Risk Assessment is Not the Same as Case Formulation

We would like to start with a story. Picture a courthouse in a struggling industrial town in Connecticut. The adult probation department is situated in the basement of this courthouse. We are beginning training with a new cohort of probation officers, teaching them how to incorporate forensic CBT techniques into their work. To start, one of the officers describes a current case and reviews the available assessment information. A quick review of the risk assessment reveals this is a high-risk case; a major area of concern is antisocial companions. We ask the officer to explain how friends and companions specifically influence criminal behavior for this justice-involved client (JIC). We get crickets! We ask, what role did friends play in the most recent offense? Again, an awkward silence permeates the room. While the officer certainly knows that antisocial companions is a risk factor for reoffending, she has not explored the nature of the JIC’s relationships and discussed with the JIC the specific role of companions in his offense history and daily routines. Unfortunately, this is a common training scenario when we begin.

In our previous blog, we described the importance of risk reduction and the Central Eight risk domains. In this blog, we present some elements of risk models that often go unnoticed by practitioners. We believe these features of criminal risk, when applied thoughtfully, powerfully enhance supervision and case management practices. Here is how we think about risk in our work with justice-involved clients (JICs).

The first question in The Coaching Habit:  Say Less, Ask More and Change the Way You Lead is known as The Kickstart Question: “What’s on your mind?” I think it is a near perfect way to start a therapeutic session with any client. Most managers now know that coaching is valuable and proven, but many do not attempt coaching because they do not know how to start. Opening statements such as, “How’s it going?”, “I just wanted to check with you on how the new position is going.”, or, my personal favorite, “Is there anything I can do for you?” are a bit like passing someone in the hallway and greeting them with, “How are you?” Each of the above openings begs for a brief response that “all is well.” The answer is reflective and social norms generally suggest that answering the question with real life concerns is inappropriate. People will quickly learn to stop asking that question if you really answer. Hopefully, therapy and/or case management is different but old habits die hard.

This blog is a continuation of the EBP Practice Models blog series started by this blog’s author Evan C. Crist, Psy.D. and other industry leading authorities on practice models, Brad Bogue, Matt Moore and Tom O’Connor.

When Brad Bogue first suggested we work on a “practice model” I was embarrassed to admit I had no idea what he was talking about. After a bit of research I realized that, while the term was foreign to me, the concept was not that complicated and was a logical extension of our agency’s evidence-based practices (EBP) training. I learned that practice models structure the use of various EBPs into a logical, coherent process to help practitioners identify the next necessary step in the intervention sequence.

Armed with lots of knowledge about EBP, but without a framework to identify and organize what techniques to use when, we recognized we did, indeed, need a practice model. Since I am writing this blog during the Christmas season, it seemed that we had lots of ornaments and tinsel but no tree on which to hang them. It became clear that without a practice model we would remain knowledgeable about EBP but unskilled in their delivery.

I looked at several of the prepackaged practice models available but found all of them lacking. They were either incongruous with my clinical experience (e.g., the importance of building motivation was essentially ignored) or contradicted my philosophy of the change process (e.g., they followed a manual but left little room for situational flexibility). With Brad at my side challenging my assumptions every step of the way, we decided to develop a practice model in house. We facilitated the process while our capable staff of case managers merged research with their experience and theory with reality.

It was a vital learning experience for me. I thought I needed to teach the case managers to think; turns out, I simply needed to create the space and let them think.

We started with the necessary requirements for the practice model:

1. It must include a variety of interventions.
2. It must include evidence-based, evidence-informed or promising practices.
3. It must be coherent.
4. It must be simple but powerful.
5. It must include situational flexibility.