Being able to formulate is a key skill for practitioners working with children whose behaviour presents a risk of harm to others; however, it is not an easy skill to master. CYCJ Information Sheet 68 detailed what formulation is, its purpose and the elements that create a good formulation. This information sheet provides some practical suggestions about how to use formulation with children and their parents/carers

Murphy, Carole

University of Strathclyde Institutional Repository

 info sheet69Feb 2018Formulation in Risk Practice 2Being able to formulate is a key skill for practitioners working with children whose behaviour presents a risk of harm to others; however, it is not an easy skill to master. CYCJ Information Sheet 68 detailed what formulation is, its purpose and the elements that create a good formulation. This information sheet provides some practical suggestions about how to use formulation with children and their parents/carers.A good formulation is like a really good story, which explains in detail how someone’s life has developed. In the youth justice context, this includes a story that explains why the child has engaged in offending behaviour. Some children have no story at all about their life, or a confused story, or a story dominated only by themes of abuse, threats and violence. Our job is to help them develop a story that offers them a comprehensive explanation of their experience and behaviour. Developing the formulation should be a collaborative process between the practitioner and the child and the child’s family/carers where this is appropriate, and should draw on information from the multi-agency team. In order to be useful, a formulation should be understood by and acceptable to the child. As a starting point for collaborative discussion, it is helpful to ask the child about their views on both the request for the assessment and what they see as the presenting problem. Whilst practitioners are the experts in assessing and managing/reducing risk, the child should be considered the expert on their experiences, and the meaning of these experiences, so it is important that they are given the opportunity to contribute as much as they can. At the same time, there are children who have no idea why things have happened and are at a complete loss to explain most of their experience. These children will need the practitioner to take a lead role in writing the story based on files. It can often take time to build up trust with the child, so the assessment and resulting formulation should be expected to take a few sessions. It can also be helpful at the outset to agree that the report will be discussed with them first and that they will be able to make comments and have these incorporated into the report prior to it being shared with others. This does not mean that you will necessarily change your view, but you want to ensure the child’s view is balanced with your view, and that the report is factually accurate.The information most relevant to the behaviour of concern can be organised and integrated using a framework such as the Four P’s in order to understand the co-dependency of factors (Weerasekera, 1996). The language of the Four P’s asks practitioners to consider predisposing factors (why me?), precipitating factors (why now?), perpetuating factors (why does it continue?) and protective factors (what can I rely on?) (Henderson & Martin, 2014). In addition, The Mindful Formulation method can be particularly useful for those new to formulation as it takes practitioners through three logical steps in the process (for a detailed explanation and case example see Havighurst & Downey, 2009). In summary, this method facilitates the process of understanding complex cases by examining patterns of strength and difficulty across the child’s environment, then systematically provides an explanation of these using the Four P’s to structure thinking. This systemic approach promotes an understanding of the intergenerational nature of many problems, and has three steps:1) Assessment. This should include the presenting problem; relationships, home and social continued overleaf www.cycj.org.ukCarole Murphy, CYCJThe Centre for Youth & Criminal Justice is funded by the Scottish Government and hosted by the University of Strathclyde environments; experience of adverse events and attachment; developmental history; safety concerns; resilience factors; and any missing information.2) Identifying patterns. This is where strengths and difficulties are identified across i) the child’s functioning, ii) the parents/carers/siblings/significant other’s functioning, iii) relationships with the child and among significant others, and iv) relationships with and amongst the community. Each of these four domains are considered across the three elements of emotions, behaviours and thoughts, to create a matrix from which patterns can be identified. Patterns can include typical behaviours, beliefs, affective expression, skills, relational patterns, actions and responses. 3) Summary and formulation. Following a brief summary, the Four P’s are used to give the formulation structure and it is recommended that a separate paragraph is used to explain each of the Four P’s (how the patterns have developed, how recent events have precipitated current patterns, how the patterns are maintained, and how patterns of strength are protective). Each of these paragraphs should draw on the information from the previous two steps and theoretical and practice knowledge.A strengths focused approach such as the Good Lives Model can be used to assist the child to list the things that they value in life, for example, their primary needs and to consider whether/how they are currently being met. Using a motivational interviewing approach, some of the problems their behaviour has generated for them can be considered and goals for the future discussed. Through being curious, responsive and empathic, the process of formulation provides an opportunity to discuss and negotiate a shared understanding of the behaviour with the child. Within this process, it is important to consider the purpose (functional analysis) of the behaviour and to consider whether it serves as a coping style or defence mechanism due to attachment or trauma experiences. The use of such a framework with children can often help them make sense of their complex experiences and understand the influence of others on their behaviour. Formulation should explain the patterns which intervention should then target. Working through this method should help to prevent overemphasising individual interventions with the child and assist in identifying wider systemic interventions that predispose and precipitate the behaviour. If we do not address these, then the problems are likely to return later, or display themselves in another form. The next stage is to write the formulation in a narrative format. It can be helpful to explain that you would like to write a few paragraphs describing what you both agree about the behaviour of concern and what could be done by everyone to manage it in the future, as well as what you both disagree on. If doing it jointly in the session then the practitioner would generally do the writing which can then be typed up and edited at the next meeting. Alternatively, it might be agreed that the practitioner prepares a draft for the next meeting to go through together. The formulation should use simple language, be succinct and avoid repetition of information. It should be the most meaningful part of the report and keeping it to a few paragraphs helps to ensure that it is read. As it is likely to be on record for a long time, it is also essential to be careful with the language used, avoid labelling and provide some context for the presenting behaviour. For instance, ‘fire-raising’, ‘assault’, ‘indecent images’ can all vary on a continuum in terms of severity, for example from lighting the spray from an aerosol can, to deliberately dousing a property in petrol with an intention to cause injury. How these behaviours are referred to is important for the child’s future. The formulation is then used to communicate and engage with others. It is the basis for monitoring change and any changes are used to determine whether the original formulation was accurate, or whether it needs to be amended based on further knowledge or understanding. It should therefore be a document that drives action plans based on an evolving understanding of the child and their behaviour. Whilst this approach may take slightly longer than simply providing a summary, it means that underlying issues can be identified and addressed, which should result in increased engagement and improved long-term outcomes. w www.cycj.org.uke cycj@strath.ac.uk  @CYCJScotland

Formulation in Risk Practice 2

The Framework for Risk Assessment Management and Evaluation (FRAME) for children and young people under 18 aims to bring consistency to the ways in which agencies assess, manage and evaluate the risks presented by offending behaviour. The five Practice Standards within FRAME set a benchmark for effective practice. ‘Risk Assessment’ is the first Practice Standard, and FRAME states that such assessments are best undertaken within the context of structured professional judgment (SPJ) and underpinned by holistic formulation. The SPJ approach guides decisions about what type of harm the individual is likely to engage in, the seriousness of the harm, the likely victim(s), in what circumstances the harm is likely to occur, and then makes recommendations as to how to prevent the harm from occurring. There are six key stages to the SPJ approach – gathering background information, identification of risk factors, formulation, scenario planning, risk management, and communication and review (Logan, 2016). This information sheet will focus on the formulation stage, as formulation or analysis of risk is included in various professional standards and guidance documents, but is often the stage that practitioners report is most complex (HCPC Standards of proficiency for Practitioner Psychologists, 2015; Care Inspectorate Inspection Handbook 2016/17: Joint inspection of service for children and young people)

 info sheet68Jan 2018Formulation in Risk PracticeThe Framework for Risk Assessment Management and Evaluation (FRAME) for children and young people under 18 aims to bring consistency to the ways in which agencies assess, manage and evaluate the risks presented by offending behaviour. The five Practice Standards within FRAME set a benchmark for effective practice. ‘Risk Assessment’ is the first Practice Standard, and FRAME states that such assessments are best undertaken within the context of structured professional judgment (SPJ) and underpinned by holistic formulation. The SPJ approach guides decisions about what type of harm the individual is likely to engage in, the seriousness of the harm, the likely victim(s), in what circumstances the harm is likely to occur, and then makes recommendations as to how to prevent the harm from occurring. There are six key stages to the SPJ approach – gathering background information, identification of risk factors, formulation, scenario planning, risk management, and communication and review (Logan, 2016). This information sheet will focus on the formulation stage, as formulation or analysis of risk is included in various professional standards and guidance documents, but is often the stage that practitioners report is most complex (HCPC Standards of proficiency for Practitioner Psychologists, 2015; Care Inspectorate Inspection Handbook 2016/17: Joint inspection of service for children and young people).Lewis and Doyle (2009) define risk formulation as a form of analysis that can assist practitioners to explain the origins, development and maintenance of risk behaviour, while providing a crucial link between assessment and management. There are various models of formulation, often linked to the theoretical basis that practitioners are working from. In the absence of a definitive theory about violence or harmful sexual behaviour (HSB), it is helpful to use an integrative formulation framework such as the 4P’s model (Johnstone & Gregory, 2015; Weerasekera, 1996). This model distinguishes between predisposing (factors in the individual’s past that may increase vulnerability to violence/HSB), precipitating (circumstances that may trigger the behaviour or disinhibit usual behavioural controls), perpetuating (factors that cause the risk to remain/hinder risk reduction attempts) and protective factors (aspects of the indi-vidual’s functioning or circumstances that moderate/mitigate the risk). The types of factors to consider include biological, psychological, family system, and social network factors. Additionally, Johnstone and Gregory (2015) state that when developing formulations with children and young people, practitioners should be developmentally, systems, trauma, and vulnerability informed. This ensures that the child’s age and stage of development and the systems within which they are embedded are considered, as well as the link between adverse childhood experiences, vulnerabilities and violence (see the book chapter for an example case formulation using this model). While the 4P’s model assists in organising information, it is necessary to ensure that these factors are combined into a coherent narrative, including the meaning that the individual has attributed to life circumstances or events (BPS, 2011). Using our theoretical knowledge, we can unpick the mechanism through which the identified dynamic risk factors might drive the child’s behaviour (for example, through limited ability to identify emotions, reinforcement of harmful behaviours by other systems, negative views of themselves and/or others, hypervigilance and proneness to perceive threat) and therefore deliver more individualised and effective interventions (Ward & continued overleaf www.cycj.org.ukCarole Murphy, CYCJThe Centre for Youth & Criminal Justice is funded by the Scottish Government and hosted by the University of Strathclyde Fortune, 2016). Psychologists often use a cognitive behavioural therapy model of formulation to aid the identification of personal meaning for the individual by linking early experiences, feelings, views of themselves and others, and behaviour.Understand the good reasons why you feel the way you do. Make sense of your experiences. Decide what changes you want in your life.It is important that formulations are collaboratively generated with the child, and their caregivers where appropriate, as this helps the child’s understanding of their behaviour and encourages motivation to consider change. The British Psychological Society (BPS) has produced a leaflet for use by Clinical psychologists to aid children’s understanding of formulation explaining it as “a way of describing problems and ways out of them”. The formulation should become the basis for determining any change achieved, and the changes should determine whether the original formulation (hypothesis) was correct or whether any adjustments to our understanding of the difficulties need to be made (Cooke & Logan, 2015). If individuals are not well understood then it is difficult to manage risk with focus, clarity of objectives and confidence (Logan, Nathan & Brown, 2011).Whether good quality formulations improve intervention planning, and therefore outcomes for children, is unknown, and formulation is an area that requires further research. To assist with research and quality assurance, a revised case formulation quality checklist (CFQC-R) has been constructed, and may be of value in the training, supervision and self-reflection of practitioners (Minoudis et al., 2013; McMurran & Bruford, 2016). The CFQC-R contains ten criteria and is based on features of good quality formulations described by Hart et al. (2011): 1. The formulation is presented in everyday language that tells a coherent, ordered, and meaningful story2. The formulation is explicitly consistent with an empirically supported theory3. The formulation is based on relevant information about the case that is adequate in terms of quantity    and quality4. The formulation rests on propositions or makes assumptions that are compatible or non-contradictory5. The formulation has a plot that ties together as much of the relevant information as possible6. The formulation ties together information about the past, present, and future of the case7. The formulation is free from unnecessary details8. The formulation goes beyond description, statement of facts, or classification to make detailed and  testable predictions. The key predictions are those about which strategies will be most effective in  treating and managing harmful behaviour9. The formulation prioritises and plans treatments10. The formulation is comprehensive, logical, coherent, focused, and informativeAs highlighted in the 2010 practice guidance for Criminal Justice Social Work reports, managers are responsible for the overall standard of reports, but report writers are accountable for the content of reports. It is therefore extremely important that opportunities to develop in line with current best practice are embedded within services. Training in risk practice needs to be accompanied by post-training support, evaluation of the application of learning to practice, and mentoring, if the desired results are to be delivered (Gailey, 2011). As identified in the BPS Guidelines on best practice on the use of psychological formulation, clinical psychologists receive the most in-depth training in formulation, and are well placed to promote its use through practice, teaching, supervision, consultancy and research. Wherever possible, clinical and/or forensic psychologists would be a good addition to the Care and Risk Management process in Local Authorities. The SPJ approach, when done well, takes time. However, if the approach leads to a more comprehensive understanding of the issues underlying engagement in harmful behaviour, then intervention planning is enhanced and should lead to less resource requirements in the longer term, in addition to better outcomes for the child and ultimately, a reduction in future victims.ReferencesPlease see reference appendix