‘… [they’re] a projective vehicle… a fantasy space for speculation, guess the pathology, games… staff dynamics, who’s got the loudest voice, some people wanting to be right or more powerful… pop psychology.’
Two participants felt that too much information, particularly about a new patient, might lead to wrong perspectives. Two others thought that the past could be overemphasised and used as an excuse for current behaviour.
Dimensions of benefit
Responses suggested four dimensions to the impact of formulations. These included ideas for management (12 mentions),
‘… gives you a way of working that you might not have seen… givesdirection. We were reminded of her sensitivity to rejection, so re-wrote some care plans in the light of this.’
Better staff-patient relationships (6 mentions).
‘… makes me more tolerant, more patient increases empathy.’
Individual staff satisfaction (5 mentions).
‘…helps when the patient is demanding, it took away the sting.’
And improved team working (5 mentions).
‘… gives a knock on, everyone part of the team.’
Mechanisms of benefit
Participants suggested various mechanisms through which benefits are achieved. These could be grouped into three areas.
Thirteen participants valued the meetings specifically and the way they bring together people and ideas, combining different information and perspectives, and leaving staff feeling valued, part of the team or able to have their say.
‘Together, we might see something that separately we can’t see. People had forgotten factors impacting on care now.
Nice getting all levels and disciplines, it gives a knock on, everyone part of the team.’
Nine participants thought formulation helped staff knowledge and understanding of patients.
‘Afterwards, the problems seemed understandable, something we could start to address.’
Eight participants mentioned that they valued formulation meetings as a space to think creatively (‘time out’) with a chance to talk without an illness or management focus, to discuss ideas, make links to theory and allow new things to emerge.
‘… brings things to consciousness.. brings out patterns. People were able to say more positive things about her… different… from other meetings about her… may be because it wasn’t focused on her management.’
Convictions competing or shared uncertainty
Although the 18 participants who had experience of working with formulations shared a view that it is beneficial, two different patterns in underlying attitudes could be discerned.
At least three participants seemed to consider formulations as statements of fact, and as helpful through being ‘right’ and leading to ‘ correct’ management. They held their own views with strong conviction, valued a chance to get these heard and were disinclined to give too much emphasis to ‘excuses’ for patients’ behaviour, or to get ‘wrong’ perspectives through reading ‘too deeply’.
At least eight participants seemed to hold a different attitude. They valued being able to speculate and discuss ideas. They saw their own and others’ views as provisional, and formulations as hypotheses.
‘… space to think…be playful, say - what about this?…[suggestions] feel both more useful and more accurate - and vaguer.’
The study findings are undoubtedly partly shaped by its methods and context. There may be self-presentation bias, for example, towards giving ‘ acceptable’ views. Researcher factors, including prior interest in formulation, may have influenced both interviews and analysis. However, the validity of the findings is supported by their internal coherence, their inclusion of negative and unexpected views and their consistency with published views and with triangulation data, such as data from observations, from questionnaires completed before and after formulation meetings and from assessment of participant definitions of formulation (details available from the author on request).
The study relates to one ward, a particular staff team and a particular approach to formulation, and some findings may reflect issues unrelated to formulation. Clearly, care needs to be taken in generalising from these findings to other contexts.
Impact of formulation and mechanisms of benefit
This study suggests possible benefits and drawbacks of using formulations in the care of in-patients with severe mental illness, and possible mechanisms through which these might arise. The perceived benefits of influencing patient care, staff-patient relationships, staff satisfaction and team work are in line with benefits suggested previously (Reference Alanen, Lehtinen, Aaltonen, Martindale, Bateman and CroweAlanen et al, 2000; Reference DavenportDavenport, 2002), as is the view that improved understanding of patients may help to achieve these ends.
The study has not shown that the actual content or validity of the formulation matters, and identified benefits may relate simply to the attempt to understand, or to viewing patients as people.
The lack of perceived impact on outcomes is unsurprising given the patient group and relative brevity of experience with formulations.
The perception of significant benefits from meetings to discuss formulation was unexpected and has several possible explanations. The important factor may be having opportunity to discuss difficult issues at work, much as in staff sensitivity groups (Reference HaighHaigh, 2000). Alternatively, similar benefits may come from staff simply feeling listened to and encouraged to think creatively, as might occur with good management practice in different forms. However, the process of formulation may be specifically helpful in working with patients with mental illness where dynamics, such as splitting and avoidance of thinking, may spill over into the staff team (Reference Davenport, Mace and MargisonDavenport, 1997).
‘Psychosis is splitting, clients are fragmented, the formulation meeting is an integrative process of integrating fragments…. it’s space to think, psychosis is not thinking…pathology is unconscious, formulation brings to consciousness.’
Participants’ attitudes to formulation may have an important bearing on its impact, and if many staff see formulation as ‘convictions competing’, its value may be limited. Training may be important in maximising any benefits, but it is also possible that using formulations may help in shifting staff culture.
Participants’ comments suggested that using formulations 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, personal development and ward duty planning. Formulation meetings and written formulations (both textual and diagrammatic) may each make distinct contributions.
The study raises many further questions. To what extent do the suggested benefits occur? Do patients see similar benefits and drawbacks? Does the content and accuracy matter? And is there any impact on patient outcomes? It seems worth exploring these issues further.
I thank all the staff who participated, and Robin Ellis, Jane Redfern, Stephanie Kennedy, Sarah Davenport and Frank Margison for ideas and support.