Article

Violence, mental disorder and risk assessment: can structured clinical assessments predict the short-term risk of inpatient violence?

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Abstract

This study considered the ability of items on the HCR-20 and VRS, structured clinical risk assessments, to predict inpatient violence within the first 6 months of admission to a secure forensic service. A retrospective file review of information available at time of admission was used to complete the Historical and Clinical scales of the HCR-20 and VRS for a sample of 44 male inpatients. The ability of these risk assessments to predict recorded incidents of violent behaviour, as measured by official incident reports, was then assessed. The predictive validity of individual scale items was also considered. The HC composite and VRS did not predict inpatient violence within the first 6 months of admission. However, the clinical sub-scale of the HCR-20 was predictive of violence, abuse or harassment. When considering repetitiveness there was some indication across the scales that static factors predicted isolated incidents and dynamic factors repetitive violence. A number of individual items within the scales appeared to act as predictive or protective factors for inpatient violence. Despite the poor predictive validity of the scales overall, this study provides some indication of the differential utility of these structured clinical assessments for predicting short-term risk of violence in inpatients. In particular the use of dynamic clinical factors in identifying those likely to engage in imminent repetitive violence.

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... To prevent future violence from occurring, it is essential that healthcare providers, especially nursing staff who are on the front lines of treatment, identify both static (i.e., risk factors that do not change over time) and dynamic (i.e., risk factors that can change over time) risk factors associated with violent behaviors (Daffern et al., 2018). Static factors related to short-term inpatient aggression include history of mental health diagnoses, gender (being male), and a lifetime history of violence and criminal behaviors or convictions (Grevatt et al., 2004;Iozzino et al., 2015;Meehan et al., 2017). Dynamic risk factors, such as active psychiatric symptoms (e.g., psychosis), hostile behaviors, poor impulse control, current substance abuse, and nonadherence with treatment, are also important when considering the potential for short-term inpatient violence (British Psychological Society, 2015;Daffern et al., 2018;Finch et al., 2016;Grevatt et al., 2004). ...
... Static factors related to short-term inpatient aggression include history of mental health diagnoses, gender (being male), and a lifetime history of violence and criminal behaviors or convictions (Grevatt et al., 2004;Iozzino et al., 2015;Meehan et al., 2017). Dynamic risk factors, such as active psychiatric symptoms (e.g., psychosis), hostile behaviors, poor impulse control, current substance abuse, and nonadherence with treatment, are also important when considering the potential for short-term inpatient violence (British Psychological Society, 2015;Daffern et al., 2018;Finch et al., 2016;Grevatt et al., 2004). Among patients not diagnosed with schizophrenia, psychiatric symptoms such as agitationexcitement, hostile-suspiciousness, and thinking disturbance have been linked to a higher risk of short-term inpatient violence (McNiel & Binder, 1994). ...
... Among patients not diagnosed with schizophrenia, psychiatric symptoms such as agitationexcitement, hostile-suspiciousness, and thinking disturbance have been linked to a higher risk of short-term inpatient violence (McNiel & Binder, 1994). Overall, research indicates that clinical and dynamic risk factors may be most predictive of inpatient physical aggression compared with static factors (Grevatt et al., 2004). ...
Article
In an effort to prevent inpatient violence on forensic psychiatric units, it is necessary to have a feasible and effective measure for nursing to screen for risk of short-term verbal and physical aggression. The Imminent Risk Rating Scale (IRRS; Starzomski & Wilson, 2015) showed promise in an initial validation study. This study aimed to further examine the predictive validity of the IRRS by utilizing clinical pilot data collected from a forensic inpatient unit. Nursing staff scored the IRRS for adults who were hospitalized for at least 1 week (n = 109), as well as outcomes related to verbal and physical aggression as measured by the Modified Overt Aggression Scale. The results from the clinical pilot data provided additional support for the potential use of the IRRS for predicting physical and verbal aggression in a forensic inpatient setting, although further rigorous empirical research is needed. The findings are important for nursing staff in the prediction and prevention of inpatient violence.
... These findings are consistent with models of aggression in mental health populations and previous experimental literature, implicating deficits in facial affect recognition (Malone, Carroll, & Murphy, 2012) and hostile attribution bias (Harris, Oakley, & Picchioni, 2014) in aggressive behaviour. Impulsivity produced heterogenous findings, as it was weakly, but significantly, associated with verbal aggression (Wang & Diamond, 1999), but not found to be statistically significant in other studies (Brugman et al., 2016;Grevatt et al., 2004). These differences could reflect general difficulties in operationalising impulsivity, as structured risk assessments often do not differentiate between trait (static) and state (dynamic) impulsivity (Nguyen, Brooks, Bruno, & Peacock, 2018). ...
... Three studies reported five dynamic risk factors for property aggression, all of which were also associated with other forms of aggression. Risk factors corresponded to heightened psychophysiological arousal (electrodermal activity and heart rate; de Looff et al., 2019), cognitive difficulties including lack of insight, mental wellbeing (Grevatt et al., 2004) and emotion recognition deficits (Brugman et al., 2016). Grevatt et al. (2004) included multiple forms of aggression, but did not report which risk factors were associated with property aggression specifically. ...
... Risk factors corresponded to heightened psychophysiological arousal (electrodermal activity and heart rate; de Looff et al., 2019), cognitive difficulties including lack of insight, mental wellbeing (Grevatt et al., 2004) and emotion recognition deficits (Brugman et al., 2016). Grevatt et al. (2004) included multiple forms of aggression, but did not report which risk factors were associated with property aggression specifically. Rates of property aggression were also lower in Antisocial behaviour (3/3) Attacking objects (1/2) Boisterousness (1/2) Confusion (1/2) Increased bad language/swearing (1/1) Increased volume (1/1) Irritability (3/3) Noncompliance with remediation attempts (1/2) Physically threatening (1/5) Plans lack feasibility (1/2) Social functioning (2/3) Education, occupation, Creativity (1/1) Problem solving deficits (1/1) Stress (1/2) Unresponsive to treatment (1/4) ...
... The same pattern of higher scores was evident for the other assessment measures also. The mean VRS Total score in the present sample was 33% higher than that reported by Dolan and Fullam (2007), 43% higher than that reported by Grevatt et al. (2004) for their sample of 44 male psychiatric inpatients detained in an independent security facility in England, and 32% higher than that reported by Wong and Gordon (2006) Dolan and Fullam (2007) reported that all HCR-20 components were significantly predictive (although they too did not include SFRJs). Grevatt et al. (2004), who also did not include data for SFRJs, reported significant AUC values for the Clinical scale in predicting an inclusive outcome of violence, abuse or harassment as well as 3 or more incidents involving physical assault. ...
... The mean VRS Total score in the present sample was 33% higher than that reported by Dolan and Fullam (2007), 43% higher than that reported by Grevatt et al. (2004) for their sample of 44 male psychiatric inpatients detained in an independent security facility in England, and 32% higher than that reported by Wong and Gordon (2006) Dolan and Fullam (2007) reported that all HCR-20 components were significantly predictive (although they too did not include SFRJs). Grevatt et al. (2004), who also did not include data for SFRJs, reported significant AUC values for the Clinical scale in predicting an inclusive outcome of violence, abuse or harassment as well as 3 or more incidents involving physical assault. In the present sample, only the AUC value of .74 ...
... Indeed, this represents one of the key challenges for the field more generally, with dynamic risk factors central to assessment of intra-individual risk over time (Douglas & Skeem, 2005) and quite distinct in practical terms from the determination of risk status that can be effectively undertaken on the basis of static risk factors (Heilbrun, 1997 Importantly, no component of the VRS significantly predicted interpersonal physical aggression for either the full or 12-month follow-up (although medium effect sizes were again found for the Total and Dynamic Factor scale), and failure rates for high-versus low-risk groups revealed no significant differences contrary to findings concerning postrelease recidivism reported by Wong and Gordon (2006). Grevatt et al. (2004) found that the VRS predicted neither damage to property nor interpersonal physical aggression in their sample over a 6-month period. In contrast, in a study looking only at physical assaults on others, Dolan and Fullam (2007) reported significant results for the Total and Dynamic Factors scale scores over a 12-month period. ...
... violence to property (AUCs 0.77Á 0.83), and physical aggression (AUCs 0.77Á0.81) in their sample of 34 mentally disordered offenders (15% of whom had a personality disorder diagnosis). Similarly, Grevatt, Thomas-Peter, and Hughes (2004) reported that scores on the HCR-20 Clinical scale significantly predicted incidents of verbal abuse (AUC 0.81) and damage to property (AUC 0.65), but not physical assaults specifically (AUC 0.60), over a 6-month period in their UK sample of 44 patients held in an independent forensic psychiatric facility (39% of whom had a personality disorder). In the same study, however, Grevatt et al. found that the Historical scale failed to predict these outcomes and neither were the VRS Total nor Static and Dynamic Factor scale scores were significantly predictive. ...
... The same pattern of higher scores was evident for the other assessment measures also. The mean VRS Total score in the present sample was 33% higher than that reported by Dolan and Fullam (2007), 43% higher than that reported by Grevatt et al. (2004) for their sample of 44 male psychiatric inpatients detained in an independent secure facility in England, and 32% higher than that reported by Wong and Gordon (2006) for their pooled sample of 918 male offenders drawn from the Canadian correctional federal and provincial systems and a forensic psychiatric facility. ...
... Dolan and Fullam (2007) reported that all HCR-20 components were significantly predictive (although they too did not include SFRJs). Grevatt et al. (2004), who also did not include data for SFRJs, reported significant AUC values for the Clinical scale in predicting an inclusive outcome of violence, abuse or harassment as well as three or more incidents involving physical assault. In the present sample, only the AUC value of 0.74 for the SFRJ among the risk assessment tools was statistically significant when the outcome was repetitive IPA (two or more incidents during the follow-up). ...
Article
Entry to the Dangerous and Severe Personality Disorder (DSPD) service in England and Wales is heavily determined by risk status, and therefore requires valid procedures for monitoring changes in risk over time in order to make risk management decisions and determine patients' suitability for transfer to lower security settings. Yet little is known about the validity of current risk assessment tools with the new DSPD population. This study reports a prospective evaluation of the predictive accuracy of the HCR-20, VRS, Static-99, and Risk Matrix 2000 with 44 consecutive admissions to the DSPD unit at a high secure forensic psychiatric hospital. Thirty eight per cent of the sample exhibited interpersonal physical aggression (IPA) on one or more instances over an average 1.5 year period following admission, and a similar percentage caused damage to property (DTP) on one or more occasions over the same period. All tools predicted DTP. HCR-20 Total and scale scores predicted IPA with structured final risk judgements also predicting repetitive (2 + incidents of) IPA. HCR-20 Risk Management scores were significantly associated with imminence of IPA. Results were discussed in terms of the practical utility of these tools with high risk forensic psychiatric inpatients.
... Wong & Gordon, 2001). To date, there have been few studies published on the validity of the VRS-2 outside its Canadian development centre, apart from one smallscale study of 44 cases in a medium security setting (Grevatt, Thomas-Peter, & Hughes, 2004). The VRS-2 has recently been adopted as one of the standard measures for 'dangerous and severe personality disorder' (Home Office & Department of Health, 2001) assessments, but it has not been extensively validated in the UK; thus, here we examine its psychometric properties -descriptive statistics, inter-rater reliability, and predictive validity of the Part A baseline assessment component of the VRS-2. ...
... Our finding that the VRS-2 had reasonable inter-rater reliability fits with Wong and Gordon's (2001) report that there are high levels of inter-rater reliability when the criteria are reviewed for each item. Our mean VRS-2 score was slightly lower than that reported in the Canadian development site (mean 45; Wong & Gordon, 2001) but marginally higher than those reported by Grevatt et al. (2004). Differences are likely to be due to differences in the populations under study -in particular their sources of referral and stage of rehabilitation. ...
... To date, there have been few studies of the VRS-2 in relation to institutional violence, but Grevatt et al. (2004) have suggested that it had modest predictive validity for physical assault at six-month follow-up in a postdictive study. Our findings are largely in agreement with these findings, but we acknowledge that both studies used largely mentally ill samples and the VRS-2 may well prove to be a more robust predictor of violence in nonmentally ill samples. ...
Article
The aim of the present investigation was to examine the validity of the Violence Risk Scale second edition (VRS-2) in a sample of 136 male medium secure psychiatric inpatients. Ratings on the VRS-2 were completed within the first month of admission based on preadmission records, court depositions, and criminal records. Construct validity was assessed using the Historical Clinical Risk-20 (HCR-20) assessment scheme in a subsample of 80 cases rated on the same basis. This showed that the VRS-2 and HCR-20 total scale scores correlated very highly, supporting the notion that the VRS-2 is a measure of violence risk. Both the HCR-20 and the VRS-2 could distinguish between violent and non-violent subgroups with reasonable effect sizes. There were highly significant correlations between the scales on the rating of items measuring comparable variables. Both measures were predictive of violence at 12-month follow-up, but the HCR-20 clinical subscore was the most robust contributor in the summary regression analysis. Our results offer preliminary evidence that the VRS-2 is a reasonably valid measure of violence risk and that it could be useful for research in this area.
... Studying a sample of psychotic male forensic inpatients in New York City, Alia-Klein et al. (2007) reported that insight into illness was significantly related to the severity of violence, even after controlling for a number of other predictors, including age, substance use, and medication adherence. In another study examining male patients in a secure psychiatric facility in England, it was found that a lack of insight was among the strongest predictors of inpatient violence (Grevatt et al., 2004). ...
... This is supported by the variable importance measures of the random forest suggesting that dynamic clinical variables regarding the patients' insight into the problems associated with their illness and their criminal behavior play a major role in predicting inpatient verbal aggression. This finding is in line with previous research showing that a lack of insight constitutes a risk factor for violent behavior (Alia-Klein et al., 2007;Grevatt et al., 2004). ...
Article
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Inpatient violence poses a great risk to the health and well-being of other patients and members of staff. Previous research has shown that prevalence rates of violent behavior are particularly high in forensic psychiatric settings. Thus, the reliable identification of forensic inpatients who are particularly at risk for violent behavior is an important aspect of risk management. In the present study, we analyzed clinicians’ assessments of N = 504 male and female inpatients of German forensic mental health institutions in order to identify risk factors for verbal institutional violence. Using a tree-based modeling approach, we found the following variables to be predictors of verbal aggression: gender, insight into the illness, number of prior admissions to psychiatric hospitals, and insight into the iniquity of the offence. A high number of prior admissions to psychiatric hospitals seems to be a risk factor for verbal aggression amongst men whereas it showed the opposite effect amongst women. Our results highlight the importance of dynamic risk factors, such as poor insight into the own illness, in the prediction of violent incidents. With regard to future research, we argue for a stronger emphasis on nonparametric models as well as on potential interaction effects of risk and protective factors.
... As violence can be explained by different factors, as we see in these results, this may possibly influence the predictive validity of this specific item in a group assessment. Grevatt, Thomas-Peter, and Hughes (2004) even found violence throughout the lifespan to be a protective factor for institutional violence, possibly due to proper identification and management by the treatment teams. This could also be the case in our population. ...
... The generally moderate predictive validity for short-term incidents in forensic psychiatry is similar to results found in previous studies, in which clinical factors show a better predictive value than static historical risk factors (Grevatt et al., 2004). However, these results were assessed for incidents at the start of treatment. ...
... As violence can be explained by different factors, as we see in these results, this may possibly influence the predictive validity of this specific item in a group assessment. Grevatt, Peter-Thomas and Hughes [37] even found violence throughout the lifespan to be a protective factor for institutional violence, possibly due to proper identification and management by the treatment teams. This could also be the case in our population. ...
... The generally moderate predictive validity for short-term incidents in forensic psychiatry is similar to results found in previous studies, in which clinical factors show a better predictive value than static historical risk factors [37]. However, these results were assessed for incidents at the start of treatment. ...
Article
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Background Rehabilitation in forensic psychiatry is achieved gradually with different leave modules, in line with the Risk Need Responsivity model. A forensic routine outcome monitoring tool should measure treatment progress based on the rehabilitation theory, and it should be predictive of important treatment outcomes in order to be usable in decision-making. Therefore, this study assesses the predictive validity for both positive (i.e., leave) and negative (i.e., inpatient incidents) treatment outcomes with the Instrument for Forensic Treatment Evaluation (IFTE). Methods Two-hundred and twenty-four patients were included in this study. ROC analyses were conducted with the IFTE factors and items for three leave modules: guided, unguided and transmural leave for the whole group of patients. Predictive validity of the IFTE for aggression in general, physical aggression specifically, and urine drug screening (UDS) violations was assessed for patients with the main diagnoses in Dutch forensic psychiatry, patients with personality disorders and the most frequently occurring co-morbid disorders: those with combined personality and substance use disorders. Results and Conclusions Results tentatively imply that the IFTE has a reasonable to good predictive validity for inpatient aggression and a marginal to reasonable predictive value for leave approvals and UDS violations. The IFTE can be used for information purposes in treatment decision-making, but reports should be interpreted with care and acknowledge patients’ personal risk factors, strengths and other information sources.
... The Violence, Abuse or Harassment Incident Form (Grevatt et al., 2004). m The Modified Overt Aggression Scale (Kay et al., 1988). ...
... Instruments specially developed to record aggression and violence, such as the Modified Overt Aggression Scale (MOAS) (Kay, Wolkenfeld, & Murrill, 1988), the Overt Aggression Scale (OAS) (Yudofsky, Silver, Jackson, Endicott, & Williams, 1986), the Staff Observation Aggression Scale (SOAS) (Palmstierna & Wistedt, 1987), the Violence, Abuse or Harassment Incident Form (VAH) (Grevatt, Thomas-Peter, & Hughes, 2004), and the Violence and Suicide Assessment Scale (VASA) (Feinstein & Plutchik, 1990) were used in five of the investigations reported here. Seven studies were based on official records such as legal charges, hospital records, and file review. ...
Article
Full-text available
Lack of insight has established itself both as an important element of models of risk of violence and as a clinical item in structured approaches to measuring risk of violence. The main purpose of this paper is to delineate findings from a review of the literature concerning the empirical basis for the existence of a relationship between insight and violence risk. A second aim is to examine whether certain dimensions of insight may have a higher violence-triggering potential, and, if so, to learn more about valid and reliable approaches for measuring these dimensions. Results of this review show that there are very few empirical studies that demonstrate a possible association between insight and violence risk. Five out of a total of nine investigations found a positive relationship between poor insight and violent behavior. Nonetheless, the strength and specific nature of the relationship remain unclear due to considerable methodological and conceptual shortcomings in the reviewed studies. Seven recommendations for future research are presented to address these shortcomings.
... Results indicated that only the Clinical, or C, scale predicted inpatient violence. Grevatt, Thomas-Peter, and Hughes (2004) reported only the C scale from the HCR-20 predicted inpatient violence in a sample of 44 patients. Daffern et al. (2007) reported that the HCR-20 was significantly better than chance at predicting both immediate aggression and self-harm in a secure mental health facility. ...
... Hospital policy mandates that each violent episode is charted in the individual's official medical record, which is considered a legal document. This methodology is consistent with most studies of inpatient violence (Grevatt et al., 2004;Hill et al., 2004;McDermott et al., 2008;Vitacco et al., 2009). Given the confines of the forensic hospital, it is likely that few violent incidents were missed; however, we do recognize that the potential exists for missed violent acts. ...
Article
Full-text available
Predicting which forensic inpatients are likely to be violent is necessary if forensic hospitals are to implement effective risk management techniques. When conducting risk assessments, clinicians have at their disposal standardized risk assessment instruments that have demonstrated ability to predict violence. The present study examined the utility of static and dynamic measures used in risk assessment to predict aggressive behavior in a sample of 103 inpatients committed to a forensic hospital after being found not guilty by reason of insanity. Results indicated that both static and dynamic measures, including psychopathy, predicted inpatient aggression; however, neither type of measure provided incremental predictive validity above and beyond the other. Implications for predicting violence with forensic inpatients is discussed with the ultimate goal of implementing effective treatment interventions aimed at reducing violence.
... Particularly concerning is that research examining violence among NGRI inpatients 5 has largely focused on psychiatric symptoms while neglecting criminogenic risk factors. 6,7 Given that an NGRI commitment status indicates a nexus between criminal behavior and mental illness, research examining traditional criminal risk factors for violence, in conjunction with psychiatric symptoms, may elucidate important treatment targets for NGRI inpatients and enhance institutional safety. ...
Article
Objective Institutional violence in state hospitals is a public health problem that has been severely understudied. Given the personal (ie, staff and patients) and fiscal harms associated with institutional violence, more research into contributing factors for violence is needed. The overarching aim of this study then was to examine associations among psychiatric symptoms, criminal risk factors, and institutional violence. Methods Participants were 200 male, female, and transgender forensic mental health inpatients adjudicated Not Guilty by Reason of Insanity and committed to the California Department of State Hospitals. Participants completed a psychiatric symptom measure, and measures of and associated with criminal risk. Institutional violence was recorded from file review and includes physical violence toward staff or patients for 6-months prior to and post patient participation in this study. Results After adjusting for previous institutional violence, results indicated that psychiatric symptoms were not associated with follow-up institutional violence; however, criminal risk was associated with follow-up institutional violence. Unexpectedly, 2 aspects of criminal risk, antisocial cognitions and associates, were not associated with follow-up institutional violence after adjusting for previous institutional violence. Results also provided a tentative cutoff score on the Self-Appraisal Questionnaire for predicting follow-up institutional violence. Conclusions These results have important implications for treating and managing patients at risk for institutional violence, including the need to assess criminogenic risk and leverage treatments that target these risk factors as a best practice approach.
... An explanation for this finding is that the Clinical scale, which relies on dynamic variables, was coded at discharge when patients' clinical symptoms were stable. The finding, however, is consistent with research with civil psychiatric patients, and other studies that established modest associations between the Clinical scale and inpatient violence (Grevatt, Thomas-Peter, & Hughes, 2004;Macpherson & Kevan, 2004;Ross, Hart, & Webster, 1998, cited in Douglas et al., 1999. Also, the Clinical scale may be a predictor of short-term but not long-term risk in psychiatric patients, thus predicting inpatient but not outpatient behaviour. ...
Article
The Historical Clinical Risk Management–20 (HCR–20) is utilised internationally to assess an individual's risk for violence. Despite being widely administered in Australian correctional and forensic populations, the predictive validity of the HCR–20 instrument has never been explored in Australian settings. This retrospective study investigated the predictive validity of the HCR–20 for an Australian cohort of 136 forensic psychiatric patients. Findings support the relationship between the HCR–20 and violent offending post hospital discharge. The HCR–20 Total, Historical, and Risk Management scales shared moderate to large positive correlations with several reconviction categories.
... In contrast, dynamic factors, for example the severity and nature of active symptoms of major mental illness, can change with time, are associated with changes in risk behaviour (Hanson and Harris, 2000) and can add significant incremental validity to risk assessment (Doyle and Dolan, 2006). Therefore, they can usefully contribute to violence risk assessment (Chu et al., 2013;Grevatt et al., 2004;McNiel et al., 2003;Wilson et al., 2013), and management strategies (Whittington et al., 2014). ...
Article
The Short-Term Assessment of Risk and Treatability (START) assists risk assessment for seven risk outcomes based on scoring of risk and protective factors and assignment of clinically-informed risk levels. Its predictive validity for violence and self-harm has been established in males with schizophrenia, but accuracy across pathologically diverse samples is unknown. Routine START assessments and 3-month risk outcome data of N=527 adult, inpatients in a UK secure mental health facility were collected. The sample was divided into diagnostic groups; predictive validity was established using receiver operating characteristics regression (rocreg) analysis in which potential covariates were controlled. In most single-diagnosis groups START risk factors ('vulnerabilities'), protective factors ('strengths'), and clinically-informed estimates predicted multiple risk outcomes with effect sizes similar to previous research. Self-harm was not predicted among patients with an organic diagnosis. The START risk estimates predicted physical aggression in all diagnostic groups, and verbal aggression, self-harm and self-neglect in most diagnostic groups. The START can assist assessment of aggressive, self-harm, and self-neglect across a range of diagnostic groups. Further research with larger sample sizes of those with multiple diagnoses is required.
... First, the SAVRY is often used to assess long-term risk, with short-term violence being relatively neglected. Research has shown that a focus on dynamic clinical factors can improve the assessment of violence occurring in the short-term within institutional settings (Grevatt et al., 2004). Despite the emphasis on historical and dynamic risk factors the SAVRY was not designed specifically to assess risk within institutions in the short-term. ...
Article
Purpose The purpose of this paper is to explore the validity and reliability of the Short-Term Assessment of Risk and Treatability: Adolescent Version (START:AV) to determine if it has predictive accuracy in relation to physical aggression, severe verbal aggression, property damage and self-harm, in a medium secure setting. In addition, the authors hoped to provide some of the first descriptive data available for the START:AV among a UK adolescent population in a medium secure adolescent unit. Design/methodology/approach The sample consisted of 90 female and male adolescents, with and without developmental disabilities. It was important to explore the measure’s predictive accuracy across specific population groups, such as between males and females, as well as those with developmental disabilities, and those without. Findings Some significant relationships were found between the START:AV and adverse outcomes. For instance, total strength and vulnerability scores were predictive for verbal and physical aggression. Differences in predictive validity were evident when comparisons were made between males and females, with relationships being evident amongst the male population only. When splitting the male sample into developmental disability and non-developmental disability groups, significant relationships were found between strength and vulnerability scores and verbal and physical aggression. Practical implications A number of practical implications are considered, such as the START:AV is relevant for use with adolescents in hospital settings and the significant inverse relationship between strength scores and negative outcomes supports the importance of considering protective/strength factors when working with at risk youths. Originality/value There is currently limited validation data for the START:AV in the UK or elsewhere.
... 1. Tragedy prevention. It is believed that mental anomalies may be the root causes of many tragedies and incidents [103][104][105]. For example, a recent plane crash was the collateral damage of a suicide incident committed by a co-pilot who was believed to have mental problems. ...
... In general, such patients are characterized by many risk factors for violence, and self-harm is of course not the only risk factor for violence. In previous research, the dynamic risk factors are shown to be the significant predictors of inpatient aggression among forensic psychiatric patients (38,39). Based on our results, we recommend that staff at high-security forensic psychiatric wards be attentive to self-harm among their female patients, since self-harm is associated with aggression. ...
Article
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Background: Inpatient aggression among female forensic psychiatric patients has been shown to be associated with self-harm, that is considered to be a historical risk factor for violence. Research on associations between previous or current self-harm and different types of inpatient aggression is missing. Aim: The aim of this register study was to investigate the prevalence of self-harm and the type of inpatient aggression among female forensic psychiatric inpatients, and to study whether the patients' self-harm before and/or during forensic psychiatric care is a risk factor for inpatient aggression. Methods: Female forensic psychiatric patients (n = 130) from a high security hospital were included. Results: The results showed that 88% of the female patients had self-harmed at least once during their life and 57% had been physically and/or verbally aggressive towards staff or other patients while in care at the hospital. Self-harm before admission to the current forensic psychiatric care or repeated self-harm were not significantly associated with inpatient aggression, whereas self-harm during care was significantly associated with physical and verbal aggression directed at staff. Conclusions: These results pointed towards self-harm being a dynamic risk factor rather than a historical risk factor for inpatient aggression among female forensic psychiatric patients. Whether self-harm is an individual risk factor or a part of the clinical risk factor 'Symptom of major mental illness' within the HCR-20V3 must be further explored among women. Thus, addressing self-harm committed by female patients during forensic psychiatric care seems to be important in risk assessments and the management of violence, especially in reducing violence against staff in high-security forensic psychiatric services.
... For the current study, Clinical and Risk Management items were coded based on information up to 3 months after each probationer's index admission date. The psychometric properties of the HCR-20 have been evaluated (Belfrage, 1998;Douglas et al., 2003;Douglas & Webster, 1999) and it has been used in several retrospective file review studies (Belfrage, 1998;de Vogel, de Ruiter, Hildebrand, Bos, & van de Ven, 2004;Dolan & Blattner, 2010;Grevatt, Thomas-Peter, & Hughes, 2004). In our study, the HCR-20 Total score had a Cronbach's α of 0.89 and an ICC of 0.81. ...
Article
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Probation orders mandating forensic mental health services are used by the courts to deal with the complex needs of probationers with mental disorders, but little is known about this particular legal leverage. The main goals of this study were to describe probationers who were mandated to receive forensic services, and to examine the relationships between measures of risks and needs, service delivery, and intermediate outcomes. To achieve this, we conducted a retrospective review of health records of 250 probationers with mental disorders using several standardized measures to assess criminogenic and psychosocial needs. The study also tracked outcomes and service utilization for an average of 9 months while probationers were receiving forensic services. A framework that integrates criminogenic and mental health needs to guide service delivery (Prins & Draper, 2009) was used as a theoretical backdrop. The probationer sample represented a heterogeneous group with a diverse range of criminogenic, clinical, and social needs. Their level of risk, service need, and clinical problems did not strongly determine the intensity of forensic services. Noncompliant probationers, representing almost half of the sample, had greater odds of psychiatric adverse events, criminal justice contacts, and violent behavior. This study represents one of the first to examine theoretical and pragmatic issues pertaining to the provision of forensic mental health services to probationers.
... Referring to the 1-year follow-up timeframe as short-term is somewhat arbitrary. Some researchers have described a 1-month follow-up as short-term (e.g., Chu, Thomas, Ogloff, & Daffern, 2011), others used 6 months as short-term (e.g., Grevatt, Thomas-Peter, & Hughes, 2004), others again have referred to a follow-up time of 12 months as short-term, similar to the present study (e.g., Ullrich & Coid, 2011). ...
Article
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Empirical studies have rarely investigated the association between improvements on dynamic risk and protective factors for violence during forensic psychiatric treatment and reduced recidivism after discharge. The present study aimed to evaluate the effects of treatment progress in risk and protective factors on violent recidivism. For a sample of 108 discharged forensic psychiatric patients pre- and posttreatment assessments of risk (HCR-20) and protective factors (SAPROF) were compared. Changes were related to violent recidivism at different follow-up times after discharge. Improvements on risk and protective factors during treatment showed good predictive validity for abstention from violence for short- (1 year) as well as long-term (11 years) follow-up. This study demonstrates the sensitivity of the HCR-20 and the SAPROF to change and shows improvements on dynamic risk and protective factors are associated with lower violent recidivism long after treatment. (PsycINFO Database Record (c) 2014 APA, all rights reserved).
... Referring to the 1 year follow-up timeframe as short-term is somewhat arbitrary. Some researchers have described a one month follow-up as short-term (e.g., Chu et al., 2011), others used 6 months as short-term (e.g., Grevatt, Thomas-Peter, & Hughes, 2004), others again have referred to a follow-up time of 12 months as short-term, similar to the present study (e.g., Ullrich & Coid, 2011). ...
Thesis
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Background and aims of the thesis This thesis concerns protective factors for violence risk and a tool specifically developed to assess these factors in risk assessment: the Structured Assessment of Protective Factors for violence risk (SAPROF; de Vogel, de Ruiter, Bouman, & de Vries Robbé, 2007; 2009). The aim of this thesis was to explore the potential additional value of protective factors for assessing violence risk and for guiding positive treatment interventions. More specifically, this thesis focuses on validating the psychometric properties and clinical applicability of the SAPROF for forensic psychiatric treatment. Overall conclusions The general conclusion of this thesis is that the SAPROF shows sound psychometric properties. The protective factors in the SAPROF show good predictive validity for no violent incidents during treatment as well as for desistance from violent re-offending long after treatment. Good results are found across different groups of patients. Two findings in this thesis are especially meaningful: 1. protective factors demonstrate to provide incremental predictive validity over risk factors in predicting violent recidivism, in other words future violent behavior can be assessed more accurately when protective factors are incorporated in the risk assessment; 2. improvements on protective factors during treatment show to be related to reductions in violent recidivism after treatment, in other words the more protective factors are developed during treatment the less likely in becomes that a person will recidivate after treatment. These results provide strong support for the value of the SAPROF as a protection-focused tool which can bring balance and increased accuracy to violence risk assessment, offers potential for treatment evaluation and may provide positive guidance for effective treatment interventions and risk management strategies for violent and sexual offenders.
... Nature of the problem. Examples of other behavior management problems in forensic PD patients are non-compliance with rules or treatment regimens, verbal aggression, substance abuse, transgressing boundaries (e.g., inappropriate intimate relationships between patients or between patients and staff members) (Grevatt, Thomas-Peter, & Hughes, 2004;. Though these behaviors do not pose an immediate or sever danger to self or others, they may be disruptive and hamper the initiation or progress of therapy. ...
... The majority of studies report the H subscale to be particularly useful for predicting any form of violent incidents during hospitalization and mostly for predicting verbal violence. 15 Regarding the C (clinical) and R (risk management) subscales, we have noted that their scores decrease as the patients stay longer in the hospital. For the majority of patients, longer hospitalizations have probably a reinforcing effect on the observance of a regular treatment and on the remission of symptoms. ...
Article
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There is a diachronic interest on the evaluation of the risk of violence by mental patients.Difficulties that have been underlined concern the definition of the term dangerousness and the different methods of approaching it. Accurate risk assessments are particularly important for psychiatric patients, with history of violence, in indoor care. The accuracy of predictions can better determine the patients designated as "at risk" for violence and avoid false designations. The aim of this study was to investigate the probability of patients, from several psychiatric units, to become violent after their discharge and over the next three years. We also investigate the predictive validity and accuracy of the HCR-20 in relation to post-discharge outcomes. Two hundred ninety five (295) psychiatric patients, from several psychiatric units, were assessed with the HCR-20, PCL: SV and GAF scales at discharge (using case file data, interviews with the patients and the clinicians of the units, and also information from the collateral informants) and were monitored for violent episodes over the following three years. The study was conducted in two phases: 1st phase: During the last week before discharge. 2nd phase: Every six months, over the following three years. Both the HCR-20 and PCL: SV scales and their subscales are significant predictors of readmission, suicide attempts and violent behavior. The GAF scale had a low positive correlation with the HCR-20 scale. A number of other variables such as duration of hospitalization, previous violent acts, diagnosis, gender, marital status, socioeconomic status, number of previous hospitalizations, were statistically related with failure of re-integration in the community. The results provide a strong evidence base that the HCR-20 is a good predictor of violent behavior in psychiatric patients, following their discharge from psychiatric wards in Greece, and hence can be used by clinicians in routine clinical practice.
... Yet the value of many such variables is considerably underplayed due to the fact that they offer little guidance for treatment. Recent research also suggests that dynamic, clinical variables contribute appreciably to assessments of acute and short-term violence risk (Gray, Snowden, & MacCulloch, 2004;Grevatt, Thomas-Peter, & Hughes, 2004;McNiel, Gregory, & Lam, 2003;Skeem & Mulvey, 2001) and that stable or static risk predictors such as psychopathy (Douglas, Guy, & Weir, 2005;Edens, Poythress, & Lilienfeld, 1999;Nicholls, Ogloff, & Douglas, 2004), substance abuse, and medication compliance might have less relevance in the inpatient setting than has been found in community follow-up studies (Serper et al., 2005). There is also the point that clients in forensic and correctional institutions have similar psychosocial backgrounds, rife with substance abuse, unstable upbringings, prior aggression to others, and maladaptive social support systems. ...
... However, many studies report that only some of the HCR-20 indices are associated with inpatient or community violence, possibly indicating that each scale has differential predictive validity across different settings and populations. Specifically, research suggests that short-term or acute predictors of violence within a psychiatric inpatient population may be related more to dynamic, clinical variables than to static and historical factors (Belfrage et al, 2000;Gray et al, 2003;Grevatt et al, 2004;MacPherson & Kevan, 2004;McNeil et al, 2003), whereas the historical indices have demonstrated particular utility in predicting postdischarge violence outcomes over a two-year followup period (Dolan & Khawaja, 2004). Developing sound methods for assessing dynamic aspects of violence risk is therefore critical for all practising clinicians (Dvoskin & Heilbrun, 2001). ...
Article
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The purpose of this study was to explore the predictive validity of the revised Problem Identification Checklist (PIC-R) in predicting inpatient and community violence using a retrospective design. The Historical Scale (H-Scale) of the HCR-20 was employed to control for static risk factors. The predictive accuracy between predictors and outcome measures was evaluated using Receiver Operating Characteristics (ROC) analysis. The PIC-R significantly predicted inpatient violence (AUC range 0.77-0.92) over a 12-month follow-up period but did not predict community violence. Conversely, the H-Scale significantly predicted community violence (AUC 0.82) but did not predict inpatient violence over a 12-month follow-up period. The findings offer preliminary validation for the predictive accuracy of the PIC-R for violence in a UK inpatient population. Additionally, the findings suggest that short-term risk of violence within a psychiatric inpatient population may be more related to dynamic and clinical risk variables rather than to static ones.
... In a pseudo-prospective study design we examined the predictive accuracy of the HCR-20 for outcomes following transfer from high to medium secure psychiatric care. As far as we know this is the first international study to look at the HCR-20 in this way as most studies have focused on either institutional or community violence [12,16,29,33,35-37,45-48]. It is also the first to report data on the validity of this measure at predicting a broader range of outcomes following transfer to lower levels of security in the UK or elsewhere. ...
Article
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Background Structured Professional Judgment (SPJ) approaches to violence risk assessment are increasingly being adopted into clinical practice in international forensic settings. The aim of this study was to examine the predictive validity of the Historical Clinical Risk -20 (HCR-20) violence risk assessment scale for outcome following transfers from high to medium security in a United Kingdom setting. Methods The sample was predominately male and mentally ill and the majority of cases were detained under the criminal section of the Mental Health Act (1986). The HCR-20 was rated based on detailed case file information on 72 cases transferred from high to medium security. Outcomes were examined, independent of risk score, and cases were classed as "success or failure" based on established criteria. Results The mean length of follow up was 6 years. The total HCR-20 score was a robust predictor of failure at lower levels of security and return to high security. The Clinical and Risk management items contributed most to predictive accuracy. Conclusions Although the HCR-20 was designed as a violence risk prediction tool our findings suggest it has potential utility in decisions to transfer patients from high to lower levels of security.
Article
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Instances of violence and aggression in acute psychiatric settings are common and highly distressing for service users and staff. They also incur financial costs. This study aimed to identify the proportion of service users at risk of consistent violence/aggression enactment. It also aimed to analyse associated service use to explore the potential need for specialised, targeted approaches. Five years’ worth of data were extracted from 2016 to 2020 on inpatient stays across South London and Maudsley NHS Foundation Trust (SLaM) acute adult wards and Psychiatric Intensive Care Units (PICUs). Service users were divided into cohorts based on relative number of violent/agressive incidents enacted. Differences in frequency of acute service use during the period 1st January-31st December 2020 were analysed. In total, 2524 service users had at least one inpatient stay during 2020. 679 were recorded as having enacted at least one incident of violence or aggression. Just 4% of all service users accounted for 50% of all violence/aggression enactment. Results further showed strong evidence of group differences between violence cohorts in the following domains: internal transfers, occupied bed days, admissions and Place of Safety (PoS) referrals. There was weaker evidence for group differences in referrals to Home Treatment teams (HTTs) and Psychiatric Liaison Teams. A small proportion of service users disproportionately account for the majority of violent and aggressive incidents and higher levels of violence and aggression are associated with more acute service use. The provision of targeted, personalised interventions for this cohort may reduce the enactment of violence and aggression, leading to improved quality life and a reduction in financial expenditure.
Article
This prospective study investigated the predictive validity of a culturally adapted version of the Historical-Clinical-Risk Management-20 (HCR-20V3) with a sample of 114 incarcerated males in a medium-security prison in Mexico City. The goal was to integrate a culturally responsive approach to violence risk assessment by incorporating culturally relevant risk factors identified by forensic mental health professionals in Latin America who conduct violence risk assessments. These risk factors related to problematic family and peer relationships, machismo, normalization of violence, and economic disadvantage. Data collection for HCR-20V3 ratings involved clinical interviews and a review of institutional documents; data on aggressive incidents were collected through document review, self-report follow-up interviews, and guard reports. Participants who engaged in institutional violence during the 3-month follow-up period were given significantly higher scores on several culturally relevant risk factors than those who did not engage in institutional violence. Although the culturally adapted HCR-20V3 items did not provide incremental validity to the original HCR-20V3 items, the culturally adapted HCR-20V3 total score produced an area under the ROC curve of .73-.74. The findings provide evidence that the culturally adapted HCR-20V3 has strong predictive validity and the utility of adapting culturally relevant risk factors for the assessment of violence risk.
Article
Objectifs Une proportion importante de patients présentant un premier épisode psychotique commettent des actes violents hétéro-agressifs. L’objectif de cette étude est d’explorer l’association entre insight et comportement violent (CV) et l’évolution de l’insight durant la période de suivi. Méthode L’étude est conduite sur une cohorte prospective de 265 patients recrutés au sein du programme de traitement et d’intervention précoce dans les troubles psychotiques et suivis sur une période de 3 ans. L’évaluation de l’insight est basée sur une échelle d’insight en 3 points et l’item de l’insight à la Positive and Negative Syndrome Scale (PANSS). Les CV ont été évalués par les case-managers, par les informations provenant des services forensiques et par l’intermédiaire d’un relevé des CV en cours d’hospitalisation. Des analyses de régression logistique uni-variées et multi-variées, des tests-t et des corrélations ont été réalisés. Résultats L’effet significatif de l’insight comme facteur associé aux CV trouvé dans les analyses uni-variées disparaît après avoir contrôlé l’effet des symptômes positifs, du diagnostic de dépendance aux substances, de l’impulsivité et de l’adhésion au traitement. Conclusion Si la prise de conscience des patients à l’égard de leur maladie évolue positivement au cours du traitement, nos résultats suggèrent que le risque de survenue de CV n’est pas influencé par le degré d’insight. Il est par contre significativement lié à l’abus de substances et à l’impulsivité, impliquant de cibler ces deux dimensions dans les stratégies préventives. L’impact de l’insight sur le CV doit être l’objet d’analyses prospectives plus précises.
Chapter
Risk assessment and case formulation are interdependent clinical activities. This chapter provides an overview of risk assessment and case formulation within the context of offender services. It describes risk assessment and illustrates the application of risk assessment of offenders. Forensic Case Formulation (FCF) is one form of case formulation, so it shares many features with other forms of formulation, but also faces additional special challenges. The chapter illustrates the applications of case formulation to two common forensic problems: personality disorders and aggression. The most pertinent example for the chapter is the example of antisocial personality disorder (ASPD) and the chapter discusses this example in some detail. Forensic mental health professionals conduct risk assessments and cases formulations to reduce the public's exposure to risk and to provide case formulations as the basis for idiographic treatments.
Chapter
This chapter identifies the following types of assessment task: assessment for prediction, assessment for understanding and formulation of the individual case, and assessment relating to treatment. It considers assessment in relation to a specific form of violence-homicide. Killing of an intimate partner because of sexual jealousy, killing a biological child due to temporary psychosis, homicide in the course of another crime, racially motivated homicide, and the more unusual cases of serial murder, mass homicide, terrorism, and homicide among children are likely to be very different. The uncertainty and complexity of the definition of violence has important implications for everything that clinical and forensic practitioners do. Making judgments of risk is an inexact and even speculative exercise, so practitioners need a clear rationale and structure underpinning their approach to risk assessment. A good risk assessment maximizes professional accountability, improving the transparency and consistency of decisions.
Book
The question of 'why' and 'how' certain individuals are drawn towards behaving in a way that contravenes the 'Law of the Land' is not an easy one to address. Researchers from various different fields have nevertheless attempted to develop theoretical explanations for the existence of different types of crime and why some individuals commit such acts. Crime and Criminality draws on criminology, sociology, psychology and neuroscience to offer a balanced perspective of crime, the criminal and criminality. Coverage includes: • a comprehensive discussion of theoretical approaches to criminal behaviour, including biological, social and 'rational choice' approaches; • an analysis of legal and social definitions of crime and how these definitions influence the way specific behaviours are labelled as criminal; • an examination of different types of crime and criminals, from delinquents to 'psychopaths' and sex offenders; • an exploration of different ways in which crime is predicted, including risk assessment and offender profiling and an overview of investigative techniques. Addressing a broad range of topics and offering a synthesis of competing theoretical explanations of criminality, this book is essential reading for students taking courses in criminology, criminal psychology, criminal behaviour, forensic psychology and psychological criminology.
Article
Résumé La question de la dangerosité est un sujet central en psychiatrie, puisqu’elle est source de stigmatisation pour de nombreux patients et qu’elle représente un élément majeur de la prise en charge médicale, mais aussi juridique et sociale. Ces dernières années de nombreuses études ont défini des sous-groupes de patients à risque. Si des facteurs tels que les symptômes positifs, une mauvaise compliance au traitement et des comorbidités tels que les troubles liés à l’usage de substance ou les traits de personnalité antisociaux ont été décrits comme prédictifs de violence, peu d’études se sont focalisées sur la corrélation entre dangerosité psychiatrique et niveau d’insight. Nous proposons une revue de la littérature portant sur l’association entre insight et dangerosité psychiatrique en abordant la dangerosité par le biais de la violence, l’agressivité, l’hostilité, l’impulsivité ou les agressions sexuelles. Les résultats sont hétérogènes, un certain nombre de biais méthodologiques peuvent l’expliquer : un manque d’uniformité dans les critères de jugement ou les méthodes de mesure choisies, le design ou la non prise en compte de facteur de confusion potentiels. Nous discutons ensuite du rôle de l’insight en tant que facteur protecteur vis-à-vis du risque de passage à l’acte, par le biais d’une meilleure observance thérapeutique, d’une plus grande flexibilité quant à ses croyances et d’une plus basse certitude quant à son jugement individuel. Concernant ce dernier point, l’étude plus spécifique de l’association entre insight cognitif et dangerosité psychiatrique semble prometteuse et encore peu exploité dans la littérature à ce jour.
Article
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Introduction: Assessing dangerousness to gauge the likelihood of future violent behaviour has become an integral part of clinical mental health practice in forensic and non-forensic psychiatric settings, one of the most effective instruments for this being the Historical, Clinical and Risk Management-20 (HCR-20). Objective: To examine the HCR-20 factor structure in Mexican psychiatric inpatients and to obtain its predictive validity and reliability for use in this population. Method: In total, 225 patients diagnosed with psychotic, affective or personality disorders were included. The HCR-20 was applied at hospital admission and violent behaviours were assessed during psychiatric hospitalization using the Overt Aggression Scale (OAS). Construct validity, predictive validity and internal consistency were determined. Results: Violent behaviour remains more severe in patients classified in the high-risk group during hospitalization. Fifteen items displayed adequate communalities in the original designated domains of the HCR-20 and internal consistency of the instruments was high. Conclusion: The HCR-20 is a suitable instrument for predicting violence risk in Mexican psychiatric inpatients.
Article
The burden of mental illness on individuals, families, and communities has created profound challenges for our society. In recent years treatments and services for the mentally ill have moved almost exclusively to community settings, yet no comprehensive and progressive policies have emerged to counter stigmatizing and facilitate integration. Applied Research and Evaluation in Community Mental Health Services brings together a range of professionals in mental health services - nurses, economists, policy analysts, psychiatrists, psychologists, sociologists, and lawyers - to provide concise overviews of the difficulties and successes of the mental health community. Contributors deal with issues such as housing, employment support, violence prevention, program oversight, and emergency and collaborative care, providing useful prescriptions for better treatment of mental illness.
Article
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Inpatient violence in psychiatric settings is a global problem, but it is particularly a problem in forensic settings containing a mix of acutely mentally ill and/or antisocial patients. The authors recognized a need for new ways to identify and to increase staff awareness and vigilance around at-risk patients. To this end, a literature review was initiated to synthesize the factors that predict forensic inpatient violence from existing literature. The results indicate that the HCR-20, the clinical scale in particular, and the Hare psychopathy scales may be particularly useful in assessing risk for forensic psychiatric inpatient violence.
Article
Citation: Douglas, K. S., Guy, L. S., Reeves, K. A., & Weir, J. (2005). HCR-20 violence risk assessment scheme: Overview and annotated bibliography. Available online: http://kdouglas.files.wordpress.com/2006/04/annotate10-24nov2008.pdf Originally published in 2005. Current version updated through November 2008.
Article
Despite significant advances in the treatment and rehabilitation of schizophrenic patients, high relapse rates in the course of this disease are still observed, frequently resulting in psychiatric hospitalization. Insight into illness is an important component of the presentation and its level may play an important role in assessing risk of hospitalization in the course of schizophrenia. This paper reviews the literature in order to determine relationships between insight into illness and the risk of hospital readmission among schizophrenic patients. Due to the complexity of the phenomenon of insight, study findings in this area are not always consistent. Lower insight may be associated with poorer compliance, more fulminant course of illness and more frequent occurrence of aggressive behavior in patients with schizophrenia, which consequently may predispose to more frequent psychiatric hospitalizations. On the other hand, lower insight may also contribute to lower severity of depressive symptoms and suicidal tendencies, which in turn may reduce the risk of hospitalization. The studies on relationships between the level of insight into illness in schizophrenia and the risk of hospitalization have to date yielded no conclusive results and should be continued.
Article
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Altas puntuaciones en el Historical Clinical Risk Management (HCR-20) y el Psychopathy Checklist-Screening Version (PCL:SV) se asocian tradicionalmente con el riesgo de comportamiento violento en enfermos mentales. En este trabajo se estudia la relación entre ambos instrumentos y la conducta violenta fuera y dentro de un Hospital Psiquiátrico Penitenciario en una muestra de hombres con patología mental (n = 29). Los resultados muestran que ambos instrumentos se asocian con la presencia de comportamiento violento dentro de la institución, mientras que se mantienen independientes de la delincuencia violenta cometida en el exterior.
Article
Over the last 20 years there have been steps forward in the field of scientific research on prediction and handling different violent behaviors. In this work we go over the classic concept of "criminal dangerousness" and the more current of "violence risk assessment". We analyze the evolution of such assessment from the practice of non-structured clinical expert opinion to current actuarial methods and structured clinical expert opinion. Next we approach the problem of assessing physical violence risk analyzing the HCR-20 (Assessing Risk for Violence) and we also review the classic and complex subject of the relation between mental disease and violence. One of the most problematic types of violence, difficult to assess and predict, is sexual violence. We study the different actuarial and sexual violence risk prediction instruments and in the end we advise an integral approach to the problem. We also go through partner violence risk assessment, describing the most frequently used scales, especially SARA (Spouse Assault Risk Assessment) and EPV-R. Finally we give practical advice on risk assessment, emphasizing the importance of having maximum information about the case, carrying out a clinical examination, psychopathologic exploration and the application of one of the described risk assessment scales. We'll have to express an opinion about the dangerousness/risk of future violence from the subject and some recommendations on the conduct to follow and the most advisable treatment. Copyright © 2014 Elsevier España, S.L. All rights reserved.
Article
Background: Structured assessment of risk is a standard element of the core psychiatric assessment, particularly in respect of individuals, who are perceived to be at risk of violence or suicide. Many acute mental health trusts have introduced risk assessment tools, often without evidence of validity.Aim: To evaluate a tool designed to predict the acute risk of violence by patients detained in a PICU.Method: A risk assessment form was completed weekly for each patient on the PICU. Multivariate logistic regression analysis was used to measure the predictive value of particular variables in respect of violent behaviour during the next two weeks.Results: Violent behaviour during the previous two weeks was a significant predictor of subsequent violence. Drug use was a negative predictor. None of the other variables tested were predictive of violent behaviour.Conclusions: A complicated risk assessment tool probably adds little to the process of predicting acutely violent behaviour in PICU patients. The introduction of procedures such as structured risk assessment tools should be subject to the same validation process as any other clinical initiative.
Article
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This paper presents results from a systematic review and meta-analysis of studies of the predictive efficacy of the Historical, Clinical, and Risk Management-20 (HCR-20) for aggressive behavior in residential psychiatric facilities. Variations in efficacy were investigated based on aggression-type, HCR-20 scale used, and as moderated by clinical, demographic and methodological variables. Comprehensive terms were used to search seven electronic databases between January 1995 and August 2012. Additional papers were located by examining references lists and hand-searching. Twenty non-overlapping studies involving 2067 participants were identified. Few (n = 4) studies reported methodology and results sufficiently to ensure a transparently low risk of bias. The summary judgment (dw = 1.166) had the largest mean effect size for prediction of any inpatient aggression. HCR-20 had best predictive efficacy among samples containing higher proportions of patients with schizophrenia, women, Caucasians, and those with greater risk of bias. Predictive efficacy was reduced in studies containing higher proportions of patients with personality disorder. HCR-20 is a significant predictor of aggression in residential psychiatric facilities but does not appear to have equal efficacy across groups. Future research should aim to verify current findings using more heterogeneous samples and should report methodology with greater rigor.
Article
Risk assessment tools are increasingly used in the management of mentally disordered offenders in Scotland, but there has been limited research into their validity among this population. The aim of this study was to examine the validity of risk assessment tools in predicting violence following discharge from a Scottish medium secure unit. The PCL-SV, the VRAG, and the historical subset of the HCR-20 were completed on 96 patients. Follow-up information regarding post-discharge violence and clinical factors was collected for two years. Four (4.2%) patients from the sample committed five serious violent offences, while 38 (40.6%) patients committed more than 100 minor violent offences. The risk assessment tools were found to have moderate predictive accuracy for violent outcomes. Thus this study provides useful evidence supporting the validity of risk assessment tools in Scotland. Individual clinical factors such as substance abuse, personality disorder, treatment non-compliance, and symptom relapse are also relevant in risk assessment and management.
Article
Assessing risk for recidivism in forensic populations is a complex task to be mastered by forensic mental health professionals. The results of such assessments have extensive implications for both the criminal and civil justice systems and society at large. This paper provides an overview of the past and current state of affairs of clinical-forensic risk assessment. It begins with a review of the modern history of violence risk assessment and includes a summary of landmark legal cases that have affected the field of risk assessment. A review of the ‘first and second generation’ research, including their associated approaches and assessment tools, and a description of the latest developments in the area is put forward. Suggestions to promote the ‘state of the art’ in risk assessment are explored. It is concluded that, although there have been great advancements in the field of risk assessment during the last decade, current assessments are limited due to insufficient training of the assessors and non-standardized use of the available assessment tools.
Article
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Using 88 studies from 1980 to 2006, a meta-analysis compares risk instruments and other psychological measures on their ability to predict general (primarily nonsexual) violence in adults. Little variation was found amongst the mean effect sizes of common actuarial or structured risk instruments (i.e., Historical, Clinical, and Risk Management Violence Risk Assessment Scheme; Level of Supervision Inventory—Revised; Violence Risk Assessment Guide; Statistical Information on Recidivism scale; and Psychopathy Checklist—Revised). Third-generation instruments, dynamic risk factors, and file review plus interview methods had the advantage in predicting violent recidivism. Second-generation instruments, static risk factors, and use of file review were the strongest predictors of institutional violence. Measures derived from criminological-related theories or research produced larger effect sizes than did those of less content relevance. Additional research on existing risk instruments is required to provide more precise point estimates, especially regarding the outcome of institutional violence.
Article
The present study aimed to consider the HCR-20 risk profiles of forensic and civil (i.e. general psychiatric) patients referred to forensic mental health services (FMHS), in the state of New South Wales (NSW), Australia. It was hoped that by better understanding patient risk, based on HCR-20 ratings, more could be understood about the differing needs of the two patient groups.Data gathered from comprehensive assessments undertaken by trained clinicians across two service settings, a medium secure forensic facility and the NSW Community Forensic Mental Health Service (CFMHS) was utilised. Data from 129 forensic patients and 105 civil patients were included. T-tests indicated significant differences between means of civil and forensic patients on the HCR-20 and odds ratios (ORs) indicated civil patients referred to FMHS were approximately six times more likely to fall into the high-risk category on the HCR-20 (i.e. score 25 or >) than forensic patients.The nature and level of risk evident between forensic and civil patients referred to FMHS in NSW highlighted two issues: (1) The differing risk/need inherent in two patient groups accessing FMHS; and (2) The level of risk observed in civil patients referred to FMHS and therein the challenges faced by generalist mental health services in managing this patient group. The need for generalist mental health services to be better supported and the need for structured, evidence-based risk management practice to be extended to civil psychiatric patient care was indicated.
Article
We investigated the impact of neighborhood and community factors on the reintegration of forensic patients leaving custodial care in British Columbia, Canada. Using geographic information systems (GIS) techniques, the residential locations of a sample of forensic patients were tracked over time and mapped in relation to each other. The frequency of a patient's return to hospital was monitored and the reasons for these returns were recorded after each unsuccessful community placement. The analysis of the findings suggested that patients who were released to certain, socially disorganized neighborhoods returned to inpatient care at a higher frequency. These neighborhoods exhibited many destabilizing features that may have significant influence on the long-term success or failure of discharge patients, such as low income, high unemployment, poor educational achievement, and concentrated rental accommodation. Further research is needed in order to explore not only the influence of neighbourhood destabilizers on the length of community placements for forensic mental health patients, but also the underlying rationale for locating patient services in socially disorganized areas.
Article
The predictive ability of static risk assessment instruments may be explained by a limited number of their items. This study examined the independent predictive accuracy of individual items in the Psychopathy Checklist-Revised (PCL-R), Violence Risk Appraisal Guide (VRAG) and Historical-Clinical-Risk Management-20 (HCR-20) for violent reconvictions following release among 1353 male prisoners in England and Wales. The study found most items in the three instruments were not independently predictive. Items not independently predictive were removed and all significant items in the original three instruments were combined, resulting in negligible gains in predictive accuracy for the VRAG and HCR-20, but a small improvement in the PCL-R. The study demonstrated that the predictive power of the PCL-R, VRAG and HCR-20 are based on a small number of their items. This may partly explain the ‘glass-ceiling’ effect beyond which further improvement cannot be achieved. Instruments lack outcome-specificity for violence, and independently predictive items include measures of general criminality.
Article
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This article represents an inchoate step in the process of reflection and reconsideration suggested by the authors of "Violent Storms and Violent People: How Meteorology Can Inform Risk Communication in Mental Health Law" (see record 83:38274) in this issue of the American Psychologist . It begins to identify and clarify some considerations relevant to selecting a method for communicating risk assessments for particular legal purposes in the context of mental health law. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Article
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Purpose. There is growing evidence that psychopathic (dissocial) personality disorder is associated with violence. The purpose of this paper is to consider the role of psychopathy in clinical assessments of risk for violence. Arguments. Risk assessments are conducted for the purpose of preventing, not predicting, violence. Yet, most research on risk for violence is conducted and interpreted within the framework of a simplistic prediction paradigm, thus underestimating the practical importance of risk factors. Despite this bias, violence predictions based on psychopathy are only slightly less accurate than predictions that cognitive behavioral therapy will reduce symptoms of depression or cardiac bypass surgery will reduce angina pain; and more accurate than predictions that smaller class sizes will lead to improved academic achievement or cardiac bypass surgery will reduce mortality. Conclusion. Information about psychopathy can be used to make relatively accurate predictions of violence. Of course, decisions concerning if and how such information should be used are another matter. The paper concludes with recommendations concerning the appropriate role of psychopathy in violence risk assessments and avenues for future research.
Article
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Until very recently, there has been little evidence of the ability of either clinicians or actuarial instruments to predict violent behavior. Moreover, a confusing variety of measures have been proposed for the evaluation of the accuracy of predictions. This report demonstrates that receiver operating characteristics (ROCs) have advantages over other measures inasmuch as they are simultaneously independent of the base rate for violence in the populations studied and of the particular cutoff score chosen to classify cases as likely to be violent. In an illustration of the value of this approach, the base rates of violence were altered with the use of data from 3.5-, 6-, and 10-year follow-ups of 799 previously violent men. Base rates for the 10-year follow-up were also altered by changing the definition of violent recidivism and by examining a high-risk subgroup. The report also shows how ROC methods can be used to compare the performance of different instruments for the prediction of violence. The report illustrates how ROCs facilitate decisions about whether, at a particular base rate, the use of a prediction instrument is warranted. Finally, some of the limitations of ROCs are outlined, and some cautionary remarks are made with regard to their use.
Article
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This study evaluated the predictive validity of the HCR-20 (Historical, Clinical, and Risk Management) violence risk assessment scheme and the Psychopathy Checklist: Screening Version (PCL:SV). Files of 193 civilly committed patients were coded. Patients were followed up in the community for an average of 626 days. Receiver operating characteristic analyses with the HCR-20 yielded strong associations with violence (areas under curve [AUCs] = .76-.80). Persons scoring above the HCR-20 median were 6 to 13 times more likely to be violent than those scoring below the median. PCL:SV AUCs were more variable (.68-.79). Regression analyses revealed that the HCR-20 added incremental validity to the PCL:SV and that only HCR-20 subscales predicted violence. Implications for risk assessment research, and the clinical assessment and management of violence, are discussed.
Article
Citation: Douglas, K. S., Guy, L. S., Reeves, K. A., & Weir, J. (2005). HCR-20 violence risk assessment scheme: Overview and annotated bibliography. Available online: http://kdouglas.files.wordpress.com/2006/04/annotate10-24nov2008.pdf Originally published in 2005. Current version updated through November 2008.
Article
The Historical, Clinical, and Risk Management (HCR-20) violence risk assessment scheme was coded in a sample of 75 Canadian male, federally sentenced, maximum-security offenders. The concurrent validity of the HCR-20 was assessed through comparison to other risk instruments and to the presence of several past indexes of violent and antisocial behavior. The HCR-20 showed moderate to strong relationships with the concurrent measures. The HCR-20 was as or more strongly related to past violence than were the Psychopathy Checklist—Revised or the Violence Risk Appraisal Guide. Scores above the median of the HCR-20 increased the odds of the presence of various measures of past violence and antisocial behavior by an average of four times. Although recognizing the limitations of a small sample and retrospective design, the results give some indication that the HCR-20 may be worth investigating as a useful tool for violence risk assessments in correctional samples.
Article
There has been a growing optimism regarding the accuracy of structured instruments for violence risk assessment in mentally disordered offenders. However, several issues pertaining to forensic assessments of risk remains unsolved, one of which is the relationship between risk assessment and risk management. In this paper we argued that research that evaluate efforts to assess risk must take into account the level of risk management in the sample. We attempted to illustrate this using prospective follow-up data on the frequency and type of inpatient violent behaviours and their relationship to risk management within the context of care. Risk assessments were made upon admission to hospital with the Historical-Clinical-Risk assessment (HCR-20, Webster et al., 1997) in 54 forensic patients followed through three different risk management conditions: High security risk management, medium risk management, and only risk monitoring (low). The results showed large differences in baserate and type of violence in the three management conditions. Results also suggested that the HCR-20 accurately assessed risk in medium and low security conditions, but not in the high security condition. We conclude that the findings reinforce rather than contraindicate the usefulness of the HCR-20 in for clinical practice.
Article
This article explores the predictive validity of two actuarial risk assessment instruments among mentally disordered offenders in Sweden: the historical part (H-10) of a historical, clinical, and risk management factors instrument (HCR-20) and the Violence Risk Appraisal Guide (VRAG). Actuarial scores were obtained retrospectively in two populations: one group of violent offenders with personality disorders and one with violent offenders diagnosed with schizophrenia. The predictive accuracy was evaluated with receiver operating characteristic analysis using a violent reconviction within 2 years from release or discharge as the criterion variable. Both scales fared better in the group of personality-disordered offenders than in the group of offenders with schizophrenia, and the H-10 fared better than the VRAG in both offender groups. The study found that historical data maintain a robust predictive validity in a population of personality-disordered offenders, whereas clinical and risk management factors may be of greater importance in offender populations in which major mental disorders are prevalent.
Article
The HCR-20 and the PCL:SV were used in a prospective study of 41 long-term sentenced offenders in 2 correctional, maximum-security institutions. The aim was to test the validity of these instruments in the prediction of institutional violence. All assessments were made by a comprehensive examination of the offenders' files, completed with clinical interviews ranging from 1 to 3 hrs. The mean follow-up time was 8 mo. Results show high predictive validity for the HCR-20's clinical and risk management items, but for almost none of its historical items. Results suggest that violence inside correctional institutions can be predicted with a certain degree of validity by using the HCR-20 and the PCL:SV, even within a selective high-risk group of offenders. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Article
Purpose. The predictive validity of the risk prediction instrument HCR‐20 was studied. Methods. Two matched groups of discharged forensic psychiatric patients, one who had recidivated into violent criminality and the other not, were assessed with the HCR‐20. This was done retrospective and blind to the outcome. Results. The results show an overall high predictive validity (AUC = .80). However, historical data had none, or a low, validity while clinical and risk management data had a very high validity. Conclusions. One of the most interesting findings in this study is that clinical and risk management factors came out as more predictive of future violence than historical factors, which is very much contrary to findings in past research. We think that one has to bear in mind that both clinical and risk management factors are heavily influenced by historical information. Thus, historical data are probably as important as is generally shown in follow‐up studies of violence in various offender groups. However, using the HCR‐20, which allows systematic and reliable coding of clinical and risk management factors, seems to make it possible to use these factors more successfully than has been hitherto possible.
Article
Within the conceptual framework of the scientist-practitioner model, this paper describes how the science of risk assessment has progressed to a point where it can be of definite assistance to clinicians. Similarly, clinicians can be of marked help to researchers as they play a role in concept definition and as they design and carry out studies to determine the accuracy of their predictions. Risk assessments ought to be carried out in accord with state-of-the-discipline knowledge. Until fairly recently, it may have been argued that the state of knowledge did not provide any sort of reliable or trustworthy direction on violence risk assessment. This position seems no longer tenable. Topic areas discussed include violence and risk assessment generally, the actuarial-clinical prediction debate, the validity of violence risk assessments, predictors of violence, violence risk assessment schemes (empirically validated structured clinical decision-making), communication of risk assessment findings, and implications for training.
Article
The authors evaluated the reliability and validity of a probabilistic approach to clinical assessment of short-term risk of violence. At admission, nurses and physicians independently rated the probability that each of 149 psychiatric patients would physically attack someone during the first week of hospitalization on a university-based locked inpatient unit. Ward behavior was measured with the Overt Aggression Scale. There was a moderate level of agreement between nurses' and physicians' assessments of risk. Ratings of ward behavior showed an increase in the proportion of assaultive patients as the level of estimated risk of violence increased. Although the overall rate of assaults was overpredicted, there was a close correspondence between clinical estimates of patients' chances of becoming violent and the proportion of patients within each risk level who later displayed some type of inpatient aggression. The reliability and validity of short-term estimates of the risk of violence among acutely disturbed inpatients may be higher than past violence research has suggested. These findings provide preliminary support for the utility of a probabilistic approach to assessment of the risk of violence.
Article
Previous research on violence and mental disorder has typically focused on the relationship between diagnosis and risk of violence or between symptoms within a particular diagnostic category and risk of violence. The authors' goal was to evaluate whether the pattern of symptoms associated with short-term risk of violence varies depending on patients' diagnoses. Subjects were 330 patients with a variety of diagnoses who were hospitalized on a university-based, locked psychiatric inpatient unit. At hospital admission, physicians rated patients' symptoms using the Brief Psychiatric Rating Scale. Nurses rated whether patients became violent during hospitalization by completing the Overt Aggression Scale at the end of each shift. Assaultive patients had different symptom patterns than nonassaultive patients. Symptoms patterns varied significantly across diagnostic groups, and the symptom patterns associated with violence also varied significantly across diagnostic groups. Higher levels of hostile-suspiciousness, agitation-excitement, and thinking disturbance were generally associated with violence, although these symptoms were less predictive of assaultiveness among schizophrenic patients than among patients in other diagnostic groups. Symptom profiles represent a useful level of analysis for understanding the relationship between violence and psychopathology. However, the value of particular symptom profiles as indicators of imminent violence varies with diagnosis.
Article
Despite a long history of interest in, and criticism of, the ability of mental health professionals to assess and predict violence, there have been few efforts to develop or evaluate interventions to improve decision making in this area. This article provides a brief overview of recent research developments on violence risk. Drawing on these advances, 3 recommendation are outlined for improving the clinical practice of risk assessment: (a) to improve assessment technology, (b) to develop clinical practice guidelines, and (c) to develop training programs and curricula.
Article
The role of premorbid factors in the violence associated with adult mental illness has received little attention. We previously found that the premorbid onset of substance abuse in early adolescence or childhood was a more powerful predictor of violence in adult patients with chronic mental illness than comorbid substance abuse. In the present study, we retrospectively assessed patients with chronic mental illness for a history of childhood conduct disorder. Consecutive referrals to a community treatment team were evaluated with a standardized protocol that included questions about violent behavior. Patients who met DSM-IV criteria for a primary diagnosis of major axis I disorder (N = 64) were assessed for behavior prior to age 15 with a checklist for DSM-IV criteria of conduct disorder using self-report data, supplemented by collateral information from charts and relatives when possible. About half of the sample had a history of committing violent acts in the community, and 26% met criteria for childhood conduct disorder. The odds of violence in adulthood was 10-fold higher for subjects with a history of childhood conduct disorder. Not surprisingly, there was considerable overlap between conduct disorder and early-onset substance abuse. About half of the patients with a history of substance abuse prior to age 15 also had a history of conduct disorder. However, these two premorbid conditions appear to be at least partially independent in predicting adult violence in this population.
HCR-20 Assessing Risk for Violence, Version 2
  • C D Webster
  • K S Douglas
  • D Eaves
  • S D Hart
Webster, C. D., Douglas, K. S., Eaves, D. and Hart, S. D. (1997) HCR-20 Assessing Risk for Violence, Version 2. Mental Health, Law and Policy Institute, Simon Fraser University.
Violence Risk Scale, Version 2. Unpublished. Distributed from Research Unit, Regional Psychiatric Centre
  • S Wong
  • A Gordon
Wong, S. and Gordon, A. (2000) Violence Risk Scale, Version 2. Unpublished. Distributed from Research Unit, Regional Psychiatric Centre, Saskatoon, Canada.
The Violence Risk Scale. Forensic Update, Issue 67, October. Division of Forensic Psychology of
  • S Wong
  • A Gordon
Wong, S. and Gordon, A. (2001a) The Violence Risk Scale. Forensic Update, Issue 67, October. Division of Forensic Psychology of The British Psychological Society.
Aggression in Psychiatric Patients Using the HCR-20 to Assess Risk for Violence in Hospital and in the Community
  • D J Ross
  • S D Hart
  • C D Webster
Ross, D. J., Hart, S. D. and Webster, C. D. (1998) Aggression in Psychiatric Patients. Using the HCR-20 to Assess Risk for Violence in Hospital and in the Community. Printed and distributed by Riverview Hospital, Medicine and Research, British Columbia, Canada (www.sfu.ca/psychology/groups/faculty/ hart.icu.pdf) 290 JOURNAL OF FORENSIC PSYCHIATRY & PSYCHOLOGY Vol. 15 No. 2 Downloaded by [Moskow State Univ Bibliote] at 07:00 16 December 2013
Printed and distributed by Riverview Hospital, Medicine and Research
  • D J Ross
  • Hart
  • C D Webster
Offenders and Corrections Unit, Research Development and Statistics Directorate, Home office
  • Johnson S Taylor