Using the Power Threat Meaning

Framework to Co-construct

Formulations and Action.

Jan Bostock, Consultant Clinical Psychologist

Nicola Armstrong, Service User and Carer Involvement

Facilitator

and with thanks to Dr Teresa Hagan and Dr Steve Jefferis

BPS Division of Clinical Psychology Annual Conference,

January 2020.

Today’s talk

“ … it is survivors who understand, through lived experience, what heals and what harms; and the importance of reversing “power over abuses.”

Sweeney and Taggart, 2018.

• About us

• Examples of promoting good practice through

- Co-produced training in 5 Ps + Plan formulation

- Understanding What Influences Your Mental Health and Wellbeing

- Promoting trauma informed practice across CNTW

- Developing Cognitive Analytic Therapy

- Reflections for Clinical Psychology

- Psychologists for Social Change

• The importance of understanding power, assets, threats and meaning, and what these mean for:

- individuals

- organisational and social change

Nicola

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Nicola: Where I come from -Community Development and Co-Production

values and aims:• Value the expertise of lived experience in mental health

work alongside clinical expertise. In partnership.• Needs led, collaborative and meaningful involvement in

formulations and decisions• Being heard and having validation is fundamental• Recognise the importance of strengths and assets and

not only problems and difficulties• The power of hope • Sharing knowledge and information and think outside of

the box to ensure we are inclusive. • Celebrate the uniqueness of individuals• Equal value for all and social justice

Jan: Where I come from –Community Psychology values and aims:

Be inclusive, collaborative, co-produceMake a difference to people’s lives

Promote social justice, prevent sufferingImprove health and wellbeing

Focus on strengths

• Understand how the social and economic reality of people’s lives affect their health and well-being

• Join with others with similar experiences to give voice to this understanding

• Engage in collective action to change these realities

Jim Orford, 2008.

Impact of CAT re-formulation for Nicola

• Telling my story of how I have got to where I am, why I felt and respond how I do.

• Having a big picture of the jigsaw of my life, past and current.

• Making sense of what has happened to me. • Thinking about my strengths and resilience“Your inner strength and determination has got you through very traumatic times and got you this far”• Moving from who can fix me to finding my own power• Validation and understanding, • From being done to, to co-developing• Finding ways to move forward• Experience has shaped me, not defined me

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Adapted from Social Action Framework (Holland, 1992)

Collective

Individual

Subjective Objective

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5 P’s + Plan: Course Outline• Two x 3hr workshops over one/two days.

• Over 1500 staff trained since beginning of 2015

• Team of Experts by Experience and MDT trainers.

• Ethos of training is supportive and co-produced .

• Draws on existing knowledge and experience of staff and training facilitators.

• Focus on practice and developing skills and knowledge.

• Focus on strengths, service user engagement and alliance building.

• Supported in pathway meetings and with supervision from local champions for routine use.

8PLEASE NOTE: do not duplicate or use without prior permission of author

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 change might be difficult?

• Remind us to ask about/includePsychological 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 Services 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?

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The P’s

Triggers Triggers that lead to the problem showing itself now.What set things off? (It might have been a collection of things).

What was the straw that broke the camel’s back?

What makes

change difficult?

Things that are keeping the problem going.

Is there anything that makes it difficult to address the problem?

What are the barriers to change?

Is there anything that is helpful in the short term but not so good in the long term?

Past

factors

Significant background information.

Origins and development of the problems: What has happened?

How did they affect the person? How did they make sense of their experiences and

history?

Lessons learned to survive?

Positives

What helps?

What strengths does the persons have?

Any good friends or helpful people in their lives?

What resources do they have available to them?

How have they survived and sorted things out before?

Plan

Interventions that might arise from this formulation.

Goals: What does the person want to do to change?

Plans: How are they going to get to their goal?

What? How? Who? When? Expected outcome?

How does the plan affect everyone involved?

Current

issues

The current difficulties experienced.

What is the person ‘bringing’?

What is getting in the way of life at the moment?

Don’t forget to note strengths too… What is going well at the moment?

PLEASE NOTE: do not duplicate or use without prior permission of author 11

What is a formulation?

Formulation

Highlights the service user’s

strengths

Helps plan change

Explains why change may be

difficult

Acknowledges different

perspectives

Describes problem(s) and

survival strategies

Ensures service user is listened

to

Helps ask the right questions

Explains how the service user got

here

Open, always evolving

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What isn’t a Formulation?

• A list (of symptoms, or goals)• A secret from the Secret User• A summary of the past• A diagnosis• Entirely psychological• Too complicated to understand• Set in stone• The ‘Truth’

PLEASE NOTE: do not duplicate or use without prior permission of author 12

Distress never “just happens”

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It asks:

• What has happened to you?’ (How has Power operated in your life?)

• ‘How did it affect you?’ (What kind of Threats does this pose?)

• ‘What sense did you make of it?’ (What is the Meaning of these situations and experiences to you?)

• ‘What did you have to do to survive?’ (What kinds of Threat Response are you using?)

• What are your strengths? (What access to Power Resources do you have?)

• What is your story? (How does it all fit together?)

www.bps.org.uk/PTM-Main

http://www.bps.org.uk/PTM-Main

Balancing power, threats and

resources

Exercise 2:

Reflect upon your own

exposure and resources

How well balanced

are your scales?

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Exposure Resources

These are important experiences from the past that mayinfluence the person’s functioning now and inform an understanding of current issues

• How did adults treat the person while they grew up?• Were there important relationships that were supportive and kind?• Were there any adverse childhood experiences?• Was there verbal, physical, sexual abuse towards them? • Did they witness:

Parental separationDomestic violenceMental health problemsAlcohol abuseDrug useImprisonment or incarceration

• How does the person make sense of what happened in the past?

Past

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Please do not copy, reproduce, or share these slides without permission from Janet.Bostock@ntw.nhs.uk or Nicola.Armstrong@ntw.nhs.uk

The positive aspects of a person’s life including -opportunities for control, predictability, participation, giving and taking, reliable public services.

Resilience is significantly influenced by the quality of social relationships.

Social resources - friends, kind neighbours, comfortable finances, safe and pleasant place to live, secure employment, leisure facilities.

Biological resources - good health, physical strength, helpful medication.

Psychological resources - interests, literacy, strategies for coping, confidence, ability to identify feelings.

Positives

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Please do not copy, reproduce, or share these slides without permission from Janet.Bostock@ntw.nhs.uk or Nicola.Armstrong@ntw.nhs.uk

Stakeholders in change

Exercise 4:

• How might they view change?

• How might they get

in the way of change

Family / Carers Service user Organisation(s)Society Staff

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Potential ways forward for

individuals

• Activities (e.g. Walking).

• Problem solving.

• Courses (e.g. Recovery

college).

• Support groups (e.g.

Hearing voices).

• Connecting with

community / friends.

• Signposting (e.g. CAB /

Housing etc.).

• Carer support.

• Psycho-education

around lifestyle

concerns; nutrition,

sleep, alcohol,

drugs etc.

• Medication; advice

and monitoring.

• Normalising. Family interventions.

• Validating. DBT Skills.

• Structured clinical management.

• Promote self-management e.g. WRAP.

• Graded exposure / behavioural activation.

Psychological

Access to

resources

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How do we help service users &

carers to think about impact?

“Understanding what Influences your

Mental Health and Wellbeing”.

This has been produced by people who use and work in

NTW services and some of their supporters. It is already

very popular with carers, service users, and staff. The

booklet aims to help people understand what is important

to their personal wellbeing. It suggests key questions that

may help them to make sense of their strengths and

difficulties as a formulation and support them in moving

forward.

https://www.ntw.nhs.uk/5P

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Please do not copy, reproduce, or share these slides without permission from Janet.Bostock@ntw.nhs.uk or Nicola.Armstrong@ntw.nhs.uk

https://www.ntw.nhs.uk/5P

How PTM framework can influence questions about the past

How PTM framework can influence questions about triggers

Trauma Informed Approaches:

Implications for Mental Health Practice

1. Safe places and treatments

2. Privilege Service User accounts

3. Staff understanding

4. Training

5. Asset based approach

6. Facilitate sharing childhood experiences

7. Ensure Services do not re-traumatise

8. Account for social inequalities, and prejudice

9. Partnerships

10. Look after staff wellbeing

11. Appropriate pathways and interventions

Adapted from Sweeney, A., Clement, S., Filson, B. & Kennedy, A. (2016). Trauma-informed mental healthcare in the UK: What is it and how can we further its development? Mental Health Review Journal, 21, 174–192.

“Reciprocal Roles” - mapping

self, others and the world

• Through repeated experiences in relationships we learn two roles, and learn to enact them both towards others and to ourselves.

• E.g. with a memorable teacher…Encouraging

Calm

Valuing

Encouraged

Confident

Valued

“Reciprocal Roles” - mapping

self, others and the world

Critical

Controlling

Worthless

Rebellious

Judgemental

Worthless

Inferior

Overwhelming

Overwhelmed

Crushed

Threatening

Threatened

Intimidated

Reciprocal roles associated with inequality, adversity and power abuse

Envious

Envied

Blaming

Blamed

Abusive

Terrified

Sharing

Power

Invited in

Connecting

Connected

1:1 work

Systemic

Able to hear

Able to say

Reciprocal Roles “exits”

Asking/naming

in solidarity

Exploring

together

OK to be wrong

Accepting

Determined

Energized

Encouraging

Energizing

PTM Framework: Implications for

Psychologists

• How do we use power in our clinical practice?

• How do we use power at work, as colleagues and

leaders?

• How do we respond to the use of power in its

different forms?

• How can we join with others to make social and

organisational changes?

PTM Framework: Implications for

Psychologists

• What threats are relevant?

• What threat responses do we use?

• What threat responses do others use?

• How do we impact on each other?

PTM Framework: Implications for

Psychologists

How do we make sense of things?

• With reference to our relative positions of power and

powerlessness.

• Our own use of ideological power?

• With reference to threats to ourselves and others and from

ourselves and others.

Implications for clinical practice• What we do

Formulation• Attend to inequality, the operation of power, adversity and threats as

well as meaning

• Consider power and resources available to people

• Understand and address the physical and embodied consequences of adversity and trauma with individuals and systems

Interventions• Ways forward need to account for opportunities for connection with

others and the promotion of living and social conditions that are safe and nurturing

• Focus on prevention and beyond individual work

• How we do it– Aim for clarification, care, solidarity and encouragement (David

Smail)

– Validate and acknowledge unfairness, threats and power abuse

– Attend to how much we collaborate, power-share

Psychologists for Social Change

PTM Framework: Ways Forward Be aware of people’s experiences of injustice, inequality and

threat.

Continue to elaborate and share understanding of how power

is used, the impact of threat and implications for practice.

Connectedness and collective action across organisations

and agencies.

Challenge disempowering practice or abuse.

Learn, train and develop together, progress co-production and

peer support.

Foster collaborative research

Share innovative and good practice

Meaningful supervision, mentoring, support

Openness and reflective awareness

References• Johnstone, L. & Boyle, M. with Cromby, J.,

Dillon, J., Harper, D., Kinderman, P., Longden, E., Pilgrim, D. & Read, J. (2018) The Power Threat Meaning Framework: Overview. Leicester: British Psychological Society.

• Lloyd J. & Pollard R., eds. (2019). Cognitive Analytic Therapy and the Politics of Mental Health. Routledge

• Ryle, T. (2010). The Political Sources of Reciprocal Role Procedures. Reformulation, Summer, pp.6-7.

• Brown, R., (2010). Situating Social Inequality and Collective Action In Cognitive Analytic Therapy. Reformulation, Winter, pp.28-34.