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Clinical formulations, something that few of us outside of mental health providers know about, but can be a critical tool in improving communication skills, especially around serious illness. Learn about them from our special guest, Dani Chammas, in this weeks GeriPal Podcast. Dani makes the case in this podcast that the single most valuable thing clinicians can do to improve communication is to get into the practice of asking yourself:

  1. What is the core psychological struggle that has this patient or family stuck?
  2. What communication techniques might I use to address that?
  3. How did their response to my intervention change my hypothesis?
  4. Repeat 1-3.

I love it when people can distill complicated topics into a couple steps that we can all try. I know I will.

Here are links to a couple papers if you want to learn more:

  • The first article is called “Taking Care of the Hateful Patient” dating all the way back to 1978!  And per Dani, it is “a total classic in psychiatry”.  Short and approachable, it is not specific to “how” to formulate – but it goes over a 4 of the types of patients that physicians by-and-large tend to dread (“dependent clingers” “entitled demanders” “manipulative help-rejectors” and “self-destructive deniers”); for each they give a brief formulation of what is often going on for such a patient and communication strategies to shoot for.
  • Here also is a paper of how of how a CBT therapist would formulate.

by: Eric Widera (@ewidera)

Eric: Welcome to the Geripal podcast, this Eric Widera.

Alex: This is

Alex Smith.

Eric: Today we have a special guest with us today, Danielle

Chamas, who is a psychiatrist and a palliative care doctor and just gave a wonderful talk to

our fellows on interesting topic which we will get to. Maybe before that, Dani, we usually

ask our guests to give Alex a song that he should sing.

Danielle: I’m going

to go with “Free Falling” by Tom Petty.

Alex: Free Falling, great song.

Alex sings “Free Falling” by Tom Petty.

Eric: Dani and I both have

our lighters going right now up in the sky.

Danielle: It’s a good song

choice!

Eric: We just had a really interesting morning core curriculum talk

on formulation. Alex have you ever heard of formulation before?

Alex: Drug

formulation?

Eric: Apparently not drug formulation, that’s what I was

thinking initially. Dani what is a formulation and why should we use it in palliative care

and geriatrics?

Danielle: A psychological formulation in the therapy world is

what you think is the core underlying issue in someone’s psyche that’s getting in our way, or

tripping them up. Similar to heart failure or in internal medicine, if someone comes in with

chest pain you don’t think about treating the chest pain, you think what is causing this?

What is underneath? That guides your treatment. In the therapy world it’s the same with

communication, you don’t just look at what the patient’s saying or doing, you think, “What is

the formulation, what is the route behind this that’s causing this?” That guides how you

treat it.

Alex: What’s the formulation for Trump?

Danielle:

How long do we have today, Alex?

Eric: There could be a lot of different

reasons people say things that they do, how do you know what’s the underlying reason that

they’re saying something? Why did Alex just bring up Trump?

Danielle: Yeah,

so it’s a good question and in general you don’t pick one specific thing a person did, but a

guiding formulation. I will say, it takes four years of psyche residency to even start

feeling comfortable during formulations, and then people keep doing this in therapy and

practice for years over their career. This is why your therapists tend to get better with

time. It’s a hard thing to do, and I’m not advocating that everybody in palliative care

immediately know how to formulate, but I am advocating that they slow it down to take the

step to wonder, “What is the route behind the behavior?”

Alex: What is an

example?

Danielle: Let’s say the behavior you’re seeing- you’re in a family

meeting and the family is stuck, they do not want to make a decision. You’re trying to get a

goals of care and they just can’t. There could be different reasons, there’s not one thing

you do for a stuck family meeting. If my psychological formulation is, “Oh my gosh, this

family is so overwhelmed by the responsibility of this choice. They are petrified of doing

the wrong thing, that they’re going to have to live with that burden forever.” Then my

communication tool is going to be something that takes away that responsibility from them. I

might give them my strong recommendation, I might stop presenting it as a choice and just

say, this is what we should do.

If my formulation is that their psyche is

really stuck on a feeling like that their loved one is just another person to the doctors,

that the doctors are pushing their agenda, and that they don’t see them as an individual and

that they’re trying to force me one way of the other. Things are going to go south if I start

giving them strong recommendations. Based on my formulation that the real core issue is, “Am

I seeing their father as a person?” That’s the place that I might start saying, “Tell me

about your dad, tell me what he would want if her was here.”

I’m going to

pick different tools from my tool it, just like you’d pick a different nausea med if you had

a different cause of nausea, or a different chest pain med if you had a different cause for

chest pain.

Alex: This is completely new to me, I’m going to make up some

words and you can tell me if this is a close approximation of what you’re talking about. It’s

trying to understand the underlying reasons that may be unspoken, behind a person’s

motivation for the way they act, behave or say.

Danielle: Exactly. What we

find in the therapy world is that actually you can see a huge array of symptoms, but most

people have a few core underlying beliefs that are guiding most of the things that come up in

their life, right? Is it that I’m unlovable, is it that I’m to blame for anything that goes

wrong? Is it the world’s to blame? Who knows what it is, but most people have some organizing

compass that might be leading them astray, and you pick your therapeutic communication

intervention to address that. Otherwise you’re just shooting at the dark, just throwing

different tool and communication styles at people.

Eric: How do you figure

out what those underlying issues are?

Danielle: What I would hope for in the

field of palliative medicine, I think that people come into palliative medicine because

they’re inherently good communicators. I think there’s a good amount of intuition already in

this field, and you see it happening. You see someone becoming naturally more paternalistic.

Something is going wrong and they just do it, or you see them become a little bit more soft,

or a little bit more this or that. What I think we need in this field is for this process to

become explicit. The same way that everything else in medicine is explicit. Why? Why did I

become like this, why did I become like that? What am I going to try with family, what do I

think is going to trip up this family?

Eric: Yeah.

Danielle:

We debrief our family meetings, we say, “Okay team, what worked and what didn’t work?” What

does that tell us? That tells us what worked or didn’t work for them, but can we extrapolate

that to every family? No. What worked and what didn’t work, why? Why in this case? I think

the more we’re doing that out loud, the more we’re going to learn and be able to hone

something that we’re all relatively good at, at baseline.

Alex: It seems like

you’d have to know the individual participants in the family meeting fairly well, in order to

extract- in order to deduce that underlying motivation. Are you saying that even without

knowing the individual participants in the family meeting as well as you might know them as

say if you had individual therapy sessions with each of them. You can still draw some ideas

or conclusions or suppositions about what might be going on, that would help your approach?

Danielle: Yeah, and I have a few thoughts on that. There are different

levels of formulating. Am I going to formulate the core issue that this family has struggled

with for years? Maybe not, I don’t know their childhood histories and whatnot. Can I

formulate what is tripping them up around the end of life care for their dad or what is the

psychologically the barrier in whatever medical thing that’s going on? Yeah, I think what we

can do that pretty quick, and I think that we all are doing it, we’re just not doing

explicitly.

I’ll add, if you watch a master therapist out in the community,

Alex, and show them about a four minute clip of one of my own therapy sessions, we used to do

this in psyche residency. You’d show them a four minute clip and they’d stop and be like,

“Wait, wait, wait, wait. Let me tell you what’s happening for this patient.” It was amazing

what they could figure out from four minutes.

Alex: Wow.

Danielle:

Yeah.

Eric: Maybe it would be helpful to do maybe a little practice

session, you give us a case, Alex and I will try formulating? Maybe that can help me flip my

head around this topic?

Danielle: All right, here’s the case. You tell me

what you think of this one. Let’s say you’re in a family meeting, and a decision needs to be

made right now about the course of a patients care. The families are listening to what the

doctors have to say, but they just refuse to make a decision, they keep saying, “Okay, thank

you for this information we need more time. We want more time.” Meeting after meeting, “We

want more time,” you can’t get a decision. Let me be clear, there isn’t a right answer to

this. This is a sample case, I don’t know the formulation, what might be a formulation for

what’s leading to this issue?

Alex: It could be, a fear of making the wrong

decision and that strong fear leads to no decision.

Eric: It could be that

they’re waiting for a family member to come in from another town?

Danielle:

Okay, so they might be petrified of making the wrong decision, they might feel like, if you

went further into the family member thing. What is? …

Eric: They don’t want

to make it alone, this decision. There’s an important family member who makes most of the

decisions, or there’s a lot of different dynamics in the family where there’s a lot of

arguing over a lot of past wrong decisions?

Danielle: Maybe they’re scared of

being blamed, yeah, that could be something.

Alex: It could be that they’re

the type of family that looks to the doctors to make a decision. That they aren’t in the

habit of making decisions and that maybe it’s, “What would you do, Doc?” You need to make a

suggestion as a doctor, would a recommendation help in this sort of case?

Danielle: Now you’re getting into what you communication tool would be based on your

formulation, but yes. It could be those things, what else could it be?

Eric:

Could be that the family is scared because their loved on is dying and if they don’t make a

decision it may make them feel like they’re not dying or they don’t have to deal with that

issue.

Danielle: Mm-hmm (affirmative), it could be avoidance of a really huge

truth they don’t want to acknowledge.

Eric: So then what do we do?

Danielle: Let me pause you there. What do we do? You took it right out of my head.

Let’s take that one, let’s say that you think the reason they’re not making a decision is

because that means they have to truly acknowledge that this person is dying. They are

petrified to do that. What might you say to that family?

Eric: Maybe go back

into my tool box, acknowledge the emotion that this is really hard to be in this situation-

to have their loved one this sick in the ICU.

Danielle: Yeah.

Alex: Yeah, draw out from them what they’re feeling at this time.

Danielle:

Mm-hmm (affirmative).

Alex: What are you seeing, what are you worried

about? Maybe getting the other members of the team to use the word dying if they’re using it

amongst themselves. A lot of times the docs, “I think they’re dying,” but then they won’t say

that to the family.

Danielle: Yeah, you guys right now, is you’re picking

your tools. You have a compass, you’re thinking to myself, “I have a guess at what the

psychological hold up is” and in my mind I’m thinking, “I want this family to feel the

message, what’s hard here is not the decision. What’s hard here is that this person is dying.

That we all sit here and own the fact that this person is dying and we’re not going to move

forward until we do that.”

Alex: Yep.

Danielle: If I had

backtracked guys, and I had picked on of those other formulations that you had brought up,

this strategy might not make sense. You with me?

Eric: Can you give an

example?

Danielle: Let’s say that this family’s issue is that they are

distrusting of health care, and they really don’t think that you care about their father.

They think that you want to get them out, they think that you’re just trying to push an

agenda, have it be done, you keep coming in for this decision and they’re like, “Whoa, whoa,

whoa hold up, this is our father, stop pushing we’re not ready.” If you go in there doing

things that just want to underscore that you really think that this guy is dying. Let me make

sure in my communication that this family gets that, “This guy is dying, let’s sit with him

dying.”

Eric: I’ve never been in a situation like that.

Alex:

Completely foreign, where do you come up with these things?

Danielle: That is

not going to go well. We see this happen, we go as palliative care to these meetings and we

see the crash coming and you’re like, “No, no don’t say it.” Then we adjust and we’re doing

so much of this implicitly. “Let me jump in and ask you about blah, blah, blah. Let me jump

in here.” But there’s so much less potential to grow and there’s so much less potential to

teach if we don’t then later think back and say, “Why? Why did I do this? Why did this work

or not work?”

Eric: It also sounds like your initial formulation may be

wrong, and you’ll know it’s wrong and then you may have to pick a completely different

formulation. For example if I thought, “They’re just not acknowledging death,” and they

respond as they would if they were just mistrustful of the healthcare system. I would have to

change my formulation pretty fast.

Danielle: Yes and you’ll know it doesn’t

work, if I’m thinking, “Oh they’re not acknowledging death,” and I sit, I take a big breath

and I say, “You know, they’re dying.” They look back at me and they’re like, “Yup, they’re

dying.” Then there’s a pause, that might be a clue, okay that didn’t work. My communication

wasn’t therapeutic. The same way that I give [pain medication], and the patient says, “Nope,

my leg still hurts.”

I’m like, “Oh, okay that didn’t work, what did I have

wrong here?”, and you adjust. What we don’t want is people either seeing something working

and thinking, “Okay that’s going to work, that’s how I do family meetings, that’s how I break

bad news, that’s how I do it.” It’s going to be different for everybody. We also don’t want

people just shooting in the dark, “Oh this didn’t work, let me ask, hopes and fears, oh that

didn’t work. Let me ask this.” There’s so much less potential for growth if we just kind of

keep shooting in the dark from some pretty good tools. We have a good tool kit.

Eric: Right.

Alex: Are there things that I can do as a palliative care

provider to practice this skill or learn more about it?

Danielle: Yeah, let’s

start with practice. I started to say this, I think some things, like I was saying, make your

thought process explicit. Don’t just recommend something communication-wise to another team

but tell them why. When you’re going into a meeting with a team and you’ve done some debrief

and given them your tips, maybe ask them something like, “You know this family best, what do

you think is going to trip them up? What’s going to be their core struggle in this room?” By

asking these questions, not only are we setting ourselves up for a much better family meeting

than our basic pre-hash does, but we’re teaching them to think like this, we’re teaching

ourselves to think like this.

We’d start there, some people get really

bothered by the thought of changing their communication, like I’m telling them to be a robot.

“For this type of person say this, and that type of person say that.” That’s not what we’re

advocating at all. What I would add is knowing yourself really well helps. Know the types of

formulations, the types of family meetings, the types of hold ups that your natural style and

the tools that you like to go for naturally work well with.

Go in on

autopilot with those ones and know the ones that you get tripped up on, so that you can think

through, “Okay I think it’s this formulation, before I go in, let me think about how I might

tweak my natural style. Do I need to be more paternalistic? A little less? A little more

straight shooter? A little less? Softer, harder?” Find authentic ways to tweak yourself, not

change yourself, but tweak yourself so that you’re therapeutic to the person.

Alex: I wish we could also, like when you said before for when you were in training,

you had some master therapist look at your therapy sessions for four minutes and give you

feedback that was remarkably elucidating. I wish we had some sort of coach that can come with

us. I think back to my training, with Susan Block there, learned so much from having those

encounters. I wish we could videotape our family meetings and bring them back to Dani so that

she could tell us what was going on.

Danielle: That would be really fun, and

a great way to think through it, yeah. A majority of my psychiatry therapy learning happened

sitting in a room, watching someone way smarter than me watch clips of me fumble.

Eric: Maybe a suggested reading so we could learn a bit more about this, we can put

some articles up on our Geripal website with this podcast?

Danielle: Yeah,

we’ll look for some. It’s funny in therapy, I don’t know how much you guys experience this,

people are very wedded to their school of therapy. “I’m an analyst. I’m a CBT person. I’m a

family therapy person.” They all teach formulation, but they do it with their own little

words and their own little processes, but the content of it is so similar. Maybe we could get

a few examples from different schools, whatever speaks to you, it’s different ways up the

same mountain.

Eric: You have one more comment?

Danielle: I

have one more comment, yeah. I was just thinking about sometimes when you’re sitting in a

therapy case, you can go hour after hour with somebody and then you know you hit something

good because one thing you say, lands differently. The whole energy of the room changes. I

know that you guys have been in a lot of family meetings, you’ve had that feeling right where

the meeting is going one way or the other and one comment from one person just shifts the

energy. You know it, you’re like, “We hit it.”

Eric: Right and I think …

Danielle: Now we know where we’re going.

Alex: In our debrief

about it, we do often go to what was the information content there? Rather than, what is the

underlying psychological construct? That dynamic that was going on in the family meeting,

what was the formulation behind that change? Not just the information.

Danielle:

Exactly because if we just went with the information that would just mean that that one

comment is going to be your money spot for every single meeting, right. It just doesn’t work

like that.

Alex: Although it’s called formulations it’s not a formula.

Danielle: Bumper sticker!

Eric: Thank you Dani.

Alex:

Thank you so much Dani. Sometimes you’re in that family meeting and you feel like you’re

in free fall.

Danielle: Sometimes you do.

Eric: I was

wondering how you were going to bring up the song, Alex.

Alex: This is my

favorite verse.

Alex sings “Free Falling” by Tom Petty.

Transcript was edited by Sean Lang-Brown

This Post Has 4 Comments

  1. Groves is indeed a classic and worth reading, with the important caveat that it is very dated in some of its language about patients (including the word "hateful") – ESPECIALLY worth noting when working with trainees. The family medicine literature has some useful papers: Hass LJ et al, Management of the Difficult Patient, Am Fam Physician 2005 and Pomm HA et al, The CALMER Approach: Teaching Learners Six Steps to Serenity When Dealing With Difficult Patients, Fam Med 2004.

  2. There is a wide range of literature from the field of Communication, specifically areas of Interpersonal, Health, and Family Communication that speak to all of what Alex is talking about. Scholars in communication have been examining formulations for a long time and could be utilized more in palliative care research, family meetings, etc., to inform providers in navigating health care interactions.

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