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

Drawing upon Contemporary Risk Assessment and Management Principles in the Revision of the HCR-20 Violence Risk Assessment Scheme . Kevin S. Douglas Simon Fraser University. Why Revise the HCR-20?. Things change 2500 studies published on violence since Version 2 was released in 1997

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

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  1. Drawing upon Contemporary Risk Assessment and Management Principles in the Revision of the HCR-20 Violence Risk Assessment Scheme Kevin S. Douglas Simon Fraser University

  2. 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

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

  4. Historical Items (0, 1, 2) Previous violence Young age at first violent incident Relationship instability Employment problems Substance use problems Major mental illness Psychopathy Early maladjustment Personality disorder Prior supervision failure

  5. Clinical Items (0, 1, 2) Lack of insight Negative attitudes Active symptoms of major mental illness Impulsivity Unresponsive to treatment

  6. Risk Management Items (0, 1, 2) Plans lack feasibility Exposure to destabilizers Lack of personal support Noncompliance with remediation attempts Stress

  7. Final Risk Judgment(Adapted from HCR-20 Manual)

  8. 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

  9. 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

  10. Reliability of Final Risk Judgments

  11. Validity: Frequency of Violence Across Risk Judgments Douglas, Ogloff, & Hart (2003)

  12. 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

  13. 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)

  14. 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

  15. Revision Strategies and Steps Consult Review the literature, 1997+ (Guy & Wilson, 2006) Review the HCR-20 literature Meta-analysis (Reeves et al., in prep) Aggregate data analyses (N = ~4500) Identify new features Draft new and revised items User feedback Field studies

  16. Limits, Weaknesses, and Remedies

  17. 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

  18. Revise Other Items Revise others Combine H7 (Psychopathy) and H9 (Personality Disorder) H7(V3): Serious Personality Disorder with Features of Dominance, Hostility, or Antagonism

  19. 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

  20. 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

  21. 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)

  22. 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

  23. 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

  24. Features to Retain or Enhance

  25. 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

  26. 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

  27. χ2 = 42.88, p < .000 CFI = .944 TLI = .926 RMSEA = .050 R1. Plans Lack Feasibility .83 R2. Exposure to Destabilizers .76 F4 R3. Lack of Personal Support .65 R5. Stress .54 H1. Previous Violence .60 H2. Young Age 1st Violence .61 H7. Psychopathy .89 F1 H8. Early Maladjustment .71 H9. Personality Disorder .72 H10. Prior Supervision Failure .63 H3. Relationships Problems .62 F2 H4. Employment Problems .81 Correlated Model H5. Substance Use Problems .41 C1. Lack of Insight .64 C2. Negative Attitudes .82 F3 C4. Impulsivity .59 C5. Unresponsive to Treatment .80 R4. Noncompliance .82 F1: Chronic Antisociality F2: Life Dysfunction F3: Disagreeableness F4: Destabilizing Context Cross-validation N = 2,047

  28. F4: Destabilizing Context Strain Theory Stresses due to … Lack of housing, homelessness Social Disorganization Theory Neighborhood context (Silver, 2000) R1. Plans Lack Feasibility .83 R2. Exposure to Destabilizers .76 F4 R3. Lack of Personal Support .65 R5. Stress .54

  29. Robustness Unit weighting works (Grann & Långström, 2006) “The Robust Beauty of Improper Linear Models” -- Dawes (1979)

  30. H1. Serious Problems with Violence H2. Serious Problems with Other Antisocial Behavior H3. Problems with Personal Relationships H3a. Intimate Relationships H3b. Non-intimate Relationships H4. Problems with Employment H5. Problems with Substance Use H6. Major Mental Illness H6a. Psychotic Disorders H6b. Major Mood Disorders H6c. Cognitive/Intellectual/PDD Historical Scale H7. Personality Disorder (w/ Antagonism; Dominance) H8. Victimization and Traumatic Experiences H8a. Victimization/Trauma H8b. Poor Parenting/Caregiving H9. Procriminal Attitudes H10. Problems with Noncompliance

  31. 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 C2. Procriminal and Violent Attitudes and Ideation C2a. Procriminal Attitudes C2b. Violent Ideation or Intent Clinical Scale C3. Current Symptoms of Major Mental Illness C3a. Current Symptoms of Psychotic Disorders C3b. Current Symptomsof Major Mood Disorders C3c. Current Symptomsof Cognitive/Intellect/PDD C4. Instability C5. Problems with Compliance or Responsiveness C5a. Problems with Compliance C5b. Problems with Non-responsivenss

  32. R1. Inadequate Plans regarding Professional Services R2. Inadequate Plans regarding Living Situation R3. Inadequate Plans regarding Personal Support Risk Management Scale R4. Potential Problems with Compliance or Responsiveness R4a. Potential Problems with Compliance R4b. Potential Problems with Responsiveness R5. Potential Problems with Stress and Coping

  33. Individual Relevance Individual relevance re case conceptualization and formulation Relevance rating Item indicators

  34. 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)

  35. 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.

  36. 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

  37. 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

  38. 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

  39. Evaluation Procedure Clinical Beta-testing Consumer satisfaction Analytic Read and critique Empirical Reliability and validity

  40. Thank You, and Contact Kevin Douglas douglask@sfu.ca http://kdouglas.wordpress.com/

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