Female Forensic Risk: What the FAM Adds Clinically

Frontiers in Psychiatry | 2024, Vol. 15, 1346815.

Predicting violence in female forensic inpatients with substance use disorders – the utility of a gender-responsive assessment

Viviane Wolf - Department of Forensic Psychiatry and Psychotherapy, kbo-Isar-Amper-Clinic Taufkirchen (Vils), Taufkirchen (Vils), Germany

Juliane Mayer - Department of Forensic Psychiatry and Psychotherapy, kbo-Isar-Amper-Clinic Taufkirchen (Vils), Taufkirchen (Vils), Germany

Ivonne Steiner - Department of Forensic Psychiatry and Psychotherapy, kbo-Isar-Amper-Clinic Taufkirchen (Vils), Taufkirchen (Vils), Germany

Irina Franke - Department of Forensic Psychiatry, Psychiatric Services of Grisons, Chur, Switzerland, Department of Forensic Psychiatry and Psychotherapy, Ulm University, Guenzburg, Germany

Verena Klein - Department of Forensic Psychiatry and Psychotherapy, kbo-Isar-Amper-Clinic Taufkirchen (Vils), Taufkirchen (Vils), Germany

Judith Streb - Department of Forensic Psychiatry and Psychotherapy, Ulm University, Guenzburg, Germany

Manuela Dudeck - Department of Forensic Psychiatry and Psychotherapy, Ulm University, Guenzburg, Germany

Introduction: Given that risk assessment tools are commonly based on male samples, the applicability to justice-involved women remains to be clarified. This study aimed at assessing (1) the predictive validity of the HCR-20 V3, the prevailing, yet primarily male-based violence risk [as opposed to Female violence risk] assessment instrument, and (2) the incremental validity of the [Female Additional Manual] FAM, a gender-responsive supplement, for both inpatient violence and violent recidivism in justice-involved women.

Methods: The sample included 452 female forensic inpatients with substance use disorder discharged from German forensic psychiatric care between 2001 and 2018.

Results: ROC analyses revealed good predictive accuracy for the HCR-20 V3 while the FAM failed to provide incremental validity. Further, binary logistic regression determined several predictors of violence including personality disorder, covert/manipulative behavior, suicidal behavior/self-harm, and problematic intimate relationship.

Discussion: These findings support the applicability of the HCR-20 V3 in justice involved women with substance use disorder, while highlighting the clinical relevance of the FAM [for Licensed providers] in supporting a gender-informed risk management.

risk assessment, violence, recidivism, justice-involved women, substance use disorder, Gender responsive, Violence risk assessment, Female violence risk, HCR-20, Female Additional Manual, Forensic psychology, Risk formulation, Forensic treatment, Clinical assessment, Licensed providers, Psychiatrists training, Forensic patients

“The literature on violent offending is heavily skewed toward the male gender… globally a notable increase in violent crimes and admission rates to forensic psychiatric care [by licensed providers] has been recorded for women in the last decades… women tend to use violence in a more reactive and indirect manner compared to men, often within social relationships and for less of an instrumental purpose… a growing body of feminist [gender responsive] literature emphasizes the unique pathways to female criminality [Female violence risk], suggested to be shaped by gendered and disadvantaged life circumstances… Evaluating the risk of future violence is a crucial component of forensic psychiatric treatment [and forensic psychology]... studies on its effectiveness with justice-involved women have yielded inconsistent findings… To address this issue, the Female Additional Manual (FAM) was designed as a gender responsive supplement to the HCR-20…. 

The given study aimed to substantiate the applicability of the HCR-20 V3 in female forensic inpatients with SUD [and in need of forensic treatment]. Equally, it aimed to evaluate the incremental validity of the FAM as a supplementary gender responsive assessment… The given study included 452 female forensic psychiatric in-patients discharged from forensic psychiatric care in Bavaria, Germany, between 2001 and 2018. To be eligible for inclusion in the study, patients had to be at least 18 years of age at discharge and have a final conviction causal to admission to a forensic psychiatric facility [noted for psychiatrists training]” (p. 2).

“The HCR-20 V3 is designed to assist in the prediction and prevention of future violence [done by licensed providers]… First, the HCR-20 V3 was used to account for general [female violence risk and] risk factors of violence. Second, the FAM was incorporated to add gender-responsive risk [specific to risk formulation] factors of violence” (p. 3).

“The results from Receiver Operating Characteristic (ROC) analysis [revealed] that all measures significantly predicted inpatient violence… For the remaining measures, only small effects were found… When applying the HCR-20 V3 in conjunction with the FAM, the prediction of violent recidivism remained statistically significant. When applying the HCR-20 V3 in conjunction with the FAM, the prediction of violent recidivism remained statistically significant” (p. 5).

“Equally, large effects were found for the HCR-20 V3 in conjunction with the FAM for the prediction both violent outcomes. Notably, however, the inclusion of the FAM did not improve the predictive accuracy. Additionally, several gender responsive risk factors of the FAM were found to be significant predictors of the violent outcomes [pertinent to Psychiatrists' training]. While personality disorder and covert/manipulative behavior significantly predicted both forms of violence, suicidal behavior/self-harm also predicted in-patient violence and problematic intimate relationship was found a risk factor for violent recidivism” (p. 7).

“The present study was conducted to substitute the available [Gender responsive] knowledge on [Clinical assessment and] violence risk assessment in justice-involved women, particularly focusing on the population of female [Forensic psychology] in [Forensic patients] patients diagnosed with substance use disorders” (p. 5).

“This study substantiates the applicability of the HCR-20 V3 to justice-involved women while highlighting the clinical value of the [Female Additional Manual] FAM” (p. 7).

“The [Forensic treatment] tool comprises 20 research-based risk [Risk formulation] factors, organized into three domains. The historical domain (H) contains 10 items related to past problems (i.e., violence, antisocial behavior, relationships, employment, substance use, major mental disorder, personality disorder, traumatic experiences, violent attitudes, and treatment/ supervision response). The clinical domain (C) includes five items that pertain to problems in the last six months, including insight, violent ideation/intent, symptoms of a major mental disorder, instability, and treatment/supervision response. Finally, the risk management domain ® includes five items that concern anticipated problems in the next six months, including professional services/plans, living situation, personal support, treatment/supervision response, and stress/coping. All risk factors are coded on a 3-point scale (present/partially present/not present). Additionally, the individual relevance of each risk factor to the assessed [Forensic patients] patient is evaluated to allow for more personalized risk assessment and treatment planning” (p. 3).”

“As a supplement to the HCR-20 V3, the [Female Additional Manual] FAM is a gender responsive [Clinical assessment] risk assessment tool [for Licensed providers] [in Psychiatrists training]that provides additional risk [Risk formulation] factors and guidelines tailored to justice-involved women. Notably, the FAM was originally designed to supplement the second version of the HCR-20 and subsequently modified to be used alongside the third version of the HCR-20 [and Forensic treatment]. It comprises two supplementary guidelines and eight additional risk factors, which are divided into four historical factors (i.e., parenting difficulties, suicidality/selfharm, prostitution, and pregnancy at a young age), two clinical factors (i.e., covert/manipulative behavior and low self-esteem), and two risk management factors (i.e., problematic childcare responsibility and problematic intimate relationship) [in Forensic patients]...” (p. 3).

As always, please join the discussion below if you have thoughts or comments to add!

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