Assessing Protective Factors for Violence Risk in U.K. General Mental Health Services Using the Structured Assessment of Protective Factors

• Author: Andrew Brown,Richard Whittington,Alina Haines,Syed Fahad Javaid,Oladipupo Omodunbi,Fayyaz Khan,Khurram Sadiq,Steve Noblett,Wahid Zaman
• DOI: 10.1177/0306624X17749449
• Published date: 01 September 2018
• Date: 01 September 2018
• Subject Matter: Articles

749449IJOXXX10.1177/0306624X17749449International Journal of Offender Therapy and Comparative CriminologyHaines et al.
research-article2017
Article
International Journal of
Offender Therapy and
Assessing Protective Factors
Comparative Criminology
2018, Vol. 62(12) 3965 –3983
for Violence Risk in U.K.
© The Author(s) 2017
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General Mental Health
https://doi.org/10.1177/0306624X17749449
DOI: 10.1177/0306624X17749449
journals.sagepub.com/home/ijo
Services Using the Structured
Assessment of Protective
Factors
Alina Haines1 , Andrew Brown2, Syed Fahad Javaid3,
Fayyaz Khan4, Steve Noblett5, Oladipupo Omodunbi6,
Khurram Sadiq7, Wahid Zaman8, and
Richard Whittington1,9,10
Abstract
Violence risk assessment and management are key tasks in mental health services and
should be guided by validated instruments covering both risk and protective factors.
This article is part of an international effort to validate the Structured Assessment
of Protective Factors (SAPROF) for violence. The SAPROF, Historical, Clinical, Risk
Management–20 (HCR-20) and the Psychopathy Checklist–Screening Version (PCL-
SV) were administered in a sample of 261 patients in U.K. forensic, general inpatient,
and community mental health settings. There was significant variation between these
groups on SAPROF scores with fewer protective factors in the forensic group. The
prospective validity of the SAPROF for nonviolence in the general inpatient and
1University of Liverpool, UK
2Mersey Care NHS Foundation Trust, St. Helens, UK
3North West Boroughs Healthcare NHS Foundation Trust, Warrington, UK
4Consultant (locum) Psychiatrist, Chester, UK
5Lancashire Care NHS Foundation Trust, Preston, UK
6Prairie Mountain Health, Dauphin, Manitoba, Canada
7Greater Manchester Mental Health NHS Foundation Trust, UK
8Curelink Healthcare, Rawalpindi, Pakistan
9St. Olavs Hospital, Trondheim, Norway
10Norwegian University of Science and Technology, Trondheim, Norway
Corresponding Author:
Alina Haines, Research Associate, University of Liverpool, Muspratt Building, The Quadrangle, Liverpool
L3 5DA, UK.
Email: haialina@liverpool.ac.uk

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International Journal of Offender Therapy and Comparative Criminology 62(12)
community samples was moderate (area under the curve [AUC] = .60). Adoption of
the SAPROF or similar instruments as a supplement to risk-focused assessments has
the potential to improve awareness of protective factors and enhance therapeutic
engagement in a range of mental health services.
Keywords
risk assessment, protective factors, risk violence, structured professional judgment,
mental health services
Introduction
In the past decade, the structured professional judgment (SPJ) approach to violence
risk assessment and management has developed with an emphasis on systematic evi-
dence-based guidance for evaluating the presence of specific types of individual risk
factors and developing responses to the overall profile which is identified. SPJ
risk assessment tools are protocols containing empirically based static and dynamic
risk factors for an individual, which are carefully interpreted by trained mental health
professionals to arrive at a well-informed final judgment of violence risk (Douglas,
Blanchard, & Hendry, 2013). Risk assessment has traditionally tended to focus on the
presence or absence of negative features such as instability and traumatic experiences.
However, this may skew the assessment negatively with implications for its validity
and clinical utility (Miller, 2006). Thus, there has been growing interest in adding a
focus on the presence of protective factors that could moderate and counterbalance the
influence of risk factors. The Structured Assessment of Protective Factors (SAPROF;
de Vogel, de Vries Robbé, de Ruiter, & Bouman, 2011) is an instrument designed in
the Netherlands with these issues in mind to guide evaluations in conjunction with
other tools, and this study was an attempt to examine the validity and utility of the tool
in U.K. mental health services.
At present, protective factors are not routinely assessed in forensic mental health
services to the same extent as risk factors. A risk-averse culture in many countries has
previously obscured the desirability of focusing as well on strengths and protective
factors and the integration of such information into routine health care decisions. This
has the potential to compromise the clinical utility of protective factors in risk formu-
lation if the rater is encouraged to think entirely in terms of a risk alone judgment.
There is a need for a conceptual change if this is to be improved. Clinicians usually
want to bring about positive change when working with patients rather than just reduc-
ing negative factors, and adding the SAPROF or some other measure of protective
factors to the assessment package enables this to happen. The patients would be more
motivated to engage in treatment if they are involved as much as possible in the risk
assessment, including being party to the findings wherever possible. Risk assessment
results are often kept away from patients, despite all of their other documentation
being made available to them, but the SAPROF has the potential to produce profile

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results that can be more easily shared and thus to encourage collaborative working in
constructing the risk management plan. The consideration of protective factors should
thus bring a more balanced appreciation of the individual presenting risks than can be
captured within current risk formulations.
The concept of a protective factor is evolving and still debated at a fundamental level
in terms of whether it is simply the absence or converse of a risk factor or whether it is
an independent entity, which may mediate or moderate the relationship between risk
and violence. It has been defined by one set of researchers as any characteristic of an
individual or their environment or situation that may moderate risk factors (de Vogel
et al., 2011). Thus, protective factors are seen as conceptually distinct from risk factors
and can act as a buffer in the relationship between risk factors and violent behaviour. De
Vogel et al. (2011) give the example of religiosity which is negatively related (i.e., pro-
tects against) with criminality, but its absence, nonreligiosity, has no relationship, posi-
tive or negative, with criminality. Another way of viewing the distinction emphasises
the orthogonality of risk and protectiveness: A person may score high on risk and high
on protective factors, which moderates the high-risk level. Those who are truly “risky”
combine high levels of risk factor with low levels of protective factors.
Based on the available evidence, it seems likely that including protective factors in
violence risk assessment is likely to lead to a more comprehensive assessment of vio-
lence propensity (Quinsey, Jones, Book, & Barr, 2006; Salekin & Lochman, 2008).
Indeed, some researchers have concluded that strengthening protective factors may be
more effective in decreasing risk behaviours and increasing prosocial behaviour than
reducing the presence of risk factors (Blum & Ireland, 2004; Resnick, Ireland, &
Borowsky, 2004). An interest in systematically assessing this aspect has led to the
development of a number of protective factor instruments in the last decade (Desmarais,
Nicholls, Wilson, & Brink, 2012; Lodewijks, Doreleijers, de Ruiter, & Borum, 2008),
including the SAPROF.
This instrument was developed as a supplement to the Historical, Clinical, Risk
Management–20 (HCR-20; Douglas et al., 2014) to assess protective factors and their
relationship to future violent behaviour in adult offenders and forensic psychiatric
patients (de Vries Robbé, de Vogel, & de Spa, 2011). It is a structured assessment
guideline intended for use in combination with a reliable and valid risk assessment
instrument such as the HCR-20 in accordance with the overall SPJ approach. The
instrument consists of two static and 15 dynamic protective items each located in one
of three domains: internal factors, external factors, and motivational factors. It aims
not only to assess protective factors but also to inform treatment planning by identify-
ing potential areas for intervention, and it can offer valuable guidance in narrowing the
gap between assessment and violence prevention. For research purposes, a global
score combining the risk and protective profiles of an individual can be calculated by
subtracting the SAPROF score from the HCR-20 score as well as considering the two
domains separately (de Vries Robbé, de Vogel, Douglas, & Nijman, 2015).
De Vries Robbé et al. (2011) report good predictive validity for the SAPROF in
relation to criminal recidivism at 1- and 2-year follow-ups in a sample of 126 Dutch
patients released from a secure forensic mental health setting. It has since been

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International Journal of Offender Therapy and Comparative Criminology 62(12)
subjected to further testing with sex offenders and other forensic groups in the
Netherlands (de Vries Robbé et al., 2015) and more widely in Canada, Singapore,
Ireland, and Germany (Abidin et al., 2013; Davoren et al., 2013; Doyle, 2014; Turner
et al., 2014; Viljoen et al., 2016; Yoon, Spehr, & Briken, 2011; Zeng, Chu, & Lee,
2015). Results so far in these forensic setting studies are mixed but promising. Doyle’s
(2014) prospective study comparing a cohort of forensic patients...