Contextualising Distress II: Formulation and Practice Plan
Contextualising Distress II: Formulation and Practice PlanIssue 21 – March 2010
Authors: Bob Diamond and Steven Coles (firstname.lastname@example.org and email@example.com)
- Personal history and social context are central factors to understanding and supporting people who are distressed
- Formulation can highlight a distressed individual’s perspective and their context. However, formulation can be problematic if expert driven and imposed upon a person.
- In supervision formulation may support staff reflection, but added care is needed to consider the perspective of the person within services
Implications for practice
- The formulation and practice plan is a flexible template covering four main areas of a person’s life: Historical and Social Context; their perspective and relationship with Mental Health Services; Current Goals and Challenges; and Resources and Strengths.
- Ideas about understanding a person and their situation should be tentative and open to change
- Any suggestions for practice and action should be negotiated with the person and their perspective sought and respected.
IntroductionA person’s life history and social context are central to shaping mental health difficulties and are also crucial to supporting a person to improve their life circumstances and well-being 1,2. However, personal and social contexts are not always given as much emphasis within mental health services as they deserve. Formulation is one potential way of highlighting an individual’s context and helping make sense of their distress; however, there is a broad range of different approaches to formulating someone’s experiences. Given this range, formulation can be problematic for example: it may pathologise the individual and ignore their context; impose an ‘expert’ perspective and undermine the views of the distressed individual; and can share many of the difficulties associated with psychiatric diagnosis3,4. Johnstone (2006)4 outlines some ideas for avoiding these difficulties when formulating such as: workers should reflect on their values and assumptions; formulations need to be flexible and tentative; they should be conducted sensitively, collaboratively and give significant weight to the perspective of the person they are focussed on; and it is necessary to include social context within each formulation. Formulations can also be used within supervision to support staff reflection on the perspective of a distressed individual, their context and how services might be hindering as well as helping. It is essential whilst conducting such a formulation to try to ‘step into the shoes’ of the person and to attempt to consider issues from their standpoint, including how it might feel given their history and current circumstances. The following gives an overview of a practical template for formulating within staff supervision. The Formulation and Practice Plan should be used flexibly and seen as a broad guide for areas to reflect upon.
Formulation and Practice PlanThe formulation and practice plan covers four main areas of a person’s life and then focuses on emerging themes and ideas for practice. The ‘Historical and Social Context’ section is completed first, as the context of a person’s life is central to making sense of a person’s distress and experience. As well as summarising what is known about a person, the section is helpful for highlighting what is not known and therefore what might be enquired about in the future. The ‘Mental Health Services’ section should be used to highlight and try to reflect on a person’s perspective and experiences of mental health services: what they like, dislike, find helpful and unhelpful. Consideration could be give to why a person might not want contact with services or reflect on their perspective on psychiatric medication. The differing perspectives between services and the person within services should be contemplated. The ‘Current Goals and Challenges’ section may cover a range of difficult issues as well as forward looking goals and hopes. Care should be taken to consider who the issue is a problem for – is it a problem for the person in services, services, family or wider society? The ‘Resources and Strengths’ section considers a range of resources and strengths such as social life, family, housing, neighbourhood, education as well as personal strengths and coping strategies (see Hagan and Smail, 19975 and Power-mapping Bite-Size 20). Following the broad discussion of a person’s life the ‘Emerging Themes’ section attempts to identify a few key issues or aspects of a person’s life. This might simply be a list, or it could start to go beyond the facts and hypothesise on possible connections between someone’s difficulties and their life experiences. This section may also draw on other social and psychological theories to help understand the issues. However, it is essential to be tentative and remain open when considering more exploratory ideas and links, and such thinking should be grounded in what is ‘known’ about the person. Issues might also include ethical dilemmas and tensions between team members on how to work with a person. The final section ‘Actions’ looks at what staff may try putting into practice. This might include drawing on what seems to have worked or helped in the past, supporting access to current resources in a person’s world, or contemplating the future and what a small step forward might look like. It is central to reflect on what the person’s goals, interests and hopes are, and if these are not known to attempt to find these out. Again ideas for actions should be flexible and it is crucial that they are negotiated with the person within services and their perspective given weight.
Historical and Social Context – Family, social, educational, occupational, culture, diversity, etc
Mental Health Services – i.e. what is the client’s view of services? What does the client find helpful / unhelpful? What is the client’s engagement with services? What’s worked in the past?
Current Difficulties and Challenges – i.e. what are the current issues? What are the key service challenges / goals? What are the client’s current unfulfilled goals? What are the barriers to progress? Relevant history of difficulties
Resources and Strengths – i.e. Coping strategies? What problems have they overcome? What are their personal strengths? What material resources do they have? What activities are they involved in? What positive relationships do they have?
What are the emerging themes and key issues? (from page 1) – What are the key issues currently and from their history? How are different aspects of a person’s life connected?)
Actions – things to be put into practice? – Consider what are the client’s goals? What would one step further look like? what would have changed? What works? What resources does the client have or could access? What has helped in the past? Care plan?
- Friedli, L. (2009). Mental health resilience and inequalities. Denmark: WHO
- Smail, D. (2005). Power, Interest and Psychology: Elements of a social materialist understanding of distress. Ross-0n-Wye: PCCS Books
- Harper, D. & Moss, D. (2003). A different kind of chemistry? Reformulating ‘formulation’. Clinical Psychology, 25, 6 – 10.
- Johnstone, L. (2006). Controversies and debates about formulation. In L. Johnstone and R. Dallos (Eds.) Formulation in Psychology and Psychotherapy. Sussex: Routledge.
- Hagan, T. & Smail, D. (1997). Power-mapping – I: Background and basic methodology. Journal of Community and Applied Social Psychology, 7, 257 – 267.
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