Welcome to the October edition of Tips and Topics.
In SAVVY, Dr. Mike McGee, psychiatrist, shares thoughts on what is a good formulation and explains some of his Formulation “C’s”: Clinicians Collaboratively and Curiously Co-creating a Comprehensive, Compassionate, Coherent, Chronicle of a Client’s life and their Current and past Conditions, Concerns, Capacities, and their Conception of a better life.
In SKILLS, Mike continues with tips on what it looks like to have "Clinicians Collaboratively” work with clients; to be "Curiously Co-creating;” and how to cultivate and maintain, in the busyness of work demands, the attitudes and values to live the Formulation “C’s.”
In SOUL, Ellen Eatough, MA poses one question to help you quickly discern if someone has the emotional depth for a truly fulfilling partnership or friendship. “Pay attention not just to what they say, but how they say it. Humility combined with self-awareness is the sweet spot.”
Long time friend, colleague and psychiatrist Mike McGee recently asked me to look over a paper he had just written titled, “Good Formulations Beget Good Outcomes - A Comprehensive, Collaborative, and Compassionate Framework for Helping Clients Heal and Recover.” Mike defined a Formulation as “a working hypothesis that explains the origin, development, and maintenance of a person’s distress and impairment in a way that informs how we help them. It is not a fixed conclusion—it is dynamic and evolves with new information.”
Like me, Mike enjoys creating alliterative, natty phrases if they have meaningful content. He developed a doozy of a one in his Formulation “C’s”: Clinicians Collaboratively and Curiously Co-creating a Comprehensive, Compassionate, Coherent, Chronicle of a Client’s life and their Current and past Conditions, Concerns, Capacities, and their Conception of a better life.
There’s a lot of content in that alliteration that I asked him to write about for this month’s Tips and Topics’ SAVVY and SKILLS Tips. Here are his Tips that I edited and modified to fit the Tips and Topics format.
About Michael McGee
Michael McGee, M.D., DLFAPA
President
WellMind
Tip 1
What is a Comprehensive, Compassionate, Coherent, Chronicle of a Client’s life and their Current and past Conditions?
Dr. McGee:
I think about “comprehensive” in a few ways.
First, what is a comprehensive understanding of the story of a person’s life? What has happened to them, both helpful and harmful? I am a “trauma hound,” so I sniff out trauma, both overt and hidden.
We prioritize “what happened to you” over “what is wrong with you.”
What challenges did patients face, and how did they cope with them?
What strengths and virtues came into play? What resources, relationships, and supports contributed to their surviving and even thriving?
If patients were sober in the past, for example, what worked, and what is different now?
Second, “comprehensive” entails an integrated and pluralistic way of understanding our patients. There is a neurobiological or neuropsychiatric understanding. This is more of a pathology or medical model of understanding that focuses on symptoms, suffering, distress, and impairments.
A comprehensive and integrative formulation transcends a narrow pathology-based view and includes other ways of understanding our patients:
There is a disability understanding.
There is a diversity understanding.
There is an ecosocial understanding.
There is a psychodynamic or developmental understanding.
There is a psychological understanding.
There is a strengths-based understanding.
And there is a socio-cultural understanding.
We need to integrate and synthesize all of these ways of understanding our patients with them in a “both-and” way.
The American Society of Addiction Medicine (ASAM) Criteria multidimensional assessment is an example of another way of attempting to arrive at a more comprehensive formulation.
A third component of “comprehensive” is an understanding of vulnerabilities and needs.
What resources do patients need to achieve a valued and meaningful life?
What supports do they need?
What help do they need?
I like Rapp and Goscha’s “The Strengths Model” framework. They base their assessment of vulnerabilities, supports, and needs on seven categories of strengths and related desired goals:
1. home/daily living
2. assets – financial/insurance
3. employment/education/specialized knowledge
4. supportive relationships
5. wellness/health
6. leisure/recreational
7. spirituality/culture
One of the most therapeutic things we can do with our patients is to co-create with them a compassionate and coherent formulation.
An Example
I recently worked with an extremely intelligent therapist who suffered from panic, depression, and suicidality. Her father is a physician who was harsh, cold, and distant when she was growing up. He once came into her room and yelled at her when she was suicidal, telling her that she was being “ridiculous,” and to “cut it out.”
Despite being a highly intelligent clinician, she could not see that this was abusive behavior, that her father was condemning and invalidating her for her deep suffering, and that this primal dynamic was at the root of much of her depression and suicidality.
Coming to a compassionate and coherent understanding of this and experiencing this in a compassionate and caring relationship with me was very healing. Again, I hope you can see that the shift here is from “what’s wrong with you” to “what happened to you?”
References:
Rapp, C, Goscha, R. The Strengths Model. 2012. Oxford University Press. New York.
Yalom, I. The Gift of Therapy: An Open Letter to a New Generation of Therapists and Their Patients. 2017. Harper Perennial. New York.
Tip 2
What is involved in assessing Concerns, Capacities?
Dr. McGee:
The foremost question that is somewhat at odds with much of our training is “what does the patient want?” (Versus what is wrong with them and what treatment do they need). This is the holy grail of recovery work.
We get to assessing the patient’s concerns by first engaging in creating a safe, caring, trusting, connected relationship, primarily through the common factors that contribute to good outcomes in all psychotherapy: empathy, warmth, acceptance, positive regard, genuineness, hope, and affirmation.
This work is foundational, and paves the way for other more traditional assessment activities, such as gathering data from the patient and their concerned collaterals (family, friends, other caregivers, the court).
We also assess capacities by:
Looking at the history of our patient’s past functioning and their current functioning
More formal assessment activities such as cognitive testing and psychological testing.
I am now doing computer-based testing for Attention Deficit Hyperactivity Disorder, and find this, along with collateral input, to be very helpful.
Tip 3
What is their Conception of a better life?
Dr. McGee:
This is where clinical humility and a fundamental respect for our patients is paramount. Our idea of what is a better life for a patient who is homeless and psychotic may be very different from theirs.
We have unintentionally inflicted untold harm on our patients by imposing upon them our conception of a better life.
It is our task to inquire deeply with our patients into what they want, what a better life looks like to them, and how we can help them achieve that.
Some mandated patients, and patients with impaired decisional capacity and imminent risk, require that we balance our prioritization on recovery -- helping patients realize their conception of a better life -- with treatment aimed at restoring capacity and reducing acute risk.
When this is necessary, we do well to continue to keep at the forefront of our minds our patients’ conception of a better life, and return to that as quickly as possible.
Dr. McGee continues with some SKILLS Tips.
Tip 1
What does it look like to have "Clinicians Collaboratively” work with clients?
Collaboration is at the heart of our healing work with our patients. The spirit is one of partnership and respect, privileging what our patients want, their ideas about how to achieve what they want, and then helping them in any ways that we realistically can.
An Example
I recently had a patient who wanted me to give her Adderall for “ADHD” because she had “trouble getting going in the morning” after drinking roughly 6 drinks every night. She had recently been discharged from a withdrawal management facility, but did not see her alcohol use as a problem. The collaborative work with her was to sit with her in this tension with empathy and care as we worked to negotiate goals and interventions we could both feel good about.
Another part of collaboration is to honor our patients as the experts in their lives.
We are guides, and can offer perspective and information, and help patients brainstorm their options.
I almost never give advice anymore, but will instead ask patients about what they know and what they think might help them. This almost always works.
Rarely will I give suggestions. If I do, I will ask permission first. For example, if a patient is having trouble with insomnia, I might ask, “What do you know about sleep hygiene?” If they say they do not know about this, I might ask, “Would you like me to teach you about this, or give you a handout?”
Tip 2
What does it look like to be "Curiously Co-creating” with clients?
Our understanding of our patients arises from continuous, curious inquiry combined with reflection and confirmation. The formulation is not something we impose on our patients-- we co-create it with them. Our patients provide us with information and their own understandings, we offer our tentative understandings in return, and together we arrive at a shared understanding.
But “arrive” is not quite the correct word, as we never arrive.
The formulation is always tentative and evolving.
We must maintain clinical humility, knowing that our understanding of our patients is always incomplete, and often incorrect.
I have been astounded over the years at how my understandings evolve and deepen over time, as new revelations occur, sometimes after years of work together!
So, the curious co-creation process is ongoing. It leads to deepening insight, awareness, understanding, coherence, and ultimately compassion and forgiveness. This is an important component of our healing work.
Tip 3
How does a clinician cultivate and maintain, in the busyness of work demands, the attitudes and values to live the Formulation “C’s”?
This is a huge topic, meriting an entire issue. In brief, you’ve got to “be good to do good.” As dynamic living systems, we all must work to maintain and enhance our vitality and flourishing. Most of us know what to do:
Have a balanced life of work, love, and play.
Practice good self-care, including nutrition, sleep, rest, exercise, meditation.
Refrain from harmful behavior.
Obtain support from people who love us, including trusted colleagues.
Along with support, process our clinical work and stresses with others. I routinely do this with my wife and some colleagues. It is critical that we engage in regular reflection on our work.
Work in a healthy, trauma sensitive environment with trauma sensitive leadership. Just as our patients’ health and flourishing depends on the eco-social system in which they live, so our clinical flourishing depends on the clinical environment in which we work. We need to kindly assert ourselves so that leadership addresses our concerns. If we are not working in a supportive environment, we need to do what we can to find such an environment.
Engage in feedback informed treatment (FIT) and deliberate practice (DP) with a coach. This is a necessity for both maintaining our morale and enhancing our clinical skills. It turns out that a big contributor to burnout is patients not doing well and the accompanying feeling of demoralization. Addressing this by modifying the therapeutic alliance or transitioning the patient to a different provider or treatment setting helps reduce burnout. Having a coach/mentor for support and guidance is hugely uplifting.
Participate in a peer support group. This is very helpful for processing work challenges and clinical/personal distress.
Cultivate your psychospiritual growth. Engage in a spiritual community to develop qualities such as equanimity, joy, compassion, gratitude, and forgiveness. Also engage in some sort of regular spiritual practice and experiences of transcendence through prayer, meditation, nature, music, art, poetry, etc. This allows us to experience stress and distress within a larger context of reverence not only for our lives, but for the sacred work that we are privileged to do.
Finally, almost all clinicians have a history of trauma, and must attend to their own healing and well-being. Like Irvin Yalom, I believe that all clinicians should be in therapy.
These life practices are fundamental to being a good clinician and healer. Of course, none of us engages in all these practices perfectly all the time, so we need to give ourselves grace. We all get off track, have good days and bad days, and fall down. I think “one day at a time” is a good way to get back up, recommit, and keep going.
Reference:
Yalom, I. The Gift of Therapy: An Open Letter to a New Generation of Therapists and Their Patients. 2017. Harper Perennial. New York.
Ellen Eatough, MA, calls herself "The Soulful Sex Coach." Sorry, this SOUL section is not about sex though. She recently wrote about dating in our later years and “how do you quickly discern if someone has the emotional depth for a truly fulfilling partnership?”
There was one question she recommends asking (“perhaps not on a first date, but early in getting to know someone”) that I think is a good question not just for dating at any age, but to get to know someone a bit more deeply as a friend:
"What have been your biggest personal growth moments in the past five years?"
Ellen says: “Pay attention not just to what they say, but how they say it. Humility combined with self-awareness is the sweet spot.”
She said their answer reveals volumes about:
Whether they see themselves as evolving or fixed
How they respond to life's challenges
Their capacity for self-reflection
What they value enough to work on
If you are interested in having friendships with people who value ongoing personal development, how they thoughtfully answer “demonstrates the self-awareness essential for profound connection.”
Ellen finishes with a reminder that I find comforting: “The healthiest relationships… aren't between two "finished" people, but between two individuals committed to continuing their growth journey – together.”
I find that comforting as I notice that I am still discovering new thoughts, feelings and emotions to stretch into. Or as Esther Hicks says: “You can’t get it wrong and you are never done.”
Thank you for joining us this month. See you in November.
David