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A Note On Formulation Use In Return To Work

After a good Twitter chat with @ClinPsySussex I needed to write out something I had forgotten to say in my last blog, a note on the place of psychological formulation in return to work scenario for mental health professionals.

Psychological formulations are a description of how your thoughts, feelings and experiences knit together to make a story to help you understand why you are feeling the way you are today. They should also be active tools to help you thing about your strengths and your stress points and inform how to help you see the way forward to your goals that you want to achieve. They are informed by both psychological theory and by the person seeking help with their distress - as expert in their own situation and thoughts and feelings. They are best made together, in mutual curiosity and openness and trust, and aspects of the formulation can change over time as progress is made through the pain of distress and more is learnt about what makes up that pain, what helps and about thoughts for the future. 

As such, formulations allow a narrative to emerge about what happened that was painful, and what is going on now. If we look at this in the context of a mental health professional wanting to recover back into mental health work, then we have an excellent tool at our fingertips to get at the deep nuance of that. The nuance is essentially, how is my internal psychological pain doing, where are there still bruises, how much do those bruises hurt and what do they hurt most or least in response to in others?

By using formulation to be able to narrate the pain, where it lies, it's extents and what impacts on it, you can navigate a more clear path to working around others pain. You can fuse the personal with the professional and understand where you need to protect (and how that changes over time) and where you can approach and engage. In this way, the formulation can help inform what a personal work plan might look like ie the types of psychological pain in others that it feels safe to be around (not all bruises are the same nor intolerable) and types that might be more triggering. 

Personal mental health support to talk through your triggers can help to get underneath why this is the case, and to the point where you can make a conscious choice to work either in areas different to your own bruises or the same. 

The mental health world is deep and broad and there are many places to find your fit, more or less clinically. I would say personally, that you can work in areas of trauma that are the same as where you have your own trauma, people do it all the time. It takes being willing to be alongside your own pain from this, as much as you are willing to be alongside it in others.  

Back to mental health trust occupational health...I'm beginning to understand that it isn't often there. I don't think we have many clinical psychologists working in occupational health. To me, in my breakdown, where I have understood my pain as a trauma narrative without labels through psychoanalysis, I had no recourse to anything other than medical descriptions of my pain in my wider care or in occupational health. None of those fitted me, my circumstances, nor therefore had a chance of narrating a personalised psychological health plan back to work. It was always going to be a non-starter.  

I hope that in the future, if i am ready and choose to do direct clinical work to help others (probably other professionals who have broken down I thought the other day!) then I would take this blog to my new clinical supervisor and occupational health professional (no doubt) and ask that we make me a formulation together to understand where I work best, informed by a good conversation about what I have learned from my analysis. By doing so we have a shared understanding of where I can flourish and help and I can be clear about any areas that would feel too painful to me. I would work in a place where I know I would be limiting my exposure to certain presentarions that would usually be seen in particular services elsewhere, and I could focus on doing a great job on the bit that I can help with. I might decide that that is assessment rather than full therapy, or peer support, and I might mix it up with service development work and research.

 The point is that there are possibilities and we should be open about navigating those, what they are and ways of doing it. This shouldn't be some kind of secret because it helps people understand that not everyone does everything, lived experience or not! Also, that capacity fluctuates naturally over career-time for everyone, dependent on what is going on in your life ie divorce, child illness, grief events, and it is normal to re-balance clinical work around this. Why? Because we use our internal world as our tool in mental health work, alongside our brains hoovering up theories, it is both. 

Things will happen in our own personal lives which impact on the balance of our internal world, it's capacity to bear the pain of others in certain areas changes when we are bearing pain ourselves in that place. Thats ok, that's normal and human, and you won't find another human who can do it differently, it is how the psyche works. So, we take time, we formulate around that and we flex, care, and we keep growing. When this natural process of living and our internal worlds is widely understood, how can there be any other way than putting in place work pathways which can mirror this organic process and allow rest and return to work due to mental health problems feel like a naturally accepted event.

Dr Natalie Kemp 

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