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 Robbé[email protected]
To order SAPROF Guidelines in English or download coding sheets see www.forumeducatief.nl
or contact [email protected]
To order SAPROF Guidelines in Portuguese see www.egasmoniz.com.pt
or contact [email protected]
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)