Psychology Formulation
Based Staff Training
Surehaven Hospital
Dr Marie-Louise Holmes
Clinical Psychologist
Surehaven Hospital
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Shaw Healthcare
Opened in Drumchapel 2010
17 bed low secure psychiatric hospital
Patients detained under the Mental Health Act and
requiring a secure care environment
• Range of presentations, psychosis, personality
difficulties, learning disabilities, brain injury
• Two wards, male and female
• MDT – Hospital managers, consultant psychiatrist,
occupational therapist, clinical psychologist, nursing
team and healthcare assistants.
Training Rationale
• 1. To empower the ward based staff in relation to the use of
empathic containment of patient distress.
• 2. To enhance staff understanding of patient behaviour from a
psychological perspective
• 3. To equip staff with skills necessary to support individual
psychological therapeutic work
• 4. To capitalise on the high level of enthusiasm and
dedication to patient care that existed within a newly
recruited staff team
• 5. To provide a rich learning opportunity aimed at increasing
insight and empathy rather than simply information provision
Forensic Psychology Matrix Guidance
• Therapeutic Milieu Training
• ‘All front line clinical staff should be made aware of the
particular difficulties of working with psychiatric in-patients
with forensic needs, and the underlying reasons for
challenging behaviours.’
• ‘They should be given training in basic psychological models
and advised of the aims of the psychological interventions
available with the service so that they can reinforce the
skills patients learn in psychological treatment.’
• ‘Special attention should be given to equipping staff with
the skills necessary to feel confident in supporting the
emotional and mental health needs of service users.’
Psychological Formulation
• A hypothesis about service users difficulties
based on psychological principles and theories
• The assumption is that this process will render
even the most unusual or disturbing
behaviour and experiences understandable:
• ‘At some level it all makes sense’ (Butler, 1998)
Key Elements of Training Design
• Training needs analysis carried out
• Particular service users difficulties considered
• Psychological interventions already underway
• MDT reflection on areas for development
• Training made mandatory for all staff
Initial Topics Identified
Understanding and Responding to –
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Personality Difficulties
Psychosis
Suicidal Behaviour
Self Harm
Introduction to –
• Compassionate Mind Therapy for Trauma
• Counselling Skills Training
Style of Delivery
• Opportunity to model warm, empathic and containing
therapeutic style
• Small numbers facilitate interactive workshop dynamic
rather than lecturing style
• Emphasis on collaboration and eliciting existing
knowledge from the audience
• Safe space for non-judgemental exploration of reality
of working with complex presentations
Content and Structure
• Participants identify what they wish to gain from the day
• Structure is flexible with interactive discussion tailored to
needs of the particular group
• Education / Theory section – interactive, elicit existing
knowledge and combine with theory
• Video clips or practical exercises to reinforce theoretical
understanding
• Case study – Participants develop basic formulation and
devise intervention
• Skills practice
• Reflective consolidation of main learning outcomes
• Feedback and further resources
Example Session
• Personality Difficulties
• Aim to increase insight and empathy
• Assumption that this will reduce staff countertransference reactions
Personality Difficulties Training
Before session staff asked to write down words that come
to mind in relation to ‘Personality Disorder’ –
• Obsessional, Manipulative
• Impatient
• Difficult to manage, burn out
• Frustration
• Helpless
• Heart sink
• Dependent
• Emotional, self harming
• No reasoning, anxious, narcissistic, controlling
Main focus of the day –
• Psychological understanding based on concept
of Early Maladaptive Schemas (Young 2003)
• Developmental psychology perspective firmly
rooted in Attachment Theory
• De-stigmatising approach
• Extreme personality traits – result of genetic
temperament and unmet needs arising from
attachment difficulties in childhood.
After session participants repeated exercise –
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Lonely
Abandoned
Self loathing
Treatable
Vulnerable
‘The behaviour is not about me’ (the healthcare professional)
Emotional needs unmet
‘..didn’t choose their genetics or environment..’
‘Still emotionally a child’
Difficulty communicating
Misunderstood
Clear shift in the themes being expressed
Compassionate Mind Therapy for
Trauma
• Key approach used at Surehaven in the treatment
of patients with chronic interpersonal trauma
histories
• Mechanism of change is teaching patient to
emotionally relate to self with compassion and
understanding rather than self loathing and
blame
• This undermines process which maintains suicidal
feelings and emotional attacks on the self
• Participants engaged in experiential therapeutic
exercises
• Reflection on their own level of self criticism
• Writing a compassionate letter to themselves
• This proved useful in terms of both personal and
professional development
• Staff were better able to support psychological
intervention using this approach by encouraging
patient to use self compassion as a response to
distress rather than self criticism
Feedback / Audit
• Feedback from all sessions very positive
• Likert scale ratings all either agree / strongly
agree –
• Theory was clearly explained
• Practical exercises enhanced learning experience
• Delivery style tailored to meet needs of the group
• Able to apply knowledge / skills in your role
Qualitative Feedback
Staff responses indicate
• Increased empathy for patient difficulties
• Increased insight into psychological factors influencing
presentation
• Improved confidence in therapeutic relationship
building
• Increased confidence in responding to distress
• Improved understanding of psychological interventions
• Increased recognition of own skills
• More realistic expectations of self and patients
Patient responses included –
• ‘Staff are better equipped to help me and
speak about my problems’
• ‘The enthusiasm from all the staff has been
great’
• ‘Its great that nursing staff can follow up my
psychology work with me’