Aims and intended learning outcomes

This article aims to enhance nurses’ understanding of team formulation, including its ideas, implementation and potential effects. It explores some of the evidence supporting team formulation, provides examples of techniques that may be used and reflects on team formulation in practice. It is hoped that this article will enable readers to develop an enhanced awareness of the concepts and issues involved, feel increasingly confident when engaging in team formulation and recognise its value and challenges in clinical practice. After reading this article and completing the time out activities you should be able to:

Introduction

Formulation is a process of developing an understanding of what is happening for a person and why, and therefore what might be helpful. It involves gathering information, drawing from personal meanings and theoretical understandings to develop a coherent narrative. Formulation diverges from diagnosis in that it does not seek to categorise experiences, but rather to understand, explain and resolve them in their unique context.

The reader is encouraged to read a previous CPD article outlining the process, value and challenges of individual formulation in therapeutic work (Cox 2020). In its more traditional individual form, it is a way of collaboratively making sense of a person’s current experiences by combining their personal history with theory and/or evidence to make a hypothesis or ‘best guess’ about what has led an issue to develop and what is keeping it going. Formulation is therefore a working hypothesis that can support the development of shared understanding and identify potential interventions (British Psychological Society (BPS) 2011).

As an alternative or adjunct to psychiatric diagnosis (Johnstone 2018), formulation is based on the complexity and personal meaning of the circumstances and interactions of each individual, rather than – or as well as – indicating a prescriptive solution based on a finite number of generalised diagnostic categories. The aim is to synthesise what the person brings that is unique to them with what is known about how people experience, manage and solve psychological issues more generally, based on research evidence and theoretical models.

Models and functions of formulation

Formulation is a flexible process and can be used in various formats, depending on the context and purpose. Traditionally, psychological interventions or therapy have been provided on a one-to-one basis between a practitioner and client (it is acknowledged that the terms ‘service user’ and ‘client’ are not universally accepted, acknowledged or appreciated and are used here sparingly for clarity). Here, the purpose of formulation is to collaboratively generate a shared understanding about what is happening for the person and why.

There is a range of models and procedures available for organising formulation, some of which are more prescriptive than others. The 5Ps model is a way of structuring relevant information to facilitate formulation (Dudley and Kuyken 2014), by organising factors into:

Each of these categories can include social, biological, psychological, cognitive and behavioural factors. These factors are summarised into a diagram and/or narrative that suggests how they may interconnect for the person in their specific context. This summary could take the form of diagrams, letters, conversations or even movement and objects, which are explored on a one-to-one basis with a therapist or key worker, often called case formulation.

The 5Ps model is often a starting point for organising information and various other frameworks or theories – such as cognitive analytic therapy, cognitive behavioural therapy and emotion-focused therapy – can then be used to develop the narrative or diagrammatic synthesis, therefore integrating the factors together with meaning and theoretical underpinnings (BPS 2011).

There are several intended functions of formulation, each with varying supporting evidence (BPS 2011, Cox 2020). It is hoped that developing a shared understanding will assist the person to make sense of their issues. It could identify links between past and present, supporting the client and practitioner to see the psychological issues as functional yet problematic responses to a challenging history, and therefore reduce self-blame. Sharing this understanding with others in the wider network – such as family members, key workers or educators – with consent may then enable the person to communicate their issues in a way that engenders compassion and understanding.

Where people are ready and willing for change, the formulation can be used to generate ideas for appropriate interventions. These interventions could involve developing specific skills, coping strategies or alternative perspectives that can address the factors that are maintaining the person’s issues, as identified in the formulation. Moreover, the formulation could indicate the need for systemic changes where contextual factors are driving these issues; for example, where social circumstances are a barrier to resolution, the practitioner and client may need to liaise with social, employment or housing agencies.

In summary, formulation seeks to support effective care in various ways, although it is important to acknowledge that these are not all evidenced fully from all viewpoints, in terms of outcomes and experiences related to practitioners, clients and others in the mental health system. Furthermore, formulation is not intended to be a uniformly ‘positive’ experience, since it often involves complex and emotionally challenging processes that require responsive and collaborative support (Morberg et al 2008, Bradley et al undated).

Team formulation

In many settings, supporting people with mental health difficulties involves much more than one-to-one therapy sessions. In inpatient wards, care homes, schools, criminal justice settings and multidisciplinary community teams, people who use services interact with various professionals who also interact with each other to provide effective care. Here, it is important to work with the person to make sense of their difficulties, as well as to ensure a shared understanding in the wider team, supporting how the team work with the client and how they work together. Therefore, in team formulation the team also become a client; their experiences, meaning and goals are incorporated into the shared understanding developed (Johnstone 2014). This process can occur in several ways depending on the setting, the needs and direct involvement of the client and the model of understanding used.

Where multiple professionals are involved in an individual’s care, it is likely that slightly different ways of working will arise. This is not necessarily an issue because different people can bring their own personalities and skills. However, using formulation to develop a shared team understanding of a person’s issues (Hollingworth and Johnstone 2014) could support a consistent approach that focuses on the area most likely to bring about positive change.

Working with people in severe distress can also raise challenging feelings and responses among team members – such as hopelessness, anxiety and frustration – which can make it hard for them to maintain compassion and may affect their well-being. Maintaining positive regard and respect for those using services is essential, ethical and necessary for effective care. Therefore, it is important that, alongside policies, procedures and effective and human rights-based service evaluation, there are spaces for staff to explore and understand what is going on for the person they are supporting and themselves, and how these experiences might interact in either helpful or harmful ways.

People who use mental health services have often had experiences of feeling blamed, finding it challenging to trust others or to obtain the support they need, which can make it challenging to develop and maintain effective therapeutic relationships. This necessitates an understanding on the part of the team in relation to what will help.

Another issue is that the systems in which staff and service users find themselves can present barriers to engagement and collaboration, with restrictive practices, competing demands, hierarchical team structures and dysfunctional processes. Staff members and service users recognise that therapeutic relationships are fundamental to positive outcomes, but there are no well-evidenced specific ways of supporting staff to manage these relationships (Hartley et al 2020).

Team formulation is a potential way to explore and understand the reasons for people’s issues, coping and relational styles; it can be seen as a form of consultation to the team (Ghag et al 2019). Supporting staff in these ways can improve staff confidence, understanding of issues, relationships and ward atmosphere, as well as reducing perceived criticism for clients (Berry et al 2009, 2016).

Formulation can potentially meet the needs of the client (effective care), the staff member (increasing confidence) and the team (working together with consistency and compassionate understanding). Potential functions of team formulation include:

Involving the whole team in formulation

Team formulation can be delivered in various ways, and may entail clinical supervisory processes, intervention care planning, supportive reflection and synthesising information. The format can involve a structured, consultation approach; semi-structured, reflective practice meetings; or an unstructured, informal sharing of ideas through routine interactions, although the evidence for the effectiveness of these different formats is unclear (Geach et al 2018).

One approach to team formulation that is commonly used involves holding a meeting, often facilitated by a clinical psychologist, in which the team share understandings of what is already known about a person’s history, issues, coping styles, goals and strengths. This is a similar process to formulation in one-to-one sessions. While staff might have differing levels of natural ability to draw together this information (Hartley et al 2016), there are many ways they can be involved and the contributions of all present are valuable. For example:

• • A healthcare assistant may know about the person’s interests and hobbies that are a source of motivation for them, or have noticed that they are calmer during the evenings than the busy daytime.

• • The person’s named nurse may have had conversations with them about their history and how their difficult family life affected their self-esteem.

• • A psychologist may have undertaken an assessment and found out that the person asks for reassurance frequently to cope with uncertainty.

• • Other team members may notice their own feelings, for example they may feel worried about supporting the person’s independence because of risks, or find it challenging to have a conversation with them because the person appears reluctant to discuss their feelings.

• • The facilitator can support the sharing of information and reflection and draws together a narrative or diagrammatic understanding.

These are all valuable contributions to the formulation; they assist the team to make sense of what is going on for themselves and the client, and why.

An example of the process of team formulation is shown in Figure 1. Here, information from various sources is brought together in a team formulation meeting, which produces a hypothesis about what is going on for an individual and why. These hypotheses are used to generate ideas for interventions, the results of which can be used to adapt the formulation. For example, if an intervention that addresses a particular maintenance factor produces a positive change, this indicates that factor is important in the formulation. The ideas are also discussed with the client, to collaboratively develop a shared understanding in line with their personal meaning and experience.

Figure 1.

Example of the process of team formulation

Case study

An example of team formulation used in practice is depicted in case study 1.

In this case study, the team used formulation to develop a shared understanding of Tracey’s history, current issue, the experiences of the client and team, and how these interact with each other. This enabled them to recognise their own feelings and Tracey’s perspective. Through formulation, the team realised that their anger and frustration was leading them to react negatively to Tracey, which was increasing her mistrust of staff and the issues at mealtimes. Staff could see how Tracey’s mistrust could be linked to how she was treated while growing up, and that mealtimes may be particularly challenging because of her anxiety about eating and gaining weight.

The team decided to attempt to spend positive time with Tracey away from mealtimes and off the ward, to re-establish a sense of trust and togetherness. The meal plan was made clear and Tracey had a copy in her room to refer to, as well as more regular sessions to review it. During mealtimes, staff sat with Tracey and reminded her that they were there to support her and acknowledged that it is a stressful time. Tracey’s named nurse and psychologist asked her about her past and started to develop a shared understanding of how it had led to her present mistrust of staff. In joint sessions and in an attempt to understand both perspectives, they explored with Tracey her experiences of staff during mealtimes and how her ways of coping and responses from the staff might be keeping the issues going. They worked collaboratively to think of positive activities that Tracey would like to work on with staff and came up with ideas for how staff could best support her.

Experience, effects and quality of team formulation

In Hartley’s (2016) service evaluation, staff identified the purpose of team formulation as understanding and supporting team working and treatment planning. In addition, important areas of focus were coping with challenges or complexity, contributing to making progress and reminding staff of the person’s journey. Formulation was seen by staff as effective in gathering information related to strengths and difficulties, generating tolerance and empathy, recognising and reducing frustration, and engendering hope in treatment plans. Despite this, staff identified several barriers to the implementation of team formulation, such as competing demands, having sufficient staff and allocated time for discussion, managing different roles and the sharing of information (Hartley 2016).

Other literature has also identified that staff members can feel unsure about sharing their emotional experiences, and may require support and structure to assist with this (Lewis-Morton et al 2015). Furthermore, moving from a clear, shared understanding to an intervention plan may not always be straightforward, particularly since various forms of interventions may be used, for example therapeutic strategies, staff behaviours, activities and risk management. Therefore, it is crucial that all team members are involved in the development and delivery of the formulation and action plan.

Alongside the complicated context in which it operates, formulation is a dynamic, mutual and person-centred process, so it is unlikely that it could be fully replicated across different occasions or facilitators. It may be for this reason that attempts to evaluate the reliability of formulation have demonstrated ambivalent results (Bucci et al 2016). Nevertheless, it may be useful for formulation to be guided by principles and structures to ensure flexibility and consistency in the process itself. The Team Formulation Quality Rating Scale (Bucci et al 2019) was developed to support the delivery of team formulation in clinical practice, to train individuals in its facilitation and to provide a conceptualisation of the core elements of the team formulation process.

It has been shown to be reliable and valid, with its use disseminated to various clinical contexts, including community teams and inpatient settings. This tool could give individuals a sense of what team formulation will involve and support facilitators in learning how to balance the various elements and reflect on the benefits.

It will be important for future work to further develop the tools and procedures related to team formulation, to continue to address issues of consent and involvement, and to ensure competency and effectiveness.

Power, ethics and the future of team formulation

Power imbalances are inherent in the mental health system and, since team formulation operates within this system, it could be experienced as harmful, despite its intention to offer compassionate, empathic understanding (Hartley 2020).

In a Twitter thread, a writer with lived experience of mental health issues, @MyNewMummyLife (2019a, 2019b), discussed the risk that team formulation processes can be experienced as controlling, violating of trust and re-traumatising, and recommended that service users should always be given explicit choices about if and how formulation is conducted. If information is shared in ways that they have not explicitly consented to, this can exacerbate their experiences of disempowerment.

Explicit rationales and informed consent about the nature of service provision and mental healthcare, including how information is used and shared, is essential for all processes within mental health services, including team formulation. Services will benefit from continuing to develop the processes involved in team formulation and ensuring meaningful collaboration between staff and service users in relation to research, evaluation and practice.

There is a need to ensure that team formulation can continue to provide a forum for enhanced understanding and effectiveness of staff teams, while promoting the rights of service users. The nuanced, multifunctional nature of the formulation process and the complexity of the issues involved require further discussion and development among those who use and deliver services.

Conclusion

Formulation is a multifaceted and multifunctional process that can be useful for mental health nurses, therapists, teams and clients. However, because of its versatility, it can be challenging to formally conceptualise or validate formulation, and there are issues related to how clients and team members work together to develop a shared understanding.

Formulation should be person-centred and based on individual experience and evidence, synthesising these to identify new meanings and solutions. Processes to support the delivery of formulation, consent and collaboration with service users and the involvement of staff members from all disciplines will support its continued evaluation and evolution.