Strengths focused Treatment

-Dr Karen Richard And Dr Lisa Cameron 2013

plus ça change, plus c'est la même chose

Pioneers of strength-focused approach

Local heroWilliam A F Browne

Dr Kirk!!

Assessing protective factorsThe SAPROF

Michiel de Vries Robbé & Vivienne de Vogel Van der Hoeven Kliniek

SAPROF Workshop April 2012

The concept of risk assessment

What is risk assessment?

The assessment of the riskof future (sexual) violent behavior

in patients / offenders with a violenthistory and/or mental disorder

What is violent behavior?

Violence is actual, attempted,or threatened harm

to one or more persons

Webster, Douglas, Eaves & Hart (1997)

1. Unstructured Clinical method Based on the experience, training and knowledge of psychiatrist, nurse, psychologist or clinician.

2. Actuarial method Based on empirically found risk factors for violence, standardized, mostly static factors, designed to predict

3. Structured Professional Judgment (SPJ) method Integration 1 & 2: Standardized risk assessment, based on empirically found risk factors for violence and clinical experience.

3 methods of risk assessment

Structured Professional Judgment

Bridging the gap between science and practice

To be coded by a trained and experienced clinician

Process of coding structures and professionalizes clinical judgment

Not just adding the scores, but interpretation / weighing / combining / discussing items

Repeated assessment is necessary

Assessment leads to consider violence scenarios and planning of risk management

The concept of protective factors

Violence risk assessmentAdvances

Increased knowledge on risk factors for (sexual) violence

Major advances in structured risk assessment procedures

Shortcomings

Almost no information on factors that can compensate for or diminish effects of risk factors

Most structured risk assessment instruments do not include protective factors.

Importance of considering

protective factors

More balance in risk assessment: complete view of the offender

Positive approach motivating for both offenders and treatment staff

Suggestions for improved risk management

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

Forensic psychologists are frequently asked to conduct evaluations of risk assessment. While risk assessment has considerable merit, recent applications to forensic psychology raise concerns about whether these evaluations are thorough and balanced. Forensic adult risk-assessment models stress risk factors, and deemphasize or disregard entirely the other side of the equation: protective factors. Mediating and moderating effects must also be considered. Moreover, base-rate estimates may produce erroneous results if applied imprudently to forensic samples without regard to their unstable prevalence rates or the far-reaching effects of settings, referral questions, and evaluation procedures.

COMMENTARYThe Uncritical Acceptance of Risk Assessment in Forensic Practice

Positive / strengths-based approach

Good Lives Model (GLM-C) (e.g.Ward et al, 2007) Focus on strengths, therapeutic alliance, holistic, tailored therapy, establishment of skills and competence needed to achieve a better life

Positive / strengths-based approach

Desistance (e.g. Maruna, 2001)

DESISTANCE AND DEVELOPMENT: THE PSYCHOSOCIAL PROCESS OF 'GOING STRAIGHT'Desistance is seen as a maintenance process, a long term abstinence from crime among individuals who had previously engaged in persistent patterns of criminal offending (e.g. through aging, maturation, “a steady job and the love of a good woman”)

What are protective factors?

Protective factors background

Are protective factors not merely the opposite of risk factors? In general the approach is very different:

What strengths are there to build uponWhat positive goals can be worked towardsWhat can be built up instead of what should be broken down

Some protective factors can be risk factors when not present(e.g. Self-control)

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

How do protective factors influence future violence risk? Remains largely unknown for now, likely:

Promotive effect for some factors (work for everybody)Protective effect for other factors (only moderating when risk

present)

What are protective factors? 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

Risk & Protection

Protective factors

Risk factors

Risk factors

Protective factors

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

Van der Hoeven KliniekUtrecht, The Netherlands

Forensic psychiatric hospital: 286 bedsMostly TBS order: involuntary treatment50/50 personality / psychotic disordersHolistic approach, emphasis on CBT & relapse

preventionTherapeutic community: taking responsibilityRehabilitation: gradual through ‘transmural phase’

Risk assessment in consensusHCR-20 & SAPROF (+SVR-20, FAM)Repeated regularly to inform treatment

Consensus model

TreatmentTreatmentsupervisorsupervisor ResearcherResearcher

SociotherapistSociotherapist

ConsensusConsensus

HCR-20 SAPROF SVR-20 if sexual offense FAM if female

Risk assessment at the

Van der Hoeven Kliniek

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

2001: Implementation HCR-20 & SVR-20 Consensus model

2009: Implementation START specific short-term groups

2005: Risk assessment mandatory in the Netherlands

2007: Implementation SAPROF

2001-2005: Dissertation De Vogel: Dutch HCR-20 & SVR-20 are valid and valuable for forensic practice

2007-2012 Dissertation De Vries Robbé: psychometric properties and value of the SAPROF for forensic practice

2011: Implementation FAM Female Additional Manual

Preface of the SAPROF

Mental health professionals desired more knowledge on protective factors

Research into protective factors is scarce

No suitable instruments for medium term prediction of violence for adults

Development SAPROFPreconditions

1. Scientific basis

2. Practically applicable: Dynamic factors, concrete guidelines for treatment, easy to code

3. In line with other risk assessment tools: SPJ model, basis and method similar to HCR-20 / SVR-20; aim = positive addition to these checklists

Additional value of the SAPROF

Risk assessment Balance risks and strengths Increased predictive validity violent recidivism and violent

incidents during treatment

Clinical practice Positive approach Dynamic Improved risk management focus

Risk defined in changeable positive factors

SAPROF Versions

2007 2008 2009 2010 2011 2012 2013

Dutch English German

Italian

Norwegian

Swedish

Portuguese

Spanish

French

Russian

English 2nd

Danish

Chinese

SAPROF-YV

Dutch 2nd

• Dutch version published in 2007:– Implemented in 2007 in the Netherlands– PhD project validation of the SAPROF

• English in 2009• Followed by: German, Italian, Spanish, French, Swedish,

Norwegian, Portuguese, Russian & English 2nd Edition• In preparation: Dutch 2nd Edition, Chinese, Danish & Youth version

Coding the Coding the SAPROFSAPROF

The SAPROF 17 protective factors (15 dynamic, past

6 months)

Three scales: Internal factors Motivational factors External factors

Should always be coded in combination with SPJ risk assessment instrument

+

1. IntelligenceLevel of intelligence (test results)Recent testing (max 6 years ago)

2. Secure attachment in childhoodAttachment with prosocial adultBased on file information before the age of 18Secure attachment + good example

Internal factors (static)

Internal factors (dynamic)3. Empathy

Empathy towards others (past/potential victims)Observation of behavior and emotions

4. CopingEffective problem solving and conflict management skillsObservation of behavior in daily life + self-rapport

5. Self-controlImpulse control and self restraining

in times of stress or temptationSelf-control and perseverance

in self-discipline

Motivational factors6. Work

Stable and suitable workDaily structure and personal developmentPaid/unpaid

7. Leisure activitiesStructuredProsocial contacts, social controlDaily structure and hobby

8. Financial management• Steady income (work or benefits)• Sound financial management, no debts• Sufficient finances for living circumstances

Work / Leisure activities not always protective …

Motivational factors9. Motivation for treatment

Insight in necessity, motivation for changeOpenness, cooperation and progress in treatment

10. Attitudes towards authorityPositive attitude, tolerance of authorityCommitment to agreements and compliance with

rules and regulations

11. Life goalsFactors that provide meaning and positive life

fulfillment (extra motivation to do better)Religion, parenting, ambitions

12. MedicationMotivation for and compliance with medicationEffectiveness of medication

External factors

13. Social networkProsocial and supportiveExperienced support of family

and friends

14. Intimate relationship• Duration and stability• Quality• Information from partner

External factors

15. Professional careAvailability mental health care Intensity: frequency and nature of support

16. Living circumstances• Supervision by health care professionals• Social control from related others

17. External control• Mandatory treatment or probation contact• Judicial proceeding• Intensity of mandatory external control

Theory of changing protection

Static protective factors1. Intelligence2. Secure attachment in childhoodDynamic 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

Blair Ghost Project Ghosts, Gothic Terror and a bit of Shakespeare…

The Blair Ghost Project was a collection of connected scenes devised and performed by patients from the Tayside Area Forensic Service.It was performed at Horsecross Theatre in Perth in 2008 both for invited audience in June and as part of Welcome to the 2nd annual Scottish Mental Health Arts and Film Festival.

Blair Ghost Project

The dust never settles…If you could reinvent yourself into anything you

wanted, what would it be? The Dust Never Settles is about journeys in the imagination

from a Spaghetti Western to dreams of comedy stardom to a late night piano bar.

Devised and performed by patients from the Forensic Psychiatry Unit, the piece involves drama, live music, songs and images. Be

prepared for some funny moments and some thoughtful moment. Be prepared for change.

Clinicians involved in developing the SAPROF

Generated ideas for SAPROF

Participated in pilot-study

Ongoing feedback on SAPROF in daily practice

SAPROF is helpful in: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 with the SAPROF

Van den Broek & De Vries Robbé (2008)

“The whole is greater than the sum of its

parts.”― Aristotle

Overview SAPROF

Structured assessment of protective factorsDynamic and positive addition to risk assessmentGood results researchEspecially valuable for clinical practice

Increasingly personalized risk assessmentPositive treatment goalsStrengths based guidelines treatment planning and risk management

There is nothing new under the sun