Interventions for Vulnerable Youth (IVY)
Formulation in Risk Assessment –
Principles and Practice
DR LEANNE GREGORY
Clinical Psychologist and Project Manager
HEATHER IRVING
Consultant 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, firesetting/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
17years
yearsold
old
•• 17
Currentlyliving
livingin
inthe
thecommunity
community
•• Currently
Subjectto
tocompulsory
compulsory supervision
•• Subject
order
supervision
order
Referredby
bysocial
socialwork
workfollowing
following
•• Referred
anxietyabout
abouthis
hissexually
sexuallyharmful
harmful
anxiety
behaviour
behaviour
Case Study: Background
Family Life
Education
Social
History/Peer
Association
Mental Health
Substance
Misuse
LAAC History
Case Study: Background
Sexual 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 presenting
problems 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 – Process
Problem
• Identify the
problem, can be
complex.
Information
• Collect a range
of information
across time
points and
informants/
• sources.
Comprehensive.
Hypotheses
Intervention
• 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.
Communicati
on
• 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