Theories on the Etiology of Deviant Sexual Interests: A Systematic Review.

Not much is known about the etiology, or development, of deviant sexual interests. The aim of this systematic review was to provide a broad overview of current theories on the etiology of sexual deviance. We conducted a systematic search of the databases PubMed and APA PsycInfo (EBSCO). Studies were included when they discussed a theory regarding the etiology or development of sexual deviance. Included studies were assessed on quality criteria for good theories. Common etiological themes were extracted using thematic analysis. We included 47 theories explaining sexual deviance in general as well as various specific deviant sexual interests, such as pedophilia and sadism/masochism. Few theories (k = 7) were of acceptable quality as suggested by our systematic assessment of quality criteria for good theories (QUACGOT). These theories indicated that deviant sexual interests may develop as the result of an interplay of various factors: excitation transfer between emotions and sexual arousal, conditioning, problems with "normative" sexuality, and social learning. Neurobiological findings could not be included as no acceptable quality neurobiological theories could be retrieved. The important roles of excitation transfer and conditioning designate that dynamic, changeable processes take part in the etiology of sexual deviance. These same processes could potentially be deployed to diminish unwanted deviant sexual interests.

Factor Analysis With Unusual Sexual Interests: A Replication Study in a Representative Population Sample.

A previous study found a variety of unusual sexual interests to cluster in a five-factor structure, namely submission/masochism, forbidden sexual activities, dominance/sadism, mysophilia, and fetishism (Schippers et al., 2021). The current study was an empirical replication to examine whether these findings generalized to a representative population sample. An online, anonymous sample (N = 256) representative of the Dutch adult male population rated 32 unusual sexual interests on a scale from 1 (very unappealing) to 7 (very appealing). An exploratory factor analysis assessed whether similar factors would emerge as in the original study. A subsequent confirmatory factor analysis served to confirm the factor structure. Four slightly different factors of sexual interest were found: extreme, illegal and mysophilic sexual activities; light BDSM without real pain or suffering; heavy BDSM that may include pain or suffering; and illegal but lower-sentenced and fetishistic sexual activities. The model fit was acceptable. The representative replication sample was more sexually conservative and showed less sexual engagement than the original convenience sample. On a fundamental level, sexual interest in light BDSM activities and extreme, forbidden, and mysophilic activities seem to be relatively separate constructs.

Prospective Field Validation of the START:AV in a Dutch Secure Youth Care Sample.

The Short-Term Assessment of Risk and Treatability: Adolescent Version (START:AV) is a risk assessment instrument for adolescents that estimates the risk of multiple adverse outcomes. Prior research into its predictive validity is limited to a handful of studies conducted with the START:AV pilot version and often by the instrument's developers. The present study examines the START:AV's field validity in a secure youth care sample in the Netherlands. Using a prospective design, we investigated whether the total scores, lifetime history, and the final risk judgments of 106 START:AVs predicted inpatient incidents during a 4-month follow-up. Final risk judgments and lifetime history predicted multiple adverse outcomes, including physical aggression, institutional violations, substance use, self-injury, and victimization. The predictive validity of the total scores was significant only for physical aggression and institutional violations. Hence, the short-term predictive validity of the START:AV for inpatient incidents in a residential youth care setting was partially demonstrated and the START:AV final risk judgments can be used to guide treatment planning and decision-making regarding furlough or discharge in this setting.

Should Relapse Always Be Punished? A Survey Study into Forensic Social Professionals' Attitudes to Substance Use.

Health professionals' attitudes to substance abusers have been reported as suboptimal with potential adverse consequences for the quality of health care provided. Less is known about professionals working with addicted clients in mandated contexts. The aim of this study is to gain insight into forensic social professionals' attitudes to substance use and examine differences between subgroups of professionals. An online survey including the Brief Substance Abuse Attitude Scale was completed by 314 Dutch forensic social professionals. Overall, forensic social professionals' attitudes to substance use and treatability were positive, but there were differences regarding needed treatment interventions and ways of controlling substance use. Professionals who work within specialist addiction services had less moralistic and stereotypical attitudes. Professionals who have personal experiences with addiction reported to be more tolerant, but at the same time more convinced of strict control of substances use of their clients.

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.

Victimization history in female forensic psychiatric patients with intellectual disabilities: Results from a Dutch multicenter comparative study.

BACKGROUND: Victimization is highly prevalent in individuals with mild intellectual disability (MID) or borderline intellectual functioning (BIF) and is an important risk factor for mental health problems and violent behavior. Not much is known, however, about victimization history in women with MID-BIF admitted to forensic mental health care. AIMS: The aim of this multicenter study is to gain insight into victimization histories and mental health problems of female forensic psychiatric patients with MID-BIF. METHODS: File data were analyzed of 126 women with MID-BIF who have been admitted to one of five Dutch forensic psychiatric hospitals between 1990 and 2014 and compared to data of 76 female patients with average or above intellectual functioning and to a matched sample of 31 male patients with MID-BIF. RESULTS: All forensic patients had high rates of victimization, but women with MID-BIF showed an even higher prevalence of victimization during both childhood and adulthood and more complex psychopathology compared to female patients without MID-BIF. Compared to male forensic patients with MID-BIF, women with MID-BIF were more often victim of sexual abuse during childhood. During adulthood, the victimization rate in these women was more than three times higher than in men. CONCLUSIONS: Victimization is a salient factor in female forensic patients with MID-BIF and more gender-responsive trauma-focused treatment is needed.

Violence Risk Assessment with the HCR-20V3 in Legal Contexts: A Critical Reflection.

The HCR-20V3 is a violence risk assessment tool that is widely used in forensic clinical practice for risk management planning. The predictive value of the tool, when used in court for legal decision-making, is not yet intensively been studied and questions about legal admissibility may arise. This article aims to provide legal and mental health practitioners with an overview of the strengths and weaknesses of the HCR-20V3 when applied in legal settings. The HCR-20V3 is described and discussed with respect to its psychometric properties for different groups and settings. Issues involving legal admissibility and potential biases when conducting violence risk assessments with the HCR-20V3 are outlined. To explore legal admissibility challenges with respect to the HCR-20V3, we searched case law databases since 2013 from Australia, Canada, Ireland, the Netherlands, New Zealand, the UK, and the USA. In total, we found 546 cases referring to the HCR-20/HCR-20V3. In these cases, the tool was rarely challenged (4.03%), and when challenged, it never resulted in a court decision that the risk assessment was inadmissible. Finally, we provide recommendations for legal practitioners for the cross-examination of risk assessments and recommendations for mental health professionals who conduct risk assessments and report to the court. We conclude with suggestions for future research with the HCR-20V3 to strengthen the evidence base for use of the instrument in legal contexts.

How Serious Is Debt Among Probation Clients? A Study Into the Prevalence and Scope of Debt in a Dutch Probation Sample.

Although studies point to a relationship between debt and crime, there is a limited understanding of their reciprocal relationship and possible mediating risk factors. Moreover, knowledge about the prevalence and scope of debt among offenders is lacking. Therefore, the present study analyzed 250 client files including risk assessment data from the Dutch probation service on the prevalence of debt and possibly related risk factors. The results show that debt is highly prevalent and complex, which underlines the importance of acquiring more knowledge about debt as a potential risk factor for relapse during supervision. It was found that problems with regard to childhood and living situation, education and work/daytime activities, and mental and physical health may be possible underlying risk factors in the relationship between debt and crime. These insights can help professionals adequately support clients with regard to debt in order to prevent recidivism.

Do Changes in Emotional States Predict Therapy Alliance in Dutch Male Offenders in Mandated Clinical Care?

Therapy alliance has been studied largely in voluntary psychotherapy but less is known about its predictive factors for positive alliance and treatment outcome in forensic populations. The aim of this study was to examine the relationship between offenders' emotional states and therapy alliance. Moreover, we were interested in the predictive impact of emotional states early in treatment on alliance at 18 months into treatment. Self-ratings of emotional states and alliance by 103 male offenders, and therapist-ratings for therapy alliance were examined using hierarchical multiple regression analyses. Participants were primarily convicted for violent of sexual offenses, and were diagnosed with antisocial, borderline or narcissistic personality disorders. Healthy emotional states were predictive of mid-treatment agreement on therapy goals and therapist ratings on tasks within the therapy. Unhealthy emotional states were predictive of patient-rated agreement on tasks. Emotional states were not predictive for the reported therapist/patient bond or global alliance ratings. This study emphasizes the importance of healthy emotional states in treatment of offenders with personality disorders.

Do We Hold Males and Females to the Same Standard? A Measurement Invariance Study on the Psychopathy Checklist-Revised.

Psychopathy in females has been understudied. Extant data on gender comparisons using the predominant measure of assessment in clinical practice, the Psychopathy Checklist Revised (PCL-R), points to a potential lack of measurement invariance (MI). If indeed the instrument does not perform equally (well) in both genders, straightforward comparison of psychopathy scores in males and females is unwarranted. Using a sample of female and male forensic patients (N = 110 and N = 147 respectively), we formally tested for MI in a structural equation modeling framework. We found that the PCL-R in its current form does not attain full MI. Four items showed threshold-biases and particularly Factor 2 (the Social Deviance Factor) is gender biased. Based on our findings, it seems reasonable to expect that specific scoring adjustments might go a long way in bringing about more equivalent assessment of psychopathic features in men and women. Only then can we begin to meaningfully compare the genders on the prevalence, structure, and external correlates of psychopathy.

Taking "the boss" into the real world: Field interrater reliability of the Short-Term Assessment of Risk and Treatability: Adolescent Version.

There is emerging evidence that the performance of risk assessment instruments is weaker when used for clinical decision-making than for research purposes. For instance, research has found lower agreement between evaluators when the risk assessments are conducted during routine practice. We examined the field interrater reliability of the Short-Term Assessment of Risk and Treatability: Adolescent Version (START:AV). Clinicians in a Dutch secure youth care facility completed START:AV assessments as part of the treatment routine. Consistent with previous literature, interrater reliability of the items and total scores was lower than previously reported in non-field studies. Nevertheless, moderate to good interrater reliability was found for final risk judgments on most adverse outcomes. Field studies provide insights into the actual performance of structured risk assessment in real-world settings, exposing factors that affect reliability. This information is relevant for those who wish to implement structured risk assessment with a level of reliability that is defensible considering the high stakes.

A Study Into the Severity of Forensic and Civil Inpatient Aggression.

Aggressive incidents occur frequently in health care facilities, such as psychiatric care and forensic psychiatric hospitals. Previous research suggests that civil psychiatric inpatients may display more aggression than forensic inpatients. However, there is a lack of research comparing these groups on the incident severity, even though both frequency and severity of aggression influence the impact on staff members. The purpose of this study is to compare the frequency and severity of inpatient aggression caused by forensic and civil psychiatric inpatients in the same Dutch forensic psychiatric hospital. Data on aggressive incidents occurring between January 1, 2014, and December 31, 2017, were gathered from hospital files and analyzed using the Modified Overt Aggression Scale, including sexual aggression (MOAS+). Multilevel random intercept models were used to analyze differences between forensic and civil psychiatric patients in severity of aggressive incidents. In all, 3,603 aggressive incidents were recorded, caused by 344 different patients. Civil psychiatric patients caused more aggressive incidents than forensic patients and female patients caused more inpatient aggression compared with male patients. Female forensic patients were found to cause the most severe incidents, followed by female civil psychiatric patients. Male forensic patients caused the least severe incidents. The findings have important clinical implications, such as corroborating the need for an intensive treatment program for aggressive and disruptive civil psychiatric patients, as well as emphasizing the importance of gender-responsive treatment.

Familicide: A Systematic Literature Review.

Familicides have received relatively little attention and are mostly discussed in studies with broader aims. Here, we reviewed 67 studies from 18 countries on familicides, in which an offender killed or attempted to kill their current or former spouse/intimate partner and one or more of their biological or stepchildren. We conducted a systematic literature search in PubMed, PsycINFO, and Google Scholar. Eight studies investigated familicide specifically, while the remaining reported on familicide cases as a subsample. We retrieved data on offenders' gender, age, and background as well as on victims and their relationship to the offender. We also retrieved data on contextual factors and offense characteristics (i.e., modus operandi, offense location, premeditation, and whether or not the offender had committed suicide). We also coded methodological aspects of the studies. Familicides were almost exclusively committed by men and about half of the familicide cases led to the suicide of the offender. Mental health problems, relationship problems, and financial difficulties were prevalent. Because few studies reported population base rates of the investigated characteristics, it is difficult to draw conclusions about specific risk factors. Future research should further investigate typologies of familicide and examine risk factors for different types of familicides.

Contact between victims and offenders in forensic mental health settings: An exploratory study.

Victim-offender contact has been studied extensively in prisons, but research on contact between victims and mentally disordered offenders in forensic mental health settings is lacking. Therefore, an exploratory study was conducted on contact between victims and offenders in four Dutch forensic psychiatric hospitals. These offenders have committed serious (sexually) violent offenses, for which they could not be held fully responsible due to severe psychopathology. During the mandatory treatment, it is possible for offenders and their victims to engage in contact with each other if both parties agree to this. To explore the conditions under which this contact is suitable, we interviewed 35 social workers about their experiences in 57 cases from four Dutch forensic psychiatric hospitals. Findings demonstrated that, according to the social workers, no type of offense or psychopathology were obvious exclusion criteria for victim-offender contact. Social workers described offenders' problem awareness, stable psychiatric condition, and ability to keep to agreements as important factors that enable victim-offender contact. Implications and suggestions for future research are provided.

Recidivism and predictors of recidivism among female high level persistent offenders after a special court order for persistent offenders in the Netherlands.

Previous research has shown that female persistent offenders have multiple psychiatric and psychosocial problems, such as substance use disorders, other mental disorders, financial problems and housing problems. The present study examined recidivism and predictors of recidivism in a sample of 74 Dutch female high level persistent offenders who had been subjected to a special court order for persistent offenders, called ISD [Inrichting Stelselmatige Daders]. The criminal records were studied to gain insight in the criminal charges against women after release from the ISD. Results showed that 43% of the persistent female offenders had registered justice contacts within one year after release, of which the majority concerned non-violent property offences. However, the number of offences was found to be significantly reduced after their release. No offence-related, demographic, substance-related, psychiatric or personal history characteristics were found to be predictive for general recidivism.

Predictors of Change of Working Alliance Over the Course of Probation Supervision: A Prospective Cohort Study.

The body of evidence that the working alliance is associated with positive outcomes for mandated clients is growing. The aim of this research was to investigate the influence of several characteristics of probation officers (POs) and offenders on the course of the working alliance during probation supervision. This study examined the patterns on the four alliance subscales: Trust, Bond, Goals-Restrictions, and Reactance of the Working Alliance With Mandated Clients Inventory (WAMCI) in 201 offenders and their 137 POs. Three patterns on each alliance subscale were found: deteriorating, improving, and stable. Multinomial logistic analysis revealed that change of POs and the preference of the PO to maintain rules were associated with a deteriorating Trust pattern. From the perspective of the offenders, being motivated to take part in supervision was associated with a stable pattern on every alliance subscale, but having problems with substance use increased the likelihood of a deteriorating pattern on every alliance subscale.

The evaluation stage of the Hoeven Outcome Monitor (HOM): Towards an evidence based groundwork in forensic mental health.

This study examined if a macro-, meso-, and micro outcome measurement instrument that constitutes the evaluation stage of a Dutch forensic psychiatric outcome monitor, the Hoeven Outcome Monitor (HOM), can provide a first step towards a more evidence based groundwork in forensic mental health. General, serious, very serious, special, and tbs meriting recidivism during treatment, after treatment, and overall were charted for forensic psychiatric patients discharged from a Dutch forensic psychiatric centre between 1999 and 2008 (N=164). Re-conviction data were obtained from the official Criminal Records System, and the mean follow-up time was 116.2months. First, the results showed that the macro-measurements provide comparative outcome measures to generate insight into the overall effectiveness of forensic psychiatric treatment. Second, the meso-measurements yielded clinically relevant treatment outcome data for all discharged patients to generate a complete view of treatment effectiveness. Finally, the micro-measurements allowed access to detailed patient and treatment effectiveness assessments that provides the empirical foundation to conduct aetiological research into the prediction and control of high-risk behaviour. Thus, an outcome measurement instrument in line with Evidence Based Medicine and best practice guidelines was designed that provides an empirically sound evaluation framework for treatment effectiveness, and an impetus for the development of effective interventions to generate an evidence based groundwork in forensic mental health.

Methodological development of the Hoeven Outcome Monitor (HOM): A first step towards a more evidence based medicine in forensic mental health.

To comply with the need for a more evidence based risk assessment and management in forensic mental health, an outcome monitor is being developed in the Dutch forensic psychiatric centre Van der Hoeven Kliniek in Utrecht, the Hoeven Outcome Monitor (HOM). Conform evidence based medicine (EBM) guidelines, the HOM is subdivided into three consecutive stages, (1) the evaluation stage, (2) the aetiology stage and (3) the implementation stage. In this article an account is provided for the design of the evaluation stage. To account for predicaments in previous research that pertain to a lack of uniformity and disregard of specific context- and patient-related characteristics, a macro-, meso- and micro-treatment evaluation instrument is developed. This instrument provides for the first step to build an evidence base for specific interventions and treatments in forensic psychiatry.

Changes in dynamic risk and protective factors for violence during inpatient forensic psychiatric treatment: predicting reductions in postdischarge community recidivism.

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 posttreatment 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.

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.