Schema therapy for violent PD offenders: a randomized clinical trial.

BACKGROUND: Violent criminal offenders with personality disorders (PD's) can cause immense harm, but are often deemed untreatable. This study aimed to conduct a randomized clinical trial to test the effectiveness of long-term psychotherapy for rehabilitating offenders with PDs. METHODS: We compared schema therapy (ST), an evidence-based psychotherapy for PDs, to treatment-as-usual (TAU) at eight high-security forensic hospitals in the Netherlands. Patients in both conditions received multiple treatment modalities and differed only in the individual, study-specific therapy they received. One-hundred-three male offenders with antisocial, narcissistic, borderline, or paranoid PDs, or Cluster B PD-not-otherwise-specified, were assigned to 3 years of ST or TAU and assessed every 6 months. Primary outcomes were rehabilitation, involving gradual reintegration into the community, and PD symptoms. RESULTS: Patients in both conditions showed moderate to large improvements in outcomes. ST was superior to TAU on both primary outcomes - rehabilitation (i.e. attaining supervised and unsupervised leave) and PD symptoms - and six of nine secondary outcomes, with small to moderate advantages over TAU. ST patients moved more rapidly through rehabilitation (supervised leave, treatment*time: F(5308) = 9.40, p < 0.001; unsupervised leave, treatment*time: F(5472) = 3.45, p = 0.004), and showed faster improvements on PD scales (treatment*time: t(1387) = -2.85, p = 0.005). CONCLUSIONS: These findings contradict pessimistic views on the treatability of violent offenders with PDs, and support the effectiveness of long-term psychotherapy for rehabilitating these patients, facilitating their re-entry into the community.

Predictive validity on clinical item-level of the HKT-R divided into clinical patient classes.

BACKGROUND: Because of the heterogeneity of forensic groups, latent class analysis (LCA) can allow for the formation of stronger homogeneous patient classes, which can improve the predictive validity of forensic risk assessment tools, such as the Historical Clinical Future - Revised (HKT-R), which was used in this study. In particular, dynamic clinical risk and protective items are important in treatment and are obligatory assessed annually for every forensic patient with a TBS measure in the Netherlands. Therefore, this study investigated the predictive validity of the HKT-R at clinical item-level per patient class. METHOD: A cohort of 332 forensic patients, who were discharged from highly secured Forensic Psychiatric Centers/Clinics (FPCs) in the Netherlands between 2004 and 2008, was followed. LCA was performed to cluster this group of patients based on psychopathology and criminal offenses. The predictive validity of the HKT-R clinical items by class was assessed with official reconviction data two and five years after discharge as outcome measure. RESULTS: Four classes were identified. The predictive validity of the HKT-R clinical items showed differences between and within classes on admission or discharge, and for predicting violent reoffending after two or five years after discharge. DISCUSSION: Different risk/protective factors of the HKT-R may play a role for different subgroups of patients. Therefore, this heterogeneity should be considered for any measure or intervention.

Burnout, work engagement and workaholism in a group of Dutch judges: distinctiveness and two-year structural stability.

The aim of this two-wave study is to investigate whether burnout, work engagement and workaholism can be empirically distinguished in one model and whether this model shows structural stability over a period of 2 years (i.e. whether the distinguishability between the constructs holds across time). The study was conducted among 118 judges in the Netherlands who completed questionnaires measuring burnout, work engagement and workaholism. The results showed that these are relatively distinguishable constructs, despite a considerable overlap of professional efficacy loading on work engagement (instead of burnout; as hypothesized), absorption loading on workaholism (in addition to work engagement; as hypothesized) and exhaustion loading on workaholism (in addition to burnout), which represents a new finding. These extra loadings led to model modifications, which were found at both time points. As hypothesized, this model appeared to be stable over time. Nevertheless, further clarification and conceptualization of these constructs are undoubtedly needed.

Bidirectional associations between self-regulation and deviance from adolescence to adulthood.

Self-regulation is considered a major predictor of crime and deviant behavior. However, longitudinal research investigating these associations, frequently looked only at the effect of self-regulation on deviant behavior, but not the other way around. The current study argued that deviance may contribute to later problems in self-regulation, and examined bidirectional associations, comparing a unidirectional and bidirectional model of associations between these variables. A Random Intercept Cross-Lagged Panel Model and eight data waves from 772 participants, aged 10-12 years to 30 years were used. Results showed that a bidirectional model fit the data better than a unidirectional model. The final model revealed an influence of deviance on self-regulation mainly in adolescence, whereas self-regulation influenced deviance only over two time points in adulthood. The results suggest that, in adolescence, problems in self-regulation may follow, rather than precede deviant behavior. Thus, decreasing deviant behavior or intervening in the aftermaths of deviant behavior in adolescence might have a positive effect on self-regulation in young adulthood, lowering the chance of adult deviant behavior. The current study shows that the long-presumed directionality of self-regulation to deviance can lead to bias, and more rigorous longitudinal research is needed in order to further inform theory and practice.

Sexual Offending Pathways and Chat Conversations in an Online Environment.

People from all over the world pay for live streaming video images of minors, also called webcam child sex tourism (WCST). Although there is an increase in research about online sexual offending, relatively few studies have investigated the approaches used by people who have committed WCST offenses (PWCST). In addition, these studies describe these approaches as active-orientated without mentioning an avoidant pathway. The aim of the study was to investigate whether PWCST use similar pathways as the four offending pathways identified by Ward and Hudson. Using qualitative thematic analysis, 195 cases of online chat conversations between PWCST and operators posing as a minor were analyzed. The Ward and Hudson pathways model was partially replicable. Evidence was found for an approach and avoidant pathway. The data also suggest three other sub-pathways and a mixed pathway. Most PWCST in this study used an approach pathway to immediately approach minors for sex, which provides important insight into the diverse nature of sexual grooming.

Cognitive-motivational, interpersonal, and behavioral functioning in relationship to treatment and research engagement in forensic patients with ADHD.

OBJECTIVES: To provide more insight into treatment and research responsivity in offenders with attention-deficit hyperactivity disorder (ADHD). METHOD: Via self-reports and patients' scores on cognitive computer tasks, it was examined whether poorer cognitive-motivational, interpersonal, and behavioral functioning were related to treatment no-shows, longer treatment time duration intervals, and no-show at the research appointment in 52 forensic outpatients with ADHD (Mage = 35.3, SD = 9.38). Treatment adherence was tracked for 10 appointments after research participation. RESULTS: Regression analyses showed that higher self-reported impulsivity was associated with research no-show, and more alcohol use with longer treatment time intervals. Yet, self-reported delay aversion was associated with fewer treatment no-shows, and, uncontrolled for alcohol use, impulsivity was associated with shorter treatment time intervals in a subsample of patients. CONCLUSIONS: These preliminary results indicate that externalizing behaviors increase the risk for nonadherence in forensic ADHD patients, but that cognitive-motivational problems also motivate patients to be more engaged.

Factor Structure and Construct Validity of the Levenson Self-Report Psychopathy Scale (LSRP): A Replication and Extension in Dutch Nonclinical Participants.

The Levenson Self-Report Psychopathy (LSRP) scale is widely used to assess psychopathic traits in noninstitutionalized samples. Recent studies suggest that a three-factor structure measuring Egocentricity, Callousness, and Antisocial factors outperformed the original two-factor structure of the LSRP. This study replicated and extended these findings by examining the factor structure and construct validity of a Dutch version of the LSRP in a community sample (N = 856, subsamples ranging between 140 and 572 participants). Confirmatory factor analysis results corroborated the superiority of the three-factor model of the LSRP, using 19 of the 26 LSRP items. Limitations included the need to specify correlated residuals for some indicators, although these were largely in line with prior studies. Across three subsamples, we found evidence for construct validity of the LSRP subscales. Egocentricity and Antisocial showed a pattern of differential associations with external correlates in accordance with theoretical expectations. Callousness shared some correlates with Egocentricity, others with Antisocial, and uniquely predicted low morality and high physical aggression. Few exceptions to the hypothesized associations were observed, mostly concerning Callousness. Overall, the LSRP three-factor model received further support in a Dutch sample, and is thus recommended in future research, possibly adding items to improve the performance of the Callousness factor.

Attachment and Personality Disorders Among Child Molesters: The Role of Trust.

The present study investigated multivariate associations between attachment styles and personality disorders (PDs)-and the mediating role of trust-in a sample of child molesters ( n = 84) and a matched control group from the general community ( n = 80). Among child molesters, canonical correlation analysis revealed that two variates resembling avoidant and anxious attachment dimensions were associated with PD traits. Attachment avoidance was related to schizoid, schizotypal, and avoidant PDs, with a marginal contribution of antisocial PD. Attachment anxiety was related to borderline and histrionic PDs, with a marginal contribution of obsessive-compulsive PD. Paranoid and dependent PDs contributed to both variates. In the control group, a more general association between attachment insecurity and PDs emerged. Finally, mistrust significantly explained the associations between attachment and PDs in both samples. Future studies should examine whether treatment for PDs in child molesters could benefit from a focus on attachment and trust.

Who Are the Victims of NGRI Acquittees? A Study of Belgian Internees.

BACKGROUND: The limited literature on victim characteristics of offenders found not guilty by reason of insanity (NGRI) shows that most victims are adults who are known to the offender. It is currently unclear whether victims are mainly male or female or whether there are differences in the type of victims according to the offenders' psychiatric disorder. METHOD: Victim characteristics were retrospectively collected from 362 NGRI acquittees, and the influence of psychiatric diagnoses on victim profiles was examined. RESULTS: Victims were mainly adult acquaintances and were equally likely to be male or female. Family members and caregivers were the most frequent type of acquaintance victims. Further analyses suggest that these victim characteristics are similar for perpetrators with different psychiatric diagnoses. CONCLUSION: Victimization of strangers and minors was unlikely in NGRI offenders.

Attributions of Blame among Victims of Child Sexual Abuse: Findings from a Community Sample.

According to the attribution theory, negative outcomes of child sexual abuse (CSA) are thought to vary depending on whether CSA victims attribute the abuse to internal or external factors, respectively, self-blame and perpetrator-blame. Therefore, the purpose of this study was to identify abuse characteristics and attitudes that influence blame attributions among CSA victims from a community sample. Data from respondents with a history of CSA (N = 1,496) have been used in predicting blame attributions; perpetrator-blame, self-blame, or both. Results from a multinomial logistic regression analysis showed that attitudes toward gender roles had a significant effect on blame: victims were more likely to blame themselves when they endorsed more conservative gender attitudes than victims with more liberal attitudes. Implications for this finding are discussed.

Effect of virtual reality aggression prevention training for forensic psychiatric patients (VRAPT): study protocol of a multi-center RCT.

BACKGROUND: Many patients residing in forensic psychiatric centers have difficulties regulating their aggression in an adequate manner. Therefore, they are frequently involved in conflicts. Evidenced-based aggression therapies in forensic psychiatry are scarce, and due to the highly secured environment, it is hard to practice real-life provocations. We have developed a Virtual Reality aggression prevention training (VRAPT), providing safe virtual environments, in which patients can practice controlling their aggressive behaviors in an adequate way. The main objective of this study is to examine whether VRAPT is effective in reducing aggression among forensic psychiatric inpatients. METHODS: Four forensic psychiatric centers in the Netherlands are participating in this study. Participants will be randomly assigned to either VRAPT or a waiting list. The two groups will be compared at several different time points: baseline (12 weeks before intervention), pre-intervention, post-intervention and at 12 weeks follow-up. After follow-up measurements are completed, participants from the waiting list will also receive VRAPT. The primary outcome is level of aggressive behavior, consisting of staff-reported and self-reported measures. Secondary outcomes are self-report questionnaires on e.g., anger, impulsivity and aggression. DISCUSSION: To the best of our knowledge this is the first study to examine the effectiveness of a VR aggression prevention training in forensic psychiatric centers. Further details on the methodological issues are discussed in this paper. TRIAL REGISTRATION: Dutch Trial Register ( NTR, TC = 6340 ). Retrospectively registered 14-04-2017.

Detection of domestic violence by community mental health teams: a multi-center, cluster randomized controlled trial.

BACKGROUND: Domestic Violence and Abuse (DVA) is associated with a range of psychosocial and mental health problems. Having a psychiatric illness increases likelihood of being a victim of DVA. Despite the evidence of a high risk for DVA and the serious effects of violent victimization in psychiatric patients, detection rates are low and responses are inadequate. The aim of the BRAVE (Better Reduction trough Assessment of Violence and Evaluation) study is to improve detection of and response to DVA in psychiatric patients. In this article, we present the protocol of the BRAVE study which follows the SPIRIT guidelines. METHODS: The BRAVE study is a cluster randomized controlled trial. We will include 24 community mental health teams from Rotterdam and The Hague. Twelve teams will provide care as usual and 12 teams will receive the intervention. The intervention consists of 1) a knowledge and skills training for mental health professionals about DVA, 2) a knowledge and skills training of DVA professionals about mental illness, 3) provision and implementation of a referral pathway between community mental health and DVA services. The follow up period is 12 months. Our primary outcome is the rate of detected cases of recent or any history of DVA in patients per team in 12 months. Detection rates are obtained through a systematic search in electronic patient files. Our secondary aims are to obtain information about the gain and sustainability of knowledge on DVA in mental health professionals, and to obtain insight into the feasibility, sustainability and acceptability of the intervention. Data on our secondary aims will be obtained through structured in depth interviews and a questionnaire on knowledge and attitudes on DVA. DISCUSSION: This study is the first cluster randomized controlled trial to target both male and female psychiatric patients that experience DVA, using an intervention that involves training of professionals. We expect the rate of detected cases of DVA to increase in the intervention teams. With early detection of victimization of DVA in psychiatric patients we hope to improve the mental health of psychiatric patients in the short and long term. TRIAL REGISTRATION: ISRCTN:14115257 . Date of registration: 15th January 2015.

PCL-R field validity in prison and hospital settings.

Recent field studies have questioned the interrater reliability (IRR) and predictive validity regarding (violent) recidivism of the Psychopathy Checklist-Revised (PCL-R). Using a forensic psychiatric sample, the current study investigated discrepancies in scoring between hospital and prison settings, as well as differences in predictive validity across these two settings. PCL-R information was collected from prison and hospital files, resulting in 224 PCL-R total scores and 74 double scores. When examining repeated measurements, large individual differences were found together with an intraclass correlation coefficient (ICCA,1) of .42 for the total score. Discrepant results were found for Factor 2, with repeated scores within the same setting having an ICCA,1 of .28 versus an ICCA,1 of .57 for repeated scores between settings. However, areas under the curve (AUCs) from receiver operating characteristic (ROC) analyses for total, factor and facet scores did not differ between settings. For the whole sample, Factor 2 scores marginally predicted violent and general recidivism after 2 years (AUC = .62 and .63), whereas Factor 1 did not predict (violent) recidivism. Consistent with recent studies from other countries, these results suggest inadequate field reliability and validity in prison and hospital settings in Flanders (Belgium). (PsycINFO Database Record

Volunteers in Circles of Support and Accountability Job Demands, Job Resources, and Outcome.

In Circles of Support and Accountability (CoSA), volunteers support a medium- to high-risk sex offender in his process toward desistance by developing a long-term empathic relationship. More knowledge is needed about the impact of this work on volunteers themselves. In a sample of 40 Dutch CoSA volunteers-at the time constituting 37% of the national population of 108 then active CoSA volunteers-we measured outcome in terms of volunteer satisfaction, determination to continue, compassion satisfaction, burnout and secondary stress, vicarious growth, civic capacities, and professional skills. We explored theoretically derived predictors of positive and negative outcome, and conceptualized them within the Job Demands-Resources model (JD-R). Volunteers reported mainly positive effects, especially high levels of volunteer satisfaction, compassion satisfaction, and determination to continue. Results indicated that job demands and most of the internal job resources were of minor importance. External job resources, especially social support and connectedness, were associated with positive outcome. Connectedness mediated the effect of social support on compassion satisfaction.

Treatment no-show in forensic outpatients with ADHD.

BACKGROUND: 'No-show' is important in today's mental healthcare services, yet in forensic psychiatry, little is known about its relationship to general and disorder-specific patient characteristics. AIMS: The aim of this article is to determine the prevalence of no-show and any general and disorder-specific features associated with no-show in a cohort of offenders with attention deficit hyperactivity disorder registered at a specialist forensic mental health clinic. METHODS: Participants were 118 adult men with a mean age just over 32 years (SD 8.75) attending forensic mental health outpatient clinics in the Netherlands who had a primary diagnosis of attention deficit hyperactivity disorder and who had been aggressive and/or delinquent. RESULTS: Over a 1-year period, most patients (101, 86%) missed at least one appointment. The average number of appointments offered was 37.88 (SD = 27.27), and the average number of no-shows was 6.53 (SD = 5.99) per patient. Multivariate linear regressions showed a 10-fold likelihood of later no-shows if the first appointment was missed; not showing up after the intake procedure was also associated with higher rates of later no-show. None of the disorder-specific characteristics contributed to the problem. CONCLUSIONS: No-show is of particular concern in forensic mental health settings. In the current study, no-show was primarily associated with features related to the time of initial consultation. More attention should thus be paid at this stage to using a standard method of assessing a wider range of variables likely to affect attendance. Copyright © 2016 John Wiley & Sons, Ltd.

Being Sexually Attracted to Minors: Sexual Development, Coping With Forbidden Feelings, and Relieving Sexual Arousal in Self-Identified Pedophiles.

This article aims to provide more insight into pedophilic attraction and risk and protective factors for offending in nonclinical pedophiles. Fifteen participants were interviewed about sexuality, coping, and sexual self-regulation. Many participants struggled with acknowledging pedophilic interest in early puberty and experienced psychological difficulties as a result. Furthermore, many committed sex offenses during adolescence when they were still discovering their feelings. Early recognition of risk factors and early start of interventions seem vital in preventing offending. Moreover, results suggest that risk for offending can be diminished by creating more openness about pedophilia and by providing pedophiles with social support and control.

Ethnic differences in help-seeking behaviour following child sexual abuse: a multi-method study.

In Western societies, groups from a minority ethnic background are under-represented in formal mental health care. However, it is unknown if the minority ethnic victims of child sexual abuse differ from majority ethnic victims regarding their help-seeking behaviours. This study used a multi-method design to investigate the prevalence of (in) formal help-seeking after child sexual abuse and the influence of attitudes towards gender roles and sexuality on help-seeking among the Dutch minority ethnic and majority ethnic victims. We also examined differences in reasons not to seek help. Quantitative survey data on help-seeking patterns among 1496 child sexual abuse victims were collected. Four qualitative focus groups were conducted with professionals working in the field of child sexual abuse and minority ethnic groups to explore help-seeking behaviour. No significant differences between ethnicity emerged in help-seeking rates. However, respondents with more liberal gender attitudes were more likely to disclose than conservative respondents. Additionally, an interaction effect was observed between ethnicity and gender attitudes, indicating that, contrary to the main effect, young people of Moroccan and Turkish heritage with more liberal gender attitudes were less likely to disclose abuse. Reasons for not seeking help differed among groups. Focus group members emphasised mistrust towards counsellors and perceptions that inhibit minority ethnic youth from seeking help.

Helping Sex Offenders to Desist Offending: The Gains and Drains for CoSA Volunteers-A Review of the Literature.

In Circles of Support and Accountability (CoSA), a group of trained volunteers support sex offenders in their desistance process by engaging in a long-lasting empathic relationship. Is it safe to employ volunteers in this way? This literature review provides an overview of both theoretical explanations and empirical evidence of the possible impact of this type of volunteerism on the volunteers themselves. Fifty original research articles and reviews met the selection criteria of a systematic search. Results on effects of volunteering in general, effects of volunteer work with offenders, and effects of working with sex offenders on professionals are summarized and integrated. Generally, volunteering supports and improves physical health and mental well-being, personal growth, and citizenship. However, working with sex offenders in an empathic relationship generates both positive and negative effects on psychological and social function. Personal characteristics, task characteristics, and organizational characteristics moderate and mediate the impact.

The Effectiveness of an Intervention to Promote Awareness and Reduce Online Risk Behavior in Early Adolescence.

The current study explored the effect of a school-based intervention on online risk awareness and behavior in order to shed light on a relatively unexplored field with high practical relevance. More than 800 Belgium primary school children (grade 4 and 6) were assessed at two measurements (n T1 = 812, 51.2 % female; n T2 = 819, 51.3 % female) before and after the intervention. Half of them received a 10 min classroom intervention indicating online risks. Children in the control group received a 10 min presentation concerning online applications without any emphasis on risks. Children in the intervention group were more likely to be aware of online risks directly after the intervention; this effect was still noticeable 4 months after. Reporting of online risk behavior in the intervention group was also higher compared to the control group who did not receive the intervention. Overall online risk awareness and online risk behavior were negatively associated and the awareness did not modulate the association between the intervention and online risk behavior. Furthermore, individual differences were assessed. Girls were more likely to be aware of online risks and asserted less online risk behavior than boys were. In line with the imperative in adolescence to become more risk taking, children in a higher grade were more likely to behave in a risky manner when online. The current study provides a valuable starting point for further research on how to decrease online risk behavior in early adolescence.

Assessing protective factors for sexually violent offending with the SAPROF.

The Structured Assessment of Protective Factors for violence risk (SAPROF) has recently been developed as a risk assessment tool to focus solely on protective factors for (sexual) violence risk. Research on protective factors for sexual offending is very limited and most risk assessment tools for adult sexual offenders do not incorporate protective factors. The current study investigates the applicability and predictive validity of the SAPROF for forensic psychiatric patients who have sexually offended. For a sample of 83 hands-on sexual offenders, risk assessments were carried out retrospectively with the SAPROF, the Historical Clinical Risk Management-20 (HCR-20) and the Sexual Violence Risk-20 (SVR-20). Results show good interrater reliability and negative correlations between the SAPROF and both risk tools. Predictive validities of the SAPROF protective factors for reconvictions of general and sexual violence were good for short-term (1-3 year) as well as for long-term follow-up (15 year). Moreover, the SAPROF remained a statistically significant predictor of future violence and sexual violence even after controlling for the HCR-20 and the SVR-20. Implications of these findings and recommendations for future research are discussed.