strengths focused treatment - dr karen richard and dr lisa cameron 2013
TRANSCRIPT
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Strengths focused Treatment
-Dr Karen Richard And Dr Lisa Cameron 2013
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plus ça change, plus c'est la même chose
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Pioneers of strength-focused approach
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Local heroWilliam A F Browne
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Dr Kirk!!
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Assessing protective factorsThe SAPROF
Michiel de Vries Robbé & Vivienne de Vogel Van der Hoeven Kliniek
SAPROF Workshop April 2012
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The concept of risk assessment
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What is risk assessment?
The assessment of the riskof future (sexual) violent behavior
in patients / offenders with a violenthistory and/or mental disorder
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What is violent behavior?
Violence is actual, attempted,or threatened harm
to one or more persons
Webster, Douglas, Eaves & Hart (1997)
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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.
3 methods of risk assessment
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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
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The concept of protective factors
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Violence risk assessmentAdvances
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.
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Importance of considering
protective factors
More balance in risk assessment: complete view of the offender
Positive approach motivating for both offenders and treatment staff
Suggestions for improved risk management
Rogers (2000): ‘Risk-only evaluations are inherently inaccurate’.
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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.
COMMENTARYThe Uncritical Acceptance of Risk Assessment in Forensic Practice
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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
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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”)
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What are protective factors?
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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 uponWhat positive goals can be worked towardsWhat 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)
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What are protective factors? SAPROF
De Vogel, De Ruiter, Bouman, & De Vries Robbé (2009)
Any characteristic of a person,his / her environment or situation,
which reduces risk offuture (sexual) violence
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Risk & Protection
Protective factors
Risk factors
Risk factors
Protective factors
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We all need protective factors
The more it rains (risk factors)the more protection we need
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Development of the SAPROF
Structured Assessment of PROtective Factors for violence risk
De Vogel, De Ruiter, Bouman, & De Vries Robbé (2007)
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Van der Hoeven KliniekUtrecht, The Netherlands
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Van der Hoeven KliniekUtrecht, The Netherlands
Forensic psychiatric hospital: 286 bedsMostly TBS order: involuntary treatment50/50 personality / psychotic disordersHolistic approach, emphasis on CBT & relapse
preventionTherapeutic community: taking responsibilityRehabilitation: gradual through ‘transmural phase’
Risk assessment in consensusHCR-20 & SAPROF (+SVR-20, FAM)Repeated regularly to inform treatment
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Consensus model
TreatmentTreatmentsupervisorsupervisor ResearcherResearcher
SociotherapistSociotherapist
ConsensusConsensus
HCR-20 SAPROF SVR-20 if sexual offense FAM if female
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Risk assessment at the
Van der Hoeven Kliniek
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
2001: Implementation HCR-20 & SVR-20 Consensus model
2009: Implementation START specific short-term groups
2005: Risk assessment mandatory in the Netherlands
2007: Implementation SAPROF
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
2011: Implementation FAM Female Additional Manual
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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
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Development SAPROFPreconditions
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
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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
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SAPROF Versions
2007 2008 2009 2010 2011 2012 2013
Dutch English German
Italian
Norwegian
Swedish
Portuguese
Spanish
French
Russian
English 2nd
Danish
Chinese
SAPROF-YV
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
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Coding the Coding the SAPROFSAPROF
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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
+
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1. IntelligenceLevel of intelligence (test results)Recent testing (max 6 years ago)
2. Secure attachment in childhoodAttachment with prosocial adultBased on file information before the age of 18Secure attachment + good example
Internal factors (static)
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Internal factors (dynamic)3. Empathy
Empathy towards others (past/potential victims)Observation of behavior and emotions
4. CopingEffective problem solving and conflict management skillsObservation of behavior in daily life + self-rapport
5. Self-controlImpulse control and self restraining
in times of stress or temptationSelf-control and perseverance
in self-discipline
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Motivational factors6. Work
Stable and suitable workDaily structure and personal developmentPaid/unpaid
7. Leisure activitiesStructuredProsocial contacts, social controlDaily structure and hobby
8. Financial management• Steady income (work or benefits)• Sound financial management, no debts• Sufficient finances for living circumstances
Work / Leisure activities not always protective …
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Motivational factors9. Motivation for treatment
Insight in necessity, motivation for changeOpenness, cooperation and progress in treatment
10. Attitudes towards authorityPositive attitude, tolerance of authorityCommitment to agreements and compliance with
rules and regulations
11. Life goalsFactors that provide meaning and positive life
fulfillment (extra motivation to do better)Religion, parenting, ambitions
12. MedicationMotivation for and compliance with medicationEffectiveness of medication
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External factors
13. Social networkProsocial and supportiveExperienced support of family
and friends
14. Intimate relationship• Duration and stability• Quality• Information from partner
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External factors
15. Professional careAvailability 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
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Theory of changing protection
Static protective factors1. Intelligence2. Secure attachment in childhoodDynamic improving factors3. Empathy4. Coping5. Self-control6. Work7. Leisure activities8. Financial management9. Motivation for treatment10. Attitudes towards authority11. Life goals12. Medication13. Social network14. Intimate relationship
Dynamic decreasing factors15. Professional care16. Living circumstances17. External control
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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.
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Blair Ghost Project
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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.
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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?’
Clinical experiences with the SAPROF
Van den Broek & De Vries Robbé (2008)
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“The whole is greater than the sum of its
parts.”― Aristotle
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Overview SAPROF
Structured assessment of protective factorsDynamic and positive addition to risk assessmentGood results researchEspecially valuable for clinical practice
Increasingly personalized risk assessmentPositive treatment goalsStrengths based guidelines treatment planning and risk management
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There is nothing new under the sun