The role of psychological formulation in inpatient settings in supporting staff empathy and therapeutic optimism for adults diagnosed with borderline personality disorder: A pre- and post-vignette study

WHAT IS KNOWN ON THE SUBJECT?: Psychological formulation brings together a service user story and expertise, with psychological knowledge, research, and practitioners clinical experience to make sense of a service users' presentation (thinking about their difficulties but also strengths). Evidence into the effectiveness of formulation is largely anecdotal, qualitative, or small scale. Although this is very valuable research, there is not a lot of research which quantitatively evidences the role of formulation for service users or services. Quantitative evidence that does exist is also conflicting. Considering how widely psychological formulation is used, and the governing guidelines that recognize this as a core competency for psychological practitioners, it is important to continue to add to the evidence base. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: Psychological formulation can increase staff empathy and hope. This could help service users to feel more understood and hopeful. Formulation; however, did not impact feelings of personal distress in staff. This research may suggest a need for the two distinct processes (i.e. team formulation and reflective practice) to support all components of empathy within inpatient services. Psychological formulation could support the provision of psychologically informed care within inpatient services, of which promotes effective care delivery.

ABSTRACT

OBJECTIVES: National Health Service (NHS) values, such as empathy and therapeutic optimism, are integral when supporting service users with complex mental health presentations. There is some evidence to suggest that psychological formulation can increase empathy and optimism in healthcare professionals. This study, therefore, aimed to investigate whether a psychological formulation of a hypothetical service user with a complex presentation, typically labelled with a diagnosis of borderline personality disorder (BPD), increased empathy and therapeutic optimism in professionals working in mental health inpatient services.

METHOD

Sixty-six mental health professionals working in NHS inpatient services took part in a pre- and post-vignette study. Participants were asked to read a case vignette about a hypothetical service user, with a diagnostic label of BPD, and complete questionnaires capturing levels of empathy and therapeutic optimism. Participants were then randomized into two conditions and either asked to read the same information again (control condition) or read a psychological formulation based on the same hypothetical service user (intervention condition). The findings were analysed using a series of ANCOVAs/ANCOHETs.

RESULTS

Two constructs of empathy (i.e. perspective taking and empathic concern), and therapeutic optimism significantly increased following exposure to the psychological formulation when compared to the control group condition.

CONCLUSION

This study warrants further replication. These initial findings; however, indicate that psychological formulation can significantly increase the ability to perspective take, display empathic concern, and hold therapeutic optimism towards service users with a presentation associated with a diagnosis of BPD.

Criminal risk and mental illness in psychiatric inpatient units: An opportunity to provide psychological services for unmet criminogenic needs

Although the overrepresentation of people with mental illness in the criminal justice system is known, research is needed to identify the frequency of criminal justice involvement and criminogenic treatment needs in inpatient populations to improve continuity of care and access to appropriate treatments. The purpose of this study is to document the frequency of criminal justice involvement among people receiving inpatient community care, as has been done for persons with mental illness in correctional institutions, and to test the association between criminogenic risk and psychiatric symptomatology. The present study uses two samples (n = 94 and n = 142) of adults from two separate acute psychiatric inpatient hospitals in Texas. Data on psychiatric symptoms, mental health history, criminal risk, and criminal justice history were gathered from file review and self-report. Linear and negative binomial regressions were used to test associations of interest. In both samples, the frequency of prior criminal justice involvement was over 50%. The current results indicate there is a significant, positive association between measures of criminal risk and psychiatric symptoms. These findings highlight the need to address the reciprocal association between mental illness and criminal risk among people receiving inpatient psychiatric treatment with appropriate assessment and treatment. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Using CBT interpersonal team formulation on mental health inpatient wards

OBJECTIVES

Team formulation involves a multidisciplinary team coming together to understand the factors leading to the development and maintenance of a patient's problems and the implications of this for future care planning.

METHOD

This paper presents a case example describing this approach in an acute inpatient setting.

RESULTS

"William" was a 59-year-old male with longstanding mental health difficulties. During his admission, he presented as verbally abusive, intrusive, and sexually inappropriate. He was also controlling and intimidating toward other patients. Staff were becoming frustrated and hopeless about managing William on the ward leading them to adopt inconsistent approaches in relating to him. A team formulation was developed to understand William's trauma history and how this impacted on his beliefs about himself and other people as well as his way of relating to others.

CONCLUSIONS

The team formulation helped staff to develop consistent care plans in relation to William's presentation on the ward and more empathy in relation to behaviors that they found challenging.

A systematic review and narrative synthesis of indirect psychological intervention in acute mental health inpatient settings

OBJECTIVES

Psychologists frequently deliver indirect psychological interventions in mental health inpatient settings to support staff to reflect upon and improve their clinical practice. However, research into these interventions is sparse. Therefore, this study aimed to undertake a systematic review and narrative synthesis of the indirect psychological interventions used in mental health inpatient settings.

METHODS

MEDLINE, PsycINFO and Embase were searched for eligible studies and forward-citation searching was undertaken. A narrative synthesis was undertaken to synthesize results. The quality of studies was assessed using the Mixed Methods Appraisal Tool.

RESULTS

Ten studies were included in the review, and all utilized a small to moderate sample size. We identified five categories of interventions involving a range of methodologies and the studies were assessed to be of good to adequate quality. The most common type of indirect intervention employed was case formulation sessions. Other types of indirect interventions included formal clinical supervision, reflective practice and staff practice-based education sessions. Overall, the utilization of indirect psychological interventions shows promise, particularly case formulation sessions.

CONCLUSIONS

The use of indirect psychological interventions within mental health inpatient settings may have benefits for patient care. However, additional larger scale research is required to further develop the evidence base of indirect interventions for this setting.

Staff perception of case discussion groups on a UK inpatient psychiatric ward: a mixed method service evaluation

BACKGROUND

Staff and patient experiences of inpatient psychiatric wards can be negative, with staff suffering increasingly higher rates of burnout and aggression, and patients dissatisfied with the lack of therapeutic climate. The need for improved support for both has long been identified, yet many group types are ill defined and their effectiveness is unclear. In response, clinical psychologist-facilitated case discussion groups (CDGs) have been implemented across limited wards within an NHS Foundation Trust to develop staff formulation and reflective skills and provide dual peer and formal support.

AIMS

This evaluation aimed to assess staff perceptions of CDG impact on staff outcomes and patient care.

METHODS

Twenty permanent unit staff members of a female acute inpatient ward participated in this mixed method evaluation. Staff were administered a two-part questionnaire. A subset of participants then completed a semi-structured qualitative interview.

RESULTS

CDG were rated extremely positively for both staff and patient care outcomes. Staff recognised increased patient contact, reduced restraint incidents, and higher levels of confidence in their role. Suggested improvements to CDG include a more formal review of action plans.

CONCLUSION

Further research is required to explore patient perceptions of CDG and explore impact across different ward types.

Recruiting and retaining participants in three randomised controlled trials of psychological interventions conducted on acute psychiatric wards: top ten tips for success

BACKGROUND

It is essential to conduct randomised controlled trials of psychological interventions on acute psychiatric wards to build a robust evidence base for clinical practice.

AIMS

This paper aims to share strategies from three different in-patient trials that successfully recruited and retained participants, to disseminate good practice for the conduct of future trials in this challenging and complex clinical setting.

METHOD

We present strategies from three in-patient trials of psychological interventions: TULIPS (Talk, Understand, Listen for Inpatient Settings), amBITION (Brief Talking Therapies on Wards) and INSITE (Inpatient Suicide Intervention and Therapy Evaluation). All studies recruited participants from acute in-patient wards, initiated therapy within the in-patient setting and followed up on participants post-discharge.

RESULTS

We summarise our recommendations for good practice in the form of ten top tips for success, based on our collective experience of conducting trials on psychiatric wards. Key themes relate to the importance of relationships between the research team and clinical staff; good stakeholder involvement and getting early buy-in from the team; and adapting to the particular demands of the clinical setting.

CONCLUSIONS

Sharing good practice recommendations can help reduce research waste arising from poor recruitment and/or retention in future in-patient clinical trials.

A cluster randomised controlled trial of a ward-based intervention to improve access to psychologically-informed care and psychological therapy for mental health in-patients

BACKGROUND

There is good evidence that psychological interventions improve patient well-being and independent living, but patients on acute mental health wards often do not have access to evidence-based psychological therapies which are strongly advised by NICE guidance for severe mental health problems. The overall aim of this programme of work is to increase patient access to psychological therapies on acute mental health inpatient wards. Stage one of the programme (which is complete) aimed to identify barriers and facilitators to delivering therapy in these settings through a large qualitative study. The key output of stage one was an intervention protocol that is designed to be delivered on acute wards to increase patient access to psychologically-informed care and therapy. Stage two of the programme aims to test the effects of the intervention on patient wellbeing and serious incidents on the ward (primary outcomes), patient social functioning and symptoms, staff burnout, ward atmosphere from staff and patient perspectives and cost effectiveness of the intervention (secondary outcomes).

METHODS

The study is a single blind, pragmatic, cluster randomised controlled trial and will recruit thirty-four wards across England that will be randomised to receive the new intervention plus treatment as usual, or treatment as usual only. Primary and secondary outcomes will be assessed at baseline and 6-month and 9-month follow-ups, with serious incidents on the ward collected at an additional 3-month follow-up.

DISCUSSION

The key output will be a potentially effective and cost-effective ward-based psychological intervention that increases patient access to psychological therapy in inpatient settings, is feasible to deliver in inpatient settings and is acceptable to patients.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov Identifier: NCT03950388. Registered 15th May 2019. https://clinicaltrials.gov/ct2/show/NCT03950388.

Overcoming barriers to implementing ward-based psychosocial interventions in acute inpatient mental health settings: A meta-synthesis

BACKGROUND

The culture of acute mental health wards is often dominated by medical models of care despite some patient dissatisfaction with care in these settings and a demand for increased access to psychosocial interventions. Research has found that psychosocial interventions can improve a number of patient and staff outcomes, however, implementation within these settings is often challenging.

OBJECTIVES

The aim of this review was to provide a comprehensive synthesis of the barriers and facilitators to implementing psychosocial interventions on acute wards, in order to develop a list of recommendations for embedding psychosocial interventions within the ward culture in acute settings.

METHODS

Databases were systematically searched using search terms related to acute mental health wards and psychosocial intervention implementation from inception to December 2019. Thirty-nine studies (forty-three papers) that explored the implementation of psychosocial interventions on adult acute mental health wards using qualitative methods met inclusion criteria. Data relating to barriers and facilitators to implementing psychosocial interventions extracted from the results sections of the papers were synthesised using the COM-B model.

RESULTS AND CONCLUSIONS

We conclude that to address barriers to the implementation of psychosocial interventions, services should provide clear information to patients regarding the benefits of engagement, and additional training for staff. A shift in ward culture is required and can be achieved through the recruitment of empathic implementers, together with providing staff with protected time for delivery of psychosocial interventions with clear accountability for intervention delivery through the provision of clearly defined roles.

A psychological intervention for suicide applied to non-affective psychosis: the CARMS (Cognitive AppRoaches to coMbatting Suicidality) randomised controlled trial protocol

BACKGROUND

Suicide is a leading cause of death globally. Suicide deaths are elevated in those experiencing severe mental health problems, including schizophrenia. Psychological talking therapies are a potentially effective means of alleviating suicidal thoughts, plans, and attempts. However, talking therapies need to i) focus on suicidal experiences directly and explicitly, and ii) be based on testable psychological mechanisms. The Cognitive AppRoaches to coMbatting Suicidality (CARMS) project is a Randomised Controlled Trial (RCT) which aims to investigate both the efficacy and the underlying mechanisms of a psychological talking therapy for people who have been recently suicidal and have non-affective psychosis.

METHODS

The CARMS trial is a two-armed single-blind RCT comparing a psychological talking therapy (Cognitive Behavioural Suicide Prevention for psychosis [CBSPp]) plus Treatment As Usual (TAU) with TAU alone. There are primary and secondary suicidality outcome variables, plus mechanistic, clinical, and health economic outcomes measured over time. The primary outcome is a measure of suicidal ideation at 6 months after baseline. The target sample size is 250, with approximately 125 randomised to each arm of the trial, and an assumption of up to 25% attrition. Hence, the overall recruitment target is up to 333. An intention to treat analysis will be used with primary stratification based on National Health Service (NHS) recruitment site and antidepressant prescription medication. Recruitment will be from NHS mental health services in the North West of England, UK. Participants must be 18 or over; be under the care of mental health services; have mental health problems which meet ICD-10 non-affective psychosis criteria; and have experienced self-reported suicidal thoughts, plans, and/or attempts in the 3 months prior to recruitment. Nested qualitative work will investigate the pathways to suicidality, experiences of the therapy, and identify potential implementation challenges beyond a trial setting as perceived by numerous stake-holders.

DISCUSSION

This trial has important implications for countering suicidal experiences for people with psychosis. It will provide definitive evidence about the efficacy of the CBSPp therapy; the psychological mechanisms which lead to suicidal experiences; and provide an understanding of what is required to implement the intervention into services should it be efficacious.

TRIAL REGISTRATION

ClinicalTrials.gov (NCT03114917), 14th April 2017. ISRCTN (reference ISRCTN17776666 https://doi.org/10.1186/ISRCTN17776666); 5th June 2017). Registration was recorded prior to participant recruitment commencing.

Team psychological formulation to create a shared understanding of distress: a qualitative study in an older people’s mental health inpatient setting

Purpose

Team psychological formulation is an organisational intervention aimed at developing a shared understanding of a person’s mental health difficulties. There is a lack of evidence regarding the therapeutic value of this approach for older people. The purpose of this paper is to explore how older people and their carers experience a cognitive-behavioural approach to team psychological formulation, within a mental health inpatient service in the UK.

Design/methodology/approach

A qualitative study using interpretative phenomenological analysis was undertaken. In total, 13 participants were interviewed: five older people/carer dyads, two lone older people and one lone carer.

Findings

Three overarching themes emerged: “Emotional impact of formulation” captured the mixed emotions that the process evoked in participants. “Making sense?” reflected the therapeutic value that participants experienced and what held them back from making gains in their recovery. “Disempowered people trapped in a biomedical world” illustrated the negative aspects of ward care, which hindered recovery.

Research limitations/implications

The findings provide insights into the therapeutic value of team psychological formulation and the difficulties in facilitating the process effectively. More consistency is required to ensure that team formulation is standardised. Further research into the outcomes of the approach for older people is recommended.

Practical implications

Recommendations are proposed for how team psychological formulation can be conducted effectively, using the mnemonic “SETUP”.

Originality/value

This study focussed on older people’s and their carers’ own perspectives regarding the team psychological formulation approach.