Drawing upon Contemporary Risk Assessment and Management Principles in the Revision of the HCR-20 Violence Risk Assessment Scheme

Kevin S. DouglasSimon Fraser University

Why Revise the HCR-20?

Things change 2500 studies published on violence

since Version 2 was released in 1997 Conceptual developments in risk

assessment We learned a lot about how the HCR-20

could be better

HCR-20 (Version 2)Webster, Douglas, Eaves, & Hart (1997)

P as t (S ta tic )D ocu m en ted

(1 0 Item s )

H is to rica l

P resen t (D yn am ic )O b served(5 Item s )

C lin ica l

F u tu re (S p ecu la tive )P ro jec ted(5 Item s )

R isk M an ag em en t

V io len ce R isk

Historical Items (0, 1, 2)

1. Previous violence2. Young age at first violent incident3. Relationship instability4. Employment problems5. Substance use problems6. Major mental illness7. Psychopathy8. Early maladjustment9. Personality disorder10. Prior supervision failure

Clinical Items (0, 1, 2)

1. Lack of insight2. Negative attitudes3. Active symptoms of major mental

illness4. Impulsivity5. Unresponsive to treatment

Risk Management Items (0, 1, 2)

1. Plans lack feasibility2. Exposure to destabilizers3. Lack of personal support4. Noncompliance with remediation

attempts5. Stress

Final Risk Judgment(Adapted from HCR-20 Manual)

Low Assessor believes the individul is at no risk, or very low risk

Individual is not in need of any special intervention or supervision

No need to monitor the individual closely for changes in risk

Moderate Assessor believes the individual is at somewhat elevated risk for violence

A risk management plan should be developed A mechanism for re-evaluation is needed

High Assessor believes the individual is at high or very elevated risk for violence

There is an urgent need for a management plan Regular re-assessments are needed

HCR-20 Research Support

More than 50 studies Risk factors predict violence

› Comparably to other risk assessment instruments

Decisions of low, moderate and high risk predict violence as well as or better than numeric use, or other instruments

Forensic Psychiatric, CommunityDouglas, Ogloff, & Hart (2003), Psychiatric Services

Research questions› Reliability and validity of structured clinical risk

ratings

Method› 100 forensic psychiatric (NCRMD) patients

released from maximum security institution› Overlapped coding on half of patients (n=50) to

permit interrater reliability analyses› Violence measured through criminal records and

records of re-admission to forensic hospital

Reliability of Final Risk Judgments

N=50 (x2) Low Med High

ICC1=.61 Low 9 4 0 13

ICC2=.76 Med 2 23 4 29

“Good” High 0 5 3 8

0% Category Errors

11 32 7 50

Validity: Frequency of Violence Across Risk Judgments

N=100 Risk Level Any Phys.

Low (n=23)

2 (9%)

1 (4%)

Mod (n=64)

12 (19%

)

7 (11%

)

High (n=13)

8 (62%

)

7 (54%

)

Base rates 22% 15%

Douglas, Ogloff, & Hart (2003)

SPJ vs Actuarial(Hierarchical Cox proportional hazard analysis)

Physical violence H, C, and R scales entered 1st

› 2 = 9.9, p < .05 HCR-20 clinical judgments (L, M, H) entered

2nd

› Significant model improvement (2 = 9.8, p < .01)

› Overall model 2 = 20.07, p < .0001› Only the clinical judgments remain significant

eB = 9.44, p < .003

Why do the Judgments Compete with Numeric (Actuarial) Prediction?

Idiographic optimization of nomothetic data?

Configural relations & pattern recognition?

Individual “theorizing?” SPJ allows additional information Optimal structure-discretion function?“Mental health professionals can make reliable and valid judgments if they are careful about the information they use … and if they are careful in how they make judgments…”

Garb (2003)

Revision Criteria for HCR:V3(Douglas, Hart, Webster, Belfrage, & Eaves)

Conceptual/clinical› Clarification of item definitions and assessment

procedures Empirical

› New items meet some minimal level of reliability and validity

› Revised items are no worse than existing items Legal

› Acceptability of items in terms of accountability, transparency, and fairness

Revision Strategies and Steps

1. Consult2. Review the literature, 1997+ (Guy & Wilson, 2006)

3. Review the HCR-20 literature› Meta-analysis (Reeves et al., in prep)

4. Aggregate data analyses (N = ~4500)5. Identify new features6. Draft new and revised items7. User feedback8. Field studies

Limits, Weaknesses, and Remedies

Overbreadth of Item Content H8: Early Maladjustment C2: Negative Attitudes

Remedy? Split some items up

› H8: Victimization and Traumatic Experiences H8a: Victimization and Trauma (across lifespan) H8b: Poor Parenting/Caregiving Youth antisocial behavior placed elsewhere

› C2: Procriminal and Violent Attitudes and Ideation C2a: Procriminal Attitudes C2b: Violent Ideation

Revise Other Items

Revise others› Combine H7 (Psychopathy) and H9

(Personality Disorder)› H7(V3): Serious Personality Disorder with

Features of Dominance, Hostility, or Antagonism

Requirement of PCL-R

PCL instruments no longer required Why?

› Other measures of psychopathic personality

› General personality research Lynam & Derefinko (2006) meta-analysis PCL-R and domains of normal personality

Neuroticism, r = .14 Agreeableness, r = -.49 Conscientiousness, r = -.37

Violence-Personality Research

Skeem et al. (2005)› 769 MacArthur patients (Monahan et al.,

2001)› PCL:SV and NEO-FFI› NEO-FFI and violence, R = .37

Antagonism (.26), neuroticism (.10) PCL R2 = .09 NEO R2 = .08

Liberal Score Thresholds; Restricted Range

H1 – Previous violence Too easy to score a 2 Doesn’t permit expression of anything beyond

one past serious act, or three past minor acts H1(v3)

› Will capture chronicity, violence across lifespan

Generally› Add another score option – present and

extreme (0, 1, 2, 3)

Manual Lacks Detail

Decision-making steps and process Summary risk ratings (low, mod, high)

› “What’s the cut-off?” › Deriving summary risk ratings› Link between nomothetic and idiographic › Facilitation of risk management plans

Assessment Steps What risk factors are present?

Individual relevance of risk factors› How do these risk factors manifest themselves

for this given person? › How are they relevant to this person’s violent

behavior?› What is the theory of violence for this person?› Idiographic (though still empirical) support

Necessary management, intervention, treatment (intensity and type)

Therefore, what risk level is the person?› Note empirical (nomothetic) support

Features to Retain or Enhance

Comprehensiveness and Generalizability

Logical/rational item selection› Review literature – any holes?

Review content of HCR in novel way – by looking at constructs as well as prediction› Enhance content domain› Minimize construct underrepresentation

Dimensions on the HCR-20(Douglas & Lavoie, 2006)

Structural analysis N = 3,156 (patients, offenders) N = 2,241 forensic psychiatric

patients› Split sample in random halves› EFAs

All 20 items Within H and CR

› CFA on second forensic sample + criminal offenders + civil patients

H1. Previous Violence .60H2. Young Age 1st Violence .61

H9. Personality Disorder .72

H7. Psychopathy .89

H10. Prior Supervision Failure .63

H8. Early Maladjustment .71

H3. Relationships Problems .62H4. Employment Problems .81H5. Substance Use Problems .41

C1. Lack of Insight .64C2. Negative Attitudes .82C4. Impulsivity .59C5. Unresponsive to Treatment .80R4. Noncompliance .82

F1

F2

F3

R1. Plans Lack Feasibility .83R2. Exposure to Destabilizers .76R3. Lack of Personal Support .65R5. Stress .54

F4

χ2 = 42.88, p < .000

CFI = .944

TLI = .926

RMSEA = .050

F1: Chronic Antisociality

F2: Life Dysfunction

F3: Disagreeableness

F4: Destabilizing Context Cross-validation N = 2,047

Correlated Model

F4: Destabilizing Context

Strain Theory› Stresses due to …

Lack of housing, homelessness

Social Disorganization Theory› Neighborhood context (Silver, 2000)

R1. Plans Lack Feasibility .83R2. Exposure to Destabilizers .76R3. Lack of Personal Support .65R5. Stress .54

F4

Robustness

Unit weighting works (Grann & Långström, 2006)

“The Robust Beauty of Improper Linear Models”

-- Dawes (1979)

Historical

Scale

H1. Serious Problems with Violence

H3. Problems with Personal Relationships

H3a. Intimate Relationships

H3b. Non-intimate Relationships

H4. Problems with Employment

H6. Major Mental Illness

H6a. Psychotic Disorders

H6b. Major Mood Disorders

H6c. Cognitive/Intellectual/PDD

H5. Problems with Substance Use

H2. Serious Problems with Other Antisocial Behavior

H7. Personality Disorder (w/ Antagonism; Dominance)H8. Victimization and Traumatic Experiences

H8a. Victimization/Trauma

H8b. Poor Parenting/CaregivingH9. Procriminal Attitudes

H10. Problems with Noncompliance

Clinical

Scale

C1. Problems with Insight

C1a. Problems with Insight into Mental Disorder

C1b. Problems with Insight into Violence Proneness and Risk Factors

C1c. Problems with Insight into Need for Treatment

C3. Current Symptoms of Major Mental Illness

C3a. Current Symptoms of Psychotic Disorders

C3b. Current Symptoms of Major Mood Disorders

C3c. Current Symptoms of Cognitive/Intellect/PDD

C2. Procriminal and Violent Attitudes and Ideation

C2a. Procriminal Attitudes

C2b. Violent Ideation or Intent

C5. Problems with Compliance or Responsiveness

C5a. Problems with Compliance

C5b. Problems with Non-responsivenss

C4. Instability

Risk Management Scale

R1. Inadequate Plans regarding Professional Services

R3. Inadequate Plans regarding Personal Support

R2. Inadequate Plans regarding Living Situation

R5. Potential Problems with Stress and Coping

R4. Potential Problems with Compliance or Responsiveness

R4a. Potential Problems with Compliance

R4b. Potential Problems with Responsiveness

Individual Relevance

Individual relevance re case conceptualization and formulation

Relevance rating Item indicators

Item Indicators

Measurement theory› How well do we actually measure this

construct (risk factor)?› If we measure it well, does that improve its

relationship to violence?

YES (Hendry, Nicholson, Douglas, & Edens,

2008, IAFMHS)

Example: Problems with Noncompliance (H10)

This risk factor reflects serious problems complying with treatment, rehabilitation, or supervision plans designed to improve the person’s psychosocial adjustment and reduce the chances of violence. The problems may include such things as poor motivation, unwillingness, or refusal to attend treatment or supervision.

H10 Indicators

Failure to establish positive working relationships with professionals

Negative (hostile, pessimistic, uncooperative) attitude toward treatment

Superficial or insincere participation in treatment or supervision

Failure to attend treatment or supervision as directed (e.g., premature termination)

Fails to abide by others’ conditions of treatment or supervision

Noncompliance has clearly escalated over time Noncompliance has been evident in the past 12 months

Item Ratings

Presence and severity› 0 – not present› 1 – possibly/partially present› 2 – definitely present› 3 – present, and extreme

Relevance› Is the risk factor relevant to this person’s

risk for violence? Yes; no; possibly

Grounded in Research

The HCR-20 meets definition of “test”› A standardized procedure to make

decisions about people Reliability and validity of items (scales)

and of summary risk ratings Summary risk ratings…

› Is it reliable and valid in the way it is intended to be used?

HCR:V3 will not be released until it is tested

Evaluation Procedure

Clinical› Beta-testing› Consumer satisfaction

Analytic› Read and critique

Empirical› Reliability and validity

Thank You, and Contact

Kevin Douglasdouglask@sfu.cahttp://kdouglas.wordpress.com/