Case Formulation Assignment | Case Formulation

Case formulation Instructions and material. Word count 1500 approximately.

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Referencing Harvard: DSM-5 is recommended to use for reference. One source can be used more than once to support the evidence.

  1. Download Assignment 1 proforma – YOU MUST USE AND SUBMIT THIS DOCUMENT – do not create your own. Let your tutor know if you are having trouble with the document.
  2. Complete the demographic information for your chosen client using the information provided in the case material, ensuring you provide your name as the report author. You will need to decide which location is relevant for your client (see Lecture 3 slides) and you can make up the name of a case manager or simply say ‘Unknown’.
    1. Case 1 – Male offender is Caucasian, DOB 7 Nov 1975
  3. Index offense: list the offender’s current charges/convictions. Provide any relevant detail about the commission of the index offense (s) that may assist in developing an understanding of the offender’s presentation. Do NOT include previous offenses in this section. Please see Lecture 3 for more detail if necessary. (Try to be accurate and complete but remember that this section does not make up a heavy proportion of the total marks for the task).
  4. Gibbs' reflective cycle in nursing
  5. Complete the case formulation, referencing as required. Please use standard in-text referencing (author, date) – include page numbers where appropriate. If you are unsure about factors that load onto the 5Ps, please revisit Lecture 3. REMEMBER TO PROVIDE DETAILS AND EXPLANATIONS (e.g. if you are listing a factor as an explanation for offending behavior, give an example/evidence of the factor from the offender’s case information). Don’t forget criminogenic needs (revisit Lecture 3 if you are unsure!)
  6. You are not required to include anything in the Other comments/issues section, but please feel free to do so if you would like to mention something that does not fit into the 5P model.
  7. In the Signed box, just type your initials. Be creative with your Title if you wish.
  8. In the References, you simply need to list the references you cited throughout the formulation, in alphabetical order. Use the Harvard referencing style. See the instructional material on Moodle if unsure.
  9. Include your word count on the Cover Sheet or at the end of your assignment. Do not include the reference list in the word count, nor words already in the proforma (342).
  10. Submit!

 

5Ps Approach to Case Formulation Must use 5 p

Presenting problem

Predisposing factors

Precipitating factors

Perpetuating factors

Protective/ positive factors

 

More on referencing:

You need to provide references that indicate there is evidence for the factors that you identify within the 5P model. While there generally aren’t references in a case formulation, the author of the formulation has done the research to know that there is evidence to support the formulation. ALL case formulations are based on empirical evidence and are grounded theoretically – so while the references are not included, they underlie all that has been said. In this assessment task, you are required to provide the references to indicate that you have developed the skill of applying research to the client and are not speculating, but rather formulating the case on the basis of the evidence available in the literature.

Referencing (in text and reference list) will look something like this:

Mr. Chip reported a happy, loving childhood with prosocial values and positive parenting. However, his very early marriage (Potter, 2011), closely followed by the death of both of his newborn twins (Skywalker, 2002) revealed his tendency to internalise and over-control emotions (Stark, 2013), a pattern which persisted over time. Additionally, it is likely that his impulsivity (Snape, 2005) and poor problem-solving skills (Baggins, 2012), both risk factors themselves, have exacerbated the issue of emotional control, preventing him from being able to develop methods to constructively resolve his emotions.

Gibbs' reflective cycle in nursing 

Case study: Mr. Sage 7 Nov 1975

Mr. Sage has been convicted of Uttering a Threat, Causing Damage by Fire, and Mischief.  Mr. Sage has been sentenced to a 4-year community correction order with the condition that he:

  • undertake medical treatment or other rehabilitation
  • be supervised, monitored, and managed by a corrections worker.

Mr. Sage was born in Melbourne in 1975. His natural father is not known. At the time he was born, his mother had been in a common-law relationship for six months, and Mr. Sage took his last name.

Mother also had two daughters by a prior relationship and both older than Mr. Sage. She also had a son by a stepfather that is younger than the patient.

Stepfather was physically abusive toward the patient’s mother and the children. Mr. Sage believes he was sexually abused by either his nominal father or stepfather and that the abuser went to jail.

The children were taken from the home and were subsequently raised by the maternal grandmother. Mr. Sage went into foster care and became a permanent ward in 1978 when he was 3 years of age.

Mother later remarried and reunited with the 3 children in her mother’s care and took a new last name. Mr. Sage stayed in foster care until he was an adult. There was little or no contact between Mr. Sage and the rest of the family during his childhood.

In 1997 when Mr. Sage was 22, his Social Worker arranged a meeting between Mr. Sage, his mother, brother, and two sisters. One sister subsequently kept in touch with him.

The other family members have not, and apparently have no desire to do so. Mr. Sage’s sister with whom is in contact currently lives in Melbourne and is married with children.

From this time until he was 20, Mr. Sage was in several foster care situations, temporary placements, respite homes, and training schools. He underwent several assessments and was on many regimes of treatment. His pattern of being a “victim of verbal and physical abuse due to (his) behavior” was established and noted when he was 7. Bizarre behavior such as barking like a dog or bringing tree branches on to the bus were noted since he was 14. Behaviors such as running away were noted since he was 18.

Subsequent to 1994, when Mr. Sage turned 19 and was no longer in foster care, DHHS continued to contract with proprietary care homes and other services under their mandate to provide services for Mr. Sage. This was a discretionary service that Mr. Sage accepted. However, while he continued to be dependent on his caregivers, he did not accept the direction they gave him and would frequently run away from his placements or otherwise be so disruptive that they did not want to have him anymore.

From 1996 to 2000, Mr. Sage attempted to live on his own, supporting himself on welfare and living in hotel rooms in Melbourne.  His housing broke down frequently and he became well known as an emergency client of shelters where he tended to stay for long periods as there were few available accommodations for him. During this period, he also became a frequent user of other services in the area. He was noted to be frequently in crisis.

Gibbs' reflective cycle in nursing

In 2003, Forensicare’s outpatient service became involved with Mr. Sage when he was referred during a six-month probation term. They continued to be involved with him on a voluntary basis after the Probation Order had expired, up until March 2006 when his treating psychiatrist retired.

Mr. Sage’s history has consistently shown that he is a person who is very dependent on the direction of others and on a predictable, unchanging routine. His behaviour problems, which have most frequently occurred when there has been a change in his life, have been interpreted by his caregivers as his way of having external controls brought on him and making his life predicable again.

Mr. Sage has never been married nor engaged to be married. He did not date as a young adult, has no peer relationships with the same or opposite sex. It does not appear on any record that he ever had any such relationship. Mr. Sage has always had multiple service providers working with him and he has referred to them as his friends.  When his service providers have changed, Mr. Sage has had trouble adjusting to the new relationships and has historically acted out at these times.

Mr. Sage was sexually abused by an older male while he was in foster care. He also feels he was sexually abused by his stepfather when he was an infant.

Mr. Sage never had any problem with alcohol or any illegal drugs.

Mr. Sage was also charged with causing a disturbance in Melbourne in early 2003. He pled guilty on February 05 2003 and was supervised through a brief period of probation.

Mr. Sage was also charged with Mischief under $5,000 in Melbourne, in May 2006. This stemmed from an incident during which he broke several windows at the home of a previous caregiver he had been visiting. It was noted at the time that Mr. Sage had broken windows on several previous occasions, but no charges had been laid. He was convicted on May 23 2006 and was given a 12-month term of probation.

During all of his terms of probation, Mr. Sage was noted to have reported as ordered, and to have taken his probation orders seriously.

Although Mr. Sage has not been convicted of other offenses, he has had a lifelong history of disturbing behavior which has challenged his caregivers to meet his needs safely. These behaviors have included outbursts during which he has yelled out inflammatory statements in public and engaged in other difficult behaviors, (e.g., tearing up books and pictures, breaking windows).

At the time of his index offense, Mr. Sage had been living in a share house, and in the weeks prior to his offense, he described the increasing conflict with his housemates and with Centrelink staff. Mr. Sage’s housemates reported that he had uttered threats that he was going to burn the house down if his Centrelink payments were not increased (he wanted to move to a different location but could not afford it). When he realized his demands were not going to be met, he piled clothing belonging to his housemates on the stove burners and started a fire. He then left the house. He believed that the house would burn down and Centrelink would be forced to assist him to find new accommodation.  After he left the house, he dialed 000 with a request to be arrested. Firesetting has also been a problem in the past. Mr. Sage states he has started several fires, and it appears that this is a behavior he uses when in crisis to help alleviate his anxiety or to get what he wants. A fire he started in a dumpster in the entrance to an emergency shelter in Melbourne in 2006 was confirmed.

Mr. Sage has previously been diagnosed as suffering from Anxiety Disorder, Conduct Disorder, and “Unspecified” mental health disorder. A variety of antipsychotic medications has been used in the past for behavior control, though Mr. Sage reports he is currently not receiving any medication. It is also notable that when Mr. Sage experiences anxiety he becomes disorganized and hard to understand. Mr. Sage has great difficulty with conflict, frustration, and anger. He has also threatened to hurt himself or others.

DIAGNOSIS – rule out pyromania, rule out bipolar disorder; personality disorder

Assessment Report – Case formulation

confidential

 

This report is based on information available at the date of writing

and is not valid for use in the event of subsequent re-offending.

 

Name Click or tap here to enter text. DOB Click or tap here to enter text.
Location Click or tap here to enter text. Gender Click or tap here to enter text.
Ethnicity Click or tap here to enter text. Case Manager Click or tap here to enter text.
Report Author Click or tap here to enter text.
Date of Report Click or tap here to enter text.

Index Offence (current episode of offending)

Provide brief summary of information about the index offence here.

No references are required in this section.

Click or tap here to enter text.

Case Formulation

Presenting problem

What is the client’s problem list? Are there any diagnoses?

No references are required in this section

Click or tap here to enter text.

Predisposing factors

Gibbs' reflective cycle in nursing

Over the person’s lifetime, what factors contributed to the development of the problem?

Provide at least one reference for each factor identified.

Click or tap here to enter text.

Precipitating factors

Why now? What are the triggers or events that exacerbated the problem?

Provide at least one reference for each factor identified.

Click or tap here to enter text.

Perpetuating factors

What factors are likely to maintain the problem? Are there issues that the problem will worsen, if not addressed?

Provide at least one reference for each factor identified.

 

Click or tap here to enter text.

Protective factors

What are client strengths that can be drawn upon? Are there any social supports or community resources?

Provide at least one reference for each factor identified.

Click or tap here to enter text.

 

Other Comments / Issues

(If none, state ‘Nil’)

Click or tap here to enter text.

 

 

Signed Click or tap here to enter text.
Name Click or tap here to enter text.
Title Click or tap here to enter text.
Date Click or tap here to enter text.

 

References:

Click or tap here to enter text.

Case Formulation Lecture Slides

 

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. As a hypothesis, a formulation is always subject to empirical test and to revision as new information becomes available. (Sturmey & McMurran)

 

Purpose of case formulation

  • To provide a structure to organize information about a person and his or her problems (explain the individual’s presenting problem)
  • To provide structure and organisation around the information about a person and the presenting problem
  • Clients produce enormous amounts of information in therapy, including verbal, behavioural, prosodic, gestural, affective, and interactional
  • Case formulation facilitates the management of this information cascade
  • To provide a blueprint guiding treatment and case management planning; to help the therapist develop and implement a treatment plan leading to a successful outcome
  • To enable the therapist to anticipate and prepare for future events

(particularly events that might interfere with therapy)

  • To help measure 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
    • To help service providers understand the offender and thereby exhibit greater empathy for the patient’s intrapsychic, interpersonal, cultural, and behavioral world

Goals of Case Formulation

  • Formulation should have treatment and management utility
  • Formulation should be concise yet adequately comprehensive
    • Do not overcomplicate a simple formulation
    • Provide sufficient information in a complex case
  • Formulation should have a balance of description and explanation
    • Do not just summarise biographical information
    • Explain how that information relates to the presenting problem
    • Formulation should be evidence based
    • Information used to develop formulation – Theory supporting formulation

Gibbs' reflective cycle in nursing

  • Sources of Evidence

 

The offender
– Reference only by style of presentation: “Mr Meyer stated …”

  • File information
    – Reference only by style of presentation: “Case file
  • information indicated …”

Psychometric data
– Reference by referring to the test used: “The offender’s

results on the Corrections Victoria Treatment Readiness Questionnaire (CVTRQ)”. If you have bibliographic details, include these.

The offender’s family or other service providers

– Reference only by style of presentation: “Mr Meyer’s mother indicated that …”

 

5Ps Approach to Case Formulation  Must use 5 p

Presenting problem

Predisposing factors

Precipitating factors

Perpetuating factors

Protective/ positive factors

 

  1. Presenting Problem

Includes issues currently relevant to the offender as problems – Diagnoses (specifically mental health)
– Recent offending and resulting legal action
– Other issues contributing to the acute stage of the client’s

presentation

Should include all issues you will later be recommended for treatment and case management

Goes beyond diagnosis to include difficulties identified by the offender and clinician, how the offender’s life is affected, and when a particular difficulty should be targeted for intervention.

– E.g. while an offender may meet criteria for the diagnosis of borderline personality disorder, presenting difficulties may include not being able to maintain employment, erratic friendships and physical health complications resulting from self-harm. Specifying such difficulties can allow for a more focused intervention.

  1. Predisposing Factors

__________________________________________________________________Gibbs' reflective cycle in nursing

Factors present throughout the person’s life that have made them vulnerable to the presenting problem

Identify using the biopsychosocial model – Biological contributors

  • E.g. organic brain injury and birth difficulties, genetic vulnerabilities (including family history of mental health difficulties)

– Psychological or personality factors
• Including core beliefs, etc., putting a person at risk of

developing a specific mental health difficulty – Social or environmental factors

  • E.g. socio-economic status, trauma, or attachment history

Caution: when providing references for these factors, ensure you apply correct theory (e.g. if you are writing up a young offender case, do not apply/reference material that is specifically appropriate to female offenders)

  1. Precipitating Factors

__________________________________________________________________

  • Factors that have acted as triggers to the presenting problem – Usually significant events preceding the onset of the

disorder, but can be a build-up of smaller events

  • Substance use

Major stressors (e.g. relationship breakdown, interpersonal, legal, occupational problems, financial hardship)

Can be situational (see Wortley, R. (1998) ‘A two-stage model of situational crime prevention’, Studies on Crime and Crime Prevention, 7, 173-188.)

  1. Perpetuating Factors

 

  • Issues that maintain the presenting problem E.g. (not an exhaustive list)

– Patterns of behaviour
• Ongoing substance abuse, avoidance or safety

behaviours in anxiety disorders, withdrawal in depressive disorders

– Acute and chronic health/mental health conditions • Insomnia, hypersomnia in depression

– Cognitive patterns

  • Attentional biases, memory biases, hypervigilance, hostile world view

 

  1. Protective / Positive Factors

Strengths or supports that may mitigate the impact of the presenting problem. E.g.:

–  Social/family support (pro-social only)

–  Skills/education

–  History of stable employment

–  Some personal characteristics (e.g. insight, empathy, work

ethic) = increased resilience

Identification of protective factors can create increased optimism in both clinician and patient and contributes to a positive therapeutic relationship

Note: References for these factors may be sourced from the same location as risk factors

 

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