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.     

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.     

HCR-20 violence risk assessments as a guide for treating and managing violence risk in a forensic psychiatric setting

Abstract

Over the past decades there has been a vast development in the research into risk factors for violence and the development of risk assessment instruments. One instrument that has been given special attention is the HCR-20 violence risk assessment scheme. However, little attention has been paid to the clinical applicability of this tool, i.e. how does this assessment scheme perform when utilized in clinical practice as a tool to guide intervention and management in order to alleviate risk of violent behaviour? The present study was a true prospective study into the utilization of the HCR-20 as a clinical routine. Data on forensic psychiatric patients (n = 81) from a forensic unit in Denmark are presented. As part of a clinical routine all patients were assessed for risk of future violence utilizing the structured professional judgement model, the HCR-20. Outcome measures were aggressive episodes during hospitalization and new convictions post discharge. The predictive validity of the HCR-20 was lower compared with previous findings. It is argued that this does not necessarily indicate poor predictive accuracy of the HCR-20. Rather, it may indicate that the HCR-20 is suitable for guiding risk management in order to prevent violent behaviour.     

Rehabilitating serious violent adult offenders: an empirical and theoretical stocktake

Extensive meta-analyses of the correctional programme evaluation literature have generated developments in the technology of programme design. However, the risk, need and responsivity principles do not constitute a rehabilitation theory and cannot answer specialist offender programme design questions. After more than a decade of involvement in programmes for seriously violent offenders, we decided to reassess the empirical evidence underpinning violence rehabilitation in adult men. We focused on both mixed and violent offender samples, reviewing the outcome data from nine evaluations of cognitive–behavioural interventions. Despite a plethora of methodological difficulties, it appears that most of the programmes had small to large effects on violent and non-violent recidivism. Little could be concluded from these evaluations about the most promising theoretical framework for future programme development. Most programmes contained only scant information on their underlying theory base. None referred to multivariate aggression or crime theories. We conclude that there is a pressing need for additional evaluative research, and theory development. To date, the case for specialist violent offending programmes has not been made.     

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.     

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.     

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.     

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.     

Integrating DSM-IV Factors to Predict Violence in High-Risk Psychiatric Patients

Abstract:  This study incorporated Axis-II and Axis-IV factors in DSM-IV to test the relationship between predicted risk for violence assessed in the psychiatric emergency room and actual violence during hospitalization. Psychiatric nurses lack an objective instrument to use during the acute psychiatric assessment. The retrospective study comprised consecutive psychiatric admissions ( n  = 161) in one tertiary veterans' hospital. Statistical testing for the predictive power of risk factors, relationships between variables, and violent events included nonparametric tests, factor analysis, and logistic regression. Of the 32 patients who committed violence during hospitalization, 12 had committed violence in the psychiatric emergency room. Statistical significance was shown for violent incidents and dementia, court-ordered admission, mood disorder, and for three or more risk factors. The 13-item Risk of Violence Assessment (ROVA) scale suggests validity and sensitivity for rating DSM-IV factors and psychosocial stressors to predict risk for violence during hospitalization. Replication studies are recommended to strengthen validity of the ROVA scale.     

Mental Disorder, Violence, and Gender

Recent studies have reported comparable rates of violence among men and women with mental disorder, raising important issues for clinical risk assessment. This study examines the relationship between gender and violence using data from the MacArthur Violence Risk Assessment Study. Patients in acute psychiatric wards were interviewed 5 times over the year following their discharge to the community. Results showed some differences between men and women in the violence committed immediately following discharge, with rates for men being higher. But the prevalence of violence over the 1 year was similar for female and male discharged patients. However, there were substantial gender differences in the situational context of the violence committed. Men were more likely to have been drinking or using street drugs, and less likely to have been adhering to prescribed psychotropic medication, prior to committing violence. The violence committed by men was more likely to result in serious injury than the violence committed by women, and men were more likely than women to be arrested after committing a violent act. Women were more likely to target family members and to be violent in the home.     

Identifying Three Types of Violent Offenders and Predicting Violent Recidivism While on Probation: A Classification Tree Analysis

This study employs classification tree analysis (CTA) to address whether 3 groups of violent offenders have similar or different risk factors for violent recidivism while on probation. A sample of 1344 violent offenders on probation was classified as generalized aggressors (N = 302), family only aggressors (N = 321), or nonfamily only aggressors (N = 717). The strongest predictor of violent recidivism while on probation was whether the offender was a generalized aggressor or not, with generalized aggressors more likely to be arrested for new violent crimes. Prior arrests for violent crimes predicted violent recidivism of generalized aggressors, but did not significantly predict violent recidivism of family only and nonfamily only aggressors. For generalized aggressors and family only batterers, treatment noncompliance was an important risk predictor of violent recidivism. CTA compared to logistic regression classified a higher percentage of cases into low-risk and high-risk groups, provided higher improvement in classification accuracy of violent recidivists beyond chance performance, and provided a better balance of false positives and false negatives. The implications for the risk assessment and domestic violence literature are discussed.     

Intensive psychological treatment of high-risk violent offenders: Outcomes and pre-release mechanisms

Research on correlates of intervention programmes that reduce expected reconviction rates (‘what works’ literature, Risk–Need–Responsivity model) has been highly influential in criminal justice systems throughout much of the western world. But while this psychological research has been acquiring widespread recognition, a deeper understanding of how programmes work and of mechanisms for desistance more generally, has still to develop. This research reports results of a quasi-experimental recidivism outcome study for a series of prison units that provide intensive psychological treatment to high-risk, persistently violent prisoners. Four outcomes were examined over the first 12 months following release on parole: parole violations, new convictions, new convictions for violence, and imprisonment sentences resulting from new convictions. Alongside these results, we conducted preliminary analyses of two potential pre-release mechanisms for surviving the first 12 months on parole without reconviction: lower dynamic risk for violence, and greater release readiness. We found that dynamic violence risk fully accounted for differences between treatment completers and comparison prisoners in proportions reconvicted for violence. However, in all other cases, the proposed mechanisms did not significantly explain treatment-related differences. We close by considering possible explanations for these unexpected results, and reiterating the importance to our field of more sophisticated treatment outcome research.     

Applying a forensic actuarial assessment (the Violence Risk Appraisal Guide) to nonforensic patients

The actuarial Violence Risk Appraisal Guide (VRAG) was developed for male offenders where it has shown excellent replicability in many new forensic samples using officially recorded outcomes. Clinicians also make decisions, however, about the risk of interpersonal violence posed by nonforensic psychiatric patients of both sexes. Could an actuarial risk assessment developed for male forensic populations be used for a broader clientele? We modified the VRAG to permit evaluation using data from the MacArthur Violence Risk Assessment Study that included nonforensic male and female patients and primarily self-reported violence. The modified VRAG yielded a large effect size in the prediction of dichotomous postdischarge severe violence over 20 and 50 weeks. Accuracy of VRAG predictions was unrelated to sex. The results provide evidence about the robustness of comprehensive actuarial risk assessments and the generality of the personal factors that underlie violent behavior.     

Determinations of negligence and the hindsight bias

Examined the hindsight bias in determinations of negligence inTarasoff-type cases. The sample of 297 community residents was asked to read clinical case scenarios involving treatment of potentially dangerous patients. Scenarios varied by outcome: (1) the patient became violent, (2) the patient did not become violent, and (3) no outcome was specified. Respondents rated the foreseeability of violence, the reasonableness of therapist actions, and negligence. It was hypothesized that respondents who were informed that the patient became violent would be more likely to find the therapist negligent than respondents in the other two outcome conditions. Findings supported this, and respondents in the violent outcome condition rated the violence as more foreseeable and therapist actions as less reasonable. Implications for mental health and legal professionals are discussed and future research ideas are suggested.     

Risk factors for violent offending in autism spectrum disorder: a national study of hospitalized individuals

Little is known about risk factors for violence among individuals with autism spectrum disorder (ASD). This study uses data from Swedish longitudinal registers for all 422 individuals hospitalized with autistic disorder or Asperger syndrome during 1988-2000 and compares those committing violent or sexual offenses with those who did not. Thirty-one individuals with ASD (7%) were convicted of violent nonsexual crimes and two of sexual offenses. Violent individuals with ASD are more often male and diagnosed with Asperger syndrome rather than autistic disorder. Furthermore, comorbid psychotic and substance use disorders are associated with violent offending. We conclude that violent offending in ASD is related to similar co-occurring psychopathology as previously found among violent individuals without ASD. Although this study does not answer whether ASDs are associated with increased risk of violent offending compared with the general population, careful risk assessment and management may be indicated for some individuals with Asperger syndrome.     

Management of violent behaviour in the correctional system using qualified risk assessments

Purpose. This study focused on whether institutional violence in a maximum‐security correctional institution could be prevented using comprehensive risk assessments followed by adequate risk management. And, could this be shown by a decrease in risk factors for violence according to the HCR‐20 Risk Assessment Scheme in the study group? Methods. Offenders with a history of violent criminality were subject to real‐life assessments using the HCR‐20 Risk Assessment Scheme. The assessments were followed by discussions with members of staff, in which risk management strategies were designed. Thus, the members of staff were fully aware of every inmate's personality characteristics (e.g. psychiatric diagnoses), what risk factors for violence they displayed, and how best to manage those risk factors. With the aim of evaluating the possible effects of our interventions, approximately one third of the study group was reassessed after a mean of 12 months. Results. The follow‐up showed no significant decrease in important risk factors for violence in the study group. However, the number of violent incidents showed a remarkable decrease during the study period. Conclusions. Not being able to reduce important risk factors for violence does not necessarily mean that one cannot decrease the risk for, or the incidence of, violence. This study indicates that proper and adequate risk management, using the best protective factors available, can reduce violence even though important risk factors cannot be decreased. The study also supports the theoretical assumption that changes in risk factors are more possible in some populations (e.g. general psychiatric) than in others (e.g. correctional) depending on the nature of the study group and the risk factors that are at hand (e.g. dynamic vs. static). This seems to be important to bear in mind when performing evaluation research using risk assessment instruments.     

Strategies for an empirical analysis of the prediction of violence in emergency civil commitment

Dix (1976) recently has proposed that a “true experiment” be conducted to assess the validity of predictions of imminent violence. A random sample of persons predicted to be iminently violent would be denied emergency civil commitment in order to test whether they do, in fact, commit a violent act. This article analyzes Dix's proposal and finds that it presents an unacceptable level of risk to the community. Four alternative methodologies by which preliminary data can be gathered on the validity of predictions of violence in emergency civil commitment are described.     

Communicated threats and violence toward public and private targets: discerning differences among those who stalk and attack

A computation of false positive and false negative rates concerning the probability that directly communicated written or oral threats predict subsequent violent behavior yields a striking difference between "public" and "private" targets. Among private targets, communicated threats appear to increase risk, but are so common that they have little predictive value. On the other hand, public targets are unlikely to receive a direct threat from those who approach to attack. The author suggests that the most parsimonious explanation for this difference is the type, or mode of violence, that is apparent. Private targets appear to be most likely victimized by affective violence, wherein the emotionally reactive subject will immediately shove, push, punch, slap, choke, fondle, or hair pull the victim without the use of a weapon, usually in response to a perceived rejection or humiliation. Public targets are most likely to be victimized by predatory violence, which is planned, purposeful, cognitively motivated, opportunistic rather than impulsive, and often involves a firearm. Implications for risk assessment are discussed.