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Changes in Dynamic Factors During Treatment Predicts Postdischarge Recidivism

lhbChangeability of dynamic risk and protective factors during treatment is useful for measuring development in forensic patients related to reduced violent recidivism. This is the bottom line of a recently published article in Law and Human Behavior. Below is a summary of the research and findings as well as a translation of this research into practice.

Featured Article | Law and Human Behavior | 2014, OnlineFirst

Changes in Dynamic Risk and Protective Factors for Violence During Inpatient Forensic Psychiatric Treatment: Predicting Reductions in Postdischarge Community Recidivism


Michiel De Vries Robbé, Van der Hoeven Clinic, Utrecht, the Netherlands
Vivienne de Vogel, Van der Hoeven Clinic, Utrecht, the Netherlands
Kevin S. Douglas, Simon Fraser University and Mid-Sweden University
Henk L. I. Nijman, Radboud University and Altrecht, Den Dolder, the Netherlands


Empirical studies have rarely investigated the association between improvements on dynamic risk and protective factors for violence during forensic psychiatric treatment and reduced recidivism after discharge. The present study aimed to evaluate the effects of treatment progress in risk and protective factors on violent recidivism. For a sample of 108 discharged forensic psychiatric patients pre- and post-treatment assessments of risk (HCR-20) and protective factors (SAPROF) were compared. Changes were related to violent recidivism at different follow-up times after discharge. Improvements on risk and protective factors during treatment showed good predictive validity for abstention from violence for short- (1 year) as well as long-term (11 years) follow-up. This study demonstrates the sensitivity of the HCR-20 and the SAPROF to change and shows improvements on dynamic risk and protective factors are associated with lower violent recidivism long after treatment.


protective factors, risk assessment, treatment progress, violence, desistance

Summary of the Research

“Studies on the dynamic factors of the HCR-20 have shown good predictive validities for violence at short- as well as long-term follow-up and have demonstrated their usefulness for treatment guidance and evaluation of violence risk. However, few studies have investigated the relationship between changes in dynamic risk factors and treatment progress or reductions in violence risk. The present study investigated the usefulness of the joint assessment of the HCR-20 and the SAPROF for measuring changes in dynamic risk and protective factors during treatment. The aim was to evaluate the predictive validity of treatment progress as measured by the tools (i.e., reductions in risk factors and improvements in protective factors) for treatment success. It was hypothesized that dynamic risk factors and protective factors would change over time during treatment and that improvements on risk factors and protective factors would be negatively related to violent recidivism after treatment” (p. xx).

Participants were 108 male patients with a history of either general violent or sexually violent offending. Treatment length averaged 5.65 years and short-term recidivism was defined as any violence committed during a 12-month follow-up period, while long-term recidivism during the maximum average follow-up period of 11 years.

The HCR-20 and SAPROF were coded at the start and end of treatment, and comparisons were made between violent recidivists and those who did not violent reoffend.

Pretreatment risk and protective factors did not significantly differ between future recidivists and nonrecidivists. “However, at discharge future recidivists had higher scores on both dynamic HCR-20 subscales and lower scores on all three SAPROF subscales compared to those participants who turned out to be long-term desisters. These differences were significant for the clinical risk scale and for the internal and motivational protection scale, as well as for the total SAPROF and HCR-SAPROF index posttreatment scores” (p. xx).

“On average patients with final judgments that were rated one risk category higher than other patients (moderate vs. low, or high vs. moderate) were 11 times more likely to recidivate violently within one year after treatment and three times more likely to recidivate in a violent offense in the long run” (p. xx)

Translating Research into Practice

“At the end of treatment, protective factor total scores were significantly greater for the nonrecidivists and dynamic risk factor total scores significantly lower, indicating that the patients who changed the most while in treatment (i.e., those who showed the greatest improvements in risk and protective factors) were the most resilient to violent offending” (p. xx).

Positive changes during treatment appear to reduce recidivism in the short and long term. The likelihood of short term recidivism may be 2 times less likely with a 5 point reduction on the HCR-20 over treatment, and 2 times less likely with a 5 point increase on the SAPROF. Additionally, a 5-point increase over treatment on the SAPROF may indicate over 3 times reduced probability of short term recidivism. “Thus, those who changed the most during treatment still showed significantly lower violent recidivism rates long after treatment had ended… the present findings exemplify that treatment changes can have fairly stable long-term positive effects on abstention from violence.”

“The findings in this study suggest that the HCR-20 dynamic risk factors and the SAPROF protective factors could be useful to measure meaningful change in risk and protection and potentially provide for attainable treatment targets in clinical practice. This implies the HCR-20 and the SAPROF could be useful in guiding effective violence reduction efforts” (p. xx).

Professionals evaluating treatment effectiveness and efficacy may benefit from analyzing the treatment changes measured by the HCR-20 and SAPROF. “This connection between dynamic factor changes and treatment success is promising for the value of dynamic risk assessment tools for evaluating treatment progress, predicting successful treatment outcome and guiding treatment interventions in psychiatric practice. Furthermore, these findings are supportive of the apparent effectiveness of forensic psychiatric treatment in reducing the likelihood of violent reoffending in a high-risk offender population” (p. xx).

Other Interesting Tidbits for Researchers and Clinicians

“The finding that change scores have relatively stable predictive validities across follow-up times suggests that, at least for the current specific subgroup of patients, improvements in risk and protection levels during forensic psychiatric treatment of offenders at high risk of violent recidivism may have long-term effects in making society safer. Due to individual cases of recidivism getting much attention in the media, the general public opinion on the usefulness of treatment of offenders at high risk has become quite skeptical. The positive results on the changeability of risk and protective factors for violent offending observed in the present study may therefore present a valuable finding in support of the potential effectiveness of forensic psychiatric treatment.”

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Contributing Author

BanfordMegan-picThis post was authored by Megan Banford.

Megan is a graduate student in the Forensic Psychology program at John Jay College. She graduated in 2013 from Simon Fraser University with a B.A. (Honors) and hopes to attain her PhD in clinical forensic psychology. Her main research interests include violence risk assessment and management, juvenile offenders and public policy.

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