Dear Mental Health Professionals, Even “Good” Formulations Can Harm
Dear Mental Health Professionals,
I have a lot of projects and things on the go at the moment, but I have taken some time today to write this blog, because it's a subject which has been bothering me. Recently I have written and shared a few things online which describe my experiences of psychological formulation and how it has been traumatising for me; including this blog and an illustrated transcript of an appointment with my psychiatrist.
Lots of professionals have been really open to hearing about how something they thought was inherently good, could also cause harm. It has been nice to see this, and to get messages from professionals describing how they have or will be changing their practice. However, many people in the pro-formulation camp have responded with something along the lines of: "what happened to you was bad, but it's not how formulation should be used, a good formulation isn't traumatising"... I just want to challenge that, and challenge the strongly held belief of many professionals that some ways of working cannot harm. This is not true. Thinking this way needs to be resisted. It doesn’t matter how well meaning your intentions, or how great you think your intervention is, there is always the potential for harm. Refusing to accept that something can be harmful if done properly can also make you complacent and defensive. If you believe you are competent and doing a good job (and as such the intervention cannot be harmful) you aren’t likely to respond openly or reflectively if someone indicates that they are being harmed, or actively look out for and guard against potential harm.
In my writing and drawings, I have detailed situations where formulation has taken place without me; been conducted by a team without my knowledge; informed my care without my knowledge; been shared between professionals without my consent; and condensed my whole being down to nothing more than a collection of experiences and attributes the clinicians felt were most important. I find it interesting that the people who feel formulation isn’t harmful “when done properly”, have been quick to denounce the way I was treated, when in reality these practices are not necessarily considered inappropriate in guidelines and literature, and some are enthusiastically encouraged. Given that research into the effectiveness of practices such as team formulation have frequently failed to ask patients what the experience was like for them (focusing often exclusively on the benefit to staff) it seems likely that people have responded in this way to my experiences due to the inclusion of detailed descriptions of how deeply hurt and traumatised I was by them - possibly something they haven’t heard before, because they have never asked.
So I just want to lay it out. Formulation is not benign, it is a value-laden process which has the potential for great harm. While it’s usually recommended it be a collaborative undertaking between patient and clinician, formulation is ultimately based on the professional being able to draw on their clinical opinion and understanding of psychological theory and research. These areas can be deeply problematic. Psychological theory and research belongs to and prioritises the experiences, beliefs, wishes, needs, opinions, and power of clinicians and researchers. Alongside this, the inherent power dynamic within the clinician-patient relationship will always privilege the opinions of the clinician. Everything will always be seen through the lens of the individual holding the power. What to include, what is important, how it is conceptualised, how it is recorded, who records it, who can access it, how it is utilised... Even the most competent, trauma-informed clinician creating a formulation is going to bring their specific understanding of the world, their preferred psychological or psychiatric framework, their unique perspective of the patient, and their own life history and emotions into the mix. I've had multiple formulations and each of them is different from the last, based not only on the mixture of theories and behavioural models being used, but also my relationship with the individual staff member; the context in which the formulation was created; the staff member’s personal/social/economic/cultural background; and their personal feelings and beliefs about me and my difficulties. Honestly they all sound like they are describing different people. Some clinicians focused on their perception of my feelings towards them; some focused on the parts of my past they believed were most relevant; some focused on interpreting my behaviour based on how it made them feel; one (written by a staunch atheist) revolved around my religious belief system. Even the parts of my formulations which were factually correct weren't right, because a person cannot be condensed down and understood so easily. Nothing is ever as simple as X happened, therefore Y; and the danger of such a distilled version of someone’s life is that nuance and complexity is erased. A whole new person can be created within a formulation, and given a patient’s notes will always hold more weight than a patient’s words, this can be difficult, or even impossible for patients to challenge.
While research suggests that some healthcare professionals view formulations as “fact” or “truth” (a problem in itself, given the highly speculative and theoretical nature of formulation), it is recommended that formulation be seen as a “hypothesis”, a “best guess”, or an ever changing, shifting, and growing concept open to repeat re-formulation. The problem with this for some people is the lack of stability in our self-conceptualisation, and how the constantly changing nature of our formulation affects our ability to access educational/occupational support, reasonable adjustments, and benefits. While those critical of psychiatry and psychiatric diagnoses are often quick to criticise people for forming an identity around their diagnosis, for many of us, such an action provides an anchor for personal stability; a connection to others for support, understanding, and answers; and a simple and useful “title” to give our unique and private difficulties when seeking formal support (from school/DWP/work etc). Personally I found the constant re-writing of my formulation deeply stressful and frightening, so much so that I stopped sharing new information with services, so as to avoid yet more re-formulation.
Nobody is formulated in a vacuum: the role of power (the clinician’s power; the power held by the mental health service; and the active removal of power from the patient by society, the clinician, and the service) is incredibly relevant. When using potentially complex psychological theories, the clinician places themselves in the position of “expert”, much like the diagnostician. The clinician may elect to “explain” psychological theory to the patient (effectively educating the patient about themselves, which if felt to be incorrect to the patient, could feel like gaslighting); or the clinician could decide not to explain or to give a simplified version, therefore using their power to decide what the patient should or shouldn’t know. The dynamics of any clinician-patient relationship can themselves cause harm, but the risk of this seems heightened when the traditional “provider of wisdom” and “receiver of wisdom” roles are emphasised. At the very least this could be experienced as disempowering, and for some could even be similar to previously experienced abusive dynamics. For processes such as team formulation (which feels like a room full of people conducting an NHS-sanctioned character assassination), British Psychological Society guidelines do not direct staff to gain consent or even tell patients this will be going ahead. Rather, they explicitly state that sharing a team formulation may be unhelpful and therefore the patient doesn’t need to be informed, seemingly even if this formulation goes on to direct and inform the patient's ongoing care. Whether or not research finds that team formulation makes staff feel better is irrelevant. Team formulations which are created without the patient, withheld from the patient, and then subsequently inform the care plan, are in my opinion deeply unethical. Mental health care is not something you do *to* someone. Analysing, psychologising, and hypothesising about a person without their involvement is wildly problematic on a number of levels. Firstly, from a really basic perspective, not involving the person you are formulating means you are going to get it wrong. Secondly, if you are using the formulation as part of the care plan, questions should be raised about the need to get the person's consent before doing so (my view is that this would constitute a component of an intervention, and as such requires patient consent) and whether this is in line with UK data laws regarding transparency about the use of personal data (which includes patient notes). Thirdly, team formulations which utilise the patient’s notes and private information, but do not inform patient care and involve staff not involved in the patient’s care, could potentially be considered a breach of GDPR and confidentiality common law, and again, would not be in line with UK law surrounding transparency in data usage. Team formulation processes which use patient information as team building exercises display a deeply offensive sense of entitlement to patients' personal and private information, as if to access your service, we owe you our very souls.
I don't want a formulation. I have never wanted a formulation. I am very slowly and gently unravelling my thoughts and feelings and experiences in therapy where I feel held and safe. I am coming to my own conclusions, in my own time, at my own pace. I have no desire for someone to come along to attempt to create a condensed, concentrated hypothesis, based on a small slice of information they believe to be pertinent. I am a person who has lived 30 years of life. Every moment which has made up those 30 years come together to make "me". That cannot be reduced down to a few lines or a page of words created in, at most, a handful of appointments. Much like traditional mental health care practices, formulation also erased the ways in which mental health services had failed me; the historic and ongoing abuses, power imbalances, and injustices within and perpetuated by psychiatry and psychology; and the wider social context of my difficulties. I was re-created in formulation as the centre and cause of all my issues. Formulation has been one of the most disempowering experiences I have had within services, and I do not say that lightly. I have felt more in control while in handcuffs, pinned to the ground, than I have felt upon discovering that my entire being had been violently dissected and rebuilt based on other’s opinions, feelings and theories.
Please hear me when I say that formulation, even when done properly and appropriately, can be harmful. This is not about petty fights on Twitter or critical psychologists vs psychiatrists. You, as the professional, have power over vulnerable people, which comes with a responsibility to centre the needs of those people and listen to us when we tell you something is hurting us. Please sit with my words long enough for them to actually mean something instead of immediately running back to twitter to tell me how brave I am, before using my words to advance your own agenda. Survivors are not here to bolster your egos or help you push your ideologies. Writing these blogs is not easy. I am sharing little pieces of myself with you, please respect that and do me the courtesy of reflecting on your power, your privilege and your practice. That doesn’t seem too big of a request.