Power, Interest and Psychology:
Developing David Smail’s Ideas.
Birmingham, 12th November 2015
Understanding Power in Order to Share
Hope: Tribute to David Smail
Jan Bostock, Psychological Services Professional Lead,
Community Services, Northumberland, Tyne and Wear
NHS Foundation Trust.
Janet.Bostock@ntw.nhs.uk
Key Tasks from David
1. To understand how the experiences of well
being and distress are linked with the operation
of power
2. To share that understanding as a means of
furthering personal and wider understanding
and change.
3. To act with common humanity and compassion
to “mitigate suffering in others as in ourselves”
Smail, 2004.
Formulation: The Influence of the Social Environment
THE IMPRESS OF POWER
(from Smail, 1996) }
Politics
Economics
}
Culture
}
Information media etc
}
Domestic situations
Education
Personal relationships
Family
Work
Benefits
}
}
}
}
Experience
Beliefs, dreams, memories
Wishes etc
Bodily sensation
Feelings of comfort, pain, fear, etc
‘Symptoms’
}
}
}
}
}
}
Distal
Influences
Proximal
Influences
The Person
What Influences our Well-Being?
Social position
(Eg. Age, Gender, Class,
Race, MH Service User)
Life Events
WELL-BEING
Critical
Incidents
Exposure
Ongoing
Difficulties
DEMANDS
CONTROL
ROLE
SUPPORT
+/-
Organisational
Access to
Resources
Educational
Physical Health
Psychological
Financial
Social
4
5 key questions pertinent to psychological
interventions:
1. What resources are available to this
person/family/community?
2. What material, social and economic power is accessible
to them?
3. What are their experiences of organisations, services
and systems?
4. What possibilities for change are afforded by their
situations and environments?
5. In whose interests is this intervention? Will potential
change for this person/family/community be affected by
the interests of others?
5 Ps + Plan
Presenting Issues
Predisposing Factors
Precipitating Factors
Perpetuating Factors
Protective Factors
Plan
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Essential Features of Formulation
• Summarise the Service User’s core problems.
• Suggest how the Service User’s difficulties may relate to
one another, by drawing on theories and principles.
• A framework for describing a problem, how it developed
and is maintained.
• May draw upon different explanatory models.
• Includes a number of provisional hypotheses and targets
for intervention.
(Johnstone & Dallos, 2014)
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5 P’s + Plan: Course Outline
• Two x 3hr workshop sessions: 129 staff
completed and evaluated
• Light on theory, draws on existing knowledge.
• Focus on practice and developing skills and
knowledge.
• Supported live group formulation sessions
• One 1½hr ‘booster’ and ‘troubleshooting’
session.
• Ongoing use of 5 P’s + Plan and supervision
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From Course: What isn’t a Formulation?
•
•
•
•
•
•
•
A list (of symptoms, or goals)
A secret from the Secret User
A summary of the past
A diagnosis
Too complicated to understand
Set in stone
The ‘Truth’
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From Course: Strength Focussed Formulation
• Use constructive language to describe
presenting issues (e.g. If I understand you correctly, you
keep yourself safe by not going out?)
• Draw out Service Users’ strengths (e.g. what’s right in
your life?)
• Formulate vulnerability AND resilience (e.g. how can
you stay well in the long run?)
• Use Service User’s language, metaphors,
stories, images.
• Think of the person and the people important to
the Service User: Family, friends, service
providers.
10
TELLING THE STORY OF WHY I AM SEEKING HELP
PRECIPITANTS (WHAT SET IT OFF)
PREDISPOSING
PRESENTING ISSUES
My main problems are…
Don’t forget: include everyone’s
perspective whenever appropriate. Even
if they differ!
What do other people think?
PERPETUATING FACTORS (WHAT KEEPS IT GOING)
PROTECTIVE
FACTORS
PLAN: WAYS FORWARD
OUR NEXT STEPS:
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Feedback from staff on what is helpful
 Formulation brings “Purpose, relevance, I believe in the
value of the 5 ‘P’s”
 Formulation sees “the Service User as central”
 Formulation means “knowing that the patient will have a
framework and that this will be followed by all
practitioners”
 Formulation “just really works and there are light bulb
moments for service users” (and for staff)
 It was helpful “doing the practice formulation and giving
me more confidence in what I do day to day”
 Helped staff to gain confidence and sense of worthwhile
involvement with service users.
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Learning:
how using 5Ps plus Plan could help
build a therapeutic alliance and hope.
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Formulation: Quality Checklist
Does this Formulation:
Is this Formulation:
Was the Service
User:
•
•
•
•
•
•
•
•
•
•
•
•
•
Describe the Service User’s
difficulties and strengths?
Take a positive, validating approach
with the Service User?
Suggest how the Service User got to
this point in their life?
Explain why the Service User might
be ‘stuck’?
Remind us to ask about/include
Psychological factors?
Remind us to ask about/include
Social factors?
Remind us to ask about/include
Biological factors?
Consider the possible impact of
trauma and abuse?
Help plan change?
Suggest how interventions may help
and/or hinder?
Link to appropriate goals?
•
•
Sensitive to cultural and
contextual factors?
Sensitive to ongoing
pressures in the Service
User’s life?
Personalised?
•
Involved in
developing this
Formulation?
Involved in choosing
between intervention
options?
Next Steps for 5Ps+ Plan
• Complete rollout of training to Sunderland, S
Tyneside, Newcastle, Northumberland, N
Tyneside, Gateshead community teams
• Live supervision of formulation discussion in
Pathway meetings with reference to Quality
Checklist
• Evaluation of impact from Service Users’
perspectives
• Continue to gain feedback from staff
Formulation
“The mere formulation of a problem is often
far more essential than its solution, which
may be merely a matter of mathematical or
experimental skill. To raise new questions,
new possibilities, to regard old problems
form a new angle requires creative
imagination and marks real advances in
science.“
Albert Einstein, Nobel Prize, 1921.
EXPERIENCE OF DOMESTIC ABUSE
• Onset of abuse
• Aspects of relationship/maintaining factors
• Causes of abuse
• Tactics of abuse
• Effects of abuse
Domestic Violence Against
Women: Understanding Social
Processes & Women’s
Experiences
Bostock, Plumpton & Pratt, 2009
PARTICIPANTS’ WAY OF DEALING WITH ABUSE
• Recognition of abuse
• Status Quo Strategies
• Strategies for independence
HOW SYSTEMS REINFORCED ABUSE
• Ineffective protection
• Too much to lose
• Lack of recognition of abuse as unacceptable
SAFETY & WELLBEING
• Experience of safety
• Isolation/support
• Relationships with children
• Hardship
• Activity & aspirations
HOW SYSTEMS CHALLENGED ABUSE
• Taking the victim’s side
• Offering a common bond
• Effective help
Psychological Formulation Example
Personal/Social Status
– Service user “ sick”
– “Victim”
– Married
– Daughter
Exposure
– Flashbacks
– Intrusive memories
+ Brownie Leader
+ Stepmother
FEAR
RAGE
DEPRESSION
– Abuse from husband
– Past sexual abuse
– Lack of recognition
– Not validated
WAYS FORWARD
 Breathing & mindfulness
 Activities: dancing, brownies
 Talking about past and on-going abuse
 Family acted against ex-husband
 Name feelings
 Do things in spite of the feelings
 New friendships
 Recognise patterns eg caring, trying to please
 Voluntary work, college, moving away
Biological/Physical
– Back pain
– +Use of medication
– Alcohol
Access to
Resources
Social
+ Education
+ Family
+ Church
+ Friends
+ Pets
+ MH services
– Money
Psychological
– Confidence
– Avoid scary situations/
stay in bed
– Cut self – relief – guilt –
medication - sleep
– Drink – relief – feel bad
– +Rescue others. Try to
please
Looking Outward:Holding the world to account
“We need Clinical Psychology to get out of the office and
beyond the therapy room because we need someone to
help make the case for those who are losing out. To do
that we need a clinical psychology that has political
understandings but which also is close enough to people to
be able to offer pragmatic support, too.”
Alisdair Cameron, Launchpad, Newcastle, September
2015.
Key References
Bostock, J., Plumpton, M., and Pratt,R. (2009) Domestic Violence Against Women:
Understanding Social Processes and Women’s Experiences. Journal of Community
and Applied Social Psychology, 19, 95-110.
Clarke, I. & Wilson, H. Eds. (2008) Cognitive Behaviour Therapy for Acute Psychiatric
Inpatient Units; working with clients, staff and the milieu. London: Routledge.
Hagan, T. and Smail, D. (1997) Power-mapping – 1. Background and basic
methodology. Journal of Community and Applied Social Psychology, 7, 257-268.
Johnstone, L. & Dallos, R. (2014) Formulation in Psychology and Psychotherapy:
Making Sense of People’s Problems (2nd Edition). East Sussex: Routledge.
Midlands Psychology Group (2014) The Draft Manifesto. Clinical Psychology, 256, 3-7.
Lambert, M (2010) Prevention of Treatment Failure: The Use of Measuring, Monitoring
and Feedback in Clinical Practice
Smail, D. (2005) Power, Interest and Psychology. Elements of a social materialist
understanding of distress. PCCS Books, UK
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