‘It’s just a bunch of people telling your story, excluding you from the telling’

Caroline Clare with her experience of implementing shared psychology case formulations for staff in a high dependency rehabilitation unit for adult males, and feedback from some of the service users who were involved.

I was at the ‘Developing Trauma informed Services’ conference, delivered by the British Psychological Society’s Division of Clinical Psychology Faculty of Psychosis and Complex Mental Health. Those who had used services, and were now trying to advocate for improved services, were talking about the experience of psychological case formulations from their perspective. ‘It’s still just a bunch of well-intentioned people, telling your story, and excluding you from the telling,’ said one… or words to that effect. Those words gave me a physical, uncomfortable feeling in my stomach.

We had tried hard to focus on formulation rather than diagnoses, and understanding a person as a whole, rather than just a label. Psychological formulation is a shared assessment process, where a client and therapist work together to understand a client’s current, and previous, distress. It draws on available psychological theory to create hypotheses, or ideas, of what might be contributing to a client’s current difficulties and what psychological therapy should offer to help that person. A range of different approaches to formulation including systemic, cognitive and psychodynamic are available. We were flexible in the approach used at Cygnet Oaks but there was a common theme: that the formulations were trauma informed. That a client’s ‘symptoms’ could perhaps be better understood as a way of adapting and surviving to the adverse environments they had experiences.

I thought we had been getting it right. We were working hard to involve the individuals in developing the formulation. And then we were sharing this with staff so that they could understand and support the service user more. But then we were excluding them from the telling, taking ownership of a story that was never ours to begin with. More exclusion – something we know is at the heart of every trauma survivor’s experience already.

By the time my train pulled in to Leeds that evening, I had decided we were going to make some changes. We were going to ask the individual to tell their story. Or at least to be there and listen to us tell it. Or at least have the choice.

The reaction from staff was interesting. ‘Won’t it make them more distressed?’ ‘What if the other staff don’t respond well to them?’ ‘What if they start talking about things we didn’t know about?’ Our attempts at protecting people from difficult feelings were leading to disempowerment. These individuals had survived the experiences, but we were deciding they were too fragile to talk about it. Yes it is important to recognise that for some people discussing past trauma is re-traumatising and has a negative effect on well-being (Levine, 2010), and this view has been shared by service users before that it could be painful to talk about their past when they weren’t ready to do so (Jennings & Ralph, 1997). But we talk about empowering the individual, and then we were making the decision on their behalf.

I asked other colleagues about their systems for sharing formulations and quickly discovered that other services were also excluding the individual from the telling. All had an established understanding of the potential benefits of psychological formulations, which is often cited in best practice guidelines including the comprehensive Division of Clinical Psychology Good Practice Guidelines (2011). People were aware of the benefits of collaborating during the production of formulations, and a range of literature supports how this practice can be empowering and reduce the unhelpful power dynamic between professionals and service users (McManus et al., 2010; Perkins & Slade, 2012). But the collaboration seemed to stop there. The Good Practice Guidelines do not explicitly suggest involving the service user in sharing the psychological formulation. A review completed by Evans (2020) explored the literature on psychological formulations across different mental health services; no reference of services delivering the formulations with the individual is made within this.

So, tentatively, we felt like we were taking a slight step in to the unknown. I approached some of the service users with my suggestion, and asked them if they would like to take part. The reaction was mixed. Anxiety was high, but this appeared to be more due to public speaking, rather than the content of what they were being asked to talk about. Reminding people that they were the expert of their experience, and that they couldn’t possibly tell their own story ‘wrong’, appeared to give some relief. Some individuals wanted to tell their story and help other people understand them better. Some were keen to attend and listen to what was being said, and to gauge the reactions from staff. Sadly, some felt that even with them in the room, or even if they told their own story, people would not be interested and would pay more attention to the professional telling it. Years of time in services had probably reinforced this view.

So we continued to deliver weekly psychological formulation meetings for staff in the hospital, and some involved the service user leading on telling their story, whilst others chose to co-deliver, or attend and listen. I am often struck by the resilience and recovery of trauma survivors. Hearing them tell their stories and share them outside of our individual therapy sessions left me with an increased sense of inspiration and admiration. Staff hearing the experience in the individual’s words, to make sense of their behaviour as survival responses (rather than ‘symptoms’ or ‘challenging behaviours’), was more impactful than reading a written formulation. The individual got to choose what was most relevant to talk about, not us. Service users would answer questions directly about what was helpful and unhelpful for them. The drive for more compassionate forensic services (Levenson et al., 2017) felt like it was in motion, and motivated me to do more.
Here are some of the experiences from the service users, in their own words:

Rob’s experience: ‘I found it helpful for everyone to know that I didn’t self-harm for no reason. The reason I was self-harming was because I was raped. I found the meeting good as it helped the staff to understand that I wasn’t attention seeking. I got to tell my truth. I found that I got a lot more support after the meeting as staff were able to understand me better. The support was more tailored to me. There was nothing I didn’t like about the meeting and I would want future formulation meetings to be delivered in the same way. My psychologist was amazing and supported me through a crisis. I feel the support changed my life for the better. She [psychologist] reassured me that I wasn’t in trouble for self-harming.’

Adam’s experience: ‘It was a new experience. It was alright, I learned a few things about my past. The psychologist read out my formulation which we worked on. It was a soothing experience and I felt comfortable whilst she was discussing my formulation. It was good to know that staff are interested in my past. I was told that if I had any issues after then I could seek help and guidance. I think it benefited me and the staff. I think it helped the staff to learn about my past and to get to know me, and what kind of person I was in the past and what kind of person I am now. I attended the meeting twice, I wouldn’t do it again, one time is enough.’

Routine practice for us has now changed. Part of the collaboration in developing psychological formulations now involves discussing with the individual how they would want their story to be shared, and who with. Some people may have already been delivering formulations in this way, and I congratulate you if so. Others may have thought about it and talked themselves out of it. For some, it may be an alien concept to you. We moved up the ladder from ‘doing for’ to ‘doing with’ on the co-production ladder (National Collaborating Centre for Mental Health document, 2019) and I would encourage others to take the next step. As this document asks professionals to do; ‘make no decision about me, without me’ (Department of Health 2012).

- Caroline Clare, Forensic Psychologist (BSc, MSc, CPsychol)
[email protected]

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