Sandy Oziel, MA Lisa Marshall, Phd, DClinPsych, CPsych David Day, PhD, CPsych

Sandy Oziel, MA Lisa Marshall, Phd, DClinPsych, CPsych David Day, PhD, CPsych

Overview of protective factors Theoretical perspectives Current literature Assessment instruments Current study Research questions Methods Procedure Preliminary findings

Every year patients found NCR receive an ORB hearing. The ORB is the governing body that determines: Whether patients pose a significant threat to the public Where patients should reside each year Primary role of psychologists is to assess risk of reoffending by administering risk tools Historically, assessments have focused on risk factors Protective factors have been partially included or overlooked altogether.

Less is known about how protective factors/patient strengths may contribute to desistance from reoffending (de Vogel, de Vris Robbe, de Ruiter, & Bouman, 2011). Lack of research investigating protective factors among NCR patients in Canada Protective factors may allow for: A more balanced and comprehensive account of future offending Inform treatment planning Inform risk management practices (de Ruiter & Nicholls, 2011).

Two prominent frameworks for understanding offending behaviour and rehabilitation Risk Need Responsivity Model (RNR; Andrews, Bonta, & Hoge, 1990) focusses on reducing risk through patient deficits Good Lives Model (GLM; Ward, 2002) focusses on building on protective factors to reduce recidivism Complementary approaches

Protective factors are the direct opposite of risk factors. Protective factors do not have corresponding risk factors, they are inherently different. Everyone wins!

Numerous definitions of protective factors Characteristics of a person that reduce the risk of future violent behaviour Can be internal, motivational or external factors (de Vogel, de Ruiter, Bouman, & de Vries Robbe, 2012). Patient strengths differ from protective factors Needs to be related to a change in reoffending

Structured Assessment of Violence in Youth (SAVRY; Borum, Bartel, & Forth, 2003). The Inventory of Offender Risks, Needs and Strengths (IORNS; Miller, 2006). The Short-term Assessment of Risk and Treatability (START; Webster, Martin, Brink, Nicholls, & Middleton, 2004). The Structured Assessment of Protective Factors for Violence Risk (SAPROF; de Vogel, de Ruiter, Bouman, & de Vries Robbe, 2009). First tool to exclusively rely on protective factors Six studies conducted since 2011

1. What is the relationship between protective factors, risk factors, mental state and general functioning of patients? 2. Do protective factors predict two outcomes: a.) Risk management decisions Change in level of security Medium security, minimum security, conditional, absolute discharge Privilege level 14 levels within the hospital

b.) Proxies of recidivism Institutional misconduct (inappropriate behaviour in the hospital) Disposition breaches (violations in the conditions outlined by the ORB) 3. Do protective factors predict these two outcomes over and above risk factors alone?

Clinical interview and file review Data collection at Ontario Shores between January 2015-August 2015 Aiming for N=100

Participants Inclusion criteria: NCRMD regardless of diagnosis Adult males and females, inpatients and outpatients Exclusion criteria Incapable of providing consent

Collected by researcher: SAPROF (de Vogel, de Ruiter, Bouman, & de Vries Robbe, 2009) Protective factors START (Webster, Martin, Brink, Nicholls, & Middleton, 2004) Risk and protective factors SANS/SAPS (Andreasen, 1983; Andreasen, 1984) Mental state GAF (American Psychiatric Association, 2000) Social and occupational functioning WASI-II (Wechsler, 2011) IQ estimate

Collected by forensic clinical psychologists: HCR-20 V3 (Douglas, Hart, Webster, & Belfrage, 2013) Violent risk LS/CMI (Andrews, Bonta, & Wormith, 2006) General risk PCL-R (Hare, 2003) Psychopathy

1.) Forensic px with upcoming ORB hearing are eligible 3.) Consent reviewed and capacity assessed by researcher 5.) File info gathered to corroborate responses and score measures 7.) Px s ORB hearing takes place approx. 1 month following interview 9.) Proxies of recidivism collected from file info 6 months following the interview 2.) Recruited by psychologists during risk assessment and capacity assessed 4.) Semi structured interview for 60-90 min 6.) Risk assessment scoring sheets collected from psychologists 8. ) ORB disposition obtained to assess changes in level of security

N=9 (25 %) Number declined/not approached = 26 (75%) Demographics Sex: Males (n=8), Females (n=1) Age (M=44 years old) Average length at hospital= 4 years and 3 months Primary diagnosis on the Schizophrenia Spectrum or Other Psychotic Disorder Disposition Detention order on medium unit (n=5) Detention order on minimum unit (n=2) Detention order with community living, outpatients (n=2)

Protective factors SAPROF total scores (M=16.22, SD=7.2) SAPROF judgment ratings (3 low, 1 low-mod, 2 mod, 1 high-mod, 2 high) Mental health status SAPS total score negatively correlated with SAPROF total scores (r=-.723, p=.028)and judgment scores (r=-.807, p=.009) Institutional misconduct over the past year SAPROF predicted misconduct (F(5,3)=22.33, p=.014) Specifically, internal items, motivational items and judgment ratings were all significant predictors Fewer protective factors may predict a greater likelihood of a patient engaging in misconduct at the hospital (e.g., violent or threatening behaviour) May have a bearing on how this risk is managed

Some patients are reluctant to participate due to paranoia Responses to self-report measures administered during the interview may lack reliability among patients with low insight Higher functioning patients with more protective factors may be more likely to participate in the study

*Special thanks to the Research Department and Forensic Clinical Psychologists at Ontario Shores.

The findings from this study may have substantial clinical implications for informing risk management decisions among NCRMD patients. Given that ORB must decide where a patient resides, greater attention to protective factors when assessing risk may be warranted to effectively reduce the level of threat posed NCR patients. Validating the SAPROF using a sample from Ontario Shores will also provide information about North American NCRMD patients.

You are invited to participate in a research study! A study is being conducted right here at Ontario Shores. You might find this study interesting because it will be looking at how patient strengths relate to ORB decisions. It will involve a unique interview discussing the good aspects of your life and aspects related to your progress. This information may provide a more balanced perspective to risk assessment. The interview will take place on your unit/at FOS and you will be compensated for your time. If you think you may be interested in participating, please let me know and I will pass on your information to the researcher who will give you more information.

Forensic unit Sex Age Date admitted to hospital Current disposition Diagnosis GAF ratings PANSS ratings IQ score Risk ratings (HCR-20, LS/CMI, PCL-R) Medication dosage current Change in medication over last year Institutional misconduct over past year Disposition breaches over past year Number of individual treatment hours attended Number of treatment groups attended Number of vocational activities participated in

Hospital and Grounds Conditions Level 1: Accompanied (please enter in the name of the person accompanying the patient) *M = mandatory for medical, legal and compassionate uses. Level 2: Indirectly Supervised: Up to 1/2 hour, 0800-1600 hrs, contact at 15 minute intervals Level 3: Indirectly Supervised: Up to 1 hour, 0800-1800 hrs, contact at 30 minute intervals Level 4: Indirectly Supervised: Up to 2 hours, 0800-2100, contacts at 60 minutes intervals Level 5: Indirectly Supervised: Up to 4 hours, 0800-2100, contacts at 2 hour intervals Level 6: Indirectly Supervised: Up to 8 hours, 0800-2100, contacts at 4 hours intervals Level 7: Indirectly Supervised: Up to 12 hours, 0800-2100, contacts at 6 hour intervals Community Conditions Level 8: Accompanied (please enter the name of the person accompanying the patient) *M = mandatory for medical, legal and compassionate uses. Level 9: Indirectly Supervised: Up to 3 hours, 0800-2100, contacts at 1 hour intervals Level 10: Indirectly Supervised: Up to 6 hours, 0800-2100, contacts at 2 hour intervals Level 11: Indirectly Supervised: Up to 8 hours, 0800-2100, contacts at 4 hour intervals Level 12: Indirectly Supervised: Up to 12 hours, 0800-2100, contacts at 6 hour intervals Level 13: Indirectly Supervised: Up to one (1) week, contacts at 12 hour intervals daily Level 14: Community Residence - Detention Order

Predictors: Tally total risk factor and protective factor scores (research purposes only) Final Protection Judgement and Final Risk Judgement ratings (low, mod-low, mod, highmod, high) Integrated Final Risk Judgement Score HCR-SAPROF index Outcomes: Proxies of recidivism: medication change of dose, institutional misconduct, disposition breaches. Risk management decisions: change in security level and privileges.

The SAPROF has successfully predicted: Treatment progress (de Vries Robbe, de Vogel, & de Spa, 2011). Institutional misconduct (de Vries Robbe, de Vogel, Wever, Douglas, & Nijman s, in press). Sexual recidivism (de Vries Robbe, de Vogel, Koster, & Bogaerts, in press), Violent recidivism (de Vries Robbe, de Vogel, Douglas & Nijman, in press), Self-inflicted harm (Davoren et al., 2013). Applied to various populations including outpatients (Yoon, Spehr, & Briken, 2011), and youth (Klein, Yoon, Briken, Turner, Spehr, & Rettenberger, 2012).

Correlational analyses Establish convergent and divergent validity between SAPROF scores and measures of risk, protection, mental state and general functioning ROC and regression analyses SAPROF scores examined individuals and combined with risk scores to predict Risk management decisions Proxies of recidivism