Index offense - Gewelddadige vrouwen

Gender issues in violence risk assessment
and treatment in forensic psychiatry
Vivienne
Vogel,
Susanne
de Haas,
Vivienne
dede
Vogel,
Jeantine
Stam,
Loes
Eline
Muller
Eva
de Hagenauw,
Spa & Michiel&de
Vries
Robbé
IAFMHS, Toronto, June 19, 2014
Ladykillers:
Hurricanes with female names deadlier
Symposium outline
Vivienne de Vogel, van der Hoeven Kliniek
Introduction, multicenter study
Susanne de Haas, van der Hoeven Kliniek
Gender differences in motivations for offending
Loes Hagenauw, FPK Assen
Female arsonists
Eline Muller, Pieter Baan Centrum
Case example
Violence risk factors and incidents
during treatment in female forensic
psychiatric patients: Results from a
Dutch multicenter study
Vivienne de Vogel
Van der Hoeven Kliniek
Presentation outline
• Female violence
• Results multicenter study
– Victimization
– Psychopathology
– Criminal characteristics
– Treatment
– Violence risk factors
Female violence
• Female violence seems to be on the rise
• Comparable prevalence rate men / women for:
– Inpatient violence
– Violence towards own children
– Intimate partner violence
• Intergenerational transfer
Nicholls et al., 2009; Serbin et al. 1998; De Vogel et al., 2012
Nature of violence by women
• Less visible: more domestic, less serious
physical injuries
• Different expression: more reactive and
relational; less sexual and instrumental
• Different motives: emotional, relational,
jealousy
Fusco, 2011; Nicholls et al., 2009
Violence risk assessment in women
• Significant differences men / women in the
expression of violence, violence risk factors and
manifestation of psychopathy
• Most tools developed / validated in males
• Questionable predictive validity tools
Are commonly used tools, like the HCR-20 or PCL-R
well enough suited for use in women?
Garcia-Mansilla et al., 2009; McKeown, 2010
Female Additional Manual (FAM)
• Additional guidelines to HCR-20 / HCR-20V3 for women:
– Additional guidelines to several Historical factors
(e.g., use of lower PCL-R cut-off score)
– New items and additional final risk judgments
• Preliminary results: promising reliability & predictive
validity for self-destructive behavior & violence to others
De Vogel et al., 2012; De Vogel, & De Vries Robbé, 2013
FAM Gender-specific items
Historical items
• Prostitution
• Parenting difficulties
• Pregnancy at young age
• Suicide attempt / selfharm
• Victimization after
childhood*
Clinical items
• Covert / manipulative
behavior
• Low self-esteem
Risk management items
• Problematic child care
responsibility
• Problematic intimate
relationship
* This item is no longer needed with HCR-20V3
Multicenter study
Characteristics of women in forensic psychiatry
Acknowledgments
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Gerjonne Akkerman-Bouwsema (GGz Drenthe)
Anouk Bohle (Van der Hoeven)
Yvonne Bouman (Oldenkotte)
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)
Multicenter study
Aims
•
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
Method
•
•
•
•
•
Five Dutch forensic psychiatric settings
Ongoing study
N > 300 female forensic psychiatric patients
N = 275 males matched on year of birth,
admittance, judicial status
Comprehensive questionnaire including several
tools (a.o., PCL-R, Historical items HCR-20 /
FAM and HKT-30) was coded based on file
information by trained researchers
General characteristics
N = 280 women
• 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
Criminal characteristics
N = 280 women
• 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
275 women versus 275 men
90
Men:
• Younger age first conviction
• More sexual offenses, less
arson
80
70
60
50
40
% Women
% Men
30
20
10
0
Convictions
Contact without
conviction
p < .01
Index offenses
N = 280 women
Index offenses
– Homicide
– Attempted homicide
– Arson
– Violent offenses
– Sexual offenses
25%
24%
29%
16%
4%
Victims of index offenses
– (ex) Partner
– Child(ren)
– Relatives / friends
– Treatment staff
– Stranger
20%
16%
39%
9%
16%
Index offenses
275 women versus 275 men
30
25
20
% Women
% Men
15
10
5
0
Homicide
Att.homicide
Arson
Violence
Sexual
All p < .001
Victims Index offenses
275 women versus 275 men
35
30
25
20
% Women
% Men
15
10
5
0
(ex)partner
Child (own)
family/acq.
supervisor
stranger
p < .001
Victimization
N = 280 women
High rates of victimization
• 72% was victimized during childhood
– Often by parent(s): 65%
– Often a combination of sexual, physical and
emotional abuse
• 54% was victimized during adulthood
– Often by (ex) partner(s): 82%
– Most often physical abuse
Victimization during childhood
275 women versus 275 men
70
60
50
40
% Women
% Men
30
20
10
0
Emotional Physical
Sexual
All three
p < .001
Victimization during adulthood
275 women versus 275 men
50
45
40
35
30
% Women
% Men
25
20
15
10
5
0
Emotional Physical
Sexual
All three
All p < .01
Psychopathology
N = 269 women
High rates of comorbidity
• 75% comorbid Axis I and II
• High rates of substance use problems: 67%
• Borderline personality disorder most prevalent:
59% + 21% traits
• Narcissistic PD least prevalent: 3%
• Psychopathy (PCL-R cut off of 23, FAM): 14%
Psychopathology
275 women versus 275 men
70
60
50
40
% Women
% Men
30
20
10
0
Borderline
Antisocial
Narcissistic
All p < .001
Treatment
N = 280 women
• Most had been in treatment before: 88%
• High treatment dropout in history: 76%
• Incidents during most recent treatment
–
–
–
–
–
–
–
Violence
Verbal violence / threats
Manipulative behavior
Self-destructive behavior
Arson
Victimization
Other
34%
47%
55%
47%
8%
8%
68%
Incidents during treatment
170 women versus 170 men
60
50
40
% Women
% Men
30
20
10
p < .01
0
Physical
Verbal
Covert
Self-destructive
Arson
Victimization
Violence risk factors HCR-20 / FAM
275 women versus 275 men
Men higher scores on:
– Previous violence
– Young age at first
violent incident
– Substance use
problems
– Psychopathy
– Problematic behavior
during childhood
Women higher scores on:
–
–
–
–
–
Prostitution
Parenting difficulties
Pregnancy at young age
Suicidality / self-harm
Victimization after
childhood
All p < .05
Predictive validity
Incidents during treatment (N = 280 women)
• FAM / HCR-20 Historical subscale score modest
predictor of physical violence, verbal violence /
threats, arson, transfer to another ward due to
problems (AUCs .67-.74)
• PCL-R total score modest predictor of
Manipulative behavior and verbal violence /
threats (AUCs .65-.68)
All p < .05
Predictive validity violent incidents
275 women versus 275 men
• FAM / HCR-20 Historical subscale score:
comparable predictive validity
• Best predictor for violent incidents:
– Women: Problematic behavior during childhood
– Men: Young age at first violent incident
• PCL-R total score better predictor violent
incidents for men than for women (AUC = .82 vs .68)
Subgroups
• Psychopathy
– Offenses: more ‘men like’, more often ‘bad’, less ‘sad’
– More treatment dropout and manipulative behavior
• Borderline Personality Disorder
– More severe victimization
– More incidents during treatment, dropout
• Intellectual disability
– More prostitution
– More stranger victims, less homicide
All p < .05
Conclusions and implications
• Overall, severely traumatized group with
complex psychopathology, high comorbidity,
many incidents during treatment
• Significant differences between women / men
and subgroups should lead to different or
adapted treatment strategies
Implications
• Gender-responsive treatment (e.g., more
attention to trauma, parenting skills)
• Clear policies (e.g., intimate relationships)
• Staff:
• Training, intervision, coaching
• Support considering high burden BPD
• Collaboration general psychiatry
Future studies
• Subgroups: e.g., offense type, diagnoses,
intellectual disability
• Effect on staff
• Effect on children
• Dynamic risk and protective factors
• Predictive validity tools for women
More information:
[email protected]
www.violencebywomen.com
Gender differences in
motivations for offending
Susanne de Haas
Van der Hoeven
After the crime has been committed
• Why did he/she do this? What motivates
people?
• Helpful
– Relapse prevention plan
– Offense analysis
– Decrease risk of recidivism?
• Object of research
Presentation outline
• The refined taxonomy
• Findings
– Reliability
– Motivations
 Most common motivations
 Index offences
• Conclusions and implications
• Future research
Taxonomy of motivations inspired by Coid (1998)
Mad
Psychotic, Compulsive urge to
harm/kill
Bad
Expressive aggression, Power
domination and control, Illicit gain,
Excitement, Undercontrolled
aggression
Sad
Cry for help/attention seeking,
(Extended) suicide, Despair,
Influenced by partner
Relational frustration
Revenge, Jealousy,
Threatened/actual loss, Displaced
aggression, Victim precipitation
Coping
Relief of tension/dysphoria,
Hyperirritability
Sexual
Paraphilia, Sexual gratification,
Sexual conflict
Reliability of the Clusters (n = 80)
• Fleiss’ Kappa
• Substantial:
– Mad (.68)
• Moderate:
–
–
–
–
–
Bad (.54)
Sad (.55)
Relational/social (.49)
Coping (.49)
Sexual (.56)
All p ≤ .001
Most common motivations (n = 436)
35
30
25
20
Women %
Men %
15
10
5
0
Mad
Bad
Sad
Relational/social
Coping
Sexual
Index offense and gender differences
• Index offenses:
–
–
–
–
–
Homicide
Attempted homicide
Sex offense
Arson
Violent offense
Index offense: Homicide
35
30
25
20
Women %
Men %
15
10
5
0
Mad
Bad
Sad
Relational/social
Coping
Sexual
p ≤ .05
Index offense: Attempted Homicide
40
35
30
25
Women %
Men %
20
15
10
5
0
Mad
Bad
Sad
Relational/social
Coping
Sexual
p ≤ .05
Index offense: Sex offense
60
50
40
Women %
Men %
30
20
10
0
Mad
Bad
Sad
Relational/social
Coping
Sexual
Index offense: Arson
50
45
40
35
30
Women %
Men %
25
20
15
10
5
0
Mad
Bad
Sad
Relational/social
Coping
Sexual
p ≤ .01
Index offense: Violent offenses
50
45
40
35
30
Women %
Men %
25
20
15
10
5
0
Mad
Bad
Sad
Relational/social
Coping
Sexual
p ≤ .05
Conclusions
Significant gender differences motivations
• In general:
– Men more by Bad and Sexual
– Women more by Sad and Relational/social
• Index offenses:
–
–
–
–
–
Homicide: Mad (m), Sad (w)
Attempted homicide: Bad (m)
Sex offense: no significant differences
Arson: Coping (m), Sad (w)
Violent offense: Sad and Relational frustration (w)
Implications
• Increase effectiveness treatment
• Decrease risk of recidivism
Suggestions future research
• Refine taxonomy into structured assessment
tool
• Other influencing factors
• Relationship Axis I and Axis II disorders
• Increase of effectiveness treatment and
decrease risk of recidivism
Thank
you
for
your
attention!
Thank you for your attention!
• Questions?
• Contact:
Susanne de Haas
[email protected] /
[email protected]
References
Coid, J.W. (1998). Axis II disorders and motivation for serious criminal behavior. In A.E. Skodol (Ed.) , Psychopathology
and violent crime (pp. 53-97). Washington, DC: American Psychiatric Press.
Fusco, S.L., Perrault, R.T., Paiva, M.L., Cook, N.E., & Vincent, G. (2011). Probation officer perceptions of gender
differences in youth offending and implications for practice in the field. Paper presented at the 4th International
Congress on Psychology and Law, Miami, March 2011.
Garcia-Mansilla, A., Rosenfeld, B. & Nicholls, T.L. (2009). Risk assessment: Are current methods applicable to women?
International Journal of Forensic Mental Health, 8, 50-61.
Klein Tuente, S., Vogel, V. de, & Stam, J. (2014). Exploring the criminal behavior of women with psychopathy: Results
from a multicenter study into psychopathy and violent offending in female forensic psychiatric patients. Manuscript
under review.
McKeown, A. (2010). Female offenders: Assessment of risk in forensic settings. Aggression and Violent Behavior, 15,
422-429.
Nicholls, T.L., Brink, J., Greaves, C., Lussier, P., & Verdun-Jones, S. (2009). Forensic psychiatric inpatients and
aggression: An exploration of incidence, prevalence, severity, and interventions by gender. International Journal of
Law and Psychiatry, 32, 23-30.
Serbin, L.A., Cooperman, J.M., Peters, P.L., Lehoux, P.M., Stack, D.M., & Schwartzman, A.E. (1998). Intergenerational
transfer of psychosocial risk in women with childhood histories of aggression, withdrawal, or aggression and
withdrawal. Developmental Psychology, 34, 1246-1262.
Vogel, V. de, & Vries Robbé, M. de (2013). Working with women. Towards a more gender-sensitive violence risk
assessment. In C. Logan, & L. Johnstone (Eds.), Managing Clinical Risk: A guide to effective practice (pp. 224-241).
London: Routledge
Vogel, V. de, Vries Robbé, M. de, Kalmthout, W. van & Place, C. (2012). Female Additional Manual (FAM). Additional
guidelines to the HCR-20 for the assessment of violent behavior by women. Utrecht, The Netherlands: Van der
Hoeven Kliniek.