Formulation can be defined as the process of constructing a hypothesis or “best guess” about the origins of a person’s difficulties in the context of their relationships, social circumstances, life events, and the sense that they have made of them. It provides a structure for thinking together with the client or service user about how to understand their experience(s) and how to move forward (Johnstone, 2017; Nixon & Bralo, 2018). The presentation of the case formulation will be conducted in accordance with the categories for consideration outlined in Weerasekara (1996) as follows: presenting issues; predisposing factors; precipitating factors; perpetuating factors and protective factors. These provide a clear comprehensive structure for reporting on the static, dynamic and contextual factors that may affect Tom’s behaviour and subsequent offending related judgements (Sheldrick, 1999). The theoretical underpinning of the case formulation will be in accordance with the biopsychosocial model of psychological understanding. Metz (2005) provided a series of key recommendation(s) to the American Psychiatric Association (APA) commission on psychotherapy concerning the definition of the biopsychosocial model, which he comprehensively defined:
‘A biopsychosocial formulation is a tentative working hypothesis developed collaboratively with the child and family, which attempts to explain the biological, psychological and sociocultural factors which have combined to create and maintain the presenting clinical concern and which support the child’s best functioning… It will be changed, modified or amplified as the clinician and family learn more and more about the strengths and needs of the child and family’.
The origins of the model came about from George Engel’s disillusionment with the isolating components of the medical model, as a medical doctor himself he became aware of the shortcomings of his own profession to address particularly social and cultural factors surrounding psychopathology (Winters, Hanson & Stoyanova, 2007). The core strength of the biopsychosocial model therefore is that it uses a holistic approach in understanding the persons’ change of behaviour, and is context-based in nature, with a dimensional outlook on human behaviour rather than dealing in absolutes. Furthermore it is able to account for developmental issues such as maturity, and changing environmental factors which gives it flexibility and the ability to account for change over time. In order to ensure that an overly cautious, solely negative approach is not taken by the clinician the case formulation will also contain the strengths and positives in the case review of Tom and his family in the protective factors section (Winters et al., 2007).
Tom’s Presenting Issues:
Tom has demonstrated shy and withdrawn behaviours towards peers and strangers; the only exception to this assertion is the relationship with his mum and sister. He appears to have developed a paternalistic attitude towards his mother and sister, with a desire to protect them from harm. Tom appears to dislike and resent Jack, there appears to be in the offence committed and the background report suggestions of an unresolved anger or hostility towards Jacks presence. He (Tom) has academically not been performing very well at secondary school, with truanting emerging during this time period – ongoing lack of engagement with educational services. He attributes his violent attack on Jack because of his fears that Jack will harm and kill his family members. This supports the paternalistic behaviour previously noted in his relationship with his mother and sister. The index offence suggests that positive offending attitudes have developed, where extreme violence has been justified to remove threats to him and his family. Furthermore there have been reports of two occurrences of bruising to his torso which has been attributed to falling off his pushbike. Bruising in this location can also constitute a risk factor/red flag for physical violence and child sex abuse (CSA) (Jensen, 2005); it has already been stated by Tracy that Jack appears to have a ‘nasty’ streak particularly when intoxicated, becoming violent with Tracy – with Tom it is reported that only lighter incidents of violence have occurred to date.
Tom’s predisposing (background) factors:
Tom has been in a chaotic family environment where he has witnessed his mum on the receiving end of violence and arguments with Jack in the family house. Therefore he has been exposed to an environment where violence is the norm of the household, which puts him at a higher risk of adopting positive-offence attitudes to life stressors. It has been reported that he has previously engaged in verbal disputes on the playground of an aggressive nature.
Tom’s background of early parental loss may have led to attachment difficulties with the death of his Dad in a car crash. This loss occurred at a key developmental age of 4, whereby following the significant family loss his Mum was preoccupied with his sister who was badly injured in the hospital for some time. Tom stayed with his neighbours during this period, after it was reported he became “clingy” and “difficult, with night terrors”. Therefore at an early age he was experiencing symptoms of traumatic based events. This may have led to an insecure/avoidant attachment style, with a desire to protect and prevent risk/harm to the two core members of his family; as was the case that Tom claimed precipitated to the violent offence against his stepfather.
Tracey, his mum, was diagnosed with post-traumatic stress disorder and prescribed antidepressants following the car crash and the loss of her boyfriend/husband. This therefore as a contextual factor is one of mental health issues running in the family; increasing the likelihood of the children having mental health related problems due to genetic heritability. During this time she became exhausted and after work would head to bed. Tom therefore became the paternal figure in the house at a very early age taking adult responsibilities to look after his even younger sister and doing household chores. Therefore his socialisation appears to have been largely constrained to forming a close relationship with his sister, with no/little opportunity to engage with peers outside of school hours due to his household obligations and support of his younger sister. He has had a reclusive/peer isolating background – little age-appropriate youth socialisation.
Tom’s precipitating factors (triggers):
Tom appears to have engaged in the violent offence with a precipitating interpersonal conflict with his mum and her boyfriend; the nature of their dispute was violent, with the neighbours assisting to break up the dispute in front of both siblings. Therefore Tom’s trigger to violence appears to be when he perceives either his mother or his sister to be under threat from serious violence; therefore he has a maladaptive paternalistic/guardian mentality surrounding these two family members. Pro-offence attitudes towards perceived threats to his family members.
Tom’s perpetuating (maintaining) factors:
Tom appears to his cohort and teachers that he is not interested in engaging with others. This may stem from his preoccupation with his family members and the events that go on at home. Tom does not feel that he has time for others, since he has been looking after his younger sister and helping his mother out. Furthermore he has been a witness to numerous arguments between Tracy and Jack which have sometimes resulted in domestic incidents. His engagement with studies has suffered, and he appears ‘distant’ with other people and school does not appear to be his main priority and concern; once again likely due to his family circumstances which create stress and uncertainty due to living in a hostile environment to the child; becomes preoccupied and distracted by stressful events.
Tom’s protective factors (strengths):
Tom appears to have developed several prosocial traits; when his mother was going through a difficult time he would look after his sister and undertake small household chores whilst she went to bed frequently after work. At such a young age when the focus is often on socialising and developing independence it is also a positive that he has a sense of altruism and has displayed an ability to have an affective work ethic/pro-social sense of responsibility for others. Tom appears to have developed several potential coping mechanisms for stress and problems in his own life by focusing on the wellbeing and security of his mother and sister. Although Tracey claims that Tom had some kind of resentment against Jack it appears to be justifiable in light of the domestic incidents that have occurred between Tracy and Jack over the course of two years. Tom may have developed the protector/guardian role for him family, furthermore since Tom is developing into a man he may also jointly view Jack as a rival to the head of the family; growing sense of masculinity and need to challenge authority as he comes into pubertal development.
The biopsychosocial model that has been applied to the case formulation of Tom does however have several limitations. The model in its purpose to be holistic and contextual in nature is keen to not overstate any one factor or contextual issue. Therefore it is possible that a particular detail of the case, such as historical issues are underestimated in surmising the probability of recidivism, or as a factor for understanding the persons’ psychopathology. Therefore it may be the case that a clinician is keen to not appear overly cautious or be seen to commit to one factor in the formulation.
The biopsychosocial model has the purpose of presenting contextual factors in a holistic manner, which enables clinicians to assess and take account of all the factors that may influence a persons’ psychopathology. The model has become increasingly concerned with cultural factors that impact upon an individual, for example what is the persons’ cultural values? What are cultural norms of the country that he/she has come from? These impact upon the way a person behaves later in life, for example the way women are viewed from those in Libya are likely to be fundamentally different from the understanding of a western clinician. Segregation exists to a larger degree in these countries, therefore the role of gender and views on masculinity shape more so whether a man engages in violence. The biopsychosocial model is able to take account of a wide-array of risk assessment instruments since it is compatible with a broad empirical dataset.
Risk Assessment Instrument/Case Formulation:
The risk measure that will be utilised is the Structured Assessment of Violence Risk in Youth (SAVRY), an instrument for assessing risk for violent crimes amongst adolescents from 12 to 18 years (Borum, Bartel & Forth, 2003; Borum, Bartel, & Forth, 2006). The instrument comprises of 24 empirical risk factors e.g. impulsivity and negative attitudes. There are also 6 protective factors within, allowing for assessment of strengths and coping mechanisms. It allows for a combination of empirical summing up with the summary risk rating (SSR) and structured professional judgement where the assessor can interpret the results (Astrom, Gumpert, Andershed & Forster, 2017) from a wide arrange of available data such as interviews and record reviews (Borum et al., 2003). Furthermore it is one of the most widely used risk assessment tools for those in juvenile detention centres (Hilterman, Bongers, Nicholls & Nieuwenhuizen, 2018). Guy (2008) concluded that Individual/Clinical, Social/Contextual, and Protective Factors were significant predictors of future physical, sexual and non-violent offending. This is the most valid measure to apply to Tom, in reflection of his index offence which was violent in nature. Many of the other risk instruments focus to a large degree on sexual offences and potential recidivism of those offences, such as the J-SOAP-II. The Juvenile Sex Offender Assessment Protocol-II (J-SOAP-II) purpose is to review the risk of boys in the age range of 12 to 18 who have committed sexual and criminal offending (Prentky & Righthand, 2003). Since Tom is currently 12 years old he meets the required age threshold to be assessed by this risk assessment. It is meant to form part of a comprehensive review of risks in youth, but not be used in isolation to other risk assessments; as stipulated by the authors. Tom has no reported issues surrounding sexually deviant or inappropriate behaviour; however with his background predictors of isolation/loneliness and disengagement from the world around him, during his puberty and critical sexual development years other instruments such as the J-SOAP-II may become necessary and should be considered in future assessment(s). Literature suggests that isolation, poor peer relations and issues surrounding poor attachment, insecure style, as demonstrated with Tom’s historical background with his mother and sister are linked to increased likelihood of developing sexually deviant strategies. The courts often request that long-term risk be assessed; however this should be resisted in favour of short-term continuous risk assessments subject to review periods (Sheldrick, 1999).