Prof. dr. mr. Frans Willem Winkel, Professor of Victimology, Tilburg University: Effective victim support from an evidence-based trauma perspective

1. The European Victim Guideline
(2012): effective victim support
from an evidence-based trauma
perspective
Prof. dr. mr. Frans Willem Winkel
f.w.winkel@tilburguniversity.edu
Zagreb-conference, November, 27- 30,
2012

2. Specific targets suggested by the
guideline (e.g. art 18…)
• General purpose: to (further) enhance the
social and juridical position of crime victims.
• More specific targets, include:
• (1) The prevention of chronic suffering,
chronic coping problems due to victimization;
• (2) The prevention of repeat victimization,
and
• (3) The prevention of secondary
victimization / secondary traumatization

3. Victim Support: how to accomplish
these specific targets??
• Psychological evidence suggests that most crime
victims are resilient, and thus are not in need of
support;
• However: traumatized victims – victims at risk of
developing PTSD - are in need of support.
• A first step in developing effective services is to
acknowledge the importance of a trauma
perspective:
• Ergo: support workers should have knowledge
about risk factors / mechanisms underlying PTSD

4. Support from a trauma perspective
• Effective programs include (at least) two
components, namely:
1. Early identification of victims at risk of
developing chronic PTSD, and
2. Swift referral to the mental health system
1. Tea and sympathy by volunteers is not enough;
2. These victims are in need of trauma-focused
treatment by professional psychologists
3. Evidence-based interventions – incl. EMDR and
cognitive processing therapy – are available

5. Victim support and trauma
• The gold standard to identify victims with
chronic PTSD is an extensive diagnostic
interview by a psychologist / psychiatrist!!
• However: a number of screening tools have
been developed for non-psychologists / e.g.
police and victim support workers;
• Important tools include: the Trauma Screening
Questionnaire(TSQ), Coping self-efficacy scale,
and the Scanner

6. Relevance of a trauma perspective
• An important criterion to evaluate the success of the
European guideline:
• The utilization of (validated) screening instruments to
identify victims in need of support
– In the NL since 2012 the TSQ is used as part of an
(internet-based) e-screening procedure;
• However: many organizations affiliated with Victim
Support Europe still do not use screeners as part of an
Early identification and referral procedure (many
victims in need are not identified)

7. Two other arguments for a trauma
perspective
• Victimological evidence suggests that PTSD is
a conditional risk factor for
• REPEAT VICTIMIZATION, AND
• SECONDARY VICTIMIZATION /
TRAUMATIZATION, due to delivery of a victim
impact statement during trial of the suspect.
• Some subtypes of PTSD are relatively strong
(versus weak) risk factors for these outcomes

8. PTSD and repeat victimization
Slides relating to
Presentation on wednesday

9. Repeat victimization: the re-
involvement in domestic violence
• Female victims exposed to domestic violence
are defined as vulnerable victims in the
Guideline
• Some of these victims are in Danger: at
substantial risk of short-term revictimization
• Challenge: is it possible to early identify
victims who are in danger on the basis of
validated Risk Assessment Instruments (RAIs).
– Yes, we can!!

10. RAIs: forensic psychology
• RAIs with acceptable psychometric properties
(reliability, predictive validity) have been
developed in Forensic Psychology
• Various versions:
• Professional, more detailed versions
(psychologist / psychiatrist) and “simple”
screening versions (police / victim support
workers)
• Actuarial and “non-actuarial” RAIs

11. Risk assessment instruments
• Professional assessors (forensic
psychologists):
• DVRAG (Domestic Violence Risk Appraisal
Guide)
• SARAG (Spousal Assault Risk Assessment
Guide
– (actuarial versus “non-actuarial” / no cutoff-values
for low and high risk)
– E.g. 4 risk factors = 40% risk

12. “Non-clinical” assessors: police and
victim support
• B-Safer (Brief Spousal Assault form for the
Evaluation of Risk)
• ODARA-LE (Ontario Domestic Assault Risk
Assessment – Law Enforcement)
• Danger Assessment Inventory

13. An example: ODARA

14. ODARA ITEMS: 13 risk factors
(Sumscore: 0 - 13)
(1) Prior violence against wife or children (NO = 0; YES = 1)
(2) nondomestic incident
(3) Prior custodial sentence
(4) Failure on prior conditional release
(5) Threat to harm or kill at index assault
(6) Confinement of the partner at the index offense
(7) Victim concern
(8) More than one child (from perpetrator or victim)
(9) Victim has biological child from previous partner
(10) Violence against others
(11) Substance abuse history
(12) Assault on victim when pregnant
(13) Barriers to victim support

15. ODARA: “experience table” (official
recidivism)
ODARA score Likelihood of re-assault that comes to
(Sumscore: equal weights; the attention of the police within an
Each factor = 1) average of about 5 years)
0 7%
1 17%
2 22%
3 34%
4 39%
5 of 6 53%
7 t/m 13 74%

16. DRAG = PCL-R + ODARA: an
illustration
Corrected
Perpetrator is a ODARA-score
Psychopath: “PCL-R = 1)” (different weights
per risk factor)
Psychopathy
Likelihood of
Checklist –revised
Recidivism
(PCL-R; Hare)
(experience table)
“Uncorrected” / simple ODARA-score
(PCL-R =0)
(all factors have the same weight)

17. Victimological evidence: Danger
Assessment Inventory (DAI)
• DAI has been recently developed to early
identify female victims who are in danger, at
substantial risk of short-term re-victimization
(within 3 to 6 months)
• Evidence base: two large scale prospective
studies (N> 500 victims)
• Why: the DAI has superior predictive
performance!!!
– Stronger correlation between prediction and
actual outcome

18. Why bother about Predictive validity (&
reliability)….????
Actual Outcome:
No Revictimization
revictimization (Yes)
Predicted Prediction
: HIT ERROR (“under”)
NOt at Risk
At Risk Prediction
(YES) ERROR (“over”) HIT
Error: secondary victimization

19. Danger Assessment Inventory:
screening version for police and victim support workers
Danger Assessment Inventory
Perpetrator features Victim features Scenario-features
Mutual scenario, incl.
ODARA-score > 7 Involvement in a Posttraumatic aggression
YES =1 Post Traumatic (CTS-P): Yes =1
Cycle (TSQ/CTS-V): Yes = 1
High risk of short-term revictimization: N = 3
“Corrected” ODARA-score for victims with borderline traits, incl. NEM, and impulsivity

20. DAI: features
• The DAI has a triple focus, it includes
• (1) perpetrator-related risk factors (e.g.
ODARA-score for perpetrator)
• (2) victim-related risk factors, particularly the
involvement in a PTSD-maintained cycle of
violence (posttraumatic cycle: PTC)
• (3) scenario-based risk factors: a mutual
scenario (both partners use violence; vs
unilateral scenario: male initiated violence)

21. Victimological evidence suggests,
that….
• A Posttraumatic Cycle of violence (PTC) is an
independent risk factor (e.g. controlled for
ODARA-score)
• A PTC is a strong (substantially higher risk) risk
factor, when:
• The cycle consists of mutual scenario’s (both
partners commit violent behavior) and
• The cycle is maintained by an embitterment or
an explosive (PTSD) syndrome

22. Crime-related PTSD (C-PTSD)
subtypes: 4 subtypes
PTSD Internalizing Externalizing
Subtypes: Symptomatology Symptomatology
Hopelessness
Syndrome Helplessness Embitterment
(DSM- mood
disorder/depression)
Syndrome Syndrome
(“stockholm”)
False-alarm
Syndrome Panic Explosive
(DSM- Anxiety / Anger
disorder
Syndrome Syndrome

23. Bottomline of the 2x2 table
• There are similarities among crime victims
with PTSD (DSM IV / 5 symptomatology), BUT
• There are important differences, that cannot
be ignored
– Different mechanisms underlying the
development of PTSD (cognitive versus emotional
route)
– Externalizing versus internalizing symptomatology
(dysregulation of the anger system versus the
anxiety system)

24. PTSD: conditional risk
• Explosive syndrome is a powerful risk factor
for re-victimization (stronger impact on risk
re. to “other” subtypes)
– Specific features include: hostility bias, state
anger, propensity to explode in response to
subjective (“imaginary”) danger signals, and
violent behavior (details; next slide)
• Victims with explosive syndrome are at
substantial risk of short-term revictimization

25. Peritraumatic escalation, cognitive inversion, and Shattered
Illusions (SIM).
Peritraumatic escalation:
Fight-flight response failure
Emotional Emotional
Implosion: Psychotic Explosion:
Extreme anxiety / Dissociation Blind anger /
Tonic Immobility Rage
Dysregulated Cognitive cascade:
Emergency-response: Inversion; SIM)
Hyperalert / paranoid behavior:
In standby mode
False alarm-syndrome / False alarm-syndrome /
Internalizing symptoms: Externalizing symptoms:
Self as easy target bias, Hostility bias, anger,
Anxiety, Propensity to Propensity to explode in response to
panic subjective danger-signals
Avoidant / Submissive Behavior Impulsive agressive behavior

26. PTSD and secondary
victimization
Slides relating to presentation of
thursday

27. Victim rights movement: (IRV: Joutsen, 1994; de
Mesmaecker, 2012)
• Victims should have rights, also in criminal
trials
• bring the “stolen conflict “ back to the trial
setting (versus exclusive prosecutor – suspect
– vertical link)
• Symmetry: for every right of the suspect there
should be an equivalent right for the victim,
including the right to speak
• Victim participation should be encouraged,
because it has a beneficial impact on recovery
• However: these are normative positions, there
is no credible empirical evidence

28. Secondary victimization (by the
criminal justice system)
• According to the Dutch code on criminal
procedure (some) victims have the right to
submit an oral or written statement to the
judge about the impact of the incident.
• Victim impact statements are assumed to
contribute to emotional recovery of the victim
• However: recent victimological evidence
suggests that VIS may have adverse effects,
e.g. it may result in secondary traumatization

29. Hyotheses
• Law in the books: victim rights generally have
beneficial effects for victims
• Law in action / empirical - perspective: rights
may have positive effects for some victims;
rights may have detrimental effects for other
victims
– “law of differential effect” (e.g. traumatized
versus non-traumatized victims)

30. Psychological impact of trial
participation (VIS)
Positive “Interaction – Beneficial effect:
Ritual” between the victim Emotional recovery
and the judge
Victim Impact
Statement
during trial
Negative “Interaction –
Adverse effect:
Ritual” between the victim
Secondary victimization/
and the judge
traumatization
Traumatized victims:
1.White bear-mechanism (muzzled expression)
2.Teeth for a tooth-mechanism

31. VIS: positive versus negative
experience
• Instruction to suppress anger: limited /
muzzled emotional expression during trial
• Moral dissatisfaction with the verdict
– Incomplete acknowledgement of victim distress
– “Lenient sentence”: personal distress > distress
encountered by perpetrator
• Bottomline: it is all about victim perceptions,
perceived justice

32. CREDIBLE EVIDENCE: EMOTIONAL RECOVERY
VERSUS SECONDARY TRAUMA: DESIGN
Repeated Measures Trauma Symptoms Trauma symtoms
Pre-trial Post-trial
Participants TSQ – scores TSQ-scores
(oral and / or (better alternative:
written victim impact Davidson Trauma
statement) Scale or PSS)
Non-participants TSQ-scores TSQ-scores

33. Trauma symptoms (TSQ-
scores)reported by trial
participants (VIS: yes/ no)
Victim Status: Asssessed before TSQ After trial
trial
Non-participant 3.1 2.0
(No VIS)
Participant: 7.0 5.8
Written VIS
Participant: 7.1 6.1
Oral VIS during trial

34. Bottom-line of the previous table
• There are substantial psychological
differences between participants and non-
participants (TSQ-scores: “hit between the
eyes”)
• Victims with PTSD – traumatized victims – are
more likely to participate in a trial (VIS)
• There is NO EVIDENCE for emotional recovery
– No time by participant-status interaction
• More importantly: analyses provide evidence
for secondary victimization

35. Interaction-term: F1,74 = 4.04; p < .05

36. Conclusions:
• From a law in action – perspective the
European Guideline will be a major step
forward in strengthening the social and
juridical position of crime victims, if
• The “trauma perspective” on criminal
victimization is fully acknowledged at all
levels

37. Ergo:
• Criminal justice personnel and victim support
workers should become more familiar with
this perspective (underutilization of
knowledge / knowledge-gap)
• Criminal justice personnel should be trained
in the development of trauma-sensitive
behavior;
• Victim support personnel should be trained in
the use of formal tools to identify susceptible
and vulnerable victims (e.g. DAI, TSQ, etc)