Protective Factors for Violence Risk: The Value for Clinical Practice

doi:10.4236/psych.2012.312A187

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Psychology

2012. Vol.3, No.12A, 1259-1263

Published Online December 2012 in SciRes (http://www.SciRP.org/journal/psych) http://dx.doi.org/10.4236/psych.2012.312A187

Protective Factors for Violence Risk: The Value for

Clinical Practice

Michiel de Vries Robbé, Vivienne de Vogel, Jeantine Stam

Van der Hoeven Kliniek, Utrecht, The Netherlands

Email: [email protected]

Received October 11th, 2012; revised November 9th, 2012; accepted December 5th, 2012

Violence risk assessment tools in forensic psychiatry have traditionally solely been focused on risk factors.

Recently, positive psychology inspired a more strengths-based approach to treatment and sparked an in-

novation in the assessment of violence risk: the introduction of protective factors. The Structured Assess-

ment of Protective Factors for Violence Risk (SAPROF) was developed to complement violence risk as-

sessment with an assessment of protective factors. In this article, clinical experiences with the use of pro-

tective factors in forensic practice are described and empirical findings on incorporating protective factors

in the risk assessment procedure are discussed. The results of this study underline the value of protective

factors for a balanced and more accurate violence risk assessment and exemplify their potential in guiding

treatment planning, evaluating treatment progress and improving positive risk management strategies.

Keywords: Protective Factors; Violence Risk Assessment; SAPROF; Strengths-Based; Positive

Introduction

Positive psychology has inspired an innovative direction for

treatment not only in general psychiatry but also in forensic

psychiatry. Encouragement of the healthy aspects of mentally

disordered patients and their environment can provide a valu-

able contribution to the treatment and reintegration process.

Therefore, treatment aimed at reducing violent recidivism

should not only be focused on diminishing risk factors, but also

on reinforcing protective factors (De Ruiter & Nicholls, 2011;

Ullrich & Coid, 2009). Strengths-based approaches are eagerly

being adopted by clinicians seeking hopeful and positive alter-

natives for the gloomy vision of the risk-only approach. In-

spired by this new direction in (forensic) psychology, over the

past decade clinicians and researchers in forensic psychiatry

have increasingly focused on positive and changeable treatment

related issues. As such, treatment approaches have more and

more adopted positive strategies and strengths-based interven-

tions (see for example the Good Lives Model; Ward & Brown,

2004). Although positive factors have traditionally been ad-

dressed in most treatment efforts, the notion that these positive

factors can indeed act as protective factors for violence risk in

forensic psychiatric patients is relatively new. Moreover, link-

ing this positive preventive approach to a structured evaluation

of personal and situational strengths in risk assessment was

virtually non-existing before the turn of the century. Rogers

(2000) stated that most assessments were risk-only evaluations,

which were inherently inaccurate and implicitly biased. Ac-

cording to Miller (2006), the mere focus on risk factors in most

risk assessment instruments likely results in pessimism among

therapists and over-prediction of recidivism, possibly leading to

the wrongful, lengthy detention of forensic psychiatric patients,

which is costly both for the patients, in terms of loss of personal

liberties, and for society, in terms of financial burden.

Many researchers now agree that by focusing solely on risk

factors, important information concerning the other side of the

violence risk equation, the possible risk reducing effect of pro-

tective factors, is wrongfully ignored and that a balanced risk

assessments including both risk- and protective factors is vital

for an accurate appraisal of the risk of relapse into violence

(e.g., DeMatteo, Heilbrun, & Marczyk, 2005; Gagliardi, Lovell,

Peterson, & Jemelka, 2004; Haggård-Grann, 2005; Salekin &

Lochman, 2008). However, as of yet the specific assessment of

protective factors remains understudied and the concept of pro-

tective factors is still ambiguous (Braithwaite, Charrette,

Crocker, & Reyes, 2010; De Vogel, De Ruiter, Bouman, & De

Vries Robbé, 2011). Protective factors can be personal factors

or situational factors. They are defined as: any characteristic of

a person, his or her environment or situation which reduces the

risk of future violent behavior (De Vogel, De Ruiter, Bouman,

& De Vries Robbé, 2009, 2012). If protective factors are dy-

namic in nature, they make for promising positive targets for

violence risk reduction by providing positive goals for treat-

ment programming and risk management planning (Douglas &

Skeem, 2005). In recent years, many researchers and clinicians

in forensic treatment have started to acknowledge the value of

protective factors for accurate risk assessment and effective

violence prevention (Fougere & Daffern, 2011; Lösel & Far-

rington, 2012; Ullrich & Coid, 2009; Webster, Martin, Brink,

Nicholls, & Desmarais, 2009). In this article protective factors

for violence risk will be investigated and a tool for the struc-

tured assessment of protective factors will be introduced. The

benefits of protective factors for the risk assessment and treat-

ment of forensic psychiatric patients will be described.

Assessment Tools for Protective Factors

Many risk assessment tools in forensic clinical practice fol-

low the Structured Professional Judgment (SPJ; see Douglas,

2009) approach. SPJ tools are checklists containing empirically

derived risk related factors. After coding the items in the tool,

the assessor interprets and integrates the evidence to come to an

M. DE V. ROBBÉ ET AL.

overall final judgment on the level of risk or protection present.

Integrating empirical knowledge with clinical expertise ensures

a well-informed risk judgment. Moreover, the SPJ approach

provides valuable insights into possible risk scenarios and is

able to guide treatment planning and risk management. Very

few structured violence risk assessment tools include a specific

focus on strengths. Only three SPJ tools have been developed

which include protective factors. The Structured Assessment for

Violence Risk in Youth (SAVRY; Borum, Bartel, & Forth, 2006)

is a checklist for violence risk assessment in youth containing

six protective factors in addition to 24 risk factors (e.g., Proso-

cial involvement, Resilient personality traits). Several studies

on the SAVRY found that the protective factors in the SAVRY

are good predictors of reduced violence and that they have ad-

ditional value to risk factors (Lodewijks, De Ruiter, & Dorelei-

jers, 2010; Rennie & Dolan, 2010). The Short-Term Assessment

of Risk and Treatability (START; Webster et al., 2009) is a

clinical guideline for the dynamic assessment of short-term

risks. The 20 dynamic items have to be simultaneously coded

on two three-point scales: first as strength, then as risk. In other

words, risks and strengths are regarded as opposing ends of the

same variable rather than being unique concepts. The START is

intended to be used for short-term assessments of acute risk and

is repeated bimonthly. In recent studies the START strengths-

scale (the total score of the strength side of all items) showed to

be predictive of less violence in the short-term and of success-

ful community reintegration (Braithwaite et al., 2010; Nonstad

et al., 2010; Viljoen, Nicholls, Greaves, De Ruiter, & Brink,

2011; Wilson, Desmarais, Nicholls, & Brink, 2010).

The SAPROF

Given the lack of a suitable protective factors assessment

tool which could be used in accordance with the most com-

monly used forensic assessment tools for risk factors with a

medium-term time-frame (i.e., the Historical Clinical Risk

management-20 (HCR-20); Webster, Douglas, Eaves, & Hart,

1997), the SAPROF was developed. The tool was inspired by

findings from positive treatment aspects in clinical practice and

by a strong whish from clinicians for a more strengths-based

yet empirically sound approach. Through extensive literature

reviews on protective and contextual factors, qualitative studies

on the working positive aspects of forensic clinical treatment

and pilot studies among several Dutch forensic psychiatric in-

stitutions, in 2007 the Structured Assessment of Protective

Factors for violence risk (SAPROF; De Vogel, De Ruiter,

Bouman, & De Vries Robbé, 2007; English version 2009) was

developed in the Netherlands. The SAPROF was designed as a

SPJ checklist. It was intended as a positive dynamic addition to

structured risk assessment in forensic clinical practice and thus

to be used in combination with a SPJ risk evaluation instrument,

like the HCR-20 or the Historical Clinical Risk management:

Version 3 (HCR:V3; Douglas, Hart, Webster, Belfrage, &

Eaves, in preparation). Since the publication of the English

manual in 2009, the SAPROF was subsequently translated in

10 different languages and was quickly adopted by forensic

psychiatric institutions in various countries.

The SAPROF consists of two static and fifteen dynamic pro-

tective factors organized within three scales according to their

general background: the Internal factors (e.g., Coping, Self-

control), the Motivational factors (e.g., Work, Attitudes towards

authority) and the External factors (e.g., Social network, Pro-

fessional care). Appendix 1 shows the coding sheet with an

overview of all protective factors in the SAPROF. The factors

are rated on a three-point scale (0-2), reflecting the extent to

which they are present as a protective factor for violence risk

for a given patient in a specific situation. Additionally, factors

can be indicated as particularly important for the individual in

two ways. Factors that provide much protection at the time of

assessment can be marked as key factors, while factors that are

seen as potential targets for treatment intervention can be

marked as goal factors. In clinical practice, the indication of

key factors and goal factors sharpens the view on the impor-

tance of specific protective factors for the individual, which can

be useful for the development of risk management plans and

treatment intervention strategies. Following the SPJ approach,

the SAPROF concludes with a final judgment on the overall

protection that is present to counterbalance violence risk in the

assessed situation (low, moderate, or high). Like with all SPJ

tools, the final judgment is composed by interpreting, weighing

and integrating the factors that are present. Finally, this Final

Protection Judgment is combined with the risk factors from a

SPJ risk tool to come to an integrative and balanced Final Risk

Judgment for future violent behavior. In De Vogel et al. (2011)

the background and content of the SAPROF is explained fur-

ther and its protective factors are discussed in more detail.

The Benefits of a Positive Approach Clinical

The predominantly dynamic protective factors in the SAP-

ROF aim to inform treatment with positive and attainable goals

for interventions. By doing so, the assessment of protective

factors can offer valuable guidance in narrowing the gap be-

tween risk assessment and risk management. In 2007, the

SAPROF was implemented into general risk assessment prac-

tice for violent and sexually violent offenders in the Van der

Hoeven Kliniek, a forensic psychiatric hospital in The Nether-

lands, to complement traditional risk assessment with risk-only

tools like the HCR-20 and the Sexual Violence Risk-20

(SVR-20; Boer, Hart, Kropp, & Webster, 1997). Mental health

professionals, clinical psychologists and researchers in Dutch

forensic psychiatry state that they appreciate the usefulness of

the assessment of protective factors for the atonement of treat-

ment plans and implementation of feasible and effective risk

management strategies (Van den Broek & De Vries Robbé,

2008). For example, clinicians value the use of key-factors and

goal-factors when assessing and reporting patient strengths in

relation to treatment progress. In turn, this supports well-in-

formed decision making regarding treatment phasing. More-

over, the use of a positive tool with a focus on the healthy as-

pects and strengths of a patient and his or her environment en-

courages positive communication between staff and patients

and enhances treatment motivation in both patients and clini-

cians. The value of these positive changes for treatment pro-

gress has also been recognized in the therapeutic assessment

approach by Finn and colleagues (see Finn, 2007). Although

this collaborative assessment procedure revolves much more

around patient involvement, the primary goals is very similar:

facilitating positive change in people.

Empirical

In order to provide more insight into the nature of the rela-

tionship between positive factors and a reduced likelihood of

1260

M. DE V. ROBBÉ ET AL.

recidivism, several validation studies were carried out on the

SAPROF protective factors. Although the greatest supplemen-

tal value of the SAPROF is its importance for guiding treatment

evaluation and planning, proper examination of its predictive

validity for violent recidivism, both retrospectively and pro-

spectively, is essential.

Two retrospective file studies were carried out in order to

assess the psychometric qualities of the SAPROF and evaluate

the additional value of using the SAPROF alongside traditional

risk only evaluations in clinical practice with: 1) violent of-

fenders; and 2) sexually violent offenders. The first validation

study (De Vries Robbé & De Vogel, 2012; De Vries Robbé, De

Vogel, & De Spa, 2011) included 105 male violent offenders

discharged from forensic psychiatric treatment after intensive

clinical and outpatient treatment (mean treatment duration 5.5

years). Interrater reliability was good for the total SAPROF

item scores (intraclass correlation coefficient (ICC) = .88).

Predictive validities for non-recidivism with violent offenses

after treatment within three different follow-up periods, one

year, three year and long-term (M = 8 year), after treatment

were excellent. Patients with more protective factors at dis-

charge recidivated significantly less often and less quickly than

patients with lower protective factors scores (area under curve

value (AUC) = .85 at one year; .74 at three year; and .71 at

long-term follow-up). The predictive validity of the protective

factors in the SAPROF and the risk factors in the HCR-20

combined significantly outperformed the risk-only evaluation.

In addition to ratings at the time of discharge, for part of the

sample data were also collected on ratings at the time of admis-

sion to assess the progress made by patients during their foren-

sic psychiatric treatment. A comparison between the pre- and

post-treatment ratings showed significant improvements in

protective factors scores during treatment, providing evidence

for the changeability of the dynamic protective factors in the

SAPROF and their potential usefulness for positive treatment

progress evaluation and risk management planning.

A subsequent study (De Vries Robbé & De Vogel, 2012; De

Vries Robbé, De Vogel, Koster, & Bogaerts, submitted for

publication) investigated the value of the SAPROF protective

factors for sexual offenders. The study included 83 discharged

sexually violent male offenders (mean treatment duration 5.4

years). As was found for the violent offender sample, the inter-

rater reliability of the SAPROF protective factors was good for

the sexual offenders (ICC = .85). Predictive validity results

were high as well for the sexual offender sample: the SAPROF

showed good predictive validity at different follow-up times of

1 year, 3 year and long-term (M = 15 year) both for non-re-

cidivism in sexual violence (AUC = .83; .77; .74, respectively)

and for non-recidivism in general violence (AUC = .93; .76; .71,

respectively). Again, adding the SAPROF protective factors

produced significantly more accurate assessments than assess-

ments with the risk-only HCR-20 or SVR-20 alone. Compari-

son of pre- and post-treatment ratings showed very similar ef-

fects for the sexual offender sample as for the violent offender

sample: significant positive changes on the SAPROF factors

during treatment. These treatment changes in themselves were

predictive of less recidivism, meaning that those patients who

showed the most progress on their protective factors during

treatment, also recidivated the least after treatment. Although

the results from these studies were equally good for violent and

sexual offenders, analyses revealed different protective factors

that were most predictive of no future (sexual) violence for the

two offender groups: Self-control, Work and Financial man-

agement for the violent offenders; Coping, Self-control, Moti-

vation for treatment and Attitudes towards authority for the

sexual offenders (De Vries Robbé & De Vogel, 2012).

In order to assess the usefulness of protective factors for the

assessment of inpatient aggression, a prospective study was

carried out within clinical practice (De Vries Robbé, De Vogel,

Wever, Douglas, & Nijman, submitted for publication). The

study included data on 315 assessments, which had been carried

out during different stages of clinical treatment at a Dutch fo-

rensic psychiatric hospital. Predictive validity analyses for no

inpatient aggression within the year following the assessment

showed good results for the protective factors in the SAPROF

for different groups of patients including male violent offenders

(AUC = .77), male sexual offenders (AUC = .81) and female

offenders (AUC = .70). Overall, similar to the findings in the

retrospective file studies, combining the protective factors with

the risk factors showed to provide the most accurate predictions.

When patients at different stages during their treatment were

compared, the presence of dynamic protective factors showed

to increase as treatment progressed, while the presence of dy-

namic risk factors showed to decrease over time. Together the

improved protective factors and the diminished risk factors

resulted in an overall reduction in violence risk and conse-

quently less inpatient aggression. It was found that there were

far fewer incidents of violence at the later stages in treatment

and that protective factors were particularly useful later on in

treatment, when patients had been able to use their increased

protective factors to their advantage outside the hospital walls.

Conclusion

Although protective factors inevitably have always been part

of clinical practice, their true potential for positive treatment

outcome has long been underestimated and wrongfully received

little acknowledgement. In order for treatment programs aimed

at increasing protective factors to be meaningful it is essential

to be able to evaluate the presence of protective factors that are

empirically related to reductions in violence risk. Structurally

assessing the positive characteristics of offenders and their

environment offers a valuable additional starting point for ef-

fective and achievable positive treatment interventions. Com-

plementing the risk-only focus with protective factors brings

forth a more balanced assessment of future violence risk and

consequently leads to better informed risk management. Vali-

dation studies to date on the SAPROF as a tool for the struc-

tured assessment of protective factors have provided support for

a strong relationship between the presence of protective factors

and the reduced likelihood of future violence. Moreover, the

changeability of dynamic protective factors makes them valu-

able positive treatment targets and provides clinicians with a

tool to evaluate treatment progress and guide interventions.

Focusing on strengthening these dynamic protective factors

provides clinicians in forensic psychiatry with a promising

improvement in the prevention of violent recidivism.

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M. DE V. ROBBÉ ET AL.

Appendix 1

SAPROF coding sheet.

Coding sheet SAPROF

Protective factors for violence risk

To be used only in combination with the HCR-20

or related structur ed risk assessment tools

Name: Number: Date:

Age: Gender:

□

Male

□

Female

Context risk assessment:



Internal factors Score Key Goal

1. Intelligence □

2. Secure attachment in childhood □

3. Empathy □ □

4. Coping □ □

5. Self-control □ □



Motivational fac tors Score Key Goal

6. Work □ □

7. Leisure activities □ □

8. Financial management □ □

9. Motivation for treatment □ □

10. Attitudes towards authority □ □

11. Life goals □ □

12. Medication □ n/a □ □



External factors Score Key Goal

13. Social network □ □

14. Intimate relationship □ □

15. Professional care □ □

16. Living circumstances □ □

17. External control □ □



Other considerations:



Final Prote ction Judgment and

Integrative Final Risk Judgment

SAPROF + HCR-20

Protection

□ Low

□ Moderate

□ High

Risk

□ Low

□ Moderate

□ High



Name(s) assessor(s):

Signature:

Position: