HCR-20 shows poor field validity in clinical forensic psychiatry settings

The predictive validity and temporal characteristics of the HCR-20v3 for inpatient violence in forensic inpatient settings. An international study

Aggression and violence are common day to day problems in psychiatric settings. However, the optimal means of assessing that risk remains unclear. In the context of that uncertainty many tools have evolved, among which the HCR-20 is one of the most globally accepted, though many questions remain about its performance, how and when it should be deployed and how it can be most effectively used. In this 12 month follow up study of 210 forensic psychiatric inpatients with a diagnosis of a schizophrenia spectrum disorder we explored these issues. We found that the performance of the HCR-20v3, especially its Total score, performed well up to 6 months after it was rated but its performance deteriorated after that. Repeating the HCR-20v3 at 6 months stabilised the risk assessment and led to improved performance in the second months over and above the first rating. The HCR-20v3 was good at identifying those subjects at low risk of violence over 6 months of follow up in a forensic inpatient setting. The real-world implications of this study are that the HCR-20v3 is an effective means of identifying patient at low risk of violence, but it should be reassessed every 6 months.

Using the VERA-2R, professional and organisational aspects

Introduction

Violent extremism risk assessments of individuals suspected or convicted of terrorism are relevant for legal decisions, in prison and probation settings, and in inter-professional risk collaboration. These risk assessment reports by professionals should be applicable to and usable for the different judicial contexts. Informal and formal clinical practice evaluations, in the form of practitioners feedback and standardised evaluation of professional violent extremism risk reports are needed to gain insight in the use and quality of violent extremism risk assessments.

Methods

In this study we examined how forensic professionals from three different countries (Sweden, Belgium and the Netherlands) use the VERA-2R in different judicial contexts. We also investigated which organizational aspects are important for the use of the VERA-2R. We focused on the perspective of the forensic professionals and their judicial organisations. We did a standardised survey among 86 VERA-2R trained professionals and a standardised interview with 20 executives and managers of organizations working with the VERA-2R.

Results

This study showed that professionals find the VERA-2R useful for structuring information and speaking a common risk language. However, using the VERA-2R comes with a variety of challenges, both on the professional and organisational level. VERA-2R trained professionals had few opportunities to use the instrument and when they did, they were not always offered regular supervision, intervision and booster training. Also, organisational issues in collaboration between judicial partner organisations and the lack of risk transfer information to professionals came to light.

Discussion

More research on the topic of risk transfer is needed. Policy implications are advised, for example the development of booster trainings, more organizational support, regulations on re-assessments, providing expertise and knowledge to indirect stakeholders and clear writing guidelines.

The predictive performance of criminal risk assessment tools used at sentencing: Systematic review of validation studies

Although risk assessment tools have been widely used to inform sentencing decisions, there is uncertainty about the extent and quality of evidence of their predictive performance when validated in new samples. Following PRISMA guidelines, we conducted a systematic review of validation studies of 11 commonly used risk assessment tools for sentencing. We identified 36 studies with 597,665 participants, among which were 27 independent validation studies with 177,711 individuals. Overall, the predictive performance of the included risk assessment tools was mixed, and ranged from poor to moderate. Tool performance was typically overestimated in studies with smaller sample sizes or studies in which tool developers were co-authors. Most studies only reported area under the curve (AUC), which ranged from 0.57 to 0.75 in independent studies with more than 500 participants. The majority did not report key performance measures, such as calibration and rates of false positives and negatives. In addition, most validation studies had a high risk of bias, partly due to inappropriate analytical approach used. We conclude that the research priority is for future investigations to address the key methodological shortcomings identified in this review, and policy makers should enable this research. More sufficiently powered independent validation studies are necessary.

Stable-2007 and indeterminate detention

Public safety is the primary reason to assess future risk in men with a history of sexual offending. Over the last twenty-five years our knowledge of, and ability to assess, dynamic risk factors in men with a history of sexual offending has meaningfully improved, but understanding, adoption, utilization, and reasonable implementation of the fruits of this new knowledge is not universal. This article presents a brief overview of the development of dynamic risk assessment for men with a history of sexual offending, primarily following the work of R. Karl Hanson and his associates. This is followed by a review of a meta-analysis on the reliability and validity of STABLE-2007 and two other independent studies that provide useful ancillary information. Utilizing STABLE-2007 with men faced with, or under sanction of indeterminate detention is the focus of this paper and we will review how mental health diagnoses affect recidivism assessment, some concerns about implicit assessment biases, how to employ stable dynamic assessment in secure facilities, address treatment implications resulting from dynamic assessment, and present ideas for future research. I will close by presenting nine (9) arguments why using STABLE-2007 is recommended practice with indeterminate detention populations.

The empirical evidence base for the use of the HCR-20: A narrative review of study designs and transferability of results to clinical practice

The HCR-20, a widely used method of assessing and managing risk, relies on the structured professional judgement approach. This paper reports a narrative literature review of the HCR-20 studies to explore the applicability of the study results to the use of the HCR-20 in clinical practice. From a literature search using terms "HCR-20" and "HCR 20", 206 papers were included. Of studies using the HCR-20 version 2 (n = 191), 92% (n = 176) relied on variables based on scores derived by adding item scores, and 50% (n = 95) tested the HCR-20 using predictive validity methodology. Of the HCR-20 version 3 studies (n = 21), the "presence of risk factors" step was the most commonly examined (n = 18, 86%), but 2 of the 7 steps ("scenario planning" and "management") were not examined at all. Amongst those studies whose primary focus was on the HCR-20, 67% (n = 64/95) did so by assessing the predictive validity of the tool. Only one employed a design to test whether the use of the HCR-20 affected violence rates. The predominant study design provides support for the use of the HCR-20 as an actuarial tool, and there is limited empirical evidence in support of its effectiveness as a structured professional judgement approach to the assessment and management of the risk of violence.

Non-intimate Relationships and Psychopathic Interpersonal and Affective Deficits as Risk Factors for Criminal Career: A Comparison Between Sex Offenders and Other Offenders

Sex-offenders are at risk of criminal recidivism. For the treatment to be truly effective, it must be individualized. For this purpose, an accurate assessment should focus on criminological, psychological, and psychopathological features. The present study compared sex offenders with other offenders on historical experiences (i.e., problems with violence, anti-social behaviors, problems with personal relationships, problems with substance use, traumatic experiences, and parenting style). In addition, given the association between life events and psychopathy, we explored whether the relation between life events and crime type (sexual crime vs. other types of crime) might be moderated by psychopathy traits (interpersonal and affective deficits and antisocial behavior). Eighty-eight sex offenders (76% of whom child molesters) and 102 other offenders were included. The Historical, Clinical and Risk Management - 20 item Version 3 (HCR-20V3) and Psychopathy Checklist-Revised (PCL-R) were administered. The scores of the HCR-20V3 Historical scale items were computed to assess life events. The scores of the PCL-R factors, F1 Interpersonal affective deficits and F2 Antisocial behavior, were recorded. The presence of a history of problems with non-intimate relationships was the only significant risk factor for sexual crime compared with other crimes. Interpersonal and affective deficits provided an increased likelihood of being sex offenders as compared with other offenders when problems with non-intimate relationships were possibly/partially or certainly present.

The HCR-20 and violence risk assessment - will a peak of inflated expectations turn to a trough of disillusionment?

The HCR-20 has taken on a life of its own. In forensic services it has been elevated from helpful aide-mémoire into a prophetic tool worthy of Nostradamus himself. Almost every outcome is interpreted through it. Despite the evidence of its limited utility, the difficulties of predicting rare events, the narrative fallacies and other heuristic biases it creates, and the massive opportunity costs it entails, commissioners and services alike mandate its use. Yet in routine practice the problems are not acknowledged, multiple conflicts of interest lie unobserved and other opportunities are neglected.