Considering the team in team formulation: a systematic review

Publication Date03 May 2019
AuthorValentina Short,Judith A. Covey,Lisa A. Webster,Ruth Wadman,Joe Reilly,Naomi Hay-Gibson,Helen J. Stain
SubjectHealth & social care,Mental health
Considering the team in team formulation:
a systematic review
Valentina Short, Judith A. Covey, Lisa A. Webster, Ruth Wadman, Joe Reilly,
Naomi Hay-Gibson and Helen J. Stain
Purpose Team formulation, used to understand patient problems and plan care, is a growing practice in
adult mental health and learning disability services. The purpose of this paper is to explore definitions applied
to team formulation (as distinct to therapy formulation), its underpinning theories, and the inter-relationship
between the team and the process of formulation.
Design/methodology/approach A database search (main search term of team formulation) of
peer-reviewed studies was conducted using PRISMA guidelines. A main and second reviewer conducted
quality appraisalsand thematic analysis. Data were analysed by convergent qualitativesynthesis design using
thematic analysisto transform evidence from quantitative and qualitative studies into qualitative findings.
Findings Initial searching produced 4,532 papers, 10 of which were eligible for inclusion. Team formulation has
no distinct definition. Theories underpinning the practice of therapy formulation emanating from general
psychological theory underpin team formulation. Seven studies applied psychological theories to the examination
of team formulation. No studies examined the impact of the team on the formulation. Six themes were
generated regarding the impact of team formulation on the team; increased knowledge and understanding,
altered perceptions, leading to altered relationships, feelings and behaviours,space to reflect,useful when
stuck or challenged,perceived increase in effectivenessand improved team working.
Research limitations/implications Limited evidence and variable quality compromised the availability of
review evidence.
Originality/value This is the first review to examine team formulation through the context of the team.
The authors argue that a conceptual framework to encompass team inputs, processes and outputs in
team formulation practice should guide future research.
Keywords Team formulation, Evidence-based team formulation, Team context and team formulation,
Team formulation definition, Team formulation impact, Team formulation theory
Paper type Literature review
Multi-disciplinary mental health and learning disability clinical teams, working together to develop
individual patient case formulations is an increasing practice within the UK (Johnstone, 2011). Known
as team formulation, the purpose is to develop a shared understanding of the patient to determine
the interventions (Johnstone, 2014). Research underpinning team formulation is of relevance to
clinical practice globally. National guidelines indicate that care that should be provided based on
diagnosis (see e.g. NICE, 2014a, b; NIMH, 2016), however, individualised care is also required
(HMG/DH, 2011; World Health Organization, 2015). Team formulation guides the design of individual
care for patients experiencing a range of mental health problems, some of which are considered
complex ( see e.g. Berry et al., 2009). Therefore, determining a patients unique needs through the
lens of team formulation may afford this individualised focus. Understanding the evidence base for
this practice is of critical importance in supporting teams to use evidence-based practice.
Individual psychological case formulation (therapy formulation) emanated from behaviour therapy
in the 1950s when it was developed as a central component for understanding the problematic
behaviours of individual patients (Bruch, 2015). Now it is recognised as a central tenet of most
Received 19 December 2017
Revised 7 August 2018
Accepted 7 October 2018
(Information about the authors
can be found at the end of
this article.)
DOI 10.1108/MHRJ-12-2017-0055 VOL. 24 NO. 1 2019, pp. 11-29, © Emerald Publishing Limited, ISSN 1361-9322
PAG E 11
one-to-one psychological therapies where a single therapist works with a single patient to
develop a collaborative formulation (Sturmey, 2009). Studies examining therapy formulation
report a weak evidence base. For example, a recent systematic review examining the inter-rater
and testretest reliability of therapy formulations across various therapeutic modalities reported
considerable differences in reliability. This ranged from slight to substantial, depending on
practitioner experience and therapy modality (Flinn et al., 2015). Furthermore, there is limited
evidence for impact on patient outcomes (Bieling and Kuyken, 2003; Kuyken, 2006).
Researchers examining formulation within the cognitive behavioural therapy (CBT) model
challenge whether the scientific constructs underpinning formulation are evidence based and
able to demonstrate a valid framework for understanding patient problems. Research has not yet
comprehensively examined the descriptive and explanatory elements of therapy formulation,
particularly in relation to outcome prediction (Bieling and Kuyken, 2003).
Despite these uncertain foundations, formulation has continued to evolve, from one-to-one application
in individual psychological therapy, to its most recent application by teams. The earliest published
report of formulation being used by teams was in 1997, when a practice account of the use of
cognitive analytic therapy (CAT) formulation was described as a team endeavour, used to understand
patients diagnosed with personality disorder. This descriptive account, published in a non-peer
reviewed professional forum magazine (Dunn and Parry, 1997) has preceded further descriptive
accounts (see e.g. Davenport, 2002; Robson and Quayle, 2009; Shirley, 2010; Whomsley, 2010), and
the suggested evidence for the benefits of team formulation continues to expand. However, evidence
is originating from a small research base accompanied by a greater number of practice accounts and
opinion pieces, published in non-peer reviewed publications, which attest to the benefits of team
formulation. This is evident from a succinct summary of team formulation offered by Johnstone, which
highlights the benefits of team formulation as supporting increased team functioning and well-being (e.
g. using the expertise of all team members, increasing team ability to reflect), and bringing a more
balanced and effective approach to interventions (Johnstone, 2014). This evidence base poses
several problems. Rather than evidence-based practice, team formulation is developing from a basis
of untested and poorly collated, practice-based experience. As the practice spreads, the degree to
which team formulation can be considered a separate phenomenon to therapy formulation, with its
own unique definition and underpinning theory, is not clear. Furthermore, researchers have examined
the impact of the clinician on the therapy formulation, scrutinising the level of practitioner skill and
experience on the formulation produced (Dudley et al., 2010; Eells et al., 2005), however, it is unclear
whether studies on team formulation are similarly accounting for the team context.
The impact of team processes on the execution of specific team tasks is well documented.
A large study of over 400 UK National Health Service healthcare teams, including teams from
physical and mental health care, concluded that team processes such as participation, reflexivity,
decision making, leadership and communication impacted on team levels of effectiveness and
innovative practice (Borrill et al., 2013). Teamwork is also essential for team reliability and patient
safety (Baker et al., 2006) and professional differences in teams impact on joint working and
knowledge sharing (Baxter and Brumfitt, 2008). Nonetheless, the impact of the team processes
involved in team formulating remains undefined and untested. Considerations such as these may
be crucial in developing an evidence base that embeds team formulation within the team context.
The aim of this paper is to report the results of a systematic mixed study review of team
formulation research. The specific objectives are to provide a systematic map of research on
team formulation in adult mental health and learning disability services (including forensic and
older peoples services), and to examine and synthesise the findings in relation to:
1. how team formulation is being defined as a phenomenon in its own right and as distinct to
psychological therapy formulation;
2. the theoretical underpinnings of team formulation;
3. the impact on the formulation through team involvement; and
4. the impact on the team due to formulating as a team.
The present review takes a deductive, theory-driven approach to examine if current research on
team formulation addresses these aspects and highlights the direction for future research.
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VOL. 24 NO. 1 2019

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