Evaluation of the validity and reliability of the Structured Assessment of PROtective Factors for violence risk (SAPROF) in an Italian sample of forensic and nonforensic psychiatric patients: validation study and clinical implications

Abstract

Introduction: We report the first validation of the Italian translation of SAPROF (Structured Assessment of Protective Factors for violence risk). Law 81/2014 marked a turning point in the treatment of psychiatric offenders in Italy, promoting rehabilitation and recovery­oriented models in REMS and local services. In this scenario, the evaluation of protective factors, alongside that
of risk factors, has become central for the planning of personalized interventions and the monitoring of therapeutic pathways. However, there was a lack of validated tools for the Italian population that would integrate the structured assessment of protective factors according to the structured professional judgment (SPJ) model.
Objectives: This study, the first in Italy, validated the SAPROF in a sample of forensic and non­forensic psychiatric patients, evaluating their reliability, predictive validity, sensitivity to change and discriminating ability between different clinical contexts.
Methods: 126 patients were recruited (59 in dedicated REMS/CRAP, 67 in non­forensic facilities), evaluated longitudinally up to three times over 18 months. In addition to SAPROF, BPRS­24, PCL­R, HCR­20 and GAF were administered. Inter­rater reliability was estimated on 40 cases via ICC, Spearman’s rho and Cohen’s kappa. Internal consistency was assessed with Cronbach’s alpha. The predictive analysis was based on GEE models for violence risk reduction (measured via the MOAS scale), controlling for established clinical and forensic variables. Sensitivity to change was measured by Reliable Change Index (RCI).
Results: The SAPROF showed excellent inter­rater reliability (ICC = 0.973; rho = 0.953) and good internal consistency for the total scale (α = 0.798), with lower values for some subscales (e.g. external α = 0.471). The motivational (RCI = 1.03) and external (RCI = 1.39) subscale were particularly sensitive to therapeutic changes. The GEE analysis showed that the SAPROF total score is an independent and significant predictor of the reduction in the risk of violence (p < 0.001), even after controlling for psychopathological severity (BPRS­24) and psychopathic traits (PCL­R), while the HCR­20 did not show autonomous predictive power. The SAPROF also effectively discriminated between forensic and non­forensic patients, with significantly lower protection scores and greater clinical severity in patients in dedicated REMS­CRAP.
Conclusions: The SAPROF confirms itself as a reliable, valid and change­sensitive tool for the evaluation of protective factors in the Italian psychiatric population, forensic and non­forensic and has filled a gap in national clinical and forensic practice. Its integration into forensic care pathways can facilitate the planning of personalized rehabilitation interventions, the monitoring
of therapeutic progress and a more balanced and respectful management of patients’ rights, in line with the principles of Law 81/2014 and the recommendations of the Constitutional Court (Judgment 22/2022). Strengths of this study include inclusión of both forensic and non­forensic samples and the use of the Italian translation. Limitations of the study include the need for further validation on larger and more diverse samples and the optimization of subscales with less internal consistency. The SAPROF is proposed as a “work in progress” tool, susceptible to further improvement, and represents an innovative contribution to Italian clinical practice.