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FAM
Vivienne de Vogel
Michiel de Vries Robbé
Willemijn van Kalmthout
Caroline Place
Female Additional Manual
Additional guidelines to the HCR-20V3 for
assessing risk for violence in women
FAM
Additional guidelines to the HCR-20v3 for
assessing risk for violence in women
For more information or to order the FAM please go to:
www.violencebywomen.com
For more information please contact one of the two authors below:
Vivienne de Vogel / Michiel de Vries Robbé
Van der Hoeven Kliniek
PO Box 174
3500 AD Utrecht
The Netherlands
+31(0)30-2758275
vdevogel@hoevenkliniek.nl
mdevriesrobbe@hoevenkliniek.nl
Copyright © 2014, Van der Hoeven Kliniek
Cover: Idefix Vormgeving & Communicatie
Design: www.studiosnh.nl
ISBN: 978-90-79649-29-7
FAM
Female Additional Manual
Additional guidelines to the HCR-20v3 for
assessing risk for violence in women
Vivienne de Vogel
Michiel de Vries Robbé
Willemijn van Kalmthout
Caroline Place
Table of contents
Preface from the authors
6
Preface 8
Introduction 13
Part I Background Risk assessment according to the SPJ approach Violence by women Violence risk assessment of women Use of risk assessment tools with women Protective factors in women Gender-responsive treatment The need for a gender-sensitive tool 15
15
16
19
21
24
25
26
Part II The FAM Development Aims Definition of violence Applications User qualifications
Coding procedure Research Limitations 29
32
34
34
35
35
35
41
43
Definition of the risk factors
45
Historical items H7 Personality disorder: additional guidelines to the HCR-20V3 H8 Traumatic experiences: additional guidelines to the HCR-20V3
H11 Prostitution H12 Parenting difficulties H13 Pregnancy at young age H14 Suicidality / self-harm 47
50
52
54
56
58
60
4
Clinical items C6 Covert / manipulative behavior C7 Low self-esteem 63
65
68
Risk management items R6 Problematic child care responsibility R7 Problematic intimate relationship 71
72
74
Coding sheet Coding scheme FAM Coding sheet Female Additional Manual (FAM) 77
78
References 81
Appendixes Appendix 1: Additional guidelines to HCR-20V3 items in the FAM Appendix 2: Specific risk factors for women in the FAM in addition
to the HCR-20V3 97
98
5
Preface from the authors
This is the Female Additional Manual (FAM), a tool with additional guidelines to
the HCR-20V3 for assessing risk for violence in women who have demonstrated
violent behavior before. Several risk factors for violent behavior in women differ
substantially from those in men. Mental health professionals have recognized
these differences and have expressed the need for more specific guidelines for
risk assessment in women (see also Adams, 2002).
In 2007, the idea was proposed to develop a more gender-sensitive risk
assessment tool and subsequently conduct research into the psychometric
properties and clinical value of this tool for use with female (forensic) psychiatric
patients. The internationally widely used HCR-20 was used as a basis because we
believed that although the tool as a whole is not strongly predictive for violence
in women (Schaap, Lammers, & De Vogel, 2009; De Vogel & De Ruiter, 2005),
most of the items included in the HCR-20 / HCR-20V3 are important for women.
The authors of the HCR-20 / HCR-20V3 are known with and supportive of the
development of the FAM.
The FAM was originally developed as an additional manual to the HCR-20. The
new version of the HCR-20, the HCR-20V3 (Douglas, Hart, Webster, & Belfrage,
2013) was published in 2013. Two of the FAM authors (Vivienne de Vogel and
Michiel de Vries Robbé; see De Vogel, Van den Broek, & De Vries Robbé, 2014)
have been involved in a pilot project into the HCR-20V3 and in the translation of
the tool into Dutch. When developing the FAM, the authors were already familiar
with the draft (items) of the HCR-20V3 and took the changes from the HCR-20 to
the HCR-20V3 into account as much as possible. With adaptations, the original
FAM can also be applied as an additional manual to the HCR-20V3. The present
manual is completely adapted to be used with only the HCR-20V3. Furthermore,
in the present manual we added recent research results from an ongoing Dutch
multicentre study (see De Vogel, Stam, Bouman, Van der Horst, & Lancel, 2014)
and some more information on violence towards children. No major changes
were made to the items. We would like to refer to the website for updates and
recent research results: www.violencebywomen.com.
6
The goal of the FAM is to provide mental health professionals with more concrete
guidelines for gender-sensitive risk assessment and management for women in
forensic psychiatry, but possibly also in general psychiatry or in the penitentiary
system. We hope that the tool will be valuable for daily practice, in the way that
it provides improvements for violence risk assessment in women and concrete
guidelines for risk management. The FAM should be seen as work in progress;
there is not yet sufficient evidence for the predictive validity of (the factors in)
this tool for repeated violence in women and research into this topic is strongly
needed. Although the FAM is still in development and should be interpreted with
great caution, we believe that the combination of the HCR-20V3 and the FAM can
be considered as best practice and that there is presently no suitable alternative
available for the assessment of violence risk in adult women.
We would like to thank all mental health professionals from the Van der Hoeven
Kliniek who contributed to the development of the FAM. Jeantine Stam has
made an important contribution to the development of the FAM with her master
research study on the FAM Research Version and more recently with her work
for the multicentre study. We also kindly thank Duncan Greig for his valuable
assistance with the English translation of the FAM.
Finally, we welcome all comments and suggestions regarding the FAM or the
subject of (risk assessment for) violence in women, as this may help us to improve
and refine gender-sensitive risk assessment with the FAM.
Vivienne de Vogel, Michiel de Vries Robbé, Willemijn van Kalmthout and
Caroline Place
September 2014
7
Preface
It is a considerable honour and a pleasure to be invited to write a preface for
the Female Additional Manual (FAM). Although it has long been passionately
discussed in the literature (Correctional Service of Canada, 1990; Corston,
2007), few concrete advances have been achieved to address concerns that the
assessment, classification, management, and treatment of women offenders
require gender-informed approaches. Increasingly, a light has been shone on
the urgent need to include women in research samples and disaggregate data
whenever possible (e.g., Canadian Institutes of Health Research, 2011). It is
evident such efforts have had some success as the literature on female offending
is burgeoning (Blanchette & Brown, 2006; Gendreau, Little, & Goggin, 1996;
Zaplin, 2008) but those findings have been slow to be translated in advances in
clinical practice. In particular, there has been considerable debate with regard
to the extent to which clinicians working with women can comfortably rely on
currently available risk assessment measures, ostensibly constructed with men
in mind (Garcia-Mansilla, Rosenfeld, & Nicholls, 2009). Yet, with the exception of
the Early Assessment Risk List for Girls (see Augimeri, Enebrink, Walsh, & Jiang,
2010), measures developed from the outset to inform evaluations with female
populations at risk for violence are nonexistent.
The lack of empirically validated woman-centered practices in the violence
risk assessment and risk management field largely reflects the fact that female
violence is widely acknowledged to be a problem of a much smaller magnitude
than that of male violence. As De Vogel and her co-authors remind us, on the
whole, the data unequivocally support this conclusion. Gender is regarded as one
of the best predictors of violent and criminal behaviour (Monahan et al., 2001).
Worldwide, women represent a small proportion of individuals who perpetrate
violence and as such they are found in much smaller numbers within offender
and institutionalized populations of relevance to violence risk assessments
(e.g., ~10% of inpatient forensic hospitals). The gender disparity in incarceration
rates is particularly large for violent crimes. For instance, in the United Kingdom,
the total prison population is comprised of 6.1% women, 17% of whom were
incarcerated for violent offences (Home Office, 2003), these proportions are
highly consistent with other Western nations (Nicholls, Greaves, & Moretti, 2008).
Acknowledging that men are by far the predominant perpetrators of violence
and offending does not, however, overshadow the relevance and necessity
of evidence-informed practice in the assessment of women’s risk for violence.
8
The number of women who are the focus of violence risk assessments is
not insubstantial, particularly if one considers the diverse populations and
settings in which risk for violence is considered (jails, prisons, forensic and civil
psychiatric inpatient and community settings) (e.g., women represent ~40%
of civil psychiatric inpatients). It has been widely acknowledged that violence
risk assessments are a well-entrenched aspect of mental health law and firmly
rooted in the responsibilities of diverse mental health professionals and allied
disciplines. There is little question that these assessments invariably have
significant ramifications, regardless the gender of the individual being assessed
(see Melton, Petrila, Poythress, & Slobogin, 2007).
In addition to the wide-ranging demand for violence risk evaluations, as the
authors of the FAM demonstrate, research reveals ever-increasing numbers
of girls and women being charged and incarcerated for criminal offences.
Data across international borders suggests the growth rate in the number of
individuals in prisons and jails is substantially higher among women than among
men (Nicholls et al., 2008). For instance, the proportion of Canadian women
charged with criminal offences has increased steadily over the past three decades,
up from 15% in 1979 to 21% in 2009 (Hotton-Mahony, 2011). These increases in
female offending tend to be relatively small once population growth is taken into
account but it is noteworthy that they often are seen in parallel with decreasing
rates of male offending (e.g., Federal Bureau of Investigation [FBI], 2005).
As the number of women in conflict with the law has continued to rise there
has been an increasingly urgent call from decision makers (Auditor General
of Canada, 2003), and academics alike (Hannah-Moffat, 2004; Webster & Doob,
2004) to avoid what some consider systematic bias against minority groups
(women as well as ethnic minorities) in violence risk assessments. Many have
been calling for a ‘woman-wise’ agenda for decades (Carlen, 1985; see Heilbrun
et al., 2008). As De Vogel and her colleagues demonstrate so clearly in the
FAM, there likely is considerable overlap in the variables of relevance to risk
assessments with men and women; hence the value of the FAM as an ‘add on’ to
the existing HCR-20 violence risk assessment scheme (Webster, Douglas, Eaves,
& Hart, 1997). However, they remind us that not only does the rate of women’s
offending differ dramatically from that of men, in many ways the form and
function of women’s violence is unique (Nicholls et al., 2008). This suggests that
the outcome criterion of interest may differ in meaningful ways when assessing
violence risk in men versus women. Women tend to be arrested for different
offences than men (embezzlement, prostitution; FBI, 2005, 2006). In fact, some
9
crimes are virtually unique to women (neonaticide) or men (uxoricide) or at least
the rate of offending is drastically differentiated by the sex of the perpetrator. For
instance, sexual offending (4-5% are women, Cortoni & Hanson, 2005), stalking
(15-20% are women, Meloy & Boyd, 2003) and familicide (95% of perpetrators
are male, Wilson, Daly, & Daniele, 1995) are predominantly perpetrated by
one gender or the other. In contrast, other forms of violence are more evenly
distributed across the sexes (e.g., child abuse, partner abuse, Archer, 2000; Hamel
& Nicholls, 2007). In addition, women’s violence most often is less chronic and on
average their offences are predominantly of a minor nature when compared to
their male counterparts (Nicholls et al., 2008).
When they are involved in violence, the victims of women’s offences and the
circumstances of their offending often also differ from that of men (HottonMahony, 2011; Monahan et al., 2001; Morash, Bynum, & Koons, 1998). Although
recent research suggests that perhaps women’s changing societal roles and
socialization may be decreasing these differences (Weizmann-Henelius, 2006).
Unlike men, women do not generally commit crimes in pairs or in groups, they
are less likely to use weapons, and these differences translate into lower out
of pocket expenses and fewer injuries for their victims (e.g., Greenfield & Snell,
1999; Kruttschnitt, Gartner, & Ferraro, 2002). Commentators also contend that
the motivations that drive the timing and nature of women’s offending often
are unique from that of men (Zaplin, 2008). In sum, the context (Triplett & Myers,
1995) or ‘gestalt’ of offences varies by the sex of the perpetrator and these
discrepancies are asserted to increase as the severity of the offence increases
(Daly, 1994; Zaplin, 2008).
As the FAM authors articulate, men and women do share many risk factors, but
even then gender differences often are evident suggesting these variables may
carry differential significance (Nicholls et al., 2008). Women tend to present
with more severely dysfunctional backgrounds reflected in exceptional service
needs even compared to male offenders who also present with high rates of
disadvantage and victimization histories (e.g., disproportionately high rates of
sexual and physical abuse, mental illness, drug abuse, adulthood victimization)
(Abram, Teplin, & McClelland, 2003; Browne, Miller, & Maguin, 1999; Morash et
al., 1998; Teplin, Abram, McClelland, 1996). There also is substantial evidence
to support a consideration of feminine-specific risk factors that may have a
causal relationship with girls’ and women’s entries into aggressive and antisocial
behaviour. The research suggests that different pathways may bring men and
women into contact with the justice system (Holtfreter & Cupp, 2007; Salisbury
10
& Van Voorhis, 2009) or that the threshold for the risk of antisocial behavior may
be met earlier on in boys than in girls (Moffit & Caspi, 2001). For these reasons,
additional variables or differing critiera may be required to inform violence
assessments as well as prevention and intervention planning to ensure successful
recovery in females. Finally, there is a measure to support such efforts.
Van Voorhis and Presser (2001) completed interviews with representatives
of 50 US state correctional agencies and the Federal Bureau of Prisons (Feb to
May, 2000) and found that a resounding 92% of respondents asserted that
women have unique needs that should be addressed in correctional settings.
Yet, Hardyman and Van Voorhis (2004) demonstrated that many agencies still
rely on gender-neutral assessments for women. The absence of a validated
gender-informed risk assessment model has had unknown but potentially
dramatic implications for our efforts to successfully prevent and treat women’s
crime and violence. As I noted, many clinicians, academics, and decision-makers
have decried the absence of ‘woman-centered’ services (Pollack, 2005) but
experts caution that there is an absence of a strong empirical basis to support
novel ‘gendered’ approaches (Heilbrun et al., 2008; Zaplin, 2008; though see
Van Voorhis, Salisbury, Wright, & Bauman, 2008). The FAM authors’ cautious
recommendations in the FAM and its intended use in concert with the HCR-20
therefore represents a very welcome measured and responsible approach to
introducing a gendered risk assessment measure to the field.
Despite forty years of progress, a critical limitation in the violence risk assessment
field to date has been the failure to integrate our knowledge of the unique
offending trajectories and profile of women offenders into risk assessment
and risk management research and clinical practice in a systematic way. There
also remains a pressing need to test the implications of efforts to optimize
predictive accuracy (i.e., do female specific risk items add incremental validity
over established risk items). The FAM is one in a long series of exceptional
contributions from De Vogel and her colleagues at the Van der Hoeven Kliniek.
This manual represents a pioneering effort to advance forensic mental health
services. It simultaneously opens up new opportunities for research, potentially
presents an innovation over existing assessment approaches, and provides
possible avenues for improving clinical outcomes with at risk women.
Tonia L. Nicholls, PhD
University of British Columbia / BC Mental Health and Addiction Services
January 2012
11
12
Introduction
While women still represent a minority of the forensic psychiatric and prison
population, worldwide the number of women committing violent crimes has
increased steadily over the past two decades, especially among young girls. In
addition, some types of violence, such as intimate partner violence and inpatient
violence by psychiatric patients are as common in women as in men (see Violence
by women). There are growing concerns, however, about whether the theoretical
knowledge we have on violence in men and on violence risk assessment and
management in men is sufficiently valid and useful for women. Research has
demonstrated that different risk factors may be important for women compared
to men and that the present risk assessment tools are not sufficient for predicting
violence in women (see Violence risk assessment in women).
In 2007, the idea was proposed in the Van der Hoeven Kliniek to develop a
gender-sensitive risk assessment tool. The Van der Hoeven Kliniek is a 262-bed
forensic psychiatric hospital in the Netherlands admitting both male and female
patients, mostly suffering from personality disorders (see for more information
about this hospital Van Binsbergen, Keune, Gerrits, & Wiertsema, 2007; www.
hoevenkliniek.nl). Most patients are admitted because of a tbs-order, which is
a Dutch judicial measure implying compulsory inpatient psychiatric treatment
(see for more information Van Marle, 2002). Females constitute approximately
20 percent of the patient population, and men and women live on mixed wards.
Previous research within this setting into the value of the internationally widely
used risk assessment tool for violence, the Historical Clinical Risk management-20
(HCR-20; Webster, Douglas, Eaves, & Hart, 1997) and of the Psychopathy
Checklist-Revised (PCL-R; Hare, 2003) in both female and male patients has
demonstrated that both tools have good predictive validity for violence for
men, but questionable predictive power in women (De Vogel & De Ruiter, 2005).
These results are comparable with international findings (see Garcia-Mansilla,
Rosenfeld, & Nicholls, 2009). More recently, however, greater effect sizes were
found in samples containing higher proportions of women (O’Shea, Mitchell,
Picchioni, & Dickens, 2013). Considering the equivocal results on the value of
risk assessment tools for violence in women and the wish from mental health
professionals for more specific knowledge on violence risk assessment in women,
we decided to formulate a tool with gender-sensitive risk assessment guidelines
and subsequently conduct studies into the psychometric properties and clinical
value of this tool. Because of the considerable level of similarity in risk factors
for men and women (see also Guy & Douglas, 2006), we chose not to create a
completely new risk assessment tool for women but instead use the HCR-20 as
13
a basis. The result was an additional manual to the HCR-20 for the assessment of
risk for violence in adult women who have shown violent behavior before: the
Female Additional Manual (FAM). In 2013, the revision of the HCR-20 has been
published; the Historical, Clinical, Risk Management Version 3 (HCR-20V3; Douglas,
Hart, Webster, & Belfrage, 2013). Initiallly, the FAM was designed as an additional
manual to the HCR-20, but the present manual is to be applied as an addition
specifically to the HCR-20V3.
In Part I Background the method of risk assessment according to the Structured
Professional Judgment (SPJ approach is briefly discussed. Next, the literature
into violence by women, risk and protective factors for violence in women, the
application of risk assessment tools in women and gender-responsive treatment
will be summarized. The central focus in this literature review is to determine
whether a specific risk assessment tool for women is needed or desirable. In Part
II The FAM, the development and coding procedure of the FAM will be described
as well as the actual coding instructions of specific risk factors for women and
the additional guidelines for women to two HCR-20V3 items.
14
Part IBackground Risk assessment according to the SPJ approach
Like the HCR-20V3, the FAM provides guidelines for violence risk assessment
according to the Structured Professional Judgment (SPJ) approach. In the mid1990’s, researchers from Simon Fraser University in Vancouver, Canada developed
the SPJ model. Their goal was to bridge the gap between clinical practice and
empirical knowledge by developing a guideline for violence risk assessment
that structures clinical judgment – and thus increases interrater reliability and
validity – and can be used by trained mental health professionals in their day-today practice. In the SPJ model, risk factors are critically examined, combined, and
integrated in order to reach a conclusion.
The best-known checklist based on this model is the HCR-20 (Webster et al.,
1997) for the assessment of risk for violent behavior. Research in different settings
and countries has demonstrated that the HCR-20 can be used reliably and validly
(see for a comprehensive summary of research results: Douglas, Guy, & Weir,
2006; Douglas & Reeves, 2010; www.hcr-20.com). The Dutch HCR-20 has been
implemented in several forensic psychiatric hospitals in The Netherlands. In one
of these, the Van der Hoeven Kliniek, a research program into the value of the SPJ
model for forensic clinical practice was conducted. The studies in the program
provided strong support for the SPJ method of violence risk assessment in Dutch
forensic clinical practice (De Vogel, 2005; see also De Vogel, Van den Broek, &
De Vries Robbé, 2014). For men, the HCR-20 has demonstrated good interrater
reliability and predictive validity for violent recidivism after discharge as well as
for violent incidents during treatment, and predicts significantly better than does
unstructured clinical judgment. For women, significant predictive validity was
only found for the final risk judgment and not for the HCR-20 scores (De Vogel
& De Ruiter, 2005). In 2013, the official HCR-20V3 was published (Douglas et al.,
2013), as well as the Dutch version of the HCR-20V3 (De Vogel, De Vries Robbé,
Bouman, Chakhssi, & De Ruiter, 2013), which was immediately implemented in
the Van der Hoeven Kliniek.
Two recently developed SPJ tools are mentioned here because of their influence
on the development of the FAM: the Structured Assessment of PROtective Factors
for violence risk (SAPROF; De Vogel, De Ruiter, Bouman, & De Vries Robbé, 2009,
2012) and the Short-Term Assessment of Risk and Treatability (START; Webster,
Martin, Brink, Nicholls, & Middleton, 2004; Webster, Martin, Brink, Nicholls, &
Desmarais, 2009). The SAPROF is a recently developed tool for the assessment of
protective factors intended to be used in conjunction with SPJ risk assessment
15
tools such as the HCR-20. This tool has been in use in the Van der Hoeven Kliniek
since 2007 and the results thus far with respect to interrater reliability and
predictive validity are good (De Vries Robbé, 2014). The START is a tool for shortterm assessment of risks and treatability that is fully dynamic. In the START, not
only is the risk for violence to others evaluated, but as are the specific risks such
as risk for self-harm, suicide, unauthorized leave, substance abuse, self-neglect,
and being victimized.
Violence by women
Prevalence of violence
Women commit fewer violent offenses than men, and ‘being male’ is one of
the best predictors of violent and criminal behavior (Archer & McDaniel, 1995;
Monahan et al., 2001). Although women constitute a minority within the prison
system and in forensic psychiatry, it seems that violent behavior by girls and
women is on the rise (Batchelor, 2005; Blackburn & Trulson, 2010; Heilbrun et al.,
2008; Meichenbaum, 2006; Odgers, Moretti, & Reppucci, 2005; Pollock & Davis,
2005; Weizmann-Henelius, Viemerö, & Eronen, 2004). In a recently published
Dutch study on juvenile delinquency between 1996 and 2007 it was found
that although the proportion of male offenders is still clearly greater than the
proportion of female offenders, offense rates for girls / women increased more
(Van der Laan, Blom, Tollenaar, & Kea, 2010). Between 2002 and 2007, offense
rates (convictions) increased 33% for 12-17 year old girls, and 48% for 18-24 year
old women (for boys / men there was an increase of 19% and 20%, respectively).
This refers to all forms of offenses, but violent offenses in particular increased
sharply (see also Chesney-Lind & Pasko, 2004). A possible explanation for the
increase in violent offenses by females is the emancipatory explanation; the
catching up of girls with boys. It should be noted that changes in policies, police
efforts, or changes in societal toleration for girls’ and women’s behavior may
be skewing the data on increased female violence (Hawkins, Graham, Williams,
& Zahn, 2009; Willison & Lutter, 2009). On the other hand, it is still true that in
general there is a tendency to treat female offenders more leniently than male
offenders, specifically with respect to arresting and sentencing (e.g., see Jeffries,
Fletcher, & Newbold, 2003).
Nature of violence
Research has shown that in general, the nature, severity, frequency, and victim
characteristics of violent offenses committed by women are significantly
different from those committed by men. Overall, female violence less often
16
results in serious injuries and is less visible and more subtle, manifesting more
often as relational violence, child abuse, or violence towards relatives (Monahan
et al., 2001; Nicholls, 2001; Robbins, Monahan, & Silver, 2003). The most common
victims of violence by adult women are partners or child(ren) and the most
common victims by girls are brothers / sisters and peers (Batchelor, 2005).
Violence by women is more reactive, indirect, less instrumental and occurs
more commonly within the context of social relationships and less instrumental
compared to men (Crick & Grotpeter, 1995; Monahan et al., 2001; Nicholls,
2001; Odgers et al., 2005; Robbins et al., 2003). Several explanations for this are
discussed in the literature (see for a comprehensive review Bennett, Farrington,
& Huesman, 2005). A commonly cited explanation is the different method of
socialization, whereby boys are encouraged to act assertively while girls are
encouraged to bond with others (see for example Brownie, 2007). In adulthood,
women are more likely to describe themselves in terms of their relationship with
others than in terms of their individual characteristics (Cross & Madson, 1997).
Furthermore, women seem to have different motives for violent offenses; female
violence is more often reactive and relational and less often characterized as
instrumental (Crick & Grotpeter, 1995; Monahan et al., 2001; Nicholls, 2001;
Odgers et al., 2005; Robbins et al., 2003). Claimed motives for violence by women
are, for example, jealousy, self-defense and feeling disrespected by the other
(Kruttschnitt & Carbone-Lopez, 2006). Women compared to men are more likely
to use knives or so-called personal weapons, such as hands and teeth when they
commit violence (Koons-Wit & Schram, 2003). Motives for offenses committed
by girls were more often seen in the social sphere or within relations (revenge,
jealousy and gossip) than in boys. In a recent U.S. study of the explanations for
violent offenses by girls as seen by probation officers, the three most frequently
cited explanations for girls were: 1) emotional outburst; 2) relational violence;
and 3) history of abuse (Fusco, 2011). For boys, these three explanations were
not once mentioned. The three most frequently cited explanations for violent
offenses for boys were: 1) ego driven; 2) peer pressure; and 3) survival.
Summarizing, violence by women is in general different in nature than violence
by men. Research, however, also demonstrated that there is a subgroup of girls/
young women who seem to show more ‘masculine’ forms of violence. In this
subgroup of females, instrumental aggression, hostility, committing robberies
and criminal gang membership is more prevalent (Babcock, Miller, & Siard, 2003;
Batchelor, 2005; Bottos, 2007; MacKenzie & Johnson, 2003).
17
Five specific types of violence by women are discussed more in detail below.
1. Intimate partner violence
Intimate partner violence is the most studied form of violence committed by
women. Research has demonstrated that the prevalence rate of intimate partner
violence of women is comparable to or even higher than that of men (Adams,
2002; Magdol et al., 1997; Straus, 2008). However, violence by women in intimate
relationships is less likely to lead to serious injury (Archer, 2000; Meichenbaum,
2006). Some researchers argue that violence by women towards the partner is
almost always a response to previous violence by the male partner (Allen, Swan,
& Raghavan, 2009; Swan & Snow, 2006). Others, however, found few differences
between men and women regarding the prevalence of and motives for intimate
partner violence (Archer, 2000; Carney, Buttell, & Dutton, 2007; McFarlane,
Willson, Malecha, & Lemmey, 2000).
2. Violence towards own children
It has been suggested in the literature that overall prevalence rates of violence
towards (step)children do not significantly differ between mothers and fathers.
Moreover, certain types of violence towards children, like neonaticide (killing of
a baby younger than 24 hours), infanticide (killing of a baby younger than one
year), and Münchausen by Proxy syndrome (deliberately inducing or feigning
health problems in a child to gain attention) are almost exclusively committed
by mothers. Differences have been found between women and men killing their
own child. Mothers were more often diagnosed with depression and psychoses,
were more often suicidal and more often had a history of severe abuse. Fathers
more often had financial problems and alcohol abuse problems (Putkonen et al.,
2010; Verheugt, 2007). Usually, the victims of fathers were older than victims of
mothers and the offense more often concerned a familicide. Fathers were more
often held criminally responsible by the court for their offense compared to
mothers.
3. Sexual violence
The literature on sexual violence by women is rather limited. Research has
demonstrated that women form only a small proportion of the total sex offender
population (between 4-5%; Cortoni, Hanson, & Coache, 2010; Gannon & Cortoni,
2010; Logan, 2008). The question, however is whether official figures may
underestimate the true prevalence rate. Sexual abuse by a woman is generally
less visible, for example, occurring within the context of a nurturing role, or as a
18
teacher who has a sexual relationship with a student (see Wijkman, Bijleveld, &
Hendriks, 2010). In a large international meta-analysis into recidivism of female
sexual offenders (N = 2490), Cortoni and colleagues (2010) found that only 1
to 3% of the women were re-convicted of a sexual offense, 4 to 8% for a nonsexual violent crime, and 19 to 24% for an offense in general. The majority of
female sexual offenders commit sexual assaults against young people (Logan,
2008; Wijkman et al., 2010). Female sexual offenders compared to male sexual
offenders are more likely to be in a caretaking position and less likely to abuse
strangers (Rudin, Zalewski, & Bodmer-Turner, 1995; Tsopelas, Spyridoula, &
Athanasios, 2011). Furthermore, it is known that when women commit sexual
offenses this occurs relatively often with a male accomplice (Beech, Parrett, Ward,
& Fisher, 2009; Wijkman et al., 2010).
4. Arson
Women compared to men are more likely to be charged with or convicted of
arson and to have previous histories of fire-setting behavior (Coid, Kahtan, Gault,
& Jarman, 2000). In a literature review, Gannon (2010) concluded that research
to date suggests that female arsonists differ in three ways from male arsonists:
1) pathology (often depression and absence of sexual fetishism associated with
arson), 2) motivation (higher prevalence of attention seeking / ‘cry for help’) and
3) problems in childhood (higher prevalence of sexual abuse).
5. Inpatient violence
Regarding inpatient violence, it has repeatedly been demonstrated that female
psychiatric patients cause as many violent incidents as male psychiatric patients
(De Vogel & De Ruiter, 2005; Lam, McNiel, & Binder, 2000; Newhill, Mulvey, & Lidz,
1995; Nicholls et al., 2009; Tardiff et al., 1997). However, it has also been found
that violent incidents by female psychiatric patients are less likely to result
in serious injury compared to violent incidents by male psychiatric patients
(Krakowski & Czobor, 2004).
Violence risk assessment of women
Research has demonstrated that unstructured clinical judgment relating to
violence risk is sensitive to sex-based biases; mental health professionals of both
genders tend to underestimate the risk for violence in female psychiatric patients
(Skeem et al., 2005). Use of structured risk assessment tools is recommended
to avoid these types of biases (Borum, 1996), however, widely used structured
risk assessment tools such as the HCR-20 / HCR-20V3 are developed based on
19
violence risk research conducted primarily in male samples. Moreover, research
into the psychometric properties of these tools has been carried out almost
exclusively on men. Some scholars have taken the position that there is no
reason to assume that male-based tools do not apply to women because most
risk factors are considered valid for both sexes (Loucks & Zamble, 1999; Newhill
et al., 1995), also referred to as the ‘gender-blind’ perspective (Garcia-Mansilla et
al., 2009). However, there is little empirical evidence to support this perspective
(Odgers et al., 2005). Recent research results and reviews on risk factors and risk
assessment in female offenders suggest that although many violence risk factors
seem to be valid for both men and women, the assessment and formulation of
violence risk differs at least to a certain degree between men and women, and
consequently, that there is a need for more gender-sensitive risk assessment (De
Vogel & De Ruiter, 2005; Funk, 1999; Garcia-Mansilla et al., 2009; Logan, 2003;
Logan & Blackburn, 2009; McKeown, 2010; Odgers et al., 2005; Penney & Lee,
2010; Rossegger et al., 2009; Salisbury, Van Voorhis, & Spiropoulos, 2009; Schaap
et al., 2009; Van Voorhis, Wright, Salisbury, & Bauman, 2010; Vitale & Newman,
2001; Warren et al., 2005; Willison & Lutter, 2009).
It has been found that there are certain risk factors that have stronger effect for
women compared to men, such as child abuse, adult victimization, disruptions
in relationships and families, and economic disadvantages (Benda, 2005; Bottos,
2007; Funk, 1999; Odgers et al., 2005; Widom & Maxfield, 2001). A distinction can
be made between factors to which women are exposed more often (e.g., sexual
victimization) and factors for which the sensitivity of women is greater, i.e., those
factors that have a stronger effect on later violent or criminal behavior for women
than for men (e.g., disruptions in relationships). On the contrary, some risk factors
have stronger effect on men than on women, for example, the presence of
‘threat control-override symptoms’ (Teasdale, Silver, & Monahan, 2006). Recently,
Willison and Lutter (2009) reviewed the literature and concluded that although
many of the risk factors for violent male offending also hold true for women,
the route by which the two genders arrive at violence diverges sharply. It has
been suggested that the interaction among risk factors, the causal mechanisms,
and manifestation of violence do not fit the general models designed for male
offenders (e.g., Heilbrun et al., 2008).
20
Use of risk assessment tools with women
HCR-20 / HCR-20V3
Several studies have been conducted into HCR-20 scores in female samples. Guy
and Douglas (2006) examined a large set of HCR-20 data from aggregated samples
with Item Response Theory and found no big differences between men and
women in how the items are relevant to the construct. Strand and Belfrage (2001)
compared the HCR-20 scores of female and male forensic patients and found no
significant differences in mean subscale scores and total scores. In a Dutch study
in the Van der Hoeven Kliniek the HCR-20 was studied in a group of women and
a matched group of men (De Vogel & De Ruiter, 2005). No significant differences
were found between men and women with respect to mean subscale and total
scores. However, there were significant differences in individual items: women
obtained higher scores on Relationship instability and Impulsivity and lower scores
on Young age at first violent incident, Psychopathy, and Negative attitudes.
Furthermore, several studies have been conducted in which the predictive
validity of the HCR-20 was examined. Nicholls and colleagues (2004) examined
the HCR-20 in female and male civil psychiatric patients and found good
predictive validity for inpatient violence for men and women. Regarding
violence in the community, they found modest levels of predictive accuracy for
the occurrence of ‘any violence’ for both sexes. Predictive accuracy for ‘physical
violence’ in the community was significant for men, but not for women, except
for the Historical subscale. De Vogel and De Ruiter (2005) examined the HCR-20
in a group of female forensic patients and a matched group of male patients. For
men, the HCR-20 total score demonstrated good to excellent predictive validity
for violent outcomes. For women, only the HCR-20 final risk judgment, but not
the HCR-20 total score, demonstrated significant predictive validity for violent
outcomes. Thus, while a simple addition of individual HCR-20 risk factors was not
adequate in predicting violence risk in female patients, the SPJ method based on
the HCR-20 seemed to perform well. The same was recently found for the START
(Petersen, Douglas, & Nicholls, 2011). Schaap and colleagues (2009) examined
the predictive validity of the HCR-20 in female patients from two Dutch forensic
psychiatric hospitals1 and found no significant predictive accuracy for HCR20 scores for violent outcomes. The same was found in a group of incarcerated
women (Warren et al., 2005) and in a group of female short-term psychiatric
inpatients (Strub, 2010). In a meta-analysis, however, greater effect sizes were
found in samples containing higher proportions of women (O’Shea et al., 2013).
The codings of 15 women from the study of De Vogel and De Ruiter (2005) were included in this study.
1
21
Concluding, the results are equivocal and the predictive accuracy of the HCR-20
items in female samples has not been convincingly proven. A similar conclusion
was expressed in two recent reviews of risk assessment for violence among
women. Garcia-Mansilla and colleagues (2009) reviewed the literature on
different methods of violence risk assessment in a range of female populations.
They concluded that structured methods of risk assessment are more accurate
than unstructured methods, but that overall, the research supporting
applicability of violence risk assessment tools in female populations remains
equivocal. McKeown (2010) did a literature review into violence risk assessment
with the HCR-20 in women and concluded that for now, the research supports
the use of the HCR-20 with female populations, but that more research is needed
and that a particular focus on additional risk factors that may further inform
violence risk assessment in women would be valuable. No research has yet been
published with respect to the predictive validity of the HCR-20V3 for women.
Other risk assessment tools
A number of studies have been conducted into the predictive validity of actuarial
risk assessment tools such as the Level of Service Inventory (LSI; Andrews &
Bonta, 2000) or youth versions of the LSI. The LSI is not specifically developed
for assessing risk for violence, but rather of general recidivism, and most studies
were conducted within populations with mainly property or drug related
offenses. A group of American researchers has been working since 1999 to
develop a more gender-sensitive method to predict general recidivism (see for
example, Salisbury et al., 2009; Van Voorhis et al., 2010). They have adapted the
LSI for use in women with the idea that it is more efficient to adjust an existing
tool then to create a completely new instrument (Van Voorhis et al., 2010). The
results for this adapted LSI for women show that both gender-sensitive factors
and gender-neutral factors were predictive of misconduct in prison and general
recidivism after release (Salisbury et al., 2009; Van Voorhis et al., 2010). Other
studies found that the LSI performs equally well in male samples as in female
samples in predicting general reoffending, though evidence was found for
misclassification with respect to violence offenses (Reisig, Holtfreter, & Morash,
2006; Schwalbe, 2008).
There are several risk assessment tools developed for the assessment of intimate
partner violence, such as the Spousal Assault Risk Assessment guide (SARA; Kropp,
Hart, Webster, & Eaves, 1999) and the Brief Spousal Assault Form for the Evaluation
of Risk (B-SAFER; Kropp, Hart, & Belfrage, 2005). Although according to their
respective manuals these tools may be used for both men and women, the same
22
cautions warranted for other risk assessment tools are relevant for the SARA and
the B-SAFER: the items are mainly based on studies in male populations, and
there is little research on the value of these types of tools for female offenders.
The item descriptions are generally expressed from the perspective of the
male perpetrator and female victim. As far as we know, there is no specific tool
available for assessing the risk for intimate partner violence by women.
Psychopathy and the use of the PCL-R with women
A number of reviews have been published on the use of the Psychopathy
Checklist-revised (PCL-R; Hare, 2003) in female samples (Logan, 2009; Nicholls,
Ogloff, Brink, & Spidel, 2005; Vitale & Newman, 2001). Although the PCL-R is
not a risk assessment tool, psychopathy is an important risk factor and often
incorporated in risk assessment tools like the HCR-20. It can be concluded from
the reviews that there is considerable evidence that psychopathy is an important
risk factor for violence in women, but that the effect is not as strong as it is for
men. In general, a lower prevalence of psychopathy among women compared to
men was found, as well as lower scores on the PCL-R. Good support was found for
the reliability of the PCL-R in women, but only modest support for its predictive
validity. Overall, the findings thus far are not sufficiently convincing so as to allow
for conclusions about the applicability of the PCL-R structure across genders
(Logan, 2009; Nicholls et al. 2005; Vitale & Newman, 2001). Some PCL-R items
might not be adequately assessing the construct of psychopathy as it is expressed
in women (Forouzan & Cooke, 2005; Weizmann-Henelius et al., 2010) and it might
be useful to formulate the items differently for women. Also, it might be useful to
lower the PCL-R cut-off score for women (e.g., Falkenbach, 2008; Kennealy, Hicks,
& Patrick, 2007; Weizmann-Henelius et al., 2010). A measure that is more tailored
to the assessment of psychopathy in women / girls could be valuable for forensic
practice. Ideally, the PCL-R will be adjusted for use in women.
Recently, a Dutch multicentre study on psychopathy was conducted in 221
female forensic psychiatric patients (Klein Tuente, De Vogel, & Stam, 2014). In
this study it was found that women with psychopathy as defined by the FAM
cut-off score of 23 clearly differed from women without psychopathy regarding
their criminal behavior. More specifically, psychopathic women were younger at
their first conviction and had more criminal versatility in their offense histories.
With respect to the index offense it was found that women with psychopathy
less often committed a fatal index offense, were more likely to have stranger
victims and more often committed offenses out of a Bad motivation (e.g., power,
dominance, personal gain) compared to women without psychopathy.
23
In a second phase of this study, results were compared between 197 female
forensic psychiatric patients from this sample and a matched group of 197
male forensic psychiatric patients. Men scored significantly higher on the
total score, the Hare two factors / four facets and the Cooke and Michie three
factors. Furthermore, men scored significantly higher on all individual PCL-R
items, except for the item Many short-term marital relationships for which the
mean score of women was significantly higher and for the items Conning/
Manipulative, Poor behavioural controls and Impulsivity for which no significant
difference between men and women was found. Furthermore, clear differences
were found in criminal and psychiatric characteristics between both women and
men with psychopathy versus women and men without psychopathy. It was
concluded that women with psychopathy are more ‘like men’ in their offending
(e.g., younger age at first conviction, more criminal versatility), but still important
differences were found between women with psychopathy and men with
psychopathy. Women with psychopathy compared to men with psychopathy
were more often diagnosed with Borderline Personality Disorder, committed
more fraud, offended more often out of relational motives, and demonstrated
more manipulative and self-destructive behaviour during treatment (De Vogel &
Lancel, in preparation, see www.violencebywomen.com).
Protective factors in women
Gender-responsive assessment should not only consider risk factors but
also evaluate strengths and signs of resilience (Meichenbaum, 2006). It has
been suggested that each sex may respond differently to protective factors
(Rumgay, 2004). For example, Hawkins and colleagues (2009) found that family
connectedness and religiosity provided significant protection for girls, but not
for boys. Positive social relationships were found to have a stronger protective
effect for adolescent girls compared to boys (Hart, O’Toole, Price-Sharps, &
Shaffer, 2007). Borowsky and colleagues (1997) found in a nonclinical population
of students that academic achievement was a protective factor for sexually
violent behavior specifically for female adolescents. In a Dutch study into gender
differences in risk assessment using the Structured Assessment of Violence Risk in
Youth (SAVRY; Borum, Bartel, & Forth, 2006) in adolescent girls and boys, it was
found that scores on the protective factor Positive attitude towards interventions
and authority were significantly higher for girls compared to boys (Lodewijks,
De Ruiter, & Doreleijers, 2008). The total score on the six protective factors was a
significant predictor of non-recidivism for both girls and boys.
24
For adult women, it has been found that marital satisfaction, employment and
adequate financial management reduce recidivism (Holtfreter & Cupp, 2007).
A protective factor for adult women that is often mentioned in the literature
is dedication to their children2; this factor could be an important incentive
for treatment (Benda, 2005; Kreager, Matsueda, & Erosheva, 2010; Simmons,
Lehmann, & Dia, 2010; Willison & Lutter, 2009), although child care responsibility
can also be an extra risk factor (see p. 72 FAM item R6 Problematic child care
responsibility). In a study into gender-sensitive risk and protective factors for
women in prison in the United States evidence was found for self-confidence,
support from the family and partner, sound finances and education as protective
factors for general recidivism (Van Voorhis et al., 2008; 2010). In a study into the
intergenerational transfer of risk it was found that children of mothers with more
education showed less antisocial behavior (Serbin et al., 1998). In a prospective
study in the Van der Hoeven Kliniek it was found that the predictive validity of
the SAPROF for abstention from violence during treatment was fairly good for
women, but not as good as for men. There were differences in which factors were
the most valuable. For men, the items Self-control and Attitudes towards authority
were the best predictors for not committing violent incidents during treatment.
For women, the items Coping and Intelligence were the strongest predicting
factors (De Vries Robbé, 2014). Regarding the START it was found that female
forensic psychiatric patients who made successful returns to the community had
significantly higher START strength scores compared to women who were still in
recovery (Viljoen, Nicholls, Greaves, De Ruiter, & Brink, 2011).
Gender-responsive treatment
In the past ten years, several authors have recognized a number of specific
treatment needs of female offenders, often referred to as gender-responsive
approaches (e.g., Blanchette & Brown, 2006; Bloom, Owen, & Convington, 2003;
Bottos, 2007; Heilbrun et al., 2008; McClellan, Farabee, & Crouch, 1997; Morgan
& Patton, 2002). In general, these treatment models stress the importance of
using gender-sensitive risk assessment and addressing issues such as trauma,
(sexual) abuse, and the role of social relations and disruptions in these relations
in treatment. A central concept in North-American treatment programs for
women is empowerment; i.e., increasing women’s self-esteem and internal
locus of control (Salisbury et al., 2009). It has been stated that the practice of
violence risk management in women should respond to the observed high
2
Obviously, this can also be a protective factor for men, but it is assumed that the impact is stronger for women.
25
levels of psychiatric comorbidity, especially Axis I/II comorbidity (Logan &
Blackburn, 2009). Lewis (2006) recommends a treatment model for incarcerated
women that recognizes gender differences but also gender challenges, i.e., the
acknowledgement that working with female offenders is in some respects harder
than working with male offenders. Foley (2008) reviewed twelve gender-specific
programs for delinquent girls and concluded that most of these programs did
not yet sufficiently incorporate relevant theories and gender-specific risk and
protective factors into their curriculum. Dowden and Andrews (1999) conducted
a meta-analysis of the value of the Risk Need Responsivity model (Andrews &
Bonta, 1998, 2010) specifically for female offenders and concluded that there is
sufficient empirical support for this model for both men and women. Hubbard
and Matthews (2008) studied the “What works’’ literature (see for example
Latessa, Cullen, & Gendreau, 2002) and “Gender-responsive treatment” literature
(see for example Chesney-Lind & Pasko, 2004) and concluded that they are more
complementary than competitive, and that together they provide a blueprint for
how to effectively work with females.
The need for a gender-sensitive tool
In a recent meta-review into the predictive validity of risk assessment tools it
was found that tools developed for a specific target group have better predictive
value than general tools (Singh, Grann, & Fazel, 2011). The authors recommend,
therefore, the development of tools for specific populations or specific types
of offenses. Despite the many important advances in the field of violence risk
assessment in the past thirty years and the fact that many risk assessment tools
have become available for populations of different ages and for different types
of violence, virtually no ‘specific’ tools have been developed for the assessment
of risk for antisocial or violent behavior in female offenders. One exception is the
Early Assessment Risk List for Girls (EARL-21G; Levene et al., 2001) for girls between
6 and 12 years old. Other than the risk factors valid for both boys and girls, this
tool contains two items specific to girls; Caregiver-daughter interaction and Sexual
development. Positive results have been found in terms of reliability, predictive
validity and clinical applicability of the EARL-21G (Augimeri, Enebrink, Walsh, &
Jiang, 2010). However, there is no such tool available for violence risk assessment
in adolescent girls or adult women.
More knowledge on violence risk factors in female offenders as well as gendersensitive risk assessment and management strategies is needed to prevent
repeated violence in women. Many mental health professionals work with
women on a daily basis recognize these differences and have called for more
26
gender-sensitive assessment of factors explanatory of violence risk in female
offenders and relevant for its management (Adams, 2002; Odgers et al., 2005).
Adams (2002) examined attitudes of professionals working in the field of
domestic violence and concluded that many professionals indicate that there
is a lack of appropriate guidelines to assist them in assessing violent women,
and there is a need for more training in this area. Better risk assessment
and management in women is also important from a public mental health
perspective because research has demonstrated an intergenerational transfer
of risk for violence between mothers and children; mothers with a history of
violent offenses are more likely to raise disruptive, aggressive children (Kim et al.,
2009; Meichenbaum, 2006; Motz, 2001; Serbin et al., 1998). Concluding, violent
behavior by women is a problem that cannot be ignored and there is reasonable
doubt as to whether the current theoretical understanding of male violence,
violence risk, as well as prevention and treatment is sufficiently valid and
applicable to women. In the next part, gender-sensitive guidelines for violence
risk assessment are provided.
27
28
Part II The FAM
In the FAM, additional guidelines for women were formulated for two Historical
HCR-20V3 items and eight new items were incorporated. Table 1 present the items
of the HCR-20V3 and the FAM (see also Appendix 1 and 2). Additionally, two new
coding aspects were incorporated in the FAM also based on clinical experiences
with other tools like the HCR-20, the SAPROF and the START; 1) marking the final
judgment on a five-point scale instead of a three-point scale; and 2) coding the
extra risk ratings.
29
Table 1. Items of the HCR-20V3 and the FAM
HCR-20V3
FAM
Historical items
H1
Violence
H2
Other antisocial behavior
H3
Relationships
H4
Employment
H5
Substance use
H6
Major mental disorder
Additional guidelines for women to
the following HCR-20V3 items
H7
Personality disorder
H7
Personality disorder
H8
Traumatic experiences
H8
Traumatic experiences
H9
Violent attitudes
H10
Treatment or supervision response
Specific risk factors for women
H11
Prostitution
H12
Parenting difficulties
H13
Pregnancy at young age
H14
Suicidality / self-harm
Clinical items
C1
Insight
C2
Violent ideation or intent
C3
Symptoms of major mental
disorder
C4
Instability
C5
Treatment or supervision response
Specific risk factors for women
30
C6
Covert / manipulative
behavior
C7
Low self-esteem
HCR-20V3
FAM
Risk management items
R1
Professional services and plans
R2
Living situation
R3
Personal support
R4
Treatment or supervision response
R5
Stress or coping
Specific risk factors for women
R6
Problematic child care
responsibility
R7
Problematic intimate
relationship
Conclusory opinions
Risk for future violence
Risk for future violence
Risk for serious physical harm
Risk for serious physical harm
Risk for imminent violence
Risk for imminent violence
Extra risk ratings for women
Self-destructive behavior
Victimization
Non-violent criminal behavior
Note. The HCR-20V3 items are reproduced with permission from the authors (see Douglas et al., 2013).
See Tables 3, 4 and 5 for the subitems of the HCR-20V3 items (p. 49, 63, 71).
31
Development
The FAM was developed on the basis of:
1. A literature review.
2. Clinical expertise:
a. The most frequently coded Other considerations in the HCR20 for female forensic psychiatric patients;
b. Semi-structurend interviews with mental health professionals
from different disciplines;
c. Experiences with the coding procedure of other assessment
tools (SAPROF, START).
3. A pilot study into the interrater reliability and gender specificity
of the FAM: Research Version.
Literature review
In 2007, the development of the FAM was initiated. First, a review of the literature
on violence by women and violence risk factors in women was conducted
(Van Kalmthout & Place, 2007). More specifically, a search was carried out
for the applicability of the HCR-20 items with respect to female populations.
Support was found for most Historical items of the HCR-20 although there were
differences in interpretation and implication of some of the items for women.
Almost no empirical studies on the dynamic HCR-20 items were retrieved in
female samples, thus no direct empirical support was found for the validity of the
dynamic HCR-20 items in women. Further, empirical studies on gender-specific
risk factors that are not sufficiently covered by the items of the HCR-20 were
searched. Overall, the literature review resulted in suggestions for additional
guidelines to several Historical items and the inclusion of gender-specific risk
factors such as a history of prostitution, pregnancy at young age and self-harm
or suicidality (Blanchette & Brown, 2006; Messer et al., 2004; Morgan & Patton,
2002).
Clinical expertise
In a previous study, mental health professionals working in forensic psychiatry
were specifically asked to consider case-specific risk factors that do not fit
within the HCR-20 item descriptions (see De Vogel & De Ruiter, 2005). The three
most frequently coded other considerations for women were 1) (pattern of )
32
problematic partner choice; 2) problems with child care responsibilities, and
related stress; and 3) prostitution, particularly the often coinciding vulnerability
and maladaptive lifestyle. Next, semi-structured interviews with mental health
professionals from different disciplines were conducted, which revealed more
new risk factors specific to women including covert behavior (i.e., hiding or
concealing the truth, incitement), as well as a manipulative way of dealing with
sexuality (i.e., sexual self-exploitation for personal gain) and low self-esteem (see
Van Kalmthout & Place, 2007). Integration of the literature and clinical expertise
led to a first draft of the FAM. This draft was implemented at the end of 2007 for
all women in the Van der Hoeven Kliniek. In 2010, we revised the draft based on
user feedback and experiences with coding procedures of other tools, specifically
the SAPROF and the START. The revised tool was named the Female Additional
Manual: Research Version (FAM:RV; De Vogel, De Vries Robbé, Van Kalmthout, &
Place, 2010).
Pilot study FAM:RV
In 2010, a prospective pilot study was carried out on the psychometric properties
of the FAM:RV in the Van der Hoeven Kliniek with the aim of establishing
interrater reliability and gender specificity of the FAM items for women (Stam,
2010). The pilot study resulted in several revisions, such as the sharpening of
some coding guidelines, for example of the item with the lowest interrater
reliability Problematic child care responsibility; the revision and adaptation of
the Historical item Manipulative sexual behavior into the Clinical item Covert /
manipulative behavior and the deletion of a number of additional guidelines that
on closer inspection proved irrelevant or insufficiently prevalent. The results of
the pilot study led to the FAM.
The FAM as an additional manual to the HCR-20V3 instead of the HCR-20
In 2013, the FAM was slightly adapted for use as an additional manual to both
the HCR-20 and the HCR-20V3. The present manual is completely adapted for use
with HCR-20V3. The additional guidelines to the HCR-20 items H7 Psychopathy
and H9 Personality disorder are now additional guidelines to HCR-20V3 item H7
Personality disorder. These additional guidelines are generally still applicable, but
have slightly been changed with respect to use with the HCR-20V3 (see p. 50 and
Appendix 1). The additional guidelines to HCR-20 items H6 Major mental illness,
H8 Early maladjustment and H10 Prior supervision failure are no longer necessary
when using the HCR-20V3.
33
With respect to the FAM items specific for women: almost all FAM items are still
considered useful in addition to the HCR-20V3. Only FAM item H15 Victimization
after childhood is no longer necessary as a new item as this is now included in the
HCR-20V3 item H8a Victimization / trauma. HCR-20V3 item H8a considers traumatic
experiences at any point during the lifespan (including victimization after
childhood). The authors of HCR-20V3 recognize the importance of victimization
and traumatic experiences during the different developmental stages (child,
adolescence, adulthood) and have therefore included indicators3 that consider
these different developmental stages for coding item H8a. However, we feel that
for women the distinction between victimization during childhood and after
childhood deserves to be made more explicit, given the empirical knowledge
on the severe impact on women of victimization during multiple developmental
stages in life. From a clinical and research perspective it is also valuable to be
able to make a distinction between victimization during childhood versus
victimization during adulthood. Concluding, since research has demonstrated
that victimization after childhood is a strong risk factor for women in addition to
victimization during childhood, it is recommended to divide the HCR-20V3 item
H8a into H8a1 Victimization and trauma during childhood and H8a2 Victimization
and trauma after childhood. The coding guidelines for item H15 in the previous
version of the FAM can still be used for H8a2. Thus, instead of the former FAM
item H15, new additional guidelines are offered for the HCR-20V3 item H8a.
Aims
The goal of the FAM is to provide a clinically relevant and useful additional tool
for accurate, gender-sensitive assessment of violence risk, which offers concrete
guidelines for risk management in women.
Definition of violence
The definition of violence in the FAM is basically the same as in the HCR-20V3.
Interpersonal violence is defined as actual, attempted, or threatened infliction of
bodily harm on another person (Douglas et al., 2013, p. 36). This definition includes
all violent offenses, homicides, sexual offenses and arson. There does not need
to be a court conviction, but the violent behavior must be serious enough to
potentially result in criminal or civil sanctions. In the FAM influencing someone
else to commit violence or being accessory to violence is explicitly included in
the definition of violence. It is not clear from the definition of violence in the HCR Coding indicators are representative examples of the kinds of information that evaluators should look for
when making judgments regarding the presence of risk factors (see Douglas et al., 2013, chapter 3, p. 50).
3
34
20V3 if these types of behavior are included. The reason for the explicit inclusion
of this in the FAM is because it is assumed that, relatively speaking, more women
than men are convicted of aiding and abetting, although no official data could
be retrieved. Mental health professionals believe that women are more likely
than men to incite someone else to commit violent / antisocial behavior and
their own share may not always be clearly seen. In addition, women may not
actually commit violence themselves but may be accessory to violent behavior,
for example, by failing to intervene when their partners commit violence.
Applications
The FAM is designed as an addition to the HCR-20V3 for violence risk assessment
in adult women. Like the HCR-20V3, the FAM can be used to evaluate risk for
violence when there is a legal or clinical need to do so. The FAM is possibly also
useful for women in prison or in general psychiatry who have demonstrated
violence to others. For assessing violence by young girls (between 6 and
12 years), we refer to the EARL-21G. For adolescent girls there is - as far as we
know - no gender-sensitive risk assessment tool available. The FAM may possibly
be partly useful for violence risk assessment in adolescent girls, but caution is
warranted because there are some risk factors specifically valid for adolescent
girls that are not included in the FAM, such as interaction with deviant peers,
being a member of a gang, and running away from home (see Funk, 1999; Hart
et al., 2007; Park, Morash, & Stevens, 2010). Moreover, some of the FAM items
are obviously not applicable for adolescent girls, for example, Victimization after
childhood.
User qualifications
User qualifications are similar to those described in the HCR-20V3 (Douglas et al.,
2013, p. 38-39). The evaluator should have expertise in conducting individual
assessments and be familiar with the most recent empirical and theoretical
knowledge of violence and the prediction of violence. Moreover, the evaluator
should be familiar with the HCR-20V3. Training in the use of the HCR-20V3 and FAM
is highly recommended.
Coding procedure
The coding procedure of the FAM is basically the same as the coding procedure
of the HCR-20V3. In the HCR-20V3, seven steps are distinguished (see Figure 1;
Douglas et al., 2013, pp. 40-65). In the FAM, some adaptations were made in
step 2 (Presence of risk factors) and step 7 (Final opinions). Based on clinical
35
experience (see also General recommendations, see p. 40) an additional
suggestion is provided regarding step 3 (Relevance). It should be mentioned that
this recommendation can also be valuable for men.
An example of the coding sheet that can be used for coding the FAM is provided
on p. 78.4 For coding the FAM and HCR-20V3 it is necessary to apply both manuals
simultaneously. For coding the HCR-20V3 items H7-H8 the evaluator is referred to
the additional coding instructions for women in the FAM. These items should be
coded on the FAM coding sheet and not on the HCR-20V3 coding sheet in order to
prevent double rating of the same concepts.
3. Relevance 4. Formulation
5. Scenarios
Taking action
1. Gather
information
2. Presence of risk
factors
Making meaning
Identifying facts
Figure 1. HCR-20V3 steps adopted from Douglas et al., 2013
6. Management
7. Final opinions
Step 1: Gather information (see Douglas et al., 2013)
Step 2: Presence of risk factors (see also Douglas et al., 2013)
The items are coded on a three-point scale based on the degree to which the risk
factor is present; a ‘No’ indicates that the risk factor is absent or hardly present; a
‘Partially’ indicates that the risk factor is possibly or partially present, but there
The FAM Coding sheet can be downloaded from www.hoevenkliniek.nl or www.violencebywomen.com or be
obtained digitally from the authors.
4
36
is no conclusive evidence for its presence; and a ‘Yes’ indicates that the risk
factor is definitely or clearly present (see Table 2). If the information necessary
to code the item is lacking or insufficient, the evaluator should first try to obtain
the information, for example, by using multiple sources, deliberation with
colleagues, or by asking the woman herself. If there is no information at all about
a given item, or if the information is considered completely unreliable, the item
has to be omitted. This option should be used sparingly and should not be used
in case of doubt about the presence of the item (more indicative of a score of
‘Partially’). When more than six items are omitted in total in the HCR-20V3 (not the
subitems) and FAM the risk assessment is no longer usable. The item Parenting
difficulties is not applicable if the woman has never had children (to take care of ).
In this case, there is the option to rate the item as n.a. (not applicable) and this is
not seen as an omit. If the evaluator believes one or more risk factors are present
in a given case that are not covered by any of the items in the HCR-20V3 and FAM
these factors can be coded under Other considerations.
Table 2. Coding the presence of items
No
The risk factor is definitely not present or does not apply.
Partially
The risk factor is possibly present, or is present to a limited
extent.
Yes
The risk factor is obviously present.
Omit
There is insufficient valid information to decide upon the score.
Step 3: Relevance (see Douglas et al., 2013)
Although the judging of relevance of the risk factors is seen as an important
step in the coding procedure, in some settings coding the relevance of all risk
factors may not be possible or realistic because it is too time-consuming. As an
alternative to coding the relevance of all items, the evaluator could mark critical
items, that is, risk factors that are considered essential for the case at hand.
These items are intended to steer the development of treatment goals and to
tailor clinical interventions. The option to code critical items is also available in
the START and SAPROF and is highly appreciated by mental health professionals
because it structures their thinking and helps them to focus and prioritize
treatment goals (see De Vries Robbé, 2014).
37
Step 4: Formulation (see Douglas et al., 2013)
Step 5: Scenarios (see Douglas et al., 2013)
Step 6: Management (see Douglas et al., 2013)
Step 7: Final opinions
Similar to the HCR-20V3 and related tools, the final risk rating of future violence
to others is not only determined by adding up the individual items, but depends
on the interpretation, weighing, and integration of the items. In the FAM, the
final risk ratings can be made on a five-point scale: 1) low; 2) low to moderate; 3)
moderate; 4) moderate to high and; 5) high risk. The reason to apply five-point
scales instead of three-point scales is because it is easier to pinpoint nuances; in a
forensic population where the treatment progress is usually slow, it can be useful
and motivating to be able to show small changes. In addition, research in the Van
der Hoeven Kliniek showed higher predictive validities for five-point scales than
for three-point scales (De Vries Robbé & De Vogel, 2012). Using a five-point scale
instead of a three-point scale may also be valuable for men. The final risk rating
should be made for the coming year and will not only include the likelihood of
violent behavior, but also the context, frequency, duration and possible time
frame in which violence could take place, as well as the identification of potential
victims. In the HCR-20V3, this process is referred to as Risk scenario planning (see
for more details Step 5, Douglas et al., 2013).
Coding the extra risk ratings
In the FAM, the evaluator is invited to not only decide upon the three Final
opinions Risk for future violence (including influencing others to commit
violence or being accessory to violence), Risk for serious physical harm, Risk for
imminent violence, but also to judge the Risk for self-destructive behavior, the
Risk for victimization and the Risk for non-violent criminal behavior. This method
of judging different types of risks is also applied in the START. Although there
is presently no empirical evidence supporting the assumption that the risk
factors in the FAM are indeed related to these specific risks, the distinction
between the different types of risk may be useful for clinical practice. These three
judgments should thus be seen as experimental and future research will have to
demonstrate their value.
It is likely that the final judgments are related to each other (see also Strub,
2010). Hillbrand (2001) summarized the literature on co-occurring aggression
38
against self and others and concluded that there is a strong link between the two
forms of aggression and that both types of risk assessment should occur jointly.
Furthermore, research has shown that self-destructive behavior or a history
of suicide attempts in women is a predictor of general recidivism (Blackburn &
Trulson, 2010; Blanchette & Brown, 2006; Motz, 2001; see also the FAM item
Suicidality / self-harm). Victimization may also lead to violent behavior, for
example, in the form of reactive aggression or self-defense, but also indirectly, for
example because the victim is experiencing stress or starts to abuse substances
in response to traumatic experiences (see Hiday et al., 2001; additional guidelines
to HCR-20V3 item H8 Traumatic experiences).
1. Risk for self-destructive behavior
Self-destructive behavior includes any behavior that results in injury or harm
to the own body. This includes self-harm and suicidal behavior (see also p. 60),
but also severe self-neglect by excessive use of alcohol, drugs or medication, or
by not complying with medication requirements for physical symptoms with
potentially serious consequences, or very poor personal hygiene. This should
include serious self-destructive behavior, that is, it should lead to a clearly
observable deterioration in the mental and physical condition of the woman.
The items Substance use problems, Major mental illness, Suicidality / self-harm and
Low self-esteem are especially important for assessing the risk for self-destructive
behavior. It should be noted that the FAM is not a tool to assess the risk for
suicide; there are predictors of suicidal behavior that are not included in the FAM
(see for instance Bouch & Marshall, 2005).
2. Risk for victimization
Victimization is defined as being the victim of damaging behavior caused by
another person. The most obvious cases are in victims of violence, such as
violence within an intimate relationship, sexual abuse or being forced into
prostitution. The items Relationship instability, Traumatic experiences, Prostitution,
Covert / manipulative behavior, Low self-esteem and Problematic intimate
relationship are especially important for assessing the risk for victimization.
3. Risk for non-violent criminal behavior
Non-violent criminal behavior includes all (non-violent) behaviors that are not in
conformity with the law. This includes all offenses not involving (sexual) violent
behavior, including fraud, arson without risk to persons, property offenses, and
drug related offenses. Research into predictors of general recidivism (including
violence) has found support for quite a few of the Historical items in the HCR39
20V3 / FAM, especially factors relating to mental illness, victimization, problems
in relationships and problems with child care (see Van Voorhis et al., 2010).
In addition to the above mentioned risk factors, the items Other antisocial
behavior, Prostitution and Covert / manipulative behavior seem to be important
for assessing the risk for non-violent criminal behavior, but this has yet to receive
empirical support.
General recommendations
Based on experiences in clinical practice at the Van der Hoeven Kliniek, several
recommendations are made here (see also De Vogel, Van den Broek, & De Vries
Robbé, 2014). First, it may be useful to judge the Risk management items and
the final risk ratings for different contexts, for example the situation ‘inpatient
setting’ and the situation ‘supervised living in the community’. By scoring for
different contexts the evaluator can gain more insight into the possible need
for continued treatment. In daily practice this way of coding is seen as useful, for
instance, when writing a report to the court upon termination or extension of the
tbs-order (compulsory treatment). Second, it is recommended to also examine
protective factors in addition to risk factors, for example, using the SAPROF. By
not only looking at risk factors but also at existing protective factors or protective
factors that can be developed, it is possible to conduct a more balanced
risk assessment and thus provide a more complete picture of the person.
Furthermore, the positive, strengths-focused approach of the SAPROF may be
motivating for both staff and patients, leading not only to a more balanced risk
assessment, but also to more elaborate and patient-adjusted risk management
strategies and improved risk communication (see for more information De
Vogel, De Vries Robbé, De Ruiter, & Bouman, 2011; De Vries Robbé, 2014; www.
saprof.com). Third, we highly recommend the consensus model for a valid risk
assessment. It has become clear from research at the Van der Hoeven Kliniek
that risk assessment using the consensus model (coding by both researchers
and mental health professionals followed by extensive discussion in order to
reach consensus) leads to a significantly more accurate prediction of the risk
for recidivism (De Vogel, 2005; De Vogel & De Ruiter, 2006). During these case
conferences, possible effects of rater bias can be ruled out; raters can sharpen
their understanding of the items, and can correct each other, share information
that is not available to everyone, discuss the meaning of the items, and discuss
possible additional risk factors or protective factors and risk management
strategies.
40
Risk communication
After the evaluator has scored the FAM, a report must be prepared in which
the main risk factors (and protective factors) are described in relation to each
other. The intention here is not to merely mention scores, but instead to report
descriptively. In formulating the final risk rating, not only should the risk for
violent behavior be reported, but also the possible context, time, frequency,
duration of violent behavior, as well as the potential victims. It is desirable to
communicate the main results of the risk assessment to the woman, preferably in
the presence of treatment staff. Finally, a risk assessment should be followed by
a risk management plan based on the main conclusions of the risk assessment.
Research
Research on the FAM is still limited. In 2011, a prospective study was started on
the clinical value and psychometric properties of the FAM in the Van der Hoeven
Kliniek. In this study, the FAM, HCR-20 and SAPROF are scored on standard risk
assessment moments5 for all female patients admitted to the Van der Hoeven
Kliniek. The first part of this research has been completed (Stam, 2010; De Vogel
& De Vries Robbé, 2011). In this project, the FAM, the HCR-20, and SAPROF were
scored for 42 female patients and 42 male patients. The women and men were
matched with respect to their phase in treatment, type of psychopathology
and type of offense. For 20 women, the tools were scored by two independent
raters to determine interrater reliability. Good interrater reliability was found
for all new FAM items and HCR-20 items with additional guidelines for women,
the integrated total score of the HCR-20 and FAM, and the final risk judgment of
Future violence (Intraclass Correlation Coefficient single measure (ICC) individual
items ranging from .63 to .97, all p < .05; total score ICC = .95, p < .001; and final
risk judgment Future violence ICC = .95, p < .001). For the extra final risk ratings
moderate to high interrater reliabilities were found (ICC = .54-.85, all p < .001).
Regarding the differences between women and men on FAM scores, it was
found that women had significantly higher scores on seven of the nine new
items; Prostitution, Pregnancy at young age, Suicidality / self-harm, Victimization
after childhood, Covert / manipulative behavior, Low self-esteem and Problematic
intimate relationship (see www.violencebywomen.com). No significantly higher
scores were found for women on the HCR-20 items with additional guidelines for
women and for two of these items the men scored significantly higher, i.e., on
Psychopathy and Problematic behavior in childhood. The latter was anticipated.
The standard risk assessment moments in the Van der Hoeven Kliniek are: 1) upon admission; 2) prior to the
first supervised leave; 3) prior to the first unsupervised leave; and 4) at the start of the transmural phase. From
step 2, the risk assessment is repeated yearly. Furthermore, the risk assessment may be repeated if deemed
necessary (for example, in case of a changed context or a specific question from the treatment team).
5
41
In a preliminary analysis of a group of 46 women it was found that, overall, the
FAM had good predictive validity for incidents of violence to others during
treatment, but even more so for incidents of self-destructive behavior during
treatment (De Vogel & De Vries Robbé, 2013). In an ongoing Dutch multicentre
study it was found that the FAM / HCR-20 Historical subscale score was a
significant, but modest predictor of different types of incidents during treatment
(physical violence, verbal violence, verbal threats and arson). Furthermore, the
FAM / HCR-20 Historical subscale score significantly predicted if a woman had
to be transferred to another ward in the treatment setting, usually because of
serious problems (De Vogel et al., 2014). Further research into the predictive
validity of the FAM for incidents during treatment and recidivism after discharge
will take place in the coming years.
In general, studies into female populations will encounter several difficulties,
most importantly small sample sizes (see also Burman, Batchelor, & Brown, 2001).
The group of female forensic psychiatric patients is relatively small and many
of these women have such severe problems that they are admitted in forensic
or general psychiatry for an extensive period of time, often even chronically.
Most of these women do not return completely to society. Therefore, it will
be relatively easy to study violent behavior within institutions, but it will be
very difficult to examine violence in society. Also, a relatively large number of
female forensic psychiatric patients die at a relatively young age. Eight of the 42
women who were examined in a previous study in the Van der Hoeven Kliniek
(De Vogel & De Ruiter, 2005) had died within seven years after the study (of
which two by suicide). In a British study, it was found that women from medium
secure settings have an almost ten times higher mortality rate than the general
population and two times higher than for men who were discharged from the
same institutions (Davies, Clarke, Hollin, & Duggan, 2007). Furthermore, women
who were treated in medium secure units in the UK were readmitted more
often than men (Sahota et al., 2010). In short, research on violence by women
and predicting such behavior is difficult and requires a longer period of time as
well as good cooperation between institutions. In addition, the generally used
outcome measures for violent recidivism are probably less useful in women,
considering the different nature of violence by women compared to men and
the fact that violence by women is still underrated. It is recommended for future
research to use different outcome measures, such as self-destructive or suicidal
behavior, victimization, or examine more subtle forms of violence such as verbal
abuse, and other forms of antisocial behavior. It is possible that self-report and
observational data in addition to data on official convictions may be more
suitable to examine repeated violent behavior by women.
42
Limitations
The most important limitation of the FAM is that there is relatively little empirical
evidence for the new risk factors and additional HCR-20V3 item guidelines for
women employed in the FAM. For some of the factors there is clear empirical
support with respect to the relation with general criminal offending, but not
specifically for the relation to violence. In addition, for a number of items a
correlation was found with violent behavior in the past, but this does not
necessarily mean that the factor is also related to future violent behavior. Future
research in various settings will have to examine whether the items in the FAM
actually predict repeated violence to others. It is also still unknown whether the
items actually have empirical value for the prediction of the extra risk ratings
of self-destructive behavior, victimization and non-violent criminal behavior.
Another limitation is that the FAM contains relatively many historical items. These
items may point out important issues for mental health professionals to keep
in mind, but unfortunately as a risk factor they are not or hardly changeable by
clinical intervention. However, with the addition of the relevance ratings in the
HCR-20V3, the historical items become more useful clinically as their relevance is
evaluated for the current level of risk.
43
44
Definition of the risk factors
The additional guidelines to the coding instructions of two HCR-20V3 items, as
well as the new risk factors for women are described in the following section.
For every new item, a definition is given for the inclusion of this item in the FAM
based on the literature and the results of the interviews with mental health
professionals, as well as a clinical case example. It should be noted that in the
definitions in the FAM references to the literature are included, whilst for the
HCR-20V3 items they are not included. A detailed description of the literature
per item can be found on the website www.hcr-20.com. Furthermore, indicators
and coding notes are provided in order to assist with the coding of the items.
For coding the original HCR-20V3 items, the evaluator is referred to the HCR-20V3
manual (Douglas et al., 2013).
45
46
Appendixes
Appendixes
References
References
Coding sheet
Coding sheet
Risk Management items
Risk management items
Clinical items
Clinical items
Historical items
Historical items
Historical items
The Historical items refer to the woman’s past up until the moment of the
assessment. Additional coding guidelines were formulated for two Historical
HCR-20V3 items (H7-H8) and four new Historical risk factors for women were
incorporated in the FAM (H11-H14). For coding the original HCR-20V3 Historical
items, the evaluator is referred to the HCR-20V3 manual (Douglas et al., 2013).
47
48
Table 3. Historical items of the HCR-20V3 and the FAM
Historical items
H1
Violence
As a child (12 and under)
As an adolescent (13-17)
As an adult (18 and over)
H2
Other antisocial behavior
As a child (12 and under)
As an adolescent (13-17)
As an adult (18 and over)
H3
Relationships
a.Intimate
b. Non-intimate
H4
Employment
H5
Substance use
H6
Major mental disorder
a. Psychotic disorders
b.Major mood disorders
c. Other major mental disorders
Additional guidelines for women to the
following HCR-20V3 items
H7
Personality disorder
a. Antisocial, psychopathic,
and dissocial
b.Other
H7
Personality disorder
a. Antisocial or psychopathic
b.Other
1.Cluster B (other than antisocial)
or traits of suspiciousness
2.Other personality disorders
H8
Traumatic experiences
a. Victimization / trauma
b.Adverse childrearing
experiences
H8
Traumatic experiences
a. Victimization / trauma
1.During childhood
2.After childhood
H9
Violent attitudes
H10
Treatment or supervision
response
Specific risk factors for women
H11
Prostitution
H12
Parenting difficulties
H13
Pregnancy at young age
H14
Suicidality / self-harm
Note. The HCR-20V3 items are reproduced with permission from the authors (see Douglas et al., 2013).
49
H7 Personality disorder
additional guidelines to the HCR-20V3
H7a Antisocial, Psychopathic, and Dissocial
Personality Disorder
Psychopathy is no longer an item in the HCR-20V3. Nevertheless, it is still advised
to consider the level of psychopathy for the coding of subitem H7a Antisocial or
psychopathic personality disorder. The differences between men and women with
respect to psychopathy are relevant for the HCR-20V3 item H7a. Therefore we
recommend to apply a different cut-off score for women when using the PCL-R
to code HCR-20V3 subitem H7a.
Definition
In general, lower scores are found on the PCL-R for women as compared to
men as well as a lower prevalence of the diagnosis of psychopathy (Logan,
2009; Nicholls et al., 2005; Vitale & Newman, 2001; see also p. 23). It has been
suggested in the literature to lower the cut-off score of the PCL-R in women
(e.g., Falkenbach, 2008; Kennealy, Hicks, & Patrick, 2007; Weizmann-Henelius et
al., 2010). In the FAM, this advice is followed and the cut-off score of the PCL-R
and the Psychopathy Checklist: Screening Version (PCL:SV; Hart, Cox, & Hare, 1995)
are lowered. In a recent study into psychopathy in women, it was found that the
diagnostic cut-off score of 23 as used in the FAM clearly differentiated women
with psychopathy from women without psychopathy (Klein Tuente et al., 2014;
De Vogel & Lancel, in preparation). Therefore, it may be argued that using a lower
diagnostic cut-off score for the PCL-R is a meaningful aspect of the FAM. This cutoff score should still be seen as experimental and mainly to be used for research
purposes and not to exclude women from treatment because of a high score.
Additional coding notes for women
• A score above 23 on the PCL-R, or above 15 on the PCL:SV should be
interpreted as definite / serious psychopathy and should be coded as Yes.
• A score of 14-23 on the PCL-R, or 11-15 on the PCL:SV should be interpreted as
possible / less serious psychopathy and should be coded as Partially.
• A score of under 14 on the PCL-R, or under 11 on the PCL:SV should be
interpreted as non-psychopathic and should be coded as No.
50
H7b Other personality disorders
When using the HCR-20V3 for women it is advised to divide H7b Other
personality disorder into: H7b1 Cluster B disorders (other than antisocial) or traits of
suspiciousness and H7b2 Other personality disorders.
Definition
Research has demonstrated that not all personality disorders are related
to violence. The relationship with violence is particularly clear for Cluster B
personality disorders and the paranoid personality disorder (Berman, Fallon,
& Coccaro, 1998; Coid, 2000; Coid, Kahtan, Gault, & Jarman, 1999). This applies
to both men and women. In a study of the relationship between personality
disorder and violence in women, a relationship was found between previous
violence and Cluster B disorders, specifically antisocial and narcissistic
personality disorders (Warren et al., 2002). Further, borderline personality
disorder was shown to be linked to violence within the sample. This study also
found a relationship between Cluster A symptoms (suspiciousness and bizarre
thoughts) and previous violent behavior. No significant relationship was found
for Cluster C symptoms and previous violent behavior. Weizmann-Henelius and
colleagues (2004) found a higher frequency of antisocial personality disorder and
a high degree of psychopathy in women who had repeatedly been convicted of
violent behavior compared to women who were first-time violent offenders.
Additional coding notes for women
• For coding item H7b1 for women the evaluator should explicitly consider
cluster B personality disorders or personality disorders involving
suspiciousness, such as paranoid personality disorder.
• An official diagnosis of one or more cluster B personality disorders or
personality disorders involving suspiciousness should be coded as Yes.
• Possible / less serious cluster B personality disorders (traits) or personality
disorders with traits of suspiciousness should be coded as Partially.
• No diagnosis of a cluster B personality disorder or personality disorder with
traits of suspiciousness should be coded as No on H7b1.
• Although there is little evidence of a relationship between cluster C personality
disorders and violent behavior (Warren et al., 2002), these are coded under
H7b2. The same goes for cluster A personality disorders, other than those
involving suspiciousness.
51
H8 Traumatic experiences
additional guidelines to the HCR-20V3
H8a Victimization/Trauma
In the HCR-20V3 subitem H8a Victimization / trauma victimization at any point
during the entire lifespan is considered (see the indicators for coding the item
concern childhood, adolescence and adulthood). As for women victimization
during multiple developmental stages increases violence risk, it is advised to
divide item H8a into: H8a1 Victimization / trauma during childhood and H8a2
Victimization / trauma after childhood.
Definition
Victimization / trauma during childhood
Research shows that women who were neglected as a child or who were victims
of (sexual) abuse have a greater chance of problems in adulthood, such as
substance abuse and committing violent crimes (Bishop, Mahmoodzadegan,
& Warren, 2008; Blackburn & Trulson, 2010; Herrera & McCloskey, 2003; Penney
& Lee, 2010; Siegel, 2000). This relationship also exists for men, but seems to
be stronger for women (Belknap & Holsinger, 2006; Blackburn & Trulson, 2010;
Bottos, 2007; Widom & Maxfield, 2001). There is a strong relationship between
having been a victim of child abuse and being a perpetrator of child abuse in
later life (De Ruiter & De Jong, 2005). Furthermore, a relationship was found
between other types of problematic circumstances in childhood and later
perpetration of violent behavior. Parental divorce and witnessing abuse within
the family distinguished women who have committed repeated violent behavior
from women who had shown violence only once (Weizmann-Henelius et al.,
2004). Women who committed violent offenses are more likely to have parents
with mental health or substance abuse problems than women who committed
non-violent offenses (Pollock, Mullings, & Crouch, 2006). For female inmates, a
relationship was found between problematic circumstances during childhood,
particularly physical and mental abuse by the mother, and being diagnosed with
Cluster B personality pathology in adulthood, especially borderline personality
disorder (Loper et al., 2008), which in itself constitutes a risk factor for violent
behavior.
52
Victimization / trauma after childhood
Research has shown that victimization after childhood is related to: 1) violent
behavior; 2) sexual offending; and 3) general criminal behavior. First, with regard
to violent behavior it has been demonstrated that female violent offenders are
more likely than non-offenders to have been mentally and physically abused as
children and as adults (Weizmann-Henelius et al., 2004). Swan and colleagues
(2005) found that women who frequently have been victims of violence by
their partner often exhibit violent behavior towards their partner, especially if
the woman was also victimized in childhood. Women who are abused by their
partners use more aggressive discipline with their children than women who
are not abused (Margolin, Gordis, Medina, & Oliver, 2003). Furthermore, it was
found that these women have a greater chance of developing post-traumatic
stress disorder and depression, and hence the risk for violent behavior towards
others is increased. Second, women who commit sexual offenses often have a
history of sexual abuse, both in childhood and in adulthood (Gannon & Cortoni,
2010). Women who are sexually abused are more likely to suffer from depression,
post-traumatic stress disorder and feelings of anger / irritability (Spataro, Mullen,
Burgess, Wells, & Moss, 2004), which in turn can lead to violent behavior. Third,
there is a significant association between victimization in adulthood and general
recidivism (Benda, 2005; Van Voorhis et al., 2010). Victimization is a risk factor for
violence to others for both men and women, but the correlation is stronger for
women (Benda, 2005). Women are generally more often exposed to victimization
than men. In a study of female inmates nearly all women had at least one
traumatic experience in adulthood (Green et al., 2005). In general, traumatic
experiences are predictive of other risky behaviors such as substance abuse and
risky sexual behavior (Rheingold, Acierno, & Resnick, 2004) and thus indirectly
also serve as a risk factor for violence (Briere & Elliott, 2003; Coker et al., 2002).
Additional coding notes for women
• Victimization / trauma that occurred during childhood should be coded under
H8a1, victimization / trauma that occurred during adulthood under H8a2.
• The severity of victimization depends on the duration, degree of bodily injury,
material damage, and physical and / or psychological consequences for the
victim.
• According to some mental health professionals, female patients may easily
take on the role of a victim. Therefore, the credibility and reliability of sources
that indicate victimization or trauma should be carefully considered.
53
H11 Prostitution
Definition
Past research (Morgan & Patton, 2002) and interviews with mental health
professionals have identified prostitution as a risk factor for violence in women.
Prostitution is defined as the act of performing sexual activities in exchange for
money. Different causes and motives may underlie prostitution. Prostitution
can be a personal choice, but can also be forced. Both voluntary and forced
prostitution are seen as a risk factor for violent behavior. Forced prostitution
is an indication of the suggestibility and vulnerability of a woman and her
inability to set limits. A woman who is forced into prostitution is probably more
vulnerable to the influence of others such as an antisocial partner or antisocial
friends. A woman may end up in the criminal circuit as a result of the influence of
such people. Voluntary prostitution can also be a risk factor for violent behavior.
Voluntary prostitution may indicate an antisocial attitude. Prostitution can arise
from a desire for power or money or can be used to fund a drug addiction.
Furthermore, a woman who works as a prostitute may find herself in dangerous
situations, especially in case of street prostitution. This may lead to victimization
of the woman, but may also lead to her perpetration of violence as necessitated
in self-defense.
Indicators
• Has worked as a prostitute for a period of time
• Has worked as a street or window prostitute
• Has worked as prostitute in a club
• Voluntary prostitution
• Was forced to work as prostitute
Coding notes
• This item involves both voluntary and forced prostitution.
• Assigning a score of Partially or Yes depends on the frequency and duration
of prostitution. If a woman has worked as a prostitute only once or for a short
period of time and no clear pattern was observable it should be coded as
Partially.
54
Case example
Lisa has presented with many problems from an early age. Since the age of 13
she engages in school truancy, drug use, and (violent) offending behavior. She
completely ignores and disrespects her parents, who try to impose boundaries on her.
Lisa is sexually active since age 13. Since age 18 she works as a prostitute soliciting on
the street, in sex shop windows, in nightclubs, and through and escort agency. She
also becomes involved in the business end of the escort agency. She is repeatedly
being accused of robbing her clients. At the age of 22, Lisa catches her boyfriend in
bed with another woman. She becomes furious, grabs a knife and threatens to kill
the woman. Lisa physically assaults the woman and cuts off her hair. Subsequently,
she forces her boyfriend’s brother to rape the woman.
55
H12 Parenting difficulties
Definition
There is a relationship between parenting difficulties and: 1) violence towards
a child or children6; 2) violence towards an intimate partner; and 3) general
criminal behavior. First, research has demonstrated that parents who abuse their
children more often have inadequate parenting skills (see De Ruiter & De Jong,
2005; De Ruiter et al., in preparation). Motz (2001) suggests that women’s own
experiences of abuse and neglect may evoke negative feelings, which can lead
to strong emotions and ultimately to the abuse of their own children. Second, an
exploratory study on the relationship between parenting and domestic violence
showed that women see parenting stress as a justification for violence to their
partner, especially if they have low feelings of effectiveness in their parenting
role and if they feel that the needs and demands of their children dominate their
lives (Simmons et al., 2010). Third, a longitudinal study by Messer and colleagues
(2004) demonstrated a strong link between parenting difficulties and general
criminal behavior. An important factor here is that bringing up children can be
very stressful, especially for a mother who is alone and has no partner to support
her (Van Voorhis et al., 2010).
Indicators
• Structural neglect of children
• Physical abuse of children
• Emotional abuse of children
• Sexual abuse of children
• Failed to intervene in child abuse by the partner
• Intervention by professionals was required, e.g., Youth Bureau, Council of Child
Care and Protection Board and other aid agencies
• Outplacement or custodial control of children
• Transfer of parental authority
6
56
Henceforth referred to as children, for reasons of readability.
Coding notes
• This item deals with problems with raising / taking care of children. Raising
non-biological children (e.g., children of a spouse or adopted children) is also
included in this item.
• When coding this item it is important to examine whether intervention by
professionals was required. Contacts with Youth Bureau, Council of Child Care
and Protection Board and other aid agencies are an indication of parenting
difficulties. The outplacement or custodial control of children and transfer of
parental authority indicate serious parenting difficulties.
• Whether to assign a code of Partially or Yes depends on the nature, severity
and duration of the parenting difficulties.
• If a woman never had (foster / step) children and thus has never adopted a
parenting role, the item is not applicable and the box n.a. should be checked.7
Case example
Sasha is a 33-year-old woman who was sentenced to a tbs-order following the
manslaughter of her 2-year-old son. As a child, Sasha is severely neglected and
abused by her mother. Since becoming a mother herself, she shows the exact same
behavior towards her children. The authorities remove her two children from the
home as a result of the severe abuse and neglect they are suffering at the hands of
their mother. A few years later, Sasha has two children with another man. She is not
able to take care of the oldest boy and neglects and abuses him severely. The boy
eventually dies as a result of physical abuse combined with malnutrition.
The reason that this item includes an n.a. option is that it distinguishes between a lack of parenting
opportunities (scored n.a) and an absence of parenting problems (score of 0).
7
57
H13 Pregnancy at young age
Definition
Results of a longitudinal study by Messer and colleagues (2004) suggest a
strong association between teenage pregnancy (before the age of 20) and
criminal behavior. Becoming a mother at a young age may hinder a woman’s
own development and can lead to several negative consequences in the area
of finances,
​​
education and social / intimate relationships (see also Serbin et
al., 1998). Furthermore, if a mother loses her child after birth, for example, to
adoption, this may have a strong emotional impact and possibly become a risk
factor for violence (Motz, 2001).
Indicators
• Was pregnant before the age of 20
• Pregnancy before age 20 had a strong impact on life
• Pregnancy before age 20 had physical, psychological, social or financial
consequences
• Was not able to finish her education because of pregnancy before the age of
20
• Pregnancy before age 20 resulted in serious problems in intimate relationship
• Pregnancy before age 20 caused severe stress
• Had an abortion before the age of 20 and this had strong negative impact
• Had a miscarriage before the age of 20 and this had strong negative impact
Coding notes
• This item deals with negative consequences of a pregnancy before the age of
20.
• When coding this item, the evaluator should also consider whether the
woman has had an abortion or miscarriage, if she has had to give her child up
for adoption, and whether it appears that such events have had a significant
impact on her. Depending on the frequency and impact this will lead to a
score of Partially or Yes.
58
Case example
At age 16, Lily unexpectedly becomes pregnant. Lily is seriously addicted to drugs and
fails to stop using drugs during her pregnancy. Eventually, her daughter is born very
preterm. The child is taken away almost immediately from Lily and placed within a
foster family. Since then things have gone further downhill for Lily; she has many
unstable relationships, often commits property and violent offenses and is regularly
admitted to psychiatric institutions. At age 24, Lily is convicted to compulsory
treatment because of robbery. In the hospital, Lily is diagnosed with schizophrenia in
addition to personality disorder traits and substance use problems. Lily suffers from
delusions and hallucinations that frighten her very much, for example, the delusion
that she is pregnant and that she feels a child moving in her belly. This calls forth
painful memories of her pregnancy and the surrendering of her daughter.
59
H14 Suicidality / self-harm
Definition
Both interviews with mental health professionals and past research have
identified a relationship between self-harm or a history of suicidality and violent
behavior towards others in women (Blanchette & Brown, 2006; Blanchette &
Motiuk, 1995; Morgan & Patton, 2002; Völlm & Dolan, 2009; Weizmann-Henelius
et al., 2004). A relationship was also found between suicidal thoughts and general
criminal behavior in women (Benda, 2005; Wilkins & Coid, 1991). In forensic
psychiatry and in prison, self-harm and suicide attempts are more common in
women than in men (Belknap & Holsinger, 2006; Coid et al., 2000; Motz, 2001;
Nicholls, 2001). A possible explanation is that self-harm is more common in
disorders like depression and borderline personality disorder - disorders that
generally occur more frequently in female forensic psychiatric patients than in
male forensic psychiatric patients (Coid et al., 2000; Coid, Wilkins, Coid, & Everitt,
1992). Motz (2001) argues that aggression directed towards the self is a typical
form of anger expression in females. Mental health professionals recognize this
in daily practice; men tend to turn their aggression outward (externalizing), and
women inward (internalizing). According to mental health professionals, suicidal
behavior and self-harm evidence the presence of despair and frustration. When
a woman exhibits destructive behavior to herself, this may turn into aggression
directed against others or others’ property. Mental health professionals further
indicate that suicide may be the motive behind some offenses, like arson or
infanticide (see also Wilson & Daly, 1988). The term suicidality is defined as
encompassing a range of thoughts and behaviors involving deliberate attempts
to injure or inflict death upon oneself (see Russell & Martson, 2010).
Indicators
• Serious self-harm (e.g., skin scratching or cutting, scraping, burning, banging
head against walls, taking large amounts of toxic drugs or medication)
• Had a serious wish to end her own life
• Suicide attempts
• Suicidal thoughts or plans
• Had taken serious preparations for suicide
60
Coding notes
• In determining the severity, the evaluator should take into account the nature,
severity and frequency of suicidal behavior / self-harm and the physical and /
or psychological consequences.
Case example
Mary grows up in a strictly religious family. She is close with her father, but has a
bad relationship with her mother who often hits her. When Mary is 9 years old, she
is sexually abused by a family friend over the period of a couple of months. She tells
her mother about the abuse but her mother blames Mary and tells her that she is
dirty and evil. From that moment on, Mary begins to hurt herself, for example by
cutting herself with sharp objects. She leaves home when she is 15 years old but is
not capable of setting up a stable life or fostering interpersonal relationships. After
she has been raped by an acquaintance, she carries out her first suicide attempt.
Numerous suicide attempts follow, mostly using medication or drugs. Mary is often
admitted to psychiatric hospitals, but treatment does not seem to work. Mary often
behaves very aggressively towards nursing staff and she destroys things or commits
arson to channel her anger. Eventually, she is sentenced to compulsory treatment
after setting a fire in her room in a psychiatric hospital posing great danger to others.
61
62
Appendixes
Appendixes
References
References
Coding sheet
Coding sheet
Risk Management items
Risk management items
Clinical items
Clinical items
Historical items
Historical items
Clinical items
For coding the Clinical items the evaluator should mainly focus on
observable behavior during the past 6 months and up until the moment
of the assessment. In the FAM, two new Clinical risk factors for women were
incorporated (C6 and C7). For coding the original HCR-20V3 Clinical items, the
evaluator is referred to the HCR-20V3 manual (Douglas et al., 2013).
In coding the HCR-20V3 Clinical items the evaluator should be cognizant of the
fact that as a result of sex differences in socialization processes women are more
sensitive and aware of their social environment than men, and thus are adept at
determining what is socially desirable (Bennett, Farrington, & Huesmann, 2005).
Therefore, it might be easier to overrate women’s self-insight and motivation
for treatment compared than it is for men. Furthermore, it is often assumed that
women have better verbal skills compared to men, although strong empirical
evidence for this assumption is lacking (Wallentin, 2009).
Table 4. Clinical items of the HCR-20V3 and the FAM
Clinical items
C1
Insight
a. Mental disorder
b.Violence risk
c. Need for treatment
C2
Violent ideation or intent
C3
Symptoms of major mental disorder
a. Psychotic disorder
b.Major mood disorder
c. Other major mental disorders
C4
Instability
a.Affective
b.Behavioral
c.Cognitive
C5
Treatment or supervision response
a.Compliance
b.Responsiveness
Specific risk factors for women
C6
Covert / manipulative behavior
C7
Low self-esteem
Note. The HCR-20V3 items are reproduced with permission from the authors (see Douglas et al., 2013).
63
64
C6 Covert / manipulative behavior
Definition
Though direct empirical evidence for this item’s predictive validity with respect
to violent behavior has yet to be established, one indication for its value comes
from studies that found that women show more indirect aggression than men
(see for example Archer & Cote, 2005; Crick & Grotpeter, 1995; Hess & Hagen,
2006). Indirect aggression (also called relational or social aggression or covert
social manipulation) is defined as a deliberate attempt to hurt another person
through social relationships or by affecting others’ social status, such as by
gossiping or excluding others. Several studies found significantly more indirect
aggression in girls than in boys (Brownie, 2007; Österman et al., 1998). There is
less research into indirect aggression in adult women and the research results
so far are less consistent than for girls. In a Dutch study into sex differences in
forensic patients, it was found that women report significantly more indirect
aggression on the Buss-Durkee Hostility Index-Dutch (BDHI-D) than men (Graat et
al., (2011). Further, there may be a link between indirect aggression in women
and a high Factor 1 score on the PCL-R (Isoma & Guyton, 2011). Importantly,
however, the fact that, in general, women exhibit more indirect aggression then
men does not necessarily imply that it is a predictor for future / direct violence.
Mental health professionals have frequently mentioned covert behavior as a
potential risk factor for violence (in particular the incitement of violence or other
kinds of antisocial behavior) and as an important target for treatment. Female
patients are seen as more adept at manipulating their environment than men,
and often seem to play a less conspicuous role in violent incidents or disruptive
behavior by others. Such practices do not necessarily lead to violence, but may
lead to conflicts and problems. A specific form of manipulative behavior that is
seen by mental health professionals as a strong risk factor for (inciting) violence
is manipulative sexual behavior. Sexuality may have different functions for
women and they may use their sexuality as leverage to have others do things for
them. This is found relatively often in women with a high degree of psychopathy
(Forouzan & Cooke, 2005). The deployment of sexuality to manipulate others
(usually men) may also increase the chance of inciting others to engage in
violent behavior. Finally, manipulative sexual behavior increases the risk for
victimization, for example, when the other person realizes that he or she is being
used.
65
Indicators
• Covert / manipulative behavior
• Gossiping
• Lying about having an intimate relationship
• Deceiving behavior
• Letting others do the dirty work for her
• Playing people against each other
• Unclear or subtle involvement in violent or disruptive incidents that take place
in her social environment
• Using somatic complaints to avoid treatment programs
• The intentional use of sexuality for personal gain
Coding notes
• Covert behavior within an institution can be identified by observing how a
woman moves within her social environment, for example the living-group
in which she resides, by evaluating the extent of her influence over the group
and by noting her involvement in violent or disruptive incidents that take
place in her social environment.
• Covert and manipulative behavior may be symptoms of certain disorders such
as psychopathy or borderline personality disorder, which are already scored
with the Historical item Personality disorder. The current item, however, is
dynamic; it pertains to behavior in the past six months and should be scored if
present, even if it was already included in the Historical factors.
• To determine what score should be assigned, the evaluator should focus on
concrete behavior during the past six months and also take into account the
nature and severity of this behavior.
66
Case example:
Grace is a 46-year-old woman who has repeatedly been convicted of fraud,
embezzlement and forgery. A few times she has engaged in (verbal) threatening
behavior. She will readily deceive friends, acquaintances, and strangers alike. Grace
commonly will engage in a behavioral pattern whereby she starts a relationship
with a man, steals large sums of money from him and then disappears. Eventually,
she is sentenced to compulsory treatment with a maximum duration of two years. In
the forensic psychiatric hospital, Grace shows a pattern of covert and manipulative
behavior: she frequently gossips and causes all kinds of misunderstandings and
problems. She is involved in sale of mobile phones and facilitates secret relationships
in the hospital by putting her room up for rent. Furthermore, she plays supervisors
against each other. She asks other patients with leave privileges to bring her things
and she borrows money from other patients or from the group budget, which she
does not repay. Grace follows her treatment program irregularly and frequently
claims to be ill. The treatment staff has the strong suspicion that she expresses her
somatic complaints to avoid treatment and obligations.
67
C7
Low self-esteem
Definition
In a meta-analysis, an association was found between women’s low self-esteem
and antisocial and violent behavior towards others, especially to vulnerable
others such as children (Larivière, 1999). In a study of criminal careers of girls in
the Netherlands, it was demonstrated that almost all girls who had committed
crimes had low self-esteem. Further, all girls with extremely low self-esteem had
problems relating to regulation of aggression (Wong, Slotboom, & Bijleveld,
2010). Having low self-esteem was also associated with other risk factors. It has
also been shown that women who have been abused in the past tend to have
low self-esteem (Salisbury et al., 2009) and that low self-esteem is associated with
an increased tendency to abuse substances (Hubbard & Matthews, 2008). Mental
health professionals indicate that women’s negative beliefs about themselves
resulting from low self-esteem may be acted out through violent behavior both
directed towards others and towards themselves.
Indicators
• Serious signs of low self-esteem
• Has negative attitudes about herself
• Has negative cognitions about herself
• Has negative feelings about herself
• Is devaluing herself
• Is making disparaging statements about herself
• Beliefs she is worthless
• Has feelings of hopelessness
• Feels she has nothing to lose
Coding notes
• In coding this item the evaluator must consider how this low self-esteem
may, in a given case, increase the risk of the woman acting out violently; for
example, feelings of hopelessness or having nothing to lose may facilitate
violence towards others and / or themselves.
• To determine what score should be assigned, the evaluator should look at
concrete behaviors in the past six months.
68
Case example
Chloe is a 30-year-old woman. As a child, she is belittled by her father and she grows
up as an extremely insecure and timid girl. From an early age Chloe lies about many
things, including telling others that she has serious diseases that she in fact does not
have. Her motivation for doing so is to garner positive attention from parents and
peers. The lying is pathological in nature and Chloe becomes increasingly entrenched
in her own lies. To control her feelings of stress, Chloe begins to set fires that pose
danger to both person and property. She is sentenced to compulsory treatment
with a maximum duration of 2 years. In the hospital, Chloe is seen as a very insecure
woman who has difficulties establishing her boundaries. This makes her vulnerable
to abuse by others, but at the same time, she is manipulative and she constantly lies
to both staff and fellow patients. Consequently, others do not take her seriously, do
not respect her and ultimately reject her. In addition, she pushes others away with
her lack of self-care and bad personal hygiene. This all leads to an accumulation of
frustration and she shows destructive behavior, both to herself (self-harm) and to
others in the hospital (arson, sabotage, indirect aggression).
69
70
Appendixes
Appendixes
References
References
Coding sheet
Coding sheet
Risk Management items
Risk management items
Clinical items
Clinical items
Historical items
Historical items
Risk management items
For coding the Risk management items, the evaluator should make a prediction
about the woman’s risk for engaging in certain behaviors in the near future:
within the 12 months after the risk assessment. It may be useful to code the
Risk management items for different contexts in order to compare and decide
upon the needed future intervention or aftercare, for example, continued
sheltered living versus (conditional) discharge from a forensic psychiatric
hospital. In forensic cases that appear in court, the double codings may be
helpful for the evaluator to explain and justify their risk assessment to the court.
In the FAM, two new Risk management risk factors for women were incorporated
(R6 and R7). For coding the original HCR-20V3 Risk management items, the
evaluator is referred to the HCR-20V3 manual (Douglas et al., 2013).
Table 5. Risk management items of the HCR-20V3 and the FAM
Risk management items
R1
Professional services and plans
R2
Living situation
R3
Personal support
R4
Treatment or supervision response
a.Compliance
b.Responsiveness
R5
Stress or coping
Specific risk factors for women
R6
Problematic child care
responsibility
R7
Problematic intimate
relationship
Note. The HCR-20V3 items are reproduced with permission from the authors (see Douglas et al., 2013).
71
R6 Problematic child care responsibility
Definition
This item is concerned with two issues: 1) the heavy burden and responsibility
of taking care of an underage child or children8; 2) the anger, frustration and
sorrow that can result from the loss of contact or limited contact with children.
First, raising children requires skills and entails many responsibilities that may
be too difficult for women with severe problems or psychopathology.9 Research
has demonstrated that women who have responsibility to children recidivate
more often, especially in combination with poverty, limited social support and
substance use problems (Greene, Haney, & Hurtado, 2000; Van Voorhis et al.,
2008). Furthermore, the literature shows that when a woman has previously
neglected or abused her children, having child care responsibility increases the
risk for future violence towards both her own and other children who are under
her care. (Motz, 2001; De Ruiter & De Jong, 2005; De Ruiter et al., in preparation).
Second, it was found that women who have limited contact with their children
because of detention or admission to an institution have elevated levels of
stress and more psychological problems (Van Voorhis et al., 2010). If there is a
threat that the woman will lose her children, for example, by transfer of parental
authority this can often lead to intense feelings of anger and sorrow (Batchelor,
2005; Van Voorhis et al., 2008).
Mental health professionals recognize that problems may arise if women
experience feelings of failure and disappointment stemming from an inability to
help their children when their absence is as a result of the woman’s detention
or psychiatric admission. Further, unrealistic expectations about the frequency
and intensity of contact with or care of her children may lead to feelings of anger
and frustration directed towards the foster family or those who question her
parenting skills, which may ultimately increase her risk of behaving violently.
Indicators
• There is a probability of problematic child care responsibility
• Feels frustrated, guilty or angry by not being able to take care of her children
• Is not willing to accept guidance in how to raise her children
• Will probably not regain custody of her underage children and feels frustrated
by that
• Is not equipped to raise children
8
9
72
Henceforth referred to as children, for reasons of readability.
Having children may also have a protective effect (see p. 24. See also the SAPROF item Life goals).
Coding notes
• Child care responsibility does not only concern a woman’s own children, but
•
•
•
•
also, for instance, the children of a partner.
Score assignment is based on the expected severity of problems the woman
will face in caring for children.
This item may seem to overlap with the Historical item Parenting difficulties.
However, the present item is dynamic and has a broader scope. This item not
only concerns parenting skills, but also problems in relation to desired child
care responsibility, such as the consequences of not being able to raise or help
children due to detention or hospital admission.
This item refers predominantly to the (desired) care for underage children, but
may also concern (young) adult children, for example, when there are specific
circumstances in their life, such as serious psychological problems, illness
or disability. These circumstances or problems may affect the woman, for
example, cause a lot of worries and feelings of stress.
If it is not likely that there will be a (desired) child care responsibility the item
should be scored No.
Case example
Fatima grows up in affective neglectful conditions. She is almost totally incapable
of bonding with others and has a lot of problems in intimate relationships and with
social contacts. At age 30, she begins a relationship with a man with whom she has
three children. However, her partner ends the relationship a year after the birth of
their youngest child. Fatima is devastated, abandons her children and starts to live
on the street. She begins to accrue debt and fails to honor visitation arrangements
with her children who are living with her ex-husband’s family. Fatima threatens to
abduct the children and to hurt her ex-partner and his family. After a restraining
order has been imposed on Fatima, she continues to make threats to her ex-husband,
his family, and her children. Finally, she is sentenced to compulsory treatment in a
forensic psychiatric hospital because of stalking. At the beginning of treatment the
children visit Fatima. However, as it becomes clear that this is too heavy a burden
for both Fatima and the children, the hospital together with the guardian decides to
stop the visits. Fatima is very upset and initiates a lawsuit seeking the custody of her
children. Though this certainly increases her stress, treatment staff believes that the
lawsuit also serves as an excuse for Fatima to avoid treatment.
73
R7
Problematic intimate relationship
Definition
Women who exhibit violent behavior are more likely to have antisocial, violent
and / or addicted partners than women who have not committed violent
offenses (Leverentz, 2006; Weizmann-Henelius et al. 2004). Living together
with an antisocial partner, having a marriage of poor quality, and lacking the
support of the partner are strongly related to criminal behavior (Benda, 2005;
Farrington, Barnes, & Lambert, 1996; Messer et al., 2004; Van Voorhis et al.,
2010). The relationship between having a problematic intimate relationship
and criminal behavior applies to both women and men, but the correlation is
stronger for women (Benda, 2005). Women who have been sexually abused
often seem to repeatedly become involved with the same type of partner
(McCartan & Gunnison, 2010). They are more likely to continue the relationship
with a problematic partner or to start a relationship with similar types of abusive
partners.
Mental health professionals indicate that a problematic intimate relationship may
lead to risk for future violence in several ways. First, in a problematic relationship
characterized by violence and conflicts, the partner is a potential victim (see also
p. 18). Second, many women commit offenses together with their partner as an
antisocial partner may involve the woman in the commission of his crimes.
Indicators
• High probability of problematic (future) intimate relationship
• Likely (financially) dependent on partner
• Cannot bear to not be in a relationship
• Is inclined to flee in unstable relationships
• Unstable relationships characterized by many conflicts are anticipated
• Relationships are anticipated in which there is oppression or abuse
• Relationships with antisocial partners are anticipated
Coding notes
• This item applies to an existing or anticipated intimate relationship in which
major problems are seen or expected.
• This item may be seen to overlap with the Historical item Relationships as both
items involve (a pattern) of instability and problems in intimate relationships.
The distinction is that the current item focuses on the future. This includes
the expectation that a woman will maintain a problematic relationship or
74
will begin a new problematic relationship. A high score on the Historical item
Relationships does not necessarily mean that a woman will also score highly on
the current item, but the chances of this are considerably larger.
• Relationships in which there is a strong fusion or dependency are susceptible
to the risk of joint offending. This includes not only actually committing
offenses, but also being accessory to or inciting someone else to commit an
offense.
Case example
Kimberly is a 27-year-old woman who, together with her boyfriend killed her uncle
when she was 16. Kimberly suffers from a severe borderline personality disorder
and she has been treated for a long time in a forensic psychiatric hospital. Despite
her motivation and commitment to the treatment she does not manage to direct
her own life. She is very vulnerable, is easily influenced by others, and is unable to
establish boundaries. Kimberly has had many relationships within the hospital, with
both men and women. These relationships seem to destabilize her every time. Her
present relationship is with a man with severe addiction problems who frequently
relapses into alcohol consumption. As alcohol is a risk factor for Kimberly herself,
she finds it difficult to cope with his problems; she is angry with her boyfriend,
but at the same time she craves alcohol. Also, she has a strong fear of losing her
boyfriend, which causes her to be overly responsive to his dubious requests. For
example, together they are involved in drug dealing within the hospital. Kimberly
acknowledges the problems the relationship poses for her, but she also admits that
she cannot live without her partner.
75
76
Appendixes
Appendixes
References
References
Coding sheet
Coding sheet
Risk Management items
Risk management items
Clinical items
Clinical items
Historical items
Historical items
Coding scheme FAM
Additional guidelines to the HCR-20V3 for women
Identifying facts
➊ Gather information
➋ Presence of risk factors
Use both manuals for coding the items of the HCR-20V3 (HCR-20V3 items
H7-H8 with the additional guidelines in the FAM) and the items of the
FAM.
Making meaning
➌Relevance
➍Formulation
➎Scenarios
Taking action
➏Management
➐ Final opinions
Make the three additional risk ratings:
- Self-destructive behavior (e.g., self-harm, suicide attempt)
- Victimization (e.g., victim of domestic violence)
- Non-violent criminal behavior (e.g., property offenses, fraud)
Note. For more detailed instructions see Coding procedure (p. 35). Further, it is advised to also examine
protective factors, for example, with the SAPROF.
77
Coding sheet Female Additional Manual (FAM)
Additional guidelines to the HCR-20V3 for women
Name:
Date:
Age:
Context of risk assessment:
Historical items
H7
Code
Relevance
Code
Relevance
Code
Relevance
Personality disorder: additional guidelines to the HCR-20V3
a)Antisocial, psychopathic, and dissocial (lower PCL-R cut
off scores for women)
b)Other personality disorder:
1. Cluster B (except antisocial/psychopathic) or traits of
suspiciousness
2. Other personality disorder
H8
Traumatic experiences: additional guidelines to the HCR-20V3
a)Victimization / trauma
1. During childhood
2. After childhood
b)Adverse childrearing experiences (original HCR-20V3
coding guidelines)
H11
Prostitution
H12
Parenting difficulties
H13
Pregnancy at young age
H14
Suicidal behavior / self-harm
Clinical items
C6
Covert / manipulative behavior
C7
Low self-esteem
Risk management items
R6
Problematic child care responsibility
R7
Problematic intimate relationship
Other considerations
78
❑ n.a.
Final risk ratings near future (12 months)
Final risk ratings violence to others
Future violence
Serious physical harm
Imminent violence















Low
Low - Moderate
Moderate
Moderate - High
High
Low
Low - Moderate
Moderate
Moderate - High
High
Low
Low - Moderate
Moderate
Moderate - High
High
Extra risk ratings
Self-destructive behavior
Victimization
Non-violent criminal
behavior















Low
Low - Moderate
Moderate
Moderate - High
High





Low
Low - Moderate
Moderate
Moderate - High
High
Low
Low - Moderate
Moderate
Moderate - High
High
Optional:
Final judgment protective factors
(assessed with the SAPROF)
Evaluator(s):
Low
Low - Moderate
Moderate
Moderate - High
High
Position evaluator(s):
Relevance: Yes/Partially/No; relevance of each item for the current risk for violent behavior.
The original HCR-20V3 items need to be coded with the HCR-20V3 manual (Douglas et al., 2013).
© Copyright 2014, Van der Hoeven Kliniek
Vivienne de Vogel, Michiel de Vries Robbé, Willemijn van Kalmthout and Caroline Place
79
80
Appendixes
Appendixes
References
References
Coding sheet
Coding sheet
Risk Management items
Risk management items
Clinical items
Clinical items
Historical items
Historical items
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Appendixes
Appendixes
References
References
Coding sheet
Coding sheet
Risk Management items
Risk management items
Clinical items
Clinical items
Historical items
Historical items
Appendix 1: Additional guidelines to HCR-20V3
items in the FAM
HCR-20V3 items
Additional guidelines in the FAM
Historical items
H7
Personality disorder
a. Antisocial,
psychopathic,
and dissocial
The expression of the construct of psychopathy is likely
different in women compared to men. The PCL-R cut-off
score is lowered for women.
b. Other
Research has demonstrated that for women (and men)
there is a relationship between violence and all cluster B
disorders and/or traits of suspiciousness. When using the
HCR-20V3 for women it is therefore advised to divide H7b
into:
A code No should be given when there is a score under 14
on the PCL-R, or under 11 on the PCL:SV; a code Partially
should be given when there is a score of 14-23 on the
PCL-R, or 11-15 on the PCL:SV; a code Yes should be given
when there is a score above 23 on the PCL-R, or above 15
on the PCL:SV.
7b 1) Cluster B disorders (other than antisocial) or traits of
suspiciousness;
7b 2) Other personality disorders.
A code No should be given for 7b1 when there is no
diagnosis of personality disorder of cluster B or with traits
of suspiciousness; a Partially should be given when there
is a possible / less serious personality disorder of cluster
B or with traits of suspiciousness; a Yes should be given
when there is a definite / serious personality disorder of
cluster B or with traits of suspiciousness.
H8
Traumatic experiences
a. Victimization /
8a 1) During childhood;
trauma
8a 2) After childhood.
b. Adverse
childrearing
experiences
97
Appendix 2: Specific risk factors for women in
the FAM in addition to the HCR-20V3
FAM items
Brief description
Literature
Historical items
H11 Prostitution
Morgan & Patton,
Has worked as a prostitute for a
2002
substantial period of time. Often
maladaptive living circumstances /
life style of a prostitute are seen as
risk factor. Moreover, the vulnerability
of a woman forced into prostitution
makes her also vulnerable to be
dragged into offenses.
H12 Parenting
difficulties
Serious parenting difficulties, for
instance, abuse or emotional neglect
of children. Information is needed
from official institutions like the Child
Welfare Council.
H13 Pregnancy at
young age
Messer et al., 2004;
Serious impact of pregnancy at
Serbin et al., 1998
young age (before the age of 20).
Abortions or miscarriages can also be
included.
H14 Suicidality /
self-harm
Serious and / or repeated suicide
attempt(s) and / or self-harm. As level
of suicidality increases, so does the
frequency of externalizing violence.
Suicide is also seen as motive for
some violent offenses like filicide and
arson.
Benda, 2005;
Blanchette & Brown,
2006; Blanchette &
Motiuk, 1995; Coid et
al., 2000; Motz, 2001;
Morgan & Patton,
2002; Völlm & Dolan,
2009; WeizmannHenelius et al., 2004
Serious indications of covert or
manipulative behavior. Examples of
covert behavior are concealing or
hiding the truth, stirring things up,
gossiping, lying about relations, or
blackmailing others. Examples of
manipulative behavior are utilizing
her sexuality in order to obtain
power or other gains or utilizing
somatic complaints in order to avoid
treatment program.
No direct empirical
evidence
Messer et al., 2004;
Motz, 2001; Salisbury,
2007; Simmons et al.,
2010; Van Voorhis et
al., 2010
Clinical items
C6
98
Covert /
manipulative
behavior
FAM items
Brief description
C7
Larivière, 1999; Van
Negative beliefs and emotions
Voorhis et al., 2008;
about her own worth that may
Wong et al., 2010
result in feelings of despair,
hopelessness, having nothing to lose
and consequently acting violently
towards others and / or herself.
Low self-esteem
Literature
Risk management items
R6
Problematic child
care responsibility
Serious problems because of the
(desired) care for children. Raising
children might be too stressful
considering the woman’s own
problems / pathology. Also, grief
over the loss of child(ren) through
termination of parental rights, anger
towards others for questioning
her skills and / or taking away her
parental rights.
Greene et al., 2000;
Van Voorhis et al.,
2010
R7
Problematic
intimate
relationship
Problematic (anticipated) intimate
relationship, e.g., living with a
criminal partner, intimate partner
violence.
Benda, 2005;
Leverentz, 2006;
Messer et al., 2004;
Van Voorhis et al.,
2010; WeizmannHenelius et al., 2004
99
While women still represent a minority of the forensic
psychiatric and prison population, worldwide the number
of women committing violent crimes has increased steadily
over the past two decades. Several risk factors for violent
behavior in women differ substantially from those in
men. Mental health professionals have recognized these
differences and have expressed the need for more specific
guidelines for risk assessment in women. Assessment
of gender-sensitive risk factors in addition to general risk
factors is vital for accurate assessment and management of
women’s violence risk. Despite the great advances in risk
assessment over the past decades, very few tools have
been developed specifically for the assessment of violence
risk in females.
The first Female Additional Manual (FAM) was published in
2012 as an additional manual to the HCR-20. The present
FAM is entirely adapted to be used with the new HCR20V3 and contains additional guidelines to two historical
items of the HCR-20V3 and eight new items with specific
relevance to women. The aim of the FAM is to provide
mental health professionals with a comprehensive violence
risk assessment that offers additional guidelines for risk
management in women.
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