Caroline Logan 06/07/2015
1
exercise 1
define formula2on how long are your formula2ons?
how do you tell a good formula2on from a poor one?
why do formula2on at all …?
my objec2ves
to develop your skills in preparing formula2ons for your use in your direct work with service
users
to develop your skills in preparing formula2ons with others for them to use in their direct work
with service users
exercise 2
please prepare a formula2on of a service user you are working closely with at this 2me, one about whom you have concerns rela2ng to risk
of harm to self or others
risk formula2on
• why think about risk? • risk formula2on • is your formula2on any good? • a stepped approach • does formula2on make a difference? • conclusions RISK
why are we interested in this again …?
Caroline Logan 06/07/2015
2
• what ac2on is required to minimise or prevent all the hazardous outcomes that are in any way foreseeable?
harm preven2on or minimisa2on
• uncertainty assessment/management • complex, interac2ng, unknown or unknowable
understanding
• transparency – understanding, decision-‐making
• consistency & accountability professional accountability
• protec2ng the rights of offenders, past and poten2al future vic2ms, and services legal protec2on
• what ac2on is required to minimise or prevent the hazardous outcomes (that are foreseeable)?
harm preven2on or minimisa2on
• uncertainty assessment/management • complex, interac2ng, unknown or unknowable
understanding
• transparency – understanding, decision-‐making
• consistency & accountability professional accountability
• protec2ng the rights of offenders, past and poten2al future vic2ms, and services legal protec2on
why? (encapsulated in a
formula2on)
• what ac2on is required to minimise or prevent the hazardous outcomes (that are foreseeable)?
harm preven2on or minimisa2on
• uncertainty assessment/management • complex, interac2ng, unknown or unknowable
understanding
• transparency – understanding, decision-‐making
• consistency & accountability professional accountability
• protec2ng the rights of offenders, past and poten2al future vic2ms, and services legal protec2on
• what ac2on is required to minimise or prevent the hazardous outcomes (that are foreseeable)?
harm preven2on or minimisa2on
• uncertainty assessment/management • complex, interac2ng, unknown or unknowable
understanding
• transparency – understanding, decision-‐making
• consistency & accountability professional accountability
• protec2ng the rights of offenders, past and poten2al future vic2ms, the public, and services and their employees
legal protec2on
RISK FORMULATION the history and the mystery
formula2on underpins clinical prac2ce
personality disorder & complex cases
(discre)onary) risk
assessment & management
Caroline Logan 06/07/2015
3
organisa2onal framework for producing (generally) a narra2ve
that explains the underlying mechanism of the
presen2ng problem and proposes hypotheses regarding
ac2on to facilitate change
the purpose of case formula2on
organise
mutual understanding
connec2ons
interven2on
communica2on
case formula2on vs problem formula2on
risk formula2on
a variety of problem formula)on
the purpose of case formula2on
organise
mutual understanding
connec2ons
interven2on
communica2on
problem(s)
predisposing factors the 5 Ps of
formulaDon
protecDve factors
precipitaDng factors
perpetuaDng factors
vulnerability factors triggers
maintenance factors
organising informa2on (i) (from Weerasekera, 1996) or motivators, factors that increase the perceived benefits or rewards of harmful behaviour e.g., profit, honor, release, expression, status
factors that decrease the perceived costs or negative consequences of harmful behaviour e.g., lack of empathy, negative attitudes, lack of insight, lack of guilt or anxiety
factors that disturb a individual’s ability to monitor and control
their decision-making e.g., impaired reasoning, racing thoughts, impaired
problem-solving or reasoning
organising informa2on (ii)
drivers
disinhibitors destabilisers
the 3 Ds of formula2on
Caroline Logan 06/07/2015
4
drivers or mo2vators
• factors that increase the perceived likelihood of gains or benefits of problem behaviour e.g., profit
• what was the service user trying to accomplish by engaging in problem behaviour in the past?
• which factors increased the perceived gains or benefits of problem behaviour?
eg. perceived rewards of harm
to others
defence distance
jus2ce
honour
gain
profit
control
change status
esteem
release
expression
arousal
ac2vity
proximity
affilia2on
from Hart, 2013
e.g., perceived rewards of self-‐harm
coping crisis
interven2on
calm
comfort
control
cleanse
confirma2on of existence
comfortable numbness
from SuVon 2005
organising informa2on (iii)
birth
father leX & mother fell ill
disrup2ve behaviour & taken into care
offending behaviour …
sequential functional analysis
NB organising informa2on
there is no ‘right’ way to organise
4/5Ps model is very popular but there are others, and its acceptable to use
combinations of ways to organise
just be sure to organise the information you have
once organised, stand back and think …
decision theory why has the service user engaged in harmful
behaviour before? why might s/he do so again?
Caroline Logan 06/07/2015
5
once organised …
decision theory why has the service user engaged in harmful behaviour before? why might s/he do so again?
(a) entertained no2on of being harmful and not dismissed (b) posi2ve consequences were iden2fied (c) nega2ve consequences acceptable
(d) op2ons for being harmful were/are feasible
once organised …
decision theory why has the service user engaged in harmful
behaviour before? why might s/he do so again?
scenario planning under what circumstances might s/he decide to
engage in harmful behaviour again?
SPJ in a nutshell
structured professional judgement
relevant factors FORMULATION risk management
risk
protecDve
treatment
monitoring supervision
vicDm safety planning
risk of what?
treatment
treatment (or rehabilita2on) strategies designed to moderate risk factors or enhance protec2ve factors;
interven2ons intended to repair or restore deficits in adjustment and func2oning
risk management planning: changing decision-‐making about harmful behaviour
supervision
restric2ons on ac2vity, movement, associa2on, or communica2on that are intended to control risk factors – limits on opportunity to be harmful;
enhancements to lifestyle in the form of structure, boundaries, role expecta2ons intended to enhance protec2ve factors
monitoring
the iden2fica2on of those early warning signs that are an indica2on of a relapse to harmful behaviour
any indicators of a change in risk
Caroline Logan 06/07/2015
6
vic2m safety plan
guidance to past or future possible vic2ms to help them avoid or to reduce the impact of (re-‐)vic2misa2on
is your formulaDon any good …?
$64,000 dollar ques2on
the challenge: to demonstrate that the process of
formula2on improves the effec2veness and u2lity of risk management with harmful service
users
re. Hart, S. et al. (2011). Forensic case formula2on. Interna)onal Journal of Forensic Mental Health, 10, 118-‐28.
if we can iden2fy the common features of formula2ons, we can
create a framework for evalua2on that will help us move from the art to the
science of formula2on
the ‘formula2on checklist’ x 2
Case Formula)on Quality Checklist
case formula2on quality checklist
narraDve
the degree to which the formula2on is presented in everyday language that
tells a coherent, ordered and meaningful story
from Hart, S. et al. (2011). Forensic case formula2on. Interna)onal Journal of Forensic Mental Health, 10, 118-‐28.
Caroline Logan 06/07/2015
7
external coherence
the extent to which the formula2on is explicitly consistent with an
empirically supported psychosocial theory of criminal behaviour
case formula2on quality checklist
from Hart, S. et al. (2011). Forensic case formula2on. Interna)onal Journal of Forensic Mental Health, 10, 118-‐28.
factual foundaDon
the extent to which the formula2on is based on informa2on about the case that is adequate in terms of quan2ty
and quality
case formula2on quality checklist
from Hart, S. et al. (2011). Forensic case formula2on. Interna)onal Journal of Forensic Mental Health, 10, 118-‐28.
internal coherence
the extent to which the formula2on rests on proposi2ons or makes
assump2ons that are compa2ble or non-‐contradictory
case formula2on quality checklist
from Hart, S. et al. (2011). Forensic case formula2on. Interna)onal Journal of Forensic Mental Health, 10, 118-‐28.
completeness
the extent to which the formula2on accounts for a substan2al amount of the cri2cal evidence (it has a plot, that
2es together the 5Ps/3Ds)
case formula2on quality checklist
from Hart, S. et al. (2011). Forensic case formula2on. Interna)onal Journal of Forensic Mental Health, 10, 118-‐28.
events relate over Dme
the extent to which the formula2on 2es together informa2on about the
past, present and future
case formula2on quality checklist
from Hart, S. et al. (2011). Forensic case formula2on. Interna)onal Journal of Forensic Mental Health, 10, 118-‐28.
simplicity
the extent to which the formula2on is free from unnecessary details, proposi2ons and assump2ons
case formula2on quality checklist
from Hart, S. et al. (2011). Forensic case formula2on. Interna)onal Journal of Forensic Mental Health, 10, 118-‐28.
Caroline Logan 06/07/2015
8
predicDve
the degree to which the formula2on goes beyond mere descrip2on, statement of facts, or classifica2on/diagnosis to make
detailed and testable predic2ons (re. if we do …, then … may happen statements)
case formula2on quality checklist
from Hart, S. et al. (2011). Forensic case formula2on. Interna)onal Journal of Forensic Mental Health, 10, 118-‐28.
acDon-‐oriented
the degree to which the formula2on priori2ses and plans treatments and
interven2ons
case formula2on quality checklist
from Hart, S. et al. (2011). Forensic case formula2on. Interna)onal Journal of Forensic Mental Health, 10, 118-‐28.
overall quality
the extent to which the formula2on is comprehensive, logical, coherent,
focused, and informa2ve
case formula2on quality checklist
from Hart, S. et al. (2011). Forensic case formula2on. Interna)onal Journal of Forensic Mental Health, 10, 118-‐28.
RISK FORMULATION a stepped approach
offender personality disorder strategy
• 2011 on • successor to the DSPD Programme • Nick Joseph and Nick Benefield • establishment of pathways of variable ‘dose’ interven2ons and support across custodial (prison) and community (proba2on) services that addresses the needs of high risk men and women with personality disorder
offender personality disorder strategy
• for offenders who … – have a current offence of serious harm and are likely to be serving determinate sentences
– are likely to have a severe form of personality disorder
– are assessed as presen2ng a high risk of commidng a further serious offence
– there is a clinically jus2fiable link between personality func2oning and future risk
Caroline Logan 06/07/2015
9
improved offender wellbeing
beVer informed workforce
reduced re-‐
offending
offender personality disorder strategy
higher level outcomes formula2on is at the heart of this work
(risk and case formula2on)
re. the challenge: to demonstrate that the process of
formula2on improves the effec2veness and u2lity of risk management with harmful service
users
1. a stepped approach to formula2on 2. a simpler way of evalua2ng the quality of
formula2ons 3. and a broader use of the formula2on process
level 1 level 2
level 3
The Stepped Approach to Case Formula)on Craissa2 & LPP
level 1 level 2
level 3
a level 1 formulaDon will: (a) give an indica2on of the paVern of behaviour (risk of what?) (b) it’ll iden2fy the range of informa)on relied on (d) it’ll connect some of those pieces of informa2on with one another in a psychological explana)on (e) it’ll provide a basis for decision-‐making in terms of risk management or other interven)ons (f) it’ll be easy to understand and relevant to those for whom it is intended – and short (around a paragraph in length)
Caroline Logan 06/07/2015
10
level 1 level 2
level 3
a level 1 formulaDon e.g., In the first of ten family therapy sessions (b), Mr A explained that he is aggressive to his wife, verbally and physically. This is his primary concern – and that of his wife (a). It emerged as the session went on that he is aggressive to her because he feels threatened by her independence (d). Further family therapy sessions are indicated as Mr A appears able to express himself to his wife in front of a therapist and he appears determined to change (e).
level 1 level 2
level 3
a level 2 formulaDon will: (a) give an indica2on of the paVern of behaviour (risk of what?) (b) it’ll iden2fy the range of informa)on relied on (c) it’ll try to account for the developmental history of the case or problem and paVerns in presenta2on (d) it’ll connect some of those pieces of informa2on with one another in a psychological explana)on (ie. it’ll connect important pieces of informa2on), be based on an ac2ve collabora2on with the service user, and discuss the ac)va)on and maintenance of the service user’s problem(s) (e) it’ll provide a basis for decision-‐making in terms of risk management or other interven)ons (f) it’ll be easy to understand and relevant to those for whom it is intended – and quite short (2-‐3 paragraphs)
level 1 level 2
level 3
a level 2 formulaDon e.g., In the first of ten family therapy sessions (b), Mr A explained that he is aggressive to his wife, verbally and physically. This is his primary concern – and that of his wife (a). He informed me that he grew up in a family where substance misuse and violence between his parents were frequent and open (c). His father leX the family home when Mr A was 9 years of age, and his mother was thereaXer unable to establish any kind of control over her son. Very quickly aXer his father leX, Mr A took up with a group of rebellious young boys and girls about the same age as him, and misused solvents and alcohol, later illegal drugs, for fun then to help him cope with a life he was really struggling to control. Mr A married but he found it really hard to feel secure in his rela2onship. He con2nued to abuse alcohol and drugs (cocaine), and he controlled his wife with violence in order to manage his feelings and fears. In a family therapy session, Mr A explained that he is aggressive to her because he feels threatened by her independence (d). Further family therapy sessions are indicated as Mr A appears able to express himself to his wife in front of a therapist and he appears determined to change (e).
level 1 level 2
level 3
a level 3 formulaDon will: (a) give an indica2on of the paVern of behaviour (risk of what?) (b) it’ll iden2fy the range of informa)on relied on (c) it’ll try to account for the developmental history of the case or problem and paVerns in presenta2on (d) it’ll connect some of those pieces of informa2on with one another in a psychological explana)on (ie. it’ll connect important pieces of informa2on), be based on an ac2ve collabora2on with the service user, and discuss the ac)va)on and maintenance of the service user’s problem(s) and be underpinned by psychological theory (e) it’ll provide a basis for decision-‐making in terms of risk management or other interven)ons (f) it’ll be easy to understand and relevant to those for whom it is intended – but it’ll be quite long (about 2-‐4 pages)
therefore …
Basic Formula)on Checklist
basic formula2on checklist (a)
the presenDng problem(s) or risk of what?
the extent to which the formula2on states clearly what it seeks to explain
re. Hart, S. et al. (2011). Forensic case formula2on. Interna)onal Journal of Forensic Mental Health, 10, 118-‐28.
Caroline Logan 06/07/2015
11
informaDon base
the extent to which the formula2on indicates the range and quality (the credibility) of the informa2on on
which it’s based
re. Hart, S. et al. (2011). Forensic case formula2on. Interna)onal Journal of Forensic Mental Health, 10, 118-‐28.
basic formula2on checklist (b)
developmental origins
the extent to which the formula2on describes the developmental trajectory of the problem
re. Hart, S. et al. (2011). Forensic case formula2on. Interna)onal Journal of Forensic Mental Health, 10, 118-‐28.
basic formula2on checklist (c)
psychological explanaDon
the extent to which the formula2on provides a psychological explana2on
of the problem(s) (risks)
re. Hart, S. et al. (2011). Forensic case formula2on. Interna)onal Journal of Forensic Mental Health, 10, 118-‐28.
basic formula2on checklist (d)
acDon oriented
the extent to which the formula2on facilitates hypotheses for ac2on to
create change (mi2ga2on)
re. Hart, S. et al. (2011). Forensic case formula2on. Interna)onal Journal of Forensic Mental Health, 10, 118-‐28.
basic formula2on checklist (e)
accessible
the extent to which the formula2on is easily understood and relevant
re. Hart, S. et al. (2011). Forensic case formula2on. Interna)onal Journal of Forensic Mental Health, 10, 118-‐28.
basic formula2on checklist (f)
exercise 3
please re-‐examine the formula2on you prepared at the beginning of today – see if you think it could be improved in any way, and
decide whether you think it is a level 1, 2 or 3 formula2on
Caroline Logan 06/07/2015
12
a broader use for formula2on
• in direct work with service users – developed collabora2vely, or developed by you and shared and amended with the service user; used as a basis for interven2on and monitoring change
– level 1 through to 3 formula2ons
a broader use for formula2on
• in indirect work with service users – developed collabora2vely with another prac22oner (e.g., prison officer) to be used by that person to improve the quality of their work with the service user
– level 1 to level 2 formula2ons
FORMULATION does it really make a difference?
this much we know
• research in London (Minoudis et al, 2013) with PD offenders has demonstrated that the (10 item) Case Formula2on Quality Checklist has – internal consistency: ‘excellent’ – test-‐retest reliability: ‘excellent’ – inter-‐rater reliability: ‘moderate-‐to-‐good’
this much we also know
• but non-‐mental health prac22oners are not good at doing formula2on
• good at using them though, and report improved quality of work with service users as a result of the joint formula2on process
• evalua2on ongoing
but this much we have s2ll to learn
• how does formula2on-‐based risk management planning make a difference to (a) the prac22oner, and (b) the client?
• can good formula2ons be derived from the informa2on to hand? – can a silk purse always be made from a pig’s ear?
• can other professionals be encouraged to prepare good (enough) formula2ons alone?