Forensic Case Formulation

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Author: Mary McMurran | Peter Sturmey

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“Peter Sturmey and Mary McMurran have edited an excellent book on forensic case formulation for this Wiley-Blackwell series. The authors of the chapters are well-respected experts in the forensic field. Readers who work in forensic services will find the chapters on case formulation both informative theoretically and helpful clinically. Work with offenders will be enhanced by assimilating the ideas and suggestions in this book.”

Effective assessment and treatment of offenders is important for reducing the likelihood of further offending. Understanding the processes which initiate and maintain offending behavior is integral to the design and evaluation of appropriate, individually tailored interventions. Forensic Case Formulation describes the principles and application of case formulation specifically for forensic clinical practice. In this edited volume, contributors review the fundamental aspects of case formulation, including definitions, reliability, and validity. The practical applications of case formulation applied to violence, sexual offenses, personality disorder, and substance abuse are described, and illustrated with case studies. Also covered is the interrelationship between case formulation and risk assessment. Forensic Case Formulation offers rich insights into the use of case formulation with forensic clients.

Peter Sturmey is Professor of Psychology at Queens College and The Graduate Center, City University of New York. He has published extensively on developmental disabilities, applied behavior analysis, and on issues relating to staff and parent training. Mary McMurran is Professor of Personality Disorder Research in the University of Nottingham’s Institute of Mental Health. She has written extensively on personality disorders, alcohol-related aggression, and readiness to engage in therapy.

Cover image: Image © linearcurves/iStockphoto Cover design by Nicki Averill Design

Forensic Case Formulation

Kate Davidson, Professor of Clinical Psychology, University of Glasgow, UK

Edited by Sturmey and McMurran

Forensic Case Formulation

Edited by

Peter Sturmey and Mary McMurran

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FORENSIC CASE FORMULATION



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WILEY SERIES IN

FORENSIC CLINICAL PSYCHOLOGY Edited by

Clive R. Hollin School of Psychology, University of Leicester, UK and

Mary McMurran Institute of Mental Health, University of Nottingham, UK For other titles in this series please visit www.wiley.com/go/fcp



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FORENSIC CASE FORMULATION Edited by

Peter Sturmey Queens College and City University, New York, USA and

Mary McMurran Institute of Mental Health, University of Nottingham, UK

A John Wiley & Sons, Ltd., Publication



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This edition first published 2011 © 2011 John Wiley & Sons, Ltd. Wiley-Blackwell is an imprint of John Wiley & Sons, formed by the merger of Wiley’s global Scientific, Technical and Medical business with Blackwell Publishing. Registered Office John Wiley & Sons Ltd, The Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, UK Editorial Offices The Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, UK 350 Main Street, Malden, MA 02148-5020, USA 9600 Garsington Road, Oxford, OX4 2DQ, UK For details of our global editorial offices, for customer services, and for information about how to apply for permission to reuse the copyright material in this book please see our website at www.wiley.com/wiley-blackwell. The right of Mary McMurran and Peter Sturmey to be identified as the authors of the editorial material in this work has been asserted in accordance with the UK Copyright, Designs and Patents Act 1988. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, except as permitted by the UK Copyright, Designs and Patents Act 1988, without the prior permission of the publisher. Wiley also publishes its books in a variety of electronic formats. Some content that appears in print may not be available in electronic books. Designations used by companies to distinguish their products are often claimed as trademarks. All brand names and product names used in this book are trade names, service marks, trademarks or registered trademarks of their respective owners. The publisher is not associated with any product or vendor mentioned in this book. This publication is designed to provide accurate and authoritative information in regard to the subject matter covered. It is sold on the understanding that the publisher is not engaged in rendering professional services. If professional advice or other expert assistance is required, the services of a competent professional should be sought. Library of Congress Cataloging-in-Publication Data Forensic case formulation / edited by Peter Sturmey and Mary McMurran. p. cm. Includes index. ISBN 978-0-470-68395-8 (cloth) – ISBN 978-0-470-68394-1 (pbk.) 1. Correctional psychology. 2. Criminal psychology. 3. Criminals–Rehabilitation. I. Sturmey, Peter. II. McMurran, Mary. HV9276.F67 2011 614 .15–dc22 2011009359 A catalogue record for this book is available from the British Library. This book is published in the following electronic formats: ePDFs 9781119977025; Wiley Online Library 9781119977018; ePub 9781119976899 Set in 10/12pt Palatino by Aptara Inc., New Delhi, India. 1

2011



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CONTENTS About the Editors About the Contributors Series Editors’ Preface

vii ix xiii

Preface

xvii

PART I GENERAL ISSUES 1 Theoretical and Evidence-Based Approaches to Case Formulation Tracey D. Eells and Kenneth G. Lombart

1 3

2 Current Issues in Case Formulation Gregory H. Mumma

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3 Does Case Formulation Make a Difference to Treatment Outcome? Ata Ghaderi

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PART II VIOLENCE

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4 Formulation of Violence Risk Using Evidence-Based Assessments: The Structured Professional Judgment Approach Stephen D. Hart and Caroline Logan

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5 Cognitive Behavioral Approaches to Formulating Aggression and Violence Kevin Howells

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6 Formulation of Serious Violent Offending Using Multiple Sequential Functional Analysis Aidan J.P. Hart, David M. Gresswell and Louise G. Braham

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7 Forensic Case Formulation, Substance Abuse Disorders, and Anger Ellen Vedel and Paul M.G. Emmelkamp

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CONTENTS

PART III SEXUAL OFFENDING

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8 Sexual Offenses Against Children James Vess and Tony Ward

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9 Sexual Offenses Against Adults Stacey L. Shipley and Bruce A. Arrigo

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PART IV SPECIFIC POPULATIONS

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10 Forensic Case Formulation with Children and Adolescents Phil Rich

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11 Formulating Offending Behavior with People with Mild Learning Disabilities William R. Lindsay

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12 Case Formulation for Individuals with Personality Disorder Lawrence Jones

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PART V CONCLUSION

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13 Forensic Case Formulation: Emerging Issues Peter Sturmey and Mary McMurran

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Index

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ABOUT THE EDITORS Peter Sturmey is Professor of Psychology at Queens College and The Graduate Center, City University New York and a member of the Learning Processes and Behavior Analysis and Neuropsychology doctoral programs at City University of New York. He has published over 150 articles and 15 books on developmental disabilities. His current research focuses on applied behavior analysis and staff and parents training. Mary McMurran is Professor of Personality Disorder Research at the University of Nottingham’s Institute of Mental Health, United Kingdom. Her research interests include: social problem solving as a model of understanding and treating people with personality disorders; the assessment and treatment of alcohol-related aggression and violence; and understanding and enhancing offenders’ motivation to engage in therapy. She is a Fellow of the British Psychological Society, and recipient of the Division of Forensic Psychology’s Lifetime Achievement Award in 2005.

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ABOUT THE CONTRIBUTORS Bruce A. Arrigo Professor of Criminology, Law, and Society in the Department of Criminal Justice and Criminology at the University of North Carolina – Charlotte. He holds affiliated appointments in the Departments of Psychology and Public Health Sciences, and in the Public Policy Program and the Center for Professional and Applied Ethics. He is a Fellow of the American Psychological Association and the Academy of Criminal Justice Sciences. Dr Arrigo’s numerous recognitions include the American Society of Criminology’s Critical Criminologist of the Year Award (2000), the Society for the Study of Social Problem’s Book of the Year Award in Crime and Delinquency (2005), the Academy of Criminal Justice Sciences’ Bruce Smith Sr. Distinguished Research Award (2007), and the First Citizens Bank Scholars Medal (2008). Dr Arrigo’s latest book is The Ethics of Total Confinement: A Critique of Madness, Citizenship and Social Justice (2011) Oxford University Press. Louise G. Braham Acting Lead Psychologist and Consultant Clinical and Forensic Psychologist, Mental Health Service, Rampton Hospital, Nottinghamshire Healthcare NHS Trust and Senior Clinical Tutor for the Trent Clinical Psychology Training Programme, University of Nottingham, UK. Louise has worked in Forensic Mental Health Services for over 15 years. She is a practising clinician, has published and is interested in violence, forensic case formulation, neuropsychological functioning and the experience and symptoms of psychosis related to risk. Tracy D. Eells Clinical Psychologist and Professor in the Department of Psychiatry and Behavioral Sciences at the University of Louisville in Louisville, Kentucky, USA. He earned a Ph.D. from the University of North Carolina, Chapel Hill. His primary area of scholarship is psychotherapy research, particularly expertise in case formulation. He is editor of the Handbook of Psychotherapy Case Formulation and is advisory editor for the journals Psychotherapy Research and Pragmatic Case Studies in Psychotherapy. Paul M.G. Emmelkamp Full professor of clinical psychology at the University of Amsterdam and senior consultant at the forensic psychiatry centre, De Waag. Over the years he has published widely on the etiology and treatment of anxiety disorders. He is involved in therapy-outcome studies on adults with work-related distress, substance abuse disorders, personality disorders, domestic violence, depression, and anxiety disorders, and on youth with ADHD, conduct disorder



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ABOUT THE CONTRIBUTORS

and anxiety disorders. He has written and co-edited many books, and over 450 publications in peer reviewed journals or books. He is Editor of Clinical Psychology & Psychotherapy and of BMC-Psychiatry: Forensic Psychiatry. He has received a number of honors and awards, including a distinguished professorship (“Academy Professor”) by the Royal Academy of Arts and Sciences. Ata Ghaderi Clinical Psychologist, Licensed Psychotherapist, and Professor of Psychology at the Department of Psychology, Uppsala University, Sweden. His main field of research is prevention and treatment of eating disorders. His interests include philosophy of science in psychology in relation to assessment and diagnosis, psychotherapy research focusing on treatment matching and individualization, dissemination of evidence-based treatment, and basic research on perception and cognition. He is currently running several projects on the intensive treatment of obsessive-compulsive disorder, preventive parent training, treatment of chronic anorexia nervosa, obesity and body dismorphic disorder. David M. Gresswell Co-Director of the Trent Clinical Psychology Training Programme and works part-time as a Consultant Clinical Psychologist in NHS forensic services in Lincolnshire. Mark has worked in forensic mental health services for over 25 years in high and low security settings and in the community. He has a special interest in behavioral approaches and functional analysis. Aidan J.P. Hart Clinical Forensic Psychologist and Senior Lecturer in Clinical Psychology, University of Lincoln, UK. Aidan has worked in hospital and community settings with physically and sexually violent offenders. He has also worked in both inpatient and outpatient settings in the assessment and treatment of both early episode and severe and enduring mental health problems. He has an interest in behavioral analysis and in particular third wave behavioral approaches, such as Relation Frame Theory, and their application to understanding and furthering assessment and treatment processes. Stephen D. Hart Professor in the Department of Psychology at Simon Fraser University and Visiting Professor in the Faculty of Psychology at the University of Bergen. His work focuses on the assessment of violence risk and psychopathic personality disorder. He has co-authored more than 160 articles, chapters, and books, including several violence risk assessment guides. He is a recipient of the Career Achievement Award from the Society of Clinical Psychology (APA Division 12), the Saleem Shah Award for Early Career Research Excellence in Psychology and Law from the American Psychology-Law Society (APA Division 41) and the American Academy of Forensic Psychology, and the Distinguished Achievement Award from the Association of Threat Assessment Professionals. Kevin Howells Clinical and forensic psychologist. He was until recently Professor of Forensic and Clinical Psychology in the Institute of Mental Health and Division of Psychiatry at Nottingham University. He has worked as a clinician in the United Kingdom, Australia and the USA. He has published widely in the field of forensic clinical psychology and headed a research unit at Rampton Hospital investigating interventions for people with personality disorder and high risk. He has



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particular interests in cognitive behavioral treatments for offenders, anger and violence, therapeutic climates and readiness for treatment. Lawrence Jones Lead Psychologist and Consultant Clinical and Forensic Psychologist at the Peaks Unit, Rampton Hospital, Nottinghamshire Healthcare NHS Trust. He is a former chair of the division of forensic psychology in the British Psychological Society. He has worked in community, prison and secure hospital settings with offenders. Has published and is interested in planned environment based interventions, personality disordered offenders, sex offenders, forensic case formulation, motivational interventions and using offence paralleling behavior to inform intervention and risk management. William R. Lindsay Consultant Psychologist and Clinical Lead (Scotland) in Castlebeck, Darlington and Professor of Learning Disabilities and Forensic Psychology at the University of Abertay, Dundee. He is also Honorary Professor at Bangor University, Wales. He is a practicing clinician who has over 200 academic publications. Current clinical and research interests include sex offenders, pathways through learning disability forensic services, programmes for criminal behaviour, the assessment of personality and personality disorder, risk assessment and cognitive behaviour therapy. Caroline Logan Consultant Forensic Clinical Psychologist in Greater Manchester West Mental Health NHS Foundation Trust and an Honorary Research Fellow in the Department of Community Based Medicine at the University of Manchester. She has worked in forensic settings for many years, working directly with clients who are at risk to themselves and others and, in a consultancy role, with the multidisciplinary teams and local and national organizations that look after and manage them. Dr Logan has research interests in the areas of personality disorder, psychopathy, and risk, and a special interest in gender issues in offending. Kenneth G. Lombart Clinical Psychologist and Visiting Assistant Professor in the Department of Psychology at the University of Massachusetts Lowell. His primary research interest is in expertise in psychotherapy case formulation. Gregory H. Mumma Associate Professor of Psychology in the Clinical Ph.D. Program at Texas Tech University. His interests include behavioral and idiographic assessment, intra-individual construct validation, cognitive-behavioral case formulation, and clinical decision making for formulation-based, tailored treatment of complex and comorbid cases. His research focuses on person-specific quantitative methods to validate and test cognitive-behavioral case formulations using daily ratings and ecological momentary assessment. His research, as well as his part-time clinical practice, focuses on adults with comorbid mood and anxiety disorders. Phil Rich Former Clinical Director and the current Director of Clinical Program Development of the Stetson School, a 111-bed long-term residential treatment program for sexually reactive children and juvenile sexual offenders in Massachusetts. Phil holds a doctorate in applied behavioral and organizational studies and a master’s degree in social work, and is a licensed independent clinical social worker. He



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presents and trains nationally and internationally, and is the author of Understanding Juvenile Sexual Offenders: Assessment, Treatment, and Rehabilitation; Attachment and Sexual Offending: Understanding and Applying Attachment Theory to the Treatment of Juvenile Sexual Offenders; Juvenile Sexual Offenders: A Comprehensive Guide to Risk Evaluation; and the Stages of Accomplishment Workbooks for Sexually Abusive Youth. Stacey L. Shipley Dr Shipley has specialized in psychological services at the crossroads of psychology and the law. Her training has focused on both adults and adolescents. She is a licensed psychologist in three states and is the Director of Psychology at North Texas State Hospital, the only maximum-security forensic hospital in Texas. She specializes in forensic evaluation, treating maternal filicide offenders, and evaluation or treatment for individuals adjudicated by the courts as Not Guilty by Reason of Insanity or Incompetent to Stand Trial for violent offenses. She has published articles on psychopathy, wrote chapters on maternal filicide and serial rape and murder typologies, and co-authored Introduction to Forensic Psychology: Issues and Controversies in Crime and Justice (2nd edition) and the upcoming 3rd edition published by Academic Press. She was first author of The Female Homicide Offender: Serial Murder and the Case of Aileen Wuornos (2004) published by Prentice Hall. Ellen Vedel Cognitive behavior therapist and treatment manager at the Jellinek Addiction Treatment Centre in Amsterdam. As a senior researcher, she is currently involved in clinical trials testing integrated treatment protocols for substance abuse and Post traumatic Stress Disorder and for substance abuse and intimate partner violence. Together with Paul Emmelkamp she is the co-author of Evidence-based Treatments for Alcohol and Drug Abuse: A Practitioner’s Guide to Theory, Methods and Practice. Dr Jim Vess Senior Lecturer at Deakin University in Victoria, Australia and a member of the Clinical Forensic Research group of the Deakin Forensic Psychology Centre. He has over 25 years of clinical and research experience with forensic populations. After receiving his PhD in clinical psychology from Ohio State University in the United States, he then served in a variety of treatment, assessment, and supervisory roles at Atascadero State Hospital, the maximum security forensic psychiatric facility in California. He has been a Senior Lecturer at Victoria University of Wellington, New Zealand, where his research focus was primarily on risk assessment with violent and sexual offenders, as well as public policy dealing with high risk offenders. He has remained active in forensic practice, and has provided expert witness evidence in a variety of High Court and Court of Appeals cases involving high risk sexual offenders. Tony Ward Head of School and Professor of Clinical Psychology at Victoria University of Wellington, New Zealand. His research interests include cognition in offenders, rehabilitation and reintegration processes, and ethical issues in forensic psychology. He has over 285 academic publications and his most recent book is Desistance from Sex Offending: Alternatives to Throwing away the Keys (with Richard Laws; Guilford, 2011). He will be taking up a research chair in Clinical Forensic Mental health at Deakin University, Melbourne, Australia in June 2011.

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SERIES EDITORS’ PREFACE ABOUT THE SERIES At the time of writing it is clear that we live in a time, certainly in the UK and other parts of Europe, if perhaps less so in areas of the world, when there is renewed enthusiasm for constructive approaches to working with offenders to prevent crime. What do we mean by this statement and what basis do we have for making it? First, by “constructive approaches to working with offenders” we mean bringing the use of effective methods and techniques of behaviour change into work with offenders. Indeed, this view might pass as a definition of forensic clinical psychology. Thus, our focus is the application of theory and research in order to develop practice aimed at bringing about a change in the offender’s functioning. The word constructive is important and can be set against approaches to behaviour change that seek to operate by destructive means. Such destructive approaches are typically based on the principles of deterrence and punishment, seeking to suppress the offender’s actions through fear and intimidation. A constructive approach, on the other hand, seeks to bring about changes in an offender’s functioning that will produce, say, enhanced possibilities of employment, greater levels of self-control, better family functioning, or increased awareness of the pain of victims.A constructive approach faces the criticism of being a “soft” response to the damage caused by offenders, neither inflicting pain and punishment nor delivering retribution. This point raises a serious question for those involved in working with offenders. Should advocates of constructive approaches oppose retribution as a goal of the criminal justice system as a process that is incompatible with treatment and rehabilitation? Alternatively, should constructive work with offenders take place within a system given to retribution? We believe that this issue merits serious debate.However, to return to our starting point, history shows that criminal justice systems are littered with many attempts at constructive work with offenders, not all of which have been successful. In raising the spectre of success, the second part of our opening sentence now merits attention: that is, “constructive approaches to working with offenders to prevent crime”. In order to achieve the goal of preventing crime, interventions must focus on the right targets for behaviour change. In addressing this crucial point, Andrews and Bonta (1994) have formulated the need principle:


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SERIES EDITORS’ PREFACE Many offenders, especially high-risk offenders, have a variety of needs. They need places to live and work and/or they need to stop taking drugs. Some have poor self-esteem, chronic headaches or cavities in their teeth. These are all “needs”. The need principle draws our attention to the distinction between criminogenic and noncriminogenic needs. Criminogenic needs are a subset of an offender’s risk level. They are dynamic attributes of an offender that, when changed, are associated with changes in the probability of recidivism. Noncriminogenic needs are also dynamic and changeable, but these changes are not necessarily associated with the probability of recidivism. (p. 176)

Thus, successful work with offenders can be judged in terms of bringing about change in noncriminogenic need or in terms of bringing about change in criminogenic need. While the former is important and, indeed, may be a necessary precursor to offence-focused work, it is changing criminogenic need that, we argue, should be the touchstone in working with offenders. While, as noted above, the history of work with offenders is not replete with success, the research base developed since the early 1990s, particularly the meta¨ analyses (e.g. Losel, 1995), now strongly supports the position that effective work with offenders to prevent further offending is possible. The parameters of such evidence-based practice have become well established and widely disseminated under the banner of “What Works” (McGuire, 1995, 2008). It is important to state that we are not advocating that there is only one approach to preventing crime. Clearly there are many approaches, with different theoretical underpinnings, that can be applied. Nonetheless, a tangible momentum has grown in the wake of the “What Works” movement as academics, practitioners, and policy makers seek to capitalise on the possibilities that this research raises for preventing crime. The task that now faces many service agencies lies in turning the research into effective practice. Our aim in developing this Series in Forensic Clinical Psychology is to produce texts that review research and draw on clinical expertise to advance effective work with offenders. We are both committed to the ideal of evidence-based practice and we will encourage contributors to the Series to follow this approach. Thus, the books published in the Series will not be practice manuals or cook books: They will offer readers authoritative and critical information through which forensic clinical practice can develop. We are both enthusiastic about the contribution to effective practice that this Series can make and look forward to continuing to develop it in the years to come.

ABOUT THIS BOOK Although the context may be different, when it comes to practitioner skills in working with offenders, the same rules of good practice apply as they would with any other group. One of the bedrocks of practice lies in assessment and case formulation: The process of gathering information and then making sense of it, formulating it, within a given theoretical framework. Of course, formulation is independent of theory, so that meaningful formulations of, say, a given behaviour


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SERIES EDITORS’ PREFACE

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can be made from different theoretical perspectives. The point of a case formulation is to guide practice based on the available case material, theoretical strictures, and extant empirical knowledge. In this book an impressive list of authors cover every angle concerning case formulation. The chapters range from discussion of the finer points of the theory and practice of case formulation, to applying these principles to specific offender and groups and to specific types of offences. There is a great deal to be taken at many levels from this book and we are pleased to see it as part of the growing body of work addition the Series represents. Clive Hollin Mary McMurran

REFERENCES Andrews, D.A. and Bonta, J. (1994) The Psychology of Criminal Conduct. Anderson, Cincinnati, OH. ¨ Losel, F. (1995) Increasing consensus in the evaluation of offender rehabilitation? Psychology, Crime, and Law, 2, 19–39. McGuire, J. (ed.) (1995) What Works: Reducing Reoffending. John Wiley & Sons, Chichester. McGuire, J. (2008) A review of effective interventions for reducing aggression and violence. Philosophical Transactions of the Royal Society, B, 363, 2577–97.


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PREFACE Clinical case formulation is understood by forensic clinical psychologists and forensic psychiatrists to be key in designing appropriate and so potentially effective treatments for offenders. In forensic work, what is effective in treatment is usually taken to mean that an individual’s risk of reoffending is reduced. While treatments to ameliorate other problems are part of the work of forensic mental health professionals, they cannot ignore the expectation that their treatments should aim to reduce risk. This places an unusual burden upon this group of people in that they are to some degree responsible for their clients’ behavior and for any harm to others that this may cause. If case formulation is indeed the key to effective interventions, then it is imperative that it should be done well. Research into some of the basic issues in case formulation is lacking in the forensic literature and this lack urgently needs to be addressed. Fortunately there is some evidence about reliability, validity, and utility from clinical work in general, and we present this information here for forensic practitioners to draw upon. Additionally, there are forensic practitioners who have given a great deal of thought to the principles upon which forensic case formulation should rest. These ideas are also presented in this book. We are indebted to the authors who have made such excellent contributions to this volume. We hope that by drawing together this body of work we might create an impetus for further research in this important area. Peter Sturmey Mary McMurran December 2010

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PART I

GENERAL ISSUES

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Chapter 1

THEORETICAL AND EVIDENCE-BASED APPROACHES TO CASE FORMULATION TRACY D. EELLS University of Louisville, USA

KENNETH G. LOMBART University of Massachusetts Lowell, USA

Our task in this chapter is to introduce the concept of case formulation. We begin by discussing the definition, functions and goals of case formulation, including why formulation is important. We continue by reviewing theoretical and evidentiary sources of information to guide the development of a formulation. Next, we summarize several structured case formulation models that have been developed to increase reliability and validity. Finally, we propose a general framework the therapist can use to structure a formulation and conclude with some practical tips.

WHAT IS A CASE FORMULATION? Our working definition of case formulation comes from a cross-theoretical perspective: “A psychotherapy case formulation is a hypothesis about the causes, precipitants, and maintaining influences of a person’s psychological, interpersonal and behavioral problems” (Eells, 2007, p. 4). A formulation involves inferences about predisposing vulnerabilities, a pathogenic learning history, biological or genetic factors, sociocultural influences, currently operating contingencies of reinforcement, conditioned stimulus–response relationships, or schemas, working models, and beliefs about the self, others, the future or the world. The aim of the formulation is to explain the individual’s problems and symptoms. The specifics of the formulation will vary depending on the theoretical orientation of the case formulator. As a hypothesis, a formulation is always subject to empirical test and to revision as new information becomes available. Forensic Case Formulation, First Edition. Edited by Peter Sturmey and Mary McMurran. C 2011 John Wiley & Sons, Ltd. Published 2011 by John Wiley & Sons, Ltd.


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A case formulation serves multiple functions (Eells, 2007). First, it provides a structure to organize information about a person and his or her problems. Clients produce enormous amounts of information in therapy, including verbal, behavioral, prosodic, gestural, affective, and interactional. Formulation facilitates the management of this information cascade. Second, formulation provides a blueprint guiding treatment. Its primary purpose is to help the therapist develop and implement a treatment plan that will lead to a successful outcome. The formulation therefore enables the therapist to anticipate future events, for example, therapy-interfering events, and to prepare for them. Third, a formulation serves as a gauge for measuring change. Indices to assess change may come from goals included in the formulation, from relief of problems identified in the formulation, or from the revision of an inferred explanatory mechanism that did not seem adequate when tested. Fourth, a formulation helps the therapist understand the patient and thereby exhibit greater empathy for the patient’s intrapsychic, interpersonal, cultural, and behavioral world. Kuyken, Padesky and Dudley (2009) offer another definition of case formulation, emphasizing its collaborative and resilience-building aspects. They define formulation as a “process whereby therapist and client work collaboratively first to describe and then to explain the issues a client presents in therapy. Its primary function is to guide therapy in order to relieve client distress and build client resilience” (p. 3). Using the metaphor of a crucible and focusing on cognitivebehavioral therapy (CBT), these authors emphasize that formulation integrates and synthesizes a client’s problems with CBT theory and research. Essential ingredients of a productive conceptualization are empirical collaboration between therapist and client, the development of the formulation over time from the descriptive level to an explanatory level, and the elicitation of both client strengths and problems. These authors also describe functions of a CBT case formulation. These include (1) synthesizing client experiences, relevant CBT theory and research; (2) normalizing and validating clients’ presenting issues; (3) promoting client engagement; (4) making complex and numerous problems more manageable for the client and therapist; (5) guiding the selection, focus, and sequence of interventions; (6) identifying strengths and suggesting ways to build resilience; (7) suggesting cost-efficient interventions; (8) anticipating and addressing problems in therapy; (9) helping the therapist understand nonresponse to therapy; and (10) facilitating high-quality supervision. Persons (2008) embeds her approach to formulation within a framework of clinical hypothesis testing. She emphasizes that the formulation is fundamentally a hypothesis that is constantly refined in the course of treatment. She views a complete formulation as one that ties the following elements together into a coherent whole: (1) the patient’s symptoms, disorders, and problems, (2) hypotheses about the mechanisms causing the disorders and problems, (3) precipitants of those disorders and problems, and (4) a statement of the origins of the mechanisms. Following similar lines, Tarrier and Calam (2002) define formulation as “the elicitation of appropriate information and the application and integration of a body of theoretical psychological knowledge to a specific clinical problem in order to understand the origins, development and maintenance of that problem. Its purpose is both to provide an accurate overview and explanation of the patient’s problems that is open to verification through hypothesis testing, and to arrive collaboratively with the


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THEORETICAL AND EVIDENCE-BASED APPROACHES TO CASE FORMULATION

5

patient at a useful understanding of their problem that is meaningful to them” (pp. 311–12). The case formulation is then used to inform treatment or intervention by identifying key targets for change.

WHY FORMULATE? Multiple mental health care disciplines view case formulation as an essential clinical skill. A core competency for psychiatrists trained in the United States is the ability “to develop and document an integrative case formulation that includes neurobiological, phenomenological, psychological and sociocultural issues involved in diagnosis and management” (American Board of Psychiatry and Neurology, 2009, p. 1). Similarly, the American Psychological Association promotes evidence-based practice, which includes the application of “empirically supported principles of psychological assessment, case formulation, therapeutic relationship, and intervention” (APA Presidential Task Force on Evidence-Based Practice, 2006, p. 284). The British Psychological Society views formulation as a core skill (Division of Clinical Psychology, 2001, p. 2). Multiple authors support the importance of case formulation as a “lynchpin concept” (Bergner, 1998), the “first principle” underlying therapy (J. S. Beck, 1995) and the “heart of evidence-based practice” (Bieling and Kuyken, 2003). Formulation is a core skill for several reasons. First, and most importantly, formulation is where theory and empirical knowledge about psychotherapy, psychopathology, personality, development, culture, and neurobiology merge to inform the understanding and treatment of an individual, group, couple, or family. Formulation provides a structure to apply nomothetic knowledge to an idiographic context. Second, current nosologies are almost exclusively descriptive and symptomfocused. Thus, they provide no account of why a client has symptoms, what the origins of those symptoms are, and what triggers and maintains them. Major depressive disorder, one of the most commonly diagnosed disorders, is a case in point. According to the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (American Psychiatric Association, 1994, DSM-IV) to be diagnosed with this condition, one must meet five of nine criteria for two weeks, including depressed mood or loss of interest or pleasure. In addition, one must exhibit distress or impairment in one’s social or occupational functioning and meet other rule out criteria. The criteria say nothing about biochemical, psychological, behavioral, situational, or environmental factors that may be producing the depression. Formulation fills this explanatory gap between diagnosis and treatment. A third reason that formulation is essential is that diagnosis alone does not provide a sufficient guide to treatment selection. The same diagnosis might be treated with different types of empirically defensible treatments and interventions, creating the dilemma of which one to choose. Further, few psychotherapy outcome studies include diagnosis by treatment interactions and thus do not address the sensitivity and specificity of treatment for a specific diagnosis (Sturmey, 2008). A single treatment that is found effective for one diagnosis may also be effective for other diagnoses. Fourth, a case formulation approach tailors treatment to address individual circumstances. Empirically supported treatments (EST) do not provide guidance in


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a number of situations (Persons, 2008). These include when the client has multiple disorders and problems, when multiple providers are treating the individual, when a situation arises that is not addressed by an EST, when no EST is available, when the client does not adhere to an EST, when establishing a collaborative therapeutic relationship proves problematic, and in cases of treatment failure. With regard to the latter point, as many as 40–60% of individuals do not respond to a first-line empirically supported treatment (Westen, Novotny and Thompson-Brenner, 2004).

THE GOALS OF FORMULATION If a formulation is to serve the above functions, it should meet at least five goals. First, a formulation should be accurate and fit the individual for whom it is constructed. The benefits of an accurate formulation have been demonstrated in a number of studies (Crits-Christoph, Cooper and Luborsky, 1988; Crits-Christoph et al., 2010; Silberschatz, 2005b). One way to assess accuracy of an individual formulation is to evaluate the patient’s response to a formulation-consistent intervention and to compare those responses to how the patient responds to formulation-inconsistent interventions. If the patient responds as the formulation predicts, one has evidence of its accuracy. Another way to assess accuracy is to share the formulation with the patient and get the patient’s opinion. Opinions vary as to whether and to what degree a formulation should be shared with a patient. CBT therapists tend to prefer sharing the formulation and see this as an important component of developing a collaborative relationship with the patient (Kuyken et al., 2009) More psychodynamically oriented therapists have expressed caution in sharing the formulation. Luborsky and Barrett (2007) advise sharing it in its component parts rather than as a whole. Curtis and Silberschatz (2007) advise deciding whether to share or not on the basis of what the formulation predicts the patient’s response will be. Ryle’s (1990), cognitive-dynamic model, on the other hand, includes sharing the formulation, composed as a letter from the therapist to the patient, as part of treatment. A second goal of formulation is that it have treatment utility (Hayes, Nelson and Jarrett, 1987). The formulation should contribute to the treatment beyond what would have been achieved in the absence of a formulation. One measure of utility is the contribution of the formulation to treatment outcome. There is little research in this area, and research that has been done has produced equivocal results (Bieling and Kuyken, 2003; Kuyken, 2006). Another index of treatment utility is the extent to which the formulation benefits the process or efficiency of the delivery of the therapy. Further, a formulation may have benefits for the therapist that filter indirectly to the patient and therapeutic process, for example by increasing the therapist’s confidence or improving his/her communication with the client. For example, Chadwick, Williams and Mackenzie (2003) found that while formulation-guided therapy did not predict alliance ratings among a group of psychotic patients, it was associated with improved therapist ratings of the therapeutic relationship. A third goal of formulation is that it should be parsimonious yet sufficiently comprehensive. Some problems and clients require relatively simple and circumscribed formulations whereas others need multifaceted and complex formulations,


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especially when the client behaves in contradictory ways, meets criteria for multiple disorders, or has major problems in multiple spheres of functioning. The formulation should provide a structure to optimally and efficiently represent enough information about the patient to benefit treatment, but not more. A fourth goal of formulation is to strike the right balance between description and explanation. Research has shown that it is difficult to achieve good reliability when formulations are based on psychological constructs that are too distant from the experience and behavior of the patient (Seitz, 1966). On the other hand, if a formulation is to be genuinely explanatory, it must do more than summarize biographical information about a client. Notwithstanding this distinction, it is noteworthy that description and explanation can blur as one proposes an underlying mechanism. As Kazdin (2008, p. 12), wrote, “Depending on the detail, level of analysis, and sequence of moving from one to the other, description can become explanation” (p. 12). A final goal of formulation is that it should be evidence-based. The APA Task Force on Evidence-Based Practice in Psychology stated that evidence-based formulations apply the best research, knowledge, experience, and expertise to the task: What constitutes appropriate evidence in a case formulation? Various types of evidence may best be viewed in relative terms along a continuum. At the most clearly evidence-based end, one could imagine compelling outcomes from empirically supported treatments, well-demonstrated mechanisms underlying forms of psychopathology, powerfully predictive epidemiological data, or well-documented and replicated findings about basic psychological processes, for example, the age at which reliable autobiographical memories can be formed. At the other end of the continuum one might place a therapist’s hunches or intuitions. These might offer valuable insights that could be tested, but in themselves probably would not be described as evidence-based by most observers. Between these two end-points might be included data such as psychological test findings, rating scale results, a patient’s narrative of a relationship episode, a dream account, a thought record, a patient’s account of automatic thinking or an assertion by the client or therapist that a thought is a core belief. No consensus currently exists on what constitutes appropriate evidence for a case formulation. Therefore, our advice is that therapists create a plausible continuum and use their best judgment in evaluating evidence they gather as they formulate cases. If the above five goals of case formulation are met, the therapist is well on the way toward developing a productive tool to facilitate treatment. In the following section, we discuss two major sources of hypotheses about clients: theory and evidence.

THEORY AS A GUIDE TO FORMULATION Earlier we stated that the most important reason to formulate a case is because it provides an opportunity to apply theory and evidence to a specific case. In this section, we provide an overview of some primary sources of theory, illustrating the application of these sources to case formulation. We begin with four major theories underlying broad models of psychotherapy: psychodynamic, cognitive, behavioral, and humanistic.


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Psychodynamic Theory Psychodynamic theory originates in the work of Freud and provides a rich source of inference for case formulation. Beginning with his early formulation that “hysterics suffer from reminiscences” (Breuer and Freud, 1955), Freud has contributed a multitude of ideas that have shaped our understanding of normal and abnormal psychology. Most prominently, these include the notion of psychic determinism and unconscious motivation. The former entails the assumption that all human thought has a specific cause, nothing is random or accidental. The latter is the idea that majority of mental activity is outside of awareness and is goal-directed or purposeful. Other ideas contributed by Freud are that of overdeterminism, the symbolic meaning of symptoms, symptom production as a compromise formation, ego defense mechanisms as stabilizers of the psyche, and the tripartite theory of the mind, that is, its division into id, ego, and superego. Messer and Wolitzky (2007) succinctly grouped contemporary psychodynamic theory, at least as practiced in North America, into three broad categories: the traditional Freudian drive/structural theory, object relations theory, and self-psychology. We will briefly describe each with a focus on what is formulated and why. The drive/structural theory proposes that human behavior is driven by intrapsychic conflict originating in sexual and aggressive drives that seek pleasure and avoid pain (the “pleasure principle”) but become thwarted when they confront obstacles such as fear, anxiety or guilt. The structural component of the drive model involves the tripartite division of the mind into the id, which is the repository of drives, the superego, which contains both our conscience and who we ideally would become (the “ego ideal”), and the ego, which mediates between the impulses of the id and the strictures of the superego. The ego utilizes defense mechanisms in an attempt to avoid anxiety and maintain psychic equilibrium. When these attempts fail, neurotic symptoms develop. These mental structures and specific defenses arise as the individual navigates through four psychosexual stages – oral, anal, phallic, and genital – each of which is associated with specific conflicts that if not resolved persist into adulthood. The key feature of a case formulation based on the Freudian drive/structural theory is an “emphasis on unconscious fantasy, the conflicts expressed in such fantasy, and the influence of such conflicts and fantasies on the patient’s behavior”, and further, the assumption that these conflicts originate in childhood (Messer and Wolitzky, 2007). Treatment focuses on helping patients appreciate the nature and pervasiveness of their unconsciously driven motives and the ways that they avoid awareness of them. The object relations perspective on psychodynamics focuses on mental representations of self and other and models of affect-laden transactions between the two. The approach tends to dichotomize self and other into “good” and “bad” components that are often viewed as compartmentalized and not integrated. Defense mechanisms such as projective identification, splitting, and role reversal are used frequently by practitioners of this perspective. Relationships constitute basic drives rather than instinct. Case formulations based on this perspective focus on this inability to integrate, the disavowal of rage toward attachment figures that are also loved and needed. The individual may project an image of self as “good” while projecting the “bad” onto others.


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The self-psychology (Kohut, 1971, 1977) perspective emphasizes the development and maintenance of a cohesive and coherent sense of self. Kohut viewed the self as the center of intention and experience, as the core of our being (GalatzerLevy, 2003, p. 479). Cohesion refers to a sense of the self as maintaining continuity across time and place. Temporal coherence is the experience of oneself as a person with sameness and history across time. Spatial coherence refers to the sense that various aspects of oneself are alive and share a common intention. Kohut’s primary tool for understanding others was through empathic connection and comprehension. He viewed empathy as the ability to understand another’s psychological experience, as a kind of vicarious introspection. Using this approach, he identified a number of disturbances in the development of self in his patients. For example, they seemed to experience “empty” depressions, in which life appeared colorless, alienating, pointless, and lacking in vitality. Others experienced traumatic states in which experiences could not be integrated into a coherent sense of self. Kohut also treated people subject to seemingly unexpected, situationally discrepant states of rage. Kohut explained these experiences in terms of caretakers’ failure to provide sufficient empathic responsivity to enable one to develop a cohesive sense of self. One of Kohut’s most distinctive concepts is that of the “selfobject”. He posited that the presence of others in one’s life is an essential prerequisite for mental wellbeing. A selfobject is an unconscious mental representation of a connection between self and other, as if the other is an extension of oneself. He identified two basic types of selfobject: idealized and mirroring. An idealized selfobject is revealed in the experience of feeling alive, vital and powerful through one’s connection to another whom one admires. As Messer and Wolitzky write, one with an idealized selfobject seems to be saying, “I admire you, therefore my sense of self and self-worth are enhanced by my vicarious participation in your strength and power.” A mirroring selfobject vitalizes the self through the sense of being affirmed by others to whom one feels connected. Messer and Wolitzky characterize the mirroring selfobject as, “You admire me, and therefore I feel affirmed as a person of worth.” Formulations from the self-psychology perspective emphasize explanations of disturbances in a cohesive sense of self due to failures of empathic responsiveness from caretakers. The nature of the patient’s transference to the therapist – as idealizing or mirroring – is an important component to understanding the patient. Practitioners of psychodynamic therapy can draw from any or all of these basic perspectives in drawing up a case formulation; however, according to Messer and Wolitzky (2007), who in turn draw from Rapaport and Gill (1959), a comprehensive contemporary psychodynamic case formulation should contain five components. First, it should address the patient’s major dynamic conflicts, for example, between wishes and the feared consequences of those wishes. Second, it should address those aspects of the patient’s personality involved in the conflicts, for example, the id, ego, supergo, or inferred selfobjects. Third, the formulation should address the antecedent and developmental events leading to the conflicts. For example, what were the crucial experiences in childhood that gave rise to the patient’s current concepts of self and others? Or, what were the episodes of failed empathic responsiveness on the part of caretakers that led to a disturbance in self cohesion? Fourth it should address the adaptive and maladaptive compromise formations that comprise the patient’s defensive and coping strategies. Which compromises


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are relatively successful accommodations to the conflicts and which ones do not and lead to symptoms? Finally, the formulation should state the degree of conscious awareness of the conflicts.

Cognitive Theories Theories underlying contemporary cognitive therapies can be traced to the “cognitive revolution”, which took place in the mid-twentieth century as a response to what was increasingly perceived as the inadequacies of behavioristic, stimulusresponse models of learning that discounted the role of mentation and human agency (Mahoney, 1991). Borrowing terminology and concepts from information theory, computer science, and general systems theory, the interests of cognitive scientists turned toward “understanding and influencing the fundamental processes by which individual humans attend to, learn, remember, forget, transfer, adapt, relearn and otherwise engage with the challenges of life in development” (Mahoney, 1991, p. 75). As Bruner (1990) put it retrospectively, “that revolution was intended to bring ‘mind’ back into the human sciences after a long cold winter of objectivism” (p. 1). It was further intended “to establish meaning as the central concept of psychology – not stimuli and responses, not overtly observable behavior, not biological drives and their transformation, but meaning” (p. 2). Influential writings at the time included works by Bruner (e.g., Bruner, Goodnow, and Austin, 1956), Chomsky (1959), Festinger (1957), Kelly (1955), Postman (1951), and Simon and Newell (1958). As the cognitive revolution filtered into the social sciences and psychiatry, multiple theories of cognitive therapy took shape. More than 15 years ago, Kuehlwein and Rosen (1993) identified ten different models of cognitive therapy alone. As Nezu, Nezu and Cos (2007) pointed out, there is no single cognitive therapy, but rather a collection of therapies that share a common history and perspective. They hold in common not only their heritage within the cognitive revolution, but also the assumption that our appraisals of events are much more crucial to our mental well-being than are the events themselves. In this section we will review some of these theories and discuss their implications for formulation. In doing so, we recognize that most of these models also blend elements of behavior theory, which will be discussed later in the chapter. With regard to cognitive theories, we will emphasize Beck’s model since it is the most influential and has been subject to the most empirical scrutiny. Beck’s (1963) cognitive theory originated from observations of persistent thought patterns in depressed patients he interviewed. These individuals expressed views of themselves as inferior in areas of their lives that mattered to them. They viewed the world as depriving and saw the future as bleak. These observations led Beck to develop his now well-known “cognitive triad”, which is a framework he proposed to describe the automatic and systematically biased thinking of depressed patients. It was later expanded to describe a wide range of problems and psychological conditions. Automatic thoughts are brief, episodic, and often emotionally laden forms of thinking that occur unbidden and are often at the threshold of awareness. For example, one might think, “Writing this chapter is too hard. I’ll


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never get it done,” which could be followed by a feeling of deflation or demoralization. Negative automatic thoughts are often erroneous, illogical, and unrealistic. Beck identified specific characteristic forms of thought distortion. Examples are arbitrary inferences, selective abstraction, overgeneralizations, catastrophizing, and personalization in which one erroneously explains events in terms of one’s own perceived shortcomings rather than considering other explanations (A.T. Beck, 1963; J.S. Beck, 1995). In addition to the cognitive triad and the notion of cognitive distortions, a third major characteristic of Beck’s cognitive theory is the idea of schemas. These refer to tacit, organized cognitive structures that influence perception and appraisal. The schemas give rise to beliefs about the self, world and future. At the most fundamental level are “core beliefs” (J.S. Beck, 1995), which are the most fundamental layer of beliefs and are assumed to develop in childhood and to be global, rigid and overgeneralized. In their negative form they tend to focus on beliefs of helplessness or unlovability. Between core beliefs and situationally specific automatic thoughts lie “intermediate beliefs”, which are rules, attitudes and assumptions that are more subject to revision and change than core beliefs but less so than automatic thoughts. The ideas reviewed above are relevant to cognitive case formulation in that formulation within a cognitive model entails identifying the client’s automatic thoughts, intermediate beliefs and core beliefs (J.S. Beck, 1995). Second, the assumption that characteristic patterns of thinking are specific to diagnostic categories suggests that implicit nomothetic explanatory mechanisms underlie diagnoses and can serve as templates for formulations (Persons, 2008). If the template fits the client, an empirically supported treatment may be suitable for the individual in question. Other cognitive theories of therapy have also developed since the cognitive revolution. These include those of Ellis (1994; 2000), Young (1990); Young et al. (2003), and Hayes and Strosahl (2004). A distinctive style of formulation can be identified from each of these approaches.

Behavioral Theories Behaviorism offers a rich theoretical source of ideas for case formulation. It represents a departure from the structuralism of the cognitive approach (Sturmey, 2008). The previous approaches all posit the existence of presumed cognitive structures that influence behavior, cognition and affect. Rather than viewing behavior as primary data, cognitive approaches see it as a derivative of unseen mental structures. One problem with structurally based explanations is that they may be based on circular reasoning. As Sturmey (2008) writes, “Cognitive psychologists use behavior to infer the presence of the unobservable structures . . . then use the unobservable structure to explain the observable behavior” (p. 9). Behaviorists have made three distinct contributions to the field of case formulation (Eells, 2007). First, consistent with their emphasis on observable behavior, they place primary emphasis on understanding and modifying symptoms. Using functional analysis, they examine the antecedents and consequences of symptoms


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in order to change them. They also look at what events elicit and reinforce symptomatic behavior. From this standpoint, behaviorism is an inherently practical approach to helping people. Second, behaviorists emphasize the influence of the environment on behavior. A behavior analysis always examines what characteristics of an individual’s immediate surroundings may be affecting behavior. The presence of alcohol in the home of a person with alcohol dependence, for example, is likely to increase the chance of continued abuse. Removing the alcohol can play a major role in helping the person. This environmental emphasis is also less stigmatizing since it rejects the assumption that the source of problems is something inherent within the individual. A third contribution of behaviorism to case formulation is its emphasis on empirical assessment to test a formulation. Evidence of the accuracy of a behavioral assessment is readily determinable since behavioral tests can be run. For example, Wilder (2009) hypothesized that delusional behavior exhibited by an young male with schizophrenia could function either as attention-seeking behavior, as an attempt to escape work, or as self-stimulating activity. In developing his formulation, he devised separate behavioral tasks to determine which of these hypotheses is supported. Behavioral approaches can be broadly categorized as based on operant or respondent learning. In the following two sections, we will describe each, showing their application to formulation.

Operant Conditioning Operant conditioning models focus on the antecedents and consequences of behavior. For example, habit reversal is a technique based on operant learning that is intended to reverse problematic behavior such as trichotillomania and tics by identifying the antecedent and consequent reinforcers of these behaviors then changing them to eliminate the behavior. Case formulation from the operant conditioning perspective involves conducting a functional analysis of behavior. Skinner (1953, p. 35) defined functional analysis as follows: The external variables of which behavior is a function provide for what may be called a causal or functional analysis. We undertake to predict and control the behavior of the individual organism. This is our “dependent variable” – the effect for which we are to find the cause. Our “independent variables” – the causes of behavior – are the external conditions of which behavior is a function. Relations between the two – the “cause-and-effect relationships” in behavior – are the laws of a science. (p. 35)

Since Skinner, the term has been expanded to describe a wide range of interventions. Functional analysis is at the core of most behavioral case formulation approaches and some cognitive-behavioral approaches (Haynes and Williams, 2003; Nezu, Nezu and Cos et al., 2007; Persons, 2008). Functional analysis should take into account several aspects of operant conditioning. These include establishing operations (such as satiation or deprivation states), adaptive and maladaptive


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shaping, adaptive and maladaptive extinction, modeling, chaining, avoidance and escape activity that may preempt positively reinforced activity, consequences of debilitating naturalistic schedules of reinforcement, punishers, and variability of behavioral repertoires (Ferster, 1973; Sturmey, 2008). As Sturmey (2008) notes, the operant conditioning framework provides a structure for case formulation since operant learning is involved in the acquisition and maintenance of many forms of maladaptive behavior. For example, a depressed individual may withdraw interpersonally, missing out on reinforcers that would counter depressive affect. In addition, others may avoid the depressed person, thus maintaining maladaptive avoidance and isolation. A case formulation based on operant conditioning should assess these possibilities and identify the contingences that may be maintaining the problematic behavior. It could also include hypotheses about why current contingencies do not support adaptive behavior and why contingencies that once supported independence are no longer present. Clinicians could also consider schedules of reinforcement operable in the client’s life. A variable ratio schedule should result in higher rates of responding than a fixed ratio schedule. Consequently, a clinician observing high rates of behavior might infer the presence of variable ratio schedules. Conversely, low rates of desired behavior may indicate reinforcement schedules for these behaviors that are weak or perhaps punishing. The clinician can evaluate not only the rate and frequency of reinforcement but also how immediately the consequences occur and whether they comprise primary or secondary reinforcement. The clinician can also assess whether behaviors are or are not under stimulus control. For example, a chronically anxious client may lack stimulus control of relaxation (Sturmey, 2008). Interventions can be planned accordingly, for example, teaching the client to take deep breaths, think pleasant thoughts, or engage in imagery while present in anxiety arousing environments. As a final example, behavioral chaining can be analyzed and treatment plans developed to help the client learn alternative behavior (Koerner, 2007).

Respondent Conditioning In contrast to operant behavior, which is controlled by its consequences, respondent behavior is elicited by its antecedents. The classic example is that of Pavlov’s dogs who were trained to salivate at the sound of a bell. This was accomplished by pairing the presentation of meat, which elicited salivation, with the presentation of the bell. When the pairings occurred enough times, the bell alone could elicit salivation. The meat is considered to be an unconditioned stimulus (US) and salivation an unconditioned response (UR). The bell came to serve as a conditioned stimulus (CS) that could elicit what is now considered a conditioned response (CR), that is, the salivation. Respondent behavior is said to be rooted in responses that are naturally occurring as a result of our evolutionary past. Examples of unconditioned responses are fear at the site of a genuine threat to life, hunger when food is present, startling in response to a loud sound, and recoiling from a bitter smell. These responses share the characteristic of being unlearned. They can all, however, be brought under the control of other stimuli through pairings, such as the bell with the meat in the case of Pavlov’s dogs. For example, repeated exposure to gunfire (UCS) in war settings setting off a startle response can create an exaggerated startle


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response in a veteran such that the sound of a car door closing (CS) elicits a startle response (CR), as well as fear associated with the war experience. Respondent conditioning has been associated with many psychological disorders, including post-traumatic stress disorder, phobias, and obsessive-compulsive disorder. There are several principles of classical conditioning that one can use to understand how psychological disorders develop, are maintained and may be treated (Persons, 2008; Sturmey, 2008). These, in turn, can be incorporated into a case formulation. One principle is that the greater number of pairings of a CS and a UCS, the more likely the CS is to elicit a CR. For example, the more often one experiences a spontaneous panic attack (a UCS that elicits a UCR of fear) while at a restaurant (CS), the more likely visiting a restaurant may elicit a panic attack (which is now a CR). Another principle is that when a CS occurs repeatedly in the absence of a UCS the CS exerts less and less control over the CR. This is the principle underlying the behavioral technique of flooding, which has been used to treat phobias and other anxiety disorders. Flooding involves repeated exposure to a CS (e.g., plastic spiders, heights, public speaking) until it is no longer able to elicit a CR (fear). A third principle is that counterconditioning, or elimination of a CR, occurs when one pairs a CS to a UCS that elicits a new response that is incompatible with the old one. This is the principle that underlies Wolpe’s systematic desensitization technique for treating phobias and anxiety. Wolpe held that one cannot simultaneously experience relaxation and fear. In systematic desensitization, one first teaches the patient relaxation exercises. Then, when the patient is relaxed, he or she is exposed to increasing levels of anxiety arousing experiences until those experiences no longer elicit anxiety. Case formulation from the standpoint of respondent conditioning has several components. First, the therapist must identify events that serve as the UCS, CS, US and CR. Second, the therapist should be alert to how these can be affected by other factors. Third, the clinician should consider the relationship between stimulus and response pairings. For example Bouton (2002) summarized evidence that extinction of a CS–CR pairing does not eliminate a link to the UCS, but rather establishes alternate, benign associations to the CS. If true, extinction is rarely permanent, an important consideration in treatment planning. Fourth, the therapist should inquire closely into the patient’s actual experience when symptomatic behavior occurs. Presumed exposure to a CR, for example, may not be what it appears to be. To illustrate, Behar and Borkovec (2006) propose that generalized anxiety disorder (GAD) persists despite the patient’s repeated exposure to anxiety arousing events due to compensatory mechanisms aimed at psychologically avoiding the CR. For example, GAD patients tend to worry or ruminate rather than immerse themselves experientially in the threatening situation. Were they to do so repeatedly, the consequent exposure would theoretically lead to extinction.

Humanistic Theory Humanistic theory emerged in the 1950s as an alternative to the determinism of the psychodynamic and behavioral approaches current at the time. In contrast to the


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view that humans are the inevitable product of their reinforcement history and environment or of their unconscious minds, the humanistic framework sees humans as self-actualizing and goal-directed. The task of therapy is to provide a nondirective, empathic and supportive environment in which the client can recapture his self-actualization tendency. From this standpoint, formulation or “psychological diagnosis” was de-emphasized and viewed as potentially detrimental to the therapeutic process (Rogers, 1951). As Rogers (1951) wrote,

the very process of psychological diagnosis places the locus of evaluation so definitely in the expert that it may increase any dependent tendencies in the client, and cause him to feel that the responsibility for understanding and improving his situation lies in the hands of another. (p. 223)

In addition, to the extent that the client comes to see the therapist as the only person who can really understand him, there is “a degree of loss of personhood” (p. 224). A second objection to formulation from the humanistic point of view is based on social and philosophical grounds: “When the locus of evaluation is seen as residing in the expert, it would appear that the long-range social implications are in the direction of the social control of the many by the few” (p. 224). Notwithstanding these objections, a distinct theory of personality emerged from the humanistic standpoint that can be formulated. Rogers posited that human nature is driven by one master motive: the self-actualizing tendency, which is an inherent drive to survive, grow and improve. Further, we all live in a subjective world through which we assess what is consistent or inconsistent with selfactualization. The self emerges from experience, and develops positively when met with unconditional positive regard from others. When it is not, incongruence develops as an individual no longer grows in a manner consistent with the self-actualizing tendency. The self as experienced is incongruent with the real or genuine self. The task of therapy, therefore, is to facilitate greater congruence. When collaboratively developed, formulation can potentially facilitate such a process. Other theories identified within the humanistic tradition have been developed by Maslow (1987), Kelly (1955), Perls, Hefferline and Goodman (1965) and more recently, by Greenberg (2002) and Bohart and Tallman (1999), among others. It is noteworthy that contemporary proponents of the humanistic school are more accepting of formulation as a useful tool in therapy, although the emphasis tends to be on formulating moment-by-moment experiences rather than developing a global case formulation (Greenberg and Goldman, 2007). As noted elsewhere (Eells, 2007), the primary contributions of humanistic psychology to formulation include its emphasis on the client as a person instead of a disorder, the focus on the here-and-now aspect of the human encounter rather than an intellectualized “formulation”, and its view of the client and therapist as equal collaborators. An additional contribution of the humanistic approach is its emphasis on humans as capable of self-determination and free choice.


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Eclectic Approaches Before leaving this section on theoretical contributions to case formulation, we note that a number of case formulation approaches and theories about the development of psychological disorders blend two or more of the approaches we have described. One example based on animal research is Mowrer’s (1960) theory of the development and maintenance of fear. He posits that respondent conditioning establishes fear and operant conditioning maintains it through negative reinforcement of avoidance responses. This theory is the basis of modern exposure-based treatments of phobias and other anxiety disorders. Wachtel (1977) gives other examples of how common disorders can be viewed compatibly within both the behavioral and psychodynamic perspectives. The combination of cognitive and behavioral approaches is also characteristic of several structured case formulation approaches.

EVIDENCE AS A GUIDE FOR FORMULATION As noted above, the APA Task Force on Evidence-Based Practice recommends that systematic case formulations be based on empirically supported principles. In this section we describe five sources of evidence that can guide case formulation. One draws from the patient, one from the psychometric tradition, and three from the base of empirical knowledge within psychology.

The Patient as a Guide When discussing definitions of case formulation we emphasized their hypothetical nature. That is, a formulation should be considered a hypothesis to be revised as indicated and warranted. It must be tested against the patient’s response to interventions based on it. Evidence from the patient can include (1) direct feedback when the formulation is presented by the therapist, (2) narratives the patient tells that either confirm or disconfirm the hypothesis, (3) dreams or fantasies the patient reveals in therapy, (4) changes in the patient’s symptoms based on interventions consistent with the formulation, and (5) autobiographical information the patient discloses. Although the patient is a crucial source of information to refine and revise the formulation, the therapist should attempt to understand the material in the context of the scientific evidence base in psychology.

Psychometric Applications Psychometric data can provide useful information for case formulation. Studies have shown that structured interviews, personality inventories, and brief selfrated and clinician-rated measures provide incremental validity regarding diagnosis, assessment of psychopathology and personality, and prediction of behavior, although the contribution to case formulation validity itself is unexplored


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(Garb, 2003). The use of symptom rating scales is recommended by a number of case formulation experts (Kuyken, Padesky and Dudley, 2009; Persons, 2008). These provide a time efficient, reliable and valid way of assessing the range of problems, current level of general distress, red flag issues (e.g., dangerousness), and social and adaptive functioning (A.T. Beck et al., 1988; A.T. Beck et al., 1961; Derogatis, 1983; Halstead, Leach and Rust, 2008; Lambert and Finch, 1999). Further, comprehensive personality tests such as the Minnesota Multiphasic Personality Inventory or the Personality Assessment Inventory can provide useful information for case formulation that allows the therapist to compare the patient’s responses against a standardization sample. Interview-based measures can also be helpful, for example the Structured Clinical Interview for DSM Disorders (SCID) (First et al., 1995; Spitzer et al., 1992).

Psychotherapy Process and Outcome Research Psychotherapy models investigated in efficacy studies contain implicit mechanisms of change and, thus, implicit case formulations. Since these implicit formulations are linked to outcome data, they can be useful starting points for individual formulations. Persons (2008) recommends that these implicit case formulations within empirically supported treatments serve as default nomothetic formulations that are then tailored for individual patients. One should be cautioned, however, that little is known about these presumed mechanisms. Kazdin (2007) has observed that although cognitive-behavior therapy is effective for depression, evidence suggests that symptom change occurs before a change in cognition, which runs counter to the model’s assumption that a change in cognition will lead to a change in symptoms. Improving our understanding of the processes involved in helping individuals with specific problems and diagnoses will be important for case formulation. As Kazdin (2008, p. 152) wrote, Evidence-based mechanisms of change could prove to be even more interesting or important than EBTs [evidence-based treatments]. We might be able to use multiple interventions to activate similar mechanisms once we know the mechanisms of change and learn how to optimize their use.

Psychopathology Research Research on psychopathological processes is also relevant for case formulation. The more we understand the predictors of psychopathology and the mechanisms that underlie, precipitate and maintain these conditions, the better we can plan treatment for them. One example is the role of rumination in depression (NolenHoeksema, Wisco and Lyubomirsky, 2008). Rumination as a thinking process is characterized by a perseverative, passive, and nonproductive fixation on symptoms of distress and the possible causes and consequences of the distress, but without any active attempt at problem solving. Nolen-Hokesema and colleagues have demonstrated that rumination exacerbates depression, enhances negative


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thinking, impairs problem solving, erodes social support and interrupts instrumental behavior. Rumination predicts the onset of depression, may contribute to its course, and may also contribute to disorders such as anxiety, post-traumatic stress disorder, binge-eating, binge-drinking, self-harm, and maladaptive grief reactions. These researchers have also investigated methods to combat rumination, such as distraction and increasing awareness of its nonproductive and negative function. This research can inform case formulation and treatment planning. It helps the therapist recognize the seductive but deceptive nature of rumination as a phenomenon that gives the appearance of solving problems when in reality it is a problem in itself. Other examples include research on anxiety (Mineka and Zinbarg, 2006), on adverse effect of repressive coping on subjective well-being (DeNeve and Cooper, 1998), and on the function of psychotic symptoms (Freeman, Bentall and Garety, 2008).

Epidemiology Epidemiology is the study of “how disease is distributed in populations and of the factors that influence or determine its distribution” (Gordis, 1990, p. 3). It includes study of the causes of disease, including mental disorders, and associated risk factors, the extent of disease in a population, and the natural history and prognosis of disease. Unlike psychotherapy, which primarily focuses on the individual, epidemiology focuses on entire populations. Epidemiology can be helpful in case formulation in a number of ways. First, epidemiological information can sensitize the clinician to how psychological conditions are predicted by factors such as low socioeconomic status, general disease status, and neighborhood safety. This knowledge can help the clinician gain insights into the individual’s condition, assess prognosis, and plan interventions. Second, epidemiological information helps the clinician understand what is normative in a community. Deviations from this norm inform case formulation. Third, epidemiology can help the therapist form prognoses. Knowledge of the natural course of disorders such as depression (Kessler and Wang, 2009; Wells et al., 1992) or alcoholism (Vaillant, 1995), for example, helps a therapist predict risk and shape treatment. Fourth, epidemiological information can help the clinician predict comorbidity. Knowing that alcohol abuse commonly co-occurs with social anxiety (Randall et al., 2008), for example, should lead the therapist to thoroughly assess substance abuse in the socially anxious individual. Fifth, base rate information can help predict sources of problems. A patient with borderline personality disorder may claim to be a victim of ritualistic abuse, but even our imperfect knowledge of the prevalence of such activity can help the therapist put such claims into a probabilistic context (Frankfurter, 2006). In addition, knowledge of differences among psychological disorders related to age of onset, gender, ethnicity, and region facilitates the development of explanatory mechanisms. Tarrier and Calam (2002) noted that causal inferences in case formulation are more credible when based on epidemiological data relevant to base rates associated with the development of a disorder rather than the patient’s retrospective recall of life events. The latter form of inference risks tautology and is subject to error in retrospective recall. Sixth,


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epidemiological data can help the clinician assess risk factors a patient faces. For example, knowledge of the relative risk factors for suicide attempts and suicide gestures can inform a case formulation and treatment plan (Nock and Kessler, 2006). Seventh, epidemiology data can help with treatment planning and motivation. Explaining risk of heart disease and diets, for example, can be part of treatment for obesity. Epidemiologically derived knowledge of the benefits of exercise, combined with a clinicians’ skill in developing behavioral plans, can combine to treat obesity. The seven sources of evidence just reviewed provide a broad knowledge base that can be paired with theoretical models. Together, they form the basis for a comprehensive formulation. Additionally, several structured case formulation models have been developed. These case formulation models can be used in developing formulations for individual clients. In the following section, we describe several of these structured case formulation models.

STRUCTURED SYSTEMATIC CASE FORMULATION MODELS Several decades ago, psychotherapy researchers and clinicians began developing systematic, structured methods of psychotherapy case formulation. They emerged as part of the need to develop systematic manuals to study psychotherapy research outcomes, as well as to facilitate clinical work. As more of these methods were developed, a major concern was that they be both reliable and valid. Reliability refers to the extent to which independent clinicians can develop similar formulations based on the same case material. Validity refers to the extent that the resulting formulations predicted events in therapy. Initial efforts to measure reliability were not encouraging (Seitz, 1966) as it appeared that therapists tended to focus on different aspects of case material, to make inferences that went too far beyond the available supporting data, and presented the formulation in formats that were difficult to compare. The newer structured case formulation methods produced much more reliable formulations owing to a number of features they shared. First, they structured the formulation by identifying preset categories of information necessary for the formulation. These include categories such as a problem list, core beliefs, schemas of self and other, relationship schemas, defense or coping styles, strengths/assets, and precipitants. Second, they involved relatively low-level inferences, often by linking inferences directly to case material such as therapy transcripts. There was no effort to infer “deep” psychological structures; rather, all inferences could be traced to biographical information or other statements or narratives provided by the client. Third, the process for case formulation was well-defined and structured. Finally, the therapists producing the formulations underwent training in the method. In the following section, we review some of these structured case formulation methods.

Core Conflictual Relationship Theme Based on the psychodynamic concept of therapeutic transference (Freud, 1958a, 1958b; Luborsky et al., 1991), the Core Conflictual Relationship Theme (CCRT) was


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developed by Luborsky (1977), and is the earliest and most researched relationshipbased structured formulation model. The CCRT assumes that early interpersonal experiences predict later interpersonal relationship patterns. When early interpersonal experiences are traumatic, they serve as maladaptive interpersonal templates that harm the individual in later life. The CCRT is identified primarily by focusing on the person’s relationship narratives in therapy. From these narratives, the clinician identifies the client’s most common interpersonal wishes, the expected responses of others to those wishes, and, in turn, the responses of the self to the expected responses from others. The most frequent of these wishes and responses comprise the CCRT. A relatively simple and basic case formulation method, the CCRT is reliable and has convergent validity with similar, interpersonally focused methods (Luborsky and Barrett, 2007). It has been linked to therapy outcome and to symptom onset in therapy sessions; further, CCRTs tend to remain consistent longitudinally, across different relationships and throughout a course of therapy. They have also been associated with specific diagnoses and defense styles (Luborsky and Barrett, 2007).

Role Relationship Models Configuration The Role Relationship Model’s Configuration (RRMC) method expands upon the CCRT by, among other changes, positing a set of CCRTs formed into a configuration of wishes, fears, and compromises to those wishes and fears, and by adding inferences about the individual’s concepts of self and others (Horowitz, 2005, 1991b). The theoretical basis of the RRMC is person schemas theory (Horowitz, 1991a), which seeks to integrate elements of psychodynamic and cognitive theory. Person schemas theory assumes that an individual’s maladaptive interpersonal behavior patterns, including emotions, perceptions, memory, and actions in interpersonal situations, are organized by mental representations of the self, others, and the self with others. Like the CCRT, the RRMC has demonstrated good reliability and convergent validity.

Control Mastery Theory and the Plan Formulation Method of Case Formulation With roots in both psychodynamic and cognitive theory, Weiss’ control mastery theory (1993; Weiss and Sampson, 1986) begins with the assumption that humans have evolved to need stable attachments to others, a reliable conception of reality, and safety (Silberschatz, 2005a). From this starting point, Weiss asserts that psychopathology stems from “pathogenic beliefs” originating in traumatic childhood experiences. These beliefs are unconscious, powerful, emotion-laden, threatening, and emotionally distressing. They organize perception in close relationships throughout a person’s life and function to preserve stable relationships, but can also damage one’s personal development. Burdened by these pathogenic beliefs, individuals develop an adaptive and usually unconscious “plan” to disconfirm


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their own pathogenic belief. The plan organizes behavior, including the choice to enter therapy. The goal of therapy is to facilitate the patient’s plan; therefore, it unfolds as a series of tests the patient engages in to determine whether the pathogenic beliefs can be safely abandoned. The Plan Formulation Method (Curtis and Silberschatz, 2005) is the case formulation model developed for therapy based on control mastery theory. Since planning treatment is highly individualistic, the development of an idiographic case formulation is essential. The formulation has the following components and steps: (1) identify traumas the patient has experienced; (2) infer the resulting pathogenic beliefs; (3) identify the “potential behaviors, affects, attitudes or capacities” (Curtis and Silberschatz, 2005, p. 89) the patient would like to adopt, in other words, the patient’s goals; (4) predict the “tests” the patient will employ in therapy to disconfirm pathogenic beliefs; and (5) identify the insights or knowledge to be acquired during therapy that will help the patient achieve his or her goal. The Plan Formulation Method has been demonstrated to have excellent reliability and predicts both process and outcome events in therapy (Silberschatz, 2005b).

Beck’s Cognitive Case Formulation Method Beck (1995) developed a basic formulation approach for cognitive therapy. The formulation links automatic thoughts to deeper-level beliefs and the experiences that led to their development. The therapist first identifies automatic thoughts and their associated emotions and behavior and then links these thoughts to compensatory strategies, intermediate beliefs such as assumptions and rules, and core beliefs. The core beliefs are traced to experiences that contributed to their development and maintenance. When the formulation is complete, the therapist has mapped out past experiences that led to core beliefs, the resulting intermediate beliefs, and the compensatory strategies that developed in response to automatic thoughts that are associated with specific situations, emotions, meanings, and behavior.

Persons’ Cognitive-Behavioral Formulation Persons and colleagues developed a cognitive case formulation approach emphasizing hypothesis testing (Persons, 1989, 2008; Persons and Tompkins, 2007). After assessment information is gathered, the therapist generates a comprehensive list of the client’s problems from which a multi-axial DSM diagnosis is assigned and an anchoring diagnosis is selected. The anchoring diagnosis is used to develop a nomothetic formulation which serves as a template of the psychological mechanisms hypothesized to be at work. The nomothetic formulation is derived from formulations that are implicit in empirically supported treatments or derives from cognitive and emotional theory. The nomothetic template is then individualized to account for client-specific details, including items on the problem list. The clinician hypothesizes mechanisms about how those problems are maintained, infers the origin of the mechanisms, and the precipitants that trigger the mechanisms


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causing the problems. This information is then used to develop a comprehensive treatment plan.

Collaborative Cognitive Case Conceptualization Kuyken, Padesky and Dudley (2009) developed a distinct approach to cognitive case conceptualization, emphasizing collaborative empiricism and building on the client’s strengths. Collaborative empiricism involves “integrating the client’s experience with appropriate theory and research in an unfolding process of generating and testing hypotheses” (p. 27). Emphasizing client’s strengths incorporates resilience into a treatment plan, thus enhancing chances of a lasting recovery. These authors describe three levels of conceptualization: Descriptive, cross-sectional, and explanatory. The descriptive level involves eliciting and characterizing the client’s presenting issues in cognitive and behavioral terms and in the context of relevant cognitive-behavioral theory (CBT) and research. The goal is to connect the client’s experiences with the descriptive language of CBT theory. The cross-sectional level of conceptualization focuses on understanding the triggers and maintenance factors of a client’s problems. The primary task is to use cognitive and behavioral mechanisms to explain the situations in which the triggers arise and the factors operating to maintain the problems. The explanatory level of conceptualization seeks to understand predisposing and protective factors. Developmental history is used to understand and contextualize the current problems.

Haynes’ Functional Analytic Clinical Case Models Haynes’ Functional Analytic Clinical Case Models (FACCMs) approach is an elaborated functional analysis of behavior problems (Haynes, Leisen and Blaine, 1997; Haynes and Williams, 2003). The method produces an individualized behavioral treatment plan based on the clinician’s judgments about specific problems that have been identified. It considers the impact of situational factors, events that trigger and maintain problems, and the behavioral skills with which a client enters treatment. More specifically, the FACCM approach involves the clinician’s analysis of the relative importance, interrelationships and effects of behavior problems and goals. It includes inferences about causal mechanisms and their clinical utility, and an assessment of how causal mechanisms operate and are related to problem behaviors. The clinician also assesses moderating variables and estimates their impact. A diagram is then produced that depicts the problems, the inferred causes, mediating variables, and the interrelationships among them. The diagram includes numerical estimates of the impact of the problems, estimates of how modifiable the causal variables are, and estimates of the likelihood that interventions under consideration will have an impact. The FACCM guides the therapist in determining which problems and causal variables to target in treatment and which interventions may have the greatest effect.


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A Problem-Solving Perspective for CBT Case Formulation Nezu’s problem-solving model of case formulation (Nezu and Nezu, 1993; Nezu and Nezu, 1989; Nezu et al., 2007; Nezu, Nezu and Lombardo, 2004) is also based on functional analysis and is similar in other respects to Hayne’s FACCM approach. It is distinctive in its major emphasis on goal analysis and goal setting. In goal setting the clinician first identifies ultimate outcome goals (Nezu et al., 2007). These are the primary goals the therapy aims to achieve and reflect the reason for the therapy in the first place. Ultimate outcome goals may include relieving depression, improving a marital relationship or eliminating a phobia. They may be contrasted with instrumental outcomes, which are goals that serve as instruments for the attainment of the ultimate outcomes. For example, increasing self esteem may help relief depression. Instrumental outcomes may also serve as instruments for the attainment of other instrumental outcomes that eventually lead to an ultimate outcome. For example, improving coping skills can lead to increased self efficacy that, in turn, leads to reduced depression. The problem-solving approach to case formulation involves a systematic analysis that leads to the identification of ultimate outcomes, the instrumental outcomes that help the client achieve the ultimate outcome, and the relationships among them.

Emotion-Focused Therapy Case Formulation Emotion-focused therapy (EFT), developed by Leslie Greenberg (2002), has roots in the humanistic experiential tradition, and also in modern emotion theory and affective neuroscience (Greenberg and Goldman, 2007). Unlike the other case formulation methods described, it focuses on the moment-to-moment experiences unfolding in therapy and the attendant emotion, with a goal of strengthening the self. It does not involve developing a global case formulation of a client. “In EFT, formulations are never performed a priori (i.e., based on early assessment) as we do not attempt to establish what is dysfunctional or presume to know what will be most salient or important for the client” (Greenberg and Goldman, 2007, p. 380). The major means of formulation is “process diagnosis”, whereby the focus is on how people are currently experiencing their problem and whether they are doing so in an adaptive manner aimed at resolution, or not. Formulations are developed and redeveloped continually in a collaborative fashion with clients. The case formulation aspect of the therapy involves “identifying the client’s core pain and using that as a guide to the development of a focus on underlying determinants generating the presenting concerns” (Greenberg and Goldman, 2007, p. 384). Presenting problems are viewed as reflections of “underlying emotion-schematic processing difficulties” (p. 384). Put another way, the approach attends primarily to diagnosing clients’ manner of cognitive-affective processing rather than diagnosing clients per se. The therapist aims to identify markers of current emotional concerns and tasks to help resolve these concerns. Markers are client statements or behaviors that signify problems in need of attention as possible determinants of the presenting problem. These markers guide intervention, rather than an explicit case


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formulation. Emotion-focused therapy, based on this approach to formulation, has been demonstrated to be efficacious for those with major depression (Goldman, Greenberg and Angus, 2006; Greenberg and Watson, 1998).

A GENERAL FRAMEWORK FOR FORMULATION Thus far we have defined formulation and made a case for its importance. We reviewed a range of theories and a variety of empirical sources that inform formulation. We then reviewed several structured case formulation models that can also be used as a basis for developing a case formulation. With all this theory, these sources of empirical evidence, and these formulation models available, how should one choose among them? The clinician committed to a single theoretical orientation could answer this question straightforwardly simply by disregarding the approaches that do not fit his or her orientation. We do not recommend this approach since we believe that each theory, source of information and formulation model has something to offer. For this reason, we recommend initial consideration of several models, recognizing that there is overlap among a number of them. Several of the structured models and theories, for example, share the concept of a cognitive schema that predicts behavioral tendencies. In addition, different theories tend to focus on different aspects of functioning. Behavioral models focus on symptom production and maintenance whereas psychodynamic models tend to emphasize personality organization, internal conflict, and the quality of interpersonal relationships. Cognitive models emphasize relatively accessible thought processes and how they shape behavior. These features need not be incompatible. In order to facilitate the choice among theories, models, and empirical sources, we recommend beginning with a general case formulation framework. Several are available in the literature (Eells, Kendjelic and Lucas, 1998; Meier, 2003; Mellsop and Banzato, 2006; Porzelius, 2002; Sperry et al., 1992). In addition, some methods designed for specific theoretical approaches are adaptable to a general model (e.g., Persons, 2008). All these methods view case formulation as lying between data gathering and formally providing treatment. Further, psychological problems are viewed within a diathesis-stress framework in which a mechanism is proposed that reflects a vulnerability on the part of the individual toward the development of problems and precipitants are proposed that trigger symptoms or episodes of distress. We propose the general model depicted in Figure 1.1, which due to space limitations we can only describe in a cursory fashion. As shown, the case formulation process is embedded in a general therapy model. Formulation itself occurs after information gathering and prior to providing treatment, although in actual practice one moves more fluidly among these stages. The model begins with gathering information because case formulation requires inputs. Information gathering can include a standard intake interview in which the clinician learns the presenting complaint, the history of the complaint, past history of mental health problems, medical history, the current living situation, developmental and social history, and related information (Morrison, 1993). In addition to gathering these biographical


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Monitor, Test and Assess

Gather Information

Create Problem List

Formulate

Diagnose

Treat

Develop Explanatory Hypothesis

Terminate

Plan Treatment

Sources: Theory Evidence Components: Precipitants Origins Resources Obstacles

Figure 1.1 General case formulation mode.

details the clinician will likely want to know the client’s appraisals of the events described (Eells and Lombart, 2004). Other sources of information may be psychological testing results, symptom measures, medical records, and records from previous episodes of psychological treatment as well as information from family members. All this information serves as input to help develop the formulation. The general case formulation model itself has four major components. First is the identification of a set of problems to work on. These may or may not be the initial problems the client presents. Eliciting and collaboratively agreeing on the problems to focus on is a critical task since it is the problems themselves that are formulated. These goals should be specific, measurable, achievable, realistic, and timely. The second step is diagnosis. Despite controversies regarding the value of psychological diagnosis, we conclude that it is essential for a least three practical reasons. First, many treatment protocols are designed for individuals meeting specific diagnostic criteria. Knowledge of diagnosis, therefore, helps the clinician select treatment and, since treatment models contain implicit formulations and are linked to diagnoses, diagnosis can provide an initial lead on developing an explanatory hypothesis. Second, diagnosis facilitates communication among mental health professionals. If the client is obtaining concurrent services from others, such


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as psychopharmacological treatment from a psychiatrist, providing that individual with diagnostic information can facilitate communication and consequently treatment. Third, diagnosis is often a practical necessity in order to bill and collect for one’s services. The third step in the general formulation model, developing the explanatory hypothesis, is the most crucial. It is the step in which the theoretical and evidentiary sources described earlier in this chapter come to bear on a specific individual Multiple explanatory hypotheses can often be proposed for a specific set of problems. There may not be a single correct explanation. Rather, the power of the explanatory hypothesis is evidenced primarily in its practical application. Nevertheless, we suggest that a high-quality explanatory hypothesis be adequately comprehensive in explaining the items on the problem list, be sufficiently elaborated and complex in linking together multiple facets of the individual’s functioning, be coherent in the sense of being internally consistent, be precise in the use of language, and be the product of systematic approach to formulation. Although the explanatory hypothesis could have multiple and varying components depending on the specific model one is following, we suggest that four are of primary importance. First, consider precipitants. These are events, stressors, experiences, or appraisals that trigger the onset of symptoms or the hypothesized mechanism that leads to symptoms. Second, provide an account of the origins of the proposed mechanism. This can include a hypothesized learning history that led to the individual’s vulnerability to the problems. Alternatively it can include traumas or empathic failures that hurt the person, genetic or other biological vulnerabilities, or contributing cultural factors. Third, consider the individual’s personal resources or strengths. These can be used to marshal hope, motivation, and leverage to recover. Examples of resources include unimpaired areas of functioning, premorbid functioning, intelligence, inferred level of psychosocial development, social support, capacity for pleasure, and sense of humor or irony. The final component we suggest for all formulations is a listing of obstacles that may impair a successful treatment outcome. These can be quite varied. Examples may include primitive or image distorting defense mechanisms, dichotomous thinking patterns, low capacity for the tolerance of ambiguity, poor social skills, financial problems, poor housing or living in a crime-ridden neighborhood, or lack of social support. The final step in the general case formulation model is that of treatment planning. It is also a critical step since it provides the link from the explanatory hypothesis to treatment implementation. Without a well thought out treatment plan, formulation is little more than an intellectual exercise. Regardless of its specific details, the treatment plan should flow directly and logically from the prior formulations steps and it should be sufficiently well elaborated and sequenced. One approach, as discussed earlier, is to begin with ultimate aims or goals for the treatment, then list process or instrumental goals that, if accomplished, should lead to the desired ultimate outcome. Once the formulation is developed, it should be testing in treatment and revised as necessary. Note the feedback loops in Figure 1.1. These depict the process of regular monitoring of outcome, or testing and revising the formulation, and of constantly assessing progress or the lack thereof. The final step, as shown, is termination.


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PRACTICAL TIPS FOR CASE FORMULATION We conclude this chapter with some practical tips to consider in formulation. First, write down the case formulation be written down and reference it prior to each session, at least the early sessions. In our experience, writing down the formulation facilitates a well thought out and comprehensive product. Often sketching a diagram rather than preparing a narrative helps to depict relationships among components of the formulation. Referencing the formulation prior to the session brings it back in memory and facilitates therapist consistency from session to session. Second, formulate a case using more than one theoretical approach or structured model. Viewing a client from multiple angles facilitates a flexible therapeutic approach and helps the therapist see the strengths and weakness of each formulation. Third, devise specific tests of your formulation. The best test of a formulation is how well it contributes to treatment outcome. Consider interventions that test the validity of a formulation and predict what response should be expected if the formulation is valid or if it is not. Fourth, be aware of biases in reasoning. Researchers have documented multiple judgment errors that individuals are prone toward (Ruscio, 2007). Clinicians are not immune to these errors and should be aware of them. Fifth, keep in mind that case formulation is a tool to help guide your treatment planning. It needs to work for you not the other way around. That is to say, one need not rigidly adhere to a formulation regardless of what transpires in therapy. Rather, consider the formulation as a map guiding empathic and effective interventions. It is a map that will change as the terrain of therapy changes. Finally, we recommend sharing the formulation with the client and getting feedback. Ideally, the formulation should be developed, tested, and revised collaboratively.

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Chapter 2

CURRENT ISSUES IN CASE FORMULATION GREGORY H. MUMMA Texas Tech University, USA

CHAPTER GOALS The first three sections of this chapter describe psychometric issues relevant to the scientific status of clinical case formulation (CF). These sections focus on content validity, reliability, and additional validity issues in CF. There is a particularly strong emphasis on validity issues due to their relative neglect in the CF literature. The next section briefly covers certain treatment validity or utility issues that supplement the main treatment validity focus of Chapter 3 by Ata Ghaderi. These issues include the effects of sharing the CF with the patient on the therapeutic relationship and treatment outcome. A brief final section of this chapter focuses on aspects of clinical training and expert-novice differences in CF. Due to the breadth of coverage combined with length limitations, this chapter does not attempt to comprehensively review the literature in these areas, but instead will highlight some of the major theoretical, methodological, and clinical-practice issues in each of these areas and, when helpful, discuss either representative or particularly noteworthy theoretical, methodological, or empirical contributions. A few terminology issues: I will use the terms “construct” or “variable” to describe behaviors or constellations of behaviors grouped together because of theoretical or clinical relevance (e.g., depressive symptoms). A “target” or “outcome” variable, construct, or behavior refers to symptoms, dysfunction, or behaviors that are characteristic of a disorder or problem, and which may be targeted for intervention. “Causal variable” refers to both triggering and maintaining variables, as well as other variables that may influence the topography of the target behavior (Haynes, 1992; Haynes and O’Brien, 2000). Such variables may be considered “functional causal” variables if they have a functional relationship to a target variable. Briefly, this involves statistical and temporal relationships (e.g., the parent’s attention follows the child’s aggression which it functions to positively reinforce). See Haynes and O’Brien (2000) for a more detailed discussion of these issues. Forensic Case Formulation, First Edition. Edited by Peter Sturmey and Mary McMurran. C 2011 John Wiley & Sons, Ltd. Published 2011 by John Wiley & Sons, Ltd.


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This chapter focuses on CFs from a number of different theoretical perspectives including behavioral, cognitive, and psychodynamic. Empirical research within each of these theoretical frameworks has made important contributions that may have important scientific implications for CF within other frameworks and for developing areas such as forensic case formulation.

SCIENTIFIC BASES I: CF COMPONENTS AND CONTENT VALIDITY Construct Explication and Content Validity in CF The components of a CF are relevant to the issue of content validity as well as construct explication. These issues are important because reliability and other types of validity issues are tied to this. Generally, construct explication is a largely theorydriven delineation of the facets and elements of a construct as well as its relationship to other constructs (Nunnally and Bernstein, 1994; Shadish, Cook and Campbell, 2002). For CF, construct explication involves a theoretically driven delineation of both the content and structure of the CF within that framework. This may include the components that should comprise the CF, including both outcome variables, such as depression, or functioning in school or work, and causal variables, such a environmental or cognitive triggers. Additional CF components are the relationships between the causal and outcome variables, including functional, correlational, or temporal relationships. Construct explication provides general guidelines on a theoretical level – it provides a structure for the development of a CF. This is often done as a manual. For example, Persons (1989, 2008) described the components that should be included in a cognitive-behavioral CF: Problem list, developmental origins, precipitants or triggers, and mechanisms causally linking these. These “guidelines” may be general, as in the components of a cognitive-behavioral CF generally, or may be specific to certain disorders or types of problems, such as a CF template for generalized anxiety disorder or post-traumatic stress disorder (Nezu, Nezu and Lombardo, 2004; Needleman, 1999; Wells, 2006). Of course, on either level, different investigators within the same theoretical framework may explicate different structures, components, or relationships between them for a CF. For example, for cognitive-behavioral case formulation we can contrast the approaches of J.S. Beck (1995) versus Persons. Likewise, for behavioral CF we can contrast the Clinical Pathogenesis Map of Nezu and colleagues versus the Functional Analytic Clinical Case Model of Haynes and O’Brien (1990, 2000).

Content Validity Content validity of a CF refers to the extent to which the relevant target and causal variables, their components (facets and elements), and their relationships are represented or included in the CF for a particular person (cf. Haynes and O’Brien, 2000). Thus, the content validity of a CF will vary between clinicians and cases. That is,


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even when using the same approach on the same case, the content validity of one CF may be quite strong whereas another may be weak, as when two clinicians independently develop a CF of the same person. Content validity includes two main components – relevance and coverage (or representativeness), which together determine the fit of the hypothesized CF to the data for a particular person. Content validity involves the empirical evaluation of these two components. The content validity of a CF is constrained by construct explication of the CF variables and their facets as well as description of the procedures in the CF manual. However, content validity is empirically evaluated for specific cases, just as the content validity of an educational test is evaluated by comparing it to the content or subject matter it purports to measure. Analogous to behavioral observation, in which a manual may carefully define and exemplify the coding criteria for various target behaviors (e.g., “aggression” involves physical contact with apparent intent to injure or cause pain or distress), content validity in CF refers to whether the CF accurately captures the frequency and severity of the most relevant target behaviors for that particular individual. This would include the particular facets of aggression relevant for that person in contexts that adequately represent those important in his or her life. In forensic CF, relevant target behaviors may be defined legally, or by the patient or client, such as parent or teacher for a child’s aggressive behavior. The content validity of a CF may also include other potentially relevant target behaviors, such as the child’s anger and depression, as well as constructs/behaviors that may function as triggering or maintaining variables. Some of these components may be suggested in a CF template for that problem or disorder, based on aggregate-level psychopathology research. However, the content validity of a CF covers the problems or issues and causal variables of greatest relevance for that particular person. For example, the likelihood of partner aggression for a particular person may be related to highly specific and idiosyncratic external situational triggers (e.g., the partner says something in an angry tone) combined with recent stressors (e.g., the person was “chewed out” by his/her boss) and internal states (angry and depressed, has been drinking, interprets the partner’s communication as insulting). It is important to note that results of aggregate-level research may find that some of these variables are only weakly related to the target. For example, having been “chewed out” by the boss may be relevant in only 5% of cases, but may be strongly related for that particular person. Thus, content validity of a CF needs to be evaluated, at least in part, on a case-by-case level. The main issues are the relevance of the variable/construct for that person and the representativeness or coverage of the problems/issues and relevant causal variables (Haynes and O’Brien, 2000; O’Brien, Oemig and Northern, 2010). But what are the specific criteria for relevance and coverage? Given the absence of a gold standard, issues involving convergence of ratings between, say, the patient and the clinician may play a central role (Kuyken, 2006).

Content Validity in Psychodynamic CF This often involves evaluating recurring maladaptive relationship patterns such as the Core Conflictual Relationship Theme (CCRT: Luborsky and Crits-Christoph,


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1998) or Configurational Analysis (Horowitz and Eells, 2007). The CCRT attempts to capture recurring relationship patterns consisting of a wish, response of other, and response of self as reported by the patient for particular interactions with others. Configurational analysis involves developing a set of four role relationship models involving dreaded, desired, adaptive, and problematic compromises. Role relationship models are diagrams that organize relationship schema and core interactional patterns between the patient and others (Horowitz and Eells, 2007). Content validity issues include whether the CCRT or Configurational Analysis captures patterns or issues occurring in the most important relationships in a person’s life, such as a spouse or partner, in domains where dysfunction is particularly problematic for that person, such as relationships with a supervisor or possibly coworkers, or a relationship with an adolescent child, and in the therapeutic relationship – the transference (Fried, Crits-Christoph and Luborsky, 1998). To evaluate content validity, clinical judges rate the relevance of items from the target patient’s formulation and compare these to ratings of items developed for other cases, which is referred to as the “method of mismatched cases” (Curtis et al., 1994; Levine and Luborsky, 1981). A potential content validity issue in psychodynamic formulations such as the CCRT or Configurational Analysis is the extent to which the CF includes problems or issue relevant to the patient’s specific problems/dysfunction or general life functioning. Whereas depression, worry, anger, or aggression would likely be specifically and clearly targeted as a problem in a cognitive-behavioral or behavioral CF, this is not necessarily the case with certain types of psychodynamic formulations that focus primarily on core maladaptive relationship patterns.

Content Validity in Cognitive-Behavioral and Behavioral CFs For cognitive-behavioral and behavioral CFs, content validity is important for the causal variables as well as the target behaviors (Haynes and O’Brien, 2000). Omission of potentially important causal variables means that important functional or causal relationships may be missed in the CF. A common approach to increase the content validity of the causal variables is to start the CF with a template formed through aggregate-level research for the relevant diagnosis: the “nomothetic formulation of the anchoring diagnosis” (Persons and Tompkins, 2007, p. 301) or for that type of behavioral problem (Haynes, Kaholokula and Nelson, 1999; Haynes and O’Brien, 2000). Unfortunately, evaluations of the content validity of cognitivebehavioral CFs are relatively scant and have generally occurred when evaluating reliability, discriminant validity, the effects of training, or expert-novice differences (see below). One approach used in cognitive-behavioral CF and cognitiveinterpersonal approaches, similar to the method of mismatched cases (Levine and Luborsky, 1981), involves rating the relevance of cognitive items, such as thoughts and beliefs, taken from clinical material for that person versus items taken from other cases (Mumma, 2004; Mumma and Mooney, 2007a; Muran, Samstag and Segal, 1998; Muran et al., 2001; Muran and Segal, 1992).


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Summary and Comments Content validity, which includes coverage and relevance, is a matter of degree and needs to be evaluated on a case-by-case basis. The CF’s focus on the individual permits potentially high content validity because the assessment can be tailored to the unique situation and idiosyncratic life circumstances of a particular person. The incorporation of idiographic assessment can result in a fine-grained, highly relevant CF that covers the problems/issues and causal variables of greatest importance to that individual. To evaluate content validity, the method of mismatched cases – comparing formulation components for the target patient to other cases – has been used across a variety of theoretical frameworks. It is the methodology of choice at this time for research and clinical training or practice.

SCIENTIFIC BASES II: RELIABILITY A second major scientific challenge for CF is the extent to which the CF or its components can be reliably identified for a specific case or cases. The type of reliability that has been considered most important and been evaluated most frequently is interrater, or more aptly, interformulator reliability. However, several additional forms of reliability are potentially relevant and will be discussed briefly.

Interrater Reliability A CF is developed or generated by the clinician, so the term “interformulator” reliability is probably more apt than “interrater” because there is far more involved in CF than making ratings. Interrater reliability is critically important in behavioral observation and coding and in behavioral ratings (e.g., clinician ratings). Generally, two or more raters/clinicians view the same material, which is often videotaped. For behavioral observation, observers are frequently trained to criterion prior to making observations. Reliability may be increased, and observer drift decreased, by increased operationalization of criteria and using examples, but having too many codes can decrease reliability. Interrater reliability for behavioral observation is readily calculated using percentage agreement between the coders, or a chance-corrected agreement statistic such as Kappa. Interrater reliability for numeric ratings is often calculated using the intraclass correlation coefficient, which can be used to estimate the reliability of a single, “average” judge or any number of judges.

Interformulator Reliability This is somewhat more complicated because it involves CF components, such as target behaviors, relevant causal variables and their interrelationships, that are generated by each clinician. These components must then be somehow coded or rated to study interformulator reliability.


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Cognitive-Behavioral CFs Two studies have been completed by Persons and one by Kuyken and colleagues which address this topic. Persons, Mooney and Padesky (1995) studied 46 clinicians who had just completed the morning portion of a workshop on cognitivebehavioral CF using Persons’ (1989) approach. Clinicians were able to reasonably well identify most problems and issues on two cases (67% and 100% agreement). However, the reliability of identification of underlying mechanisms even when presented in a multiple-choice questionnaire was substantially lower (mean intraclass correlation coefficient = .46, range = .07 to .70). In a replication study, Persons and Bertagnolli (1999) found similar results with reliability of identification of overt problems “excellent” (>90%) for four problems, and “moderate” (>67%) for three more problems for two cases (p. 26). However, reliability of ratings of strength of belief in underlying schemas presented on a list was more problematic for an average clinician (mean intraclass correlation = .37, range = .13 to .66). Specifying the context for the ratings (e.g., “at work” or “with boyfriend”) did not improve reliability. Two points are worth noting. First, the reliability of problem identification was calculated only for those problems defined by the expert clinicians and would probably be lower if a list of all problems generated by the trainee clinicians had been rated. Second, interrater reliability for ratings of core beliefs or schema were made from a predetermined list of beliefs in the self, other, and world domains rather than beliefs generated by the trainee clinicians, a procedure that may over-estimate reliability in routine clinical practice (Aston, 2009). Kuyken and colleagues (2005) increased structure in the cognitive-behavioral CF procedure by having clinicians use the Case Conceptualization Diagram developed by J. Beck (1995). Adequate reliability (>60% agreement) was found for just two of the seven items of childhood data (e.g., “father critical”) identified by J. Beck in her benchmark formulation, on two of three core beliefs (e.g., “I’m incompetent”), and on one of four compensatory strategies (e.g., “avoidance”, “self-harm”). This study assessed interformulator reliability because the clinicians’ responses about childhood data, core beliefs, etc. were open-ended and coded from what was written on the Case Conceptualization Diagram. This response format likely provides a more challenging and realistic test of reliability than providing clinicians with a list of beliefs or mechanisms, as was done in the two Persons’ studies.

Comments and Issues for Cognitive-Behavioral CFs There is reasonably strong evidence that, after a rather brief period of training, clinicians can learn to identify most of the overt problems for a case with reasonable interrater reliability. These problems serve as a starting point for a CF. However, results of brief training sessions relevant to the variables that are triggering and maintaining the target behaviors are less encouraging. There are two points worth considering here. First, in contrast to more behavioral or functional analytic approaches to CF, Persons’ cognitive-behavioral CF approach includes few methods for testing the formulation once developed. This limits the feedback available to the clinician. Second, the amount of training provided in these workshops is minimal compared to the extent of practicum training received by students in doctoral


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scientist-practitioner training programs. Cognitive-behavioral CF is a complex skill that probably can not be learned very well in half a day or a weekend!

Psychodynamic CFs Interformulator reliability evaluation for two types of psychodynamic CFs, the Plan Formulation Method and the CCRT, are summarized next. In the Plan Formulation Method, based on material from clinical interviews, the clinician formulates the goals, obstructions, tests, and insights expected from the patient during therapy (Curtis et al., 1994). Interformulator reliabilities for each of these components ranged from .47 to .72 for a single or “average” experienced clinician (psychologists with >5 years of CF experience) but were somewhat lower (.41 to .50) for graduate students. For the CCRT, a series of reliability studies using data from relationship episodes described during therapy, have found agreement (weighted kappa) on the wish, negative response of other, and negative response of self components between. 61 to .81 (Crits-Christoph, Cooper and Luborsky, 1988; Luborsky and Diguer, 1998; Barber et al., 1995; Lefebvre et al., 1996; Popp et al., 1996). Kappas in this range indicate good to excellent (>.75) chance-corrected reliability (Fleiss, 1981). Most interrater reliability studies for the CCRT use the standard category clusters, as opposed to the standard categories, a methodology that may increase the reliability due to aggregation. Studies investigating the reliability of the CCRT components generated idiographically require an additional set of raters who compare the tailored CCRT component responses across formulators. This methodology seems to be used relatively infrequently. An example is a preliminary study of a single patient using idiographic CCRT components (Levine and Luborsky, 1981) that found poor reliabilities for two of the three CCRT components.1

Comments and Issues The relatively large number of studies of interrater reliability in psychodynamic CFs is laudable, yet a number of limitations to the CCRT reliability studies should be noted. First, in these research studies relationship episode transcripts were selected from psychotherapy transcripts prior to development of the CF. This probably increases reliability compared to a clinical context in which clinicians may differ in the material selected for formulating the CCRT. Indeed, Zander and colleagues (1995a, b) found significantly higher coder agreement for preselected relationship episodes versus not. Second, calculating the interrater agreement for each of the three components of the CCRT (wish, response of other, response of self) is procedurally necessary, but probably overestimates the reliability of the entire CF which is a conjunction of the reliabilities of each part. Finally, as mentioned above, 1 For example, averaging across two agreement judges, student judges agreed that theme elements were

from the same case 12 times versus from a different case 9.5 times for the Wish component of the CCRT, but were 9.5 (same) versus 20.5 (other) for the Response of Other and 12 (same) versus 16 (other) for the Response of Self.


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for some psychodynamic approaches, including the CCRT, a clear identification of the problems or symptoms is not necessarily made in the CF.

Internal Consistency Reliability This basic type of reliability is typically evaluated for multi-item measures. Scores on items intended to measure the same construct should be intercorrelated because they all purport to measure the same construct. A reasonably high, average interitem correlation combined with a sufficient number of items will yield a satisfactory coefficient alpha – a widely used measure of the internal consistency reliability of the entire scale. Multiple items or operationalizations are necessary to evaluate this type of reliability, which is closely related to convergent validation on the item level (Burns and Haynes, 2006). Interestingly, this type of reliability is rarely investigated in CF, apparently because many investigators appear satisfied with single-item operationalization of the target constructs or behaviors in the CF. However, there are several exceptions. For example, Curtis et al. (1988; 1994) provided the relevance ratings of items from each of the four components of the Plan Formulation (goals, obstructions, insights, tests) but they did not compute the internal consistency reliability for items developed for the target patient. For the CCRT, internal consistency is inherent to formulating central relationship themes. That is, to infer a core conflictual relationship theme, it must be present over a relatively large number of relationship episodes for that patient. In fact, pervasiveness, the percent of relationship episodes evidencing the particular wish, response-of-other, or response-of-self component of the CCRT (Crits-Christoph and Luborsky, 1998; Wilczek et al., 2004), is basically a measure of internal consistency reliability. Although cognitive-behavioral CFs may include multiple examples of thoughts and beliefs for a schema (e.g., Beck, 1995), they have rarely been evaluated for internal consistency or item-level convergent validity. However, methods to do so are available when data is collected repeatedly over time. For example, using verbatim statements from the patient, Mumma (2004) and Mumma and Mooney (2007a,b) developed multiple items tapping into each cognitive schema, stressful event, and distress construct in the CF for that person. The internal consistency of each construct was evaluated with a form of confirmatory factor analysis appropriate for daily ratings made by the patient on each item.

Test-Retest Reliability and Stability Test-retest reliability generally involves re-administration of a test after a relatively brief (e.g., two-week) interval and comparing the scores from the two administrations. A parallel form of the test may be used to reduce recall effects. An appropriate test-retest interval is related to the presumed temporal stability of the targeted construct (e.g., trait versus state anxiety or anger; Spielberger et al., 1999). For a CF, test-retest reliability would be evaluated by re-collecting the relevant clinical data following a relatively brief period and reformulating the case. To properly control for recall effects by the clinician, the reformulation should be done by a different


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clinician than the first. Thus, interformulator reliability places a ceiling on testretest reliability for CFs. Additionally, reactivity – whereby the patient reacts to, and may change from the collection of data for the first CF – is a potential issue, one probably difficult to control. Finally, the interval between evaluations is important – estimation of test-retest reliability assumes the underlying trait, construct, or process is stable from time 1 to time 2. The longer the interval the more likely the retest evaluates both reliability and stability. Evaluation of test-retest reliability of CFs is rarely done. Despite the paucity of CF test-retest evaluations, several studies have evaluated the stability of psychodynamic CFs, such as the CCRT (Barber et al., 1995; Luborsky et al., 1998). For example, Luborsky and colleagues (1998) evaluated the stability of each of the three components of the CCRT (wish, response other, response of self)when rated from relationship episodes prior to therapy versus sessions 3 and 5. Agreement ranged from .77 to 1.00.

SCIENTIFIC BASES III: VALIDITY OF CF AND ITS COMPONENTS General Issues Pertaining to Validity of CFs Few scientists would disagree that validation is an essential process for developing scientifically useful measures of a construct or variable. Furthermore, few clinicians would use a measure with a patient if there was no reasonable evidence for its validity. Yet, with several exceptions, validity is an issue that has received relatively little attention in the case formulation literature, even within theoretical frameworks, such as cognitive behavioral, that have typically presented a strong empirical basis for treatment efficacy (Bieling and Kuyken, 2003; Kuyken, 2006; Kuyken, Padesky and Dudley, 2009). There are several types or forms of validity and each has a meaning or application to CF that may differ somewhat from its conceptualization, evaluation, or use with traditional tests or measures. As a general principle for this discussion consider that “Technically speaking, it is not the measurement tool itself that is valid, but rather it is the inferences (or interpretations) that we make from that tool that require evidence of validity” (Michael and Li, 2010, p. 350). Although the meaning of this statement is relatively clear for interpreting a person’s score on a standardized measure, say, of intelligence or depression, in terms of criterion or construct validity (Furr and Bacharach, 2008; Nunnally and Bernstein, 1994; Shadish, Cook and Campbell, 2002), its meaning when applied to CF seems less clear. Next, after discussing several general issues relevant to validity in CF, issues specific to a number of types of validity issues in CF are described.

Incremental Validity The CF must yield explanations, predictions, or intervention implications that justify the cost of the additional complexity and effort over and above standardized assessment using nomothetic models of psychopathology, such as a disorder-level theory. The criteria for evaluating the validity of a CF for a particular case are


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analogous to the incremental validity criteria necessary for the development of a new standardized measure of a nomothetic construct (cf. Haynes and Lench, 2003).

Individual and Aggregate Levels Validity issues in CF are complicated by the fact that the formulations are focused on the individual – each CF is an idiographic theory of the person-situation. Validity is relevant on this individual level – how valid is the formulation of this particular individual? Specifically, how accurate are predictions of behavior for a particular individual? Does the CF adequately cover the various facets of the target problem and the relevant causal variables? Does the CF for this person improve treatment planning and outcome for him/her? Validity issues are also relevant on the aggregate level. Here, concerns focus on the validity of the approach and its theoretical framework. For example, does this CF approach improve prediction (e.g., of suicide attempts) or treatment outcomes over and above that of standardized protocols?

Idiographic Assessment The use of idiographic or individualized assessment has important implications for validity on both the aggregate and individual levels. Comparisons of formulationbased versus manualized or standardized treatment, for example, have almost exclusively measured nomothetic constructs – idiographic measurement has generally not been used. However, measurement of individually relevant and specific problems, relationships, including functional relationships, and intervention targets is an important aspect of CF on the individual level within both behavioral and cognitive frameworks. Indeed, evaluating the validity of a CF for a particular individual without including individually-relevant (idiographic) problems, goals, mechanisms, and outcomes is probably inadequate (Haynes and O’Brien, 2000; Nelson-Gray, 1996; Tarrier and Calam, 2002).

Approach- or Theory-Specific Aspects of Validity As mentioned, certain validity issues are relevant generally and apply to CFs regardless of the particular approach within which it was developed. Alternatively, the particular issues relevant to other kinds of validity may vary with the theoretical orientation within which the CF is developed. For example, the validity of stimulus generalization and functional response classes is relevant to behavioral approaches to CF (Sturmey, 2008); the validity of measures of negative self-referent cognitive schema is relevant in a cognitive-behavioral CF for depression (J. Beck, 1995; Persons, Davidson and Tompkins, 2001); and the validity of central maladaptive relationship patterns is relevant to the CCRT or Configurational Analysis (Horowitz, 1997; Luborsky and Crits-Christoph, 1998). This concern is further complicated by the increasing number of approaches to CF within a particular theoretical framework. For example, there are different additional validity issues relevant to different approaches to behavioral case formulation, such as the basic learning approaches of Wolpe, Turkat and Follette (Sturmey, 2008), the Clinical


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Pathogenesis Map (Nezu, Nezu and Lombardo, 2004) and the Functional Analytic Clinical Case Model (Haynes and O’Brien, 1990, 2000).

The Complexity of Validity in CF Validity issues in CF have received somewhat scant attention compared to reliability concerns. This may, in part, be due to the complexity of these concerns. Some different types of validity issues relevant to CF are summarized in Table 2.1. Notice that for each type of validity, relevant issues can be defined on the individual and aggregate level. Also, there are several distinguishable facets for a number of these types of validity. For example, as discussed above, content validity involves facets or components of coverage and relevance. Given space limitations, we will focus on several of the validity issues that may be particularly relevant for forensic CF.

Predictive Validity Within traditional psychometric frameworks, criterion validity is typically broken down as to whether the measure is predicting a criterion at the present time (concurrent validity) or in the future (predictive validity). For example, scores on a standardized achievement test may concurrently correlate with students’ grades, as determined by other measures, in a class taken when the test was administered; or the test may predict future performance, such as a grades as a graduate student in that discipline. However, for validity issues pertinent to CF, I will use the term criterion validity to compare the CF skills of novice or trainee clinicians to experts, where the latter is the criterion. This is discussed briefly later. An additional meaning of criterion validity – expected differences in the CFs of patients from a target group versus another population – is covered under discriminant validity issues (see Table 2.1). Predictive validity in CF refers to how well the CF predicts the behavior of the client, when this behavior is empirically measured as opposed to reported during an interview. The CF should enable prediction of behavior with greater specificity and precision than would be obtained from aggregate-level studies. For example, research using between-persons designs indicates a number of variables that are predictive of suicide attempts or urges, including prior suicide attempts, substance abuse, family history of suicide or psychiatric hospitalization, etc. (Qin, Agerbo and Mortensen, 2002). The risk or probability of a suicide attempt can be estimated from a person’s scores on these predictors using between-persons logistic regression. However, the CF may specify additional conditions or situations under which suicide attempts/urges are more probable for a particular person. Perhaps a client finds interactions with a verbally abusive mother in law particularly distressing, such that a recent interaction substantially increases the likelihood of suicidal urges. Another person may be more likely to make an attempt when she is feeling overwhelmed, has thoughts that she is worthless at work, and has just had an argument with her teenager. Thus, the CF can increase the level of specificity and the situational embeddedness of triggering variables so that they are fine


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Table 2.1 Validity issues in case formulation. Validity type

Level

Component/ facet/focus

Content

Individual

Coverage Relevance

Aggregate

Ecological

Coverage

Individual Aggregate

Criterion

Both

Predictive

Individual

Assessment

Aggregate

Construct Convergent

Individual

Item level (multi-item measurement)

Aggregate

Item level

Both

Variable level

Both

Formulation

Individual

Across types of CFs

Validity issues Are important target problems/issues covered in CF? Are important causal or concomitant variables included? Are target and causal variables/ constructs relevant to that person? Are the facets and elements of each variable selected the most relevant for that person? Are standardized measures used valid for this population in this context? Does the disorder level model include empirically based causal variables? Are the variables operationalized and measured so as to maximize “real life” functioning and issues? Are standardized measures tapping into real-life, functional issues for this population (i.e., not just diagnostic criteria)? How do CF skills of novices or trainees compare to experts? How well does the CF predict empirically measured relationships between variables within that person? Does a CF approach improve ability to predict the likelihood or severity of a target behavior compared to prediction from nomothetic aggregate studies? Do items converge to measure a variable or construct for that person? Which items are better measures of the targeted variable/ construct for that person? How well do certain items measure the target construct for individuals with that problem or disorder? Do scores on different measures of a variable or construct converge (agree), especially when different methods are used? Do different types of raters/ formulators agree/converge on CF? Do different types of CFs developed by independent formulators converge on certain characteristics of the case?


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Table 2.1 (Continued ) Validity type

Level

Component/ facet/focus

Discriminant

Individual

Item level

Aggregate

Item level

Aggregate

Variable level

Both

CF level: Between individuals CF level: Between groups

Both

Intra-individual Tx Response

Both

Both

Within-person generalizability

Treatment

Individual

Prediction of tx response Comparison to other txs

Aggregate

Between groups: RCT

Within group

Both

Sharing CF with pt

Validity issues Do items intended to measure a construct for that person not measure another construct? Do items intended to measure a construct not load significantly on factors for other constructs? Does the average score on a standardized measure differ between those with target problem/disorder versus those with other problems/disorders? Does the CF or aspects of the CF for this person correctly discriminate between CFs for other individuals? (Method of mis-matched cases) Do CFs or aspects of the CF for individuals with this problem/disorder differ, on average, from CFs for other populations? When using the CF as a (complex) outcome measure, do components change in predicted ways in response to tx? Does the CF or aspects of the CF generalize across data obtained from different situations or contexts? Does the CF predict the pt’s response to a specific intervention or type of tx, or to an event occurring within session? Are CF-based interventions for this person more helpful/useful than no treatment, standardized tx, or previous tx? Does CF-based tx result in better outcomes than standardized tx for this problem, disorder, or population? (See Chapter 3 by Ata Ghaderi.) Within a sample receiving tx, do pts receiving interventions consistent with the CF have better (sub)outcomes than those receiving inconsistent interventions? Does sharing the CF with the pt impact outcome or the therapeutic alliance?

Note: Tx = Treatment (or intervention). RCT = Randomized controlled clinical trial. Pt = Patient. CF = Case formulation.


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tuned to a particular individual. Situational embeddedness can be external, such as the specific people with whom the person is interacting, or internal, such as the person’s thoughts or beliefs. Such highly specific variables may not predict enough of the proportion of variance in the outcome measure, suicide attempts/urges in this example, in aggregate-level, nomothetic research, to be clinically or statistically significant. Also, the number of individuals for whom the situation is relevant may be so small as to not justify measuring it for all individuals. However, such idiosyncratic external and internal conditions or stimuli can be assessed idiographically and might have strong predictive power within a particular individual (Haynes, Mumma and Pinson, 2009; Mumma, 2001; Mumma and Mooney, 2007b). Note that within a functional analytic approach to behavioral CF, such prediction is inherent to specifying discriminative stimuli, establishing operations, or contingencies relevant for a particular individual.

Predictive Validity in Behavioral CF An important aspect of predictive validity in CF is that the level of a variable (e.g., anger) and the relationship between variables (e.g., anger above a certain level when in a particular situation) may be functionally related to a target problem (e.g., they trigger physical aggression). For example, based on data from a clinical interview with a couple, the clinician may hypothesize that the probability of aggression from Bill toward his partner increases greatly once his anger passes a particular level, but only when there has been a recent argument and Bill feels stressed from his job. Aggression may be measured with a number of items including impulses or action tendencies (“felt like hitting”), automatic thoughts (image of hitting in the past), or verbal aggression (e.g., insults, swearing). Predictive validity for this nonlinear CF prediction can be evaluated using data collected by both Bill and his partner (cf., Haynes, 1992). Given the strong emphasis on assessing functional relationships and on collecting data through behavioral observation, the predictive validity of many behavioral CFs may be quite good (Cipani and Golden, 2007).

Predictive Validity in Cognitive-Behavioral CF Cognitive schemas are given a central role in Beck’s theories of depression and anxiety (Clark and Beck, 1999, 2010). The specificity of cognitive content to certain disorders and types of distress has been the focus of a number of between-subjects, aggregate studies (Clark and Beck, 1999; Smith and Mumma, 2008). Although a number of investigators have urged careful empirical study of the relationship between cognitions and behavior/symptoms hypothesized in CFs (Bieling and Kuyken, 2003; Kuyken, 2006), relatively little empirical work has been done to evaluate hypothesized relationships between cognitions and distress on the intraindividual level. Mumma and colleagues (Mumma, 2004; Mumma and Mooney, 2007a, b) have addressed the dearth of work on predictive validity in CBCF by using daily ratings of items to test hypothesized relationships in CBCFs including thoughts/beliefs and stressful events predicting type and severity of distress (depression, anxiety). Data are analyzed using one or both of two approaches:


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Dynamic time series regression is a form of multiple regression analysis that models serial dependence in the data while evaluating lagged relationships between the predictors and outcome variable.2 Confirmatory dynamic factor analysis is a form of structural equation modeling applied to multivariate times series data that evaluates (a) the concurrent and lagged relationships between item scores and constructs, (b) the lagged relationships within each construct, and (c) the concurrent and lagged relationships between predictor and outcome constructs. Further refinements of this approach have used an ecological momentary assessment paradigm involving multiple ratings per day (Riggins and Mumma, 2008) and could use observations and ratings by a partner.

Predictive Validity in Psychodynamic Case Formulations Three types of PD formulations focus on core maladaptive relationship patterns – the CCRT (Luborsky and Crits-Christoph, 1998), Configurational Analysis (Horowitz, 1997; Horowitz and Eells, 2007), both of which were briefly described above, and the Cyclical Maladaptive Pattern (Levenson and Strupp, 2007). . The latter involves idiosyncratic “vicious cycle(s)” of maladaptive interactions involving inflexible, negative, and self-defeating behavior of the patient, expectations of others’ reactions, and the report of others’ behaviors (p. 171). Although several studies have examined the relationship between, say, the CCRT for the client’s interactions with the therapist versus others (e.g., Fried, Crits-Christoph and Luborsky, 1992, 1998), client self-report of relationship episodes and the CCRT method were used for both. To meet the definition of predictive validity suggested in this chapter, CF hypotheses about relationship themes need to be validated against behaviors measured by methods other than interview-based client self-report. For example, predictive validity could be evaluated within sessions using the client’s response to therapist behaviors (cf. Curtis and Silberschatz, 2007) or to interactions with a family member. These interactions could be videotaped, coded, and evaluated for consistency with the CF predictions. Alternatively, extrasession events could be used, again provided behavior is measured using methods other than the patient’s interview-based report of these events. Plausible methods include direct observation of extrasession interactions, ratings by significant others, or ecological momentary assessment.

Construct Validity Part I: General Issues and Convergent Validity A CF, as an idiographic theory of the person-situation, consists of a number of variables or constructs, both target and causal. Thus, construct validity issues would seem relevant. Construct validity is a complex notion (Burns and Haynes, 2006; Nunnally and Bernstein, 1994; Shadish et al., 2002) that includes the following 2 Serial

dependency is present when the error or residual component of today’s depression score, the dependent variable, is correlated with yesterday’s error score on the dependent variable. An example of a lagged relationship would be yesterday’s score on a measure of hopelessness predicting today’s score on a measure of depression.


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issues: A construct (a) consists of multiple facets so that a single operationalization or item typically provides insufficient coverage and carries unwanted variance associated with other constructs (mono-operational bias) while each facet may include a number of response modes (Haynes and O’Brien, 2000); (b) is best measured using at least two different measurement methods (e.g., self report, observer rating) so as not to confound methods and target construct variance (Campbell and Fiske, 1959: Eid, Lischetzke and Nussbeck, 2006); (c) should be conceptually/theoretically defined in terms of its expected relationships to other constructs; and (d) these predicted relationships should be tested empirically using well-validated measures. Finally, if a nomothetic construct does not adequately cover the specificity, relevance, or uniqueness of a variable for a particular person, methods are available to evaluate the psychometrics of an idiographic measure. The two most important components of construct validity are convergent and discriminant validity (Campbell and Fiske, 1959). Each of these can be evaluated on item, measure (Burns and Haynes, 2006), and CF levels (see Table 2.1).

Convergent Validity on the Item Level This evaluates the extent to which different items tap into the same construct. For between-persons, aggregate level research, this is readily evaluated using factor loadings initially from exploratory then from confirmatory factor analyses. Items with higher factor loadings are better measures of (i.e., share more variance with) the construct. A recent model developed by Haynes, Mumma and Pinson (2009) permits the importance (loading) of an item to vary across individuals. For example, the item “My face feels flushed” as a measure of anger may have a high loading (i.e., is a good measure of anger) for one individual but a relatively low loading for another. On the individual level, convergent validity of items can be evaluated with repeated ratings on the items, such as with daily ratings or ecological momentary assessment. Intra-individual item loadings can be evaluated with P-technique3 – or, preferably, confirmatory dynamic factor analysis (see Mumma, 2004; Mumma and Mooney, 2007a for examples in cognitive-behavioral CF). The items may measure a nomothetic or an idiographic construct or variable.

Convergent Validity on the Measure Level This is probably most familiar to readers – to what extent do different measures of a construct or variable converge or agree in their scores, particularly if different methods are used (Campbell and Fiske, 1959)?

3 P-technique

factor analysis (Cattell, 1978) uses the same methods as the more familiar R-technique factor analysis except the rows of the data matrix are the item scores from repeated observations within the same individual instead of scores from different individuals. Unlike dynamic factor analysis, however, P-technique factor analysis does not model serial dependency either in the form of autocorrelated errors/residuals or lagged relationships between factor scores. Essentially, the rows (occasions) can be randomly shuffled and the results will not be affected.


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Interformulator Convergent Validity This involves having different raters, or types of raters or formulators rate, evaluate or develop the CF or its components. This issue overlaps somewhat with interformulator reliability but is broader in that it encompasses convergence across different types of raters who may vary in perspective, extent of training, etc. (cf. Burns and Haynes, 2006). For example, in developing self-scenarios and interpersonal scenarios, Muran and colleagues (Muran and Segal, 1992; Muran et al., 1998, 2001) had the scenarios and their components rated for relevance by the formulator, patient, interviewer, and observer.

Convergent Validity across Different Types of Formulations In a far too rare evaluation of convergent validity between formulation approaches, Perry et al. (1989) report the similarities between components of the CCRT, an early version of the Plan Formulation Method, and the Idiographic Conflict Formulation based on a single case. Each of the three formulations was developed independently by different teams using the videotape of a single session. The authors report “significant similarity” (p. 318) between items generated when several components shared by these three methods were compared.4

Construct Validity Part II: Discriminant Validity Discriminant validity, the second major component of construct validity, was originally conceptualized in terms of whether two measures targeting two different constructs have empirically distinct scores, even when the two measures share the same method (such as self-report; Campbell and Fiske, 1959). Types of discriminant validity relevant to CF are generally analogous to the types of convergent validity discussed above.

Item Level Again, a distinction between aggregate and individual level concerns can be made. For between-person, aggregate level research, item-level discriminant validity is present if an item intended to measure construct A does not also load on construct B (i.e., is not a double-loading or complex item). This structure can be tested with confirmatory factor analysis (Anderson and Gerbing, 1988). On the individual level, discriminant validity has been evaluated in several ways. First, Mumma and colleagues (Mumma, 2004; Mumma and Mooney, 2007a) used confirmatory dynamic factor analysis on daily ratings by a patient to evaluate whether each item loaded on the target construct (e.g., depression) but not other factors (e.g., anxiety). Second, investigators from a number of different theoretical frameworks have a used the method of mismatched cases (Levine and Luborsky, 1981) to evaluate 4 Unfortunately, the authors report only that these comparisons were made with paired t-tests and were

statistically significant “ B > C to indicate that it is not necessary to establish causal relationships within an A:B:C sequence, but that the events in question tend to occur in a particular temporal order and are therefore likely to have some form of functional relationship. When functional relationships between As, Bs and Cs are considered it is not necessarily just cause and effect relationships that are of interest but an understanding of the relationship between the independent and dependent variables and how variation in the former relates to variations in the later (Skinner, 1953). As stated above, the goal of functional analysis is prediction and influence with precision, scope and depth. In a forensic context, this would mean that any analysis of a repertoire of offending behavior should allow us to predict the circumstances and contexts under which reoffending is likely to occur. Because an analysis of the offending behavior should allow us to identify the function of behavior, a good MSFA should also facilitate the identification of institutional offending and offense paralleling behaviors. A particular problem that arises when carrying out an MSFA in forensic settings is that it can be difficult to identify the correct controlling stimuli and the functional relationships between them. To complete an analysis, the assessing clinician often has to rely on collateral file information or narrative accounts that might be incomplete or inaccurate for a multitude of reasons. In order to aid the identification of the correct variables, it is important that some degree of analysis and assessment is ongoing. For example, if particular variables are identified as being controlling stimuli, then it is important to look for the presence or absence of those stimuli within the offender’s current and other previous environments. If the stimuli are present but no behavior is observed, or if the behavior is present and the stimuli are absent, then this suggests that there may be an inaccuracy in the analysis or that there is an additional contextual factor that has been missed. In this regard, carrying out an analysis is an ongoing dynamic interaction with the case material and client behavior.

CASE STUDIES: BOB AND LEON Two illustrative case formulations are presented: “Bob” and “Leon”, who both killed other men through inflicting multiple stab wounds. The case formulations show that during early childhood, both men had similar developmental experiences but that their developmental pathways diverged during adolescence. This nevertheless resulted in offenses which, while topographically similar, also have key functional differences that impact on treatment pathways and institutional risk management. Both cases are heavily disguised and incorporate common clinical case material based on many years of working with and assessing mentally disordered violent individuals.

Childhood and Early Secondary School Developmental Experiences Bob and Leon were both in their mid-twenties when they committed their index offenses and both men gave accounts of unsettled childhoods in which they described poor relationships with their mothers and abusive relationships with


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FORMULATION OF SERIOUS VIOLENT OFFENDING

135

their stepfathers. Bob gave an account of having been sexually abused during puberty by one of his mother’s boyfriends. Leon did not disclose any sexual abuse but gave an account of severe physical abuse from his stepfather, who also subjected him to harsh criticism and instilled in Leon the idea that he should be tough and that real men always fight and win. When Leon was bullied at school, his stepfather beat him and made him go out and “beat up” the boys who delivered the bullying. Table 6.3 summarizes this.

Table 6.3 Functional analysis sequence 1: Childhood and early secondary school developmental experiences. Bob

Leon

A

Distal Antecedents Experience of poor parenting Sexual abuse at hands of stepfather Proximal antecedents/establishing operations Criticized by teachers for having poor concentration in school SD Bullied by other children at school

Distal Antecedents Experience of poor parenting Proximal antecedents/establishing operations “Respected” but feared by other children at school for his violence and bullying Few friendships: associations with other children focused around his bullying SD Physical abuse at hands of stepfather

B

Overt Socially isolates self and withdraws Covert: Mixed/ambivalent feelings about abuser Violent fantasy of taking revenge on abuser Ambivalent feelings about sexual orientation Increased social anxiety

Overt Uses aggression against other children Covert: Anxieties/inhibitions about violence habituated Use of violent fantasy of taking revenge on abuser

C

Attempts at social interaction are punished through lack of peer recognition/low social status (negative punishment) and bullying (positive punishment) Social isolation keeps him safe from bullies (negative reinforcement)

Increased status/peer recognition (positive reinforcement) Financial gain (positive reinforcement)

Key learning

Cannot gain peer recognition Avoidance of others keeps you safe Other males are a threat to him He is inadequate and not deserving of friendship

Social and material gains from violent behavior Being a bully protects him from being a victim


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Both men indicated that, as boys, they had struggled at school with problems of concentration and, particularly in Leon’s case, problems with conduct. Consequently, both men indicated that they had experienced educational failure in junior school and both consequently struggled to form effective peer relationships. Bob described himself as being withdrawn, somewhat isolated and vulnerable to bullying. Withdrawal and isolation may have been negatively reinforced for Bob by avoidance of the aversive social stimulus. From Leon’s account, it would appear that he also had very few if any close friends. Despite this, Leon gained some status within his peer group because of his aggression, bullying and willingness to fight other pupils, no matter what their size or reputation. Leon recalled that, even at this early age, he gained some material benefit from his violence including acquiring possessions and influencing other children to do things for him. Indirectly, there was a further gain for Leon as a result of his aggression in that he gained his stepfather’s approval, which in turn reduced the frequency of his own beatings. Thus, for Leon aggression and bullying others may have been positively reinforced by the acquisition of tangible items and increased social status and negatively reinforced by reduction in the beatings from his stepfather. Both men reported ambivalent relationships with their abusers. Leon indicated that he was frightened of his stepfather and could recall the fear associated with his stepfather returning from drinking binges and the anticipation of violence directed at both him and his mother. Yet, despite this, he also reported respect for his stepfather who had some social standing within the community because of his reputation as a “local hard man”. Leon admitted that achieving and bettering his stepfather’s social standing was something he actively aspired to do. Despite reporting he respected his stepfather, Leon also described anger toward his stepfather and disclosed a history of violent fantasy involving taking revenge on his abuser. Bob, on the other hand, disclosed how his sexually abusive stepfather was in some ways good to him and his mother and how he could be funny and engaging. Bob recalled how his abuser would comment on Bob’s penis becoming erect during the abuse and would tell him that he was special and the abuse was their special secret. Although Bob disclosed that he found the abuse physically painful, and feared his stepfather’s attentions, his physiological responses to the abuse made him feel ashamed and confused about his own sexual orientation. Bob indicated, however, that after his abuser left the family and he became aware of the true nature of what had been done to him, he also (in common with Leon) experienced revenge fantasies. Bob reported that he became fearful and suspicious of other men, particularly those he believed to be homosexual. Bob now admits he had mistakenly connected homosexuality to sexual abuse.

Adolescent Development It would appear from the initial analysis set out above that both Bob and Leon entered adolescence and secondary school with an underlying fear of being a victim, albeit with a different repertoire of topographically different behaviors to


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manage this fear. Bob reported that this fear led to him being cautious in forming friendships with others. This seems to have marked Bob out as different to the other children who began to bully and ostracize him and compounded his anxiety and led to a further reduction in his social behavior. In effect, his already limited social behavior was subjected to a combination of positive punishment in the form of bullying of a physical and emotional nature and negative punishment in the form withdrawal of social attention from others. For Bob this led to an increase in his avoidance behaviors, which functioned to help him escape from the aversive stimulation of being bullied and rejected by others (negative reinforcement). For Bob because of the level of aversive stimuli at school, the school environment may have eventually become a conditioned discriminative stimulus (SD) for eliciting a fear response in the form of physiological arousal with associated fearful cognitions and subsequent avoidance behaviors. In line with these anxious responses, it can be hypothesized that this response may also have generalized from specific bullies to other children of whom Bob became increasingly fearful and avoidant of, both in and out of school. These problems were compounded by his poor educational attainment, which also elicited aversive responses from his teachers and teasing from the other children. He developed a pattern of increasingly avoidant behavior, isolating himself and truanting from school. These coping strategies, while preventing him from being bullied, also stopped Bob forming meaningful social relationships. This created a negative feedback loop where Bob’s isolation, his inability to trust others, and his negative self-concept began to self-perpetuate. Bob indicated that an important formative experience for him occurred while he was truanting when he was picked up by some youths who were out of school and intent on stealing a car. Bob went along with them and was involved in the car theft, but looking back felt that he had been set up and that the other boys were probably motivated to involve him in the theft by the wish to ‘take the piss’. After stealing the car, which was wrecked, Bob was the only one who was caught. Although Bob was dealt with through a community sentence, this experience further lowered his social standing at school and he felt he was then made fun of for his incompetence as a car thief and for being gullible and allowing himself to be set up by the other boys. Leon, in common with Bob, also experienced educational failure and struggled with basic skills, such as literacy and numeracy. Leon also truanted from school, but, unlike Bob, he truanted with a peer group, some willing and some bullied into accompanying him. While truanting, he began to associate with older boys who were involved in minor criminal activities including burglaries, car thefts and drug misuse. Leon reflected that he had felt more accepted by this deviant peer group and had gained status for his violence and risk-taking criminal activities. Perhaps inevitably, Leon became increasingly well known to the police through his criminal activities and received a variety of community disposals for car theft and burglary before eventually being given a custodial sentence in a Young Offenders Institution (YOI). Leon acknowledged that he was certainly no longer of high status in his first YOI, where he mingled with young men who were tougher and more experienced than he was; however, the experience seems to have


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further desensitized him to violence and further embedded him within a deviant criminal peer group. From a behavior analytic perspective two things may have happened here. Firstly, through repeated exposure to violence Leon habituated to the associated physiological arousal. Secondly, Leon’s violent behavior was also being reinforced by others. Whilst tangible reinforcement may not always be forthcoming, it was hypothesized that intermittent reinforcement in the form of a variable ratio schedule would be enough to maintain this behavior. Due to his own change in status and the lack of respect and status initially received within the YOI, Leon increased his criminal offending within the YOI by getting involved in racketeering and collecting and enforcing debts for higher status prisoners. From a behavioral analytic perspective the acquisition of new criminal behavior is evident. This new behavior was hypothesized to be maintained by tangible reinforcers, such as money or tobacco1 and other social reinforcers. In this environment, there would be little reinforcement for conventional, nondeviant behavior, which was in any case likely to have been at a relatively low response rate for Leon at this stage. The status given to Leon from the other prisoners further reinforced Leon’s antisocial behavior. On his release, Leon’s offender status had increased, with conventional social relationships and legitimate employment being of little value to him. In behavioral analytic terms, there are two classes of behavior being affected. First, his conventional social behavior is at a weak level and instances of positive social behavior unlikely to be reinforced and might have been punished. Second there were likely to have been concurrent schedules of reinforcement operating on his deviant and criminal behavior operating.

Summary It can be seen in the analyses set out in Table 6.4 that Bob and Leon’s paths have diverged at this point. A major hypothesis here is that Bob was unable to gain recognition and status with his peer group. His one significant attempt to join in with a peer group when stealing a car resulted in the extremely punitive and frightening experience of getting caught and the increased the level of ridicule he experienced as a result. Bob developed a set of negatively reinforced avoidance behaviors as a means of avoiding the aversive stimulation of his peer group. By contrast, Leon was becoming more physically dominant and increasingly enmeshed with a deviant peer group; however, for Leon although there was a unity against external forces within the peer group, he constantly felt that he had to justify and maintain his position within the hierarchy, typically with increasing levels of violence and aggression. This inevitably made Leon a high status target for other criminals and led to him carrying a concealed weapon. For example, he stated that “I always had to watch my back in those days.”

1 In

many correctional institutions tobacco is used as a currency in the absence of actual money


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Table 6.4 Functional analysis sequence 2: Adolescent development. Bob

Leon

A

Previous learning set out in Functional analysis 1 (Table 6.3) Establishing operation Absence of peer approval S-d Encouraged to steal car with peers

Previous learning set out in Functional analysis 1 (Table 6.3) Establishing operation Previous violent offending reinforced by peers S-d Sees opportunity to commit burglary

B

Skips school and steals a car

Commits burglary

C

Is abandoned by peers and is caught alone, and charged – acquires criminal record (positive punishment) Ridiculed by peers and is further isolated (positive and negative punishment)

Is caught and charged, acquires criminal record (initial weak positive punishment) becomes associated with praise by his peers for criminal record (positive reinforcement)

Key learning

Other people can not be trusted and will seek to harm him He is no good at anything and is “worthless” in the eyes of others

Crime gets you status so the more crime committed the greater the status achieved You don’t get caught often so it is worth the risk

Further Adolescent Experiences Bob From adolescence onwards, Bob became increasingly socially anxious around others (see Table 6.5) and continued to use avoidance strategies as a means of coping with this anxiety and thus increased his social isolation. During this time of his life, Bob continued to develop fantasies of taking revenge against his stepfather for the sexual abuse inflicted upon him and began to use alcohol as a coping mechanism in a number of different contexts. Mostly, he reported that he began to use alcohol to increase his self-confidence in social situations. Alcohol use in this case was being concurrently reinforced on negative and positive reinforcement schedules; negatively reinforced in that there was a reduction in anxiety in social situations and positively reinforced in that it facilitated an increase in his social contact with other people. During this time, however, Bob also began to use alcohol for the secondary function of emotional regulation, namely to reduce or “block out” memories and the associated anxiety and feelings of vulnerability and defectiveness resulting from his sexual abuse. Nevertheless, Bob reported that his alcohol abuse did not have the desired effect, and he reflected upon two side-effects of this strategy. First, he noted that alcohol began to strengthen the aversive affect he experienced and made him more likely to experience revenge fantasies; the strength of these fantasies was related to


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Table 6.5 Functional analysis sequence 3: Further adolescent development and origins of offence pathway. Bob

Leon

A

Previous learning set out in functional analysis 2 (Table 6.4). Establishing operations Bullied and ridiculed following car theft S-d Other people and social situations function as aversive stimuli

Previous learning set out in functional analysis 2 (Table 6.4). Establishing operations Father dies in pub fight S-d Increased attention on Leon as a potential target

B

Overt: Uses alcohol as a coping strategy to deal with abuse flashbacks (covert) Attempts to be more social Goes out drinking Covert: Attempts to cope with abuse flashbacks through violent fantasy

Overt: Increases his offending and the level of violence he uses Covert: Has flashbacks to his father beating him Is upset at being reminded of the abuse

C

Alcohol acts as CS for eliciting negative affective states Is hospitalized

Gains more respect from others (positive reinforcement) Stature as a target increases creating the need for more violence Emotional upset decreases with violence (negative reinforcement?)

Key learning

There is something wrong with him People think he is gay and that means he is in danger Needs to continue to avoid people and places to keep safe

In order to keep safe, increasing levels of violence are needed

how drunk he seemed to be – until he passed out. Second, Bob’s revenge fantasies seemed to function to not just reduce his negative mood but to help him feel like a strong and powerful man. Bob also reported that the fantasies disturbed and scared him: emotional responses that he attempted to reduce with more alcohol. He reflected that back then he would attempt to drink himself out of his low mood and fantasies only to find himself in a downward spiral. Bob reflected that by the time he realized what was happening, he was probably an alcoholic. Bob also reported that, the more he used alcohol in this manner, the more likely he was to think about his abuse and engage in fantasies when drinking. From a behavioral perspective, it seems that alcohol and alcohol-related contexts began to function both as conditioned stimuli for eliciting abuse memories and associated revenge fantasies from Bob and as discriminative stimuli for alcohol-related avoidance behaviors.


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141

A further key learning experience occurred for Bob during this period of his life. One evening whilst drinking with some acquaintances, Bob was assaulted in the street and was hospitalized as a result. In essence the experience is likely to have maintained the conditioned stimulus functions of “other people being dangerous”. As such, other people continued to elicit a fear arousal response from Bob. A key aspect of this assault for Bob was that his attacker called him a “poof”.2 Bob seems to have linked this to his own doubts about his sexuality that resulted from his sexual abuse. He began to think that other people could tell there was something wrong with him sexually and that he was vulnerable to harm as a result. During this time Bob became increasingly fearful that others could see there was “something not right” with him. He eventually began to suspect strangers in the street could also see this and suspected that the police were following him to see if he was gay. It can be hypothesized that this experience acted as an establishing operation for strengthening Bob’s avoidance behavior. In essence, the experience is likely to have increased the aversive stimulus properties of other people, leading to an increase in the negatively reinforcing value of his avoidance behavior. Another consideration at this stage is a possibly concurrent deterioration in Bob’s mental state. Given that Bob became increasingly isolated, misinterpreted environmental stimuli as aversive and became what could be described diagnostically as paranoid, the possibility that at this time Bob was in the early or prodromal stages of psychosis must be considered.

Leon Leon also had a number of functionally significant learning experiences during adolescence. Leon’s stepfather died following a fight in a pub. Following his stepfather’s death, Leon assumed the role of the man of the family. Leon reflected that it just seemed like he was expected to do this. He also reflected that he stepped into his stepfather’s shoes as a local hard man and felt that he had something to prove, given his stepfather’s reputation. As a result, Leon made additional efforts to demonstrate that he was bigger, better and stronger than his stepfather. Leon also stated that, despite the difficulties with his stepfather, he had somehow felt that he was protected from retaliation for his criminal actions as a result of his stepfather’s reputation. He stated that after his stepfather was killed, he had to prove he could make it on his own. He therefore increased his focus on offending and in particular on the levels of violence he would use. In practice this attempted escalation in his offending behavior seems to have led to further difficulties for Leon because, in order to preserve his status as a hard man, he became harder and tougher; however, whilst this kept rivals at bay to a certain degree, it also made him more vulnerable in other ways. As Leon explained: “the bigger the bastard, the bigger the payout for taking him down”. In this regard, Leon stated that at that period he always felt he was living on borrowed time and said you had to “watch you friends even closer than your enemies”. Leon also reported feeling under scrutiny for his lack of girlfriends and he believed that other people thought he was homosexual. He explained that, in 2A

pejorative term in the UK and Ireland for a homosexual man


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his world, being labeled “gay” would have been a potential death sentence. He reported that he had once smashed a beer glass into the face of an associate who made a joke about his sexuality; Leon reported that this was the last time until the index offense that someone made such remarks to his face. In the context of Leon’s learning history, this behavior can be understood in the following A:B:C analysis. The antecedent in this context is likely to have been the joke about being gay. Leon’s behavior included perceiving that being seen as gay would be a signal for other people to attack him. In this regard, being labeled was a signal for impending danger. The consequences of the violent assault (the behavior) on this associate were that the threat was removed and his violence was negatively reinforced by the termination of the aversive social behavior/threat from others. During this period Leon rapidly gained an even stronger reputation for being a local hard man and as an enforcer for local gangsters. His reputation was further solidified by a number of short stints in prison/young offender institutes.

Summary While both men used coping strategies that appear topographically different (Bob primarily uses alcohol, whilst Leon uses violence and offending behavior), there are a number of functional similarities between them that are notable. Both men used negatively reinforced avoidance strategies as a means of surviving in their respective environments: social isolation for Bob and a criminal underworld for Leon. Paradoxically the longer-term consequences of both Leon and Bob’s strategies seems to have been to inadvertently increase contact with the aversive stimulation both were attempting to avoid, thus eliciting further problematic avoidance behaviors of a similar nature; for Bob maintaining his use of alcohol and for Leon maintaining his use of aggression and offending behavior.

Adulthood and Development of Offense Pathway Bob As Bob’s alcohol use and social isolation continued, he experienced deterioration in his mental health to the extent that he was sectioned under the Mental Health Act and admitted to a psychiatric ward. After an initial assessment, Bob was detained under the Mental Health Act for further assessment, was diagnosed with a psychotic illness and placed on antipsychotic medication and antidepressants. During his stay in hospital, Bob disclosed his history of being sexually abused; however, Bob reported that he did not receive the response he had hoped for. Bob perceived that the staff did not believe him and considered his report to be delusional, choosing to increase his medication rather than offering other help or support. (See Table 6.6 for a summary of adult development.) After his discharge from hospital, Bob was placed back in his own accommodation community mental health services where he felt increasingly vulnerable and isolated. He had gained weight as a side-effect of his medication and his neighbours were aware he had been in a psychiatric hospital and, according to Bob,


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Table 6.6 Functional analysis sequence 4: Development of offence pathway 2. Bob

Leon

A

Previous learning set out in functional analysis 3 (Table 6.5) Distal antecedent Hospitalized SD Encouraged to “open up” by staff

Previous learning set out in functional analysis 3 (Table 6.5) Distal antecedent Incarcerated S for pro-social behavior Surrounded by senior criminal peers SD for offending Surrounded by senior criminal peers

B

Discloses history of sexual abuse

Carries on offending in prison

C

Disclosure not believed (absence of reinforcement) Medication increased (positive punishment) Remains on the periphery of his social group Told to make more efforts to be social able (Sd for further behavior – likely under aversive control)

Increased status in prison (positive reinforcement) Reduced criminal status on return to the community (withdrawal of reinforcement, Thinning out of schedule)

Key learning

Other people can not be trusted Needs to use alcohol if he is to be more sociable

Criminal behavior will need to be increased to regain status

avoided him more than usual and sniggered when he walked past. His front door was vandalized with graffiti which referred to his mental health. Bob found it increasing difficult to cope with his environment and took a medication overdose which he reported was a suicide attempt. In the context of the history presented above it can be hypothesized that this suicide attempt functioned as an effort to ultimately terminate the aversive stimulation in Bob’s environment. Whilst Bob had not attempted suicide before, and by definition completed suicide can have no reinforcement history, this behavior can still be understood from a behavioral analytic perspective. Skinner (1953) argued that suicide is a form of self-regulatory behavior, which, while having no complete reinforcement history, does have a generalized reinforcement history for its component parts of self-regulation and negative reinforcement. Bob’s self-harm resulted in a further brief stay in hospital, before he was discharged back to his own accommodation and to the care of a community mental health team. Bob’s community nurse worked actively with Bob to increase his social skills and social integration, encouraging Bob to be more socially active and going to the extent of putting Bob in contact with others in a similar situation to himself. Bob reported that he tried hard to make contacts, but could only do so with the aid of alcohol, something he hid from his community nurse. While this


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intervention was well intentioned, in practice Bob was assessed without a functional analysis of his problems having been undertaken and consequently led to suboptimal outcome. Given the previously established functions of alcohol for Bob, this intervention led to a situation where Bob was experiencing negative thoughts and emotions about his abuse and associated revenge fantasies in the company of a number of people he did not know very well and of whom he was potentially scared. Bob reported that he remained on the periphery of this social group. He explained there were some people he knew from hospital who were OK, but there were always others he did not know coming in and out of the group and social gatherings, which Bob found very unsettling.

Leon During this time, Leon’s reputation amongst his underworld peers and superiors continued to grow. He became known as someone reliable and who could get things done. He began to be offered money for contracted threats and beatings. Leon said that because of his reputation, when he threatened people with violence, they listened to him and treated him with respect because they knew he was capable of carrying out any threats made. In effect the schedules of reinforcement established in prison that strengthened and diversified his repertoire of criminal behavior now also occurred in the community. Leon also became increasingly involved in recreational violence and alcohol use, reflecting that “if there was no alcohol or fighting involved, it was not a good night out”. His use of violence escalated to him using weapons such as screwdrivers and baseball bats. During his early adulthood, Leon spent a further longer period of time in prison, where his reputation and considerable use of violence led to him achieving top dog status, stating that “even the screws3 were afraid of me”. Although he was able to achieve this status in prison, Leon reported that, on his return to his local community, he found himself in an unexpected position: On this occasion he did not return to find his status, position and reputation unequivocally enhanced. Instead he found himself in a different position. His status was if anything diminished: his criminal record, familiarity to the police and frequent periods in prison had led to his criminal peers to question his reliability and discretion and in his absence a number of other criminals had fulfilled his role to the satisfaction of various gangland bosses. Nevertheless, shortly after his return to the community, Leon stated he was offered a job that he saw a chance to re-establish himself in the gangland hierarchy. Leon reported that a senior-ranking criminal, Dave, suspected to be conducting an affair with another’s girlfriend and Leon was instructed to “warn Dave off, physically if necessary”. Leon reported that, given the rank of the target, this was a high profile job that many others were afraid to take. Therefore, he saw it as a perfect chance to re-establish his status amongst his gangland peers. The sequences of offenses 1 and 2 for Bob and Leon are shown in Tables 6.7 and 6.8.

3A

pejorative term in the UK and Ireland for a prison officer


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Table 6.7 Functional analysis sequence 5: Development of offence pathway 2. Bob

Leon

A

Previous learning set out in functional analysis 4 (Table 6.6) In the pub Meets a group of acquaintances Presence of a gay man

Previous learning set out in functional analysis 4 (Table 6.6) Discharged from prison Lowered social standing Accepts high status job Consumption of alcohol Being made fun of by his victim

B

Overt Drinks a lot of alcohol Invites people back to his flat Hides a knife for his protection Covert I must be more sociable Increased sense of threat from Tom

Overt Continues to drink alcohol Covert Increasing anger at his victim Increasing discomfort at being put down in front of others Worry about his social standing

C

People come back to the flat People drink all of this alcohol He is left alone with Tom

Dave continues to disrespect him Others are witness to Dave’s disrespect

Key learning

He is in danger. It has been a set up to get him alone with Tom Tom means to cause him harm

If he does not follow through with his plans he is finished

Index Offense Bob On the night of his index offense, Bob went out drinking and met a group of acquaintances at a local bar. There were also some people there who Bob did not know very well, including one person Bob was fearful of, Tom. Bob knew that Tom was gay and he explained during interview that he was wary of him for the reasons outlined above. At closing time, Bob invited everyone back to his flat for more drinks. Bob reported that he was unsure why he had done this, but reflected that he was trying to make an effort and do things to prove his fears wrong – as suggested by his community psychiatric nurse. Once back at Bob’s flat, the group drank Bob’s alcohol and made fun of him and the spartan conditions in which he lived. After consuming all the available alcohol the group decided to go to a night club and all left with the exception of Tom who stayed in Bob’s flat, saying he wanted to finish his drink. Once alone with Tom, Bob became anxious about Tom being in his flat, having previously mislinked homosexuality and sexual abuse in his own learning history. This fear was compounded by his alcohol use that night and by him already thinking about his abuse and experiencing some revenge fantasies. Becoming increasingly fearful for his safety Bob went to the kitchen to get a knife


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Table 6.8 Offence sequence 2. Bob

Leon

A

Previous learning set out in functional analysis 5 (Table 6.7) Offence sequence 1 Tom touches him on the shoulder Smell of alcohol

Previous learning set out in functional analysis 5 (Table 6.7) Offence sequence 1 Dave goads and makes fun of Leon

B

Covert: Memory of his own experience of abuse Immediate sense of physical threat Overt Stabs Tom

Covert: Memory of his stepfather’s abuse Threat to integrity Threat to criminal progression Increased anger Overt Stabs Dave

C

Tom is killed and the threat is immediately removed (Sr− ) Bob is arrested and sectioned under the MHA

Dave is killed, the threat is removed (Sr− ) but also the chance for reward (Sr+ ) is increased

Key learning

He is safe and the threat is removed (negative reinforcement). Aversive stimulus functions of social situations and gay men are maintained and likely to be strengthened

He is safe and that violence still works as a way of keeping himself safe. Increasing levels of violence might be needed

while Tom was using to toilet which he hid under a cushion on his seat. Bob reported that he wanted Tom to leave but was underassertive and to anxious to ask him to go. This situation frustrated Bob and reminded him of the passive role he believed he took in his own abuse and elicited further thoughts about how weak he was and how others constantly took advantage of him. Bob reported that he became increasingly angry with himself and Tom as a result but nevertheless claimed that toward the end of the night he fell asleep on the sofa only to be woken by Tom who was saying goodbye before he left. The smell of alcohol on Tom’s breath, the closeness of his face and the touch on Bob’s shoulder triggered a flash back to Bob’s own abuse. The next thing Bob says he remembered was Tom lying on the floor having been fatally stabbed.

Leon On the night of Leon’s index offense he went out drinking with a group of acquaintances, including his victim Dave (the person Leon was to be paid for “warning off”). Leon reported that, on the night of the offense, Dave was constantly calling him “sonny” and “boy”. Leon reported that he considered this to be disrespectful and made him angry, reminding him of how his stepfather would mistreat him as


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a child. On leaving the pub, Dave invited everyone back to his house to continue drinking. As the night wore on everyone left and Leon recognized that he has an opportunity to deliver the warning to Dave. Dave responded to Leon’s threat by laughing at him. Leon reported that this was something he had not experienced for a long time and he became very angry, pulling out a knife and holding it to Dave’s throat. As Leon attempted to increase the level of threat against Dave, Dave responded by laughing and ridiculing Leon, and according to Leon Dave told him that he was going to take the knife off him and was going “to stick it up Leon’s arse”, implying that Leon was gay would consequently surely enjoy the experience. Leon reported that at this point he “saw red and lost it” stabbing Dave in the neck. Leon reported that Dave stumbled back holding his neck but despite his injury continued to express contempt for Leon who then stabbed Dave repeatedly – only stopping once the blade broke.

Offense Paralleling Behaviors and Clinically Relevant Institutional Behaviors Bob From this analysis of Bob’s developmental trajectory and index offense, it can be hypothesized that the primary function of Bob’s index offense was one of self-protection and the removal of a particularly threatening and aversive stimuli from his environment. The majority of the behaviors that have been identified as functionally relevant in Bob’s case can been seen to be negatively reinforced avoidance behaviors. Bob’s history is such that other people with certain characteristics may have become conditioned discriminative stimuli for threat and danger, which Bob avoided by social isolation and self-medication with alcohol. Bob’s trajectory was relatively free of offending prior to his index offense; however, based on this analysis, it may still be possible to make predictions about Bob’s institutional behavior and risk factors for further violence. Given the documented abuse history, it can be hypothesized that prison or a male-dominated secure hospital would be laden with discriminative stimuli signalling danger for Bob. In this regard, a number of institutional behaviors were observed in Bob that were hypothesized to be relevant to his offending behavior. Initially Bob refused to wash and shower within his secure environment. Given Bob’s history of mental health difficulties, this was viewed by some as a recurrence of a depressive episode or negative symptoms signifying a psychotic relapse; however, based on the analysis above it can also be hypothesized that this presentation may be connected to Bob’s previously conditioned threat sensitivity and ideas about homosexuality. Washrooms and showers in the secure setting were semi-communal. In the context of Bob’s learning history, the showers and the potential to be naked around a number of other male strangers was likely to have acted as a conditioned aversive stimulus for Bob, which, as expected, he attempted to avoid in line with his learning history. Attempts to encourage Bob to behave differently independent of his previous learning could actually be counter-therapeutic and place him and others at risk.


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Leon While the index offense for Leon had both topographical and functional similarities to Bob’s, it can be hypothesized that there were significant functional differences. Whilst Bob’s offense has been hypothesized to be a function of a prolonged and ingrained negative reinforcement schedule, Leon’s index offense can be thought of as being a function of a mixed negative and positive reinforcement schedule, in which increasing criminality and violence served to increase status and financial reward (positive reinforcement) and remove threats from his environment (negative reinforcement). While Leon’s violence has served to remove threats from his environment, such threats were usually a consequence of his previous violence. Therefore, it has been hypothesized that the most important reinforcement for Leon’s violence has been the financial reward or status. Therefore, within the prison system it can be hypothesized that Leon was likely to continue this pattern of behavior and engage in behaviors such as intimidation of others and bullying and racketeering, which he did attempt to do in the early stages of his incarceration.

DISCUSSION As this chapter highlights, forensic case formulation presents a number of unique challenges. Given the criticisms of formulation outlined previously – particularly that it is subjective, lacking in both consistency and validity and is thus unreliable (Kuyken et al., 2005), clinicians need to find a way of enhancing explanations of a forensic patient’s behavior. MFSA provides a vehicle in which to do this. As discussed in the introduction to this chapter, MSFA was originally described in the early nineties (Gresswell and Hollin, 1992). The more recent literature supports the use of functional assessment and analysis by clinicians working with aggression and violence (Daffern et al., 2007; Jones, 2004). Both Daffern et al. (2007) and Jones (2004) highlighted the importance of functional assessment and analysis in improving clinician understanding and consequently assessing risk and providing treatment. Furthermore, in arriving at a psychologically relevant formulation critical to the understanding of the patient’s actions, the clinician is required to determine the role of thought and action, and ultimately the function of the behavior leading to the offense in question. In this chapter two men have been described whose index offense behaviors are topographically similar in many ways and yet whose diagnoses, presentations, and forensic histories are very different. Furthermore, and perhaps more importantly, the treatment efforts and risk issues presented are even more at odds with each other. In both of the cases described, a difference in the function of behavior can be identified, the motivation for which is uncovered by applying MSFA to unpick the issues. MSFA can also sit within a wider formulation. For example, considering the case of Leon, the function of each of his behaviors can be considered at a number of different levels or stages. So, the understanding of the function and purpose of behavior, can sit within a wider systemic formulation to include the family, peer


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group, education system and support system each of which is considered in the prior learning.

Treatment Implications In relation to intervention, management whilst in an institution and reducing the risk of future offending, it is ever more important for clinicians to defend their opinions and provide the appropriate treatments. Psychologists have recognized for a long time that to provide appropriate psychological treatments it is unwise to simply look at the end behavior without knowing what drives it. In the cases of Bob and Leon, on the surface they look similar save for the differences in forensic history. Both men experienced some form of early abuse by a stepfather, are poorly educated, used alcohol prior to the offense, had poor family relationships and generally had impaired social relationships. Both men stabbed their older male victims with in frenzied attacks in a private home within the context of having consumed alcohol and with a background of fantasy of revenge on their childhood abuser stepfather. The function of the behavior in both cases was to remove a perceived threat, with the functions established in both men’s early history of abuse. Surely, then, given these similarities, treatment considerations should be much the same? This is not the case. When considering the context/environment within the functional analysis at the different stages, changes in patterns of behavior in both cases are uncovered. In both cases, the behavior of the victim in that particular situation was the trigger to ignite the emotional response driving the overt behavior. By understanding the emotional responses (fear and anger), the function behind the resulting behavior can be better understood. In Bob’s case it was initially fear then anger and rage related to flashbacks of his stepfather and desire for revenge. In Leon’s case it was initially an instrumental plan that turned into rage following his perception that the victim was treating him disrespectfully and with contempt, triggering an emotional reaction of anger and rage and desire for revenge. In both cases, the behavioural shift happened following this trigger. For Leon, this was an unusual response to violent confrontations which were usually carried out with confidence and self-assurance. In Bob’s case this violence was unusual in that he had never committed a violent offense prior to or following this one. What may be of importance is that Bob had successfully avoided these contexts prior to the night of his index offense. Leon, however, had been in similar situations before without such a loss of control. Leon’s recent loss of criminal status and the need to recapture this was an important establishing operation in his case. In considering treatment for these two individuals, some clear similarities as well as important differences can be found. Both might be considered to need support around interpersonal relationships and the development of social skills, although both men are likely to need different sets of social skills. While it may appear that both men may also benefit from improving their self-esteem, the above MSFA would indicate that this would be a simplistic view. Both men have very different needs in this respect. Bob probably has little self-esteem, whereas Leon gets his from criminogenic sources. In this case, Bob’s deficit may be easier to work


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with by establishing and shaping a behavioral repertoire to aid this. Leon, on the other hand, will be more difficult to work with given the significant history of reinforcement for his criminal behavior in the past. Both men might also benefit from developing skills to deal with their anger experiences resulting from their abuse histories. Both Bob and Leon need to resolve their own issues and feelings related to their stepfathers who abused them – indeed this is imperative considering the identified trigger in both cases involved a degree of stimulus generalization from the abuse situation to the one of the index offense – leading both of them to kill. Notably, though, this work would be very different in each case. Here, however, the similarities end. Bob’s treatment needs include work around vulnerability and safety as well as psycho-education in relation to mental health experiences (psychosis). He also needs to learn about the impact of alcohol on his emotional and mental health functioning. Finally, Bob needs to understand the situational or contextual factors that make him more likely to become a risk to others (real or perceived threat) as well as his lack of assertiveness and vulnerability. Bob’s risk factors include his level of fear of others. Bob might, therefore, benefit from graded exposure to aversive stimuli along with social and assertiveness skills training to allow him to stay in and tolerate aversive situations for longer so that he may learn that the threat is not great, thus extinguishing his fear response. Teaching Bob social skills would also increase the chances of successful social interactions (i.e., positive reinforcement of alternate behavior). Leon’s treatment needs to focus more on the criminogenic factors, such as previous instrumental violence and his perception of vulnerability to others if he does not maintain his status. Leon’s previous behaviors indicate an underlying acceptance of violence as an appropriate means of gaining respect, approval and cash, something borne out by his experience of the world. A treatment program for Leon will need to include a means to shape up and reinforce alternative methods of gaining these rewards in a prosocial manner; for example, Leon could be encouraged to work in the prison in roles that require some form of increasing responsibility, such as work that requires cooperating with others. Given the very low base rate of such behaviors, Leon is likely to need ecologically valid social reinforcement which may be difficult to engineer in a prison environment: normal praise and attention from staff may be aversive for him (and therefore act as punishers). Some form of tangible reinforcer that has a positive function during his incarceration (e.g., increases in privileges, for example) may be effective but would need to be well managed and clearly contingent upon a reduction of offending behaviors within the institution if his bullying is not to be accidentally maintained. A further key factor in Leon’s offending has been the lack of empathy for others, with the distress of others failing to act as inhibiting stimuli for violent behavior. This in itself has treatment implications for Leon. Many offender treatment programs contain victim empathy sections. Those working with Leon will need to be aware that attempting to increase Leon’s empathy for others may be difficult, given the very low rate of base behavior and the different stimulus functions the distress of others is likely to serve for Leon; it can be hypothesized above that the distress of others is likely to function as a generalized positive reinforcer for Leon.


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Thus, the importance of the context becomes clear in the commission of the violence in both cases. Given what is known of Bob and of the functional assessment carried out, it may be considered unlikely that he would carry out such an offense again in the absence of the specific contextual factors that arose at the time. In Leon’s case, murder can perhaps be considered a progression from the many violent assaults which he carried out in the past. He has gained much that is important to him from these assaults which reinforce the necessity of doing it again; however, this was Leon’s first murder and consideration needs to be given to whether the progression would have happened without the contextual factor reminiscent of his stepfather’s abuse. What is clear is that, in terms of further violence, the functional assessment indicated a higher risk for Leon in terms of his reinforcement history because of the high likelihood of key discriminative stimuli being present within his environment in the future.

CONCLUSION Scrutinizing behaviors in the way MSFA requires raises questions that would otherwise have been missed and allows hypothesis-driven testing of such ideas. It helps provide a scientific basis for the formulation method, one that is systematic and defensible and less likely to leave scope for wide variability. Understanding the function of a given behavior is arguably imperative in any case formulation, especially one that leads us to decision making with regards treatment and risk. The versatility of MSFA means that it can be applied to all situations whether community forensic or inpatient cases. MSFA can help conceptualize assaultative behavior within institutions and allow patterns to emerge. Carrying out MSFA with each situation over time will build up a comprehensive picture to allow intervention points to emerge. Furthermore, it can be applied to individual offenses carried out by one individual, allowing an understanding to develop in relation to consistency and changes in patterns of offending behavior. Offense paralleling behaviors are beginning to gain credence in terms of what they can tell us about an offender’s motivation to offend. By identifying offense paralleling behaviors the clinician can often see the different functions of similar appearing behavior across different contexts. Discrete behavioral episodes may not carry the weight of importance often ascribed to them once entrenched within a MSFA. Ultimately, it is hoped that use of such an analysis will help improve the quality and accuracy of individual formulations improving long term the possible outcomes for these individuals.

REFERENCES Braham, L., Jones, D. and Hollin, C.R. (2008) The Violent Offender Treatment Program (VOTP): development of a treatment program for violent patients in a high security psychiatric hospital. International Journal of Forensic Mental Health, 7, 157–72. Daffern, M., Ferguson, M., Ogloff, J.R.P., Thomson, L. and Howells, K. (2007) Appropriate treatment targets or products of a demanding environment. The relationship between


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aggression in a forensic psychiatric hospital with aggressive behaviour preceding admission and violent recidivism. Psychology, Crime and Law, 13, 431–41. Ferster, C.B. and Skinner, B.F. (1957) Schedules of Reinforcement. New York: AppletonCentury-Crofts. Gordon, A. and Wong, S.C.P. (2000) Violence Reduction Program: Facilitator’s Manual. Department of Psychology, University of Saskatchewan. Gresswell, D.M. and Hollin, C.R. (1992) Towards a new methodology for making sense of case material: an illustrative case involving attempted multiple murder. Criminal Behaviour and Mental Health, 2, 329–41. Harris, G.T. and Rice, M.E. (2007) Characterising the value of actuarial violence risk assessments. Criminal Justice and Behaviour, 34, 1638–58. Hart, S.D., Michie, C. and Cooke, D.J. (2007) Precision of actuarial risk assessments. British Journal of Psychiatry, 190, 60–5. Jones, L. (2004) Offence paralleling behaviour (OPB) as a framework for assessment and intervention for interventions with offenders. In A. Needs and G. Towl (eds), Applying Psychology to Forensic Practice (pp. 34–63). Oxford: BPS, Blackwell. Kuyken, W., Fothergill, C.D., Musa, M. and Chadwick, P. (2005) The reliability and quality of cognitive case formulation. Behaviour, Research and Therapy, 43(9), 1187–1201. Quinsey, G., Harris G., Rice, M. and Cormier, C. (1996) Violent Offenders: Appraising and Managing Risk. Washington, D.C.: American Psychological Association. Skinner, B.F. (1938) The Behaviour of Organisms. New York: Appleton-Century. Skinner, B.F. (1953) Science and Human Behaviour. New York: Macmillan. Webster, C.D., Douglas K.S., Eaves, D. and Hart, S.D. (1997) HCR-20: Assessing Risk for Violence (Version 2). Burnaby, BC: Mental Health Law and Policy Institute, Simon Fraser University. Wilson, K.G. and DuFrene, T. (2009) Mindfulness for Two: An Acceptance and Commitment Therapy Approach to Mindfulness in Therapy. Oakland, CA, New Harbinger.


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Chapter 7

FORENSIC CASE FORMULATION, SUBSTANCE ABUSE DISORDERS, AND ANGER ELLEN VEDEL Jellinek Substance Abuse Treatment Center, Amsterdam, Holland, The Netherlands

PAUL M.G. EMMELKAMP University of Amsterdam, Holland, The Netherlands

INTRODUCTION A relatively large number of substance abusing patients will come into contact with the criminal justice system. The relationship between substance use disorder and criminal behavior is complex and in the treatment of substance abusing and offending patients a thorough case formulation is needed to insure that the different problem areas, substance use, criminal behavior but also associated concurrent disorders are assessed properly and that the right screening and diagnostic tools are used. In the context of such a case formulation clear hypothesis are formulated about how these problem areas are related, which behaviors should be targeted first and which specific interventions are probably most effective. This chapter starts with a short overview of the literature on the relationship between substance abuse, criminal behavior and associated problems. Different assessment tools are discussed, after which a case is presented of a male substance dependent patient with a history of criminal and violent behavior.

Substance Use Disorders and Criminal Behavior Although there is consensus in the literature about a relationship between substance abuse and offending, different interpretations of the nature of the relationship abound, varying according to the substances used, the specific sample studied, such as normal populations (McKinney et al., 2010), forensic populations Forensic Case Formulation, First Edition. Edited by Peter Sturmey and Mary McMurran. C 2011 John Wiley & Sons, Ltd. Published 2011 by John Wiley & Sons, Ltd.


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(Kraanen, Scholing and Emmelkamp, 2010), substance abusing populations (Chermack et al., 2009), and the social context (Erickson, Macdonald and Hathaway, 2009). Instances of reckless criminal behavior may be directly due to intoxication and in severely dependent substance abusers crime may be a means to obtain money for financing their substance use. Also, underlying vulnerabilities and personality pathology have been held responsible for both criminal behavior and substance use disorders. For example, there is some evidence from longitudinal studies that experiencing childhood abuse in youth is a significant risk factor for not only alcohol and drug use (Burnette et al., 2008), but for crime and violence as well (Thornberry et al., 2010).

Substance Use Disorders and Violence In the US, 40–50% of all murders, over 50% of rapes and over 50% of deaths resulting from car accidents are alcohol-related. Together with bipolar disorder and psychosis, substance use disorders are associated with relative high prevalence rates of interpersonal (Corrigan and Watson, 2005) and partner violence (Kraanen, Scholing and Emmelkamp, 2010; Moore et al., 2008). In the case of alcohol, violence can often be explained by the ingestion of alcohol before the violent offense (H˚aggard-Grann et al., 2006). Cannabis use may be connected to violence not by the direct intoxicating effects of the drug but rather via withdrawal from the substance. There is some evidence that during withdrawal from cannabis subjects report greater irritability. However in the case of young marijuana dependent patients, violent offenses can best be explained by a juvenile history of conduct disorder (Arseneault et al., 2000). Also in sexual violence there is a clear relationship with substance abuse. In a recent review, it was concluded that about half of sex offenders had a history of substance abuse, a quarter to half had a history of alcohol misuse and that about one-fifth to a quarter had a history of drug misuse (Kraanen and Emmelkamp, 2011). Furthermore, about a quarter to half of the sex offenders appeared to be intoxicated at the time of the offense. Another aspect of violence is violence toward the self. Suicidal behavior and substance abuse are closely linked. In a review of studies on suicide in alcohol dependence, Inskip, Harris and Barraclough (1998) found that substance abusers were seven times more likely than nonsubstance abusers to commit suicide. In opiate users and mixed intravenous drug users, the risk of committing suicide was found to be even greater (Wilcox, Conner and Caine, 2003). This high prevalence of suicidal behavior in patients with substance use disorders can partly be explained by the high prevalence of other psychiatric disorders which are associated with suicide, like depression. However, it is not only the presence of the comorbid disorder on its own, which explains the elevated risk for suicide. Depressed patients who abuse alcohol are more likely to commit suicide compared to non-abusing depressed patients (Dumais et al., 2005). Clinicians should be particularly alert for the increased risk of suicide not only with depressed patients, but also with impulsive substance abusing patients (often with borderline or antisocial traits.) It is wrong to assume that impulsive aggression in substance abusers is limited to violence


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toward others (e.g., intimate partner violence); many suicides are committed as an impulsive act when intoxicated.

Substance Use Disorders and Personality Disorders A substantial number of substance abusers share personality characteristics that predispose them to criminal behavior, such as antisocial personality disorder. In recent years a great deal of research attention has been given to the relationship between personality disorder and substance abuse, most notably with borderline personality disorder and antisocial personality disorder. In the National Comorbidity Survey (NCS) community study, the odds ratio for comorbidity between antisocial personality disorder and substance and drug use disorders were 11.3 and 11.5 respectively (Emmelkamp and Vedel, 2006; Emmelkamp and Kamphuis, 2007). The median reported prevalence rates of substance abuse disorder in borderline patients is 67% and the median prevalence rate of borderline personality disorder within substance abuse populations is 18% (van den Bosch et al., 2002). The emphasis in this chapter is on a substance abusing patients diagnosed with antisocial personality disorder. Patients with antisocial personality disorder tend to disregard the rights of others and are prone to unethical behavior. Antisocial personality disorder is often associated with drug and alcohol problems and criminal behavior. People with antisocial personality disorder tend to be irresponsible, and do not “learn” from previous mistakes. For example, they are often unable to keep a job or meet adult financial responsibilities. As a result of low frustration tolerance, antisocial personality disorder patients can be quite aggressive and impulsive. More often than not, remorse and guilt are absent for the negative consequences their behavior may have for others; in fact, some may derive pleasure from the suffering of others. There are also more cunning and planful variations, however the formal classification of antisocial personality disorder in the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 2000) heavily emphasizes the antisocial behaviors, which sets it apart from the concept of psychopathy. There is an extremely high comorbidity between substance abuse and antisocial personality disorder, higher than with any other mental disorder (Emmelkamp and Vedel, 2006). It should be noted that in a number of substance dependent patients the diagnosis of antisocial personality disorders is not warranted. Although these patients formally fulfill the necessary criteria, their antisocial behaviors may be the result of their substance use disorder, rather than the result of a personality disorder (Emmelkamp and Vedel, 2006). Many clinicians hold that substance dependent patients with antisocial personality disorder have poorer treatment outcomes compared than patients without antisocial personality disorder. Earlier studies supported this notion, but poor prognosis and response to treatment may have been confounded by pretreatment severity. Substance abusing patients with antisocial personality disorder often use more alcohol and drugs and have more associated legal and psychiatric problems at baseline compared to substance dependent patients without antisocial personality disorder (Verheul et al., 1998). Results of studies with substance dependent patients indicated that those with co-occurring antisocial personality disorder were


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more disabled at baseline and follow-up, but improved as much as the patients without antisocial personality disorder (Cacciola et al., 1995; McKay et al., 2000). In a review of treatment outcome studies of opiate dependent drug users meeting the criteria for comorbid antisocial personality, few differences were observed for those with and without antisocial personality disorder receiving treatment for opioid dependence with respect to retention, reductions in HIV risk behaviors, and drug use (Havens and Strathdee, 2005). However, in those continuing to use cocaine and benzodiazepines while enrolled in a methadone program, response to psychotherapy and pharmacological therapy was lower among opiate users with comorbid antisocial personality disorder.

Assessments in Substance Use Disorder Screening Instruments A number of screening instruments for substance use problems have been developed. For alcohol use disorders, the Michigan Alcoholism Screening Test (MAST; Skinner and Sheu, 1982) or the Alcohol Use Disorder Identification Test (AUDIT, Babor et al., 1992) can be used. The AUDIT has also been adapted to include drug use (AUDIT-ID, Babor et al., 2001; Campbell et al., 2004). An alternative drug screening instrument is the Drug Abuse Screening Test (DAST, Skinner, 1982). In adolescents, the Drug Use Screening Inventory (DUSI-R; Tarter, 1990) can be used. One subscale of this instrument, the Violence Proneness Scale (VPS), predicts aggressive events three years (Kirisci, Tarter and Reynolds, 2009) to seven years later (Tarter et al., 2002).

Structured Interviews The Time-line follow-back interview (TLFB; Sobell and Sobell, 1996) is a semistructured interview and uses a retrospective method for assessing alcohol and drug use patterns and related events and possesses adequate reliability. The TLFB procedure estimates daily alcohol/drug use through the employment of various memory aids, such as a daily calendar, key dates (e.g., birthdays, personal events, clinic appointments, visits from family), anchor points ([un]employment, illnesses, holidays), and other memory aids to facilitate recall. The TLFB provides useful information about antecedents and consequences of heavy drinking and illicit drug use and of high-risk situations for relapse, which may be of help for treatment planning. The Addiction Severity Index (ASI; McLellan et al., 1992) is a semistructured interview and provides a comprehensive assessment of substance use (history, frequency, and consequences of alcohol and drug use). In addition, it assesses family history, psychological symptoms, health problems, and legal issues. ASI scores on the major domains may be used to plan treatments targeting these domains. The ASI is available free of charge, and takes roughly 45–60 min to administer.


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Measuring Dependence and Impaired Control To evaluate the degree of alcohol dependence, the Severity of Alcohol Dependence Questionnaire (SADQ, Stockwell et al., 1979) may be used. A score of 31 or higher on the 20-item SADQ correlated with clinicians’ ratings of severe dependence, while a score of 30 or less correlated with ratings of mild to moderate dependence. Related to the degree of alcohol dependence is impaired control over drinking, which can be assessed with the Impaired Control Scale (ICS: Heather et al., 1993). This instrument showed good evidence of reliability, concurrent validity (Heather, Booth and Luce, 1998; Marsh et al., 2002) and predictive validity (Heather et al., 1998). The clinical value of the ICS and the SADQ include their use in deciding the recommended drinking goal of treatment: moderate drinking versus abstinence.

Measures to Assess High-risk Situations, Motives, and Coping A number of paper and pencil measures are particularly useful for the purpose of conducting functional analyses and understanding patterns of substance use. These instruments offer the clinician a profile of high-risk situations, and motives or reasons patients may endorse for substance abuse. This information can provide guidelines tailored to each individual patient for how to manage high-risk situations. The Inventory of Drinking Situations (IDS; Annis, 1982) and the Inventory of Drug-Taking Situations (IDTS; Annis and Martin, 1985; Turner, Annis and Sklar, 1997), which assess specific antecedents of alcohol and drug use. Motives or reasons for drinking may also provide important information for treatment planning. Measures include the 14-item Reasons for Drinking Scale (Farber, Khavari and Douglass, 1980), and the 15-item Drinking Motives Measure (Cooper et al., 1992), which contains subscales for social, coping, and positive affect enhancement motives. The following measures can be helpful in selecting inadequate specific coping skills, which may be targeted in treatment: the Situational Confidence Questionnaire for alcohol abusers (Breslin et al., 2000), and for substance abusers (Barber, Cooper and Heather, 1991). These measures were developed to assess substance abusers’ confidence in their ability to resist urges to use. The Drug-Taking Confidence Questionnaire (DTCQ; Sklar, Annis and Turner, 1997) assesses coping self-efficacy for a number of different types of drug and alcohol use.

Assessment of Comorbid Axis I and Axis II Disorders The Structured Clinical Interview for DSM–IV Axis I (SCID-I; First, Spitzer, Gibbon and Williams, 1995a) can be used to confirm substance use disorder diagnosis and to establish whether there are comorbid disorders. Two measures can be used for assessing personality disorders: (1) the Personality Diagnostic Questionnaire-4 (PDQ-4; Hyler, 1994) and (2) the Personality Assessment Inventory (PAI; Morey, 2007). Both measures, however, have the tendency to overrate, thus it is clinically wise to confirm a positive diagnosis using the Structured Clinical Interview for DSM–IV Axis II (SCID-II; First et al., 1995b). It is important to note that many psychiatric symptoms can be the direct result of intoxication/substance abuse. It


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is advisable to assess comorbidity after a prolonged period of abstinence (rule of thumb: at least four weeks abstinence). In sum, when not working in the field of substance abuse treatment intake should always including screening for problematic alcohol and/or drug use. If a patient screens positive, quantity, frequency and the negative consequences of his or her substance use should be assessed. Preparing for treatment several further analyses of the problem behavior are needed. For example, assessing concepts such as selfefficacy and impaired control can give valuable additional information. Regarding the assessment of other Axis I and Axis II disorders, caution should be exercised when the patient is still active abusing substances given the likelihood of the psychiatric symptoms being substance induced.

CASE FORMULATION The case presented here describes the treatment of a patient referred through the criminal justice system to our substance abuse treatment center. The patient received a regular intake of two sessions, which is standardized practice at out institution. The intake was used to gather information to allocate the patient to the right substance abuse treatment intensity (outpatient, day hospital or inpatient treatment) based on stepped care principles. After this intake, the patient was referred to his therapist who used the first phase of treatment to increase motivation for change and to gather further information about the problem behaviors to enable a case conceptualization. Planning and practicing behavioral change (decreasing levels of substance use) often parallels the phase of gathering information about the problem behavior (substance use and craving) and is not postponed until after the making of a functional analysis. Tom (44 years of age) was referred through the criminal justice system to receive treatment for his substance use disorder after having been arrested in connection to armed robbery. The treatment in the substance abuse treatment center was mandatory, in exchange for early parole. Tom had a very long substance abuse history; he started using cannabis and alcohol at the age of 12 and by the time he was 17 he was using heroin, speed and cocaine as well. Parallel to his substance abuse, Tom started his criminal career. He dropped out of school at the age of 15, engaging in all kind of criminal activities. At the age of 20, Tom was arrested for robbery and assault and went to prison for the first time. After being released, Tom continued his criminal career and continued abusing substances. At the age of 26, Tom met Paula, who was also a substance user, with whom he tried to settle down. During this period Tom and Paul had two children. Both Tom and Paula were unsuccessful in cutting down on their substance use. Eventually, pressured by child welfare services, Paula’s sister and her husband got custody of the children. During the following years, Tom’s substance use became more severe and he became more and more aggressive. After a severe incident of domestic violence, Tom and Paula split up. A few months after their split-up, Tom – under the influence of drugs and alcohol – tried to commit suicide by driving his car off the road. At the hospital where he was admitted, Tom was seen by psychiatrist and diagnosed with


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antisocial personality disorder. In the years to follow, Tom repeatedly got arrested for assault and other criminal activities.

Information Gathered at Intake The Addiction Severity Index was used to assess Tom’s history, frequency and the negative consequences of his alcohol and drug use. In addition, family history, psychological symptoms, health problems, and legal issues were assessed. Before his last incarceration, Tom’s substance use was characterized by daily use of large amounts of alcohol and cocaine (snorting) and incidental use of cannabis. Tom had stopped his use of heroin and speed (amphetamine) several years ago. He reported problems with anger management, and financial and housing problems: after being released from prison he was staying with friends and was unable to find work. Tom was interviewed in detail about his angry outbursts in the past. In all incidents, he had been heavily under the influence of substances; during periods in which his substance use was significantly less (e.g., in jail) he reported no physically violent behavior. Tom’s probation officer was present at one of the two intake sessions and Tom was given clear information to what extent his probation officer would be informed about disclosures during treatment. The meeting together with the probation officer was also used to explore to what extent the probation officer and/or our outpatient treatment facility could support Tom in finding a job, vocational training, and stable housing. It was decided that Tom and his probation officer, together with one of our social workers, would focus on housing and finding a job. Treatment would primarily focus on changing Tom’s substance use and on his anger management.

Increasing Motivation for Change In many psychiatric conditions, like anxiety or mood disorders, the treatment goal is often clear from the start – the patient wants to get rid of his/her panic attacks or depressed mood. Although the treatment interventions to achieve change are often negotiated (as in the case of exposure in vivo), the treatment goal itself is seldom a topic of discussion. In the treatment of substance use disorders, patients often enter treatment without the wish to get rid of the problem behavior (i.e., stop drinking or drug taking behavior); rather, they desire to moderate their substance use, or reduce the harmful/negative consequences of their use without stopping use altogether. This ambivalence about behavior change is in many ways comparable with the ambivalence or low motivation observed in patients entering forensic treatment facilities. The “old school” therapeutic way of dealing with “unmotivated” substance abusing patients was a confrontational approach, which was thought to be necessary to overcome the resistance of the patient, the ‘pathological denial’ of substance abuse, and the perceived inherent lack of motivation about changing substance abuse. These characteristics were often seen as inherent qualities of the patients themselves. Around 1980, a new style of interviewing substance abusing people who were ambivalent about change emerged (Miller, 1983). The clinical


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method of Motivational Interviewing was developed specifically to work through this ambivalence and to enhance intrinsic motivation for change. Motivational Interviewing combines a supportive and empathic counseling style with a directive method for resolving ambivalence in the direction of change. Thus, this therapeutic approach integrates relationship building principles of nondirective therapy (Rogers, 1961) with active behavioral strategies directly related to the patient’s stage of change according to the model of Prochaska and DiClemente (1982) and has been found moderately effective in motivating patients to change substance abuse (Emmelkamp and Vedel, 2006). In the case of Tom, it may not come as a surprise that he was not very enthusiastic about his mandatory substance abuse treatment. During the first phase of treatment, motivational interviewing techniques were used to increase intrinsic motivation for change. We focused on the three critical components of motivation: being ready, willing and able. “Willing” stands for the extent to which a person (in this case Tom) wants, desires or wills changes in substance use and aggressive behavior. “Able” stands for the confidence the person has that change is possible (general efficacy) and the confidence a person has that he is able to make that change (self-efficacy). “Ready” refers to the extent to which the person gives change priority above other issues. One of the motivational techniques used to explore Tom’s ambivalence was the ‘the balance sheet’. Tom was asked to list out the advantages and disadvantages of change versus the advantages and disadvantages of not changing (Miller and Rollnick, 2002). Because the advantages and disadvantages of change may vary per substance, Tom was instructed to make separate balance-sheets, one for cocaine and one for alcohol. Tom’s balance sheet also helped to explore the relationship between his substance use and his criminal lifestyle and how changing his substance use may influence his criminal lifestyle (see Tables 7.1 and 7.2).

Table 7.1 Balance sheet – alcohol. Advantages of using

Disadvantages of using

Short-term: - Better able to relax - Makes me feel ‘alive’ Long-term:

Short-term - Getting into trouble with you and my probation officer - Having hangovers Long-term: - Not able to lead a normal life - Bad for my health

Advantages of change

Disadvantages of change

Short-term: - Keeps the probation officer of my back - Saves me money Long-term: - Better for my health - Will be able to have stable contact with my children

Short-term: - Not able to blow off steam - Can’t hang out with my friends Long-term: - Life will become boring


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Table 7.2 Balance sheet – cocaine. Advantages of using

Disadvantages of using

Short-term: - Gives a tremendous Kick/very nice feeling - Don’t feel anxious while being on the job/ doing my thing. Long-term: - None

Short-term - Paranoia - Need other substances to counter the negative side effects of cocaine - Getting in trouble with you/the treatment clinic and probation officer - Expensive Long-term: - Eventually it will kill me - Will not be there for my children - Very expensive, have to resort to crime to finance this way of living - Getting into jail

Advantages of change

Disadvantages of change

Short-term: - Keeps the probation officer of my back - no paranoia Long-term: - Will be able to get a new lifestyle - Saves money

Short-term: - None Long-term: -Have to leave my old lifestyle behind

Building a Therapeutic Relationship The first phase of treatment was not only used to increase motivation for change but was also use to increase the quality of the working alliance/therapeutic relationship between Tom and this therapist. A number of patients with antisocial personality traits are characterized by a fearful attachment style (Timmerman and Emmelkamp, 2006). This attachment style is characterized by avoidance of close relationships because of fear of rejection, a sense of personal insecurity and a distrust of others. Most of them have a history of early traumatic experiences (Zanarini and Gunderson, 1997) in which parental figures often play a causal role in violating their trust in them. Further, in an addictive and often criminal milieu, distrusting others might be of major importance to ‘survive’. Further, many patients with a criminal history feel unfairly treated by the criminal justice system. Difficulties in the treatment of individuals with antisocial personality traits often have to do with fear of trusting therapists and fear of showing vulnerabilities. Individuals with antisocial personality traits are, in general, reluctant to be open about their emotions and the problems they encounter. Acting in a brutal, manipulative, or avoidant manner is often done in order to keep others at an emotionally safe distance. For clinical practice, this implies that effort will be needed to build a good therapeutic relationship and a safe environment in which the patient with antisocial personality traits dares to be open about the difficulties he is facing. Even the smallest suspicion of unreliability on the part of therapists can immediately undo the trust that was built (Timmerman and Emmelkamp, 2006).


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During the first phase of treatment, we tried to enhance the working alliance between Tom and his therapist by keeping sessions primarily focused on current substance use and associated problems. Tom was not prompted for emotional disclosure nor was he extensively questioned about his background (being a child of alcoholic parents), his life with Paula, and his children.

Monitoring the Problem Behavior Tom’s willingness to change his substance use and aggressive outbursts increased as a result of the motivational techniques and the problem-focused working alliance, so the time was right to introduce the self-monitoring diary. Monitoring problem behavior helps to elucidate the conditions under which the behavior occurs. Diary information can illuminate crucial associations between the problem behavior and critical events (antecedents and consequences of the problem behavior). In the treatment of substance use disorders, self-monitoring of daily craving and substance use enables the patient and the therapist to identify specific recurring situations, thoughts, or feelings that elicit craving and to identify the positive and negative consequences of the problem behavior. This information can later be use to construct a functional analysis. In general, such diaries address the following questions: 1. 2. 3. 4. 5. 6. 7.

Which day and what time was it (external cue)? What was the situation you were in (external cue)? What were your thoughts while you were in this situation (internal cue)? How did these thoughts make you feel (internal cue)? Did you experience any bodily sensations (internal cue)? What was the intensity of your craving, between 0–100 (internal cue)? What happened next, how did you cope (did you use substances and if yes what and how much?) 8. What were the consequences of this coping behavior? Because of Tom’s anger issues, we added a second diary, one specifically monitoring feelings of anger (between 1 and 100) and monitoring aggressive behaviors (e.g., yelling, throwing things, fighting). Contrary to our expectations, Tom was quite motivated to monitor his craving, substance use and anger. In addition, we asked Tom to complete three questionnaires: the Inventory of Drinking Situations (IDS; Annis, 1982), the Inventory of Drug-Taking Situations (IDTS; Annis and Martin, 1985;Turner, Annis and Sklar, 1997), and the Drug-Taking Confidence Questionnaire (DTCQ; Sklar, Annis and Turner, 1997).

Setting Goals for Treatment Together with Tom we discussed the specific goals for treatment. Tom had become increasingly motivated to changing his cocaine use (and recreational use of cannabis) and was prepared to strive for abstinence for at least the next 12 months;


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however, regarding his alcohol use, Tom remained ambivalent and wanted to strive for controlled use. In the literature, there is much debate about whether controlled alcohol use is a realistic treatment goal (Emmelkamp and Vedel, 2006). The fact is that some patients are able to reduce their alcohol intake to nonharmful levels and that, from a motivational perspective, demanding abstinence as the only realistic treatment goal is therapeutically unwise but you may have to recommend abstinence, e.g., if you have a seriously physical ill dependent drinker. In the case of Tom we proposed a ‘behavioral experiment’, which is an effective way of letting patients discover from their own experience whether moderation is a realistic goal. We explained about acceptable limits to drinking behavior, both in terms of the number of drinks per day and the number of alcohol-free days a week. As a general guideline, we used the following limits: not more than three drinks a day and a minimum of three alcohol free-days per week. In addition, patients are discouraged from drinking in high-risk situations because this will interfere with learning new coping skills, as well as enhance the likelihood of lapsing. If a patient is unable to keep the agreed goals in assignments, the belief endorsed by the patient that he or she is able to control drinking is empirically rejected. Difficulties encountered in such a guided attempt at moderation can lead to increased motivation for abstinence. Tom wanted to be able to drink during the weekends, the limit of “only” three units (a standardized unit is defined as containing 10 milliliters of pure alcohol/ ethanol) per day, however, he found unacceptable. We negotiated a maximum of 5 units on Friday and 5 units on Saturday for a period of two weeks. During this behavioral experiment, Tom was asked to continue monitoring his craving and substance use using the diary. During these two weeks, Tom was unable to limit his alcohol use to 5 units per night, and, during several alcohol binges, Tom lapsed into cocaine use as well. Tom was very disturbed by the fact that even when “putting his mind into it” he was unable to control his drinking, and he was even more distressed by lapsing into cocaine use. We used the next session to renegotiate goals for treatment and Tom committed himself to abstinence from alcohol for a period of 12 months.

Functional Analysis Using the self-monitoring diary, with recordings of craving and substance use, and the two questionnaires, a functional analysis was constructed. A functional analysis is a hypothetical working model of the problem behavior (e.g., substance abuse) from which specific treatment interventions are derived. The key questions that we attempted to answer in the functional analysis were the following: (1) What are the situations in which craving and substance use occur? (2) Which responses (emotional, physiological, cognitive, overt behaviors) occur? and (3) What are the consequences of substance use that reinforce use? There are different kinds of consequences that can reinforce substance use. The most obvious are positive rewards, for example an increase in self-esteem, and negative reinforcement, for example a decrease in anxiety or depressed mood. Because antecedent and consequences


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FORENSIC CASE FORMULATION EXTERNAL CUES

Situation Being home alone Having been in contact with government officials/or agencies (authority figures) Specific days or times of the day Evenings and weekends most difficult

Specific places Specific pubs

Specific people

Other specifics

Some drinking pals

Alcohol ads of TV

⇓ INTERNAL CUES Thoughts They are out to make my life miserable They want to get me down

Feelings Angry

Bodily sensations Tense muscles

⇓ CRAVING Physical manifestations Dry throat

Cognitive manifestations I need a drink now!

Behavioral manifestations Restless

⇓ BEHAVIOR What substance Alcohol

How much Between 10–15 units

How is it used Oral

⇓ CONSEQUENCES

Short-term

Long-term

POSITIVE Decrease in tension Increase in feeling capable of facing the troubles ahead

NEGATIVE Increased craving for cocaine Loss of control

None

Health problems Disturbs relation with children

Figure 7.1 Functional analysis of alcohol use.

may vary by substance, we made a functional analysis by substance (see Figures 7.1 and 7.2). Tom’s diary revealed a close link between increased craving for alcohol and high levels of anger (internal cue) which was associated with interacting with specific people (external cue). Cocaine craving was clearly associated with being under the influence of alcohol, feeling bored and negative self-talk (internal cues).


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EXTERNAL CUES Situation Going out for a walk with no specific plan of where I want to go / what I want to do Seeing other people surrounded by luxury (expensive cars, restaurants)

Specific days or times of the day Evenings Weekends

Specific places

Specific people

The inner-city

Meeting/talking to friends “from the old life”.

Other specifics Being under the influence of alcohol

⇓ INTERNAL CUES Thoughts This is not fair I won’t be able to change my ways and become a “normal” person

Feelings Anger

Bodily sensations Headache

⇓ CRAVING Physical manifestations Tense muscles Sensations in stomach

Cognitive manifestations Just using once won’t be a big problem

Behavioral manifestations Restlessness

⇓ BEHAVIOR What substance Cocaine

How much 1–3 grams

How is it used Snorting

⇓ CONSEQUENCES

Short-term

Positive Physical arousal Feeling superior No negative thoughts about the future/past

Long-term

Figure 7.2 Functional analysis of cocaine use.

Negative Start drinking even more alcohol

Increase paranoia Increase likelihood of aggressive behavior • Need money; will resort to stealing/dealing


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Treatment Plan Because Tom had no substance abuse treatment experience, we introduced an evidence-based cognitive behavioral treatment (CBT) program for substance use (for review see Emmelkamp and Vedel, 2006) and we added an anger management module. The treatment rationale of the CBT program was explained to Tom, namely that from a cognitive behavioral perspective, substance abuse and dependence is defined as a habitual, maladaptive method for attempting to cope with the stresses of daily living. This maladaptive way of coping is triggered by internal and external cues and reinforced by positive rewards and/or avoidance of punishment (Monti et al., 1989). The treatment thus focused on overcoming skill deficits. Different techniques are used to increase the ability to detect and cope with high-risk situations that commonly precipitate relapse. Treatment is characterized by monitoring problem behaviors and cognitions, behavioral practice, and homework assignments.

Avoiding Cues versus Learning to Cope Differently Overall there are two main strategies that target the antecedents of the problem behavior. Tom could try to avoid cues that trigger substance use or could learn to deal differently with high-risk situations. Avoiding strategies are in general easier to apply compared to learning new coping skills but, although being an effective short-term solution, not all high-risk situations can be avoided and some are so strongly intertwined with living conditions that avoiding them permanently is in fact unrealistic. Together with Tom, we listed all situations that were linked with an increase in craving or an elevated risk for lapsing to alcohol or cocaine use. We discussed which of these situations Tom was able and willing to avoid.

Coping Skills: Handling Craving Almost all patients experience craving in response to changing their drinking or drug taking habits, although its intensity and frequency differ greatly among individual patients (and substances). Tom reported frequent and intense craving in his diary recordings. Because craving is closely linked to (re)lapse and sometimes highly disturbing to patients, it is important to target craving early on in treatment by educating patients about the phenomenon, addressing distorted beliefs about craving (Tom: “If I experience craving, this is a sign of weakness and lack of motivation”), and teaching new coping skills. We introduced the five main strategies of coping with craving: distraction, social support, recalling the negative consequences of substance use, supportive self-talk, and mind-surfing. Tom was prompted to experiment with all these strategies under different circumstances and found distraction (taking a long walk, watching a movie, taking a shower) and recalling the negative consequences of substance use (thinking of his time in jail, how his substance use damaged the lives of his two children) the most effective. Although Tom effectively used these skills to handle craving, his level of alcohol


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craving remained high. We discussed the option of anticraving medication as an add-on to the psychological treatment and Tom was referred to one of our medical doctors. Tom was prescribed naltrexone (anticraving medication) which had a positive influence on his level of craving.

Coping Skills: Handling Anger We used an adaptation of an anger management treatment protocol developed for substance abusing and/or mental health patients as an add-on to our regular CBT substance abuse treatment program (Reilly and Shopshire, 2002). Tom was asked to make a balance sheet of the pros and cons of aggressive behavior versus the pros and cons of change (not reacting in an aggressive fashion). We discussed with Tom the issue of when anger becomes a problem and the myths about anger (e.g., anger automatically leads to aggression, anger is an effective way of getting what you want). We used Tom’s diary recordings to identify events associated with anger build-up and identified Tom’s physical, behavioral, emotional and cognitive cues when feeling angry. We introduced the time-out procedure and other strategies to enable behavioral control when feeling angry. We also introduced relaxation training but Tom was not very fond of this particular intervention and refused to rehearse in-between treatment sessions.

Relapse Prevention During treatment, Tom encountered many high-risk-situations. Often he was quite able to cope effectively, but sometimes he lapsed into substance use. This is a common phenomenon; in fact, most patients lapse during the course of treatment and many experience relapses during or after finishing treatment. In 1985, Marlatt and Gordon presented their very influential cognitive behavioral model of the relapse process. The model gives a detailed classification of factors or situations that can precipitate or contribute to relapse episodes. The key elements of this model are seemingly irrelevant decisions, possible poor coping skills, possible low selfefficacy and the abstinence violation effect. The model postulates that entering a high-risk situation is often preceded by seemingly irrelevant decisions. These small decisions or rationalizations apparently have no direct link with direct alcohol or drug use, however, they enhance the likelihood of entering a high-risk situations. In response to entering a high-risk situation, a patient may effectively use coping skills that will increase self-efficacy and thus decrease the likelihood of relapse. If coping skills are not used or not used effectively, self-efficacy will decrease and the positive outcome expectancies for the effects of alcohol or drugs will increase. This will enhance the likelihood of lapse, which will trigger the abstinence-violation effect. The abstinence-violation effect refers to feelings of guilt, shame and failure in reaction to a lapse, which instead of strengthening the patient to remain abstinent triggers thoughts of the perceived positive effects of alcohol or drugs use and thus enhances the likelihood of renewed alcohol or drugs use in order to cope with these negative thoughts and emotions.


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We used Tom’s diary records to identify seemingly irrelevant decisions and Tom’s negative self-evaluation associated with the abstinence-violation effect. We constructed a relapse prevention plan to cope effectively in the case of a lapse to prevent a full relapse which consisted of: (1) things Tom could do during the lapse to prevent full relapse; (2) identify helping thoughts that would counter negative self-talk during the lapse; (3) plan whom Tom could ask for social support during and after the lapse to prevent full relapse; and (4) plan specific behaviors after the lapse to prevent relapse. We used lapses during treatment to test the effectiveness of the relapse prevention plan and to make adjustment.

Role Play We extensively used role-play during the treatment sessions. We wanted to prepare Tom for situations in which, were he to be offered alcohol or drugs, the likelihood that he would be able to withstand temptation or social pressure would be increased. During role-play, we not only rehearsed the verbal component of refusing but also paid attention to body language and the behavioral expression of refusing (for example, by walking away). In addition to skill enhancement, we also scanned for possible dysfunctional beliefs that would interfere with practicing refusal skills (e.g., “They’ll think I’m a loser”).We also used role play to practice nonaggressive assertiveness and – very important to Tom – how he effectively could interact with his teenage children and their caretakers (his ex-wife’s sister and her husband).

Treatment Progress Three months into treatment, Tom had a 4 day relapse into alcohol and cocaine use. This relapse was triggered after several frustrating interactions with a housing agency. The relapse paralleled a motivation crisis and Tom did not show up for several treatment sessions. We chose to set the CBT program on hold and return to motivational interviewing techniques to explore Tom’s renewed ambivalence. During these sessions, Tom opened up more about feeling down, being pessimistic about the future and feeling guilty about things from the past. Tom confirmed that dysphoric mood had frequently triggered craving. Subsequently, we focused on helping Tom to recognize and identify negative cognitions that were associated with his depressed mood and how his depressed mood was associated with specific behavior (inactivity). We combined cognitive restructuring with reinforcement for constructive and pleasant behaviors. We listed out activities Tom used to enjoy but had ceased doing, and scheduled these as homework assignments. After 6 months in treatment, Tom was finally accepted at a combined housing and vocation training program for ex-convicts. This special program had a zerotolerance policy regarding alcohol and drug use and, although Tom found this policy highly annoying, it stimulated him to remain abstinent, which he succeeded in doing. The anger management module helped Tom to cope more effectively when feeling angry: during treatment there were several incidents of anger build-up and verbal aggression but no incidents of physical aggression.


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At the end of treatment, Tom’s probation officer started raising questions about the validity of the diagnosis antisocial personality disorder. Our observations were that Tom was avoidant in disclosing emotions, to some extent bitter and cynical about life and the intentions of others, but Tom also felt genuine remorse about behaviors in the past, including not being able to take care of his children. We concluded that at least for the past year, Tom had not met criteria for antisocial personality disorder (using the antisocial personality disorder section of the Structured Clinical Interview for DSM–IV Axis II, SCID-II). We also asked Tom to fill out the Drug-Taking Confidence Questionnaire (DTCQ; Sklar, Annis and Turner, 1997). Compared to the beginning of treatment, Tom showed an overall strong increase in self-confidence to withstand tempting situations.

Follow-up We had three follow-up sessions with Tom, one, three and six months after treatment. We used the TLFB method to assess drinking, drug use and violent behavior. During the second follow-up period, Tom relapsed into alcohol use after leaving the housing project and moving into a new apartment of his own. Tom contacted us and we scheduled 4 booster sessions to help Tom quit drinking again and handle this new situation with more liberties compare to living in the ex-convict housing project. Tom successfully remained abstinent during the third follow-up period. During the total 10 month follow-up period, Tom reported two incidents of verbal aggression while under the influence of alcohol; in several other incidents Tom had been able to use self-control (leaving the situation) to prevent escalation.

CONCLUDING REMARKS A number of evidence-based treatments are currently available for the treatment of substance use disorders, motivational interviewing and cognitive behavioral interventions being the most thoroughly tested and most effective (Emmelkamp and Vedel, 2006). The present case formulation shows that these treatments were also effective in a forensic case. Given the high prevalence of substance abuse in offenders (Kraanen et al., 2010; Kraanen and Emmelkamp, 2011), it is surprising to see that well-controlled studies using these therapies in violent offenders are lacking. Further, although these treatments are effective in a number of substance abusing patients, results in the long run are mixed; unfortunately lapses and relapses in substance abuse is rather common. In violent offenders, relapse in substance abuse may also lead to relapse in violence (Hirschel, Hutchison and Shaw, 2010; Mignone, Klostermann and Chen, 2009). There is a clear need of studies into treatment for substance abuse including regular booster sessions for substance abusing offenders. As illustrated in the description of this case, a case formulation based on a thorough assessment of the problem behaviors and the functional analyses of these behaviors is of paramount importance in the treatment of substance abuse in forensic cases. Although a number of treatments for substance-abuse are empirically supported, results cannot be generalized to forensic patients. Here, a thorough case conceptualization is a condition sine qua non.


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PART III

SEXUAL OFFENDING



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Chapter 8

SEXUAL OFFENSES AGAINST CHILDREN JAMES VESS Deakin University, Australia

TONY WARD Victoria University of Wellington, New Zealand

Assessment of individuals who commit sexual offenses requires knowledge of both the causes of sexual offending and effective means of reducing the risk of reoffending. Assessment involves the systematic collection of relevant information in order to detect clinically significant phenomena or problems in functioning, in order to provide clear treatment targets and risk management strategies. Without accurate assessment it is impossible to determine the nature of the risk an offender presents, nor the suitability and focus of intervention. Accurate assessment also allows for the subsequent determination of whether treatment has had a positive impact. In conducting assessments, practitioners must bring evidence based knowledge of sexual offenders as a population together with knowledge about a particular offender. In contemporary clinical practice this means taking into account a sex offender’s array of stable and acute risk factors. In essence, dynamic risk factors can be construed as distal, proximal, and contextual casual factors of sexual offending (Ward and Beech, 2004). The focus of this chapter is on psychological assessment and case formulation in the rehabilitation and risk management of individuals who have been convicted of sexual offenses against children. It begins with a review of the research literature on sex offender risk assessment, followed by a discussion of the relationship between risk, etiology and case formulation. Finally, a risk etiology framework for case formulation is applied to a clinical case example.

Forensic Case Formulation, First Edition. Edited by Peter Sturmey and Mary McMurran. C 2011 John Wiley & Sons, Ltd. Published 2011 by John Wiley & Sons, Ltd.


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RISK ASSESSMENT WITH SEX OFFENDERS There is now a large and growing professional literature on risk assessment with sex offenders. As the field of risk assessment with sex offenders continues to develop, there is a need to empirically identify the best measures and methods to use (Abracen et al., 2004; Borum, 1996; Miller, Amenta and Conroy, 2005). Although there is continuing debate over the optimal utilization of static and dynamic risk factors in the detection and management of risk (Quinsey et al., 2006, vs. Hanson and Harris, 2001; Craig, Browne and Stringer, 2004), actuarial measures have demonstrated a statistically significant level of predictive accuracy regarding the risk of sexual reoffending, and consistently outperform unstructured clinical judgement (Hanson, 1998; Hanson and Thornton, 2000). While their limitations need to be recognized, the predictive accuracy of these standardized measures for sexual reoffending is now well-established and widely utilized in judicial decision-making. The primary value of risk assessment using actuarial procedures is to convey the relative likelihood of specific types of reoffending, against specific types of victims, over specified periods of time, for subgroups of offenders sharing similar levels of specific risk factors. In addressing the statistical properties of such assessments, Hanson and Thornton (2000) have noted, “most decision makers are not particularly concerned about the ‘percent of variance accounted for’. Instead, applied risk decisions typically hinge on whether offenders surpass a specific probability of recidivism” (pp. 129–30). The probability for sexual reoffending based on available empirical measures of risk may vary depending on offender characteristics such as offender age and the types of victims in their offense history. One of the limitations of most current measures in common use is that separate recidivism rates for different age groups and for child versus adult victim sex offenders are largely unavailable. Hanson and Bussière (1998) reported an average sexual recidivism rate for rapists of 18.9% and a rate for child molesters of 12.7%, in contrast to Harris and Hanson (2004) who reported that rapists and child molesters had similar rates of sexual recidivism, although subgroups within the child molesters had significantly different reoffense rates. Recently reported research findings suggest that those who sexually offend against children and older offenders, as well as incest offenders and those with male victims, may sexually reoffend at different rates than younger offenders with adult victims or those that offend only against females (Skelton and Vess, 2008). A related issue is whether most sex offenders “specialize” in a specific victim type or even in sexual offending. Research suggests that there is a substantial degree of crossover in victim age between adult and child victims (Vess and Skelton, 2010).

Dynamic Factors One limitation to an actuarial measures that utilize only static factors is that they are insensitive to factors which may moderate the risk for an individual offender. Static measures also provide little information about the immediacy of


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the risk for reoffending, and therefore are not helpful in developing an ongoing risk management plan. Dynamic, changeable factors which have demonstrated an empirical association with sexual reoffending should therefore also be considered in the assessment and management of individual cases. These dynamic factors arguably constitute psychological vulnerabilities and can provide a more individualized understanding of risk, identify those factors that should be monitored over time in order to detect changes in risk, and indicate areas of focus for supervision and intervention efforts. There are two types of dynamic risk factors: Stable dynamic risk factors are defined by Hanson et al. (2007) as, “personal skill deficits, predilections, and learned behaviors that correlate with sexual recidivism but that can be changed” through intervention (p. i). Acute dynamic risk factors are defined as highly transient conditions that only last hours or days. These factors include “rapidly changing environmental and intrapersonal stresses, conditions, or events that have been shown by previous research to be related to imminent sexual re-offense (Hanson et al., 2007, p. i). The first commonly used measure for dynamic variables was the Sex Offender Need Assessment Rating (SONAR), an actuarially based measure of dynamic risk factors empirically related to rates of sexual recidivism (Hanson and Harris, 2001). The SONAR was developed to measure and evaluate changes in dynamic risk factors over time. The SONAR has more recently evolved into two separate measures to assess variables across the two domains of stable dynamic factors and acute dynamic factors. The STABLE-2007 identifies 13 stable dynamic factors (Hanson, et al., 2007). The ACUTE-2007 (Hanson et al., 2007) is designed to assess these factors, including items such as victim access, rejection of supervision, collapse of social supports, and substance abuse. Acute dynamic risk factors exert an influence in the immediate environment in close temporal proximity to potential sexual offending. It is therefore typically not possible to assess these factors meaningfully while an offender remains incarcerated, although it is sometimes possible to anticipate factors that may be present in the post-release environment and extrapolate from current functioning.

Combining Measures The assessment of dynamic risk factors using structured measures such as the STABLE-2007 results in a standardized score that is used to categorize an offender’s risk as low, moderate, or high risk. These results are then used to adjust the level of risk as measured by the static actuarial risk factors (e.g., using the STATIC-99) to yield an overall categorization of the offender’s assessed risk for sexual reoffending. Recent research on sex offenders has shown that risk predictions made by static actuarial measures can be enhanced by incorporating dynamic variables to give a fuller picture of individualized prediction of risk (Craig et al., 2004; Craissati and Beech, 2005). Studies have given empirical support to the hypothesis that including an assessment of dynamic factors can strengthen the utility of static actuarial measures designed to measure sexual recidivism (Beech et al., 2002; Thornton, 2002; Hanson and Morton-Bourgon, 2005).


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Reliability and Accuracy of Risk Assessment For the purposes of applied risk assessment with sex offenders, the first concern is interrater reliability. The key issue here is whether different assessment experts arrive at similar findings regarding risk, using standardized assessment measures. Actuarial measures, such as the Rapid Risk Assessment for Sex Offender Recidivism (RRASOR) and Static-99, have demonstrated consistently high levels of interrater reliability, with reliability coefficients of .90 and higher, largely because of highly specific scoring criteria involved in this form of standardized assessment measure (Barbaree et al., 2001; Doren, 2002; Sjostedt and Langstrom, 2001). Standardized measures of dynamic risk factors such as the STABLE-2000 and STABLE2007 have also demonstrated adequate interrater reliability when administered by trained assessors according to specified scoring criteria, with an interclass correlation coefficient of .89 for STABLE-2000 total scores (Hanson et al., 2007). As La Fond (2005), has stated, “Actuarial instruments reduce much of the variability in predictions that can generate very different results when individual clinicians bring their different training, experience, and normative preferences to the task of assessing sex offenders for risk.” La Fond goes on to note, “No serious dispute exists about the fact that these instruments only allow experts to conclude that a particular individual belongs to a group with certain risk factors; however, they cannot be used to state authoritatively that an individual has a certain probability of reoffending” (p. 53). The predictive accuracy of risk assessment measures for sex offenders has been reviewed in detail elsewhere, and is beyond the scope of the current chapter (Hanson and Morton-Bourgon, 2009; Vess, 2009). It is important to recognize that none of the statistical indices yet developed can completely answer the question of how accurate a risk assessment measure is (Gottfredson and Moriarty, 2006). Some researchers (Quinsey et al., 2006) have argued that Relative Operating Characteristic (ROC) analysis offers the best index of statistical accuracy because it is independent of the base-rate variations in different samples of offenders. Yet others argue that the base rate of sexual recidivism cannot be ignored in considering the accuracy of a given measure in a particular application. Knowing the relevant base rate, and its impact on the accuracy of risk predictions based on various measures, is important for making sense of statements made about the risk measures used in a particular case (Gottfredson and Moriarty, 2006). An important issue related to the accuracy of actuarial risk assessment measures is whether they can be appropriately applied with individual offenders. This issue was highlighted by Hart, Michie and Cooke (2007), who concluded that the margin of error for actuarial risk assessment instruments is far too great to be used to estimate an individual’s risk for future offending, and should be used with great caution or not at all; however, this position has been criticized on several points, as recently summarized by Craig and Beech (2010) who cite evidence that the replication studies for the Static-99 provide empirical evidence that is more consistent than would be the case if the measure were as inaccurate as Hart et al. (2007) assert, and suggest that the internal logic of their argument regarding risk in terms of probability is inconsistent. Additional criticisms have focused on the mathematical basis for the margin of error figures, whereby the substitution of the


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number “1” in place of the group figure of “n” in the formula used for calculating the margin of error renders the results uninterpretable (Mossman and Sellke, 2007; Harris, Rice and Quinsey, 2007). The idea that it is wrong to use group data as a basis for decisions about individuals has been refuted previously (Grove and Meehl, 1996; Harris et al., 2007; Quinsey et al., 2006). In light of the margin for error inherent in current actuarial measures, more individualized risk assessments are desirable, preferably those that take into account dynamic and aetiological factors (Ward and Beech, 2004). In our view, such assessments should culminate in a case formulation that depicts the etiological significance of the different dynamic risk factors that are present for the specific offender being assessed. The clinical use of these measures in a mechanical, formulaic way does not result in an explanatory formulation of risk that accounts for the idiosyncratic pathway to sexual offending, in other words the how and why of offending, for the particular individual who is being assessed. Such a formulation requires a detailed understanding of the specific behaviors, cognitions and affects that result in sexual offending (Vess, 2008).

Case Formulation and Risk Assessment Psychological assessment involves a systematic process of collecting, evaluating, and integrating relevant information about a client’s problems to arrive at conclusions about their nature, etiology, and implications (Ward and Haig, 1997; Ward, Vertue and Haig, 1999). A clinical assessment is said to be complete when the assessor arrives at a clear formulation of the client’s difficulties which enables the referral questions to be answered, at least provisionally. Relevant questions include: What are the main presenting problems or issues? How are these problems interrelated and what etiological explanations account for their occurrence? What options for modifying these difficulties are most likely to be efficacious for this person? Assessment is also an integral part of treatment in that practitioners must monitor and evaluate the effectiveness of their work with clients. This requires the establishment of rapport with the client. A forensic case formulation derived from the assessment process is a conceptual model representing an offender’s various problems, the hypothesized underlying mechanisms, and their interrelationships. It should be clearly linked to contemporary theory and research on offending behavior. A forensic case formulation is in effect a clinical explanation in the form of a testable hypothesis that specifies how an offender’s symptoms or problems are generated by psychological mechanisms, for example, dysfunctional core beliefs or behavioral deficits (Ward et al., 1999). Furthermore, a case conceptualization provides a rational basis for determining treatment needs that can be used to tailor interventions to individual offenders with the aim of achieving optimal outcomes, including but not limited to reduced reoffending. Optimal risk assessment and management requires the extension of case formulation skills, whereby risk factors are identified within an etiological framework (Ward and Beech, 2004). While it is important to be aware of the static and dynamic factors associated with a given type of risk, these factors


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are most useful for risk management purposes when they are formulated into a coherent set of interrelated causal mechanisms (Collie, Ward and Vess, 2008; Vess, Ward and Collie, 2008). This requires examination of several categories of contributing factors, including historical (e.g., offense history, past episodes of violence, previous treatment compliance and response, performance under supervision or parole), developmental (e.g., adverse developmental events, nature of family relationships, attachment style), cognitive (e.g., level of intelligence, cognitive distortions, attitudes supportive of criminality or violence), personality (e.g., psychopathy, or traits such as impulsivity and hostility) and clinical (e.g., psychiatric diagnosis, level of functioning, substance abuse). In light of these individual factors, it is important to recognize that risk is contingent upon current situational or contextual variables (Doren, 2002). Even high risk cases will not be at imminent risk at all times, but will vary in their likelihood of reoffending depending on such factors as access to victims, current degree of alcohol or drug use, access to and compliance with treatment and supervision services, the nature of interpersonal relationships and support systems, and current mood states. Thus, different individuals who have similar profiles in terms of their scores on various risk assessment measures will not necessarily respond in a similar way to the same interventions or risk management plan. The recidivism risk at any given time will emerge from an etiological process determined by the interaction of individual characteristics and contextual factors. A case formation is in essence a circumscribed theoretically-grounded hypothesis and provides an explanation of why an offender acted as he did, while pointing to areas of vulnerability and harmful behavior that ought to be the focus of treatment and management (Vess, Ward and Collie, 2008). The following example illustrates this approach to case formulation.

A CLINICAL EXAMPLE: THE CASE OF JOHN DOE John Doe was a 38 year old Caucasian male currently detained in a secure treatment facility under indefinite civil commitment as a dangerous sexual offender. He was committed to this treatment program after serving a seven year prison sentence for the sexual assault of three victims, two male and one female, under 12 years of age. This was his second prison sentence for sexual offending, with prior convictions for indecent assault of a male child and rape of a female child when Mr Doe was 24 years old, for which he served 4 years in prison. He has now been civilly committed for two years, and is due for a legally mandated review of his response to treatment and current risk for sexual reoffending.

ASSESSMENTS Risk Assessment Static Factors Mr Doe’s risk of reoffending based on static historical variables was assessed using the Static-99. His score of 5 on this instrument places him in what has been


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labeled the moderate-high risk category. Offenders in this category have been reported in previous research findings to show sexual reoffending rates of 33% at five years following release from prison, 38% at ten years post-release, and 40% at 15 years (Harris et al., 2003). More recent research with larger samples of sex offenders provide new norms for sexual recidivism rates associated with specific scores on the Static-99 (Helmus, Hanson and Thornton, 2009). Using what the researchers refer to as routine correctional samples of sex offenders, those with a score of 5 showed sexual recidivism rates of 10.2% at five years and 23.1% at the years post-release. Those from preselected high risk samples showed sexual recidivism rates of 11.8% at five years and 32.1% at ten years. These rates provide an empirically derived range of recidivism risk for those with Mr Doe’s score on the Static-99. By virtue of his civil commitment as a dangerous sexual offender, he is considered to more closely resemble the high risk samples of the most recent norms. Another way to represent Mr Doe’s risk for sexual reoffending is to report the rate for those with his score relative to the typical sex offender (i.e., someone with the median score of 2 in the most recent normative samples). Someone with Mr Doe’s score shows approximately two and a half times the rate of sexual recidivism relative to the average sex offender. The variables that place Mr Doe in this category include his prior sexual convictions, having male victims, unrelated victims, and lack of a stable intimate relationship.

Dynamic Factors Mr Doe’s risk based on dynamic factors was assessed using the STABLE-2007. The item on negative social influences assesses the nature of the offender’s primary interpersonal relationships. Mr Doe identified several family members as his closest relationships, and the information he provided suggests that none of them represent clearly antisocial influences on Mr Doe’s behavior (e.g., condoning sexual abuse, supporting alcohol or drug abuse, criminal activities, or defiance of the conditions of supervision). Mr Doe has not had a stable intimate relationship of at least two years duration, and therefore has not demonstrated a capacity for relationship stability. He shows clear signs of emotional identification with children but no significant hostility toward women. He demonstrates evidence of general social rejection and lack of concern for others. Impulsivity is currently less of a problem for Mr Doe than in the past, but he still occasionally displays impulsive behavior, particularly when he is under emotional stress. Similarly, he has shown improvements in his problem solving skills and negative emotionality, although in recent months he has had episodes demonstrating problems in both of these areas of functioning. Based on the current assessment of Mr Doe’s recent functioning, there is little evidence that he continues to experience the high levels of sexual preoccupation and sex drive that were evident in descriptions of his behavior when he was younger. The observations of the Prison Officers also suggest that Mr Doe is not a sexually preoccupied or sexually active prisoner. His self-reported sexual fantasy and masturbatory behavior suggest that he still occasionally uses sex for coping when faced with environmental or interpersonal challenges, such as when he has


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experienced conflict with other inmates or has been confronted about his behavior in during treatment. His past sexual offenses suggest the presence of a deviant sexual preference for sexual activity with pre- and postpubescent children of both sexes. The results of penile plethysmograph assessment demonstrates arousal to pre- and postpubescent children of both sexes. The approach recommended by the internationally recognized expert Karl Hanson and his colleagues (Hanson et al., 2007) for combining the results of actuarial risk measures such as the Static-99 and dynamic risk measures such as the STABLE2007 to arrive at an adjusted level of risk for sexual reoffending suggests that a moderate-high level of static risk combined with a high level of stable dynamic risk yields a high overall risk. As previously described, actuarial approaches to risk assessment work by placing an individual offender in a group of offenders with similar characteristics for whom specific sexual reoffending rates over time have been observed. In order to better understand the risk presented by the offender under consideration, an individualized formulation is needed, including other factors known to contribute to increased risk.

Psychopathy Mr Doe was assessed using the revised Psychopathy Checklist (PCL-R; Hare, 2003). Mr Doe’s score on the PCL-R placed him below the usual cut-off used to classify someone as a psychopath. His total score placed him slightly above the mean (average) for male offenders, in other words slightly above the 50th percentile of male offender populations. While Mr Doe does not score in the range of the PCL-R that is properly classified as highly psychopathic, and therefore at increased risk based on this factor, he does, however, show certain psychopathic features which will likely influence his response to treatment and externally imposed supervision requirements. These characteristics, such as shallow affect, lack of empathy, manipulation, impulsivity and irresponsibility, may make it more difficult for him to internalize the goals of a treatment program, and to form the trusting therapeutic relationships necessary to progress in treatment and reduce his risk of reoffending.

Conclusions Regarding Risk The results of the current risk assessment indicate that Mr Doe remains at high risk for sexual reoffending if released to the community. Based on his pattern of previous sexual offending, Mr Doe is most at risk of reoffending when he is experiencing environmental and interpersonal distress such as conflict with peers or perceived criticism from those in authority positions, resulting in negative affect such as loneliness and depression, accompanied by feelings of being worthless, incompetent, and rejected by others. If he has unsupervised access to children at such times, especially those with whom he has established a sense of familiarity and trust, these children become his most likely potential victims.


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ASSESSMENT FOR CASE FORMULATION In order to develop a case formulation for Mr Doe, information is needed beyond a list of the static and dynamic risk factors known to be associated with risk for sexual reoffending. What is required is a more comprehensive understanding of his developmental history and current functioning in a variety of domains, so that an integrated etiological, explanatory framework for his offending can be provided. Recalling the categories of factors identified earlier in this chapter, the following sources of information are relevant for his case formulation.

Developmental History Mr Doe was born into an extremely dysfunctional family environment. His father is reported to have had significant drug and alcohol abuse problems, and had several convictions for violent offending. Mr Doe and his sisters were sexually abused by their father from an early age. His mother was ineffectual at stopping the abuse, and in fact did not believe Mr Doe’s reports of the abuse. The abuse came to light after one of the sisters informed authorities at school, whereby Mr Doe’s father was arrested, convicted and imprisoned. Mr Doe was eight years old at this time. From this dysfunctional family history it must be concluded that Mr Doe suffered severe problems with early attachment and trust, demonstrated by his vacillation during childhood between clinging dependence and emotional withdrawal from others, which subsequently interfered with the development of a stable and functional sense of self. At a behavioral level, his primary models for interpersonal and sexual relationships were severely disturbed. His psychological and psychosexual development was severely compromised by the ongoing experiences of sexual abuse by his father. Added to this was Mr Doe’s lack of compensating physical or mental abilities, whereby he has been described as physically awkward and socially immature. He lacked the interpersonal skills to fit in with others, and resorted to provocative behavior in his attempts to make social connections. As a result he was taunted, bullied, and ultimately rejected by peers. This further eroded his sense of adequacy and worth. Mr Doe’s childhood was marked by enduring emotional and behavioral problems, poor school performance, and developmental delays. At 14 years of age he began using cannabis and abusing alcohol that he would steal from his mother. His poor performance and behavioral problems at school progressively escalated, and he left school at the end of year ten (age 15 years), having failed all his academic subjects. Mr Doe reports an unstable and largely unsuccessful work history after leaving school. He has held several unskilled jobs as a labourer, janitor, and dishwasher. The longest he has held a job is 9 months, and he typically quits or is dismissed following conflicts with fellow workers and supervisors. His job performance has also occasionally been compromised by his cannabis and alcohol use.


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Offense History Mr Doe has a total of 14 criminal convictions, including public intoxication, disorderly conduct, wilful damage of property, shoplifting, and cannabis possession. Mr Doe’s first sexual offending convictions were for indecent assault of a male child and two counts of rape of a female child when Mr Doe was 24 years old. These offenses occurred in the context of having returned to live with his mother following her separation from her second husband. The victims were a 12-year-old niece and 10-year-old nephew who were also residing at his mother’s house at this time. Mr Doe engaged in penetrative sexual intercourse with the female victim on two occasions and induced the male victim to touch his erect penis. Mr Doe has consistently denied that he used force in his sexual contact with these victims, which appears consistent with available court reports. Mr Doe’s index sexual offending consisted of the indecent assault of two 8year-old boys and unlawful sexual contact with an 11-year-old girl. These victims resided in the neighbourhood where Mr Doe was living following release from prison for his earlier sentence. Mr Doe enticed the victims into his apartment with offers of video games and candy, after which he engaged in touching the genitals of the male victims and performed oral sex on the female victim. He denies that there was any penetrative sexual contact with any of these victims, but has acknowledged in treatment that he would masturbate to fantasies of such activities with these children, and probably would have attempted to progress to greater sexual contact if given more time with the victims. During treatment, he disclosed additional sexual offenses against children of both sexes beyond those for which he has been convicted.

Treatment for Sexual Offending The most intensive and focused treatment Mr Doe has received appears to have occurred in the context of his current confinement in the dangerous sexual offender treatment program. This program has emphasized the usual components of treatment currently considered by most professionals to reflect the best standard of practice in the area of sex offender rehabilitation. These components include increasing the offender’s understanding of the chain of events that led to prior sexual offenses, identifying and understanding the role of deviant sexual fantasies and cognitive distortions, increasing empathy for victims, improving skills necessary for appropriate adult relationships, effective mood management, attempts to modify sexual arousal responses to inappropriate stimuli such as children, and the identification of high risk situations along with relapse prevention plans to deal with such situations. Mr Doe has made limited progress in these standard areas of treatment. His response to these initial treatment efforts provides additional information for the clinical formulation. He has been described as being able to verbalize an understanding of his chain of offense behaviors and high risk situations, but has failed to adequately demonstrate this understanding in his daily functioning and general


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self-management. This suggests that he requires additional guidance and support to enact his intellectual understanding in his behavior. Concerns remain about his deviant sexual arousal to children and the potential for inappropriate sexual fantasies involving both male and female children. This will require sufficient rapport with treatment staff to openly explore his sexual arousal patterns. This is related to areas of functioning which appear not to have been thoroughly addressed thus far in treatment that involve his distrust of authority figures, including treatment staff, his lack of appropriate adult relationship experiences, and general reintegration issues such as employment and independent living skills. Previous reports indicate that Mr Doe has at times been reluctant or ambivalent about addressing some of these sexuality issues in the context of available treatment.

Cognitive Factors Mr Doe has been assessed previously as low average to average in his intellectual functioning, with test results on three occasions since adolescence indicating Full Scale IQ scores ranging from 82 to 98, and no substantial deficits in adaptive functioning. He tends to be somewhat concrete in his thinking, but does not show overt intellectual impairment to a degree that will significantly compromise his response to cognitive-behavioral treatment modalities. He does appear to maintain cognitive distortions related to his implicit theories about self and others, especially his perceptions of children as legitimate partners who can responsibly enter into intimate relationships to meet his emotional and sexual needs. These cognitive distortions are particularly apparent during times of interpersonal distress, when Mr Doe finds adult interactions threatening.

Clinical and Personality Features The influences of Mr Doe’s developmental history are seen as contributing to his current personality features. One feature noted evident in the current assessment is Mr Doe’s profound lack of connection to emotional experiences, both his own and those of others. This quality is potentially suggestive of a schizoid personality traits, whereby an individual has a lack of emotional reactions and is not interested in relationships with others. Mr Doe, however, shows more dependent and avoidant personality features, whereby he appears to crave attention from and a connection to others, but feels inadequate to engage in trusting intimate relationships and routinely anticipates abuse, ridicule or rejection from others. These personality features are also suggested by the results of a recent Millon Clinical Multiaxial Inventory (MCMI-III) (Millon, 1997). Mr Doe had primary elevations on the scales for Dependent, Avoidant, and Self-Defeating personality patterns, along with a significant level of anxiety. Individuals with this profile desperately want to be accepted and involved with other people but this desire is blocked by intense fear of being rejected or ridiculed. They typically perceive themselves as socially inept, inferior, and inadequate. Because of their fear of social situations and close relationships, they may rely heavily on fantasy to gratify


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their needs for affection and to cope with their anger. This has the potential to restrict them to a solitary life where they are more likely to reactivate memories of past social rejections, rather than risk forming new, more satisfactory relationships. These dependency traits augment the core avoidant tendencies and add a desire to be supported and guided by others. The passive aggressive elements suggest the presence of moodiness and resentment, with significant difficulty trusting others. Such individuals may vacillate between being friendly and cooperative and then being hostile. They will subsequently often apologize in an attempt to be accepted again by others. As they are often uncomfortable with their anger, they may resort to covert expressions of hostility, such as passive obstructionism. A compounding factor for Mr Doe is his tendency to engage in excessive consumption of alcohol and cannabis as a way of coping with stress and moderating his negative affect.

Case Formulation Mr Doe was born into an extremely dysfunctional and damaging home environment, where he had an inadequate opportunity for secure attachment to a nurturing parent figure. It appears that he has never experienced an enduring relationship with an attachment figure which did not involve abuse, neglect, or interpersonal boundary violations, often of a sexualized nature. This resulted in deep-seated problems with trust, empathy and self-worth, leading to a confused and disturbed sense of self. His experiences have provided no foundation for healthy adult relationships that are free from the threat of abandonment, violence or sexual exploitation. Mr Doe appears to have learned from the beginning of his life that the world is largely an indifferent or hostile place where others will not protect or consistently care for him, and may in fact abuse him. In response to this he has learned at a very deep and fundamental level to deny or distance himself from his own emotional experiences as a form of self-protection, and to try to present as whatever someone else wants him to be in order to obtain the acceptance and approval he craves. Alternating with this is a deep resentment, which can be expressed as either direct aggression, or more frequently in passive-aggressive and self-defeating behavior. He appears to maintain a very fragile self-image with a massive underlying sense of inadequacy and unworthiness. His occasionally grandiose or inflated presentation seems to reflect a desperate need to be perceived by others and to perceive himself as adequate in at least some areas. Mr Doe’s sexual offending can be seen as one manifestation of his attempts to obtain the basic human needs for security, acceptance, affection, and control in his life. Mr Doe emerged from his adverse developmental experiences with a pervasive and generalized view of others, especially adult authority figures, as rejecting and untrustworthy, and himself as worthless and incompetent. Mr Doe initially learned to manage these negative feelings by withdrawing into isolated fantasies, further slowing his development and distorting his reality testing in social relationships. He subsequently looked to relationships with those much younger than himself to meet his emotional needs and bolster his sense of adequacy. With the onset of adolescence, he also managed his isolation and negative emotions through smoking


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cannabis, drinking alcohol, and masturbation, focusing on deviant fantasies involving children, with whom he felt less vulnerable. These deviant fantasies were strongly reinforced through masturbation, and eventually through their enactment with children he came to know. Mr Doe’s sexual offending can also be understood in terms of the schemas or implicit theories he has developed. He learned through his early experiences to sexualize interpersonal relationships, and to associate affection with sexual contact, albeit in a conflicted way due to the negative emotions associated with his sexual abuse. His sense of self is also grossly deficient and fragile, so that his negative schemas are especially activated at times of interpersonal conflict or environmental stress. This dynamic is demonstrated in the context of his index offending, when he was living with his mother in a conflictual relationship that reactivated his anger toward her, along with his sense of vulnerability and isolation. He had also recently been dismissed from his job, increasing his sense of inadequacy and rejection. In these circumstances his need to cope with the attendant negative affect through sexual contact with children was particularly strong. He has reported that he began to see the children as potential partners who would be less rejecting than adults, and serve as outlets for his sexual needs. His judgement and sense of interpersonal boundaries were further compromised by his daily use of cannabis during this period. He also reported that he had developed what he experienced as an intimate bond with the children, and that the sexual activity was to him a natural expression of that intimacy.

The Formulation Process Developing a forensic case formulation such as Mr Doe’s is an ongoing process of identifying, testing, and integrating clinical hypotheses into a coherent explanatory theory or model of the individual based on the clinical information that is obtained. In cases of child victim sex offenders, the primary focus is typically an understanding of the sexual offending, with the goal of reducing and managing the risk for sexual recidivism. The forensic clinician starts with the known history of sexual offending, and bases the initial estimates of the probability of reoffending on empirically validated static and dynamic risk measures such as the Static-99, STABLE-2007, and ACUTE-2007. Specific attention should also be paid to the factors of psychopathy and deviant sexual arousal, as these are important risk factors identified in the research literature. Beyond these factors, case formulation involves a detailed examination of the process by which prior sexual offending has occurred, including the cognitions, emotions, interpersonal and environmental factors involved. This will depend on the cooperation of the offender to obtain a specific and accurate account of his or her offending process, sometimes called an offense cycle or behavior chain. In the case of Mr Doe, this aspect of the assessment and formulation was compromised and delayed by his reflexive distrust of others, particularly authority figures associated with the criminal justice system. A process of rapport building over many months was necessary, with several ruptures in the therapeutic alliance that required repair before additional disclosures were forthcoming to inform the formulation.


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One initial false start was the hypothesis that Mr Doe had significant narcissistic elements to his personality, based on the perception by some staff that he displayed a sense of entitlement and grandiosity, and that narcissistic defenses would be a challenge to the therapeutic process; however, results of the MCMI-III indicated an unusually low score on the narcissism scale. Behaviorally, it soon became apparent that Mr Doe was struggling much more overtly with a massive sense of inadequacy, and displayed more dependent and avoidant personality patterns in his relationships rather than the inflated self regard typical of narcissism. Once this was understood, the attendant needs to offer reassurance and not to restimulate the punitive and rejecting dynamics that have marked most of his important adult relationships became apparent. The therapists in the treatment program were able to directly and consistently address Mr Doe’s sensitivities to criticism, while still holding him accountable to follow program rules and address the issues necessary for treatment progress. This issue led to another revision in the treatment approach with Mr Doe. Like many sex offenders, an aggressively confrontive approach intended to break down denial and encourage taking responsibility for his offending had the effect of exacerbating Mr Doe’s sense of shame and personal inadequacy, with a corresponding increase in defensiveness and reversion to the maladaptive behavior patterns associated with his offending. It was found that a more collaborative, supportive approach, with specific and ongoing attention to the effects of the content of the treatment process on the therapeutic alliance, has begun to enable Mr Doe to undertake a more direct and less distorted examination of his offense cycle.

Treatment Implications In light of Mr Doe current psychological characteristics, there will be challenges to achieving significant therapeutic gains. A primary factor in any treatment effort will be the challenge of creating and maintaining a strong therapeutic alliance between Mr Doe and the clinician. Mr Doe’s problems with trust have been noted. His pervasive and largely unconscious internal models concerning others lead to resilient beliefs that adult males are victimizing and females are unreliable to protect him. These problems will be compounded by the potentially adversarial nature of treatment within the correctional system, whereby staff are explicitly responsible for both treatment and for protecting the public safety. To the degree that Mr Doe feels vulnerable to negative consequences in response to disclosures he may make, this will inhibit the development of a therapeutic process that would allow for the exploration of these issues. Mr Doe also shows evidence of significant emotional and personality difficulties that bear upon his responses to treatment. He lacks the communication and social skills to develop effective interpersonal relationships, including those with treatment staff. His attempts to manage his interpersonal anxiety and make social contact with others continue to involve awkward and immature attempts at humour, often resulting in experiences of rejection. He is largely disconnected from his own emotional experiences, and has limited recognition of the emotional reality


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of others. This limits his capacity for empathy, and will make it difficult for him to experience the emotions that normally inhibit acts that inflict harm on others. A final treatment implication concerns the approaches or models of treatment that may be most effective. It appears that Mr Doe has thus far received a primarily cognitive-behavioral approach, which in the context of the current treatment program has been applied to the areas that are usually associated with effective sex offender treatment. While such an approach has shown some success in reducing reoffending with a portion of the sex offender population, and undoubtedly has content that is relevant for Mr Doe, it appears likely that his emotional and personality characteristics may prevent this approach from being optimally effective. Specifically, the formulation for Mr Doe suggests that his early developmental experiences have resulted in a pervasive sense of his own inadequacy, a distrust of others that is especially pronounced with those in authority positions, and a sense of vulnerability in relationships that involve intimate personal disclosures. All of these factors present obstacles to the therapeutic process. In light of Mr Doe’s abusive and damaging early developmental history, and the idiosyncrasies of his personality and sense of self, it may prove beneficial augment further treatment efforts with a approach that emphasizes these early experiences and their deepseated sequelae. This will require a patient and sensitive approach by the therapist, with ongoing attention to ruptures in the therapeutic alliance resulting from Mr Doe’s responses to clinical material that he experiences as threatening. Mr Doe will also benefit from having other needs met, needs which may assist him in establishing a more stable, rewarding and offense-free life. Mr Doe’s formulation suggests that he has deficits in multiple areas of age-appropriate functioning. These include employment, education, socialization, appropriate adult sexual experiences and relationships, as well as spiritual and personal identity needs (Ward and Maruna, 2007). Because of his deeply held beliefs about the world and others as indifferent or hostile, and the corresponding defenses that have limited his social development, Mr Doe will require a slow and supportive treatment process in these areas. He does not have the normal maturational experiences typically encountered in an individual of his age, so that his progress in these areas must begin from their current underdeveloped state. Although these issues can be identified and addressed in a preparatory way while he is in the secure treatment setting, they will be most effectively dealt with through ongoing treatment and support in the community. It is therefore crucial that an integrated aftercare plan be developed based on his individual case formulation that will address his needs for successful reintegration into the community.

Measuring Outcomes The ultimate outcome measure from the criminal justice perspective is the absence of sexual reoffending. Other, intermediate or associated outcomes can also be defined as measures of the adequacy of the case formulation and resulting interventions. In the inpatient environment, progress can be measured by progression through the identified stages of the program. Mr Doe’s treatment program, like many of its kind, is designed to facilitate advancement through various distinct


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stages, each associated with progressively more internally directed change and risk management (i.e., internal to the offender rather than imposed and directed from others). To the extent that Mr Doe is self initiating in his pursuit of understanding and modifying the factors that contribute to his offending, this is a definable treatment outcome. Specific indicators for Mr Doe are increased self-disclosure, decreased defensiveness, fewer incidents of manipulation or deceit, and improved relationships with peers and staff. Behavioral indicators for each of these areas should be defined in light of Mr Doe’s past behavior so that his progress can be assessed. He will be assisted in making the desired changes in his behavior by providing clear examples of what is needed, such as avoiding instances of lying to staff or peers, responding with nondefensive consideration of criticism offered by others, and self-initiated disclosure of personal information in appropriate interpersonal contexts. There are also standardized measures of functional skills that can be used for treatment planning and outcome measurement with forensic patients, including sexual offenders (Vess, 2001a, 2001b). Such measures can be used repeatedly over time to assess the degree of change in areas that are a focus of intervention. Measures of dynamic risk factors such as the STABLE-2007 can also be used in a secure inpatient setting, and the STABLE and ACUTE measures were specifically designed to assess areas of functioning directly related to the risk of sexual recidivism in the community. Where the assessment resources are available, penile plethysmograph assessment can be used to both provide a baseline assessment of deviant arousal for case formulation and treatment planning purposes, and to assess changes in deviant arousal in response to treatment. It should be recognized that not all offenders respond adequately to the stimuli used in such assessments, and the assessment of deviant arousal should also rely on other sources of self-report and behavioral observation data. This is best achieved in the context of a strong therapeutic alliance in which candid self-disclosure regarding sexual fantasies and behavior is possible. Finally, a functional analysis of the offense pathway for the individual offender provides a behaviorally anchored map of the cognitive, emotional, and contextual factors associated with sexual offending (Vess, 2008; Ward, Yates and Long, 2006). The results of such an analysis not only informs the case formulation for the individual, but can serve as a set of observable precursors to sexual reoffending that can be used as an ongoing measure of treatment outcome. This would require a close working relationship with the offender, especially in the community setting, to allow for adequate ongoing assessment of the offender’s functioning in the key areas identified in the functional analysis of his offending pattern.

SUMMARY AND CONCLUSIONS An important implication of the case formulation approach presented here is that risk is heavily contingent on the postrelease environment. The elements of the risk management plan will depend on the specific needs of the individual offender. Group and individual treatment modalities have the potential to reduce risk, if they are well matched to the needs of the offender and delivered with fidelity to


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the original clinical design and purpose of the intervention. The frequency and intensity of treatment and supervision activities should be based on an ongoing assessment of risk, which can increase or decrease in frequency over time depending on current contingencies in light of the offender’s individual risk factors. High risk offenders may initially need frequent and intense supervision, including scheduled office appointments and unannounced home visits by the parole agent to minimize the opportunity for acute risk of reoffense to develop. This has implications for staffing levels and case load sizes, as well as the availability of treatment and ancillary support services in the community. Offenders will vary in the set of needs they present, their level of risk and their responsivity to treatment. Some offenders will have fundamental life skills deficits which contribute to the etiological process leading up to sexual offending, and others will not. Some offenders will have clearly established patterns of deviant sexual preference, such as paedophilia, and others will be nonspecialized, opportunistic career criminals for whom sexual offenses are just one aspect of general criminal offending (e.g., the immature, impulsive and antisocial adolescent who sexually offends against a child while disinhibited by drugs, but who has no enduring sexual interest in children). These different offenders will present different needs, so it is unlikely that a “one size fits all” approach will effectively manage risk. Targeted interventions should be based on thorough, individualized assessment and case formulations. Another important implication of the contingent nature of risk for clinicians contributing to case management is to combine current empirical knowledge with a clear and realistic understanding of the local environment and resources. One must have an individualized, context specific risk formulation, and then be able to communicate the assessment findings effectively to others involved in the management of an individual case. This is best done when the clinician is also thoroughly familiar with risk hazards present in the offender’s community environment, including the nature of his intimate and social relationships, potential substance abuse, emotional and mood management, and so on, as delineated in a functional analysis of the individual’s offending. What is to be avoided in clinicians’ assessment reports is a formulaic adherence to known risk factors, combined in a mechanical fashion and resulting in a routine list of treatment recommendations. Formulaic assessments of risk are less useful than formulations of risk for the individual offender. A case formulation provides an etiological framework with which to understand the unfolding process which results in a sexual offense for this particular individual. When this understanding is combined with an accurate, detailed picture of the individual’s current life circumstances, and a knowledge of the available supervision, support and treatment resources, then a dynamic and responsive risk management framework can be developed.

REFERENCES Abracen, J., Mailloux, D.L., Serin, R.C. et al. (2004) A model or the assessment of static and dynamic factors in sexual offenders. Journal of Sex Research, 41, 321–9.


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Barbaree, H. E., Seto, M. C., Langton, C. M. and Peacock, E. J. (2001) Evaluating the predictive accuracy of six risk assessment instruments for adult sex offenders. Criminal Justice and Behavior, 28, 490–521. Beech, A., Friendship, C., Erikson, M. and Hanson, R. K. (2002) The relationship between static and dynamic risk factors and reconviction in a sample of U.K. child abusers. Sexual Abuse: A Journal of Research and Treatment, 14, 155–67. Borum, R. (1996) Improving the clinical practice of violence risk assessment: Technology, guidelines, and training. American Psychologist, 51, 945–56. Collie, R., Ward, T. and Vess, J. (2008) Assessment and case conceptualization in sex offender treatment. Journal of Behavior Analysis of Offender and Victim – Treatment and Prevention, 1, 65–81. Craig, L.A. and Beech, A.R. (2010) Towards a guide to best practice in conducting actuarial risk assessments with sex offenders. Aggression and Violent Behavior, 15, 278–93. Craig, L. A., Browne, K. D. and Stringer, I. (2004) Comparing sex offender assessment measures on a UK sample. International Journal of Offender Therapy and Comparative Criminology, 48, 7–27. Craissati, J. and Beech, A. (2005) Risk prediction and failure in a complete urban sample of sex offenders. Journal of Forensic Psychiatry and Psychology, 16, 24–40. Doren, D. (2002) Evaluating Sex offenders: A Manual for Civil Commitments and Beyond. London: Sage Publications. Gottfredson, S.D. and Moriarty, L.J. (2006) Statistical risk assessment: Old problems and new applications. Crime and Delinquency, 52, 178–200. Grove, W.M. and Meehle, P.E. (1996) Comparative efficiency of informal (subjective, impressionistic) and formal (mechanical, algorithmic) prediction procedures: The clinical – statistical controversy. Psychology, Public Policy, and Law, 2, 293–323. Hanson, R.K. (1998) What do we know about sex offender risk assessment? Psychology, Public Policy, and Law, 4, 50–72. Hanson, R.K. and Bussière, M.T. (1998) Predicting relapse: A meta-analysis of sexual offender recidivism studies. Journal of Consulting and Clinical Psychology, 66, 348–62. Hanson, R.K. and Harris, A.J.R. (2001) A structured approach to evaluating change among sexual offenders. Sexual Abuse: A Journal of Research and Treatment, 13, 105–22. Hanson, R.K., Harris, A.J.R., Scott, T.L. and Helmus, L. (2007) Assessing the Risk of Sexual Offenders on Community Supervision: The Dynamic Supervision Project. Retrieved January 25, 2008 from Public Safety Canada website at http://www.publicsafety.gc.ca/ res/cor/rep/_fl/crp2007-05-en.pdf Hanson, R.K. and Morton-Bourgon, K.E. (2005) The characteristics of persistent sexual offenders: A meta-analysis of recidivism studies. Journal of Consulting and Clinical Psychology, 73, 1154–63. Hanson, R.K. and Morton-Bourgon, K.E. (2009) The accuracy of recidivism risk assessments for sexual offenders: A meta-analysis of 118 prediction studies. Psychological Assessment, 21, 1–21. Hanson, R.K. and Thornton, D. (2000) Improving risk assessment for sex offenders: A comparison of three actuarial scales. Law and Human Behaviour, 24, 119–36. Hare, R.D. (2003) Hare Psychopathy Checklist – Revised (PCL-R) (2nd edn). Toronto: MultiHealth Systems, Inc. Harris, A.J.R. and Hanson, R.K. (2004) Sex offender recidivism: A simple question. Retrieved August 23, 2005, from Public Safety and Emergency Preparedness Canada’s Web site: http://www.psepcsppcc.gc.ca/publications/corrections/200403-2_e.asp Harris, A.J.R., Phenix, A., Hanson, R.K. and Thornton, D. (2003) Static-99 Coding Rules: Revised – 2003. www.sgc.gc.ca. Harris, G.T., Rice, M.E. and Quinsey, V.L. (2007) Shall evidenced-based risk assessment be abandoned? British Journal of Psychiatry, 192, 154. Hart, S.D., Michie, C. and Cooke, D.J. (2007) Precision of actuarial risk assessment instruments: Evaluating the ‘margins of error’ for group v. individual predictions of violence. British Journal of Psychiatry, 190 (suppl. 49), s60–s65. Heilbrun, K. (2001) Principles of Forensic Mental Health Assessment. New York: Plenum.


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Helmus, L., Hanson, R.K. and Thornton, D. (2009) Reporting Static-99 in light of new research on recidivism norms. The Forum, 21, 38–45. La Fond, J.Q. (2005). Preventing Sexual Violence: How Society Should Cope with Sex Offenders. Washington DC: American Psychological Association. Miller, H., Amenta, A. E. and Conroy, M. A. (2005) Sexually violent predator evaluations: Empirical evidence, strategies for professionals, and research directions. Law and Human Behavior, 29, 29–54 Millon, T. (1997) Millon Clinical Multiaxial Inventory-III Manual (2nd edn). Minneapolis, MN: National Computer Systems. Mossman, D. and Sellke, T.M. (2007) Avoiding errors abut ‘margins of error’. British Journal of Psychiatry, 191, 561. Quinsey, V.L., Harris, G.T., Rice, M.E. and Cormier, C.A. (2006) Violent Offenders: Appraising and Managing Risk (2nd edn). Washington D.C.: American Psychological Association. Sjostedt, G. and Langstrom, N. (2001) Actuarial assessment of sex offender recidivism risk: A cross-validation of the RRASOR and the Static-99 in Sweden. Law and Human Behavior, 25, 629–45. Skelton, A. and Vess, J. (2008) Risk of sexual recidivism as a function of age and actuarial risk. Journal of Sexual Aggression, 14, 199–209. Thornton, D. (2002) Constructing and testing a framework for dynamic risk assessment. Sexual Abuse: A Journal of Research and Treatment, 14, 139–53. Vess, J. (2001a) Development and implementation of a functional skills measure for forensic psychiatric inpatients. Journal of Forensic Psychiatry, 12, 594–611. Vess, J. (2001b) Implementation of a computer assisted treatment planning and outcome evaluation system in a forensic psychiatric hospital. Psychiatric Rehabilitation Journal, 25, 124–33. Vess, J. (2009) Fear and loathing in public policy: Ethical issues in laws for sex offenders. Aggression and Violent Behavior, 14, 264–72. Vess, J. (2008) Risk formulation with sex offenders: Integrating functional analysis and actuarial measures. Journal of Behavior Analysis of Offender and Victim – Treatment and Prevention, 1(4), 29–41. Vess, J. and Skelton, A. (2010) Sexual and violent recidivism by offender type and actuarial risk: Reoffending rates for rapists, child molesters and non-contact offenders. Psychology, Crime and Law, 16, 541–554. Vess, J., Ward, T. and Collie, R. (2008) Case formulation with sex offenders: An illustration of individualized risk assessment. Journal of Behavior Analysis of Offender and Victim – Treatment and Prevention, 1, 284–93. Ward, T. and Beech, A. (2004) The etiology of risk: A preliminary model for sexual offenders. Sexual Abuse: A Journal of Research and Treatment, 16, 271–84. Ward, T. and Haig, B. D. (1997) Abductive method and clinical assessment. Australian Psychologist, 32, 93–100. Ward, T. and Maruna, S. (2007) Rehabilitation: Beyond the Risk Paradigm. New York: Routledge. Ward, T., Vertue, F.M. and Haig, B.D. (1999) Abductive method and clinical practice. Behaviour Change, 16, 49–63. Ward, T., Yates. P.M. and Long, C. (2006) The Self-regulation Model of the Offense and Relapse Process – Volume 2: Treatment. Victoria, Canada: Trafford Publishing.


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Chapter 9

SEXUAL OFFENSES AGAINST ADULTS STACEY L. SHIPLEY North Texas State Hospital, USA

BRUCE A. ARRIGO University of North Carolina–Charlotte, USA

INTRODUCTION This chapter examines forensic case formulation for adult sex offenders who rape adult victims. This includes an overview of a range of issues relevant to male and female perpetrators and male and female victims. Along these lines, definitional, statistical, and background information are provided; classification schemas, including rapist profiles, are discussed; and the importance of assault prevalence, motive, method, victim selection, and offender disposition are delineated. For exemplification purposes, the instance of an adult male rapist who targets adult female victims is featured. Although its details are largely fictitious, presenting the clinical case makes it possible to then explore the contours of sexual violence risk assessment, case formulation, and treatment planning for this offender type. The final section of the chapter presents an illustrative case formulation and corresponding treatment plan.

LITERATURE REVIEW Sexual Assault of Adult Females Rape is typically defined as “the penetration of the anus or vagina by a penis, finger or object or the penetration of the mouth by a penis” (McCabe and Wauchope, 2005, p. 241). When a man forcibly penetrates someone else in any of the aforementioned ways, this is also considered rape. More broadly speaking, rape can be Forensic Case Formulation, First Edition. Edited by Peter Sturmey and Mary McMurran. C 2011 John Wiley & Sons, Ltd. Published 2011 by John Wiley & Sons, Ltd.


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defined as sexual contact with a nonconsenting person (Sbraga, 2003). Rapists have been categorized based on their distinct behavioral, motivational, and cognitive characteristics (McCabe and Wauchope, 2005). Theorists have indicated that an early criminogenic environment or child rearing in a subculture where criminal behavior is the norm can help to explain the onset and maintenance of sexually deviant behavior or offending in some cases (Lussier et al., 2007). This is especially the case when coupled with few external constraints, for example, lack of parental vigilance, limited attachment to conventional, prosocial institutions, such as school, church, family, and/or prolonged exposure to antisocial behaviors (e.g., antisocial parents and conduct disordered peers). Some opportunistic sexual offenders commit rape impulsively with victims of chance while others are clearly preferential in their victim type with rape as their primary criminal activity. Those who commit rape do not easily fit in a one size fits all category and their violence pathways, subsequent case formulations, and treatment and disposition planning can be quite distinct. Attachment theorists have suggested that early negative parent–child interactions damage the child’s ability to cope with stressful events and difficulties (Lussier, et al., 2007; Ward and Beech, 2006), while also failing to provide a healthy and sufficiently complete model for future intimate relationships (Marshall and Marshall, 2000). Moreover, sex offenders are often distinguished by early and enduring deficits in emotional regulation and a lack of social competence or an inability to foster healthy relationships with peers (Lussier et al., 2007). This condition is further exacerbated when raised in a sexually deviant environment and when subjected to early experiences of physical and/or sexual abuse where both the modeling of aberrant sexuality and the disinhibition of sexuality are gateways to adult criminality (Knight and Sims-Knight, 2003). Adult victimization accounts for approximately one-third of all rapes that occur in the United States each year with children representing the remainder of sexually assaulted victims (Salter, 2003). The US Department of Justice funded a national study of 8000 Americans for the Violence Against Women Survey, and their findings indicated that 17.6% of women and 3% of men reported having been raped (Tjaden and Thoennes, 1998). While the majority of all victims of rape or attempted rape are attacked by someone they know, stranger rapists are far more likely to avoid detection and to reoffend, and they are more likely to be represented in instances of serial rape. According to Salter (2003), only about 5% of all rapists ever spend a day in jail and still fewer fail to serve any significant time behind bars. A large number of rapes are perpetrated by a small number of serial offenders (Warren et al., 1991). The belief that serial rapists are all sadistic or even psychopathic is not supported by research (Pardue and Arrigo, 2008; Shipley and Arrigo, 2008). Psychopathy is the most common among opportunistic and pervasively angry rapists and infrequent in nonsadistic rapists (Richards et al., 2004). Psychopathy is far more common in rapists than child molesters (Serin et al., 1994). For many psychopathic rapists, the sexual assaults are an extension of criminal versatility. For example, the assailant may break into a home to commit a burglary and if the female resident happens to be home he will rape her without remorse (Shipley and Arrigo, 2008); however, the majority of serial rapists premeditate their assaults and utilize strategies to avoid detection (Kocsis, Cooksey and Irwin, 2002).


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Clinicians who evaluate rapists or suspected serial rapists should pay close attention to charges such as Burglary of a Habitation or Attempted Burglary of a Habitation. Kocsis et al. (2002) found that theft is common after a rape; however, it is often an opportunistic crime in that the rape, as an expression of sexual violence, is the primary motive. Psychopathic serial rapists are particularly dangerous as they are at a higher risk to reoffend than nonpsychopaths, will recidivate sooner, and will likely reoffend more violently (Arrigo and Shipley, 2001; Serin, et al., 1994; Shipley and Arrigo, 2001, 2004, 2008). The sadistic rapist is sexually aroused by the physicality and emotionality of the pain and suffering, wherein the torture or harm is primary and the sex act is secondary (Shipley and Arrigo, 2008). The psychopathic offender is aware of the pain he causes but disregards or ignores the harm as it is irrelevant to sating one’s own needs (Salter, 2003; Shipley and Arrigo, 2001; Shipley and Arrigo, 2004, 2008). While all serial rapists are not abused as children, research has demonstrated that the majority experience sexual victimization (Burgess et al., 1988; Hazelwood and Burgess, 1987). In their original sample of 41 serial rapists, Burgess et al. (1988) found that the repetition of sexually aggressive behaviors began at adolescence subsequent to the onset of rape fantasies and rape behaviors. Indeed, in regard to juveniles’ compulsive sexual fantasies, the investigators noted that: “The repetition of the fantasies did not result in the resolution of . . . inner tension; rather, repetition became a prototype for the early rape behaviors” (p. 290). Motives for rapists vary widely. Some assailants principally seek to cause pain, as well as to degrade and defile the victim; others are motivated largely by the sexual, relational, and aggressive aspects of the assault (Warren et al., 1991). The rapist typologies and profiles described below address the aforementioned components and differ considerably based on the offender’s personality and intention.

Serial Rape Typologies According to Kocsis et al. (2002), while there have been many typologies offered relevant to the psychological profiling of rape, essentially they have been elaborations of the original ideas put forth by Groth, Burgess and Holmstrom (1977). Their typologies indicated that the actual sexual act of rape was secondary to the primary motivations of power and aggression. Three main patterns of rape were classified: anger; power; and sadistic. The anger rapist uses more force than is necessary for control of the victim and is motivated by rage toward the injured party or who the victim symbolizes. The assailant uses considerable physical violence, subjects his victims to a series of degrading sexual acts, and typically causes significant harm (Kocsis et al., 2002). The power rapist is motivated by a need to assert authority and dominance over his victim, and the level of force will likely depend on the degree of victim compliance (Pardue and Arrigo, 2008). The sadistic rapist eroticizes violence. Sexual and aggressive urges are fused and the offender is aroused by the degradation, pain, suffering, torture, and possible mutilation of the victim (Shipley and Arrigo, 2008). The pain and suffering of the victim is not incidental; it is central. This offender typically uses restraints, bondage, engages in paraphilias, torture, mutilation, and significant physical injury to the victim, which can escalate to death (Purcell and Arrigo, 2006). The three categories were converted into a fourfold


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schema and include: power-reassurance, power-assertive, anger-retaliatory, and anger excitation rapists. The absence of adequate empirical validation remains the chief criticism of the reformulation; however, these categories are frequently used among those who investigate sexual crimes. Hazelwood and Burgess (1987) further developed the categories into four rapist profiles. The first typology is the power-reassurance rapist who has significant feelings of inadequacy and wants to restore feelings of masculinity. This type of rapist frequently is concerned about avoiding harm to the victim, is apologetic, makes efforts to reassure the injured party, and uses less intrusive forms of rape behavior (Warren et al., 1991). He typically relies on the threat of a weapon and may not even have one. The assailant is often known as the “gentleman rapist” (Hazelwood, 2005). He is looking for reassurance of his masculinity, is less aggressive than other rapists and his objective is to have sexual intercourse. His attacks are premeditated and fueled by persistent rape fantasies. He enjoys pretending that the rape is consensual and that the victim takes pleasure in the assault. The assailant spends a great deal of time with his victim and attempts to engage in pillow talk, asking personal questions and talking about himself. The second typology is the power-assertive rapist who uses the assault as confirmation of his virility, machismo, and ability to dominate women. He does not need reassurance; rather, he needs to display power and control (Hazelwood and Burgess, 1987). His attacks may be impulsive and unplanned. His use of force is moderate and dependent on victim resistance. He frequently uses his fists as weapons and the assault is short-lived. He is arrogant, hot headed, and has a history of conflict with women. This offender sees himself as very socially competent; however, he likely has a history of failed marriages (National Center for Women and Policing (NCWP), 2004). The third typology is the anger-retaliatory rapist who is motivated to victimize as an extension of anger and rage (Warren et al., 1991). He is likely to overtly express anger by using excessive force, relying on a knife, and projecting a macho image (McCabe and Wauchope, 2005). The rage is not sexualized and these rapes do not appear to be motivated by compulsive, sadistic fantasies. Women are viewed as whores or as dirty and cannot be trusted (NCWP, 2004). The assailant likely uses a “blitz” style of attack or quickly overpowers the victim with surprise and extreme force. The attack usually results in a severe beating and can end in murder, but this is not typical. The victim’s resistance can result in a more savage assault as it fuels the assailant’s anger. The attacker’s rape may represent displaced anger in that the assailant is reacting to a previous fight with a girlfriend, lover, or wife and causes harm to a victim to symbolically even the score with a woman perceived to have wronged him. The rape can be used to punish or humiliate and often represents a general disdain for females. The final typology is the anger-excitation rapist who is likely sadistic and enjoys the pain and suffering of his victim. This type of rapist also has been described as a sadistic-ritualistic assailant (NCWP, 2004). He is more likely to bind and transport victims, to not reassure them, and will likely try to terrorize those on whom he preys. He accomplishes this by telling his victims how he will hurt them. His interactions with his victims are detached, and he takes satisfaction from their reactions. These rapes entail greater planning and the behavior surrounding the offense is less impulsive (Warren et al., 1991). Hazelwood and Burgess (1987)


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indicated that this type of rapist is sexually stimulated or gratified by the victim’s response to or suffering from physical or emotional pain. The primary motivation is to inflict harm and to induce fear and total submission. Hazelwood and Burgess (1987) further described the offender as using a brutal level of force that often resulted in death. Rather than a blitz style of attack, this rapist is manipulative, often confidently using verbal tactics or tricks to gain victim access. Victims are often strangers but are symbolic of those in the assailant’s compulsive sadistic fantasies. He is likely to be married but his wife is firmly under his control and may be a compliant victim herself (NCWP, 2004).

Sexual Assault of Adult Males In 2006, a total of 260, 940 rape/sexual assault victimizations were reported to United States law enforcement, and approximately 26.2% or 68,366 of the victims were males (US Department of Justice, 2008). According to the 2000 National Incident-Based Reporting System (NIBRS), males make up about nine out of every ten adult sexual assault perpetrators, totaling about 26, 878 incidents within this reporting period; however, men can become victims of sexual assault, and the perpetrator’s tactics can vary from violent attacks with weapons to deliberate intoxication or verbal coercion. Those who engage in sex crimes against men are almost always male themselves. The majority of perpetrators are heterosexual and Caucasian, and most studies indicate that the majority (58% to 100%) of male victims are also Caucasian and relatively young (Frazier, 1993). Sexual offenders who assault stranger male victims are more likely to use weapons and physical violence (Stermac, Del Bove and Addison, 2004; Frazier, 1993). Studies reveal that male victims of sexual assault tend to be young, single adults who are more likely to be vulnerable given psychosocial issues such as homelessness, as well as physical, psychiatric, and cognitive disabilities (Stermac et al., 2004). These investigators reported that male victims were more likely to be subjected to anal/or fellatio assault. Moreover, male stranger perpetrator victims were more likely to be attacked by multiple assailants than were female victims, and they were more likely to be assaulted outdoors or in a park setting. Injuries suffered were similar for male and female victims, and studies have found that most male victims are known to their perpetrators as the offender typically is an acquaintance (Stermac et al., 2004). Prior research on rape myths for male victims focused on beliefs such as “getting raped doesn’t really upset men” and “male rape cannot happen” (Anderson, 1999, p. 390) or that men are less affected by sexual assault than women (Stermac et al., 2004). Kassing, Beesley and Frey (2005) described and critiqued rape myths that focus on sexual orientation; specifically, that male perpetrators are gay and that victims bring the attack upon themselves by presenting themselves as homosexual, and by engaging in high risk or reckless behavior.

Female Perpetrators with Adult Victims Limited information is available in the literature on female perpetrated sexual offenses against male or female adults (Struckman-Johnson and Struckman-Johnson,


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2006). Almost all available research on female sexual offenders involves child or teenage victimization. In part, this is due to victim accessibility and the perpetrator’s ability to control them. For example, Strickland (2008) studied a sample of 130 incarcerated females (60 sex offenders and 70 nonsex offenders) in Georgia prisons. She found that female sex offenders encountered significantly higher rates of total childhood trauma than their male counterparts. Most sadistic offenders are male. While mostly rare, sadistic females typically are exposed to this dysfunctional behavior in adolescence and, as they mature, derive pleasure from it through an adult relationship with a masochistic man (Scott, 1983). There are some adult females who are coerced into sexually assaulting adult victims by a dominant, sadistic, male partner. These women tend to be very dependent and have experienced significant abuse from their partners whom they fear will abandon them if they do not participate in acquiring and assaulting victims. The probability of these women independently undertaking sexual assaults is low. Despite evidence that the sexual victimization of males by female assailants does exist (Banbury, 2004), society typically perceives the rape of men by women as largely implausible (Davies, 2002). Rape myths and gender role stereotypes support the notion that a woman cannot force a man to have sex (StruckmanJohnson and Struckman-Johnson, 2006). Moreover, as Davies (2002) explained, “It is also difficult to believe that men can become sexually aroused and even ejaculate during a sexual assault, but still report that they did not want the situation to take place, tried to stop it, and felt fear and disgust during and after the assault” (p. 206).

ASSESSMENTS Risk Assessment for Sex Offender Recidivism Once a sexual offender has been prosecuted, the probability of rehabilitation and the appropriate place for it to occur are discussed. Issues such as the degree and type of deviant sexual arousal, the frequency and severity of the known offenses, the presence or absence of major mental illness, and the presence and degree of prosocial deficits are examined by clinicians with the requisite expertise in these areas. According to Sbraga (2003), forensic mental health questions at this juncture include the following: Is there a paraphilia? How severe is it? At what stage in the punishment/ rehabilitation process should the inmate receive treatment? And, does the paraphilia render the inmate so dangerous that treatment is mandatory prior to release? Once the inmate has entered treatment, the queries turn toward treatment gains, less restrictive alternatives for treatment, and risk of reoffending. (p. 434).

Rape and sexual sadism correlate with a high risk of reoffending and greater risk of physical harm to victims (Marshall et al., 2008). Forensic clinicians are called upon to evaluate an offender for dispositional evaluations, at intake prior to treatment, or to conduct treatment with those who may benefit. Forensic ethics stress the importance of avoiding dual relationships (Shipley and Arrigo, 2004).


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In other words, those who conduct evaluations for the court should not be those who provide the court-ordered treatment. Sbraga (2003) indicated that the separation of these functions is necessary in order to maintain objectivity and to avoid damaging the therapeutic relationship. Prior to beginning treatment, there is often some assessment to gauge where the offender is with regard to thinking errors, sexual deviance, and the like. The degree of sexual deviance is also used to determine postconviction disposition and treatment (e.g., release, parole, the degree of monitoring, or civil commitment). When forensically assessing an adult sex offender, the evaluator should conduct a detailed psychosocial interview in addition to administering any instruments that can help organize the evaluation. Information that has been provided by the offender should be identified as such in the report. The historical information provided by this self-report data should be viewed with skepticism, given the secondary gains in denying or minimizing one’s offense behavior and deviant sexual fantasies. A thorough review of collateral information (e.g., police reports, victim statements, mental health records, etc.) is essential. Records such as police reports should be reviewed to determine a history of criminal activity and to avoid the pitfalls associated with using a single source to formulate an opinion or to make recommendations. Psychological testing can also provide data about personality characteristics, the presence or absence of major mental illness, and additional information about thinking errors and the like. Assessments of various types of sexual offenders in both outpatient and inpatient treatment programs often use the polygraph and penile plethysmograph testing; however, the literature is mixed regarding physiological assessments with some reviews suggesting unclear reliability, and the validity on its use for rapists is questionable (Marshall et al., 2008). Sex offender risk assessment is typically pursued by forensic clinicians to help predict the probability of future sexual violence based on risk factors that relate to sexual offending. As with nonsexual violence, the best predictor of future sexual offending is past sexual violence. The risk assessment addresses the characteristics, frequency, and severity of prior offenses, and estimates the likelihood, imminence, and seriousness of potential future offenses. The standard practice and the preferred approach in the assessment of risk for sex offenders is to use a combination of evaluative strategies. These include structured clinical judgment guided by a strong understanding of the relevant literature and professional experience with this population, and the use of actuarial instruments. Some actuarial instruments focus on static risk factors or those that are based on past history and cannot be changed, and others consider both static and dynamic (changeable) features (Marshall et al., 2008). Whenever possible, an actuarial approach is strongly recommended given the lack of predictive accuracy of clinical judgment alone (Quinsey et al., 1998). While the list is not exhaustive, the following assessment tools may be used in the prediction of sexual reoffending:

r The Sex Offender Risk Appraisal Guide (SORAG) is a 14 item instrument that uses both static (historical or unchangeable) and dynamic (changeable) risk factors (Quinsey, et al.. 1998). One criticism is that this instrument was designed using a limited sample of sexual offenders.


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r The STABLE-2007 consists of a guided interview process covering 13 major ar-

r r r r

r r r

eas of stable dynamic risk factors in the offender that are amenable to change; for example, deviant attitudes and sexual preoccupation (Hanson et al., 2007). Marshall et al. (2008) indicated that this instrument identifies features useful for treatment. The ACUTE-2007 (Hanson et al., 2007) identifies changing factors that increase immediate risk of reoffense such as the sudden onset of negative moods, recent interpersonal conflicts, and immediate access to a victim (Marshall et al., 2008). The Minnesota Sex Offender Screening Tool-Revised (MnSOST-R) is composed of 16 items that include both static and dynamic risk factors. The Rapid Risk Assessment for Sexual Offense Recidivism (RRASOR) was created by Hanson (1997) to predict sex offender recidivism. The STATIC-99 is a static 10-item actuarial assessment instrument with a weighted key. It was developed by Hanson and Thornton (1999) for use with adult male sexual offenders who are at least 18 year of age at the time of release to the community. The Sex Offender Needs Assessment Rating (SONAR) was designed in order to apply actuarial methods to dynamic variables (Hanson and Harris, 2000). This 9-item scale was designed to measure change in risk level for sexual offenders. The Sexual Violence Risk-20 (SVR-20) is a 20 item guide for assessing violence risk in sex offenders (Boer et al., 1997). The Hare Psychopathy Checklist-Revised (PCL-R) 2nd edition (2003) is used to assess for psychopathy. The PCL-R was not designed to predict recidivism or violence; however, good empirical evidence supports that psychopathy is a strong predictor of violence to include sexual violence. The PCL-R 2nd edition is either used on its own to assess for psychopathy or as part of a risk assessment battery (e.g., with the HCR-20). Psychopathy should be considered in all sexual violence risk assessments.

Other Common Assessment Tools As well as assessment tools for risk assessment, a number of other assessments are also commonly used. The decisions about what assessment instruments are to be used by the evaluating psychologist or by an appropriately trained forensic clinician should be guided by the referral question and by evaluative tools that have the best validity and reliability for what they intend to measure. Widely used psychological tests that evaluate psychopathology or personality traits, such as the Minnesota Multiphasic Personality Inventory-2 (MMPI-2), the Millon Clinical Multiaxial Inventory-III (MCMI-III), or the Personality Assessment Inventory (PAI), will not be detailed in this chapter. They are frequently employed in psychological evaluations to aid in the differential diagnosis of psychiatric disorders and/or personality profiles. Additionally, there are various instruments that can be used specifically in the assessment of adult sex offenders. These include the Multiphasic Sex Inventory – Adult Male Form (MSI II), which is designed to measure the sexual deviance characteristics of an adult male alleged to have engaged in sexual misconduct or a sex crime; the Sexual Fantasy Questionnaire (SFQ), which is a self-report


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measure that examines the type and degree of sexual fantasy content (O’Donohue, Letourneau and Dowling, 1997), and the Aggressive Sexual Behavior Inventory (ASA), which examines both sexual and aggressive factors.

CASE FORMULATION In order to illustrate the interplay of risk assessment and case formulation of sexual offenses against adults we present the cases of Mr Smith, a 50-year-old Caucasian male, who was assessed in prison after conviction for the offense of Aggravated Sexual Assault. Mr Smith had been sentenced to a maximum-security correctional facility and his treatment needs were to be evaluated and services provided as deemed appropriate. A routine intake evaluation was conducted to quickly assess whether there was a need for further evaluation and for mental health follow-up. Due to his reported symptoms, documented past accounts of mental illness, and history of serious sex offenses, Mr Smith was referred for an evaluation to determine his current level of risk for sexual violence, assess issues that relate to his sexually deviant behavior, identify his goals for treatment, and determine if he was appropriate for placement in sex offender treatment group(s). He had a significant history of sexually deviant behavior in both institutional and community settings, as evidenced by his current charge, other prior arrests for sexual offenses, and behaviors during his incarceration. The latter included nonconsensual touching/groping of female staff and an actual attempt to sexually assault a female staff member whom he later disclosed he intended to rape.

Assessments Mr Smith’s treatment and level of security were based on his risk factors, ability to benefit from treatment, and the degree of risk the evaluator has predicted the offender would pose to the institution and eventually the community.

Risk Assessment Psychopathy Mr Smith’s overall score on the PCL:SV was 20 (91.7th percentile), which suggested that he may be psychopathic and should be further evaluated with the full PCL:R. Scores of 18 or higher offer a strong indication of psychopathy. His score on Part 1 was 9 (83.3rd percentile). This represents the affective and interpersonal characteristics associated with psychopathy such as malignant narcissism, a lack of empathy, and the selfish, callous, and remorseless use of others. His score on Part 2 was 11 (95.8th percentile). This represents a chronically unstable and antisocial lifestyle or social deviance. Out of 100 individuals in a forensic psychiatric population, only 4 would score higher on Part 2. While Mr Smith could not be classified as a psychopath with the PCL:SV, he possessed many psychopathic traits and psychopathy could not be ruled out. Mr Smith’s hospital and criminal records were utilized but they were available for only a specific period of time. Moreover, there were insufficient records to accurately


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complete the PCL-R. When additional collateral information was gathered, his scores on the PCL:SV strongly suggested that the PCL:R should be completed. SVR-20/Risk Assessment The SVR-20 is an assessment method used to organize risk factors that correlate with sexual violence. Sexual violence is defined as actual, attempted, or threatened sexual contact with a person who is nonconsenting or unable to give consent. The SVR-20 consists of 20 items organized around 11 Psychosocial Adjustment variables, 7 Sexual Offenses variables, and 2 Future Plans variables. Mr Smith was evaluated to be in the high-risk category. He had 11 out of 11 Psychosocial Adjustment risk factors, 7 out of 7 Sexual Offenses risk factors, and 2 out of 2 Future Plans risk factors. Mr Smith had the following risk factors: (a) Risk Factors (Psychosocial Adjustment): Sexual Deviation, Relationship Problems, Victim of Child Abuse, Past Nonsexual Violent Offenses (“serious”), Past Nonviolent Offenses, Substance Use Problems, Employment Problems, Psychopathy (possible/traits), Major Mental Illness, Suicidal/Homicidal Ideation and Past Supervision Failure; (b) Risk Factors (Sexual Offenses): High Density Offenses, Multiple Offense Types, Physical Harm to Victim(s), Uses Weapons or Threats of Death, Escalation in Frequency/Severity, Extreme Minimization/Denial and Attitudes Condone Offenses; and (c) Risk Factors (Future Plans): Negative Attitude Toward Intervention and Lacks Realistic Plans.

Summary of Risk Assessment Based on the results of the current risk assessment, should Mr Smith have been released to the community or into a facility or situation with little supervision, he would have posed a high risk for sexually violent recidivism. Mr Smith had a previous history of sexual violence including Aggravated Sexual Assault, Indecent Exposure, an attempted sexual assault in the prison, numerous incidents of exhibitionism, and threats to engage in deviant sexual behavior. Based on his past history, Mr Smith’s level of risk increases when he is under the influence of alcohol or other illicit substances, when he experiences auditory hallucinations or symptoms of mania, or when he becomes depressed or angry, particularly with women. Risk may be reduced with additional environmental controls, such as an increased level of structure, the lack of an available victim pool (e.g., no one-to-one contact with female staff), no access to weapons, and preventing drug acquisition. Medication management also helps to improve his impulsivity and symptoms of mental illness.

Assessment for Case Formulation A clinical interview was conducted consisting of a sexual biography, mental status examination, and a records review. In order to effectively formulate his case, understand his offense pathways, identify their possible causes, and develop appropriate treatment options, a comprehensive examination of Mr Smith’s relevant history was essential. Awareness of his sexual autobiography and developmental


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history assisted the evaluator and, eventually, the therapist in recommending and undertaking offender therapy. Moreover, this insight enabled both the treatment provider and the client to recognize those factors that led to sexual violence, as well as to specify the warning signs that occurred along his offense pathway. The mental status examination identified current symptoms of psychosis and mania to be treated with psychotropic medication. The records reviewed provided collateral information on criminal history, witness and victim statements, prior symptoms, and other relevant past behaviors.

Developmental History Mr Smith’s father was a chronic alcoholic and was physically abusive toward his wife and son. His mother was emotionally distant and Mr Smith did not feel close to either of his parents. His parents divorced when he was about 16 years old. Following the divorce, he lived with his mother in a single-parent household. Mr Smith reported that he was sexually abused, including penetration, when he was 4 or 5 years of age by a paternal uncle. Mr Smith indicated that he continues to hear the voice of the uncle who molested him saying derogatory things. When asked how the sexual abuse affected Mr Smith, he stated, “sad, angry, embarrassed”. He said he did not report the abuse as a child. Subsequently, Mr Smith had very insecure and poor attachments with his parents who either physically abused or neglected him. Mr Smith stated that he had problems relating to others and fought with his peers in school. Mr Smith was married for four years immediately after high school and had two children. Mr Smith has had no contact with either his ex-wife or his children for numerous years. He reported that he was living with his mother prior to his most recent arrest and has been violent with his mother in the past. He showed considerable lack of interest in relating to others, as well as a general tendency to harbor anger toward women. His father modeled physical aggression and his mother did nothing to protect him from violence or to comfort him. He was quite impaired in his ability to connect with and trust others and does not appear to be motivated to engage in meaningful relationships. Cognitive distortions or thinking errors typical of sexual offenders were present. These were exacerbated by symptoms of mental illness, which further disinhibited his behavior and increased the likelihood that he would impulsively and aggressively reoffend. On the other hand, when his symptoms of mental illness responded to medication management and treatment, he became a more organized sexual offender and his offenses were more predatory in nature. Mr Smith attended school until he was in the 10th grade (age 16 years). His prior intellectual testing indicated that his IQ functioning fell in the Low-Average range. Mr Smith has been unable to maintain gainful employment for any significant period of time, working sporadically in construction or as a day laborer. Mr Smith previously disclosed using alcohol, cocaine, marijuana, and LSD.

Legal History Mr Smith’s legal history included multiple arrests. His record specifies that he was first charged with Burglary of a Residence when he was 24 years old. He had spent


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a large portion of his adult life imprisoned or hospitalized in structured, supervised settings. He had prior convictions for Aggravated Robbery with a Deadly Weapon, Burglary of a Habitation (twice), Indecent Exposure, Weapons Offense, Possession of Cocaine, and the current offense of Aggravated Sexual Assault. One of his convictions for Burglary of a Habitation involved the following circumstances: Mr Smith attempted to open the door of a female stranger’s residence. When he was unable to do so, he went to the side gate but her dogs alerted her at 2:45 a.m. He then returned to the front of the house and was arrested after it was discovered that he had attempted to remove the screen from the woman’s bedroom window. Mr Smith was most recently arrested for Aggravated Sexual Assault. He approached the unknown, 23-year-old, female victim at night as she was about to enter her home carrying groceries. He reportedly asked her if she would like some help carrying her things into her house. She said “no”, but Mr Smith forced her in at knife point. He shoved her over a couch and punched her in the face a couple of times while pushing her toward the bedroom. The victim stated that he knocked her head into the wall and then he picked her up and threw her onto the bed. She screamed and he told her that he would “shut her up if he had to cut her up”. Mr Smith vaginally raped her while making derogatory statements. The victim reported that he acted dazed and “high” during the assault. He reported that he was not taking his medicine and was using cocaine at the time of the offense. Mr Smith told her that if she reported the offense he would kill her. He eventually left her home, insisting that she close her eyes and lie face down on the bed. When she was sure he was gone, the police were called and a sexual assault examination was performed at the hospital. Mr Smith stood trial and was sentenced to 10 years in the state Department of Corrections. In regard to Mr Smith’s sexual history, he indicated that his first sexual experience was “my family doing weird shit”. When asked about how he learned about sex, he stated, “watching my father and mother”. He denied having current sexual fantasies about underage persons or nonconsenting persons. Based on his history and previous reports of fantasizing about exposing himself to adult women, this statement was suspect. He denied currently masturbating to sexually deviant fantasies. He reported several other instances of exhibitionism for which he was not charged. When asked about his preferences with regard to sexual partners or potential victims, he stated, “skinny, thin, Caucasian women . . . age 20 or so . . . I’m not a child molester . . . I don’t mess with kids . . . just adults”.

Issues for Treatment Mr Smith has a history of mental illness and substance abuse. When he initially arrived at the correctional facility, he presented with paranoid delusions, labile and angry affect, illogical thinking, hypersexuality, and confusion of thought. He had a history of being diagnosed with Schizoaffective Disorder, Bipolar Type and Antisocial Personality Disorder. He exposed himself to female correctional officers and exhibited aggressive and threatening behaviors. He eventually responded adequately to his medication regimen, although, all symptoms had not resolved entirely. His thinking became more organized, his emotions were better regulated, and his demeanor was more relaxed.


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Mr Smith readily admitted his offense(s) and was willing to participate in a comprehensive sex offender treatment program. He expressed a significant number of criminal thinking errors or cognitive distortions combined with having command hallucinations that were congruent with his sexually deviant thoughts and behaviors. This put him at a higher risk of reoffense. Medication improved his disorganized thinking but redirection and offering alternatives were still frequently needed. Mr Smith attended a sex offender treatment group based on a cognitivebehavioral framework, as well as incorporating the relapse prevention model, and psycho-educational modules on issues such as anger management and social skills training. His treatment program is empirically based in that it includes standard of practice elements of sex offender treatment such as: (1) acceptance of responsibility (e.g., denial/minimization, cognitive distortions, and victim empathy); (2) offense pathways (e.g., early warning signs, dangerous situations, and relapse prevention plans); (3) coping skills; (4) intimacy and attachments, (5) sexual arousal, fantasies, and preferences, and (6) mood and symptom management. Initially, Mr Smith sometimes appeared internally preoccupied. He responded to redirection and he improved in this regard as his psychotropic medications continued to be adjusted by his psychiatrist. Mr Smith indicated that he was experiencing auditory hallucinations in the form of voices but he felt that he was better able to cope with them and did not have to do what the voices told him to do. He also disclosed that substance abuse caused an increase in his anger and was a significant risk factor for reoffense of nonsexual and sexual violence. Initially, he described having sexual thoughts almost every day but indicated that he had not acted on them or masturbated to them. He also reported that he continued to hear voices at times telling him to commit a sexual offense (e.g., “to touch a woman”), but he continued to indicate that he was able to resist acting on those commands or other deviant impulses. While in the group, Mr Smith participated but his progress was limited by the intermittent reemergence of psychiatric symptoms and/or a pattern of disregarding the impact of his actions on others. It was particularly challenging to differentiate and address criminal thinking errors or cognitive distortions that are present independent of psychosis and those symptoms of psychosis that were present with similar themes.

FORMULATION Mr Smith was a 50-year-old, divorced, Caucasian male with a history of physical and sexual abuse, poly-substance abuse, and an extensive psychiatric and legal history. His current incarceration was precipitated by the instant offense of Aggravated Sexual Assault. Mr Smith’s attack was premeditated and predatory. Based on the means by which he gained control over his victim, the degree of physical force, how he interacted with his victim, and other motives and behavioral patterns, he could be classified as an anger-retaliatory rapist. Mr Smith’s childhood was marked by fear and abuse. He did not form healthy attachments and he learned to identify with the aggressor(s). His sexual


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victimization at an early age coupled with the violence in the home created a very unstable sense of self, maladaptive relationships with others, and dysfunctional sexual development. He described a protracted history of inappropriate sexual fantasies to which he masturbated. It is apparent he developed a preference for sexual activity with nonconsenting, adult females. His history of substance abuse; academic and social failures; criminal behaviors; and rejection from parents, spouse, and peers have all contributed to his offense pathway. Mr Smith views his world as a hostile place where you take what you want and you “get them before they get you”. Moreover, he appeared to use coercive sex as a coping strategy for negative mood states or when he feels powerless or humiliated in order to reestablish his feelings of control and power. He was likely to be very opportunistic about who he chose as a victim (e.g., easiest target); although, if his preferred victim type were available, this would trigger him to act. Mr Smith felt sexual arousal or a high from violent fantasy and behavior. His psychosis, impulsivity, and deviant sexual urges were currently so extreme that his daily functioning was greatly impaired and his risk for nonsexual and sexual violence was high. He has escalated from indecent exposure to a violent, potentially sadistic rape and another attempted rape that was premeditated. It appeared that Mr Smith’s sexual assaults increased in the degree of violence used during the attack. There was a compulsive element in his behavior but he appears to have an absence of feeling and no desire to conform. There was a lack of psychological attachment or closeness to others. Drinking heavily or using cocaine made him even more likely to become selfish, unreasonable, and forceful in order to regain control of the victim. The exercise of verbal intimidation to gain power and secure dominance also spoke to his motivation and was self-revelatory. His derogatory, profane, and hostile language during the assault indicates anger toward women and his use of brute sexual behavior signified an urge to punish and degrade them. Mr Smith has a history of being aggressive with his mother. Mr Smith likely saw his victims as objects but also has a proclivity for using sex as a weapon to harm and humiliate. This mirrors what he felt and experienced as a young boy when abused sexually by an uncle and physically by his father. Mr Smith has an explosive temper, lower intelligence, does not trust others, lacks social skills, has a low socioeconomic status and leads a highly impulsive lifestyle.

Criteria for Success/Expected Outcome The ultimate goal is for Mr Smith not to reoffend in the correctional setting or in the community. Given the longstanding nature of Mr Smith’s focus on deviant sexual behavior, his resistance to treatment, and his history of offending, the most effective way to manage his risk for sexual violence is to deny him access to potential victims and to house and treat him in a highly structured environment with careful monitoring. His deviant sexual fantasies are not likely to remit, but he may become less impulsive with regard to acting on these fantasies or behaviors if his psychiatric symptoms improve. Tracking and monitoring the frequency of inappropriate sexual behaviors with the expectation that any such behaviors will cease is one expected treatment outcome. Both in an institutional setting and


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in the community, Mr Smith’s risk management strategies should focus on intensive supervision, psychiatric intervention, and environmental separation from any potential victims. Female staff should never engage him alone. A measure for success is Mr Smith’s ability to identify and then avoid or reframe any triggers, thoughts, feelings, behaviors, and high-risk situations that might ready him to sexually reoffend. As a result of his dual diagnosis and history of mania and psychotic symptoms, Mr Smith requires psychiatric services to include psychotropic medications and possible hospitalization if his symptoms become more severe. Mr Smith has traits of psychopathy but he was not definitively classified as such. To deny him certain aspects of his treatment without more evidence could cause more harm than good. If additional data were provided or if his actions conveyed the same, several treatment approaches in his plan would need to be revisited and some might need to be changed altogether. Individuals clearly identified as psychopathic or sadistic are not appropriate candidates for sex offender group therapy, particularly in a correctional environment. These individuals can mimic emotions, such as empathy or remorse, but if you scratch below the surface the façade crumbles and it quickly becomes apparent that they are going through the motions without any real foundation for what it genuinely means to express or experience these feelings (Shipley and Arrigo, 2008). The formulation identified a number of important proximal antecedents to aggression, exposure to females and rape including: hearing voices, manic symptoms, alcohol and cocaine abuse, and angry and depressed mood. Thus, his treatment program addressed these antecedents in a number of ways. For example, psychiatric symptoms were addressed by medication, promoting medication compliance and cognitive behavior therapy. Cognitive behavior therapy also was used to teach him alternate strategies when dealing with angry and depressed mood. Stable antecedents, such as cognitive distortions and indifference to other people, were addressed by cognitive restructuring and attempts to promote empathy, intimacy and attachment to others. Risk management also dictated reduction of risk by removal of opportunities to harm through supervision and reduced access to trigger situations, such as being alone with women. Thus, intervention required a balance of strategies to promote other, appropriate behavior and limiting opportunities. In evaluating Mr Smith’s response to treatment goals and in amending, if necessary, treatment planning, it is important to incorporate relevant measures of behavioral change including improvement in depression or hypersexuality stemming from mania, and demonstrated use of effective coping skills in managing sexual behavior and in managing other environmental stressors without resorting to exhibitionism or brute force.

CONCLUSIONS The sexual assaults of adult women and men are traumatic and destructive as evidenced by the enormous cost they exact from victims, their families, the mental health and justice systems, and society in general. The range of assessment, diagnostic, treatment, and programming issues as developed in this chapter amply demonstrate the complexities of forensic case formulation for adult sexual


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offenders. These significant concerns notwithstanding, McGrath’s (1991, p. 346) caution is worth noting. As he indicated, Disposition plans should not be influenced by misinformation, politics, or fear, but should be solidly grounded in clinical experience, empirical knowledge, and availability of specialized resources. Rehabilitation of offenders who show potential for change is imperative, while protection of the community must remain a continual priority (p. 346.)

In the final analysis, this is the purpose of any sound clinical case formulation and forensic evaluation. This includes those individuals whose underlying behavior is sexual, deviant, and criminal in nature.

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National Center for Women and Policing (2004). Suspect typology; profiling the sex offender. http://www.hawaii.edu/hivandaids/Suspect%20Typology%20%20%20Profiling%the% 20Sex%20Offen der.pdf. O’Donohue, W. and Letourneau, E. and Dowling, H. (1997) The measurement of sexual fantasy. Sexual Abuse: A Journal of Research and Treatment, 9, 167–78. Polaschek, D.L.L., Hudson, T. and Ward, S.M. (1997) Rape and rapists: Theory and treatment. Clinical Psychology Review, 17(2), 117–44. Prentky, R.A. and Knight, R.A. (1993) Age of onset of sexual assault: Criminal and life history correlates. In G.C.N. Hall, R. Hirschman, J.R. Graham and M.S. Zaragoza (eds), Sexual Aggression: Issues in Etiology, Assessment, and Treatment (pp. 43–62). Washington, DC: Taylor & Francis. Pardue, A. and Arrigo, B.A. (2008) Power, anger, and sadistic rapists: Towards a differentiated model of offender personality. International Journal of Offender Therapy and Comparative Criminology, 52(4): 378–400. Purcell, C.E. and Arrigo, B.A. (2006) The Psychology of Lust Murder: Paraphilia, Sexual Killing, and Serial Murder. San Diego, CA: Academic Press. Quinsey, V.L., Harris, G.T., Rice, M.E. and Cormier, C.A. (1998) Violent Offenders: Appraising and Managing Risk. Washington, DC: American Psychological Association. Ratner, P.A., Johnson, J.L., Shoveller, J.A., Chan, K. et al. (2003) Non-consensual sex experienced by men who have sex with men: Prevalence and association with mental health. Patient and Education Counseling, 49, 67–74. Richards, H.J., Washburn, J.J., Craig, R. et al. (2004) Typing rape offenders from their offense narratives. Individual Differences Research, 2(2), 97–108. Salter, A.C. (2003) Predators, Pedophiles, Rapists, and Other Sex Offenders: Who They Are, How They Operate, and How We Can Protect Ourselves and Our Children. New York: Basic Books. Sbraga, T.P. (2003) Sexual deviance and forensic psychology: A primer. In W. O’Donohue and E. Levensky (eds), Handbook of Forensic Psychology: Resource for Mental Health and Legal Professionals, London: Elsevier Academic Press. Scott, G.G. (1983) Dominant Women, Submissive Men. New York: Praeger. Serin, R.C., Malcolm, P.B., Khanna, A. and Barbaree, H.E. (1994) Psychopathy and deviant sexual arousal in incarcerated sexual offenders. Journal of Interpersonal Violence, 9(1), 3–11. Shipley, S.L. (2007) Perpetrators and victims: Maternal filicide and mental illness. In R. Muraskin (ed.), Prentice Hall’s Women in Criminal Justice Series (4th edn): It’s a Crime, Women and Justice, Upper Saddle River, NJ: Prentice Hall. Shipley, S.L. and Arrigo, B.A. (2001) The confusion over psychopathy (II): Implications for forensic (correctional) practice. International Journal of Offender Therapy and Comparative Criminology, 45(4), 407–20. Shipley, S.L. and Arrigo, B.A. (2004) The Female Homicide Offender: Serial Murder and the Case of Aileen Wuornos. Upper Saddle River, New Jersey. Shipley, S.L. and Arrigo, B.A. (2008) Serial killers and serial rapists: dichotomy or continuum- an examination of commonalities and comparison of typologies. In R. Kocsis (ed.), Serial Murder and the Psychology of Violence, Totowa, NJ: Humana Press, Inc. Stermac, L., Del Bove, G. and Addison, M. (2004) Stranger and acquaintance sexual assault of adult males. Journal of Interpersonal Violence, 19(8), 901–15. Strickland, S.M. (2008) Female sex offenders: Exploring issues of personality, trauma, and cognitive distortions. Journal of Interpersonal Violence, 23(4), 474–89. Struckman-Johnson, C. and Struckman-Johnson, D. (2006) A comparison of sexual coercion experiences reported by men and women in prison. Journal of Interpersonal Violence, 21(12), 1591–1615. Tjaden, P. and Thoennes, N. (1998, November) Prevalence, incidence, and consequences of violence against women: Findings from the National Violence against Women Survey. National Institute of Justice Centers for Disease Control and Prevention Research in Brief, 1–16. US Department of Justice (2008) Criminal Victimization in the United States, 2006 Statistical Table. Retrieved September 12, 2008, from http://www.ojp.usdoj.gov/bjs/pub/pdf/ cvus06.pdf.


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Ward, T. and Beech, A. (2006) An integrated theory of sexual offending. Aggression and Violent Behavior, 11, 44–63. Warren, J.I., Reboussin, R., Hazelwood, R.R. and Wright, J.A. (1991) Prediction of rapist type and violence from verbal, physical, and sexual scales. Journal of Interpersonal Violence, 6(1), 55–67. Whitehead, P.R., Ward, T. and Collie, R.M. (2007) Time for a change: Applying the Good Lives model of offender rehabilitation to a high-risk violent offender. International Journal of Offender Therapy and Comparative Criminology, 51(5), 578–98. Willis, D.G. (2009). Male-on-male rape of an adult man: A case review and implications for interventions. Journal of the American Psychiatric Nurses Association, 14(6), 454–61. Zgoba, K.M. and Levenson, J. (2008) Variations in the recidivism of treated and nontreated sexual offenders in New Jersey: An examination of three time frames. Victims and Offenders, 3, 10–30.


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PART IV

SPECIFIC POPULATIONS


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Chapter 10

FORENSIC CASE FORMULATION WITH CHILDREN AND ADOLESCENTS PHIL RICH Stetson School, Massachusetts, USA

INTRODUCTION AND LITERATURE REVIEW Case formulation involves the capacity to reduce and synthesize information to a more precise form that expresses broad ideas concisely. It represents an analysis and abstraction of key features of the case, and reduces history, facts, symptoms, and circumstances into a brief summary that identifies key treatment targets, provides meaning, conjectures causes, outlines current issues, and informs prognosis. To some degree, the formulation puts forth a clinical theory about the case, providing explanatory information, identifying hypothesized causes, and suggesting meaning and future action. It thus allows the basis for understanding the case, both historically and dynamically, and its likely trajectory, as well as interventions that may interrupt trajectory and create a new prognosis.

Formulation Is Not Formulaic Formulation provides an individualized approach to recognizing the idiosyncratic particulars of each case and understanding each case as unique, and does not equal a formulaic approach to or interpretation of cases. To this end, Drake and Ward (2003) write that formulation-based approaches to treatment require that evaluators understand psychological problems and vulnerabilities for individual clients, rather than utilizing a manualized or cookbook approach to understanding behavior. Despite the perspective that offenders share common dysfunctions and can thus be treated through a prescribed and common approach, Drake and Ward argue that this position is limited and results in weak and poorly targeted treatment that fails to meet individual needs. Instead, they note, case Forensic Case Formulation, First Edition. Edited by Peter Sturmey and Mary McMurran. C 2011 John Wiley & Sons, Ltd. Published 2011 by John Wiley & Sons, Ltd.


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formulation highlights specific developmental factors relevant to the case of each individual which converged to make that specific individual vulnerable to engaging in antisocial behavior. In case formulation, then, an understanding of the case is based on the individual, in which treatment interventions are not only individualized but emerge from the process of case formulation. Whereas gathering information and condensing it may follow a standard model, the process of understanding the individuals with whom we work is individually based. The data gathering process is therefore nomothetic, or based on general and universal principles, whereas the focus on the individual is idiographic, targeting only the case at hand and structured by and focused on the individual being assessed. Case formulation, then, can be thought of as idiographic practice framed within a nomothetic process (Houston, 1998). The process of case formulation helps clinicians understand the factors and motivations that shape and explain behavior, as well as prognosticate the further development or resolution of pathology. A forensic focus recognizes and seeks the presence of risk factors that contributed or led to the antisocial behavior, and perhaps the development of a troubled and/or antisocial or criminal personality structure in the individual. In particular, the forensic approach looks for the historical or current presence of criminogenic factors, or elements that produce, drive, or predict criminal behaviors. The related concept of criminogenic needs points to the presence of elements that need to be addressed if crime is to be reduced (Andrews, Bonta and Hoge, 1990). Offenders have many needs, but only some are functionally related to criminal behavior. Criminogenic needs are dynamic or changeable risk factors that are the intermediate targets in interventions that aim ultimately to reduce reoffending.

How, Why, and Where to from Here? In its forensic application case formulation addresses the intersection of legal and mental health processes and incorporates a full understanding of both. It includes the criminogenic factors that influence, shape, and drive antisocial and illegal behaviors and the mental health issues that affect, drive, or result from criminal behavior. A central question in forensic work, then, is not simply what happened, but how and why it happened, and what to do about it. We can thus think of forensic work in two areas: Evaluation and treatment. Simply put, as forensic evaluators our role is to evaluate the juvenile’s behavior based on the presence and influence historical and current psychosocial and psychological factors. In the case of forensic risk evaluation, we extend this to predictions, projections, or the likelihood of future antisocial or criminal behavior in juveniles who have already engaged in such behaviors. Most simply, Grisso (2006) has written that such evaluations are always forensic because they are performed in order to inform court decisions, although this is not always the case for children and adolescents. The contexts in which juvenile forensic evaluations occur extend beyond the court, as not every child or adolescent engaging in criminal behavior is legally prosecuted, even though the behavior itself involves the possibility of juvenile or adult criminal charges.


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In the case of forensic treatment, we can simply reframe this as the process of applying mental health and psychosocial treatment to children and adolescents who have engaged in and are at risk for re-engaging in significant antisocial and/or criminal behaviors. Such treatment includes both standard treatment interventions and specific interventions aimed at the criminogenic and other dynamic factors that specifically contribute to juvenile criminal behavior. In many respects, unlike nonforensic mental health treatment, forensic treatment for juveniles assumes, or should assume, a largely rehabilitative approach in which the goal is to build positive and prosocial attitudes, beliefs, expectations, ideas, social interactions, critical social skills, and mental representations of self and others, as well as change behavior. In the case of both evaluation and treatment, formulation is important if we are to understand the youth beyond the mere presence of historical factors and behaviors, and projections about future antisocial behavior. In either case, formulation provides the basis for understanding the juvenile and the myriad factors that have come together in his or her particular life to produce the historical behavior, the current level of psychological and psychosocial functioning, and the probability of future occurrences of problematic behavior, in which, as Kagan (2006) has noted, there is no single cause, rather, “A coherence of several factors is necessary to produce a particular phenomenon” (pp. 94–5).

Forensic Work with Juveniles: A Comprehensive, Developmental, and Contextual Framework Coffey (2006), Greenberg and Shuman (1999), Grisso (1998, 2006), and McCann (1998) describe the difference between forensic evaluation and treatment, and consider the two roles to be inherently different, incapable of being filled by the same practitioner. Nevertheless, the idea that forensic evaluation and treatment are separate processes that require separate practitioners assumes not only that the differences are irreconcilable but also that forensic work with children and adolescents is the equivalent of forensic work with adults. Acknowledging the differences between evaluation, or serving and informing the legal system, and serving and treating the client, Bluglass (1990) writes that it is the task of the forensic practitioner to reconcile these differences in order to be effective in both arenas. Indeed, in the treatment of juvenile offenders both roles must be consolidated, unless we are to separate the functions of evaluation and treatment completely, from the initial assessment of risk through all subsequent risk evaluations. Accordingly, the work of both the forensic evaluator and the forensic clinician must be synthesized into an overarching model of forensic mental health if we are to ensure an assessment and treatment model that is able to evaluate and treat children and adolescents in a single and seamless model capable of responding to youths holistically, as individuals, and as persons-in-development. Not only must we blend evaluation and treatment into a single framework, in a forensic model that evaluates and treats children and adolescents we must remain acutely aware of the developmental process and the developmental status of


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juveniles and bring these ideas to bear in both our understanding of youthful offenders and at every stage of our treatment. In advocating for this developmental framework in our work with juvenile offenders, Steinberg and Scott (2003) describe adolescents and children as developmentally immature when compared to adults, not only in general brain maturation and psychological development, but also with particular respect to their decision making capacity, increased vulnerability to social circumstances, and still forming character and personality. Similarly, Zimring (2004) admonishes us to take into account the developmental status of juvenile sexual offenders, with respect to the moral significance of their current behaviors, predictions of future behavior, and implications for treatment. Grisso (1998), too, pays great attention to the rapidly moving development of juveniles, writing that “questions of growth and development are at the heart of all juvenile forensic evaluations” (p. viii) and suggests that it may be more relevant to refer to forensic evaluations for juveniles as “forensic developmental evaluations”. He writes that “nothing about the behavior of adolescents can be understood without considering it in the context of youths’ continued biological, psychological, and social development” (p. 27). From a developmental and contextual framework, Grisso (1998) also describes the necessity of paying attention to the social environment in forensic work, recognizing the juvenile in the context of the systems within which he or she lives, interacts, and functions, and that this systemic perspective is central in the translation of evaluation data into recommendations for responses that are in the best interests of the youth and society. Indeed, the social environment is the great mediator in many of the developmental tasks faced by the developing child and the context in which personal learning take place. It is within this developmental and learning environment that the vulnerabilities described by Marshall and Eccles (1993) develop and grow into risk factors, or in which children develop the assets and strengths that serve as protective factors. In this environment, children find, or fail to find, the elements necessary to function successfully, effectively, happily, and prosocially in the world; however, just as their presence provides the greatest opportunities for children, the absence of these ideals presents an environment in which a child will have great difficulty succeeding. In fact, the developmental pathway of each individual cannot be separated from the contextual social environment into which it is woven. An ecological perspective from this point of view relates to the interconnection between and the mutual influence of each part of the environment. Described by Elliot, Williams and Hamburg (1998), the ecological-developmental approach provides a framework by which human development is understood through the interactive social contexts which influence and shape behavior. Human development and human behavior – including the antisocial and criminal behavior of juvenile offenders – occurs within a complex and multiply nested, multiply interacting, and mutually transactional environment. Our ability to understand human development and behavior thus requires an understanding of the individual affected by all levels of the ecological system. To a great degree, this becomes part of a guiding model in both the assessment and treatment of juvenile offenders, in which we understand risk in children and adolescents in the contexts of both their social and psychological development and their social learning environment, or the developmental/learning environment in which they have been raised.


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Forensic Risk When we engage in forensic work and adopt a forensic approach we must think about risk, for at least two reasons and from at least two perspectives. In risk assessment, we consider risk from the perspective of recidivism, or the potential, likelihood, or probability of future recurrence. In this case, regardless of how we evaluate risk for recidivism, we are concerned with trajectory if things remain unchanged; however, understanding risk not only helps us to understand the direction of future behaviors but also the nature of risk, the conditions that give rise to risk factors, and the conversion, in some children and adolescents, of risk factors to actual harmful behavior. When we discuss risk in relationship to juvenile criminal behavior, we are focused upon risk factors believed to be related to re-engagement in criminal behavior, as well our understanding of what caused or contributed to the behavior in the first place. Nevertheless, despite focusing on risk factors specific to juvenile delinquency and adolescent criminal behavior, a broad range of psychosocial variables is associated with risk for conduct disordered behavior (Rutter, 1994), and even a cursory review of risk factors makes it clear that forensic risk (i.e., risk for criminal behavior) is linked to risks of many types for children and adolescents. Hence, many of the essential risk factors for juvenile crime are identical to those for other personal or social problems, as is true for the presence of protective factors, or the personal and social elements that buffer against or neutralize risk. This again reflects an ecological approach to understanding the development of juvenile offending, highlighting the fact that such behavior emerges from the same social conditions that give rise to other troubling conditions, and it is the presence, convergence, and multiplicative effects of individual and sets of risk factors, at the biological, psychological, social, and environmental levels, that finally come together to produce harmful and criminal behaviors in any given individual.

The Strength of Static Risk Factors: The Early Development of Risk Static risk factors are those elements of risk that are historical, and are not subject to change. Early adverse developmental experiences and prior criminal behaviors, although in quite different categories are both examples of static factors that serve as potential indicators of future risk. Static risk factors offer a great deal to risk prediction because history counts, not just as a predictor but also as a foundation upon which present ideation and behavior is built and as the basis for continued trajectory. Just as resiliency against adversity and stress is laid down in early positive development (Sroufe et al., 2005), so too is the foundation for antisocial behavior, as well as many other kinds of risk, laid in early life. This is easily seen by the number of general risk factors that make their appearance in childhood and before age 12 years. Thus, Henry et al. (1996) note that children who become serious criminal offenders are characterized by features that consistently bring them into conflict with their surroundings during early childhood. Individual characteristics that make individuals susceptible to risk are perhaps at their greatest during early childhood


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as they come into contact and interplay with environmental conditions that may catalyze risk or build a backdrop out of which antisocial behavior may later emerge (Rutter, Giller and Hagell, 1998). Moreover, rather than unexpectedly emerging at a later point in adolescent or adult development, Loeber et al. (2005) write that risk factors for serious crime can be observed in earlier childhood, and later antisocial behavior is often based on processes that accumulate over many years, associated with multiple risk factors in multiple domains. It is thus important that we recognize the difference between what Moffitt (2003) calls life-course persistent antisocial behavior, in which persistent antisocial behavior clearly originates in childhood when the troubled behaviors of the high-risk young child are acted out in and amplified by a high-risk social environment, and adolescence-limited antisocial behaviors that are more transient and first appear during adolescence.

The Operation of Multiple Risk Domains During Childhood and Adolescence In focusing on risk factors for serious delinquency or violence, Lipsey and Derzon (1998) and Hawkins et al. (2000) identified risk residing within and spread through five essential domains: individual, family, school, peer group, and community. Figure 10.1 shows examples of risk factors found within each domain; however, of the 23 childhood risk factors identified in the US Surgeon General’s report on

Risk factor by domain Individual

• Aggressiveness • Early violent behavior • Antisocial attitudes and behavior

Family

• • • • • •

Parent criminality Child maltreatment, poor family bonding Family conflict Low parental involvement Antisocial parent attitudes Parent-child separation

School

• • • • •

Academic failure Poor school bonding Frequent school changes School truancy School dropout

Peer group

• Delinquent siblings • Delinquent peers

Community

• • • •

Poverty Community disorganization Crime ridden neighborhoods Exposure to violence and prejudice

Figure 10.1 Examples of risk factors for youth violence found in each of the five domains identified by Lipsey and Derzon (1998) and Hawkins et al. (2000).


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youth violence largely based on the work of Lipsey and Derzon (US Department of Health and Human Services, 2001), no single risk factor alone is especially powerful; however, this does not mean that these risk factors are inconsequential. Instead, it suggests that it is a combination of risk factors, and no single factor alone, that best predicts risk. That is, although some risk factors are stronger in effect than others, and are therefore better predictors of later antisocial behavior, no single factor is itself necessary for nor sufficient to predict or produce antisocial behavior. In addition, not only is risk best predicted by multiple risk factors, but the likelihood that an individual will engage in antisocial behaviors is greatly increased by the number of risk factors to which the individual is exposed (Farrington, 1997; Garmezy, 1987; Hawkins et al., 2000). Further, risk that produces antisocial behavior is driven not just by multiple risk factors but, as noted, interactions among risk factors across multiple domains (Haggerty and Sherrod, 1996; Loeber et al., 2005). Further, many of the childhood risk factors take on a greater role during adolescence whereas others drop in significance, reflecting the idea that the same risk factors operate differently at different points during childhood and adolescent development and have more or less impact based on the age and developmental level of the child. For instance, Lipsey and Derzon (1998) found that the most significant early risk factors in childhood development (ages 6–11 years) included low family socioeconomic status and antisocial parents. These were followed by factors that, while less statistically significant, were nonetheless meaningful, including poor parent–child relationships, harsh or lax parental discipline, broken homes, poor attitude toward or performance in school, and exposure to television violence, as well as weak social ties. Of note here, the influence of risk factors associated with social connection increases in strength during early adolescence (ages 12–14 years), such as weak social ties which increases considerably in effect size, and by adolescence becomes the strongest indicator in Lipsey and Derzon’s inventory of risk factors, as well as an increase in the risk power of poor child–parental relationships. During adolescence, other factors not especially prominent during childhood take on more significance; in the case of serious and violent criminal behavior, these especially include association with antisocial peers, which is a factor that may be less relevant when we consider risk for sexual reoffense and especially among those who sexually abuse children. Nevertheless, important seeds of risk are often sown early in childhood development and take greater root in adolescence, along with other risk factors that may have held less importance at an earlier point in development. As attachment patterns are considered to develop early in childhood, setting the pace for later social connections (Rich, 2006), it is not surprising that the effect size of weak social ties as a predictor of risk in Lipsey and Derzon’s model increases by 160% during early adolescence.

Secure Attachments are Protective A discussion of attachment and its secure and insecure variants is well beyond the scope of this chapter; however, whereas insecure attachment, as the by-product of suboptimal or disrupted early experience, may be considered a general risk factor


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for many difficulties, secure attachment almost certainly serves as a protective factor. In a nutshell, the attachment model proposes that early and on-going attachment experiences provide a foundation upon which identity is built and internalized. These experiences either contribute to secure attachment and resiliency, serving as a protective factor against negative or hostile life circumstances, or as a developmental vulnerability in which insecure attachment not only fails to protect but under adverse conditions, and particularly when combined with other risk factors, is quite possibly a risk factor in its own right. On the other hand, secure attachment strengthens the individual, buffering against adverse social conditions and helps neutralize and weakens both internal and external risk factors that may otherwise increase risk (Rich, 2006, 2007). Atkinson and Goldberg (2004) describe secure attachment serving a protective function because, throughout life, under adverse or anxiety provoking circumstances, it triggers distress-regulating and support seeking behaviors. The failure to internalize attachment security is assumed by attachment theorists to set in motion pathways that lead to behavioral, relational, and other functional difficulties. Fonagy (2001, 2004), for example, asserts that the capacity to adequately “mentalize,” or visualize, one’s own mental state and the mental states of others, develops directly out of the attachment experience and the child’s opportunity to observe and explore the mind of the caregiver, and that severe deprivation undermines the acquisition of this skill (i.e., metacognition). Fonagy (1999a, 1999b) describes the skills of metacognition as critical to effective social functioning, and proposes that crimes are committed by people with inadequate metacognitive capacities who instead engage in pathological attempts in order to adapt to a social environment in which metacognition is essential. Fonagy’s perspective, then, is that adolescent antisocial behavior results from a lack of both security and metacognitive skills, linked through the attachment experience. Travis Hirschi (2002), far from an attachment theorist, also considers risk for criminal behavior to be tied to attachment and social connection, writing that “the bond of affection for [prosocial] persons is a major deterrent to crime” (p. 82). He notes that we are moral beings to the extent that we have internalized the norms of society, and “that the essence of internalization of norms, conscience, or superego lies in the attachment of individuals to others” (p. 18). Simply speaking, then, secure and prosocial attachments serve as a protective rather than a risk factor. Secure attachment is implied in the capacity for close and connected relationships to parents, other adults, and adults, and further in the capacity to form bonded relationships to community organizations like schools, accept and connect with prosocial norms and values, demonstrate self-regulation, and experience self-efficacy. Secure and insecure attachment styles are thus key to the case study presented in this chapter.

Attachment, Social Connection, and Moral Behavior The Commission on Children at Risk (2003) describes a crisis in American childhood, based upon a lack of social connection, both to other people and to constructs


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such as morality and personal meaning. Their perspective is that the task is to reconnect children, not just to peers and adults in the community, but to society itself. Directly linking social attachment to moral development, and hence social behavior, the Commission describes moral behavior stemming from attached relationships as much as the acquisition of rules. They take the position that we are genetically predisposed to connect with others and form attachments, and that our sense of right and wrong originates largely from a biologically primed need for attachment. From this perspective, moral behavior stems as much from relationships as from the acquisition of standards and rules; thus, the failure to form secure attachments necessarily means the failure to form a strong moral code. The idea that moral development and behavior is linked to social connection was postulated by Piaget (1997), who believed that moral development is based on values directly related to equality and reciprocity in social relationships. Hoffman (2000) also describes empathic connections with others as the basis for moral development, as does Vetlesen (1994) who asserts that perceptions of morality are built on the experience of empathy for others. Kagan (1984) too considers the child’s acquisition of standards to be facilitated by the recognition of feelings and thoughts in self and others, mediated through the development of empathy, and he makes moral development contingent upon the development of empathy. Similarly, Stilwell et al. (1998) describe the “moralization of attachment”, or the transformation of early attachment and social experiences into the values, attitudes, and beliefs that underlie relationships and behaviors, resulting in a moral conscience. They write that the development of empathy and morality occurs in the context of early attachment relationships and later expanding relationships with other family members, adults, and friends, and within the social organizations and institutions in which children are raised and grow to adulthood. Stilwell defines moral delay, arrest, and deviancy as developmental disruptions, interruptions, and derailments that result from disruptions in attachment, neglectful parenting, or trauma (Stilwell et al., 1994). Through their social environments, then, children and adolescents become attached to the norms and values of their societies, and incorporate these into their identities and character. In the social context, we find the role models who influence the development of behavior and personal identity, and the arena in which social lessons are taught and learned. Thus, the larger social context in which child rearing and child development occurs is not just an important, but passive, backdrop to the development of antisocial behavior, but an active ingredient in terms of attachment, social connection, and the development of empathy and moral behavior.

ASSESSMENT The Application of Ideas in Case Formulation More than an exercise in psychosocial assessment, case formulation helps us to recognize the influence of past and present factors that influence and shape antisocial thinking, attitudes, interactions, and drive antisocial behavior, and central issues or problems to be addressed through the treatment process. Equally, case


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formulation provides an opportunity to think, not only about risk factors and their amelioration, but the presence and action of protective factors as well, and their central role in developing and delivering treatment interventions, not simply to contain behavioral and social deficits but to build on and develop strengths and engage in the process of rehabilitation.

Application of Structured Instruments in Case Formulation Case formulation is key to the use of the widely used Risk-Need-Responsivity model (Andrews, Bonta and Hoge, 1990; Andrews, Bonta and Wormith, 2006; Hoge and Andrews, 1996, 2003), and in the application of the model through the Level of Service/Case Management Inventory and its counterpart for adolescent offenders, the Youth Level of Service/Case Management Inventory (YLS/CMI). Simply, the RNR model provides the evaluator with a structure and guide by which to individualize the intensity, level, location, and type of case management and treatment services provided to both adult and juvenile offenders, based upon their assessed level of Risk for reoffense, an assessment of their individualized treatment Needs based on the presence of specific criminogenic factors, and an assessment of the likely Responsiveness of each individual to the process and format of case management and treatment services. Of importance, the RNR model is strongly based on case formulation, and final decisions are based on professional “override,” or the case formulated judgment of the evaluator. The RNR model not only embraces a case formulation approach, but case management and treatment programs that adhere to its model, which includes differentiated treatment based on individual case formulation, are more effective in reducing recidivism than programs that do not follow the model that are more standardized and “cookie cutter” in their approach (Andrews and Bonta, 2010; Hanson et al., 2009). Case formulation is also central, although perhaps to a lesser degree, in the use of the Structured Assessment for Violence Risk in Youth (SAVRY), which, like the YLS/CMI, is a structured instrument used to assist in the clinical evaluation of youths with respect to risk. Unlike the YLS/CMI, the SAVRY is only designed to assess risk and is not intended as a case management instrument. On the other hand, the SAVRY is a 30-item instrument that includes an evaluation of six protective factors, and thus recognizes the mediating influence of protection in predictions of recidivism, permitting the assessment of risk to be made “as a professional judgment, including consideration of . . . risk and protective factors” (Borum, Bartel and Forth, 2002, p. 17). The protective items mirror exactly those already described in this chapter: Prosocial involvement, strong social support, strong attachments and social bonds, commitment to school, and resilient personality, as well as positive attitudes toward treatment and authority. These instruments are forensic assessment tools that combine clinical judgment with empirically based structure. They both structure the assessment of risk by providing a list of risk factors to be evaluated for both presence and strength and, as noted, the SAVRY pays some attention to the presence of protective factors as well. Both instruments require a detailed understanding of the young person being assessed, but whereas the SAVRY helps formulate an assessment of risk the LSI


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goes beyond risk in order to further formulate treatment, case management, and supervision needs for the youth.

CASE STUDY Mitchell is a 15-year-old male adolescent, short in height and slight in stature, looking significantly younger than his age, and of low average IQ. Raised by two unmarried drug addicted parents, Mitchell’s mother was 18 and his father 23. He and his younger brother were significantly physically, and possibly sexually, abused by their father, who also severely physically abused Mitchell’s mother. After being severely physically assaulted, Mitchell’s mother moved into the home of her own former foster mother, taking Mitchell, 61/2 , and his four-year-old brother with her. Soon after the move, his mother began to leave the home for weeks at a time, returning to periodically live with Mitchell’s father, re-engaging in active significant drug abuse, and was arrested when Mitchell was 8 and has not returned to his life since that time. His father was later arrested for serious drug and physical assault charges and is incarcerated today, and has had no contact with Mitchell since age 6. By age 5, Mitchell had begun to engage in sexual behavior with other children, steadily and progressively continuing until age 8, by which time he was behaviorally out of control in almost all environments. By age 8, he was intermittently violent toward peers in school and had been transferred to several different schools, assaulted an unrelated male adult on the street, was stealing from peers and stores, and in the home of his foster mother he was stealing money and other things, rummaging through garbage cans for food, stealing and hoarding food, and engaging in self-injurious behavior and violence against his foster mother. After aggressive and suicidal behaviors at home, at age 8 Mitchell was psychiatrically hospitalized, followed by temporary shelter care. He refused to return to his foster home, ran away without shoes and socks, and eventually remained in shelter care for two years before being placed in a long-term residential treatment facility from ages 10–13 where he continued to engage in noncompliant and oppositional behavior, assaults against staff, and ongoing sexual behavior with peers. During this time, he engaged in periodic suicidal behaviors, mostly involving suicidal ideation, mild self-injurious behavior, and suicidal gestures, resulting in three additional psychiatric hospitalizations. He was placed in a third residential program between ages 13–15, after aging out of the prior program, where the same behaviors occurred with more frequency. Despite repeatedly not doing well in residential care, at age 15 Mitchell was placed in a community-based group home where he remained for only three months. During that period, he was suspended from school three times, engaged in several fist fights at school, threatened teachers on three occasions, engaged in shoplifting, and broke into a car. Mitchell was placed back into residential care, and after sexually molesting a female staff member by touching her breasts and stealing property from staff and peers, all within three months of his admission, criminal assault charges were pressed against Mitchell. After running away from the program, Mitchell broke into a home and two cars, and was arrested while shoplifting. At 151/2 , he was placed into a staff secure residential correctional facility, by which time he had


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been placed outside of his family since age 6, and, prior to that, had been seriously neglected and abused by his parents. He has been in residential treatment since age 81/2 , for seven of his 15 years. He has an IQ of 92, and although age 15 stands only 5 feet and 1 inch tall, physically appears to be about age 11 or 12, and has not yet reached puberty. He would like to take hormone shots for his height. In his new residential program, Mitchell almost immediately re-engaged in prior behaviors. By seven weeks postadmission, he had been physically restrained numerous times, had repeatedly reported suicidal ideation and engaged in selfinjurious behavior and, most significantly, following a minor incident, committed a serious and unprovoked assault on a female staff, telling her if he was going to get into trouble for the minor infraction it may as well be “worth it”. He repeatedly punched her in the face, head, and torso, leaving her physically harmed and feeling extremely vulnerable. Prior this, almost every day Mitchell had engaged in very troubling behavior and required much one-one staff attention. Three days prior to the staff assault, after cutting himself with a broken plastic cup and tying a shoelace around his wrist so tightly that his hand turned blue, Mitchell, while making and putting up Christmas decorations in his clinician’s office, casually discussed these self-injurious behavior with his therapist. He said he was angry at the time, but did not know how to tell staff he was upset and angry. He then clarified that he actually did not really know he was angry at the time of the self-injurious behavior.

Case Formulation Instrument-Based Formulation A cursory application of both the YLSI/CMI and the SAVRY in Mitchell’s case reveals both the presence of multiple static and dynamic risk factors and the absence of protective factors. Both instruments suggest a high level of risk and a wide range of criminogenic needs – again, personal needs and desires that propel the individual toward antisocial behavior in order to get these needs met. The YLSI also suggests the requirement for a strong level of supervision and management and a low level of responsiveness to treatment. A more detailed description of Mitchell’s case would provide fine detail, but even in a brief case one can see in his developmental history many of the elements that flag risk, point to the development of psychological vulnerabilities, and reflect a lack of age appropriate developmental protection. Not only are many risk factors obvious in Mitchell’s history, but the absence of protective factors is just as clear. Hence, we easily see a history of abuse and neglect with Mitchell as victim, exposure to significant domestic violence, parental absence and abandonment, parental substance abuse, instability in and multiple living conditions, pediatric/early onset depression, a lack of stable and adequate adult attachment figures and role models, a lack of cohesive social connection, and poor or arrested moral development. In addition, we recognize the early onset of Mitchell’s own violent behavior as a risk factor, as well as a more global early onset conduct disorder. In his current life, given Mitchell’s lack of ties to any individual or peer group, we also see the action of weak social connection at work, recalling its role in Lipsey and Derzon’s


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(1998) model in which weak ties during early adolescence is flagged as one of the strongest indicators of risk. Together, these risk factors allow us to recognize the impoverished nature of Mitchell’s relationships, the developmentally primitive and reactive source of his behaviors, his lack of connection to social norms and values, and his experience of alienation from those around him, and thus helps us to recognize the elements that come together to produce, in Mitchell’s case, antisocial behavior and the ability to act against others in a harmful manner, with a limited sense of self-agency.

Developmentally Informed Formulation Let us go further, however, than the organized and structured process that the use of risk assessment instruments can provide, and take a more detailed look at Mitchell through the lens of developmental theory, and particularly from the perspectives of attachment, social connection, and the moralization of social connection and empathy. Mitchell is alexithymic in that he has no words to describe his feelings to staff, or even recognize his feelings as he is experiencing them. Not surprisingly, as the two concepts are related and are probably derived from the same source of early experience and social development, Mitchell shows a lack of metacognitive skill (or mentalization) with respect to self-reflection. He is unaware he is even having feelings, and certainly cannot identify or name them, so it is no wonder that he is unable to express these to staff. Instead, he responds to his feelings by going directly to a learned, nonreflective, and acting out mode of behavior in order to resolve a dysphoric state of mind, draining the emotionality out of the dysphoria or diverting it, dissipating the mood, gaining staff attention and proximity, and additionally getting to engage in an angry and hostile punishing relationship with adult staff, against whom he directs his feelings. The angry feelings that Mitchell was experiencing, which led to his self-injurious behavior just days earlier, escalated to an unprovoked and serious assault physical and emotional on a member of the staff. The discussion between Mitchell and his therapist while making and putting up decorations in her office is important. In this formulation, Mitchell was capable of having that discussion, and at that time, because he was in a safe, relaxed, and socially related state, connected to both his clinician at that moment and society, while engaged in holiday festivities that indirectly Mitchell was sharing with his larger society, and feeling neither stressed nor anxious. He was thus able to demonstrate some mild self-reflection at that time, as well as a relatively honest discussion with his therapist, who was neither pressing Mitchell into working hard as a patient nor seeking anything specific from him, other than engagement. She, too, was making decorations and them up Mitchell, engaging with him in an unspoken show of connection. Overall, and especially when stressed, Mitchell demonstrates poor metacognitive skills, a weak sense of self-agency, little sense of self-efficacy, and virtually no capacity for self-regulation, all skills and capacities believed to derive from early attachment experiences, and certainly on-going experience in the social developmental/learning environment. With a battered, drug addicted, and neglectful


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mother who was unable to protect Mitchell from abuse, and who grew up in foster care herself, it was not likely that Mitchell would develop the skills of metacognition or self-regulation through his relationship with his mother. Further, she was completely out of his life by age seven, having effectively abandoned him to foster care, and to her own prior foster mother at that. We can surmise that his mother had few self-regulatory skills, given her drug addiction and her incapacity on unwillingness to remain away from a violent boyfriend, not to mention relinquishing motherhood of her two young children. By 9, even Mitchell’s foster mother was out of his life, with no contact with her or his brother since that time. Add to this Mitchell’s size and lack of physical maturation, for which he seeks hormonal remediation. We can reasonably hypothesize that this influences his self-esteem and sense of being unlike his peers, which he more than makes up for by his seriously conduct disordered behaviors. These gain him everyone’s respect through their fear of his unpredictable behavior, including an increasing capacity for violence. With respect to the development of social learning, Mitchell has not been responsible for, nor had the opportunity to demonstrate, truly independent behavior since age eight, largely growing up in the highly contained and artificial environment of institutional care. Mitchell fails to feel a significant level of empathy for others, given his own early experiences of maltreatment, and a pattern of insecure avoidant attachment that for many years has resulted in Mitchell maintaining his distance from others while actively pushing them away. In this regard, Mitchell has become the busy painter described by Anthony (1987), who writes that development is an interactive process in which children are not merely passive receptacles for experiences that simply write upon and shape them. He describes the child, from the start, as not a bucket waiting to be filled with experience but a searchlight exploring the horizon, actively creating and shaping his or her own world. That is, children and adolescents make decisions about the behaviors in which they choose to engage, even if their decision making process is different than that of adults, and different again based on their age and cognitive development or capacity. When high-risk juveniles are drawn to and actively seek out environments, peers, or conditions that allow or promote the expression of antisocial behavior, they themselves directly influence and increase the number or risk factors present in their lives, and thus the chances that antisocial behavior will actually occur. Building upon Erikson’s (1959, 1968) model of early development and the accomplishment of developmental tasks, Mitchell’s early experience of the world as unresponsive, unreliable, untrustworthy, and quite possibly a dangerous place, has contributed significantly in Mitchell’s experience of the world fitting that very schema. Mitchell’s active detachment from and avoidance of social connection, perhaps stemming back to his earliest experiences of victimization, helplessness, and abandonment, has been instrumental in creating the very circumstances in which he is now unable to connect with others and others feel little connection with him or desire to connect. In this world, Mitchell has not been able to recognize and hence experience the empathy that others may have experienced for him, and this has further limited his capacity to experience empathy for others or empathic distress at the results of his own victimization of others, and limited the development of moral judgment and behavior.


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Finally, Mitchell’s experience is one of alienation, social disconnection, and isolation. His sense of connection to a larger social environment is very much limited to his earlier chaotic and maltreated life, the world of social services and residential treatment where peers and staff come and go, and a world in which his only means to get his needs met are by force of character. With respect to those needs, given his lack of metacognition and reflectivity, Mitchell neither understands nor takes ownership for his needs. Moreover, Mitchell is showing signs of developing the callous and unemotional traits that are linked to psychopathy.

CASE FORMULATION AND TREATMENT PLANNING Summary and Process of the Formulation The formulation of Mitchell’s case and his prognosis, as well as his needs for treatment and case management, can be structured by the use of instruments such as the LSI, but a more informed and meaningful understanding and interpretation is driven by clinical insight and not instrumentation alone. This formulation and Mitchell’s behavior are both best understood by taking into account: (a) multiple risk factors and the absence of protective factors, and (b) the developmental pathways and ongoing social environment and contexts in which human development occurs and from which human behavior, beliefs, attitudes, social skills, social competence, and connections result. Tying these ideas to those introduced early in the chapter, forensic case formulation is about both prognosis and cause, and not simply risk alone, which otherwise tells us very little. Thus, in addition to risk assessment, we need case formulation to guide, shape, and define treatment and case management interventions. In the case of still developing children and adolescents, the application of a developmental approach to formulation and treatment is critical. In Mitchell’s case, in terms of assessment instrumentation, the formulation is very much influenced by a model that recognizes significant static and dynamic risk factors, and hence a high level of risk and needs when utilizing principles of the risk, need, and responsivity model. In terms of the second “r”, responsivity, we also see that Mitchell is not likely to easily or freely engage in or respond to treatment at the outpatient level, and so this formulation points to clearly identifying specific risk factors as targets for treatment through the treatment planning process (below), and providing treatment for Mitchell in a restrictive and closely managed inpatient setting, such as secure residential treatment. When also informed by an attachment-oriented perspective, formulation points to the need for the development of critical social skills, including those of social perspective taking, self-reflection and metacognition, and distress tolerance, described in more detail in the treatment planning section that follows. In terms of formulation, however, through an attachment-informed lens, Mitchell is a significantly undersocialized and highly detached individual, lacking social skills at both the intra- and interpersonal level, and hence in strong need of treatment aimed at the development of such necessary social skills.


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Treatment Planning The beauty of an RNR-influenced case formulation approach to treatment is that it allows a view of the individual first built upon his or her risk for continuing the same behaviors, and then in terms of his or her treatment needs and likely responsiveness to treatment interventions. An expansion upon both needs and responsivity leads to the fine details of the treatment plan, as well as the details, intensity, and location and form of the treatment setting or environment. In Mitchell’s case, any risk assessment instrument is likely to indicate significant risk for continued difficulty, or recidivism. Both static/history and current/dynamic risk factors clearly indicate a high likelihood of continued troubled and harmful behaviors. An assessment of needs, especially from a developmental perspective, shows the need for the development of, not simply social connections, but the development and acquisition of social skills that will allow Mitchell to experience meaningful and personally satisfying social experiences and relationships, and provide a means for meeting personal goals prosocially. This includes the development of self-regulatory skills, the ability to understand his own needs and the needs of others, and to address the “syndrome of social disability” described by Barbaree, Marshall, and McCormick (1998), who describe the contributions of early abusive and adverse family experiences to the development of deficits in critical social skills and social competence in children and adolescents, as well as the development of antisocial behavior. Both the RNR and the attachment-oriented formulation identified risk factors and clear deficits in social skills, including lack of self-regulatory skills, metacognition, and social relatedness, each of which, in Mitchell’s case, increase the risk for reoffense and general problematic behavior. In terms of specific targets for treatment, key of course to any treatment plan, treatment goals will include the development of perspective taking, problem recognition, problem-solving and decision-making skills, the recognition of internal mental states and emotional experience, the recognition of mental states and emotional experiences of others, and the skills of teamwork and collaboration, both with peers and staff. Finally, Mitchell historically has been unresponsive to treatment interventions, and persistent staff supervision and management. Accordingly, as the RNRinfluenced formulation highlights the unlikelihood of Mitchell’s working on and developing the necessary treatment tasks, or even being contained, in an outpatient treatment setting, the treatment plan for Mitchell will highlight the need for a treatment environment that is able to provide a high level of behavioral supervision and management, and is thus most likely to call for treatment in a structured residential treatment setting.

CONCLUSION When we step from forensic evaluation to the treatment of forensic cases, we step into forensic mental health, or the application of mental health ideas and techniques to the treatment and rehabilitation of criminal behaviors and other


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forms of behavior that are forensic in nature (Cordess, 2001; Rich, 2003; Welldon, 1997). When we extend these ideas to forensic work with children and adolescent, we recognize the treatment of juvenile offenders as a forensic subspecialty that crosses the lines between understanding criminal behavior, assisting the process of legal discrimination and decision making regarding the behavior, assessing the behavior for future occurrence (risk assessment), and treating the behavior. In working with juveniles, such work requires an additional understanding of the developmental and personal psychology of children and adolescents and surrounding social systems and social forces that shape and define the emotions, cognitions, and behaviors of the child. Beyond this, both to avoid formulaic treatment and to implement the ideas that drive models like risk, need, and responsivity, we must take on an approach that utilizes case formulation, and in so doing develop a model for the comprehensive assessment and treatment of juvenile offenders. Such a model will provide the basis for a deeper understanding of prior behavior, current attitudes and behaviors, and the likelihood of future behavior if things remain unchanged, as well as an individualized understanding of the treatment needs and targets of each youth with whom we work.

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Kagan, J. (2006) An Argument for Mind. Connecticut: Yale University Press. Lipsey, M.W. and Derzon, J.H. (1998) Predictors of violent and serious delinquency in adolescence and early adulthood: A synthesis of longitudinal research. In: R. Loeber and D.P. Farrington (eds), Serious and Violent Juvenile Offenders: Risk Factors and Successful Interventions (pp. 86–105). California: Sage. Loeber, R., Pardini, D., Homish, D.L. et al. (2005) The prediction of violence and homicide in young men. Journal of Counseling and Clinical Psychology, 73, 1074–88. McCann, J.T. (1998) Malingering and Deception in Adolescents: Assessing Credibility in Clinical and Forensic Settings. Washington, DC: American Psychological Association. Marshall, W.L. and Eccles, A. (1993) Pavlovian conditioning processes in adolescent sex offenders. In H.E. Barbaree, W.L. Marshall and S.M. Hudson (eds), The Juvenile Sex Offender (pp. 118–42). Guilford Press, New York, Moffitt, T.E. (2003) Life-course-persistent and adolescence-limited antisocial behavior: A 10-year research review and a research agenda. In B.B. Lahey, T.E. Moffitt and A. Caspi (eds), Causes of Conduct Disorder and Juvenile Delinquency (pp. 49–75). Guilford, New York. Piaget, J. (1997) The Moral Judgment of the Child. New York: Simon & Schuster. Rich, P. (2003) Understanding Juvenile Sexual Offenders: Assessment, Treatment, and Rehabilitation. John Wiley & Sons, Inc., New Jersey. Rich, P. (2006) Attachment and Sexual Offending: Understanding and Applying Attachment Theory to the Treatment of Juvenile Sexual Offenders. Chichester: John Wiley & Sons, Ltd. Rich, P. (2007) The implications of attachment theory in the treatment of sexually abusive youth. In M.C. Calder (ed.), Working with Young Children and People who Sexually Abuse: Taking the Field Forward (pp. 201–16). Lyme Regis: Russell House. Rutter, M. (1994) Family discord and conduct disorder: Cause, consequence, or correlate? Journal of Family Psychology, 8, 170–186. Rutter, M., Giller, H. and Hagell, A. (1998). Antisocial Behavior in Young People. Cambridge: Cambridge University Press. Sroufe, L.A., Egeland, B., Carlson, E.A. and Collins, W.A. (2005) The Development of the Person: The Minnesota Study of Risk and Adaptation from Birth to Adulthood. New York: Guilford Press. Steinberg, L. and Scott, E.S. (2003) Less guilty by reason of adolescence. American Psychologist, 58, 1009–18. Stilwell, B.M, Galvin, M.R., Kopta, S.M. and Norton, J.A. (1994) Moral-emotional responsiveness, a two factor domain of conscience functioning. Journal of the American Academy of Child and Adolescent Psychiatry, 33, 130–9. Stilwell, B.M., Galvin, M.R., Kopta, S.M. and Padgett, R.J. (1998), Moral volition: the fifth and final domain leading to an integrated theory of conscience understanding. Journal of the American Academy of Child and Adolescent Psychiatry, 37, 202–10. US Department of Health and Human Services (2001) Youth Violence: A Report of the Surgeon General. Maryland: US Department of Health and Human Services. Vetlesen, A.J. (1994) Perception, Empathy, and Judgment: An Inquiry into the Preconditions of Moral Performance. Pennsylvania: Pennsylvania University Press. Welldon, E.V. (1997) Forensic psychotherapy: The practical approach. In E.V. Welldon and Van Velsen, C. (eds), A Practical Guide to Forensic Psychotherapy (pp. 13–19). London: Jessica Kingsley Zimring, F.E. (2004) An American Travesty: Legal Responses to Adolescent Sexual Offending. Illinois: University of Chicago Press.


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Chapter 11

FORMULATING OFFENDING BEHAVIOR WITH PEOPLE WITH MILD LEARNING DISABILITIES WILLIAM R. LINDSAY University of Abertay, Dundee, UK

The purpose of a formulation is to consider the various factors in the person’s life and in the incident or incidents which have led to referral so that we may understand the reasons why the person functions in the way they do and why the incidents occurred. Once we have identified or formulated why these incidents occurred and why the person is the kind of individual they are, this will allow us to address these factors through a treatment program. All of this work is bound up in research and theory on why people behave in the way they do. Theory, supported by research findings, draws our attention to factors that are likely to influence behavior and, for this chapter, specifically offending behavior. We can look to the research literature to identify variables that may have contributed to causing this individual to act in the way they have. There are a number of empirical findings and theories related to offending behavior that account for both distal/historical factors and proximal/immediate factors, in addition to the modeling and stimulus–response models that might count for immediate actions. I will review these in brief, pointing out the way in which they affect an individual clinician’s judgement on the formulation of an individual case.

BIOLOGICAL RESEARCH AND SOCIOLOGICAL THEORIES It may seem odd to group biological findings and sociological theories under one heading, but they are certainly not antithetical. A number of theories, based primarily on genetics, have promoted research to determine the extent to which biological mechanisms of inheritance affect the likelihood of criminal behavior. Many of these studies have looked at familial patterns with antisocial behavior in children or criminal behavior in adulthood associated with a relatively high Forensic Case Formulation, First Edition. Edited by Peter Sturmey and Mary McMurran. C 2011 John Wiley & Sons, Ltd. Published 2011 by John Wiley & Sons, Ltd.


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frequency of similar problems in parents. The risk of antisocial and criminal behavior in boys whose fathers have received one prison sentence has been found to be around five times greater than those boys whose fathers had not been registered with the police (Kandel et al., 1988). Twin studies have also found greater concordance for criminal behavior for identical pairs than fraternal pairs (Christiansen, 1997). Mednick et al. (1984, 1988) conducted studies on adopted twins on the register of 14 427 Danish adoptees. The main results were that, if neither the biological nor adoptive parents were criminal, then 13.5% of their sons were criminal. If the biological parents were not criminal and the adoptive parents were criminal, the figure was only marginally greater at 14.7%. If the biological parents were criminal and the adoptive parents were not criminal, the figure rose to 20%. Finally, if both sets of parents were criminal then the figure was 24.5%. The probability of a conviction for the boy rose with the number of convictions for the biological parents from 0 to 3 times or more. In this way, we know that criminality in parents is a risk factor for an individual being convicted of a crime (Quinsey et al., 2006) and this should be considered in a formulation. One of the obvious drawbacks is that this research is wholly related to male offenders and would not have direct implications for women. Around the 1950s, sociological theories began to emerge and these in turn began to direct the nature of research into criminal groups. Cohen (1955) suggested that boys entered into delinquency because they were conforming to the expectations of their delinquent subculture. Hirschi (1969) developed these notions with control theory, paying attention to both positive learning of criminal behaviors through association with criminal peers and also to the development of self-control through appropriate social learning, including being law-abiding. He felt that the success of social training was dependent on four factors: (1) attachment to the expectations and values of society; (2) commitment to society through an understanding of the loss that will be experienced should the individual be arrested and convicted for crime; (3) involvement in and engagement with the ordinary activities of the community, such as work and education; and, finally, (4) a belief in the accepted laws of society as a reasonable framework for community cohesion. A large number of empirical tests of Gottfredson and Hirschi’s general theory (1990) have shown low self-control to be one of the most consistent predictors of crime (DeLisi, 2005). Self-control and self- regulation have been shown to be germane to the development of sociable law abiding people while deficits in these skills are related to persistent criminality. People with low self-control are impulsive, insensitive, have poor emotional regulation, and are risk takers who tend to perform poorly and fail to meet the responsibilities toward school, work, family and, ultimately, society (Gottfredson and Hirschi, 1990).This has been shown to hold across gender, race and ethnicity, In addition people with poor self-regulation commit greater amounts of deviant and maladaptive behaviors people with higher levels of self-regulation. Recent validation by DeLisi and Vaughn (2008) found that poor self-control was by far the strongest predictor of criminal careers when compared to demographic variables such as age and socioeconomic status. Because of this work, in a formulation the forensic assessor would evaluate the extent to which the individual identified and conformed with society. Issues such as prosocial influences, isolation and occupation become important considerations.


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OFFENDERS WITH MILD INTELLECTUAL DISABILITIES

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THEORIES OF SEX OFFENDING The following case illustrates the value of formulation for a sex offender with Intellectual Disabilities (ID). Lindsay (2009) has outlined a model for the treatment of sex offenders with ID that draws on theoretical variables from mainstream sex offenders and also postulates a number of variables specific to men with ID. One of the most critical developments in theory for mainstream sex offenders was that of Marshall and Barbaree (1990), who focussed on the importance of developmental experiences in men as a motivation and explanation for their wish to offend sexually. They viewed adolescence as a critical period in the development of personal understanding of aggressive and sexual impulses, the development of social and interpersonal skills, the development of problem-solving coping styles, and the development of self-regulation skills in relation to both aggression and sexual impulses. In this way, as with Hirschi’s control theory for general offending, they placed self-regulation as a central concept in the perpetration of incidents. A history of developmental adversity, such as physical or sexual abuse or oppressive parenting, may result in teenage males developing poor skills to cope with major biological and social changes. As a result, young men, who may have already been vulnerable, do not develop adequate coping or appropriate skills for developing social and sexual relationships in adulthood. If an individual has developed inadequate relationship skills, poor coping styles, low self-esteem and attachment difficulties, they are more likely to have significant problems in developing appropriate self-regulation skills in relation to sexuality and interpersonal relationships. This in turn primes certain men for a breakdown in social and sexual relationships and predisposes them to inappropriate and even violent sexuality. In terms of a formulation for individuals, this theory leads us to the consideration of a number of factors. Personal abuse in childhood is clearly important, as are developmental experiences through adolescence that may prevent the individual from developing appropriate interpersonal skills and effective self-regulation of emotion and impulses. If these various factors have not been adaptive, then the theory allows for the development of stable cognitive self-schemas, which are the beliefs the individual holds about him- or herself. Maladaptive schemas will be strengthened by chronic deficits in emotional regulation and poor relationship skills. Individuals may become increasingly isolated at a time when social identity is developing and such isolation encourages the further development of idiosyncratic world views and schemas in the absence of prosocial influences. Sexual coping is another central concept. Marshall and Barbaree suggest that men cope with emotional and interpersonal difficulties through appropriate sexual and interpersonal contact which, if not available, will result in inappropriate sexual strategies or sexual offending. The actual occurrence of an offense is likely to be further promoted by disinhibitors, such as alcohol or stress. This theory resulted in new treatment methods incorporating the promotion of self-esteem, the promotion of appropriate social and sexual strategies, a focus on victim empathy, and an analysis of cognitive distortions that might support an individual’s sexual offending. Following a formulation based on these factors, such treatments may be indicated as appropriate.


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In his precondition model of child sexual abuse, Finkelhor (1984) considered four preconditions relating to sexual abuse, all of which could be considered in a formulation. Men had to have the motivation driven by sexual arousal and sexual preference for children and this could be caused by the experience of personal sexual abuse or an emotional congruence with children. The perpetrator is also likely to be aware of the social and cultural taboos placed on adult/child sexuality and must overcome these internal inhibitions. He suggested that this might be done by the employment of cognitive distortions supporting a sexual offense or disinhibition by substance abuse. External inhibitors also have to be overcome and so sex offenders must organize opportunities and situations that might allow the commission of an offense. Finally, once these other three preconditions are met, the offender must now overcome the resistance presented by the child. Finkelhor suggested that offenders might employ a range of different methods including the pretence of playing with the child, use of pornography, use of threats or violence and emotional blackmail. Once again, the theory suggests a number of variables to be considered in a formulation, some of which are similar to those suggested by Marshall and Barbaree (1990). Hall and Hirschman (1991, 1992) proposed the quadripartite model that employed some similar factors to those mentioned previously. There were four primary factors accounting for the diversity of types of sexual offending. The first was sexual arousal to an inappropriate stimulus and this provided physiological motivation for sexual offending. The second was that men employed a range of cognitive distortions condoning or justifying the perpetration of sexual abuse. The third primary factor represented an acknowledgment that sex offenders will experience a degree of anxiety or apprehension over the prospect of committing an illegal act. The normal inhibitors, which exert some behavioral and emotional regulation over the individual, must be weakened in order that the offense can take place. The use of alcohol, or emotional dysregulation through anxiety or depression, might serve to weaken personal restraint. The final primary factor is related to personality factors, such as narcissism or antisociality. This includes consideration of maladaptive developmental experiences, such as poor attachment, physical or sexual abuse, or other adverse variables that might disrupt personality development and lead to antisocial means of responding to interpersonal situations. These factors are similar to those proposed by previous theorists, but importantly, they also postulated that each individual has a “threat threshold” that moderates and controls appropriate sexual behavior. If the motivation generated by the primary factors exceeds the threshold, then the likelihood of an offense becomes much greater. If the threat threshold is lowered in any particular situation, again the offense is more likely. For example, the threat threshold may be lowered by the perception (cognitive distortion) that the victim is complicit in a sexual act. Alternatively, if the offender experiences increased isolation and develops antagonistic views toward the world, together with a sense of entitlement through dysfunctional personality traits, then the strength of the primary factors may rise above the threat threshold. In these examples, the perpetration of a sexual offense becomes more likely. These various theories of mainstream sexual offending provide a context and a number of specific considerations when therapists are developing a formulation. There is clear research evidence supporting their importance in offenders with ID


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in relation to attachment (Novaco and Taylor, 2008; Steptoe et al., 2006), deviant sexuality (Blanchard et al., 1999, 2008), sexual abuse in childhood (Lindsay et al., 2001), and cognitive distortions (Talbot and Langdon, 2006).

A THEORETICAL CONTEXT FOR TREATMENT IN SEX OFFENDERS WITH INTELLECTUAL DISABILITIES As suggested earlier, there is evidence supporting the relevance of various motivational factors that have emerged from theory on mainstream offending. A further Counterfeit Deviance Hypothesis (Hingsburger, Griffiths and Quinsey, 1991) was developed to account for inappropriate sexual behavior particularly in men with ID. These authors noted that people with ID often live in circumstances in which sexual development, the acquisition of sexual knowledge, and appropriate sexual relationships are not supported. Many individuals will have had little experience of learning about a range of issues related to sexuality and a number of factors that are related to developmental and environmental issues, rather than sexual deviance, will contribute to inappropriate sexual behavior. They stressed the importance of differentiating counterfeit deviance from true sexual deviance, writing that individuals should not be classified as deviant when the problem may lie in a system that has failed to provide appropriate opportunities and learning for sexual expression. Initial tests of the Counterfeit Deviance Hypothesis did not support the contention that poorer sexual knowledge and poorer knowledge of the laws of society were at the root of inappropriate sexual behavior (Michie et al., 2006; Talbot and Langdon, 2006). With regard to sexual knowledge, however, Lunsky et al. (2007) conducted a sensitive study, splitting sexual offenders into deviant/ persistent offenders and na¨ıve/inappropriate offenders. They found that only the deviant/persistent offenders had greater levels of sexual knowledge than controlled participants and they concluded that the Counterfeit Deviance Hypothesis may hold only with inappropriate offenders. They suggested that it may be more relevant to inappropriate offenders than deviant offenders. Therefore, this hypothesis may continue to be important in relation to a subsection of sexual offenders with ID. Further support for the Counterfeit Deviance Hypothesis came from the Ward and Hudson (1998) self-regulation pathways model. These authors proposed four pathways – two with approach goals and two with avoidant goals. The nature of the pathway within each goal (approach or avoidant) is determined by whether the self-regulation style is active or passive. The first is the approach/explicit pathway in which the individual has a clear wish to offend sexually and uses explicit plans and procedures to carry out the act. The approach/automatic pathway involves the individual engaging in over-learned behavioral scripts (passive regulation) that are consistent with sexual offending. The individual’s behavior may be poorly planned and somewhat impulsive within the context of the behavioral scripts. The third pathway is avoidant/active, where the individual attempts to control the thoughts and behavior that might lead to sexual offending; however, as has been


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mentioned in previous theories, the strategies are ineffective and counterproductive leading to an increased risk of offending. Examples already mentioned are an increase in alcohol intake in an effort to control sexual impulses or masturbating to inappropriate sexual fantasies in an effort to “get it out of one’s system”. The fourth pathway is avoidant/passive, where the individual may wish to avoid sexual offending or abusive incidents, but either lacks coping skills to prevent this from happening or attempts to ignore the problem by hoping it will go away. Applications of this model to assessment and treatment have been developed and outlined extensively by Ward and colleagues (Ward et al., 2004; Ward, Yates and Long, 2006). In studies on sex offenders with ID, a number of the Ward and Hudson (1998) predictions emanating from their theoretical model were not supported. In particular, Hudson and Ward (2000) hypothesized that approach/explicit offenders would have a higher rate of reoffending, which has been borne out in research studies on mainstream offenders (Webster, 2005; Yates and Kingston, 2006); however, in a study on sex offenders with ID, Lindsay, Steptoe and Beech (2008a) found the opposite, with approach/explicit offenders having a significantly lower rate of reoffending following treatment. They felt that this supported a conclusion that these men may have an insufficient understanding of how inappropriate their behavior is. One function of treatment is to reinforce the extent to which sexual abuse is condemned by society. Once this realization has been achieved, stronger self-regulation strategies can be reinforced. Therefore, while these individuals are not completely na¨ıve about the fact that their behavior is inappropriate, they have not internalized the extent to which it is against the conventions of society. They had not previously understood the critical requirement for self-control in relation to sexual preference and the need to develop alternative relationship and coping skills. Further research has supported the finding that sex offenders have lower reoffending rates following treatment than mainstream offenders (Gray et al., 2007; Rice et al., 2008). This research may seem to undermine the relevance of the Ward and Hudson (1998) model for offenders with ID; however, Lindsay et al. (2008a) did find that the classifications differentiated sex offenders with ID in other ways. They reported that, after treatment, approach explicit offenders had significantly lower rates of reoffending than approach automatic offenders while the latter had significantly lower IQ. This latter finding was also reported by Langdon et al. (2007). Thus, there was empirical support for the categorization suggesting their usefulness in assessment and treatment. Lindsay (2009) has integrated these findings with the Counterfeit Deviance Hypothesis, suggesting that these sex offending pathways are indeed helpful in conceptualizing strategies used by sex offenders with ID. The concept of the threat threshold is important in relation to the Counterfeit Deviance Hypothesis. If the external threat is seen as low, then the primary factors such as sexual preference, developmental and emotional variables, coping styles, and personality features may be sufficiently activated for the individual to make an appraisal that a sex offense is worth the risk. Given the research already cited, the concept of the threat threshold seems particularly relevant to offenders with ID. If a man has not fully appreciated the extent to which inappropriate sexual behavior is condemned, then the threat threshold is likely to be lowered. In


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circumstances where developmental disturbance is high and this is combined with a degree of sexual drive, then these factors may easily exceed lower threat thresholds, resulting in inappropriate sexual behavior. The severe criticism and sanctions meted out by carers and family may simply serve to mask an understanding of the wider views of society. Individuals may be quite used to excessive criticism from carers and families and sanctions for aberrant sexual behavior are given the same status as sanctions for other less important maladaptive interactions. In this way, the experiences of individuals with ID, along with their restricted developmental histories, contribute toward a view that inappropriate sexual behavior has the same magnitude of threat as other less serious inappropriate behaviors. This is an extremely important consideration for any formulation in that it may provide a crucial variable on perception of threat to be included in the formulation. These theories also lead to important treatment considerations in that a realistic appraisal of the extent to which incidents are condemned by society becomes a major focus for treatment. The way in which this can be used as a motivational force for treatment and an incentive to develop self-restraint in relation to sexuality has been detailed by Lindsay (2009). From these theoretical considerations, it is also clear that treatments for personal sexual abuse, emotional regulation, pathways into sexual offending, the cycle of offending, and self-regulation of sexual impulses will emerge from a formulation of an individual case.

CASE STUDY Framework for the Formulation The outline of a formulation contains setting conditions which include distal, predisposing factors that have happened in the person’s development during childhood and as a young adult. One then goes on to consider antecedent events that might interact with these predisposing factors and act as more immediate triggers for the offending incidents. For sex offenders, these are clearly outlined by Beech and Ward (2004) in their elucidation of the stages of risk assessment and they are also outlined in the four pathways to sex offending in the Ward and Hudson (1998) sex offender pathways model. A formulation will then include consideration of emotional channels associated with the incident; these are the emotions, the cognitions, the behaviors and the physiological sensations associated with the incident. Finally, the formulation considers that there is a feedback loop from the outcome to the precipitating factors that will affect (strengthen) the likelihood of the incident reoccurring. In the Ward and Hudson (1998) pathways model, the feedback loop from outcome and self-appraisal of the incident is crucial in both allocating offenders to pathways and in maintaining the pathway and behavior. For example, for active explicit offenders, the feedback loop is likely to be positive and self-gratifying, emphasizing the success of the perpetration and strengthening the possibility of recurrence. For the avoidant active offender, the negative evaluation is likely to lead to self-recrimination and a determination to increase the frequency and


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intensity of the maladaptive strategies that have resulted in an inability to avoid the offending incident.

Case Study: Robert Background Information Robert is a 27-year-old man who has been diagnosed with mild intellectual disability and has committed a number of sexual offenses against pubescent children. When a cognitive assessment was conducted in 1995, he was found to have a full scale IQ of 74. This placed him in the range of borderline intelligence but since childhood intellectual assessment had placed him in the range of mild intellectual disabilities, he continued to be assigned this classification. He also fulfilled the service acceptance criterion of IQ

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