The International Journal of Psychosocial Rehabilitation

Using Psychological Formulation As A Means Of Intervention
 
In A Psychiatric Rehabilitation Setting

 

Olivia M. Hewitt, BSc (Hons), D. Clin. Psych.

 
Citation:
Hewitt, M  (2008). Using Psychological Formulation As A Means Of Intervention In A Psychiatric
 Rehabilitation Setting   International Journal of Psychosocial Rehabilitation. 12 (1)


Contact:
Dr Olivia Hewitt
Psychology Department
85 Grove Road
Emmer Green
Reading,
Berkshire 
RG4 8LJ
olivia.hewitt@berkshire.nhs.uk



Abstract
This report describes an intervention undertaken by a trainee clinical psychologist, whilst working with people with severe and enduring mental health problems in the
United Kingdom. It describes an innovative piece of work that helped to shift a difficult situation in which the staff and client were feeling ‘stuck’. The intervention described included a full assessment of the client’s background and current situation. Following this, a psychological formulation was drawn up, focusing on attachment theory, and was shared with the staff team. This then allowed a series of interventions to take place, including systemic work with the staff team. Implications for maintaining change and a critical review of the work are described.



Background Information

Following the closure of the local psychiatric hospital in 2003, twelve people with chronic psychiatric difficulties were re-housed in a private hospital staffed 24 hours a day. The residents remained under the care of a local multidisciplinary rehabilitation team, which includes psychiatrists, psychologists, nurses and occupational therapists.

Reason for Referral
Anita was referred to this multidisciplinary team (MDT) by the staff team of her residential home. She had previously received diagnoses of schizophrenia and obsessive compulsive disorder. The staff team were experiencing difficulty in managing Anita’s behavioural compulsions in a coordinated manner. They felt the frequency of her compulsions was increasing, and disagreements over managing these was causing tensions within the staff team. Therefore the home manger asked the MDT for advice on managing this behaviour. The MDT had supervised Anita’s care for many years, and felt psychology would provide the most helpful intervention for the staff team.

Aims
Following the referral several aims were identified:

Informed Consent
Anita and her key worker met to discuss psychological involvement, and to obtain consent for this. The psychologists within the MDT were well known to Anita through their involvement with care programme approach meetings. Anita gave consent for the various stages of this piece of work, such as consenting for me to communicate with her mother, or to look at her medical notes.

Initial Assessment

An extended assessment gathered information from:

·        Anita,

·        discussion with the staff,

·        medical notes,

·        discussion with the MDT,

·        informal observations at home,

·        interviewing Anita’s mother.

 

Getting to know Anita
Engagement

Anita was known to be reluctant to inform professionals about changes in her mental health. Therefore, the process of assessment took place over several weeks, during various activities e.g. shopping. This was explained to Anita as an opportunity to get to know her better and thus find ways of improving the relationship between her and the staff team.


Presentation
Anita was a casually dressed woman in her forties. Her clothes were noticeably stained. Before leaving the house she would brush her hair and put on underwear when prompted by staff. Although Anita had new clothes, she only felt able to wear one large jumper and a pair of jogging bottoms. Anita was overweight at this time.

Current Situation
Anita attends a sheltered work project twice a week, undertaking work such as stuffing envelopes, which pays a small wage. Anita enjoys eating out with members of staff, and sees her mother every other week. Anita cooks her own meals regularly, and shops independently for ingredients. She had recently started a relationship with a man who lives on a local psychiatric rehabilitation ward.

Discussion with the staff team
I interviewed several staff members including Anita’s key worker in order to understand the challenging behaviours, and learn about the relationship between the staff team and Anita. This revealed conflicting theories around managing Anita’s behaviour.

Staff did not know how to respond to Anita’s compulsive behaviour. These compulsions changed every few weeks, and once one compulsion had been eliminated, another would arise. Examples of compulsions included putting paper towels down the toilet, and touching the plastic pots used to dispense medication a certain number of times. Staff were concerned that she may jeopardise her links with the community through her restricted use of clothes and odd behaviour such as visiting a shop repeatedly to return and purchase the same item.

Anita’s medical notes

Anita had been known to psychiatric services for a number of years, and her clinical notes provided details of past interventions and changes in behaviour. Anita was first admitted to hospital aged 27. She was diagnosed with schizophrenia, and later Obsessive Compulsive Disorder.

Her behaviour in hospital was bizarre at times, for example bathing while fully dressed, and covering drinks to prevent contamination by germs. A range of medications were trialled unsuccessfully. Anita reportedly experienced a severe lack of motivation and engaged in few activities. For several years she did not leave the ward, and her ability to self care was severely impaired.

Following the introduction of clozapine[2], Anita’s motivation and engagement with others improved. The clozapine was discontinued due to physical complications, but reintroduced after a rapid deterioration in her mental health. Anita was then able to engage with some social activities. However behaviours such as hoarding food, throwing money away, and being unable to write anything down without subsequently crossing it out persisted throughout her hospital stay to the present time. At the time of referral Anita took several medications including clozapine, and citalopram[3].

Interviewing Anita’s mother
Anita gave consent for me to meet with her mother who provided information about Anita’s history. Anita currently met her mother twice a month although their relationship had been more distant previously.

Family History
Anita’s mother Pam felt she was called by God to be a nurse, and resented her marriage at the age of 21. Pam felt her children prevented continuing with her career, but felt unable to use contraception. Anita’s family tree is given in Figure 1.

Pam “spent her whole life feeling guilty” for conceiving before her wedding. The family struggled financially, at one stage living in a caravan. Anita’s father drank heavily, and the family home was noisy and crowded. Anita cared for her younger siblings while her father was at the pub and her mother was working. Pam said she couldn’t give Anita much attention due to her job, and because her son had a learning disability. The family accommodated several foster children. Pam reported that her husband was abusive to all the children but singled out Anita.

Figure 1: Genogram of Anita’s family 

Gemma married at 16 and lives in Cornwall. Anita has lost touch with all her siblings except Gemma, who sends occasional cards.

Alan spent time in the same hospital as Anita for alcohol detoxification. Cyril suffered anoxia at birth and has lived in institutions for people with learning disabilities. David is dependent on alcohol, and has no fixed abode. He has Asperger’s syndrome and is considered a dangerous person by the police, having threatened Anita and Pam with a gun in the past.

 

Personal History
Anita was described as being a very quiet child. She left home at 15, and lived with a family friend until she left school with 2 O levels at 17. She had several jobs including factory worker. At 16 she moved in with her first boyfriend. He sold drugs, and Anita used alcohol and cannabis heavily at these times. Anita and her boyfriend went abroad for several months and lost contact with Anita’s family. Whilst away, she became unwell, experiencing hallucinations and displaying bizarre behaviour such as refusing to remove her raincoat. The couple did not have enough money to return to the UK, and Anita may have been sold for sex in return for their airfare home. On their return Anita became increasingly unwell. She was unable to undress when bathing, and was admitted to a psychiatric institution. Her mother believes Anita’s compulsions as began with this admission.

Anita received psychiatric diagnoses (schizophrenia and OCD) in the past but few attempts had been made to understand her behaviour from a psychological perspective.

          
Formulation
A preliminary formulation was drawn up with supervision from my clinical supervisor, and a specialist in systemic formulations using the information gathered. This draws on several approaches including attachment theory and psychodynamic concepts.

As a child Anita lived in a context of danger (violence and bullying from father) and her needs (emotional and physical) were unmet by her parents. Her caregivers were unavailable, unpredictable and unreliable. Anita ignored her own needs in order to care for her siblings. Children whose needs are not met by caregivers may either increase their attachment behaviours in an attempt to get their needs met, or may withdraw and internalise their needs (Bowlby, 1969). From Anita’s description as a withdrawn child, she concealed her unmet needs and internalised the resulting feelings of anxiety. Individuals with insecure attachment styles may be at increased risk of developing psychosis (Berry et al, 2007). This pattern of withdrawing from others was seen during her hospital stay, when she interacted infrequently with staff and patients.

There was a deficit in caretaking during the early months of Anita’s life as her mother was incapacitated through guilt, resentment towards Anita, and the demands of her other children. Anita’s father was described as “bullying” Anita, which reportedly included criticising her appearance and behaviour, and accusing her of sexually promiscuity. This may have lead to fundamental developmental damage resulting in distortions to Anita’s basic sense of reality and whether the world and others can be experienced as dependable. This critical, negative attention is replayed by the staff team who find themselves “telling her off” for her socially inappropriate behaviour. It may be that negative feedback is ego-syntonic for Anita and that she feels more comfortable receiving this type of attention, than other, more positive interactions with the staff. Children who experience adverse circumstances in childhood (including parental mental illness, and witnessing domestic violence) have lower levels of social functioning in adulthood and are more likely to experience psychiatric illnesses (Rosenberg et al., 2007). Lack of good enough parenting (i.e. empathic attunement to the infants’ communications and needs) may fundamentally damage the capacity to relate to others and to regulate one’s own emotions (Cassidy, 1994). Anita’s anxiety, which she attempts to control through her thoughts and behaviours, cannot be contained or regulated and is experienced as overwhelming and threatening to her self. This anxiety is felt by the staff team and is reflected in their determination to ‘do something’ to help Anita, and their difficulty in tolerating her anxiety.

Anita’s subsequent relationships were with violent, unpredictable men. They were unable to provide Anita with stability, mirroring Anita’s childhood experiences of a chaotic household. Anita’s involvement with alcohol and drugs may have suppressed her emotional needs and memories of past trauma. Drugs and alcohol are frequently used as substitutes for defence mechanisms (Khantzian & Kaufman, 1994). Defences prevent feelings, ideas, impulses and entire subjective experiences from being consciously articulated or from reaching conscious awareness (Shapiro, 1989 in Khantzian & Kaufman, 1994).

During her hospital stay Anita remained detached from others, feeling unable to join others in activities for many years. The routines and rituals which protected her from perceived danger (e.g. covering drinks to protect herself from germs) may have helped to regulate her emotional distress. They provide a sense of control and predictability that had been missing from her environment, contained her anxiety, and defended against her internal pain. Obsessional checking may be a way of managing unacceptable hostility, which Anita may feel towards her parents who were both unable to meet her needs as a child and as an adult. The damage which Anita fears would result from the hostility requires the constant reassurance of the checking (Leiper, as cited in Vetere & Dallos, 2003).

Anita’s current style of relating to staff demands a large amount of staff attention.

Collaborative Reformulation with staff team
Parts of this formulation could be shared with the staff team to help them understand Anita’s challenging behaviours. The formulation was presented as a working hypothesis, and staff were encouraged to contribute further information or hypotheses about Anita’s current behaviour and her past experiences. Little was known about her social interactions or what sense she made of her experiences in hospital. Detailed notes about her medication over the years existed, highlighting the predominantly medical model in which Anita lived, perhaps with insufficient attention being paid to her internal world. Many of the staff team had known Anita over several years, and it was hoped they could contribute important detail to the formulation.  

This consultancy based session centred on the premise that the client (the staff team) is expert at understanding their own system (Anderson & Goolishan, 1992), and encouraged staff to form a narrative about their own abilities in overcoming the ‘problem’ (Wilcox & Whittington, 2003). This meeting was attended by five staff members, including Anita’s key worker, and a nurse, Brian, who worked with Anita for many years in hospital. Staff were encouraged to try to make links and hypotheses based on the information I had gathered. A number of techniques were used including Socratic and circular questioning to try to increase staff’s empathy and understanding of Anita’s situation (e.g. Vetere & Dallos, 2003).

Initially the staff team looked to me as an ‘expert’ to provide guidelines on managing Anita’s behaviour. When it became clear that I believed them to be the experts on the situation, several staff members, especially Brain questioned the value of the session. The team appeared to look to the MDT for guidance and felt uncomfortable with the idea of them as ‘experts’. I wondered whether the staff team felt pressure to ‘cure’ Anita, and worried that their continuing difficulties were viewed as a failure by the MDT.

With the acknowledgement of their expertise, and the assurance that they were not being blamed them for ‘failing’ to manage Anita’s behaviour, the atmosphere changed. Staff provided much useful information about Anita’s previous behaviour and relationships in the hospital. Examples of changes in her ability to socialise and relate to others were given, and we reflected on the progress Anita had made over the years. I learned about the challenges Anita’s behaviour had posed to staff in the past, and the resulting frustration. I highlighted changes between Anita’s past and current functioning. Her increased confidence, self-esteem, ability to form and maintain relationships and her job in sheltered employment were all discussed. Contrasts were made between her current level of independence in the home and community, and her previous inability to leave the ward in hospital. Staff also realised that the frequency of her compulsions had greatly reduced since leaving hospital and noted that these behaviours were not causing her subjective distress.

Staff participated enthusiastically in this session, and made hypotheses about Anita’s behaviour. Brian wondered whether Anita’s difficulties in self regulation may contribute to her current over eating, and considered the effect her current body shape on her self-esteem. Another staff member had noticed that Anita’s mother also crosses through her signature in the home’s visitor’s book, and wondered whether Anita had learned this behaviour. Most significant was a shift in attitude from Anita being, in Brian’s words “just really annoying”, to someone who had faced significant difficulties throughout her life, and who had made much progress.

Removing possibilities of blame allowed the team to let go of their defensive feelings, and approach the exercise with curiosity. At the end of the session, I asked the team about the implications of this session. They felt they lacked training around OCD, and would welcome a teaching session on this. Service providers should know about the impact of serious psychiatric disability such as psychiatric symptoms and the course of disorders (Corrigan et al., 2001)

A number of ideas were generated by the staff team, which linked areas of Anita’s current behaviour with information about her past. These included acknowledging the role of her early upbringing on her subsequent psychiatric difficulties, the sense of control her obsessions and compulsions may have given her in unpredictable environments, and the nature of her interactions with others in the past which have been predominantly negative. Staff suggested that any ‘positive’ attention may not fit with Anita’s view of herself and therefore would be uncomfortable for her.

The staff team drew the following conclusions from the session:

 
Staff Teaching
Following the staff team’s request for teaching on OCD, a session was planned at a convenient time. Several MDT members wished to attend the session. The staff team decided MDT members would be welcome at the teaching session, and hoped the MDT would understand more about the day-to-day challenges they faced, and would facilitate a coordinated approach to Anita’s management.
This session was conducted in Anita’s home, and was attended by MDT members. The home manager, and six members of the staff team, including Brian and Anita’s named nurse, also attended.
The session included basic education around the symptoms and diagnostic criteria of OCD. Examples of other people with OCD in both more and less severe instances that Anita were given. The discussion led onto a recent television programme by Professor Salkovskis. This featured three people with severe symptoms of OCD overcoming their difficulties through intensive cognitive behavioural interventions. The staff team wondered whether Anita could be cured by a short-term cognitive behavioural intervention, reflecting a persistent desire to ‘cure’ Anita. Thinking about the differences between Anita and the people featured in the programme revealed some of the complexities of Anita’s behaviour and the complications added by her diagnosis of schizophrenia.

 I shared the background information and hypotheses resulting from the reformulation session with the staff team. Time was spend thinking about obsessions and compulsions as occurring along a continuum, with some level of these being in the normal range and experienced by the general population. Some of the traditional interventions for OCD were discussed including the behavioural exposure response prevention strategies that had been unsuccessfully tried with Anita in the past, and more recent cognitive behavioural techniques. The group explored whether these approaches would be suitable to use with Anita. Given our increased understanding of Anita’s history, an approach based on this information would be most helpful in containing Anita’s anxieties, and helping the home staff team and the MDT work in a mutually supportive way. The group developed some guidelines for working with Anita:

In addition, we reflected on the progress Anita has made over the past 20 years. The MDT commented on the quality of care the staff team had given to Anita over the years. Both teams agreed that Anita was someone with complex and long standing difficulties and that further progress would require patience from all involved in her care. This acknowledgement that the MDT did not expect the staff team to in some way ‘cure’ Anita, and that they appreciated the day to day demands she placed on the service were welcomed by the staff team.

Evaluation
The process of engaging with Anita over several months gave Anita an experience of a therapeutic relationship in which she was able to discuss some of her difficulties, especially around her relationship with members of the staff team. Anita’s engagement with the therapist was not formally measured, although it was clear that she felt more able to discuss her distress and interpersonal conflicts freely as the therapeutic relationship grew stronger. Anita was keen to spend time with the therapist, and prioritised these sessions above other activities she also enjoyed.


Initially the staff team lacked confidence and felt overwhelmed by Anita’s behavioural difficulties. The team felt an expectation from the MDT to manage or ‘cure’ Anita, which they felt unable to do, and subsequently left them feeling disempowered, frustrated, and critical of Anita. These dynamics were established through extensive discussions with several members of the staff team, discussion with members of the MDT, and through supervision.

One aim of the intervention was to empower staff to manage and contain Anita’s anxieties. The collaborative formulation allowed staff to discover where the anxiety around Anita originated from. It also allowed them to generate strategies around how best to manage this, and how to coordinate their approach to the difficulties both within the staff team and with the MDT. Formal measures of staff morale and locus of control were not taken. However qualitative feedback from the staff team indicated that the collaborative formulation session was helpful and allowed staff members to develop a more detailed picture of Anita’s life. With this additional information came a renewed sense of empathy. When presented over many years, Anita’s progress in many areas including social skills and participation in activities was highlighted. This reportedly countered the feeling that Anita was “stuck” and that the efforts of the staff team made no difference to her quality of life.

The staff reported that the training session allowed them to understand the symptoms of OCD and current theories around treatment. Staff participated and appeared engaged in the teaching session.

One important outcome of this intervention was an improved working relationship between the staff team and the MDT. Both teams indicated that this process had enabled future work to be more coordinated and consistent, and had communicated several important messages to the staff team. These included reassurance that the MDT did not expect the staff team to ‘fix’ their clients, and an appreciation from the MDT of the day-to-day difficulties faced by the staff team.

 

Critical Review
The work lacks quantitative evaluation, and relies on qualitative feedback from individuals in the system. A more systematic method of evaluation may have collected more information and allowed stronger conclusions about the efficacy of the work to be made. Standardised measures of change over short periods of time are difficult to obtain for this client group. 

One aspect of the work I found particularly valuable was improving the communication between the staff team and the MDT. It was clear how assumptions could be made about what was expected from the staff team, or that indirect messages were being given out by the MDT. If these are not made explicit or challenged openly, the relationship between the two teams could deteriorate, affecting the quality of care for all clients in the service. Through supervision I explored the difficulties from various perspectives including the staff team, members of the MDT, and Anita. This flexibility of thinking and ability to develop empathy for all members of the system allowed me to step outside the system and gain a different perspective, whilst remaining mindful of the challenges faced by each group.

Ethical issues were carefully explored in supervision. Anita had experienced many damaging relationships in the past. The experience of a therapeutic relationship which was non-judgemental, yet curious about her story, may have been novel for Anita. Therefore I thought carefully about the impact of establishing and withdrawing this relationship on Anita. The boundaries of the relationship were explicitly explained at the beginning and throughout the relationship. Towards the end of the work, Anita and I thought together about alternative sources of support.

Alternative models of working could have been used. There is a good evidence base for the effectiveness of an individual cognitive behavioural approach for OCD, based on the cognitive model of OCD proposed by Salkovkis (1985) (e.g. Whittal, 2005). However, Anita’s difficulties in accessing her cognitions would make reappraising harm related cognitions difficult. In addition, exposure response prevention may reduce compulsions amongst individuals with OCD (McLean et al, 2001). The consistent and coordinated approach it requires from the staff team made it difficult to implement practically. This approach had reportedly been used in the past, but was unsuccessful, due to Anita’s fluctuating motivation to comply with the response prevention.

It may have been useful to use a reflecting team approach (e.g. Vetere & Dallos, 2003) to support the development of the team’s confidence, and to help with the concept of problem externalisation (White, 1989).

One challenge of working within rehabilitation settings can be the maintenance of progress. This intervention endeavoured to transfer the mechanisms and responsibility for change from an external locus (the MDT) to a more internally located locus. In order for change to be maintained, the dynamics between the two teams needs to shift, so that the staff team can feel empowered to work confidently with Anita. In turn, the MDT need to understand more about the skill mix of the staff team, and ensure that each team has a clearly defined role within Anita’s care (Firth-Cozens, 2001).




References

Anderson, H. & Goolishan, H. (1992). The client is the expert. In S. McNamee & K.J. Gergen (Eds) Therapy as a social construction. London: Sage.

Berry, K., Barrowclough, C. & Wearden, A. (2007). A review of the role of adult attachment style in psychosis: Unexplored issues and questions for further research. Clinical Psychology Review, Article in Press.

Bowlby, J. (1969) Attachment and loss: Vol. 1. New York: Basic.

Cassidy, J. (1994). Emotion Regulation: Influences of Attachment Relationships.The Development of Emotion Regulation: Biological and Behavioral Considerations. Monographs of the Society for Research in Child Development, 59, (2/3), 228-249.

Corrigan, P.W., Steiner, L., McCracken, S.G., Blaser, B. & Barr, M. (2001).

Strategies for Disseminating Evidence-Based Practices to Staff Who Treat People With Serious Mental Illness Psychiatric Services 52, 1598-1606

Firth-Cozens, J. (2001) Multidisciplinary teamwork: the good, bad, and everything in between Quality in Health Care,10, 65-66

 Khantzian, E.J. & Kaufman, E. (1994). Psychotherapy of addicted persons. Guilford Press.

McLean, P.D. Whittal, M.L., Thordarson, D.S., Taylor, S., Sochting, I.,  Koch, W.J.,Paterson, R. & Anderson, K.W. (2001). Cognitive versus behavior therapy in the group treatment of obsessive–compulsive disorder, Journal of Consulting and Clinical Psychology, 69, 205–214.

Rosenberg, S.D., Lu, W., Mueser, K.T., Jankowski, M.K. & Cournos, F. (2007). Correlates of Adverse Childhood Events Among Adults With Schizophrenia Spectrum Disorders Psychiatric Services, 58, 245-253.

Salkovskis, P.M. (1985). Obsessional–compulsive problems a cognitive-behavioral analysis, Behaviour Research and Therapy, 23, 571–583.

Vetere, A. & Dallos, R. (2003). Working systemically with families. London: Karnac White, M. (1989) The externalising of the problem and the re-authoring of loves and
relationships. Dulwich Centre Newsletter.

Whittal, M.L., Thordarson, D.S. & McLean, P.D. (2005). Treatment of obsessive– compulsive disorder: Cognitive behavior therapy vs. exposure and response prevention. Behaviour Research and Therapy, 43 (12 , 1559-1576

Wilcox, E. & Whittington, A. (2003). Discovering the use of narrative metaphors in
work with people with learning disabilities. Clinical Psychology, 21, 31-35.





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