Treatment Evaluation in Forensic Psychiatry. Which One Should Be Used: The Clinical Judgment or the Instrument-based Assessment of Change?

• Author: Erwin Schuringa,Marinus Spreen,Stefan Bogaerts
• DOI: http://doi.org/10.1177/0306624X211023921
• Published date: 01 December 2022
• Date: 01 December 2022
• Subject Matter: Articles

https://doi.org/10.1177/0306624X211023921

International Journal of

Offender Therapy and

Comparative Criminology

2022, Vol. 66(16) 1821 –1836

© The Author(s) 2021

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sagepub.com/journals-permissions

DOI: 10.1177/0306624X211023921

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Article

Treatment Evaluation in

Forensic Psychiatry. Which

One Should Be Used: The

Clinical Judgment or the

Instrument-based Assessment

of Change?

Erwin Schuringa1, Marinus Spreen2,

and Stefan Bogaerts3,4

Abstract

In forensic psychiatry, it is common practice to use an unstructured clinical judgment for

treatment evaluation. From risk assessment studies, it is known that the unstructured

clinical judgment is unreliable and the use of instruments is recommended. This

paper aims to explore the clinical judgment of change compared to the calculated

change using the Instrument for Forensic Treatment Evaluation (IFTE) in relation

to changes in inpatient violence This study shows that the clinical judgment is much

more positive about patient’s behavioral changes than the calculated change. And

that the calculated change is more in accordance with the change in the occurrence

of inpatient violence, suggesting that the calculated change reflects reality closer than

the unstructured clinical judgment. Therefore, it is advisable to use the IFTE as a base

to make a structured professional judgment of the treatment evaluation of a forensic

psychiatric patient.

Keywords

IFTE, clinical judgment, calculated change, forensic treatment evaluation, inpatient

violence

1FPC Dr. S. van Mesdag, Groningen, The Netherlands

2NHLStenden University of Applied Sciences, Leeuwarden, The Netherlands

3Department of Developmental Psychology, Tilburg University, The Netherlands

4Fivoor Research & Treatment Innovation, Poortugaal, The Netherlands

Corresponding Author:

Erwin Schuringa, FPC Dr. S. van Mesdag, Helperlinie 2, Groningen, 9700 RC, The Netherlands.

Email: e.schuringa@fpcvanmesdag.nl

1023921IJOXXX10.1177/0306624X211023921International Journal of Offender Therapy and Comparative CriminologySchuringa et al.

research-article2021

1822 International Journal of Offender Therapy and Comparative Criminology 66(16)

Introduction

Treatment of forensic psychiatric patients is most effective to prevent recidivism when

the three principles of the Risk-Need-Responsivity (RNR) model are applied (Andrews

& Bonta, 2010; Andrews et al., 1990, 2006; Polaschek, 2012). The Risk principle

argues that treatment programs must meet a patient’s risk level in terms of duration

and intensity of the treatment. High-risk offenders need longer and more intensive

treatment than low-risk offenders (Papalia et al., 2019). According to the Need prin-

ciple, treatment programs must focus on patient’s specific dynamic criminogenic

needs, which contribute to an increased risk of recidivism. Finally, the Responsivity

principle states that treatment programs must match the learning ability, motivation,

and strengths of the offender and the treatment used must be evidence-based (Skeem

et al., 2015).

The assessment of an offender’s personal risk level and needs was, until the mid-

seventies of the last century, a matter of subjective judgments by clinicians. Own

insights, intuition, professional opinion, confidence, training, and experiences were

leading in the assessment (Miller et al., 2015). This was referred to as the first genera-

tion of risk assessment (Andrews et al., 2006). Spengler et al. (2009) showed in a

meta-analysis that this unstructured clinical judgment frequently led to inaccurate

evaluations of the risk of recidivism. The lack of rules, transparency, replicability,

consistency and scoring integrity, and accuracy led to criticism of the clinical approach

(Harris & Rice, 2007). For instance, with the unstructured clinical judgment important

risk factors were overlooked or not considered, too much attention was paid to irrele-

vant factors or insufficient weight was assigned to relevant risk factors (Dawes et al.,

1989). Therefore, structured (actuarial) risk assessment tools were developed and

introduced to tackle the limitations of unstructured clinical judgments, both in the

context of legal decision-making and in forensic psychiatric treatment. These instru-

ments are referred to as the second generation of risk assessment (Ǣgisdóttir et al.,

2006; Baird & Stocks, 2013; Cooper et al., 2008). In a meta-analysis of 136 studies in

which actuarial predictions were compared with unstructured clinical predictions con-

cerning risk of recidivism, actuarial predictions were found to be more accurate than

unstructured clinical predictions in almost half (47%) of the studies (Grove et al.,

2000). No differences in predictive accuracy between both approaches was found in

about 47% of the studies and in a small minority of studies (6%), the unstructured

prediction was slightly more accurate. On average, the actuarial prediction of future

violence was more accurate than the unstructured clinical prediction by an approxi-

mately 10% increase in hit rate (Ǣgisdóttir et al., 2006).

A shortcoming of actuarial predictions was that only historical or static factors were

assessed which could not be influenced by treatment or time. Therefore, dynamic risk

factors or dynamic criminogenic needs were added to the instruments (Douglas &

Skeem, 2005). The use of risk assessment instruments consisting of dynamic risk fac-

tors in combination with static factors led to structured professional judgments of

future risk of recidivism: the third generation of risk assessment instruments (Andrews

et al., 2006). After evaluating and weighing all risk factors and considering the base