Problematic and Risk Behaviours in Psychosis: A Shared Formulation Approach

Problematic and Risk Behaviours in Psychosis: A Shared Formulation Approach

Problematic and Risk Behaviours in Psychosis: A Shared Formulation Approach

Problematic and Risk Behaviours in Psychosis: A Shared Formulation Approach


In spite of improved access to psychosocial interventions, many people with psychosis continue to experience persistent problems which act as significant barriers to their recovery. This book investigates risk and problem behaviours in psychosis, including staff and service factors that can impede the delivery of effective care.

Problematic and Risk Behaviours in Psychosisprovides a new approach for assessment, formulation and intervention within such problem behaviours in a team context. Of particular interest will be:

  • an outline of the SAFE (Shared Assessment, Formulation and Education) approach
  • an integrative model for understanding risk and problematic behaviour
  • shared risk assessment and management processes
  • approaches to reducing team and carer barriers to effective care
  • the use of CBT in day-to-day interactions with clients
  • a set of formulation-driven strategies for managing problematic behaviours
  • case studies and vignettes providing guidance and highlighting the benefits of the approach.

This book will have particular appeal to professionals working in specialist community, hospital-based and residential services who often struggle to help those with the most complex mental health problems who are hardest to reach. It is also an excellent resource for those engaged in training in psychological therapies, risk assessment and management.


Our approach detailed in this book is the product of nearly 15 years of work thinking about the needs of this client group and represents a long and at times difficult journey. One of my early experiences involved attempting to work with a young woman I shall call Lucy. I was asked to see her with a view to helping the staff manage her problematic behaviours better. She frequently attempted to harm herself by violently throwing herself against the wall and furniture in her room, she banged her head repeatedly, would masturbate in public areas of the unit and seemed cut off from others most of the time. I went to see her hoping to talk with her about her experiences, she was being restrained. the nursing staff explained that this was a common experience and they described feeling overwhelmed and stuck. I felt the same. My training in working with people with psychosis had not prepared me for this. I had spent much of my training learning about cognitive-behaviour therapy (CBT) with my supervisor (now Professor) Paul Chadwick. Cognitive therapy was just emerging then as an approach to working with people with distressing psychosis. Over the coming weeks I attempted to engage Lucy in discussions about her experiences, we made some progress in understanding her difficulties but her ability to internalise any new understanding appeared limited and she was often actively responding to voices in the sessions, was clearly distressed and at times sexually disinhibited and it was difficult to develop any sort of therapeutic relationship with her. in the coming weeks I attempted to draw on my work with learning disabled clients and implement a behavioural programme with the staff group. This met with little if any success. Lucy remained distressed, thought disordered and continued to harm herself on a regular basis. I did think that there must be a better way to work with Lucy and support the staff. Lucy had been a long-term inpatient although she was only in her early thirties. the team’s concern about her risk was paralysing, thwarting any efforts to adopt a therapeutic risk-taking approach. It often seemed to me that staff factors were a key part of the work but I lacked a framework that brought all of the separate elements that seemed potentially helpful together into an integrated approach.

Later I attended a conference organised by the International Society for . . .

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