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 David1. 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.

THE IM

PRESS O

F POW

ER

Politics EconomicsCultureInformation media etc

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Distal Influences

Domestic situationsEducationPersonal relationshipsFamilyWorkBenefits

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Proximal Influences

ExperienceBeliefs, dreams, memoriesWishes etcBodily sensationFeelings of comfort, pain, fear, etc‘Symptoms’

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The Person

Formulation: The Influence of the Social Environment (from Smail, 1996)

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What Influences our Well-Being?

WELL-BEING

+/-Exposure

Social position (Eg. Age, Gender, Class, Race, MH Service User)

Access to Resources

Life Events

Critical Incidents

Ongoing Difficulties

Organisational

Educational

Physical Health

Psychological

Financial

Social

DEMANDSCONTROLROLESUPPORT

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?

Presenting Issues

Predisposing Factors

Precipitating Factors

Perpetuating Factors

Protective Factors

Plan

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5 Ps + Plan

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.

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PREDISPOSING PRECIPITANTS (WHAT SET IT OFF)

PRESENTING ISSUESMy main problems are…

What do other people think?

PERPETUATING FACTORS (WHAT KEEPS IT GOING)

PROTECTIVE FACTORS

PLAN: WAYS FORWARD

OUR NEXT STEPS:

TELLING THE STORY OF WHY I AM SEEKING HELP

Don’t forget: include everyone’s perspective whenever appropriate. Even

if they differ!

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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.

Formulation: Quality ChecklistDoes 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

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

HOW SYSTEMS CHALLENGED ABUSE• Taking the victim’s side• Offering a common bond• Effective help

SAFETY & WELLBEING• Experience of safety• Isolation/support• Relationships with children• Hardship• Activity & aspirations

Domestic Violence Against Women: Understanding Social

Processes & Women’s Experiences

Bostock, Plumpton & Pratt, 2009

Psychological Formulation Example Personal/Social Status

– Service user “ sick” + Brownie Leader– “Victim” + Stepmother– Married– Daughter

FEARRAGE

DEPRESSION

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

Psychological– Confidence– Avoid scary situations/ stay in bed– Cut self – relief – guilt – medication - sleep– Drink – relief – feel bad– +Rescue others. Try to please

Access to Resources

Biological/Physical– Back pain – +Use of medication – Alcohol

Social+ Education + Family+ Church + Friends+ Pets + MH services– Money

– Flashbacks– Intrusive memories

– Abuse from husband

– Past sexual abuse– Lack of recognition– Not validated

Exposure

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.

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Key ReferencesBostock, 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