Presentation Vivienne de Vogel, lecturer at HU University of Applied Sciences (Prato, 2018): Gender issues in violence risk assessment and treatment in forensic psychiatry

1. Vivienne de Vogel, Jeantine Stam,
Eva de Spa & Michiel de Vries RobbéVivienne de Vogel
Prato, May 2018
Gender issues in violence risk
assessment and treatment in
forensic psychiatry

2. I. Violent and antisocial behavior in women
II. Background women in forensic psychiatry
III. Risk assessment in women: Kelly
IV. Gender-responsive treatment
Presentation outline

3. I. Violent / antisocial behavior in females
Ladykillers:
Hurricanes with
female names
deadlier
• Stereotypes of women
• Compared to criminal / violent
men:
– More often seen as victim /
mentally disordered / acting
with male accomplice
– Tendency to treat female
offenders more leniently with
respect to arresting and
sentencing

4. • Rising numbers worldwide
• Intergenerational transfer
Children of violent / antisocial mothers: high risk of
multiple problems (criminal, mental health, addiction, risk
taking behavior)
• Recognition of victims of female offending
The experience of female perpetrated (sexual) abuse is
harmful and damaging. Sometimes reported by victims to
be even worse because it led to a deeper sense of
betrayal
De Vogel & Nicholls, 2016
Importance of more knowledge
female offenders

5. Dutch Multicenter project
Gender issues in forensic psychiatry, de Vogel et al., 2016
• Vivienne de Vogel (Van der Hoeven)
• Gerjonne Akkerman-Bouwsema (GGz Drenthe)
• Anouk Bohle (Van der Hoeven)
• Yvonne Bouman (Oldenkotte)
• Mieke Bruggeman (Van der Hoeven)
• 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)
• Five Dutch forensic settings
• 275 female and 275 matched male patients
• Different tools including HCR-20, HCR-20V3, FAM,
START, SAPROF, PCL-R

6. • 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

7. • Criminal history
• Motives for offending
• Victimization
• Psychopathy
• Borderline Personality Disorder
• Intellectual disability
• Violence risk assessment
Research topics
More information:
www.violencebywomen.com

8. • 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 female forensic patients

9. • 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 female forensic patients

10. Index offenses
275 women versus 275 men
0
5
10
15
20
25
30
Homicide Att.homicide Arson Violence Sexual
% Women
% Men
All p < .001

11. Victims Index offenses
275 women versus 275 men
0
5
10
15
20
25
30
35
(ex)partner Child (own) family/acq. supervisor stranger
% Women
% Men
p < .001

12. Most observed:
Psychotic 15%
Cry for help 13%
Revenge / jealousy 11%
(Threatened) loss 9%
Illicit gain 9%
Power / dominance / 8%
expressive agression
Motives
N = 280 female forensic patients

13. Most important differences male offenders:
1) Higher prevalence (sexual) trauma
2) Psychopathology: more complex, comorbidity
3) More internalising behavior
4) Longer treatment history
II Background female offenders
de Vogel & Nicholls, 2016

14. Victimization during childhood
275 women versus 275 men
0
10
20
30
40
50
60
Emotional Physical Sexual All three
% Women % Men
p < .001

15. Victimization during adulthood
275 women versus 275 men
0
5
10
15
20
25
30
35
40
45
Emotional Physical Sexual All three
% Women % Men
All p < .01

16. High rates of comorbidity
• 75% comorbid Axis I and II
• High rates of substance use problems: 67%
• Borderline personality disorder most prevalent
• Narcissistic PD least prevalent: 3%
Psychopathology
N = 269 women

17. Psychopathology
275 women versus 275 men
0
10
20
30
40
50
60
70
Borderline Antisocial Narcissistic
% Women
% Men
All p < .001

18. • 37% in treatment before age of 17
• Most had been in treatment before: 88%
• High treatment dropout in history: 76%
Treatment
N = 280 women

19. Incidents during treatment
170 women versus 170 men
0
10
20
30
40
50
Physical Verbal Covert Self-
destructive
Arson Victimization
% Women
% Men
p < .01

20. 78 Women discharged between 1993 and 2012:
• Mean follow up period 12.1 years (range 5-23)
• 9 (12%) admitted again to psychiatric setting
• 6 (8%) no recidivism data retrieved
• 14 (18%) deceased (mean age 44, range 29-59)
Possible explanations:
– History of substance abuse
– Severe self-harm / suicide
– Trauma: health problems
(e.g., Felitti, ACE study)
Follow up study
de Vogel, Bruggeman, & Lancel, 2017

21. • Recidivism rates
– All: 34%
– Violent: 18%
• Recidivists:
– Mean number of reconvictions: 5.5 (range 1-18)
– Significantly higher scores on risk assessment
tools
• Predictive validity risk assessment tools:
− Moderate to good for all recidivism
− Low for violent recidivism
Follow up study
Recidivism after discharge N = 71

22. III. Risk assessment in women

23. • Significant differences men / women in the
expression of violence / violence risk factors
• Mental health professionals of both gender
underestimate the risk of violence in women
• Most tools developed / validated in males
– Item descriptions focus on male (antisocial) behavior
– Questionable predictive validity tools for women
Violence risk assessment in women
Funk, 1999; Garcia-Mansilla et al., 2009; Levene et al., 2001; McKeown, 2010; Odgers et al.,
2005; Skeem et al., 2005

24. Specific tool for women needed?
• Ambiguous research results
• Need from daily practice:
– Growing population females
– Wish for more guidelines risk management / better
gender informed treatment
– Prevention: intergenerational transfer
• However: also considerable overlap in risk
factors for men and women
Additional guidelines to an internationally well
established violence risk assessment tool; the HCR-20
Adams, 2002; Guy & Douglas, 2006

25. Additional guidelines to the HCR-20 / HCR-20V3
for adult (forensic) psychiatric female patients
• Additional guidelines to several Historical risk factors
• New gender-specific risk factors
• Additional final risk judgments
− Self destructive behavior
− Victimisation
− Non-violent criminal behavior
Female Additional Manual (FAM)
Available: www.violencebywomen.com

26. Historical items
• Prostitution
• Parenting difficulties
• Pregnancy at young age
• Suicide attempt / self-
harm
Clinical items
• Covert / manipulative
behavior
• Low self-esteem
Risk management items
• Problematic child care
responsibility
• Problematic intimate
relationship
FAM Gender-specific items

27. Case Kelly
• Problematic childhood
– Depressive mother, father agressive when drunk
– Serious neglected
• Sexually abused
– 9-12 by a neighbour
– From12 by her brother
• Lonely, withdrawn, no education, alcohol abuse, self-harm
• Relations: (mutual) violence
• Marries at 23th, 2 children, many financial problems
• Index-offense: sexual abuse daughter with husband

28. Case Kelly
Treatment
• First year: many incidents, sexually inappropriate behavior,
complex relationships: constant supervision is needed
• Stabilisation
– Medication
– Individual ward, highly structured
– Trauma treatment: EMDR
• Development coping skills
• Yoga, creative arts
• Slow progression: motivation and self insigth, less incidents

29. Historical items
H1 Violence
H2 Other antisocial behavior
H3 Relationships
H4 Employment
H5 Substance abuse
H6 Major mental disorder
H7 Personality disorder
H8 Traumatic experiences
H9 Violent attitudes
H10 Treatment or supervision
reponse
Clinical items
C1 Insight
C2 Violent ideation or intent
C3 Symptoms of major mental
disorder
C4 Instability
C5 Treatment or supervision
reponse
Risk managment items
R1 Professional services and plans
R2 Living situation
R3 Personal support
R4 Treatment or supervision reponse
R5 Stress / coping
HCR-20V3 Kelly
Coding:
Yes, present
Partially / maybe
No, not present

30. Historical items
• Prostitution
• Parenting difficulties
• Pregnancy at young age
• Suicide attempt / self-
harm
Clinical items
• Covert / manipulative
behavior
• Low self-esteem
Risk management items
• Problematic child
care responsibility
• Problematic intimate
relationship
FAM Kelly
Coding:
Yes, present
Partially / maybe
No, not present

31. Internal factors
1. Intelligence
2. Secure attachment in childhood
3. Empathy
4. Coping
5. Selfcontrol
Motivational factors
6. Work
7. Leisure activities
8. Financial management
9. Motivation for treatment
10. Attitudes towards authority
11. Life goals
12. Medication
External factors
13. Social network
14. Intimate relationship
15. Professional care
16. Living circumstances
17. External control
Protective factors Kelly
SAPROF
Coding:
Not present
Partially / maybe
Present
Keys:
Motivation, Medication,
Professional care and
External control
Goals:
Coping, Selfcontrol,
Network
More info: www.saprof.com

32. Case Kelly
Risk assessment
• Risk factors
– Many historical factors
– Instability and Stress relevant dynamic risk factors
– FAM gender-specific factors: suicidality, low self-esteem, covert /
manipulative behavior, child care, future intimate relationship
• Protective factors: mostly external factors
– Important goals: coping skills, self control, daily structure (work
and network)
• Conclusion
– Context with mandatory treatment: risk of (sexual) violence to
others low to moderate, risk self destructive behavior: moderate
to high
– Long term / intensive treatment and supervision is needed.

33. Risk formulation Kelly
H8 Traumatic
experiences
H7 Borderline
C7 Low
selfesteem
H3 Relationships
Self
destructive
H5 Substance
abuse
(disinhibitor)
Agression
Sexual risky
behavior

34. IV Gender responsive treatment

35. • Gender-responsive treatment (e.g., more attention to
trauma, parenting skills, financial management)
• Awareness of the risk of revictimization in mixed
treatment settings
• Frequently conduct risk assessment
• Clear policies (e.g., intimate relationships)
• Staff:
• Training, intervision, coaching
• Support considering high burden BPD
• Collaboration general psychiatry
Gender responsive treatment

36. • Female forensic psychiatric patients: highly
traumatized group with complex
psychopathology
• Treatment is not an easy task …..
• Acknowledge gender-specific aspects
• Recognition for staff
• More research is needed
Overall conclusions Dutch studies

37. • Predictive validity
• Gender responsive treatment
• Impact on staff
• Impact on children
Future directions
More research in larger samples
and with multiple outcome
measures needed

38. Thank you
More information:
vdevogel@dfzs.nl
vivienne.devogel@hu.nl
www.violencebywomen.com