caroline logan 06/07/2015 - british psychological society of forensic... · caroline logan...

Caroline Logan 06/07/2015

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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

[email protected]

•  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 …?


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•  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)?



understanding




why? (encapsulated in a

formula2on)




understanding







understanding



•  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


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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


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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?


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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


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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.


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external coherence

the extent to which the formula2on is explicitly consistent with an

empirically supported psychosocial theory of criminal behaviour



factual foundaDon

the extent to which the formula2on is based on informa2on about the case that is adequate in terms of quan2ty

and quality



internal coherence

the extent to which the formula2on rests on proposi2ons or makes

assump2ons that are compa2ble or non-‐contradictory



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)



events relate over Dme

the extent to which the formula2on 2es together informa2on about the

past, present and future



simplicity

the extent to which the formula2on is free from unnecessary details, proposi2ons and assump2ons




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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)



acDon-‐oriented

the degree to which the formula2on priori2ses and plans treatments and

interven2ons



overall quality

the extent to which the formula2on is comprehensive, logical, coherent,

focused, and informa2ve



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


•  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


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improved offender wellbeing

beVer informed workforce

reduced re-‐

offending


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)


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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



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informaDon base

the extent to which the formula2on indicates the range and quality (the credibility) of the informa2on on

which it’s based


basic formula2on checklist (b)

developmental origins

the extent to which the formula2on describes the developmental trajectory of the problem


basic formula2on checklist (c)

psychological explanaDon

the extent to which the formula2on provides a psychological explana2on

of the problem(s) (risks)


basic formula2on checklist (d)

acDon oriented

the extent to which the formula2on facilitates hypotheses for ac2on to

create change (mi2ga2on)


basic formula2on checklist (e)

accessible

the extent to which the formula2on is easily understood and relevant


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


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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?


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CONCLUSIONS

•  why think about risk? •  risk formula2on •  is your formula2on any good? •  a stepped approach •  does formula2on make a difference?

caroline logan 06/07/2015 - british psychological society of forensic... · caroline logan...

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