Formulating formulation

As a CPN I am frequently reminded that we provide episodic care, that those on my caseload should be recovered to the point of no longer requiring secondary care within a desired number of sessions. Now that is a lot of pressure on both me and the service user, with an overwhelming feeling of failure when we don’t manage that. I sometimes think we have gone beyond austerity and that this is me simply applying a dressing on the wound until the person is re-referred back in to the team. I don’t want that, I don’t think any nurse wants that, we want to walk side by side along a journey of recovery then wave the person we have nursed off into their future stronger than ever.

We CPN’s all work in different ways but I think despite knowing the time pressures it is impossible for me to walk into a persons home and say ‘Hi my name is xxxxx and could you please start engaging in this treatment plan I think is right for you’, the person and I need to build a therapeutic relationship. Maybe one or two sessions whereby we get to know each other a bit, where I tell them their dog is cute and ask them about the pictures on the fireplace, if we share a love of reading I may recommend a novel to them. I need to put them at ease, they need to be able to trust me if I want them to feel comfortable to off load their deepest and often darkest thoughts.

So the first session or two are ‘get to know you/build a therapeutic relationship’ type sessions and during the time over these couple of sessions I would try to build up a picture of risk and document this on the FACE risk which is the tool my trust uses, I’d get them to complete a consent to share document so we both know and understand where the restrictions lie. Get the basics done from a documentation point of view.

Next thing I probably ought to document is care plans but I am of the mindset that we can’t produce a care plan until we have a decent formulation. How can we decide a plan of treatment if we aren’t even 100% sure where the main issues are?

I use the 5P’s formulation which includes considering:

  1. Presenting problem(s)
  2. Predisposing factors which made the individual vulnerable to the problem
  3. Precipitating factors which triggered the problem
  4. Perpectuating factors such as mechanisms which keep a problem going or unintended consequences of an attempt to cope with the problem
  5. Protective factors

It is important for the person to know that what is important to them is important to me. As you may have noticed if you read my last blog was that I plan on having a few sessions of talking therapy myself to consider my current all encompassing worry that my work place and colleagues will connect my illness and my competence. As I plan on only having a couple of sessions to talk it through I thought it would save time if I arrived with my formulation already done… so because I am living the rock n roll life I thought I would make a start on it tonight. A Saturday night on formulation.

Whilst sat wondering if there was anything else to add to my precipitating factors list I began to realise that maybe I am more than a list (who knew?!?!?). We are all more than a list. Now I am not saying here that the 5P’s formulation is not a great tool because it is a fab way to capture what is sometimes a difficult narrative to grasp in the minimal time we as clinicians have. I always do the 5P’s formulation with the person but attempting to produce my own made me acutely aware that maybe I need to consider how I capture this vital background in a less formal and more human. I was reminded also this evening how emotional it can be to see all of this written down in black and white, reminded not to underestimate that because these formulation sessions are not ‘therapy’ as such they can still be difficult for the person I am working with and depending upon their level of distress and how much they are able to tolerate may take more than one session to complete.

It is not until now that we can even begin to produce care plans. Again this is something I do with the person I am nursing, in a session. it makes sense to co-produce them, why would someone be invested in care done to them rather than care done with them?

So now if we consider that on average with a caseload of 35 people are seen 3 weekly and taking just the above into account at roughly five sessions, which in itself is conservative as some people may take much longer to engage then this is around 15 weeks, add a couple of extra weeks for annual lave of the CPN and without any other hiatus this is four months before any actual therapeutic intervention takes place. Those four months will hopefully have helped to build trust and to have aided the person to have hope once more.  They certainly aren’t wasted weeks but they don’t fit neatly with the episodic care model as comfortably as most trusts would like. Whilst I absolutely agree that the days of the Community Mental Health Team CMHT are over and the new player is the Community Treatment Team CTT and this is a good thing however (you didn’t think you would get away from me without a however did you?) for some people the rational unbiased support and the sharing of hope that comes with that is vital and is treatment in itself. Lets never minimise the role of hand holding, sometimes we all need our hand held to get us through.

Too often we declare people as ‘treatment resistant’ when actually maybe we just need to rethink the treatment we offer rather than absolve ourselves of guilt by referring to our episodic model of care. Illness is not always neatly episodic. People are not episodic. If we explore the formulation with a solution focused approach then this in itself could be the most appropriate treatment going. I will never rush a formulation, strange that it took producing my own in a bid to save time to realise that.

2 thoughts on “Formulating formulation

  1. Great post. Sensitive, thoughtful, and highly competent (!) – you are the kind of nurse who actually does make a difference in people’s lives while still finding a way to operate within an increasingly inflexible and at times uncaring system. Thank you.

    Liked by 1 person

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