Micro-skills of group formulations in care settings: Working with expressions of staff distress

There is increasing interest in using psychosocial frameworks and processes to understand why people with dementia might act in ways that are described as challenging. The Newcastle Model (James, 2011; James & Stephenson, 2007) uses a framework incorporating elements of Kitwood’s (1997) emphasis on the unique experience of the person with dementia, Cohen-Mansfield’s needs-led framework (2001) and the cognitive behavioural framework to help staff or family carers to understand the person with dementia’s behaviour better. In this model, clinicians work with carers to develop a hypothesis about the behaviour, taking into account close and distal contextual factors (see Figure 1). OPEN IN VIEWER

Figure 1.

The Newcastle Model (James, 2011).

One of the essential ingredients of the Newcastle Model is the Shared Formulation Session (Jackman et al., 2013; Jackman, 2013) or Information Sharing Session (ISS, James, 2011). This is a facilitated meeting with a care group to develop an understanding of the person’s behaviour through sharing information about their life and experiences, their mental and physical health and their environment. This contextual information is presented in a way that prompts discussion about the reasons behind the person’s behaviour. The facilitator shifts the focus from the behaviour being a problem to the behaviour expressing unmet needs, and the group work together to meet those needs. Many teams around Britain are using this way of working, allowing for on-going discussion and evaluation of the format, process and effectiveness of these sessions. This is moving us further toward establishing a standardised protocol for facilitating sessions. This paper is one of a series of papers exploring the skills of facilitating the sharing of formulation with staff (see also Jackman, 2013). We will refer to these sessions as ISS (James, 2011) for the remainder of the paper.

In an ISS, a group of staff meet, effectively, to generate ideas to solve a problem. This brings with it many issues – as well as being potentially a positive experience for staff where ideas are exchanged, new stories created, and staff forming a problem-solving team, the session has created a new group, with all of the potential pitfalls this involves. This means the facilitator of the ISS can be characterised as a ‘group facilitator’ as defined by Schwarz (2005).

Group facilitation is a process in which a person whose selection is acceptable to all members of the group, is substantively neutral, and has no substantive decision-making authority diagnoses and intervenes to help a group improve how it identifies and solves problems and makes decisions, to increase the group’s effectiveness. (p. 21)

Schwarz acknowledges overlap between this role and that of more involved roles, e.g. facilitative consultant or facilitative trainer. In the Newcastle Model, the clinician moves between many roles or perceived roles – collaborator, overseer, outsider, judge, expert, etc. One of the skills in working within this model is moving between these different emphases when required.

The formulation process is generally successful in exploding myths about the person’s behaviour (e.g. they always ‘target’ the frail ones’, ‘he’s always been like that’), creating a new, and kinder narrative about the person’s problems (‘she thinks he’s taking her stuff’ ‘he doesn’t understand that’s not his wife’), and enabling staff to contribute their ideas about providing care for the person with dementia (e.g. Janes & Shirley, 2008; Kennedy & MacKenzie, 2007).

However, most clinicians using the Newcastle Model will admit that some formulation sessions are more difficult to facilitate than others. In this paper, we outline the phases a group engaged in this process will experience, examine the specific role of the facilitator in successfully steering the group through these phases and look at some of the group and person-factors that can make a formulation session difficult to facilitate.

A caveat – staff groups are subject to organisational and environmental influence

In working in care environments, it is crucial to be able to understand the factors that may affect carer responses to their clients’ distress. We realise that poor care is not always related to a core lack of compassion or empathy but can be driven by systemic demands – (e.g. task-oriented work schedules, fear of safe-guarding) or misguided (but common) misperceptions about the experiences of people with dementia. We also recognise factors in dementia care environments which impact on stress and ‘compassion fatigue’ (Peate, 2014). Consequently, we have found it helpful to apply our needs-focussed understanding of behaviour to all of those in the care system – including staff and families. Staff needs range from a need for basic education about dementia to representation of their difficulties at a senior level in the organisation. Formulation sessions are opportunities for us to uncover and address these needs.

We hope this paper respects the position of care staff in their role looking after some of the most complex people in the health and social care system in often quite difficult organisational and environmental circumstances.

The phases in group decision making/problem solving

Social psychology, occupational psychology and organisational science provide a substantial literature articulating the features of group processes, including how groups reach suitable and productive decisions. Reviewing these elements with respect to the format of the Newcastle model highlights areas where facilitators need to be vigilant of group process, and how to manage difficult situations if they arise.

According to Leonard, Beauvais, and Scholl (2005), the group decision-making process starts with problem identification. The group then typically moves through five further stages; problem diagnosis, generation of solutions, evaluation of options and choosing a solution, implementation of the solution and, finally, evaluation. These phases can be seen in the sequence of information-giving and information-sharing characteristic of a Newcastle Model shared formulation (Jackman & Beatty, 2015; James, 2011; MacKenzie & Smith, 2011). Leonard et al. (2005) suggest that problem identification should be clearly in terms of situation (when/where) or behaviour (what) without reference to causes and fault. This is the case with the Newcastle Model where participants are asked to define the problem and have already collected information detailing when and where the problematic behaviour presents. It is important that facilitators of shared formulations are careful to recognise the reality of the problem for the attendees, by reflecting on levels of risk and distress. The facilitator should be collaborative in their phrasing and give the message that they consider themselves part of the problem-solving group. In this phase, Leonard et al. identify the danger that group members might rush to a solution or plan and suggest this should be avoided as people can become over committed to this initial position. They further suggest that it is important to consider how closely individual group members’ identity maybe be linked to particular positions and to avoid seeming to criticise current behaviour. From the outset in ISS, the facilitator provides a role model for how to elicit and respond to alternative solutions to problems, and how to take the role of investigator rather than judge. It might be clear to the facilitator quite quickly that one or two group members’ opinions and subsequent behaviour are unhelpful but they should avoid focus on the specific actions of members of staff. Instead, one of the initial tasks is to concentrate on identifying what would need to change in order for the group to feel the problem has been resolved – how would things look if they were better or even good enough? This identification of problem and preferred outcome is essential and the point at which we may find, that a group has an agenda different to the facilitator’s (such as being intent on the movement of the identified person to a different home).

Once the problem (and potential resolved state) has been identified the following phase, problem diagnosis, is the development of a conceptualisation of the problem. In the Newcastle Model, we would refer to this as the formulation. The formulation in the Newcastle Model not only conceptualises the problem but also highlights positive attributes and patterns in the person’s life. The facilitator ‘scaffolds’ the group (Jackman, Woods-Mitchell, & James, 2014) and towards a shared understanding and consensus of opinion about needs and possible solutions through eliciting and considering ideas about the impact of various causes on the person’s behaviour. The context in which the behaviour occurs now and the context of the person’s life and experience (e.g. staff approach, environment, medication, cognitive impairment) is all considered. Causes are identified in a way that avoids placing blame on group members. Using the term ‘we’ to discuss what is currently done can be effective in decreasing feelings of being exposed (e.g. ‘I wonder if we might sometimes miss his signs of distress?’). It can also help to introduce this idea tentatively as a question rather than a statement of fact. The Newcastle Model is also known as the ‘Columbo Approach’ (after the detective series in which the main character discovers important information through being curious and naïvely ‘wondering’) and is based on this style of questioning. Through identifying the potential causes of the problem, it becomes possible to start to generate solutions, the third phase. In the Newcastle Model, this would be the phase where the group is invited to consider the person’s needs, and how to meet them (see Jackman & Young, 2013). Leonard et al. (2005) advise that, in this phase, facilitators need to be wary of possible solutions that the group might express that limit the range of approaches considered. The aim should be to encourage novel and varying ideas. The ISS facilitator encourages novel ideas and spends time weighing up the possible snags or benefits of each suggestion. They continue to model a neutral stance during this phase.

Once a range of solutions has been generated the group should work on evaluating and choosing from possible solutions. The facilitator digs down to the finer detail about the implementation of the possible solutions in order to assess with participants whether the idea is practical and possible. One of the potential criticisms of having external agencies helping problem solving in care homes is that solutions might not take into account the reality of life on the unit, leading to disillusionment and lack of credibility. The input of the facilitator in asking questions like ‘Who will do that?’ ‘How can you make sure this will happen?’ ‘What might get in the way of this happening?’ is crucial.

The role of the facilitator is further discussed in the following sections.

In terms of implementing and evaluating the solutions generated, this takes place outside of the problem-solving arena. The ISS facilitator will help care staff to develop care plans to assist in directing care, and they will support implementation by a continued monitoring through this phase. Evaluation might take place through conversation and sometimes questionnaires. Because the formulation is only ever considered a hypothesis, it is open to reconsideration if the situation does not improve, and it is not uncommon to need to ‘reformulate’. At this point, the group reconvenes and uses the extra information gained from trying out the new interventions to inform the problem-solving process.

The stance of the facilitator

The facilitator is pivotal to the success or failure of the ISS, and facilitators of these groups need to have access to reflective clinical supervision in order to consider the way in which they may respond themselves to difficult encounters in group sessions. For example, it is easy to feel some sense of threat when working with care groups – facilitators are outsiders and as such can experience some negativity from group participants. A heightened sense of threat might arise in situations one may perceive to be embarrassing or psychologically threatening, perhaps through a fear of being exposed as not knowing enough or getting things wrong, especially when facilitators can often be presented as ‘experts’.

Schwarz also warns of another possible outcome to feeling under threat which we could characterise as defensiveness.

You think of yourself as knowing all we need to know about the situation while thinking others who disagree are uninformed, you think of yourself as being right and others as being wrong, and you think of yourself as having pure motives while others’ motives are questionable. (Schwarz, 2005, p. 29)

It is important to recognise and guard against these feelings becoming part of the narrative of specialist teams (‘if only they’d listen!’ ‘If only they’d do what we agreed!’) through supervision and reflective discussion.

The facilitator must be sure of their role in the ISS and learn to recognise and manage the internal conflicts produced at times when the group may act in a hostile way. A reflective facilitator is also a good role model for teams who might have a tendency to get stuck in problem-solving situations.

Safeguarding solutions

Solutions/decisions should ideally emerge from members of the group without interference from the facilitator. However, clinicians working into care environments have a duty to ensure that safe practice is foremost in the decisions made. The facilitator is in a good position to oversee ethical, legal or logistical implications of proposed solutions. The facilitator moves from being a story teller and scaffolding understanding to more of a ‘facilitative consultant’ (Schwarz, 2010) when they work actively to ensure that participants’ ideas accord with person-centred frameworks and best practice guidelines. In doing so, they may use particular knowledge about required practice (for example, good understanding of legislation around Deprivation of Liberty or restrictive practice (Jackman & Emmett, 2014; Sells & Howarth, 2014). However, ownership should lie with the group as far as possible, and this should be clear from the facilitators’ phraseology (for example, ‘I like the way you’ve developed that idea’).

In Box 1 (Mrs Jones), we give an example of a facilitator stepping in to safeguard a residents’ rights whilst acknowledging the positive sentiment behind the group’s suggestions. Box 1. Mrs Jones.

Mrs Jones was an 89-year-old lady with some cognitive impairment and little insight. She had a life-long problems with relationships with others and was experienced as ‘manipulative’ by her family and some members of staff. She had been referred because she was making complaints against staff – saying she was being nipped while they helped her dress, and that they were ignoring her when she buzzed for them. The complaints were getting increasingly more serious. During the formulation session, the facilitator found that the staff response to this was quite inconsistent, and everyone agreed a more consistent response should be given. However, some of the suggestions about what should be done consistently were not acceptable in terms of protecting Mrs Jones’ rights and safety. For example, the favoured resolution to protect themselves was to work in twos every time they attended to Mrs Jones. This would have included taking her to the toilet and showering. The group also thought they should write down everything Mrs Jones said for the manager to discuss with her the next day. The facilitator invited the group to consider the impact this might have on Mrs Jones’ sense of privacy and dignity and to debate whether this would impact positively on her behaviour. Further, the group considered whether, if the care staff took responsibility for deciding which complaints to take forward, Mrs Jones would be safe against an actual episode of abuse.

Recognising pre-existing dynamics & managing group member roles

Evidence from research on focus groups (Morgan, 1998) highlights the importance of getting to know the group and its members, prior to working with them. Attendees at the ISS are both members of a pre-existing work group and members of a newly formed problem-solving group. It is almost never possible to recruit a whole staff team to attend an ISS. This leads to a complex set of dynamics. In order to encourage useful exchanges in sessions between the group members and the session facilitator, it is helpful to enter the session with some understanding of any pre-existing group dynamics by spending time with staff in their normal environment. This is helpful on a number of levels: it should establish the facilitator as being approachable, interested and friendly; it can be an opportunity to model good care practice; and, by spending some time with the team in their natural environment, the facilitator gains a picture of the group structure and the roles the members have within the group. An added benefit is the potential to recruit people’s interest in attending the ISS.

Kottler and Englar Carlson (2014) suggest that, according to Evolutionary Biology theory, it is normal for group members to take differentiated roles, as this has been pivotal to the success of our species. We should, therefore, expect differential roles to emerge when groups of people are brought together.

Group roles are fluid phenomena, emerging from the group process and not necessarily definitive of the people holding them during the session, but it can be helpful for facilitators to make sense of difficult interactions through reflecting on the role a person may adopt at work or have taken for the session. We will look at two potential roles in a little more detail, which we have anecdotally identified through facilitating these sessions – the ‘Spokesperson’ and the ‘Boundary spanner’. The Spokesperson is a common feature of many groups, and facilitators of group work and group cohesion often recommend the identification of a spokesperson from within the group (McKendall, 2000). However, as discussed below, the benefit of the Spokesperson to achieving the group’s goals is dependent on them representing the group accurately. The Boundary spanner has a role that is less well articulated in the literature presumably because they are a feature of organisational structures where the work of a number of groups overlaps; however, their role is increasingly being seen as pivotal in the success of inter-organisational relationships (Williams, 2002).

The Spokesperson can be thought of as the voice of the group and is the person most likely to speak up in a group situation. This can be very useful as they serve to help break the ice and initiate discussion. When the Spokesperson is on board with the aims of the session, they can be integral in bringing other group members on board too. They might help the facilitator negotiating goals and may voice the concerns of group members who are less comfortable at speaking up. Sometimes, however, the Spokesperson is not representing the group but remains a prominent voice. This can be problematic at a number of stages in the shared decision-making process. Firstly, the identification of the problem may only reflect the problem as seen by the Spokesperson and thus not providing a rounded account of the situation. Secondly, solutions generated by the Spokesperson may usurp those made by others purely because they are more confident at articulating them. Finally, the solution, evaluation and selection phases can be biased by the views of the Spokesperson. The key to managing these potential problems is building a good relationship with this group member. As part of the assessment gathering phase, we have suggested that facilitators spend time getting to know the dynamics and characters of some of the people they may work with in the ISS. It is helpful for facilitators to establish a strong rapport with the Spokesperson to try to ensure successful communication with the whole group. However, facilitators also need to incorporate strategies to encourage other, quieter, group members, to speak up and let their voices be heard. Strategies such as addressing other group members by name (the use of name badges can help with this) to try to bring them into the discussion by asking them about their specific opinions, experiences and ideas can be effective. It may even be useful to set very loose ground rules that emphasise the ‘shared’ nature of the formulation session highlighting that everybody should have a role in discussing the problem and formulating as suitable solution. The premise of shared formulation sessions is that participants will be more likely to implement strategies they have had ownership over, so it is essential for the solutions to be acceptable to the majority of the group.

In Box 2 (Dorothy), we give an example of a facilitator dealing with a strong, negative story provided by the Spokesperson. Box 2. Dorothy.

A formulation session centred around Dorothy was well underway. The facilitator had presented information which had enabled the staff to create a new narrative around Dorothy’s behaviour. This had previously been seen as her being an interfering and unpleasant woman who stole from other people’s rooms and reacted aggressively when redirected. The group had learned that Dorothy had always been known as ‘Dot’ and associated her full name with being told off as a child. She had also worked as a cleaner in a hotel. Her deficits in executive functioning which had been picked up in neuropsychological assessment. The facilitator led the group in wondering whether she thought she was at work and was being accused of doing her job badly. Her aggressive reaction was considered as lack of impulse control due to her dementia. During the final stages of the session, one member of staff introduced an incident of difficult behaviour that had not been considered before which she felt did not fit with the group’s new narrative of Dot. Acting as a Spokesperson described Dot ‘lashing out’ at another resident in the lounge ‘for no reason’ and suggested that Dot had ‘planned the attack’. Her contribution began to form the prominent narrative for the session, causing difficulties for the facilitator to generate enthusiasm to develop new care plans as the group had been invited by the Spokesperson to see Dot as posing a greater risk. It is easy to dismiss the strongly held views of one member of staff. They can seem contrary and obstructive. However, we would suggest that the views they are expressing are very likely to be (at least in part and not as vehemently) held by other members of the group (Burnham). Ignoring or deflecting comments from this person will not be helpful. In these circumstances, acknowledge this alternative point of view, thank the person for raising the point in public (and possibly at cost to themselves) and take the point absolutely at face value. There is, of course, always the possibility that this new information is vital to rethinking your formulation. Prior to the ISS, the facilitator had noted that, although abrasive to colleagues at times, the Spokesperson was patient and tolerant with residents – especially with Dot. It seemed likely that something other than dislike of Dot was leading this challenge. On further questioning, the facilitator found that this attack had been reported to the Spokesperson by another member of staff. Through careful questioning around what the Spokesperson knew of Dot’s behaviour and character, the facilitator led her to reflect that this narrative was an unhelpful story that followed Dot around. The facilitator thanked the Spokesperson for helping the group to explore and explode a myth about Dot.

It is possible that intragroup conflicts (i.e. between members of the group) will emerge, and it is important to consider what method is used to resolve this. For example, in some situations, taking a vote and following the ‘majority wins’ principle (Stasser, Kerr, & Davis, 1989) will be the most appropriate. However, particularly when groups are small, a majority may be determined by one or two members. In such instances, group members in the ‘minority’ may feel like they have been forced into a solution and thus are unlikely to engage with it.

The example of Dorothy highlights the need for facilitators to hold the opinions of all group members in mind during a session – not to get trapped into disagreeing with seemingly powerful negative speakers or blindly supporting the quieter element of the group. During the solution-generating phase, all potential solutions must be considered and given equal space for consideration. The position of the facilitator as an outsider leaves them vulnerable to appearing dismissive if an idea is not given its proper attention. Even poor or contentious ideas need to be taken seriously and discussed thoroughly.

It is essential to get as many differing perspectives as possible represented at the session, and the facilitator may have to use strategies to encourage wider thinking. People living and working in care homes can be seen as a part of an inter-dependent system. If you attempt to change only one aspect of that system, it is likely that other parts will continue to exert their influence if their voices are not ‘heard’ in the room. The concept as a group or family as being a homeostatic system emerges from family therapy traditions. Techniques from these schools of therapy can also be helpful in discovering more about ideas groups members hold about the person being discussed. Circular questioning (e.g. Nelson, Fleuridas, & Rosenthal, 1986) is one way to attempt to bring the other voices into the room. Circular questions are questions which invite the group to consider what other people’s answers to a question might be. If the spokesperson is not physically present in the room, it is possible to introduce their perspective by asking circular questions. For example, ‘often there are people who can’t come to these groups. What would they say if they were here? Would everyone agree with you? What evidence do you think they would use to support their position?’. For more information on Circular Questioning and Systemic perspectives, see Dallos and Draper, 2010.

Other group members whose roles can be integral in facilitating the success of the ISS, and in particular, the implementation of a solution is as we term here, Boundary Spanners. These are individuals whose role in the care home setting bridges sub-groups that would not otherwise interact (for example, a carer who works both night shift and day shift or an activities organiser). These individuals can provide an insight, particularly in terms of problem identification about the behaviour of the individual in different situations (at night or during activities) which might help the group to understand more accurately under what circumstances a particular behaviour is more likely to occur. They can also carry the group decisions to those in other sub-groups who are not present. The Boundary Spanner might also provide the Spokesperson function on behalf of the absent members. The Boundary Spanner should also been seen as particularly useful in evaluating the efficacy of the solution as they are able to provide an alternative viewpoint to that of the group. The efficacy of the Boundary Spanner role is evident from the organisational literature discussing it – it is considered, for example, an effective leadership style (Williams, 2002). The facilitator may also provide the role of boundary spanner between the NHS and private sector care.

One way of encouraging multiple voices in the room is to identify potential ‘Boundary Spanner’ prior to the session and encourage attendance.

Managing anxiety & managing risk

Once the group has selected a solution, the facilitator works with them to decide how to implement and evaluate it. In planning the implementation, the facilitator needs to work on reducing the resistance to change from those within the group and be mindful of possible resistance from those who have not been involved in the generation of the solution.

Planning and implementing are often the phases where ISS can get stuck.

One potential reason for this may be a general feeling of anxiety about whether the proposed interventions will work. There may be times, especially when the levels of risk from the identified person’s behaviour are high, that people attending the ISS will be anxious about the outcomes of the session and their behaviour with regards to planning and agreeing to implement plans may correspond to what we know about anxiety-driven behaviour. In other words, they may respond in ‘flight’ (it is often noticeable that there are fewer ideas emerging in care planning for people’s needs, more reluctance to agree to try out new interventions) or ‘fight’ (heightened concerns expressed about safeguarding, scepticism about the proposals, insistence on medication change or admission). Anxiety about care interventions leaves staff groups feeling reluctant to try out new ideas but they can also be reluctant for the facilitator to withdraw from the care of the presenting person. In the short term, sessions can be characterised by difficult questions which raise the risk bar. In the longer term, this can lead to long and protracted periods of involvement for the facilitator as the group may be unhappy to take over responsibility for success of the interventions. Anxiety can become self-perpetuating and lack of immediate or obvious changes in the identified person’s behaviour are often interpreted as signs of failure of the care plans. We have used the five elements model from Cognitive behaviour therapy to illustrate how anxiety might affect a staff group facing the withdrawal of support from the facilitator (Figure 2). OPEN IN VIEWER

Figure 2.

Staff anxiety—five elements model.

The cornerstone of anxiety is fear of the unknown. Just as we would advocate trying to provide a predictable and safe environment for an anxious person with dementia, the facilitator’s role is to try to create a safe and predictable environment for anxious staff. This is achieved through careful and collaborative care planning to predict problems and create plans to manage them – to make the unknown, known. Careful risk management planning taking into account all possible eventualities raised by the group (including aggression) is helpful and more likely to secure long-term benefit (see Sells & Howarth, 2014; Sells & Shirley, 2010). It can be tempting to overlook this part of the process. Ironically, it is probably especially at those times, risks of problems are high that the facilitator might unconsciously avoid approaching the difficult subject of what to do if Plan A and Plan B don’t work. This may be related to the sense of threat noted by Schwartz – fear of things going wrong and being uncovered. However, the facilitator must deal with this ‘elephant in the room’ or the process will stick, and they will eventually lose credibility with the group. This process is illustrated in Box 3 (Ronnie). Box 3. Ronnie.

Ronnie had been referred into a team due to risky sexualised behaviour and aggression toward other residents. During the Shared Formulation Session, the group learned that Ronnie had problems with facial recognition and was misidentifying other female residents as being his wife. He had always been very protective of his wife, who had been an anxious lady. The care group came to see Ronnie’s behaviour as being a misguided attempt to protect his wife. In the Shared Formulation Session, the group worked hard to produce some person-centred strategies to reduce Ronnie’s contact with the residents he mistook for his wife and came up with ways in which he could be approached when he was upset. However, towards the end of the session, members of the group expressed concern that the care plans were ‘fine but probably wouldn’t work,’ and their belief that he should go somewhere that had more staff to monitor his behaviour. The facilitator conceptualised their protest in terms of anxiety and discussed this with the group. The group admitted they felt uncomfortable accepting the level of risk Ronnie posed and were especially concerned about how they might be perceived as responsible for any emerging problems. Risk management plans were devised during the session that gave detail about how they should deal with and record an incident.

Exploring, evaluating and managing group responses

Both leadership and group dynamics factors, such as cohesiveness, can have an important impact on group function in work team settings. Highly cohesive groups are more likely to share the same ideas and opinions and, in situations where these support the development of positive care plans, this can be helpful. However, a highly cohesive group that shares negative views will hamper both the identification of a suitable solution and the implementation of it. An awareness of the cohesiveness of the group prior to undertaking the session can help the facilitator in preparing and running the session. Useful evidence to support this argument can be found in the literature on facilitating successful focus groups. Like the ISS, a productive focus group is much more than a chat session. An assumption can be made that if a group of people are gathered in a room, a collective and representative opinion will naturally emerge. In fact, the danger is that groupthink (Janis, 1972) will occur and a poorly thought out consensus will be reached led by dominant or authoritarian group members. If the facilitator is prepared for the emergence of an unhelpful and dominant narrative, they can spend more time on different stories (Crossley, 2015).

Another process sometimes played out by groups is described in the literature as ‘scapegoating’ (Johnson & Johnson, 2008). This might happen when there is, for example, an undercurrent of feeling that one person talks about but is not owned/admitted to by the rest of the group. Johnson and Johnson describe this person as acting as the ‘lightening rod’ for others’ strong feelings. However, uncomfortable this is, the facilitator must investigate this undercurrent with the same respect and interest as other, seemingly more helpful feelings. It is likely that the feeling held by this scapegoated individual is also held, to a greater or lesser extent, by other members of the care team. Again, the facilitator needs to be able to recognise this process and open up discussion to include this uncomfortable perspective.

Concluding comments

Older people’s care environments increasingly need to provide specialist care to people with some of the most complex physical, psychological, social and emotional needs. When we fail to meet these needs (which may be inevitable in the context of the impairments characterising dementia), ISS are an effective way of developing plans which are needs-based and person-centred, and which provide a good opportunity for care staff to consider their own roles in a non-blaming environment. More importantly, though, these sessions need to be collaborative in order that there is proper discussion and the development of shared beliefs about future practice in order to lessen feelings of anxiety. Effective group processes are essential for this to occur.

Within this paper, we have identified some of the microskills needed by facilitators of Shared Formulation Sessions, which include an awareness of the phases of decision-making processes and how to move care groups between them; an awareness of group roles and processes and how to manage these; and an awareness of how care groups may behave when they are anxious and how to create a safe and predictable environment for them. The literature on group processes and effective group facilitation is helpful in articulating some of the difficulties and in guiding good practice for the facilitation of Shared Formulation Sessions with groups of care staff in potentially difficult environments.