Understanding Risk Formulation in Forensic Psychology

Journal of Forensic Psychology Research and Practice | p. 1-22

Risk Formulation: A Qualitative Study of Practitioner Experiences

Emma Tarpey; Psychology Department, University of Birmingham, Birmingham, UK

Richard Barker; Psychology Department, University of Birmingham, Birmingham, UK; Psychology Department, Oxford NHS Foundation Trust, Oxford, UK

Zoe Stephenson; Psychology Department, Oxford NHS Foundation Trust, Oxford, UK

This study aimed to explore practitioners’ experiences of risk formulation . Data were gathered from10 forensic practitioners, and analysed using template analysis, revealing five themes: “Defining Risk Formulation,” “A Responsive Flexible Approach,” “Where’s the Evidence for Risk Formulation,” “The Learning Journey,” and “Roles and Responsibilities.” Findings highlighted variability in the process for developing skills and knowledge in risk formulation, and, in the absence of established feedback channels, practitioners utilise informal feedback mechanisms to validate their risk formulations. There was evidence of shared understanding of risk formulation amongst practitioners, however this was not underpinned by a set of practitioner guidelines.

Risk formulation; template analysis; forensic practice

“Within risk formulation, information is gathered, and this is used to generate a hypothesis specifically regarding the origins, development, and maintenance of risk-related behavior, the focus being on the management of risk behavior… Case formulation necessitates ‘psychological sophistication’ to organize information and generate hypotheses… alongside key competencies and skills, such as acceptance of ambiguity and not knowing, being able to work with the client to co-produce the formulation, self-reflection and monitoring, the ability to reason and generate hypotheses, and knowledge of the literature on violent offending… Despite the importance of risk formulation in informing treatment and risk management plans, empirical literature exploring the use of risk formulation and practitioners’ experiences with using risk formulation remains limited” (p. 1-3).

“Risk formulation was deemed critical in developing an understanding of an individual, described as a tangible product, something that is completed and delivered at the end of the process, and as a process… It’s the foundation really of what things should be built on… because in order to understand how you interact, manage, go forward, treat, it impacts on so many different areas… It’s about providing almost a story of the person, but something that makes sense in terms of how that person got to that presenting risk, risky problem or risky behavior. … The idea of a formulation as a process rather than a product… that you use to inform the management strategies that you put in place, that is a dynamic, and it… is a process that’s ongoing… Formulation facilitates understanding, in terms of helping other professionals to understand the person, and helping the individual to understand themselves, both with the aim of providing direction… Risk management isn’t something that’s done to them, it’s something that’s done with them” (p. 6-8).

“Participants described the four P model as the starting point for their formulations, due to the ease with which it facilitates communication… Participants also described branching out from using this framework and using different approaches… Everything and anything really… anything and everything gives you lots and lots of bits of information, a bit like a jigsaw, you pull it all together… We need to understand them. At the end of the day, they’re the expert on them… they’re the expert on their experiences” (p. 9-10).

“Participants evidenced a limited awareness of the evidence base for risk formulation… describing having faith in the approach due to the research and knowledge of experts within the field… If you asked me now what is the evidence base, I probably wouldn’t be able to tell you… None of the participants described formal feedback mechanisms for their risk formulations… rather, they relied on intuition and informal feedback from others to judge the appropriateness of their risk formulations” (p. 11-12).

“This study evidenced risk formulation as existing in two forms: as a tangible product… and as an experience, such as an activity or process, for service users to develop an understanding of themselves… Given that risk formulations are used to inform decision making about current and future risk, it is concerning that practitioners do not have a method for reviewing and evaluating their risk formulations… Ensuring that such formulations are informed by the best evidence and training is a vital element in the training of forensic psychologists… Further research is required to provide a basis upon which professional practice guidelines pertaining to risk formulation can be developed” (p. 15-19).

“This research explored a small subset of practitioners engaging in risk formulation in forensic settings, and as such, any implications for practice are preliminary and remain somewhat tentative until further research is completed. This research has identified that, for this sample of participants, risk formulation is an important aspect of forensic practice, in terms of fostering collaborative working relationships and informing future risk-related treatment and management, yet their awareness of the evidence demonstrating the efficacy of risk formulation in practice is limited. 

The findings from this study indicate that experiential learning opportunities were the means by which participants developed their risk formulation skills; therefore, it would be beneficial to include practice cases and opportunities for feedback from experienced others within risk formulation learning opportunities. Educators and supervisors should be knowledgeable about the current evidence base and the academic discourse surrounding risk formulation to facilitate reflection and critical engagement from learners. Furthermore, agreement within the discipline regarding the threshold concepts pertaining to risk formulation could facilitate the development of core curriculum content that could be utilized across educational settings. 

The research demonstrated that, for this sample of participants, the mechanisms for determining the validity and utility of their risk formulation practices are not formalized; rather, they are based on feedback from others and on intuition. Without a process for evaluating risk formulations nor any clear feedback regarding the outcomes of risk formulation practices, the opportunities for reflection and professional development are limited. It is recommended that practitioners engaging in risk formulation consider how to monitor and evaluate their risk formulation practices. This could be through the implementation of organizational and/or discipline-wide approaches, such as the adoption of monitoring and evaluation checklists based on formulation frameworks, supported by practice guidance from professional practice bodies, such as the BPS Division of Forensic Psychology (DFP). 

While case formulation—often used in clinical psychology settings—can be defined as a generated hypothesis that seeks to explain the psychological mechanisms behind a person’s thoughts, feelings, and actions (Kuyken et al., 2008; Persons, 2008), a risk formulation—while still seeking to explain a specific behavior—is usually applied in the structured professional judgment about the person’s possible future risk and consequential decision making about the management of that risk. This hypothesis about someone’s behavior may therefore be used to determine release from prison, treatment, and intervention options, recall into prison or hospital, and access (or not) to support systems. While in essence a risk formulation may have similar elements to a standard clinical case formulation, the use to which it is put may have far greater implications for an individual’s liberty and/or the impact on potential victims, families, and society in general. Thus, it is our opinion that ensuring that such formulations are informed by the best evidence and training is a vital element in the training of forensic psychologists” (p. 17-18). 

“The population from which the sample was derived excluded those forensic practitioners currently employed within the HMPPS and the NHS, with HMPPS being the main employer for forensic psychologists in the UK. The majority of participants did have prior experience working within these settings; however, it is acknowledged that not recruiting from HMPPS and the NHS is a limitation of this research that has impacted the generalizability of the findings. Similarly, the data collection was restricted to a UK population; therefore, the generalizability of the findings outside the UK is limited. 

While the majority of participants were forensic psychologists (qualified or trainee), one of the participants was a clinical psychologist and one was dual trained (clinical-forensic). Psychological formulation is one of the nine core competencies for BPS-accredited clinical doctoral programs (British Psychological Society, 2019); therefore, there may be a difference in how clinical psychologists have developed their formulation skills and knowledge, as compared with the forensic psychologist participants. 

The researcher is a qualified forensic psychologist with experience in completing risk formulations in practice and responsibility for delivering teaching to aspiring forensic psychologists. The design, data collection, and data analysis have all been influenced by the knowledge and experience of the researcher (Finlay & Gough, 2003), in terms of the motivation to explore the topic, the areas explored during the interview, the probing of participant responses, and the interpretation of the data. 

During the data collection, the researcher reminded participants that the focus of the study was risk formulation; however, with the somewhat vague and fluid notion of risk formulation, and the interchangeable use of the terms risk formulation, forensic formulation, and forensic case formulation, participants may have been describing thoughts and experiences based on other types of formulation” (p. 17).