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Vivienne de Vogel, Jeantine Stam,
Eva de Spa & Michiel de Vries Robbé
Gender issues in violence risk assessment
and treatment in forensic psychiatry
Vivienne de Vogel, Susanne de Haas,
Loes Hagenauw, & Eline Muller
IAFMHS, Toronto, June 19, 2014
Ladykillers:
Hurricanes with female names deadlier
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
Symposium outline
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
• Female violence
• Results multicenter study– Victimization
– Psychopathology
– Criminal characteristics
– Treatment
– Violence risk factors
Presentation outline
• 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
Female violence
• 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
Nature of violence by 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
Garcia-Mansilla et al., 2009; McKeown, 2010
Violence risk assessment in women
Are commonly used tools, like the HCR-20 or PCL-R
well enough suited for use in women?
• 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
Female Additional Manual (FAM)
Historical items
• Prostitution
• Parenting difficulties
• Pregnancy at young age
• Suicide attempt / self-harm
• Victimization after childhood*
Clinical items
• Covert / manipulativebehavior
• Low self-esteem
Risk management items
• Problematic child care responsibility
• Problematic intimate relationship
FAM Gender-specific items
* This item is no longer needed with HCR-20V3
Multicenter study Characteristics of women in forensic psychiatry
• 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)
Acknowledgments
• 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
• 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
Multicenter study Method
• 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 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 N = 280 women
Criminal characteristics275 women versus 275 men
0
10
20
30
40
50
60
70
80
90
Convictions Contact without
conviction
% Women
% Men
Men:
• Younger age first conviction
• More sexual offenses, less arson
p < .01
Index offenses
– Homicide 25%
– Attempted homicide 24%
– Arson 29%
– Violent offenses 16%
– Sexual offenses 4%
Victims of index offenses
– (ex) Partner 20%
– Child(ren) 16%
– Relatives / friends 39%
– Treatment staff 9%
– Stranger 16%
Index offensesN = 280 women
Index offenses275 women versus 275 men
0
5
10
15
20
25
30
Homicide Att.homicide Arson Violence Sexual
% Women
% Men
All p < .001
Victims Index offenses275 women versus 275 men
0
5
10
15
20
25
30
35
(ex)partner Child (own) family/acq. supervisor stranger
% Women
% Men
p < .001
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
VictimizationN = 280 women
Victimization during childhood275 women versus 275 men
0
10
20
30
40
50
60
70
Emotional Physical Sexual All three
% Women
% Men
p < .001
Victimization during adulthood275 women versus 275 men
0
5
10
15
20
25
30
35
40
45
50
Emotional Physical Sexual All three
% Women
% Men
All p < .01
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 N = 269 women
Psychopathology275 women versus 275 men
0
10
20
30
40
50
60
70
Borderline Antisocial Narcissistic
% Women
% Men
All p < .001
• Most had been in treatment before: 88%
• High treatment dropout in history: 76%
• Incidents during most recent treatment– Violence 34%
– Verbal violence / threats 47%
– Manipulative behavior 55%
– Self-destructive behavior 47%
– Arson 8%
– Victimization 8%
– Other 68%
Treatment N = 280 women
Incidents during treatment170 women versus 170 men
0
10
20
30
40
50
60
Physical Verbal Covert Self-destructive Arson Victimization
% Women
% Men
p < .01
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
Violence risk factors HCR-20 / FAM 275 women versus 275 men
All p < .05
• 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 Incidents during treatment (N = 280 women)
• 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)
Predictive validity violent incidents
275 women versus 275 men
• 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
Subgroups
All p < .05
• 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
Conclusions and 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
Implications
• Subgroups: e.g., offense type, diagnoses,
intellectual disability
• Effect on staff
• Effect on children
• Dynamic risk and protective factors
• Predictive validity tools for women
Future studies
More information:
www.violencebywomen.com
Gender differences in
motivations for offending
Susanne de Haas
Van der Hoeven
• Why did he/she do this? What motivates
people?
• Helpful
– Relapse prevention plan
– Offense analysis
– Decrease risk of recidivism?
• Object of research
After the crime has been committed
• The refined taxonomy
• Findings– Reliability– Motivations
Most common motivations Index offences
• Conclusions and implications
• Future research
Presentation outline
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
• Fleiss’ Kappa
• Substantial: – Mad (.68)
• Moderate: – Bad (.54)– Sad (.55)– Relational/social (.49)– Coping (.49)– Sexual (.56)
All p ≤ .001
Reliability of the Clusters (n = 80)
Most common motivations (n = 436)
0
5
10
15
20
25
30
35
Mad Bad Sad Relational/social Coping Sexual
Women %
Men %
• Index offenses:
– Homicide
– Attempted homicide
– Sex offense
– Arson
– Violent offense
Index offense and gender differences
0
5
10
15
20
25
30
35
Mad Bad Sad Relational/social Coping Sexual
Women %
Men %
Index offense: Homicide
p ≤ .05
0
5
10
15
20
25
30
35
40
Mad Bad Sad Relational/social Coping Sexual
Women %
Men %
Index offense: Attempted Homicide
p ≤ .05
0
10
20
30
40
50
60
Mad Bad Sad Relational/social Coping Sexual
Women %
Men %
Index offense: Sex offense
Index offense: Arson
0
5
10
15
20
25
30
35
40
45
50
Mad Bad Sad Relational/social Coping Sexual
Women %
Men %
p ≤ .01
Index offense: Violent offenses
0
5
10
15
20
25
30
35
40
45
50
Mad Bad Sad Relational/social Coping Sexual
Women %
Men %
p ≤ .05
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)
Conclusions
• Increase effectiveness treatment
• Decrease risk of recidivism
Implications
• 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
Suggestions future research
Thank you for your attention!
• Questions?
• Contact:
Susanne de Haas
Thank you for your attention!
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
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