The role of protective factorsin risk assessment

The SAPROF

Michiel de Vries RobbéVan der Hoeven Kliniek, The Netherlands

Fatores de Risco e de Proteção na Avaliação e Gestão do Comportamento Criminal, 19 de Junho 2012

Risk & Protection

Risk factors

Protective factors

Violence risk assessment

AdvancesIncreased knowledge on risk factors for (sexual) violenceMajor advances in structured risk assessment procedures for clinical practice

ShortcomingsNot much known about factors that compensate for effects of risk factorsMost structured risk assessment instruments do not include protective factors

Importance of considering protective factors

More balance in risk assessment: complete view of the offenderPositive approach motivating for both offenders and treatment staffSuggestions for improved risk management

Rogers (2000): ‘Risk-only evaluations are inherently inaccurate’.

Why SAPROF?

• Desire by clinicians protective factors

• Little empirical research

• No available tools

• Preconditions development SAPROF:– Scientific basis

– Clinical utility

– In line with existing risk tools (SPJ)

What are protective factors?

Protective factors definition SAPROF

De Vogel, De Ruiter, Bouman, & De Vries Robbé (2009)

Any characteristic of a person,his / her environment or situation,

which reduces risk offuture (sexual) violence

Protective factors background

• Are protective factors the opposite of risk factors?– The approach is very different– Some protective factors can berisk factors when not present

(e.g. Self-control; Coping)

– Some protective factors are not risk factors when not present (e.g. Leisure activities; Intimate relationship)

• How do protective factors influence future violence?– Remains largely unknown, likely:

• Promotiveeffect (work for everybody)

• Protectiveeffect (only moderating when risk present)

We all need protective factors

The more it rains (risk factors)the more protection we need

Development of the SAPROF Structured Assessment of PROtective Factors for violence risk

De Vogel, De Ruiter, Bouman, & De Vries Robbé (2007)

Van der Hoeven KliniekUtrecht, The Netherlands

Risk assessment practice

TreatmentTreatmentsupervisorsupervisor ResearcherResearcher

SociotherapistSociotherapist

ConsensusConsensus

� HCR-20 violence risk(incl PCL-R)

� SVR-20 sexual violence risk(if sexual offense)

� FAM female violence risk(if female)

• Tbs: patients stay in hospital for 7 years

• Risk assessment yearly

• Carried out in teams

• Tools used are SPJ:

� SAPROF protectivefactors

SAPROF Development

20102007 2008 2009 2011 2012 2013

Dutch English German

Italian

Nowegian

Swedish

Portuguese

Spanish

French

Russian

English 2nd

Danish

Chinese

SAPROF-YV

Dutch 2nd

1. Literature reviews

2. Expertise and ideas from treatment staff and researchers Van der Hoeven Kliniek

SAPROF-RV

SAPROF 3. Pilot study several inpatient and outpatient settings

4. Update manual & research SAPROF 2nd Ed.

Ana Cristina Neves & Cristina Soeiro

Coding the SAPROFCoding the SAPROF

The SAPROF

• 17 protective factors (15 dynamic)three scales: Internal, Motivational, External

• Always in combination with SPJ risk tool

1. Codethe items (0, 1, 2)

2. Mark most important items: Keys & Goals

3. Final Judgment Protection(low, moderate, high)

4. Integrated Final Judgment Riskwith risk tools(low, moderate, high)

+

HCR-20 & SAPROF

Historical factorsH1 Previous violenceH2 Young age at first violenceH3 Relationship instabilityH4 Employment problemsH5 Substance use problemsH6 Major mental illnessH7 Psychopathy (PCL-R)H8 Early maladjustmentH9 Personality disorderH10 Prior supervision failure

Clinical factorsC1 Lack of insightC2 Negative attitudesC3 Active symptoms of major mental illnessC4 ImpulsivityC5 Unresponsive to treatment

Risk Management factorsR1 Plans lacks feasibilityR2 Exposure to destabilizersR3 Lack of personal supportR4 Noncompliance with remediation attemptsR5 Stress

Risk factorsInternal factors1 Intelligence2 Secure attachment in childhood3 Empathy4 Coping5 Self-control

Motivational factors6 Work7 Leisure activities8 Financial management9 Motivation for treatment10 Attitudes towards authority11 Life goals12 Medication

External factors13 Social network14 Intimate relationship15 Professional care16 Living circumstances17 Supervision

Protective factors

• Nature: What kind of risk?

• Severity: Likely physical / psychological harm?

• Victim: Who could be victim?

• Likelihood: What is the probability?

• Imminence: How soon?

• Risk-Enhancing Factors: What factors increase risk?

• Risk-Reducing Factors: What factors prevent risk?

Producing a narrative that explains the underlying mechanism of violence and proposes hypotheses

regarding action to facilitate change

Results: Case formulation

Clinical experiences with the SAPROF

• Welcome addition to ‘usual’ risk assessment

• Suitable for clinical practice

• Focus on risk andprotection

• Structured and evidence-based

• Different factors important different people

• Motivational staff and patients

Clinical experiences SAPROFGeneral experience

Van den Broek & De Vries Robbé (2008)

SAPROF important positive addition to risk assessment:

• Justifying stages of treatment (leave/privileges, risk management)

• Formulating treatment goals (from external to motivational and internal)

• Phasing treatment: what to do first?

Clinical experiences SAPROFGeneral experience

Theory of changing protectionStatic protective factors1. Intelligence2. Secure attachment in childhood

Dynamic improving factors3. Empathy4. Coping5. Self-control6. Work7. Leisure activities8. Financial management9. Motivation for treatment10. Attitudes towards authority11. Life goals12. Medication13. Social network14. Intimate relationship

Dynamic decreasing factors15. Professional care16. Living circumstances17. External control

Start treatment End treatment

Changes in protective factors

Items 1-2Items 3-14Items 15-17

Additional value of protective factorsSAPROF

• Risk assessment– Dynamic positive addition

– Balance risks and strengths

– Increased predictive validity violence

• Clinical practice– Positive approach motivation

– Dynamic treatment goals

– Improved risk management focus

Research with the SAPROF

1. Retrospective file study– N=188 assessments of discharged patients– 105 violent / 83 sexual male– Follow-up average 11 years– Official reconvictions after discharge– N=120 pre- and post-treatment– ICC = .85/.88 (2 research raters)

2. Prospective clinical study – N=315 clinical assessments– Different treatment stages– Violent / sexual / male / female– Follow-up 12 months– Violence during treatment– ICC = .70 (3 clinical raters)

Research SAPROF Netherlands

Retrospective files studies

Predictive validity violent recidivismRetrospective file study Violent+Sexual (N=188)

AUC 1 year follow-up

14 recidivist

AUC 3 years follow-up 34 recidivists

AUC 11 years follow-up (M)

68 recidivists

SAPROF (total)

.85*

.75*

.73*

HCR-20 (total) .84* .73* .64*

HCR-SAPROF (total)

.87* .76* .70*

FPJ no violence 5-pt .83* .71* .67*

FRJ all violence 5-pt .84* .72* .68*

N = 188, * p < .01

HCR-SAPROF > HCR-20:χ² (1, N = 188) = 13.4, p < .001 (11 year)

De Vries Robbé, De Vogel & Douglas, in preparation

Logistic regression: sign. incremental predictive validity SAPROF over HCR-20

0102030405060708090

100

1 year 3 year 11 year

Lowprotection

Moderateprotection

0

10

20

30

40

50

60

70

80

90

100

1 year 3 year 11 year

LowprotectionModerateprotectionHighprotection

Moderate risk High risk

Differentiation of risk groupsFinal Protection Judgment�Low

�Moderate

�High

Final Risk Judgment�Low

�Moderate

�High

Logistic regression at all f-u: sign. incremental predictive validity FPJ over FRJ

Changes during treatmentRetrospective study (n = 108)

0

5

10

15

20

25

30

Pre-treatment Post-treatment

Historical

Clinical

Risk managementTotal HCR-20

0

2

4

6

8

10

12

14

Pre-treatment Post-treatment

Internal

Motivational

ExternalTotal SAPROF

HCR-20 SAPROF

HCR-20 total: t (107) = -11.70, d > 0.84, p < .001 SAPROF total: t (107) = 15.63, d > 1.74, p < .001Changes in HCR-20 & SAPROF scores during treatment (= treatment progress) proved predictive of recidivism

Treatment progress & recidivism

The more progresson protective factorsduring treatment..

Treatment

Treatment

Community

Community

..the less likelyviolent recidivism

Start mr. X

Start mr. Y

End mr. X

End mr. Y

Prospective clinical studies

Changes in scores over timeN=315 Clinical risk assessments

0

5

10

15

20

25

30

35

Intramural Supervisedleaves

Unsupervisedleaves

Transmural

HCR-20SAPROFHCR-SAPROF

Violence risk

29% 15% 7% 3%

Violent incident rate

Treatment progress

Tot

al s

core

Violent offenders ♂

(17/148)

Sexual offenders ♂

(9/97)

Total sample ♂

(26/245)

Total sample ♀

(8/70)

Total sample

(34/315)

SAPROF (total)

.77**

.81**

.78**

.70

.77**

HCR-20 (total) .74** .85** .79** .78* .79**

HCR-SAPROF (total) .81** .84** .82** .76* .81**

FPJ no violence .69* .73** .70** .69 .70**

FRJ all violence .75** .81** .77** .72* .76**

* p < .05, ** p < .01

Predictive validity violent incidentsduring treatmentProspective study (N=315)

De Vries Robbé, De Vogel & Douglas, in preparation

The valueof consensusSAPROF total scores N=47

Consensus most accurate predictions

TreatmentTreatmentSupervisorSupervisor

ResearcherResearcher

SociotherapistSociotherapist

ConsensusConsensus

.75.75.74.74

.84

.70.70

Strongest predicting SAPROF factors

Retrospective- Violent ♂: Self-control, Work, Financial management

- Sexual ♂: Coping, Self-control, Motivation, Attitudes

- Total ♂: Self-control, Attitudes

Prospective - Violent ♂: Self-control, Attitudes, Work, Motivation, Medication

- Sexual ♂: Coping, Leisure activities, Attitudes, Network

- Total ♂: Self-control, Attitudes, Work

- Total ♀: Intelligence, Coping, Work, Financial management

All p < .05

Summary research results

Good reliability & predictive validity

Combined use risk & protective factors works

Violent as well as sexual offenders

More protective factors less violence

Changes during treatment less violence

Overview SAPROF

Structured assessment of protective factorsDynamic and positiveaddition

Good results researchEspecially valuable for clinical practice

Personalized motivating risk assessment

Positive treatment goals

Strengths based guidelines risk management

Thank you!

Michiel de Vries Robbémdevriesrobbe@hoevenkliniek.nl

To order SAPROF Guidelines in English or download coding sheets see www.forumeducatief.nl

or contact saprof@hoevenkliniek.nl

To order SAPROF Guidelines in Portuguese see www.egasmoniz.com.pt

or contact gpforense@egasmoniz.edu.pt

SAPROF Translationsde Vogel, V., de Ruiter, C., Bouman, Y., & de Vries Robbé, M. (2007). SAPROF. Richtlijnen voor het beoordelen van

beschermende factoren voor gewelddadig gedrag. Dutch Version.[SAPROF. Guidelines for the assessment of protective factors for violence risk. Version 1]. Utrecht, The Netherlands: Forum Educatief.

de Vogel, V., de Ruiter, C., Bouman, Y., & de Vries Robbé, M. (2009). SAPROF. Guidelines for the assessment of protective factors for violence risk. English version.Utrecht, The Netherlands: Forum Educatief.

de Vogel, V., de Ruiter, C., Bouman, Y., & de Vries Robbé, M. (2010). SAPROF. Leitlinien für die Erfassung von protektiven Faktoren bei einem Risiko für gewalttätiges Verhalten (German translation of the SAPROF guidelines by Aranke Spehr and Peer Briken).Utrecht, The Netherlands: Forum Educatief.

de Vogel, V., de Ruiter, C., Bouman, Y., & de Vries Robbé, M. (2010). SAPROF. Linee Guida per la valutazione deifattori protettivi per il rischio di violenza (Italian translation of the SAPROF guidelines by Margherita Spissu).Utrecht, The Netherlands: Forum Educatief.

de Vogel, V., de Ruiter, C., Bouman, Y., & de Vries Robbé, M. (2011). SAPROF. Guide d’évaluation des facteurs de protection pour le risque de violence (French translation of the SAPROF guidelines by Jean-Pierre Guay and Tiziana Costi).Utrecht, The Netherlands: Forum Educatief.

de Vogel, V., de Ruiter, C., Bouman, Y., & de Vries Robbé, M. (2011). SAPROF. Manual para la valoración de los factores de protección para el riesgo de violencia (Spanish translation of the SAPROF guidelines by Ed Hilterman, Assumpta Poch and Rodrigo Venegas Cárdenas). Utrecht, The Netherlands: Forum Educatief.

de Vogel, V., de Ruiter, C., Bouman, Y., & de Vries Robbé, M. (2011). SAPROF. Retningslinjer for vurdering avbeskyttelsesfaktorer for voldsrisiko (Norwegian translation of the SAPROF guidelines by Tone Sandbak, Knut Rypdal, Helge Andreas Hoff and Erik Risnes).Utrecht, The Netherlands: Forum Educatief.

de Vogel, V., de Ruiter, C., Bouman, Y., & de Vries Robbé, M. (2011). SAPROF. Riktlinjer för bedömning avskyddsfaktorer mot våldsrisk (Swedish translation of the SAPROF guidelines by Märta Wallinius, StaffanAnderberg and Helena Jersak).Utrecht, The Netherlands: Forum Educatief.

de Vogel, V., de Ruiter, C., Bouman, Y., & de Vries Robbé, M. (2011). SAPROF. Manual para a Avaliação de Factores de Protecção para o Risco de Violência (Portuguese translation of the SAPROF guidelines by Ana Cristina Neves and Cristina Soeiro).Utrecht, The Netherlands: Forum Educatief.

de Vogel, V., de Ruiter, C., Bouman, Y., & de Vries Robbé, M. (2012). SAPROF. Руководство по оценке защитныхфакторов риска насилия (Russian translation of the SAPROF guidelines by Vera Bulygina).Utrecht, The Netherlands: Forum Educatief.

de Vogel, V., de Ruiter, C., Bouman, Y., & de Vries Robbé, M. (2012). SAPROF. Guidelines for the assessment of protective factors for violence risk. English version 2nd Edition.Utrecht, The Netherlands: Forum Educatief.

Referencesde Vogel, V. (2005). Structured risk assessment of (sexual) violence in forensic

clinical practice. The HCR-20 and SVR-20 in Dutch forensic psychiatric patients.Amsterdam: Dutch University Press (http://dare.uva.nl/document/13725).

de Vogel, V., & de Vries Robbé, M. (in press). Working with Women. Towards a more gender-sensitive violence risk assessment.In L. Johnstone, & C. Logan (Eds.), Managing Clinical Risk: A guide to effective practice.

de Vogel, V., de Vries Robbé, M., de Ruiter, C., & Bouman, Y.H.A. (2011). Assessing protective factors in forensic psychiatric practice. Introducing the SAPROF. International Journal of Forensic Mental Health, 10, 171-177.

de Vogel, V., de Vries Robbé, M., van Kalmthout, W., & Place, C. (2011). FAM. Female Additional Manual: Additional guidelines to the HCR-20 for assessing risk for violence in women.Utrecht: Forum Educatief.

de Vries Robbé, M., de Spa, E., & de Vogel, V. (2007). Protective factors for violence risk. Clinical experiences and first results with a new instrument for risk prevention, the Structured Assessment of PROtectiveFactors for violence risk (SAPROF).Fuller version abstract for the fifth Congress on Violence in Clinical Psychiatry, Amsterdam, The Netherlands, October 25-27, 2007.

de Vries Robbé, M., & de Vogel, V. (2009). Assessing protective factors for violence risk. American Psychology-Law Society News, 29, 11-12.

de Vries Robbé, M., & de Vogel, V. (2009). Protective factors for (sexual) violence. Results with the SAPROF in a sample of (sexually) violent offenders.Fuller version abstract for the sixth Congress on Violence in Clinical Psychiatry, Stockholm, Sweden, October 22-24, 2009.

de Vries Robbé, M., & de Vogel, V. (2010). Addendum to the SAPROF Manual. Updated research chapter.Utrecht, The Netherlands: Van der Hoeven Stichting.

de Vries Robbé, M., & de Vogel, V. (2010). Protective factors for violence risk: SAPROF prospective results. Paper presented at the tenth Conference of the International Association of Forensic Mental Health Services, Vancouver, Canada.

de Vries Robbé, M., & de Vogel, V. (in press). Protective factors for violence risk: Bringing balance to risk assessment.In L. Johnstone, & C. Logan (Eds.), Managing Clinical Risk: A guide to effective practice.

de Vries Robbé, M., de Vogel, V., & Douglas, K.S. (in preparation). The additionalvalue of protective factors: Violence risk assessment with the SAPROF and the HCR-20.

de Vries Robbé, M., de Vogel, V., Koster, K., & Bogaerts, S. (in preparation). Protective factors for sexually violent offenders.

de Vries Robbé, M., de Vogel, V., & de Spa, E. (2011). Protective factors for violence risk in forensic psychiatric patients. A retrospective validation study of the SAPROF. International Journal of Forensic Mental Health, 10, 178-186.

de Vries Robbé, M., de Vogel, V., Wever, E. & Douglas, K.S. (in preparation). Risk and protective factors in clinical practice: A prospective study into clinical risk assessment with the SAPROF and the HCR-20.

Douglas, K.S., Guy, L.S., & Weir, J. (2006). HCR-20 violence risk assessment scheme: Overview and annotated bibliography. Available: http://www.sfu.ca/psyc/faculty/hart

Douglas, K.S., Webster, C.D., Hart, S.D., Eaves, D., & Ogloff, J.R.P. (Eds.) (2001). HCR-20 violence risk management companion guide. Vancouver, British Columbia, Canada: Mental Health, Law, and Policy Institute, Simon Fraser University.

Doyle, M., & Logan, C. (2011). Measuring and managing short-term risk: making the START work in practice. Paper presented at the seventh European Congress on Violence in Clinical Psychiatry, Prague, Czech Republic.

Maruna, S. (2001). Making Good: How ex-convicts reform and rebuild their lives.Washington, DC: American Psychological Association.

Mossman, D. (1994). Assessing prediction of violence: Being accurate about accuracy. Journal of Consulting and Clinical Psychology, 62, 783-792.

Otto, R.K., & Douglas, K.S. (2010). Handbook of Violence Risk Assessment.New York: Taylor & Francis.

Rice, M.E., & Harris, G.T. (1995). Violent recidivism: Assessing predictive validity. Journal of Consulting and Clinical Psychology, 63, 737-748.

Rogers, R. (2000). The uncritical acceptance of risk assessment in forensic practice. Law and Human Behavior, 24, 595-605.

van den Broek, E., & de Vries Robbé, M. (2008). The supplemental value of the SAPROF from a treatment perspective: A counterbalance to risk?Paper presented at the eight Conference of the International Association of Forensic Mental Health Services, Vienna, Austria.

Ward, T., Mann, R.E., & Gannon, T.A. (2007). The good lives model of offender rehabilitation: Clinical implications. Aggression and Violent Behavior, 12, 87-107.

Webster, C.D., Douglas, K.S., Eaves, D., & Hart, S.D. (1997). HCR-20. Assessing the risk of violence. Version 2. Vancouver, BC, Canada: Simon Fraser University and Forensic Psychiatric Services Commission of British Columbia.

Linkswww.forumeducatief.nl

www.cognitivecentre.com

www.violence-risk.com

www.forensicpsychiatry.ca

www.sgc.gc.ca

http://www.sfu.ca/psyc/faculty/hart/(bibliography Douglas HCR-20 studies)

http://dare.uva.nl/document/13725 (thesis Structured Risk Assessment De Vogel)