Dynamic risk assessment HCR-20 & SAPROF. IAFMHS 2012. M. de Vries Robbé

Dynamic risk assessmentHCR-20 & SAPROF

Michiel de Vries Robbé, Vivienne de Vogel & Ellen van den Broek

Van der Hoeven Kliniek, The Netherlands

12th Annual Conference IAFMHS, Miami 2012

Presentation outline

• Dynamic risk assessment HCR-20 & SAPROF• File study results• Clinical results• The individual case

Van der Hoeven KliniekUtrecht, The Netherlands

• Forensic psychiatric hospital: 286 beds– Mostly TBS order: involuntary treatment– 50/50 personality / psychotic disorders– Holistic approach, emphasis on CBT & relapse prevention– Therapeutic community: taking responsibility– Rehabilitation: ‘transmural phase’

• Risk assessment in consensus– HCR-20 & SAPROF (+SVR-20, FAM)– Repeated regularly to inform treatment

Risk & Protection

Risk factors

Protective factors

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

Research with the HCR-20 & SAPROFVan der Hoeven Kliniek, The Netherlands

1. Retrospective file study- N = 188 violent + sexual ♂- 108 also pre-treatment rating- Treatment length 5.7 years- Outcome: Reconvictions for violence- Follow-up in community after discharge

- 1 year- 3 year- M = 11 year

De Vries Robbé, De Vogel & Douglas, in preparation

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

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 < .001

Treatment changesRecidivists (n = 33) vs. Non-recidivists (n = 75)

HCR-SAPROF Change Recidivists vs. Non-recidivists:t (106) = -4.11,d > 0.85, p < .001

0

2

4

6

8

10

12

14

16

Recidivists Non-recidivists

HCR-20 ChangeSAPROF ChangeHCR-SAPROF Change

HCR-20 and SAPROF Change between pre- and post-treatment ratings

Treatment progress & recidivism

The more progress onprotective & risk factorsduring treatment..

Treatment

Treatment

Community

Community

..the less likelyviolent recidivism

Start mr. X

Start mr. Y

End mr. X

End mr. Y

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

Research with the HCR-20 & SAPROFVan der Hoeven Kliniek

2. Prospective clinical study• 879 assessments on 325 offenders ♂/♀ (max 1 RA / stage)

- intramural (233)- supervised leaves (159)- unsupervised leaves (141)- transmural first (162)- transmural last (113)- discharge (72)

• Outcome for 315 assessments:- Violent incidents during treatment (12 months)

De Vries Robbé, De Vogel, Wever & Douglas, in preparation

Changes duringtreatmentN = HCR-20 879/ SAPROF 452risk assessments

0

5

10

15

20

25

30

Intramural Supervisedleaves

Unsupervisedleaves

Transmuralfirst

Transmurallast

Discharge

HCR-20SAPROFHCR-SAPROF

Violence risk

Treatment progress

Tot

al s

core

233 159 141 162 113 72

HCR-SAPROF total Intramural vs. Discharge: t (123) = 8.95, d > 1.68, p < .001

Predictive validity violent incidentsn = 315 Clinical risk assessments

0

5

10

15

20

25

30

35

Intramural Supervisedleaves

Unsupervisedleaves

Transmural

HCR-20SAPROF

HCR-SAPROF

Violence risk

29% 15% 7% 3%

Violent incident rate

Total sample 34 incidents

SAPROF (total)

.77*

HCR-20 (total) .79*

HCR-SAPROF (total) .81*

FPJ no violence .70*

FRJ all violence .76*

n = 315, * p < .001

The individual case

0

5

10

15

20

25

30

Intramural Supervised Leaves Unsupervisedleaves

Transmural Discharge

Treatment progress

Tot

al s

core

Changes in scores: theoreticalHCR-SAPROF scores of different risk assessments during treatment

Changes in scores: actualN=1 HCR-SAPROF scores

0

5

10

15

20

25

30

Transmural theoretical Transmural actual

RA 1RA 2RA 3RA 4RA 5RA 6RA 7

Treatment progress

Tot

al s

core

Relapse Relapse

Dynamics of risk assessmentHCR-20 & SAPROF

• The dynamic factors HCR-20 & SAPROF show clinically valuable changes in risk and protective factors

• The more change, the less recidivism

• Individual change in clinical practice is less smooth than the group average suggests

Thank you!Michiel de Vries Robbé /

Vivienne de Vogel / Ellen van den Broek

Van der Hoeven KliniekP.O. Box 174, 3500 AD Utrecht

mdevriesrobbe@deforensischezorgspecialisten.nlvdevogel@deforensischezorgspecialisten.nl

evandenbroek@hoevenkliniek.nl