Journal of Forensic Practice

Case formulation quality checklist: a revision based upon clinicians ' views
Mary McMurran Sophie Bruford
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Mary McMurran Sophie Bruford , (2016),"Case formulation quality checklist: a revision based upon clinicians ' views",
Journal of Forensic Practice, Vol. 18 Iss 1 pp. 31 - 38
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 Case formulation quality checklist:
a revision based upon clinicians’ views
Mary McMurran and Sophie Bruford
Professor Mary McMurran and
Downloaded by Florida Atlantic University At 02:15 23 March 2016 (PT)
Sophie Bruford both are
based at Institute of Mental
Health, School of Medicine,
University of Nottingham,
Nottingham, UK.
Received 6 May 2015
Revised 9 June 2015
30 June 2015
Accepted 30 June 2015
DOI 10.1108/JFP-05-2015-0027
Abstract
Purpose – Evaluations of the impact of case formulation on outcomes for offenders are needed. The quality
of case formulations may impact on outcomes, hence one essential aspect in outcome evaluation is quality
assessment. A case formulation quality checklist (CFQC) was constructed and showed good reliability and
internal consistency. However, feedback from users was the CFCQ could be improved. The purpose of this
paper is to ascertain the opinions of professionals who had used the CFQC to provide a basis for its revision.
Design/methodology/approach – This was a qualitative study, in which ten professionals who had used
the CFQC were asked their views about it. An inductive thematic analysis was used to organise the data.
Findings – Seven themes were identified. First, the importance of assessing quality in case formulation;
second, the appropriate and comprehensive content of the CFQC; third, the practicality of the CFQC;
fourth, validity and reliability issues; fifth, ways to improve the CFQC; sixth, potential as a training tool;
seventh, limitations of the use of the CFQC. The CFQC was revised in light of these comments, producing
the CFQC-R.
Research limitations/implications – The reliability and consistency of the CFQC-R needs to be examined,
as does validity, particularly predictive validity. This information will better enable research into whether case
formulation improves outcomes for service users, and whether better quality case formulations lead to
greater improvements.
Practical implications – The CFQC-R may be of value in training and supervising clinicians in constructing
case formulations.
Originality/value – The CFQC-R is reproduced here so that researchers and practitioners may use
the checklist.
Keywords Thematic analysis, Case formulation, Case formulation quality checklist, Offender pathway,
Qualitative survey, Revised checklist
Paper type Research paper
Case formulation may be defined as the organisation of information about the client and his or her
problems to explain the origins and maintenance of those problems (Eells, 2007; Johnstone and
Dallos, 2006). Case formulation should lead to a logical treatment plan. Case formulation has
long been a core feature of a clinical psychological approach to understanding an individual’s
problems and working to ameliorate them (Division of Clinical Psychology, 2011).
Recently, there has been an increased application of case formulation in forensic services (Hart
et al., 2011; Sturmey and McMurran, 2011a). One new application of case formulation is in the
joint NHS and National Offender Management Service Pathway for offenders with personality
disorder (OPD) (Department of Health and Ministry of Justice, 2011). The OPD pathway aims to
reduce offenders’ risk of reoffending and improve psychological wellbeing by early identification
of high-risk offenders, understanding their offending through case formulation, and using case
formulation to plan the offender’s pathway. Central to the OPD pathway is that assessment
and case formulation will inform sentence planning in a logical manner, such that the offender will
receive support, services, and treatment appropriate to his or her needs.
VOL. 18 NO. 1 2016, pp. 31-38, © Emerald Group Publishing Limited, ISSN 2050-8794 j JOURNAL OF FORENSIC PRACTICE j PAGE 31
 The value of case formulation in the OPD pathway needs to be established, in particular whether
labour-intensive case formulations improve outcomes for offenders. Based on the premise
that the quality of case formulations may impact on outcomes, one essential aspect in outcome
evaluation is assessment of the quality of case formulations.
Recently, Hart et al. (2011) described the features of a good quality case formulation, providing a
list of criteria against which the quality of a case formulation could be measured. In summary,
these criteria were that the case formulation should be a coherent and understandable narrative
account of the case, which is based on a sufficiency of good quality and relevant factual
information that is interpreted in line with a generally accepted theory, and which yields detailed
and testable predictions about which strategies will be most effective in treating and managing
the problem behaviour. These criteria formed the basis of a case formulation quality checklist
(CFQC) (McMurran et al., 2012). This consisted of ten items in which the criteria were defined
and a four-point Likert scoring system was applied (0 – does not meet this criterion, 1 – meets this
criterion somewhat, 2 – meets this criterion satisfactorily, and 4 – meets this criterion
exceptionally well).
As part of an OPD pathway pilot project, Minoudis et al. (2013) evaluated probation officer case
formulation training using the CFQC. Case formulations produced at baseline and after either an
educational training programme (n ¼ 35) or case formulation consultation discussions (n ¼ 43)
were assessed by two raters. The CFQC showed good inter-rater reliability (intraclass correlation
(ICC) ¼ 0.63-0.75), excellent test-retest reliability (ICC ¼ 0.85-0.99), and excellent internal
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consistency (Cronbach’s α ¼ 0.92). However, feedback from raters was the checklist could be
improved. The purpose of this study, therefore, was to ascertain the opinions of professionals
who had used the CFQC to provide a basis for its revision.

Method
Sample
The participants were all professionals who had used the original CFQC. Ten people who had
participated in the CFQC research project were approached and, in a snowballing procedure,
we asked these people to name others who might have used the checklist. An additional four
people were identified, bringing the total number of potential participants to 14. All were
psychologists or psychiatrists. Of the 14 people who were approached to take part in the
study, ten provided data: two did not reply to the e-mails and two refused because of lack of time.
Eight of the ten participants were forensic professionals: five forensic clinical psychologists,
two forensic psychologists, and one forensic psychiatrist. The other two were non-forensic
clinical psychologists.

The interview
The interview consisted of six questions asking participants’ their views on the checklist in
general, its positive and negative aspects, whether it covered all the components that indicate
quality within a case formulation, if there was anything important that the checklist did
not capture, and any changes that the participant would recommend to improve the checklist.
There were also three rating scale questions regarding how easy it was for the participant to learn
to use the checklist, how easy it actually was to use, and how useful they believe it to be.
Four of the interviews were conducted over the telephone; three were administered face-to-face,
and three people responded via e-mail, with two of these three participants located overseas.
The telephone interviews lasted on average 16.5 minutes (range 11-26 minutes) and the
face-to-face interviews lasted on average 32 minutes (range 21-40 minutes).

Procedure
Clinicians who had used the CFQC were e-mailed with information about the study and
requesting their participation. Once they agreed to take part, they were sent a participant
information sheet and a consent form. Upon receipt of the consent form, arrangements were
made to conduct a face-to-face or telephone interview or for submission of a response by e-mail,

PAGE 32 j JOURNAL OF FORENSIC PRACTICE j VOL. 18 NO. 1 2016

 depending on their location. Interviews were conducted by a trained third year medical
student (SB). Notes were taken during interviews and were written out in full to be as close to
verbatim accounts as possible. Approval for the project was obtained from Nottingham Medical
School Research Ethics Committee.

Data analysis
An inductive thematic analysis was used to organise the data (Braun and Clarke, 2006).
The interview notes and e-mail submissions were read carefully by both authors so that they were
fully familiar with the data. First, codes were identified in the narratives independently by both
authors. Codes are the most basic element of the raw data and they identify any feature that is of
interest to the analyst (Braun and Clarke, 2006). The authors then independently organised
related codes into overarching themes. A theme is a recurrent idea in the material (interviews).
The authors then met to discuss codes and themes and come to a consensus about the
organisation of the data.

Results
Themes
Seven themes were extracted from the data.
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Importance of quality in case formulation. The view was expressed that it was important
to assess the quality of case formulations and the CFQC has the potential to contribute to
this assessment:
We need to demonstrate [the quality of case formulations] empirically in order to improve the quality of
formulations. The formulation checklist represents a means of achieving these goals (P7, Forensic
Clinical Psychologist)

However, there was a view that the criteria for a good quality case formulation were set
unattainably high. In practice, the CFQC could be difficult to score for poor quality case
formulations that contained insufficient information:
I think the benchmark is very, very high […] It provides a framework for assessing formulations in which
most formulations will score very low I think (P8, Forensic Psychologist).

I think sometimes I’ve found it hard but I think it’s partly again because of the standard of the
formulations I was rating – they were all extremely poor […] I think sometimes it’s hard to differentiate
between “meets the criteria somewhat” and “meets it not at all” because sometimes they would say
something but I think it was really because of the poor quality and trying to find something useful out of
the formulation (P2, Clinical Psychologist).

Content of the CFQC. The CFQC content was considered to be appropriate and
comprehensive:
[I found the checklist] very thorough. It sets out what a good formulation needs and what you should
find in one that is very comprehensive, well written, well thought out (P (Participant) 2, Clinical
Psychologist).

In terms of the checklist, I think the checklist is absolutely fine […] I mean it does cover all the areas you
need to consider, I think (P4, Forensic Clinical Psychologist).

Positive comments were made on specific aspects:

I like the emphasis on a narrative form and that you use an accepted psychological theory to form it
(P5, Clinical Psychologist).

For me it’s about giving the framework; making them think about the theory and I guess they’re
prompts aren’t they […] I think as a practitioner they should have to think about what predictions
we are going to make out of this (P10, Forensic Psychologist).

I like the idea around making sure that the practitioners would be basing their information in the
formulation to make predictions; sometimes that can get lost a little bit. It actually ties the practitioners
to make predictions based assessments and evaluate (P10, Forensic Psychologist).

VOL. 18 NO. 1 2016 j JOURNAL OF FORENSIC PRACTICE j PAGE 33

 However, one issue considered absent from the checklist was an assessment of relevance and
usefulness:
There’s no question in here about the utility – do people think this captures the relevant stuff?
(P3, Forensic Clinical Psychologist).

There were also comments related to the over-specification of case formulation content:
I’m not sure all these ingredients need to be made explicit in a formulation; they are often there implicitly
(P9, Forensic Clinical Psychologist).

I think the scoring system makes it [the checklist] less useful for shorter formulations (P5, Clinical
Psychologist).

Practicalities. Many participants approved of the short length of the CFQC:

In terms of length there’s not too many items, not too many points on the rating scale, it’s on
a side of A4; the number of items feels manageable, so all of that is fine (P4, Forensic Clinical
Psychologist).

In contrast to the extract above, some thought that the CFQC was too time consuming:
It takes a long time to do it [evaluate a formulation] (P2, Clinical Psychologist).

Validity and reliability. The lack of evidence linking case formulation quality with outcomes was
mentioned:
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In some ways a good description could be irrelevant. Just because I can write a good account,
doesn’t necessarily mean that would be of any use to reducing somebody’s risk, or changing how
they see the world, or helping them think about things in a new way or whatever (P3, Forensic
Clinical Psychologist).

Concerns were raised about the differences in how people rated the CFQC:
I think some of the constructs are hard to operationalize in a reliable way. My definition of “coherent” is
likely to be different from others (P9, Forensic Clinical Psychologist).

One of the things that came out of our recent use of it was that the inter-rater reliability was not great
(P8, Forensic Psychologist).

Ways to improve the CFQC. A common criticism was the complex language used in the CFQC,
suggesting the need for simplification of the checklist:
I think the language is unhelpful at times. I think diachronicity is a spectacularly unhelpful word
(P8, Forensic Psychologist).

Several respondents made suggestions for improving instructions and guidance for using
the CFQC:
More descriptive information of each of the qualities is required and exemplars for each of the anchor
points is necessary (P1, Forensic Clinical Psychologist).

Maybe a little example like this may be something you would rate, like a manual where you have a little
example. For example […] just a couple of sentences and in there you would say “this is what we
would write as four for meeting this criteria” and “this is what we would write as 1” so you have a bit of
an idea (P6, Forensic Psychiatrist).

A common consideration was that an additional point is required in the scoring system between
“meets the criteria somewhat” and “meets the criteria exceptionally well” as there is quite a jump
between the two:

I suppose you’ve got the rating scale haven’t you; it jumps from “somewhat satisfactorily” to
“exceptionally well” so all the way from somewhat satisfactorily to exceptionally well is a big jump,
isn’t it? (P10, Forensic Psychologist).

Concern was expressed that one item had multiple components (namely, factual foundation),
which required many different criteria to be met in awarding a score:

[…] point 3 [factual foundation] there’s a lot of information you have to get from your assessment for
that (P10, Forensic Psychologist).

PAGE 34 j JOURNAL OF FORENSIC PRACTICE j VOL. 18 NO. 1 2016

 A common theme that arose was that of unequal item weighting. Many participants felt that some
of the items required more criteria to be met than others in order to score well:
The first issue is that everything is of seemingly equal weighting […] You’ve got the general description
then you’ve got these ten pointers that are given equal weighting, but they don’t have equal weighting
in their description. So, for instance you’ve got number two [external coherence] demands “explicitly
consistent” which is what I would see as quite a high threshold. Whereas here [diachronicity] you’re
asking “ties together information about past, present […]” which is a very low threshold (P3, Forensic
Clinical Psychologist).

There are ones [items] that are more important than others, you know, is a “total score” meaningful?
(P3, Forensic Clinical Psychologist).

The item “overall quality” was considered unnecessary, since scores on the other items can be
added to produce an overall quality score:
Overall quality; I mean you get a score anyway from the entire thing (P5, Clinical Psychologist).

Potential as a training tool. Many of the participants spoke about using the CFQC in training.
The CFQC was thought to consist of all the relevant components of a good CF and so it was
helpful as a focus for training professionals to write formulations:
This sort of rating scale does highlight the right points to be thinking about when looking at
formulations. You can sort of highlight the shortcomings in peoples […] or deficits in these sorts of
formulations (P4, Forensic Clinical Psychologist).
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The positive aspects of the checklist are […] the fact that it can be used to teach people what the basic
characteristics of a formulation ought to look like so that they know what it is they should try to achieve
in their formulations (P7, Forensic Clinical Psychologist).

Limitations. Many people noted that the use of the CFQC might be limited to specific and qualified
professionals:
I think some professional groups get it easily (e.g. psychologists, because this is hugely what
they do). I think other professional groups struggle (e.g. nurses, offender managers) because
while they understand the point of formulation, they are possibly not confident about doing them or
they lack the range of information that would help them to do them well (P7, Forensic Clinical
Psychologist).

Others noted the disparity between ease of use for supervisors and trainees:
I think there is a difference in that as somebody who is very interested in formulation and has used the
checklist and read about stuff it’s relatively easy. If I was asking a trainee to use it, I think they’d go pale
(P3, Forensic Clinical Psychologist).

Some participants identified restrictions that the CFQC imposed, in particular, the fact that the
CFQC only allows for narrative formulations:
Lots of the formulations we use within our service are diagrammatic so the story will be between
therapist and patient using the diagram. The only thing you’ve got to rate is the diagram and the
diagram itself isn’t a narrative. So it’s taking the formulation as being an event on a piece
of paper, a story, whereas in our service we write our stories with pictures (P3, Forensic Clinical
Psychologist).

Regarding specific forensic applications, the CFQC was seen as privileging psychosocial theory
and being non-specific to criminal behaviour:
[The checklist] does privilege psychosocial theory of criminal behaviour. And that’s the other thing
actually; all the rest of this could be used more broadly than with offending it’s only that one [external
coherence] that really hones into criminality (P3, Forensic Clinical Psychologist).

Ratings
Participants were asked to rate three items on a scale of 0-10. Ease of learning (where easy ¼ 0
and difficult ¼ 10): mean ¼ 4.0, standard deviation (SD) ¼ 2.0; ease of use (where easy ¼ 0 and
difficult ¼ 10): mean ¼ 3.7, SD ¼ 1.8; usefulness (where not useful ¼ 0 and very useful ¼ 10):
mean ¼ 7.8, SD ¼ 1.9.

VOL. 18 NO. 1 2016 j JOURNAL OF FORENSIC PRACTICE j PAGE 35

 Discussion
Users’ ratings of the CFQC showed that they considered it to be a useful instrument, but that
there was a need to improve its ease of use. Since the quality of case formulation was considered
important, revising the CFQC is worthwhile. Bearing in mind the need to keep the CFQC relatively
short, users’ suggestions were taken up to produce a revised CFQC (CFQC-R) (see Appendix).
In the CFQC-R, no particular theory is stated, although there remains the expectation that an
accepted theory is used to guide the formulation. The CFQC-R may be applied to criminal
behaviour, but is not restricted to this. While forms of case formulation other than narrative forms
are used in practice, the CFQC-R relates only to narrative versions.
In the CFQC, the language was simplified and compound items were eliminated. The rating scale
was expanded from a four-point Likert scale to a scale from 0 to 10 with three anchor points:
0 – does not meet this criterion at all, 5 – meets this criterion somewhat, and 10 – meets this
criterion exceptionally well. The relevance of the information contained in the case formulation
was emphasised. The ten criteria were retained at this stage, allowing further investigation of the
“overall quality” item relative to the sum of the other items. A manual was not produced, since
illustrations of good or poor quality case formulations are difficult to portray without considerable
background information. However, a training session in CFQC-R scoring has been designed.
The CFQC-R may be of value in training clinicians to construct case formulations. It lays forth
criteria that clarify what a good case formulation should contain, and these may be useful in
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teaching and training, through practitioner self-assessment and assessment as part of the
supervision process. This approach may be useful with practitioners from different professional
backgrounds and at different levels of experience.
One major shortcoming of the CFCQ-R is that its psychometric properties have not been
examined. There is a need for research on the reliability and consistency of the CFQC-R,
replicating the analyses by Minoudis et al. (2013) on the original CFQC. The validity of
the CFQC-R requires examination, particularly the predictive validity. That is, does case
formulation predict better outcomes for service users, and do better quality case formulations
predict greater improvements? The added value of case formulations is has not been empirically
evaluated in relation to offender management and treatment (Sturmey and McMurran, 2011b).
Ghaderi (2011) recommends experimental studies to test the effectiveness of case formulation,
with variables such as client characteristics, problem severity, and quality of case formulations
taken into account. He notes the need “to develop a psychometrically robust measure of the
quality of case conceptualisations for further research” (p. 76).

Implications for practice

■ Case formulation is the organisation of information about the client and his or her problems
to explain the origins and maintenance of those problems. This should lead to a logical
treatment plan.
■ A good quality case formulation should be a coherent and understandable narrative account of the
case, based on a sufficiency of good quality and relevant factual information that is interpreted in line
with a generally accepted theory, and which yields detailed and testable predictions about which
strategies will be most effective in treating and managing the problem behaviour.
■ A ten-item revised CFQC-R may be used to assess case formulations against these standards.

■ The CFQC-R may be useful in training and supervision of practitioners in case formulation.

References
Braun, V. and Clarke, V. (2006), “Using thematic analysis in psychology”, Qualitative Research in Psychology,
Vol. 3 No. 2, pp. 77-101.
Department of Health and Ministry of Justice (2011), Consultation on the Offender Personality Disorder
Pathway Implementation Plan, Department of Health, Leeds.

PAGE 36 j JOURNAL OF FORENSIC PRACTICE j VOL. 18 NO. 1 2016

 Division of Clinical Psychology (2011), Good Practice Guidelines on the Use of Psychological Formulation,
The British Psychological Society, Leicester.

Eells, T.D. (Ed.) (2007), Handbook of Psychotherapy Case Formulation, 2nd ed., Guilford, New York, NY.
Ghaderi, A. (2011), “Does case formulation make a difference to treatment outcome?”, in Sturmey, P. and
McMurran, M. (Eds), Forensic Case Formulation, Wiley-Blackwell, Chichester, pp. 61-79.

Hart, S., Sturmey, P., Logan, C. and McMurran, M. (2011), “Forensic case formulation”, International Journal
of Forensic Mental Health, Vol. 10 No. 2, pp. 118-26.

Johnstone, L. and Dallos, R. (2006), Formulation in Psychology and Psychotherapy, Routledge, Hove,
East Sussex.
McMurran, M., Logan, C. and Hart, S. (2012), “Case formulation quality checklist”, unpublished checklist.

Minoudis, P., Craissati, J., Shaw, J., McMurran, M., Freestone, M., Chuan, S.J. and Leonard, A. (2013),
“An evaluation of case formulation training and consultation with probation officers”, Criminal Behaviour and
Mental Health, Vol. 23 No. 4, pp. 252-62.
Sturmey, P. and McMurran, M. (Eds) (2011a), Forensic Case Formulation, Wiley-Blackwell, Chichester.
Sturmey, P. and McMurran, M. (2011b), “Forensic case formulation: emerging issues”, in Sturmey, P. and
McMurran, M. (Eds), Forensic Case Formulation, Wiley-Blackwell, Chichester, pp. 283-304.
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Appendix. Case formulation quality checklist

Please read the following description of what makes a good case formulation. Once you are
familiar with this, please rate each case formulation on the criteria listed, using a scale of 0-10.

Definition
“A good quality case formulation is a narrative that ties together information about the past,
present, and future of the case. It is based upon a sufficient quantity of relevant and reliable
information that is interpreted from the perspective of a generally accepted theory. The case
formulation draws on this theory to identify relevant facts in the individual case. The formulation
should be easy to understand, which means that it will be free from unnecessary details,
unsubstantiated assumptions, and internal contradictions. The formulation is likely to be
understood by and agreed upon by other professionals, and in most cases also by the person to
whom it relates. It should yield testable predictions about which strategies will be most effective in
treating and managing the problem behaviour”.

VOL. 18 NO. 1 2016 j JOURNAL OF FORENSIC PRACTICE j PAGE 37

 Table AI Case formulation quality checklist

0 5 10
Does not meet this Meets this criterion Meets this criterion
criterion at all somewhat exceptionally well
Criterion Definition Rating

1. Narrative The formulation is presented in everyday language that tells

a coherent, ordered, and meaningful story
2. External coherence The formulation is explicitly consistent with an empirically
supported theory
3. Factual foundation The formulation is based on relevant information about the
case that is adequate in terms of quantity and quality
4. Internal coherence The formulation rests on propositions or makes
assumptions that are compatible or non-contradictory
5. Completeness The formulation has a plot that ties together as much of the
relevant information as possible
6. Events are understood The formulation ties together information about the past,
by the way they relate present, and future of the case
over time
7. Simplicity The formulation is free from unnecessary details
8. Predictive The formulation goes beyond description, statement of
facts, or classification to make detailed and testable
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predictions. The key predictions are those about which

strategies will be most effective in treating and managing
harmful behaviour
9. Action oriented The formulation prioritises and plans treatments
10. Overall quality The formulation is comprehensive, logical, coherent,
focused, and informative

Corresponding author
Professor Mary McMurran can be contacted at: mary.mcmurran@nottingham.ac.uk

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