This document discusses dynamic risk assessment using the HCR-20 and SAPROF tools. It summarizes two studies conducted at a forensic psychiatric hospital in the Netherlands. The first was a retrospective file study that found the HCR-20 and SAPROF effectively predicted violent recidivism. The second was a prospective clinical study that found risk scores decreased during treatment and were predictive of in-treatment violence. The document concludes by demonstrating changes in scores for an individual case.

1. Dynamic risk assessment
HCR-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

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

3. Van der Hoeven Kliniek
Utrecht, 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

4. Risk & Protection
Risk factors
Protective factors

5. HCR-20 & SAPROF
Risk factors Protective factors
Historical factors Internal factors
H1 Previous violence 1 Intelligence
H2 Young age at first violence 2 Secure attachment in childhood
H3 Relationship instability 3 Empathy
H4 Employment problems 4 Coping
H5 Substance use problems
5 Self-control
H6 Major mental illness
H7 Psychopathy (PCL-R) Motivational factors
H8 Early maladjustment
6 Work
H9 Personality disorder
7 Leisure activities
H10 Prior supervision failure
8 Financial management
Clinical factors 9 Motivation for treatment
C1 Lack of insight 10 Attitudes towards authority
C2 Negative attitudes 11 Life goals
C3 Active symptoms of major mental illness 12 Medication
C4 Impulsivity
C5 Unresponsive to treatment External factors
13 Social network
Risk Management factors
14 Intimate relationship
R1 Plans lacks feasibility
R2 Exposure to destabilizers 15 Professional care
R3 Lack of personal support 16 Living circumstances
R4 Noncompliance with remediation attempts 17 Supervision
R5 Stress

6. Research with the HCR-20 & SAPROF
Van 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

7. Predictive validity violent recidivism
Retrospective file study Violent+Sexual (N=188)
De Vries Robbé, De Vogel & Douglas, in preparation
AUC 1 year AUC 3 years AUC 11 years
follow-up follow-up follow-up (M)
14 recidivist 34 recidivists 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)
Logistic regression: sign. incremental predictive validity SAPROF over HCR-20

8. Changes during treatment
Retrospective study (n = 108)
HCR-20 SAPROF
Historical
30 14 Internal
Clinical Motivational
Risk management
25 12 External
Total HCR-20 Total SAPROF
10
20
8
15
6
10
4
5 2
0 0
Pre-treatment Post-treatment Pre-treatment Post-treatment
HCR-20 total: t (107) = -11.70, d > 0.84, p < .001 SAPROF total: t (107) = 15.63, d > 1.74, p < .001

9. Treatment changes
Recidivists (n = 33) vs. Non-recidivists (n = 75)
HCR-20 and SAPROF Change between pre- and post-treatment ratings
16
14
12
10
HCR-20 Change
8 SAPROF Change
6 HCR-SAPROF Change
4
2
0
Recidivists Non-recidivists
HCR-SAPROF Change Recidivists vs. Non-recidivists: t (106) = -4.11, d > 0.85, p < .001

10. Treatment progress & recidivism
End mr. X
Start mr. X
Treatment Community
End mr. Y
Start mr. Y
Treatment Community
The more progress on
..the less likely
protective & risk factors violent recidivism
during treatment..

11. Differentiation of risk groups
Final Risk Judgment Final Protection Judgment
Low Low
Moderate Moderate
High High
Moderate risk High risk
100 100
90 90
80 80
70 Low 70
protection Low
60 60 protection
Moderate
50 protection 50
Moderate
40 High 40 protection
30 protection 30
20 20
10 10
0 0
1 year 3 year 11 year 1 year 3 year 11 year
Logistic regression at all f-u: sign. incremental predictive validity FPJ over FRJ

12. Research with the HCR-20 & SAPROF
Van 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

13. Changes during treatment
N = HCR-20 879 / SAPROF 452 risk assessments
233 159 141 162 113 72
30
HCR-20
25
SAPROF
20 HCR-SAPROF
Total score
15
10
5
Violence risk
0 Intramural Supervised Unsupervised Transmural Transmural Discharge
leaves leaves first last
Treatment progress
HCR-SAPROF total Intramural vs. Discharge: t (123) = 8.95, d > 1.68, p < .001

14. Predictive validity violent incidents
n = 315 Clinical risk assessments
Violent incident rate
29% 15% 7% 3% Total
sample
35 HCR-20 34 incidents
SAPROF
30
HCR-SAPROF SAPROF (total) .77*
25
HCR-20 (total) .79*
20
15 HCR-SAPROF (total) .81*
10 FPJ no violence .70*
5 FRJ all violence .76*
0
Intramural Supervised Unsupervised Transmural n = 315, * p < .001
leaves leaves
Violence risk

15. The individual case

16. Changes in scores: theoretical
HCR-SAPROF scores of different risk assessments during treatment
30
25
20
Total score
15
10
5
0 Intramural Supervised Leaves Unsupervised Transmural Discharge
leaves
Treatment progress

17. Changes in scores: actual
N=1 HCR-SAPROF scores
Relapse Relapse
RA 1
30
RA 2
25 RA 3
RA 4
20 RA 5
Total score
RA 6
15
RA 7
10
5
0
Transmural theoretical Transmural actual
Treatment progress

18. Dynamics of risk assessment
HCR-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

19. Thank you!
Michiel de Vries Robbé /
Vivienne de Vogel / Ellen van den Broek
Van der Hoeven Kliniek
P.O. Box 174, 3500 AD Utrecht
mdevriesrobbe@deforensischezorgspecialisten.nl
vdevogel@deforensischezorgspecialisten.nl
evandenbroek@hoevenkliniek.nl