The Classification of Violence Risk COVR Development & Evaluation Michael Doyle Nurse Consultant & Honorary Res

2. The Classification of Violence Risk COVR Development & Evaluation Michael Doyle Nurse Consultant & Honorary Research Fellow

3. Acknowledgements • National Forensic R&D Programme • Professor Mairead Dolan • Stuart Carter • Professor John Monahan • Rebecca Rowles • Jenny Vo • Des Kelly • Professor Jenny Shaw

4. Aims of presentation • Describe development of the COVR • Highlight findings from recent European studies • Present findings from study of non-forensic discharged psychiatric patients in Greater Manchester, England • Discuss future research considerations

5. BackgroundMacArthur Violence Risk Assessment Study(Monahan et al. 2001) • Examined 134 dispositional, historical, clinical, and situational risk factors • Compared factors assessed while inpatient with community violence • 939 male and female civil psychiatric patients • Comparison group of 519 • Age 18 - 40 • Time at risk 20 weeks post-discharge

6. MacVRAS Big Predictors20 weeks post-discharge

7. Iteration #1 Total sample n=939; 18.7% violent Seriousness of Arrest Property, minor, drugs n=306; 20.3% Seriousness of Arrest Robbery, rape, assault, murder n=208; 36.1% Seriousness of Arrest None n=425; 9.2% Father Used Drugs No n=255; 16.5% Father Used Drugs Yes n=51; 39.2% High Risk Group Motor Impulsiveness High n=66; 21.2% Recent Violent Fantasies No n=134; 26.9% Recent Violent Fantasies Yes n=74; 52.7% Motor Impulsiveness Low n=359; 7.0% High Risk Group Classification of Violence Risk Monahan et al, 2005

8. 36.5% 26.4% 10.9% 6.7% 19.5%

9. Monahan, J., Steadman, H., Appelbaum, P., Grisso, T., Mulvey, E., Roth, L., Robbins, P., Banks, S., & Silver, E. (2005). The classification of violence risk. Lutz, FL: Psychological Assessment Resources.

10. Classification of Violence RiskDescription • Interactive software programme • Estimate risk of post-discharge violence • Brief Chart review • 5-10 minute interview with participant • Self-report option

11. Categorical Risk Communication • Category 1: very low risk • [corresponding to a risk of 1%/1 of 100] • Category 2: low risk • [corresponding to a risk of 8%/8 of 100] • Category 3: average risk • [corresponding to a risk of 26%/26 of 100] • Category 4: high risk • [corresponding to a risk of 56%/56 of 100] • Category 5: very high risk • [corresponding to a risk of 76%/76 of 100]

12. COVR: Research Evidence • Construction study (Monahan et al., 2001; Banks et al., 2004) • Estimated ten different risk assessment models • Different risk factors were chosen to be the lead variable upon which a classification tree was constructed • Five risk groups - likelihood of violence to others ranged from 1% to 76%. • Validation study (Monahan et al., 2005;2006) • Low Risk = 9% v High-Risk = 49% • Shrinkage in predictive power • “..validated only on samples of psychiatric inpatients in acute facilities in the United States who would soon be discharged into the community”.

13. Prospective Validation of COVRMonahan, Steadman, Robbins, Appelbaum, Banks, Grisso, Heilbrun, Mulvey, Roth, and Silver (2005)

14. Concerns • McCusker, 2007 • Clinical use questionable • ‘Shrinkage’ in predictive power as construction study fit the data too specifically • Unreliable responses in clinical setting • Environmental influences • Further validation required

15. COVR: Research Evidence • Doyle et al. 2007 • COVR strong correlation with Historical, Dispositional & Clinical factors previously found to be correlated with violence risk. • Good concurrent validity compared with established violence risk measures e.g. HCR-20, VRAG • Snowden and Gray, 2008 • 52 inpatients in 4 medium secure units in Wales over 6 months • COVR good predictor of verbal and physical aggression • Lindqvist and Sturup, 2008 • 352 civil psychiatric patients discharged into community • Only 3% high or very high risk • 5% committed violent act; base rate much lower than USA and UK • Uncertain benefits of COVR in Swedish population

16. Preliminary Evaluation in a UK Sample

17. Rationale • Evidence supports structured professional judgement approach that combines static & dynamic factors (e.g. Doyle and Dolan, 2006) • COVR untested in UK population • Need for efficient decision support tool for use in clinical practice

18. Hypotheses • Participants with higher baseline rating on the COVR will be significantly more likely to be violent in the 20 weeks post discharge

19. Procedure (1) Baseline assessment • Current civil psychiatric inpatients • Interview • Case note review • Liaison with primary nurse • Staff rated measures • Administer COVR computerized programme

20. Procedure (2) Follow-up assessment • Violent behaviour in the community measured 20 weeks post discharge. • Interview with the participants, record review and speaking to someone who knows the person well (e.g. friend, relative, carer). • Baseline measure then compared with violence in the community post-discharge.

21. Violence Definition “ . . any acts that include battery that resulted in physical injury; sexual assaults; assaultative acts that involved the use of a weapon; or threats made with a weapon in hand.” (Monahan et al, 2001)

22. Sample • Sample size: 93 • Age: Mean – 40 years (Range - 18-60) • White Caucasian 92.5% (n = 86) • Male 58% (54) Female 42% (39) • Mean length of Stay: 36.2 days Med = 19 days • Involuntarily detained: 36.6% (34) • Previous Serious Violence: 20.4% • Definite/Serious Substance Use Problems 31.2%

23. Primary Chart Diagnosis

24. Representativeness of Sample

25. COVR Risk Category

26. COVR Risk CategoryComparison with MacVRAS

27. Prevalence of Violence

28. Frequency of Violence 40 incidents

29. COVR Risk CategoryViolence 20 Weeks

30. MacVRAS Category & Violence at 20-weeks

31. COVR Risk CategoryViolence 20 Weeksx2 = 6.024, df, 2, p = 0.049*

32. Summary of Preliminary Findings • Insufficient sample size • Lower risk scores compared to MacVRAS • Different sample characteristics e.g. nationality, age, diagnosis, length of stay • Self-report with no adjustment • High-Very High risk participants identified and managed • Predictive accuracy not replicated although trend • Women more likely to be violent in 20 weeks post-discharge

33. Future Research • Repeat with larger sample • Concurrent ‘clinical’ rating by 1 or more raters • ? Link with structured professional judgement • Examine integration in clinical practice • Investigate the relative contribution of COVR & established tools in predicting violence • Examination of the validity of the tools based on • (i) gender • (ii) treatment, support and supervision available • Trial in forensic population

34. “…there is an obvious conclusion, but we’re not allowed to jump to it!”Webster, 2008

35. C/O Coronation Street

36. Final Thoughts • …We can never prove how many people we have prevented from being violent.. • Good judgement comes from experience, and experience comes from bad judgement • Tools and scales don’t make decisions...people do!!

37. References • Banks, S., Robbins, P. C., Silver, E., Vesselinov, R., Steadman, H. J., Monahan, J., et al. (2004). A multiple-models approach to violence risk assessment among people with mental disorder. Criminal Justice and Behavior, 31, 324–340. • McCusker, P. J. (2007) Issues regarding the Clinical Use of the COVR Assessment Instrument. International Journal of Offender Therapy & Comparative Criminology. Doi:10.1177/0306624x07299227 • Monahan, J., Steadman, H., Appelbaum, P., Grisso, T., Mulvey, E., Roth, L., Robbins, P., Banks, S., & Silver, E. (2005). The classification of violence risk. Lutz, FL: Psychological Assessment Resources. • Monahan, J, Steadman, H., Robbins, P., Appelbaum, P., Banks, S., Grisso, T., Heilbrun, K., Mulvey, E., Roth, L., & Silver, E. (2005b). An actuarial model of violence risk assessment for persons with mental disorders. Psychiatric Services, 56, 810–815. • Monahan, J., Steadman, H. J., Silver, E., Appelbaum, P. S., Robbins, P. C., Mulvey, E. P., et al. (2001). Rethinking risk assessment: The MacArthur study of mental disorder and violence. New York: Oxford University Press.

38. Contact Details Dr Michael Doyle Nurse Consultant, Professional Lead, Hon Research Fellow Adult Forensic Mental Health Service Edenfield Centre Greater Manchester West NHS Mental Health Trust Bury New Road Prestwich Manchester England M25 3BLTel: 0161 772 4611/3879 Email: Mike.Doyle@gmw.nhs.uk