The European Victim Guideline (2012): effective victim support from an evidence-based trauma

perspectiveProf. dr. mr. Frans Willem Winkelf.w.winkel@tilburguniversity.edu

Zagreb-conference, November, 27- 30, 2012

Specific targets suggested by the guideline (e.g. art 18…)

• General purpose: to (further) enhance the social and juridical position of crime victims.

• More specific targets, include:• (1) The prevention of chronic suffering,

chronic coping problems due to victimization;• (2) The prevention of repeat victimization,

and• (3) The prevention of secondary

victimization / secondary traumatization

Victim Support: how to accomplish these specific targets??

• Psychological evidence suggests that most crime victims are resilient, and thus are not in need of support;

• However: traumatized victims – victims at risk of developing PTSD - are in need of support.

• A first step in developing effective services is to acknowledge the importance of a trauma perspective:

• Ergo: support workers should have knowledge about risk factors / mechanisms underlying PTSD

Support from a trauma perspective

• Effective programs include (at least) two components, namely:

1. Early identification of victims at risk of developing chronic PTSD, and

2. Swift referral to the mental health system1. Tea and sympathy by volunteers is not enough;2. These victims are in need of trauma-focused

treatment by professional psychologists3. Evidence-based interventions – incl. EMDR and

cognitive processing therapy – are available

Victim support and trauma

• The gold standard to identify victims with chronic PTSD is an extensive diagnostic interview by a psychologist / psychiatrist!!

• However: a number of screening tools have been developed for non-psychologists / e.g. police and victim support workers;

• Important tools include: the Trauma Screening Questionnaire(TSQ), Coping self-efficacy scale, and the Scanner

Relevance of a trauma perspective

• An important criterion to evaluate the success of the European guideline:

• The utilization of (validated) screening instruments to identify victims in need of support– In the NL since 2012 the TSQ is used as part of an

(internet-based) e-screening procedure;• However: many organizations affiliated with Victim

Support Europe still do not use screeners as part of an Early identification and referral procedure (many victims in need are not identified)

Two other arguments for a trauma perspective

• Victimological evidence suggests that PTSD is a conditional risk factor for

• REPEAT VICTIMIZATION, AND• SECONDARY VICTIMIZATION /

TRAUMATIZATION, due to delivery of a victim impact statement during trial of the suspect.

• Some subtypes of PTSD are relatively strong (versus weak) risk factors for these outcomes

PTSD and repeat victimization

Slides relating toPresentation on wednesday

Repeat victimization: the re-involvement in domestic violence

• Female victims exposed to domestic violence are defined as vulnerable victims in the Guideline

• Some of these victims are in Danger: at substantial risk of short-term revictimization

• Challenge: is it possible to early identify victims who are in danger on the basis of validated Risk Assessment Instruments (RAIs).– Yes, we can!!

RAIs: forensic psychology• RAIs with acceptable psychometric properties

(reliability, predictive validity) have been developed in Forensic Psychology

• Various versions:• Professional, more detailed versions

(psychologist / psychiatrist) and “simple” screening versions (police / victim support workers)

• Actuarial and “non-actuarial” RAIs

Risk assessment instruments

• Professional assessors (forensic psychologists):

• DVRAG (Domestic Violence Risk Appraisal Guide)

• SARAG (Spousal Assault Risk Assessment Guide– (actuarial versus “non-actuarial” / no cutoff-values

for low and high risk)– E.g. 4 risk factors = 40% risk

“Non-clinical” assessors: police and victim support

• B-Safer (Brief Spousal Assault form for the Evaluation of Risk)

• ODARA-LE (Ontario Domestic Assault Risk Assessment – Law Enforcement)

• Danger Assessment Inventory

An example: ODARA

ODARA ITEMS: 13 risk factors(Sumscore: 0 - 13)

(1) Prior violence against wife or children (NO = 0; YES = 1)

(2) nondomestic incident

(3) Prior custodial sentence

(4) Failure on prior conditional release

(5) Threat to harm or kill at index assault

(6) Confinement of the partner at the index offense

(7) Victim concern

(8) More than one child (from perpetrator or victim)

(9) Victim has biological child from previous partner

(10) Violence against others

(11) Substance abuse history

(12) Assault on victim when pregnant

(13) Barriers to victim support

ODARA: “experience table” (official recidivism)

ODARA score(Sumscore: equal weights;Each factor = 1)

Likelihood of re-assault that comes to the attention of the police within an average of about 5 years)

0 7%

1 17%

2 22%

3 34%

4 39%

5 of 6 53%

7 t/m 13 74%

DRAG = PCL-R + ODARA: an illustration

PsychopathyChecklist –revised(PCL-R; Hare)

Perpetrator is aPsychopath: “PCL-R = 1)”

(PCL-R =0)

Corrected ODARA-score(different weightsper risk factor)

“Uncorrected” / simple ODARA-score(all factors have the same weight)

Likelihood ofRecidivism(experience table)

Victimological evidence: Danger Assessment Inventory (DAI)

• DAI has been recently developed to early identify female victims who are in danger, at substantial risk of short-term re-victimization (within 3 to 6 months)

• Evidence base: two large scale prospective studies (N> 500 victims)

• Why: the DAI has superior predictive performance!!!– Stronger correlation between prediction and actual

outcome

Why bother about Predictive validity (& reliability)….????

Actual Outcome:

No

revictimization

Revictimization

(Yes)

Predicted:

NOt at Risk HIT

Prediction

ERROR (“under”)

At Risk

(YES)

Prediction

ERROR (“over”) HIT

Error: secondary victimization

Danger Assessment Inventory:screening version for police and victim support workers

Danger Assessment Inventory

Perpetrator features Victim features Scenario-features

ODARA-score > 7YES =1

Involvement in aPost TraumaticCycle (TSQ/CTS-V): Yes = 1

Mutual scenario, incl.Posttraumatic aggression(CTS-P): Yes =1

High risk of short-term revictimization: N = 3

“Corrected” ODARA-score for victims with borderline traits, incl. NEM, and impulsivity

DAI: features• The DAI has a triple focus, it includes• (1) perpetrator-related risk factors (e.g.

ODARA-score for perpetrator)• (2) victim-related risk factors, particularly the

involvement in a PTSD-maintained cycle of violence (posttraumatic cycle: PTC)

• (3) scenario-based risk factors: a mutual scenario (both partners use violence; vs unilateral scenario: male initiated violence)

Victimological evidence suggests, that….

• A Posttraumatic Cycle of violence (PTC) is an independent risk factor (e.g. controlled for ODARA-score)

• A PTC is a strong (substantially higher risk) risk factor, when:

• The cycle consists of mutual scenario’s (both partners commit violent behavior) and

• The cycle is maintained by an embitterment or an explosive (PTSD) syndrome

Crime-related PTSD (C-PTSD) subtypes: 4 subtypes

PTSDSubtypes:

InternalizingSymptomatology

ExternalizingSymptomatology

HopelessnessSyndrome(DSM- mood disorder/depression)

HelplessnessSyndrome (“stockholm”)

EmbittermentSyndrome

False-alarmSyndrome(DSM- Anxiety / Angerdisorder

PanicSyndrome

ExplosiveSyndrome

Bottomline of the 2x2 table

• There are similarities among crime victims with PTSD (DSM IV / 5 symptomatology), BUT

• There are important differences, that cannot be ignored– Different mechanisms underlying the

development of PTSD (cognitive versus emotional route)

– Externalizing versus internalizing symptomatology (dysregulation of the anger system versus the anxiety system)

PTSD: conditional risk

• Explosive syndrome is a powerful risk factor for re-victimization (stronger impact on risk re. to “other” subtypes)– Specific features include: hostility bias, state

anger, propensity to explode in response to subjective (“imaginary”) danger signals, and violent behavior (details; next slide)

• Victims with explosive syndrome are at substantial risk of short-term revictimization

Peritraumatic escalation, cognitive inversion, and Shattered Illusions (SIM).

Peritraumatic escalation:Fight-flight response failure

PsychoticDissociation

DysregulatedEmergency-response:Hyperalert / paranoid behavior:In standby mode

False alarm-syndrome / Externalizing symptoms:Hostility bias, anger,Propensity to explode in response tosubjective danger-signals

False alarm-syndrome / Internalizing symptoms:Self as easy target bias, Anxiety, Propensity topanic

Avoidant / Submissive Behavior Impulsive agressive behavior

EmotionalImplosion:Extreme anxiety / Tonic Immobility

EmotionalExplosion:Blind anger / Rage

Cognitive cascade:Inversion; SIM)

PTSD and secondary victimization

Slides relating to presentation of thursday

Victim rights movement: (IRV: Joutsen, 1994; de Mesmaecker, 2012)

• Victims should have rights, also in criminal trials

• bring the “stolen conflict “ back to the trial setting (versus exclusive

prosecutor – suspect – vertical link)• Symmetry: for every right of the suspect there should be an equivalent right for the victim, including the right

to speak• Victim participation should be

encouraged, because it has a beneficial impact on recovery

• However: these are normative positions, there is no credible

empirical evidence

Secondary victimization (by the criminal justice system)

• According to the Dutch code on criminal procedure (some) victims have the right to submit an oral or written statement to the judge about the impact of the incident.

• Victim impact statements are assumed to contribute to emotional recovery of the victim

• However: recent victimological evidence suggests that VIS may have adverse effects, e.g. it may result in secondary traumatization

Hyotheses

• Law in the books: victim rights generally have beneficial effects for victims

• Law in action / empirical - perspective: rights may have positive effects for some victims; rights may have detrimental effects for other victims– “law of differential effect” (e.g. traumatized

versus non-traumatized victims)

Psychological impact of trial participation (VIS)

Victim ImpactStatement during trial

Positive “Interaction –Ritual” between the victimand the judge

Negative “Interaction –Ritual” between the victimand the judge

Beneficial effect:Emotional recovery

Adverse effect:Secondary victimization/traumatization

Traumatized victims:1.White bear-mechanism (muzzled expression)2.Teeth for a tooth-mechanism

VIS: positive versus negative experience

• Instruction to suppress anger: limited / muzzled emotional expression during trial

• Moral dissatisfaction with the verdict– Incomplete acknowledgement of victim distress– “Lenient sentence”: personal distress > distress

encountered by perpetrator

• Bottomline: it is all about victim perceptions, perceived justice

CREDIBLE EVIDENCE: EMOTIONAL RECOVERY VERSUS SECONDARY TRAUMA: DESIGN

Repeated Measures Trauma SymptomsPre-trial

Trauma symtomsPost-trial

Participants(oral and / or written victim impactstatement)

TSQ – scores(better alternative:Davidson Trauma Scale or PSS)

TSQ-scores

Non-participants TSQ-scores TSQ-scores

Trauma symptoms (TSQ-scores)reported by trial

participants (VIS: yes/ no)

Victim Status: Asssessed before trial

TSQ After trial

Non-participant(No VIS)

3.1 2.0

Participant:Written VIS

7.0 5.8

Participant:Oral VIS during trial

7.1 6.1

Bottom-line of the previous table

• There are substantial psychological differences between participants and non-participants (TSQ-scores: “hit between the eyes”)

• Victims with PTSD – traumatized victims – are more likely to participate in a trial (VIS)

• There is NO EVIDENCE for emotional recovery– No time by participant-status interaction

• More importantly: analyses provide evidence for secondary victimization

Interaction-term: F1,74 = 4.04; p < .05

Conclusions:

• From a law in action – perspective the European Guideline will be a major step forward in strengthening the social and juridical position of crime victims, if

• The “trauma perspective” on criminal victimization is fully acknowledged at all levels

Ergo:• Criminal justice personnel and victim support

workers should become more familiar with this perspective (underutilization of knowledge / knowledge-gap)

• Criminal justice personnel should be trained in the development of trauma-sensitive behavior;

• Victim support personnel should be trained in the use of formal tools to identify susceptible and vulnerable victims (e.g. DAI, TSQ, etc)