Transcript Strengths focused Treatment

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 hero
William A F Browne
Dr Kirk!!
Assessing protective factors
The 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 risk
of future (sexual) violent behavior
in patients / offenders with a violent
history 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)
3 methods of risk assessment
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.
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 assessment
Advances
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
Rogers (2000): ‘Risk-only evaluations are
inherently inaccurate’.
More balance in risk assessment: complete
view of the offender
Positive approach motivating for both
offenders and treatment staff
Suggestions for improved risk management
COMMENTARY
The Uncritical Acceptance of Risk Assessment in
Forensic Practice
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.
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 upon
 What positive goals can be worked towards
 What 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
Any characteristic of a person,
his / her environment or situation,
which reduces risk of
future (sexual) violence
De Vogel, De Ruiter, Bouman, & De Vries Robbé (2009)
Risk &
Protection
Risk
factors
Risk
factors
Protective
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 Kliniek
Utrecht, The Netherlands
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: gradual through ‘transmural phase’
 Risk assessment in consensus
 HCR-20 & SAPROF (+SVR-20, FAM)
 Repeated regularly to inform treatment
Consensus model
 HCR-20
 SAPROF
 SVR-20 if sexual
offense
 FAM if female
Sociotherapist
Consensus
Treatment
supervisor
Researcher
Risk assessment at the
Van der Hoeven Kliniek
2001
2002
2003
2001: Implementation
HCR-20 & SVR-20
Consensus model
2004
2005
2006
2005: Risk assessment
mandatory in the
Netherlands
2007
2008
2009
2010
2011
2007: Implementation
SAPROF
2009: Implementation
START specific
short-term groups
2011: Implementation FAM
Female Additional Manual
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
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 SAPROF
Preconditions
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
Dutch
2008
2009
2010
2011
2012
2013
English
German
Spanish
Russian
SAPROFYV
Italian
French
English 2nd
Norwegian
Danish
Swedish
Chinese
Portuguese
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
SAPROF
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
+
Internal factors (static)
1.
Intelligence
 Level of intelligence (test results)
 Recent testing (max 6 years ago)
2.
Secure attachment in childhood
 Attachment with prosocial adult
 Based on file information before the age of 18
 Secure attachment + good example
Internal factors (dynamic)
3.
Empathy
 Empathy towards others (past/potential victims)
 Observation of behavior and emotions
4.
Coping
 Effective problem solving and conflict management skills
 Observation of behavior in daily life + self-rapport
5.
Self-control
 Impulse control and self restraining
in times of stress or temptation
 Self-control and perseverance
in self-discipline
Motivational factors
6.
Work
 Stable and suitable work
 Daily structure and personal development
 Paid/unpaid
7.
Leisure activities
 Structured
 Prosocial contacts, social control
 Daily structure and hobby
8. Financial management
Work •/ Steady
Leisure
activities not always protective
income (work or benefits)
… • Sound financial management, no debts
• Sufficient finances for living circumstances
Motivational factors
9. Motivation for treatment
 Insight in necessity, motivation for change
 Openness, cooperation and progress in treatment
10.
Attitudes towards authority
 Positive attitude, tolerance of authority
 Commitment to agreements and compliance with rules and
regulations
11.
Life goals
 Factors that provide meaning and positive life fulfillment
(extra motivation to do better)
 Religion, parenting, ambitions
12.
Medication
 Motivation for and compliance with medication
 Effectiveness of medication
External factors
13. Social network
 Prosocial and supportive
 Experienced support of family and
friends
14. Intimate relationship
• Duration and stability
• Quality
• Information from partner
External factors
15. Professional care
 Availability 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 factors
1. Intelligence
2. Secure attachment in
childhood
Dynamic improving factors
3. Empathy
4. Coping
5. Self-control
6. Work
7. Leisure activities
8. Financial management
9. Motivation for treatment
10. Attitudes towards authority
11. Life goals
12. Medication
13. Social network
14. Intimate relationship
Dynamic decreasing factors
15. Professional care
16. Living circumstances
17. 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.
Clinical experiences with the SAPROF
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?’
Van den Broek & De Vries Robbé (2008)
“The whole is greater than
the sum of its parts.”―
Aristotle
Overview SAPROF
Structured assessment of protective factors
Dynamic and positive addition to risk assessment
Good results research
Especially valuable for clinical practice
Increasingly personalized risk assessment
Positive treatment goals
Strengths based guidelines treatment planning
and risk management
There is nothing new under the sun