Interventions for Vulnerable Youth (IVY)

Formulation in Risk Assessment – Principles and Practice

DR LEANNE GREGORYClinical Psychologist and Project Manager

HEATHER IRVINGConsultant Social Worker (RMA)

CYCJ Annual Conference, Dundee, 2014

Outline Youth violence risk assessment, the context

Case study outline

Formulation within risk assessment

Formulation – definitions

Formulation – Principles

The 4 Ps model

Formulation – process

Formulation – outputs – group task and case example

Discussion and reflections

Youth Violence – the context The health, psychological, social, and financial burdens of crime – and violence in

particular - are well established.

Young people are most likely to be the victim of youth crime, however, victims can include peers, parents, siblings, strangers, professionals, intimate partners and vulnerable others.

Youth homicides account for 41% of the formal figures and homicide is a leading cause of death among adolescents (World Health Organisation, 2011).

can include serious and life threatening interpersonal violence, fire-setting/arson, theft, vandalism and various behaviours considered to be antisocial. Indeed, adolescents account for a disproportionate amount of perpetrated rapes and child abuse (Radford et al, 2011; Vizard et al, 2007).

In order to intervene with this population, it is essential to assess and understand the nature of the risk posed and the factors that contributed to the onset, development and maintenance of the problems. Contemporary practice guidelines advocate the use of formalised risk assessment approaches.

Risk Assessment Process

Identification Analysis Evaluation Communication

Framework for Risk Assessment Management and Evaluation (FRAME)http://www.rmascotland.gov.uk/standardsandguidelines/

Case Study

Case Study: Jamie

Jamie• 17 years old• Currently living in the

community• Subject to compulsory

supervision order• Referred by social work

following anxiety about his sexually harmful behaviour

• 17 years old• Currently living in the

community• Subject to compulsory

supervision order• Referred by social work

following anxiety about his sexually harmful behaviour

Case Study: Background

Family Life EducationSocial

History/Peer Association

Mental Health Substance Misuse LAAC History

Case Study: BackgroundSexual Behaviour

• Age 11: Staff find kitchen implements in Jamie’s bedroom – suspected use for sexual purposes

• Age 11: Allegations of sodomy against an 9 year old boy in residential care.

• Age 13: Concerns of inappropriate sexual contact with his 4 year old cousin

• Age 15: Two claims of alleged rape against his then girlfriend who was deemed to be vulnerable to exploitation

• Currently: Relationships with a range of young women some of whom are known to be vulnerable

Violent/Aggressive Behaviour• Violent behaviour reported at home and

school from a young age• Threats and actual violence towards staff

in residential care, both male and female• Fellow residents reported to be “petrified

of him”• Possession of weapons in both residential

and community settings• Victim and perpetrator of domestic

violence in relationship with former partner

• Anger is targeted at individuals (usually staff) although he can remain calm with others who are present.

• Displays disproportionate responses to minor or inconsequential events

Case Study: Current Presentation

Avoidant of and aggressive towards staff

Disengaging from support and supervision

Whereabouts is frequently unknown

Concern about peer associations/relationships

Chaotic with poor self care

Formulation: Definitions

“…a process by which a set of hypotheses is generated about the etiology and factors that perpetuate a patient’s presentingproblems and translates the diagnosis into specific, individualized treatment interventions.” (Winters et al, 2007).

“…Case formulation generally refers to an integrative process that synthesizes how one understands the complex, interacting factors implicated in development of a patient’s presenting problems. It is explicitly comprehensive and takes into account the child and family’s strengths and capacities that may help to identify potentially effective treatment approaches. The case formulation serves as a testable explanatory model that gives rise to ideas for intervention and eliminates some options that do not fit the model….” (Winters et al 2007)

Definitions

“Formulation is the preparation of an evidence-based explanation of a person’s difficulties – their form,

their origins, and their development and maintenance over time (Johnstone & Dallos,

2006; Tarrier, 2007).

Benefits of formulation Where theory and empirical knowledge merge with the

understanding of an individual/family/system

Allow us to understand why a difficulty exists rather than simply describing a set of symptoms/problems

Fills the gap between describing and intervening

Guides intervention

Individually sensitive and specific

Allows us to understand complexity/comorbidity

Principles (Hart et al, 2011)

Inferential

Make speculations about possible futures based on what is known, rather than

quantitative forecasts. Provide explanations and justifications for

speculations.

Principles

Action Oriented

Points to treatment targets and appropriate interventions, and consequently has value

across the system. Offers a way to proceed with case.

Principles

Theory Driven

Theories from a range of perspectives allow us to identify salient features in large amounts of

information.

Principles

Individualised

What is happening for this particular person at this time, what might happen in the future,

what might work best for this person. Supplementing theory with person centric

information

Principles

Narrative

Formulation defies quantification with numbers; it is a qualitative approach to

understanding driven by theory and case specific information.

The narrative should contain critical elements and have strucutre

Principles

Diachronic

The formulation should span time and containe information about the past the present and

possible futures. In childhood it is important to understand the child’s age and stage of

development at present, and the potential change associated with maturation.

Principles

Testable

As an explanatory theory, the formulation should be testable.

Principles

Ampliative

The formulation should generate new information and knowledge with the caveat

that as an entity the formulation is not a certainty but a dynamic understanding subject

to revision over time.

Formulation: 4 P’s Approach predisposing (i.e., factors in the individual’s past that may increase his

proclivity or vulnerability to violence)

precipitating (i.e., events or circumstances that may trigger the behaviour or disinhibit usual behavioural controls); (motivators, disinhibitors)

perpetuating (i.e., factors that cause the risk to remain) (impeders, unresolved vulnerabilities)

protective factors (i.e., aspects of the offender’s functioning or circumstances that moderate the risk)

Formulation – ProcessProblem Information Hypotheses Intervention Communicati

on

• Identify the problem, can be complex.

• Collect a range of information across time points and informants/• sources.

Comprehensive.

• Make sense of the relationship between the 4 Ps. Make into a narrative and shared, sensible, formulation.

• Formulation will point to appropriate treatment targets and facilitate planning interventions.

• Communicate, share and discuss formulation so that approach is coordinated.

Formulation:Exercise

Formulation Exercise

Formulation: Communication

A story not a sum…

Consider the reader and use clear and meaningful terminology

Convey the key facts of the case

Provide a structure or plot to your story Beginning, middle, end Pattern, nature, seriousness, likelihood, imminence Who, what, when, where, why, how Theoretical framework

Reflections and Discussion