Field validity of the HCR-20 in forensic medium security units in Flanders

Structured risk assessment has become a part of routine practice in forensic settings. However, little attention has been paid to the clinical applicability of existing tools. The present research focused on the performance of the Historical Clinical Risk Management-20 (HCR-20) – one of the most commonly used tools for structured professional judgment – in the daily practice of three medium security units in Flanders. Areas under the curve for the prediction of violent recidivism during (N?=?168) and after (N?=?105) medium security treatment were non-significant. In addition, analyses showed that the HCR-20 was mainly of interest in identifying low-risk individuals. Further research measuring different aspects of predictive validity in applied settings is recommended.     

Violence risk profile of medium- and high-security NGRI offenders in Belgium

Under Belgian law, offenders not guilty by reason of insanity (NGRI) are committed by the courts to forensic mental health treatment. The use of violence risk assessment tools has become routine in these settings. However, there are no national statistics regarding violence risk assessment in the Belgian forensic population. A study was undertaken to collect risk assessment data (PCL-R, VRAG, HCR-20) on a large cohort of forensic patients committed to Medium Security units in the Flanders region and in High-Security units in the Walloon region. Flemish patients were expected to present a lower risk compared with their Walloon counterparts. Instead, data yielded by a structured risk assessment method demonstrate the opposite. Moreover, the majority of patients in Flemish facilities had committed violent offenses and were institutionalized for shorter periods whereas the majority of Walloon patients had committed sexual offenses and were institutionalized for markedly longer periods.     

Understanding dynamic risk factors for violence

ABSTRACT

Recent years have seen a consensus emerge regarding the dynamic risk factors that are associated with future violence. These risk factors are now routinely assessed in structured violence risk assessment instruments. They provide a focus for treatment in structured group programmes. However, relatively little attention has been paid to risk-related theoretical issues, whether these dynamic risk factors are causally related or simply correlates of violent offending, or the extent to which they change as a consequence of treatment. More challenging is the lack of evidence to suggest that changes in these dynamic risk factors actually result in reductions in violent offending. In this paper we consider the meaning of the term dynamic risk, arguing that only those factors that, when changed, reduce the likelihood of violent recidivism, can be considered to be truly dynamic. We conclude that few of the violence risk factors commonly regarded as dynamic fulfil this requirement. There is a need to think more critically about assessment findings and treatment recommendations relating to dynamic risk, and conduct research that establishes, rather than assumes, that certain dynamic risk factors are directly related to violence. Some suggestions for advancing knowledge and practice are provided.     

Assessing change in dynamic risk factors in forensic psychiatric inpatients: relationship with psychopathy and recidivism

This study explored change in dynamic risk for violence using the Clinical and Risk Management subscales of the Historical Clinical and Risk Management-20 version 3 (HCR-20 v3) and sought to determine whether change was associated with violent recidivism. The association between the magnitude of change and psychopathy was also assessed. Participants were 40 male (n = 32) and female (n = 8) forensic psychiatric inpatients discharged from a secure forensic mental health service. Results showed that participants significantly improved on the HCR-20v3 Clinical subscale but significantly worsened on the Risk Management subscale. Psychopathy was unrelated to change in Clinical and Risk Management subscales. The hypothesis that changes in dynamic risk would predict recidivism over and above total pre-treatment risk (HCR-20v3 Total score) and psychopathy was not supported. These results suggest that improvements in mental state risk factors alone are insufficient with regard to lowering violence risk.     

The Impact of Confidence on the Accuracy of Structured Professional and Actuarial Violence Risk Judgments in a Sample of Forensic Psychiatric Patients

Some previous research indicates that confidence affects the accuracy of probabilistic clinical ratings of risk for violence among civil psychiatric inpatients. The current study investigated the impact of confidence on actuarial and structured professional risk assessments, in a forensic psychiatric population, using community violence as the outcome criteria. Raters completed the HCR-20 violence risk assessment scheme for a sample of 100 forensic psychiatric patients. Results showed that accuracy of both actuarial judgments (HCR-20 total scores) and structured professional judgments (of low, moderate, and high risk) were substantially more accurate when raters were more confident about their judgments. Findings suggest that confidence of ratings should be studied as a potentially important mediator of structured professional and actuarial risk judgments.     

Understanding the risk factors for violence and criminality in women: the concurrent validity of the PCL-R and HCR-20

This study explores the performance of 132 female maximum-security inmates on the Psychopathy Checklist-Revised (PCL-R) and the HCR-20 (Historical, Clinical, and Risk Management Scheme) to examine the concordance between these two risk assessment instruments, and to assess their potential usefulness in determining level of risk for violent behavior and other forms of criminality. The two instruments demonstrated consistent and highly significant correlations across total scores, factor scores, and subscale scores. When the two instruments were entered into a multiple regression analysis to predict violent and non-violent crime, the HCR-20 did not add to the variance explained by the PCL-R. These results confirm earlier research that suggests that there is little or no difference between these two risk assessment instruments in their relationship to community or institutional violence. Further, Receiver Operating Characteristics (ROC) analyses show that both instruments demonstrated an inverse ability to predict convictions for murder, a close to chance ability to predict violent crime, but a shared ability to predict property and minor crime. Broadly, these results suggest that psychopathic women are involved in chronic patterns of non-violent criminality, while women charged and convicted of murder generally do not have elevated scores on the PCL-R or HCR-20. The relevance of these findings to rehabilitation and treatment is discussed.     

Static screening instruments for risk of minor and major violence

Background: Screens for violent convictions that are simple, accessible and parsimonious are needed, as a first stage in identifying those at high risk for further assessment. Aims: To construct and validate screening tools for minor and major violence convictions for released prisoners. Methods: Internal validation sample of 1647 serious offenders and an external validation of 46,704 general prisoners. The outcomes were binary indicators for having at least one conviction for minor and major violence. Risk factors were convictions for violence and age. Results: In the external validation sample, the instrument for risk of minor violence (PMIV) identified correctly 60.8% of male and 66.2% of female general prisoners. For risk of major violence, the instrument (PMAV) identified correctly 68.0% of male and 79.3% of female prisoners. Conclusions: The PMIV and PMAV will efficiently assist practitioners in a first stage of screening before in-depth clinical assessment of risk for future violent convictions.     

Twenty years of progress in violence risk assessment

Violence risk assessment has advanced considerably in the last 20 years. In the 1980s, leading professionals questioned the very possibility of valid violence risk assessments; now, many of the major risk factors have been identified, and professional debate focuses on how best to combine these risk factors into meaningful evaluations. An important contributor to this advance in knowledge has been the rise of meta-analytic reviews. Through quantitative summaries, the cumulative findings of small, potentially insignificant studies have provided important answers to questions concerning the effective assessment and treatment of violent offenders.     

The predictive validity of youth violence risk assessment tools: a systematic review

ABSTRACT

This paper reports the findings of a systematic search of published literature which reports the predictive validity of violence risk assessment tools specifically designed for use with youth. A total of 38 studies, involving 9,307 participants, reported data for six different tools; the most common of which were the SAVRY and the YLS/CMI. Each of the tools demonstrated at least moderate levels of predictive validity, with the predictive validity of several newer assessment tools yet to be established. The results provide an up-to-date overview of the state of knowledge in an area in which practitioners make choices about which tools to use on an almost daily basis. It is important that practitioners are aware of the strength of evidence that is available to support the choice of violence risk assessment tools and the interpretation of results.     

Mental disorder in violent women in secure settings: Potential relevance to risk for future violence

The relevance to women of common violence risk factors identified in men has in many instances yet to be established. Consequently, there is a reluctance to accept without question the application to women of practices relating to violence risk assessment and management developed from research into men. This study examines mental disorder in women who are violent in order comment on its relevance to the practice of violence risk assessment and management. A sample of 95 violent women in high secure prison and forensic psychiatric care were assessed. Structured assessments of Axis I and II mental disorders and psychopathy were undertaken on all women and conviction histories were recorded. Very high levels of psychiatric morbidity were noted and patterns in comorbidity were detected. Among Axis I conditions, psychotic disorders and disorders of mood co-occurred at a very high rate. Among the Axis II conditions, dimensional ratings of borderline personality disorder (PD) correlated with dimensional ratings of avoidant, dependent and paranoid PDs while ratings of antisocial PD correlated with those of narcissistic, histrionic and obsessive–compulsive PDs. Women who had been incarcerated for a major violent offence were four times more likely to have a diagnosis of borderline PD than women whose index offence was one of minor violence. A number of the findings reported are in contrast to those reported in similar studies of men. Findings suggest that practitioners are right to question the application to women of knowledge derived from research into men. The practice of violence risk assessment and management with women should emphasise the development of individual risk formulations and responding to psychiatric comorbidity should be the rule rather than the exception with this population.     

Assessment of violence risk in youth for juvenile court: relevant factors for clinical judgment

BACKGROUND: Assessment of violence risk in youth for juvenile court needs to be improved. AIM: To determine which items of the Structured Assessment of Violence Risk in Youth (SAVRY) are recorded in pre-trial mental health evaluations and which of these items are associated with the clinical judgment of the risk of violent recidivism. METHOD: A total of one hundred forensic diagnostic juvenile court files were rated with regard to the presence or absence of the thirty SAVRY risk items: ten historical, six contextual and eight individual items, and six protective items. Univariate and multivariate logistic regression analysis were used to examine the relationship between SAVRY risk items and the clinical judgment of violence risk. RESULTS: Most SAVRY-items had been recorded in the files. However, five historical items and the contextual item 'rejection by peers' did not appear in 25-62% of the files. Especially SAVRY items like 'negative-attitudes' and 'psychopathic traits' were the most powerful predictors for clinical judgment of high violence risk. Unexpectedly, historical items played a minor role in clinical judgment. CONCLUSION: Prospective research is needed with the use of SAVRY-items to improve evidence based violence risk assessment in court ordered mental health evaluations of youngsters.     

Implementing violence and incident reporting measures on a forensic mental health unit

The assessment of risk and prediction of violence in mental health units can play a large role in creating a safer environment for both the staff and the patients. Nurses in forensic units are in a unique position in regards to assessment of violence as they spend a great deal of time with the patients. Nurses on a forensic mental health unit scored the Brøset Violence Checklist (BVC) twice daily for 12 weeks for all patients either resident on or admitted to the unit (N?=?46). The Staff Observation Aggression Scale-Revised (SOAS-R) was used to report any adverse incidents (N?=?51). Data were examined at the both the item and scale level. Main results showed the area under the curve values of the BVC score, slide rule, and the sum of BVC and slide rule score in turn demonstrated strong predictive accuracy for inpatient aggression (0.68–0.73). Through logistic regression analyses the BVC uniquely predicted inpatient aggression but adding the slide rule did not improve prediction. Predictive accuracy was found across three diagnostic groups – dementia, psychosis and substance use disorders. These results provide further support on the predictive accuracy of the BVC for short-term violence in forensic mental health settings.     

Issues in violent risk assessment: lessons learned and future directions

Realizing that the assessment of dangerousness with a yes/no format as a poor form of violent risk assessment has been the most important lesson learned about violence in the last 20 years. Further examining (a) what outcome and (b) how the indicators of the outcome should be measured has resulted in better violent risk assessment. The most promising methodological innovation in violent risk assessment has been the introduction of the receiver operating characteristic to assess the efficiency of risk prediction. In the future, the tension between prediction and explanation of violence will need to be maintained while focusing on a mechanism-driven strategy of risk management.     

Dynamic risk factors: scientific kinds or predictive constructs

ABSTRACT

There are a number of theoretical problems evident in the concept of dynamic risk factors that arise from their (increasing) importation into the explanatory and treatment domains of forensic and correctional practice. More specifically: (a) the concept of dynamic risk factors has not been well defined; (b) relatedly, there is a lack of clarity whether dynamic risk factors refer to causal processes or are predictive constructs; and finally (c) because of the above problems no one is sure how best to integrate them into clinical assessment and treatment. I will examine each of these three conceptual problems in this paper and make some suggestions about how to utilise dynamic risk factors in explanations of offending.     

Prospective Replication of the Violence Risk Appraisal Guide in Predicting Violent Recidivism Among Forensic Patients

An exhaustive survey of a cohort of forensic patients provided an opportunity for a prospective replication of the predictive accuracy of the Violence Risk Appraisal Guide (VRAG). Data collected during the original survey also permitted a test of the predictive accuracy of clinical assessments of risk on the same cohort. The VRAG yielded a large effect size in predicting violent recidivism (ROC area = .80) over a constant 5-year follow-up and performed significantly better than averaged clinical opinions. The superiority of the VRAG was also observed at very short follow-up times and for very serious violence. Moreover, for 16 subsamples, observed rates of violent recidivism did not differ significantly from the expected rates. VRAG score was unrelated, and clinical judgments inversely related to violent recidivism in the small low-risk sample of female forensic patients. The authors conclude that, regardless of length of opportunity or severity of outcome, actuarial methods are more accurate than is clinical judgment.     

Behind closed doors: the effect of pretrial publicity on jury deliberations

Abstract

Effective treatment of aggressive behaviour and accurate release decision making are necessary components of adequate clinical practice in forensic psychiatric units. Unfortunately, methods to identify treatment targets and ameliorate aggressive behaviour have developed at a slower pace than risk assessment technologies. Recent progress on the identification of offence paralleling or functionally equivalent behaviour offers a framework for individually tailored treatment and idiographic release decision making, although empirical scrutiny of this approach is inadequate. This paper describes an examination of the relationship between aggressive behaviour prior to admission with aggression during inpatient psychiatric treatment, and reconviction for violent offending following discharge. Results showed a relationship between pre- and post-admission aggression but no relationship between aggression during inpatient psychiatric treatment with either pre-admission aggressive behaviour or violent recidivism. These findings indicate the importance of state psychological variables, specifically those states affected by symptoms of psychiatric illness, as well as environmental activators and inhibitors of violence that operate within the hospital. These require inclusion in an adequate functional analysis of aggressive behaviour for forensic psychiatric patients.     

An empirical investigation of written risk communication in forensic psychiatric evaluations

Abstract

There has been an increased interest in approaches for improving violence risk assessment, but less so how to communicate risk assessment results. We studied the written risk communication of 142 cases of forensic psychiatric evaluations in Sweden. The results suggested that risk for criminal recidivism was communicated in the vast majority of the cases (122 out of 142), but that risk was primarily communicated when the risk was perceived to be high. A six-item protocol to assess the content of the risk communication suggested that the communication was well elaborated in 21/122 of the cases, moderately elaborated in 53/122, poorly or very poorly elaborated in 43/122, and non-elaborated in 5/122 of the cases. Level of elaboration was only vaguely related to sociodemographic characteristics pertaining to the assessed (sex, age, citizenship) and the type of crime committed, but highly correlated to clinical diagnoses (DSM-IV) as well as contextual factors of the evaluation (which professional group and which clinic the assessment was performed).     

Sexual violence perpetrated against women in India: the role of forensic evidence

ABSTRACT

In response to the upsurge in acts of sexual violence against women in India, Parliament passed the Criminal Law (Amendment) Act of 2013, amending existing statutes and rules of evidence relating to crimes of sexual violence and the practices of forensic professionals in the country. While a step in the right direction, this law paid little attention to forensic evidence in sexual violence cases, which can provide a more objective, scientific account of events, aid in the reconstruction of crimes, and help strengthen cases against perpetrators. The objectives of this article are twofold: to raise awareness for the need for a more prominent role of forensic evidence in sexual violence cases and to recommend ways to establish uniform and comprehensive policies and procedures on the collection and preservation of forensic evidence in order to ensure that cases of sexual violence against women are heard in Indian courts.     

Characteristics and offences of women with borderline personality disorder in forensic psychiatry: a multicentre study

Although female forensic patients diagnosed with borderline personality disorder (BPD) are generally considered taxing in clinical practice, little is known about their specific characteristics or offences. In this study, 156 female forensic psychiatric patients diagnosed with BPD were compared to 113 diagnosed otherwise. Information on demographic and psychiatric characteristics, victimization, index offences, and incidents during treatment was gathered from patient files. Risk factors for recidivism were assessed using the PCL-R and historical items of the HCR-20, including items from the new Female Additional Manual (FAM). Compared to non-BPD women, BPD women were more likely to have been abused as children and to have a history of outpatient treatment. While less likely to be convicted for (attempted) homicide, a higher percentage of BPD women was convicted for arson. Comorbid substance abuse was more frequent in the BPD group and incidents towards others and themselves were more violent in nature. The PCL-R and the H-scale of the HCR-20/FAM indicated several risk factors especially important for BPD women, such as poor behavioural control, impulsivity, and irresponsibility. The results support the clinical impression that women diagnosed with BPD are a subgroup within the female forensic psychiatric population, with specific focus points for treatment and management.     

Violence risk and gang affiliation in youth offenders: a recidivism study

Abstract

Youth gangs are ubiquitous around the world and have been problematic for the social and criminal justice agencies. Despite widespread public concern, there has been relatively scarce empirical scrutiny of youth gangs internationally and little outside of America and Europe. In particular, the activities of youth gangs, the function of gang membership, the criminogenic needs of gang-affiliated youth, and the risk of criminal recidivism for gang-affiliated youth remain unclear. Against this background, this study explored the sociodemographic characteristics, risk and rate of criminal recidivism in a cohort of 165 male youth offenders in Singapore, of which 58 were gang-affiliated. Multivariate analyses revealed that gang-affiliated youth offenders were significantly more likely to have histories of substance use, weapon use and violence than nongang-affiliated youth offenders. Gang-affiliated offenders also scored higher on measures of risk for recidivism (SAVRY and YLS/CMI), and engaged in violent and other criminal behaviors more frequently during follow-up. These differences indicate a significant relationship between gang affiliation and criminal recidivism in youth offenders. Furthermore, these findings have important clinical and policy implications, indicating an increased requirement for additional and more intensive assessment and tailored interventions for gang-affiliated youth offenders.