Gender issues in violence risk assessment and treatment in ... · Gender issues in violence risk assessment and treatment in forensic psychiatry Vivienne de Vogel, Susanne de Haas,

Vivienne de Vogel, Jeantine Stam,

Eva de Spa & Michiel de Vries Robbé

Gender issues in violence risk assessment

and treatment in forensic psychiatry

Vivienne de Vogel, Susanne de Haas,

Loes Hagenauw, & Eline Muller

IAFMHS, Toronto, June 19, 2014

Ladykillers:

Hurricanes with female names deadlier

Vivienne de Vogel, van der Hoeven Kliniek

Introduction, multicenter study

Susanne de Haas, van der Hoeven Kliniek

Gender differences in motivations for offending

Loes Hagenauw, FPK Assen

Female arsonists

Eline Muller, Pieter Baan Centrum

Case example

Symposium outline

Violence risk factors and incidents during treatment in female forensic psychiatric patients: Results from a Dutch multicenter study

Vivienne de Vogel

Van der Hoeven Kliniek

• Female violence

• Results multicenter study– Victimization

– Psychopathology

– Criminal characteristics

– Treatment

– Violence risk factors

Presentation outline

• Female violence seems to be on the rise

• Comparable prevalence rate men / women for:

– Inpatient violence

– Violence towards own children

– Intimate partner violence

• Intergenerational transfer

Nicholls et al., 2009; Serbin et al. 1998; De Vogel et al., 2012

Female violence

• Less visible: more domestic, less serious physical injuries

• Different expression: more reactive and relational; less sexual and instrumental

• Different motives: emotional, relational, jealousy

Fusco, 2011; Nicholls et al., 2009

Nature of violence by women

• Significant differences men / women in the expression of violence, violence risk factors and manifestation of psychopathy

• Most tools developed / validated in males

• Questionable predictive validity tools

Garcia-Mansilla et al., 2009; McKeown, 2010

Violence risk assessment in women

Are commonly used tools, like the HCR-20 or PCL-R

well enough suited for use in women?

• Additional guidelines to HCR-20 / HCR-20V3 for women:

– Additional guidelines to several Historical factors

(e.g., use of lower PCL-R cut-off score)

– New items and additional final risk judgments

• Preliminary results: promising reliability & predictive

validity for self-destructive behavior & violence to others

De Vogel et al., 2012; De Vogel, & De Vries Robbé, 2013

Female Additional Manual (FAM)

Historical items

• Prostitution

• Parenting difficulties

• Pregnancy at young age

• Suicide attempt / self-harm

• Victimization after childhood*

Clinical items

• Covert / manipulativebehavior

• Low self-esteem

Risk management items

• Problematic child care responsibility

• Problematic intimate relationship

FAM Gender-specific items

* This item is no longer needed with HCR-20V3

Multicenter study Characteristics of women in forensic psychiatry

• Gerjonne Akkerman-Bouwsema (GGz Drenthe)

• Anouk Bohle (Van der Hoeven)

• Yvonne Bouman (Oldenkotte)

• Nienke Epskamp (Van der Hoeven)

• Susanne de Haas (Van der Hoeven)

• Loes Hagenauw (GGz Drenthe)

• Paul ter Horst (Woenselse poort)

• Marjolijn de Jong (Trajectum)

• Stéphanie Klein Tuente (Van der Hoeven)

• Marike Lancel (GGz Drenthe)

• Eva de Spa (Van der Hoeven)

• Jeantine Stam (Van der Hoeven)

• Nienke Verstegen (Van der Hoeven)

Acknowledgments

• To gain more insight into criminal and psychiatric characteristics of female forensic psychiatric patients, especially characteristics that may function as risk or protective factors for violence.

• Possible implications for psychodiagnostics, risk assessment and treatment in forensic psychiatric settings, but possibly also in general psychiatry or in the penitentiary system.

Multicenter study Aims

• Five Dutch forensic psychiatric settings

• Ongoing study

• N > 300 female forensic psychiatric patients

• N = 275 males matched on year of birth, admittance, judicial status

• Comprehensive questionnaire including several tools (a.o., PCL-R, Historical items HCR-20 / FAM and HKT-30) was coded based on file information by trained researchers

Multicenter study Method

• Mean age upon admission 35.7 years

• 84% born in the Netherlands

• At the time of the index offense:

– 40% had an intimate relationship

– 53% had child(ren), but most of them were

not capable of taking care of their children

82% of child(ren) not living with their mother

94% high score on FAM item Parenting difficulties

General characteristics N = 280 women

• Majority had previous contacts with law

enforcement: 72%

– 20% without conviction

• Mean age at first conviction: 23 years

• Mean number of previous convictions: 4

• Mostly violent or property offenses

Criminal characteristics N = 280 women

Criminal characteristics275 women versus 275 men

0

10

20

30

40

50

60

70

80

90

Convictions Contact without

conviction

% Women

% Men

Men:

• Younger age first conviction

• More sexual offenses, less arson

p < .01

Index offenses

– Homicide 25%

– Attempted homicide 24%

– Arson 29%

– Violent offenses 16%

– Sexual offenses 4%

Victims of index offenses

– (ex) Partner 20%

– Child(ren) 16%

– Relatives / friends 39%

– Treatment staff 9%

– Stranger 16%

Index offensesN = 280 women

Index offenses275 women versus 275 men

0

5

10

15

20

25

30

Homicide Att.homicide Arson Violence Sexual

% Women

% Men

All p < .001

Victims Index offenses275 women versus 275 men

0

5

10

15

20

25

30

35

(ex)partner Child (own) family/acq. supervisor stranger

% Women

% Men

p < .001

High rates of victimization

• 72% was victimized during childhood

– Often by parent(s): 65%

– Often a combination of sexual, physical and emotional abuse

• 54% was victimized during adulthood

– Often by (ex) partner(s): 82%

– Most often physical abuse

VictimizationN = 280 women

Victimization during childhood275 women versus 275 men

0

10

20

30

40

50

60

70

Emotional Physical Sexual All three

% Women

% Men

p < .001

Victimization during adulthood275 women versus 275 men

0

5

10

15

20

25

30

35

40

45

50

Emotional Physical Sexual All three

% Women

% Men

All p < .01

High rates of comorbidity

• 75% comorbid Axis I and II

• High rates of substance use problems: 67%

• Borderline personality disorder most prevalent:

59% + 21% traits

• Narcissistic PD least prevalent: 3%

• Psychopathy (PCL-R cut off of 23, FAM): 14%

Psychopathology N = 269 women

Psychopathology275 women versus 275 men

0

10

20

30

40

50

60

70

Borderline Antisocial Narcissistic

% Women

% Men

All p < .001

• Most had been in treatment before: 88%

• High treatment dropout in history: 76%

• Incidents during most recent treatment– Violence 34%

– Verbal violence / threats 47%

– Manipulative behavior 55%

– Self-destructive behavior 47%

– Arson 8%

– Victimization 8%

– Other 68%

Treatment N = 280 women

Incidents during treatment170 women versus 170 men

0

10

20

30

40

50

60

Physical Verbal Covert Self-destructive Arson Victimization

% Women

% Men

p < .01

Men higher scores on:

– Previous violence

– Young age at first

violent incident

– Substance use

problems

– Psychopathy

– Problematic behavior

during childhood

Women higher scores on:

– Prostitution

– Parenting difficulties

– Pregnancy at young age

– Suicidality / self-harm

– Victimization after

childhood

Violence risk factors HCR-20 / FAM 275 women versus 275 men

All p < .05

• FAM / HCR-20 Historical subscale score modest

predictor of physical violence, verbal violence /

threats, arson, transfer to another ward due to

problems (AUCs .67-.74)

• PCL-R total score modest predictor of

Manipulative behavior and verbal violence /

threats (AUCs .65-.68)

All p < .05

Predictive validity Incidents during treatment (N = 280 women)

• FAM / HCR-20 Historical subscale score:

comparable predictive validity

• Best predictor for violent incidents:

– Women: Problematic behavior during childhood

– Men: Young age at first violent incident

• PCL-R total score better predictor violent

incidents for men than for women (AUC = .82 vs .68)

Predictive validity violent incidents

275 women versus 275 men

• Psychopathy

– Offenses: more ‘men like’, more often ‘bad’, less ‘sad’

– More treatment dropout and manipulative behavior

• Borderline Personality Disorder

– More severe victimization

– More incidents during treatment, dropout

• Intellectual disability

– More prostitution

– More stranger victims, less homicide

Subgroups

All p < .05

• Overall, severely traumatized group with

complex psychopathology, high comorbidity,

many incidents during treatment

• Significant differences between women / men

and subgroups should lead to different or

adapted treatment strategies

Conclusions and implications

• Gender-responsive treatment (e.g., more

attention to trauma, parenting skills)

• Clear policies (e.g., intimate relationships)

• Staff:

• Training, intervision, coaching

• Support considering high burden BPD

• Collaboration general psychiatry

Implications

• Subgroups: e.g., offense type, diagnoses,

intellectual disability

• Effect on staff

• Effect on children

• Dynamic risk and protective factors

• Predictive validity tools for women

Future studies

More information:

[email protected]

www.violencebywomen.com

Gender differences in

motivations for offending

Susanne de Haas

Van der Hoeven

• Why did he/she do this? What motivates

people?

• Helpful

– Relapse prevention plan

– Offense analysis

– Decrease risk of recidivism?

• Object of research

After the crime has been committed

• The refined taxonomy

• Findings– Reliability– Motivations

Most common motivations Index offences

• Conclusions and implications

• Future research

Presentation outline

Taxonomy of motivations inspired by Coid (1998)

Mad Psychotic, Compulsive urge to

harm/kill

Bad Expressive aggression, Power

domination and control, Illicit gain,

Excitement, Undercontrolled

aggression

Sad Cry for help/attention seeking,

(Extended) suicide, Despair,

Influenced by partner

Relational frustration Revenge, Jealousy,

Threatened/actual loss, Displaced

aggression, Victim precipitation

Coping Relief of tension/dysphoria,

Hyperirritability

Sexual Paraphilia, Sexual gratification,

Sexual conflict

• Fleiss’ Kappa

• Substantial: – Mad (.68)

• Moderate: – Bad (.54)– Sad (.55)– Relational/social (.49)– Coping (.49)– Sexual (.56)

All p ≤ .001

Reliability of the Clusters (n = 80)

Most common motivations (n = 436)

0

5

10

15

20

25

30

35

Mad Bad Sad Relational/social Coping Sexual

Women %

Men %

• Index offenses:

– Homicide

– Attempted homicide

– Sex offense

– Arson

– Violent offense

Index offense and gender differences

0

5

10

15

20

25

30

35

Mad Bad Sad Relational/social Coping Sexual

Women %

Men %

Index offense: Homicide

p ≤ .05

0

5

10

15

20

25

30

35

40

Mad Bad Sad Relational/social Coping Sexual

Women %

Men %

Index offense: Attempted Homicide

p ≤ .05

0

10

20

30

40

50

60

Mad Bad Sad Relational/social Coping Sexual

Women %

Men %

Index offense: Sex offense

Index offense: Arson

0

5

10

15

20

25

30

35

40

45

50

Mad Bad Sad Relational/social Coping Sexual

Women %

Men %

p ≤ .01

Index offense: Violent offenses

0

5

10

15

20

25

30

35

40

45

50

Mad Bad Sad Relational/social Coping Sexual

Women %

Men %

p ≤ .05

Significant gender differences motivations

• In general:

– Men more by Bad and Sexual

– Women more by Sad and Relational/social

• Index offenses:

– Homicide: Mad (m), Sad (w)

– Attempted homicide: Bad (m)

– Sex offense: no significant differences

– Arson: Coping (m), Sad (w)

– Violent offense: Sad and Relational frustration (w)

Conclusions

• Increase effectiveness treatment

• Decrease risk of recidivism

Implications

• Refine taxonomy into structured assessment tool

• Other influencing factors

• Relationship Axis I and Axis II disorders

• Increase of effectiveness treatment and decrease risk of recidivism

Suggestions future research

Thank you for your attention!

• Questions?

• Contact:

Susanne de Haas

[email protected] /

[email protected]

Thank you for your attention!

Coid, J.W. (1998). Axis II disorders and motivation for serious criminal behavior. In A.E. Skodol (Ed.), Psychopathology

and violent crime (pp. 53-97). Washington, DC: American Psychiatric Press.

Fusco, S.L., Perrault, R.T., Paiva, M.L., Cook, N.E., & Vincent, G. (2011). Probation officer perceptions of gender

differences in youth offending and implications for practice in the field. Paper presented at the 4th International

Congress on Psychology and Law, Miami, March 2011.

Garcia-Mansilla, A., Rosenfeld, B. & Nicholls, T.L. (2009). Risk assessment: Are current methods applicable to women?

International Journal of Forensic Mental Health, 8, 50-61.

Klein Tuente, S., Vogel, V. de, & Stam, J. (2014). Exploring the criminal behavior of women with psychopathy: Results

from a multicenter study into psychopathy and violent offending in female forensic psychiatric patients. Manuscript

under review.

McKeown, A. (2010). Female offenders: Assessment of risk in forensic settings. Aggression and Violent Behavior, 15,

422-429.

Nicholls, T.L., Brink, J., Greaves, C., Lussier, P., & Verdun-Jones, S. (2009). Forensic psychiatric inpatients and

aggression: An exploration of incidence, prevalence, severity, and interventions by gender. International Journal of

Law and Psychiatry, 32, 23-30.

Serbin, L.A., Cooperman, J.M., Peters, P.L., Lehoux, P.M., Stack, D.M., & Schwartzman, A.E. (1998). Intergenerational

transfer of psychosocial risk in women with childhood histories of aggression, withdrawal, or aggression and

withdrawal. Developmental Psychology, 34, 1246-1262.

Vogel, V. de, & Vries Robbé, M. de (2013). Working with women. Towards a more gender-sensitive violence risk

assessment. In C. Logan, & L. Johnstone (Eds.), Managing Clinical Risk: A guide to effective practice (pp. 224-241).

London: Routledge

Vogel, V. de, Vries Robbé, M. de, Kalmthout, W. van & Place, C. (2012). Female Additional Manual (FAM). Additional

guidelines to the HCR-20 for the assessment of violent behavior by women. Utrecht, The Netherlands: Van der

Hoeven Kliniek.

References