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FACILITATOR GUIDE TO ACCOMPANY MHPOD TOPIC: FORMULATION Instructions for a 45-60 minute workshop for workers who have completed the MHPOD topic:
FORMULATION.
WORKSHOP NAME: From formulation to intervention plan
Workshop purpose statement:
While not all workers need to be skilled in constructing formulations they need to know how existing formulations can inform practice and planning in order to improve outcomes for consumers and their families. This is particularly the case when consumers present complex and challenging issues for a team or individual worker. • give workers an opportunity to review a well constructed formulation and use it to • improve capacity for teams and individuals to draw on constructed formulations, to beneficially inform their plans and practice with consumers, families and other agencies. Workshop preparation and timing
Recommended time needed: 45-60 minutes
Preparation and Resources needed:
• It is assumed that the facilitator and all workshop participants have completed the MHPOD topic: Formulation.
• Copies of chosen scenario (Charise or Mark): one per participant. • Copies of blank plans: one or more for each small group – you may choose to enlarge these onto A3 sheets for easier working in a group. • Room set up with whiteboard and pens. Facilitator Guide
Instructions to facilitators:
• Complete the topic: FORMULATION, familiarising yourself with the range of resources
• Identify the scenario (located in the Workshop resources section) of most relevance to • Read and familiarise yourself with the formulation and plan for your chosen scenario. You may want to make some additional notes of information that you would expect to be in a plan for Charise or Mark. Suggestions for working with a virtual group:
• Email chosen formulations and blank plan worksheets to participants prior to • Conduct the activities as a large group discussion, actively facilitating the participation of everyone. Where possible draw on the range of discipline expertise to contribute to the intervention plan. Where relevant, consider local issues / services/barriers. Facilitator Information
This information is provided to support facilitators in confidently managing the workshop content and in facilitating effective discussions with participants. The aim should be to draw knowledge from participants and use the following information to fill gaps, correct misunderstandings/ misinterpretations of the material. This information should not be used in a lecture format. For activity point 1.
• What are the key components of a formulation and how do they add to our practice? A formulation usually consists of 3 parts: 1. Summary
• Statement of the consumer’s demographic status. • Involvement with the service. • Reason for presenting care. • Biological, psychological and social risk factors. • Biological, psychological and social protective factors. • Developmental or spiritual domains. • Patterns in the consumer’s life. 3. Conclusion
• Statement of planned treatment and prognosis. Remind participants that this is not the only way to write up or think about a formulation. Workers who follow particular theoretical frameworks (e.g. psychodynamic, cognitive behavioural) may have alternative approaches to formulation. To consider how they add to practice, after seeking input from participants, summarise by reading from: Havinghurst, Sophie & Downey, Laurel. (2009). Clinical reasoning for child and adolescent mental health formulation: The mindful formulation, Clinical Child Psychology and Psychiatry, 14(2), 251. What is a formulation?
“A formulation is the clinician’s hypothesis about the intra- and inter-personal dynamics that underlie the client’s difficulties. It is the process by which the clinician integrates all of the information known about a client and their environment with clinical knowledge and theory, in order to understand their presenting difficulties, the history of these difficulties, and how they are maintained (Herbert, 2001; Johnstone & Dallos, 2006). A good formulation is also collaborative, accounting respectfully for the client’s own hypotheses about the problem (for more in-depth exploration of this idea see Dallos et al., 2006). The formulation becomes a working hypothesis that directs the clinician’s choice of intervention and assists them in predicting issues that may impede or assist in efforts to bring about change. "Good formulation helps the clinician obtain a broader and deeper understanding of the client, guides selection of one treatment modality over another, assists in prediction and understanding of non-compliance, treatment failure and setbacks, and enables the clinician to understand and work within the therapeutic relationship (Persons, 1993).” (Havinghurst & Downey, 2009, p. 254). Havinghurst, S. & Downey, L. (2009). Clinical reasoning for child and adolescent mental health practitioners: The mindful formulation. Clinical Child Psychology and Psychiatry, 14(2). For activity points 2 & 3.
Use the following tables as a guide to facilitate feedback on the plans that small groups develop for Mark/ Charise. While not exhaustive plans, they identify some of the key issues raised in their formulations. Participants in your workshop may identify other highly relevant issues. Factors that should be incorporated into a plan for Mark
Plan: informed by formulation
Short/medium term: Needs secure supported accommodation from which to establish compliance with Clozapine and implement comprehensive rehabilitation plan, with a focus on building his skills in daily living and developing a meaningful routine and occupations. Aim should be to build trusting relationship with workers that can be maintained in the long term when he moves into less supported housing. Mark has two Axis 1 diagnoses that need active treatment. A trial of Clozapine is recommended as this facilitated optimal control of his symptoms in the past. His response to ECT and mood needs to be monitored. He needs secure and supported accommodation in order to implement a trial of Clozapine with a view to stable long term community housing that can support his active engagement with Clozapine and the required monitoring. Mark presents a significant risk to self, people and property when he is acutely unwell. Aggressive behaviour has been noted as an early indicator of relapse and any threats/signs of aggression should be taken seriously, with increased monitoring and support. A motivational interviewing approach to address his polysubstance abuse should be trialled. His substance use is a risk factor and increases risk of other behaviours. Need to understand his cognitive ability in order to tailor a psychoeducation strategy to meet his needs. Need to determine whether noncompliance/disengagement with mental health services has resulted from lack of understanding of his illness and needs rather than from any intention to deny or resist his illness or system supports. Psychological testing will be important to determine his strengths and limitations, cognitive capacity, and the kinds of educational strategies likely to be most effective. This testing will also provide information on rehabilitation approaches that are likely to optimise success. Plan: informed by formulation
Mark has a history of disengaging and resisting supports. Considerable efforts need to be made to build positive relationships with Mark as part of his rehabilitation. A willingness to work with Mark to identify his personal interests and goals, and a preparedness to tolerate challenges to the relationship will be critical in demonstrating acceptance and interest in Mark, as a foundation to a therapeutic relationship with him. A comprehensive program that facilitates Mark to build skills in a gradually more challenging environment over an extended time is required. Further assessment of his capacity for daily living skills, leisure and vocational skills, relationship skills and skills for community living is required. This needs to be linked with a clearly focused program of skill building that enables Mark to acknowledge and celebrate progress. Goals need to allow success, rather than reinforce Mark’s deficits and challenges. Factors that should be incorporated into a plan for Charise
Plan: informed by formulation
Has existing accommodation but suitability may need investigation. Strategies for accommodation workers to understand and support Charise’s complex mental health and social issues need to be implemented. Building strong relationships between accommodation workers and mental health workers will be important, for support, shared management and development of a rehabilitation and support plan that Charise finds acceptable. Ongoing fluctuations in mental state as a result of psychosocial stressors – attempts to be made to reduce psychosocial stressors. Ongoing psychoeducation to promote compliance with medication that seems to be effective. Plan: informed by formulation
Significant ongoing risks: self harm, substance abuse, sexual abuse/vulnerability, homelessness, disengagement with all support services. Active attempts to monitor and manage risks, build positive relationships that can tolerate challenges (e.g. increased support provided to accommodation staff to facilitate their positive relationships with Charise), and educate Charise about risks. Efforts to connect with and provide support and education to protective service workers (education on Charise’s mental health and social issues and management strategy for these). Collaborative working with protective services will be important to prevent splitting. Aim to develop relationships and supports that can extend over long periods and provide ongoing support as Charise transitions into adulthood and out of child/youth services. Support for Charise around developing her personal social network (friends and partners). Helping Charise to identify potential interests and to establish roles and routines will be critical. Boredom and social disengagement are likely to exacerbate other problems so developing meaningful educational, vocational and leisure occupations with which Charise can fill her days is important. Developmentally appropriate opportunities need to be accessible for Charise with an opportunity to build skills in graded environments. Workshop plan with instructions for facilitator
Activity Point
Spend the first few minutes reflecting on the topic and degree of knowledge of participants on the construction and use of formulations in practice. • What are the key components of a formulation and how do they Break into small groups to consider a formulation (either Charise or Mark) with the aim of developing a plan based on the issues identified in the formulation. (Aim for each small group to have some mix of disciplines if participants have a range of professional backgrounds). Small groups should read the formulation and brainstorm a list of factors that should be addressed within the intervention plan. Discuss intervention strategies to address the identified issues (small groups with feedback to large group OR large group discussion). Discuss the benefits of using the formulation, some of which may include: • Potential conflicts identified and avoided. • Pre-emptive action taken especially around identified risk factors. • Patterns/themes identified across a person’s life, leading to more effective intervention strategies to address these. • Staff attitudes impacted by increased knowledge/understanding • Increased awareness of strengths, resources and protective factors that can be used in intervention. • Relevant education/information provided to consumer/family/carers/ other workers leading to more effective • Relevant services and their expertise included in timely way. Activity Point
• how formulation might be used locally. • team structures that would allow time for reflecting on information gathered through assessment to be incorporated into a meaningful intervention plan. • how workers can develop skills in formulation. • resources available to build skills in the construction and use of Workshop resources
Mark formulation
Mark is a 28 year old man whose first contact with mental health services occurred when he was aged 18 during 1998. Mark has a well established diagnosis of treatment-resistant schizophrenia which has been incompletely controlled even on high doses of depot antipsychotic in the community. It seems probable that Mark also has a significant depressive element to his chronic psychosis, consistent with his case manager's concerns about lowered mood and suicidality. His chronic paranoia has been associated with multiple assaults on others and significant instability in accommodation, and treatments that were reportedly effective such as Clozapine have been difficult to sustain in the community setting due to his lack of insight and/or engagement. Mark's serious assault in 2002 appears to have occurred in the context of psychosis. The man assaulted is described as a stranger to Mark, and a clear-cut psychotic relapse followed in custody. In the later episode of concern, Mark assaulted a 65 year old woman believing that she had sexually assaulted him, and may have assaulted another elderly person (a man) at the same accommodation around this time. He has also assaulted nursing staff on inpatient admissions, his case manager while in the community, and damaged property including shattering a plate glass door at the entry to his Community Mental Health Service for which he was arrested and charged. He has also been sentenced to a Community Based Order twice for theft and has not complied with the terms of either order. This history of severe interpersonal violence raises the possibility of a personality disorder, which is unfortunately difficult to substantiate or exclude given the lack of a good collaborative history of his early years. Although there is early evidence of substance use (alcohol and cannabis at the age of 10) and learning disorder, there is no known history of violence or forensic contact until after the age of 22 years, by which stage he had been diagnosed as having a chronic schizophrenic illness for over four years. It appears likely that his violence arises in the context of his psychosis rather than an underlying antisocial or borderline personality. Effective treatment of Mark's schizophrenia is the most important priority at present. In view of his previously good response to Clozapine, the reintroduction of this medication in a secure environment should be actively pursued, with a focus on finding ways to support him in the community once he is stabilised. Consideration may also be given to the further use of ECT, particularly for psychotic relapse, in view of the response he has shown during the most recent admission. Neuropsychological and intelligence testing may be useful to identify strengths and weaknesses for Mark and to assist services in shaping their psychoeducation and rehabilitation approach. Mark has demonstrated willingness and some capacity for work and if his psychosis can be brought under effective control he is likely to benefit from vocational rehabilitation. The clinical records indicate that Mark has a long history of non-compliance with his medication regime due to minimal insight, requiring management on a Community Treatment Order and depot. Further complicating the clinical picture is his recurrent poly substance abuse and his lack of stable accommodation. Mark's insight and compliance, his financial skills, self-care, literacy, executive function and attentional deficits are all issues that long-term secure residential rehabilitation would be useful to address. Diagnostic Hypotheses
Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision (DSM-IV-TR): Axis I: Chronic schizophrenia Major Depressive Disorder Plan for Mark
In your small group use the information available to you in the formulation to identify some of the issues that need to be addressed for Mark. Consider how the formulation supports your ideas around intervention. Be prepared to share your plan with the larger group. Plan: informed by formulation
Charise formulation
Charise is an adolescent girl (15 years old) who has a history of behavioural issues and substance abuse. She was admitted via a revoked Community Treatment Order in the context of medication noncompliance and behavioural difficulties at her State Government Child Protection accommodation. She has been diagnosed as having borderline personality disorder and drug-induced psychosis. At the time of admission Charise was on Risperidone Consta 25 mg every fortnight and Risperidone 2mg bd. Charise comes from a family where there is a history of both learning problems and mental illness. Her father's alcoholism may also have masked other mental problems. The chaotic experiences of her early life and the verbal and physical abuse from her father have impacted heavily on her self-esteem. As a schoolchild she was initially shy and awkward at school but seems to have learned early that one way to avoid unwanted tasks (where one might fail) or aggression from others is to be the aggressor. This pattern has presumably been reinforced by her learning difficulties and lack of other ways to fit in, and together with her personal insecurities has resulted in a presentation most consistent with a borderline personality disorder. Charise has clear learning difficulties and struggled at school from an early age. Her current functional level is poor and while issues such as epilepsy and substance use (particularly chroming) are likely to have affected her abilities, it is possible that some of this deterioration may result from a schizophrenia-related cognitive decline. Other possibilities in the context of her previous history of petit mal epilepsy include sub-threshold seizure activity impairing her abilities. Charise appears to have had a clear onset of mental illness at age 12, with a depressive prodrome followed by the development of a delusional system which was shared to some degree with her sister. It is not clear whether she had already started using substances, but the early age of symptom onset argues strongly that her later episodes of psychosis are not solely related to substance use. She is in a category of increased risk in the context of her learning difficulties, epilepsy and family history of mental illness. Her tendency to experience psychotic symptoms in the context of psychosocial stressors may be the result of an underlying schizophrenia spectrum disorder interacting with her environment and personality disorder. It is interesting to note that the onset of Charise's petit mal epilepsy coincided with the onset of her prodromal illness, but she has clear recall of the psychotic symptoms which makes it less likely that she was experiencing peri-ictal psychosis. It therefore appears quite appropriate that she remains on Risperidone at this stage. In general, despite an array of complex psychiatric, developmental and social problems Charise manages surprisingly well. She presents well at interview, and tends to settle quickly on inpatient units. Her issues arise in the context of her everyday life, which she is unable to negotiate without significant interpersonal conflict, which has repercussions on her mental health. She has experienced a wide variety of different care situations: the chaotic and abusive setting of her early life, group homes as a young adolescent where she was exposed to substance use, mental health inpatient units, and State Government carer support where she has been challenged to control her behaviours and learn new skills. Diagnostic Hypotheses (DSM-IV)
Her current plan is to live with her boyfriend and receive supports from mental health and child protection. She was expelled from her most recent school (her second expulsion) and is not interested in reengaging with school. She remains a young girl at high risk, however, and her partner has also had abuse issues to deal with. It is not recommended that she be supported independently at this stage, although she could be supported to plan practically towards this. In her support (from both mental health and child protection) she will need to have clear expectations of who will be supporting her, how, and what options are available to her in a crisis. Plan for Charise
In your small group use the information available to you in the formulation to identify some of the issues that need to be addressed for Charise. Consider how the formulation supports your ideas around intervention. Be prepared to share your plan with the larger group. Plan: informed by formulation
Plan: informed by formulation

Source: http://www.mhpod.gov.au/assets/docs/Fac_guide_Formulation.pdf