Kevin S. Douglas Simon Fraser University

 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

1. Previous violence 2. Young age at first violent incident 3. Relationship instability 4. Employment problems 5. Substance use problems 6. Major mental illness 7. Psychopathy 8. Early maladjustment 9. Personality disorder 10. Prior supervision failure

1. Lack of insight 2. Negative attitudes 3. Active symptoms of major mental illness 4. Impulsivity 5. Unresponsive to treatment

1. Plans lack feasibility 2. Exposure to destabilizers 3. Lack of personal support 4. Noncompliance with remediation attempts 5. Stress

 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

 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

 N=50 (x2)LowMedHigh  ICC 1 =.61Low94013  ICC 2 =.76Med  “Good”High0538  0% Category Errors

N=100Risk LevelAnyPhys. Low (n=23) 2 (9%) 1 (4%) Mod (n=64) 12 (19%) 7 (11%) High (n=13) 8 (62%) 7 (54%) Base rates22%15% Douglas, Ogloff, & Hart (2003)

 Physical violence  H, C, and R scales entered 1 st ›  2 = 9.9, p <.05  HCR-20 clinical judgments (L, M, H) entered 2 nd › Significant model improvement (  2 = 9.8, p <.01) › Overall model  2 = 20.07, p <.0001 › Only the clinical judgments remain significant  e B = 9.44, p <.003

 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)

 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

1. Consult 2. Review the literature, (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 features 6. Draft new and revised items 7. User feedback 8. Field studies

 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 others › Combine H7 (Psychopathy) and H9 (Personality Disorder) › H7(V3): Serious Personality Disorder with Features of Dominance, Hostility, or Antagonism

 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

 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 R 2 =.09  NEO R 2 =.08

 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)

 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

 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

 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

 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.60 H2. Young Age 1st Violence.61 H9. Personality Disorder.72 H7. Psychopathy.89 H10. Prior Supervision Failure.63 H8. Early Maladjustment.71 H3. Relationships Problems.62 H4. Employment Problems.81 H5. Substance Use Problems.41 C1. Lack of Insight.64 C2. Negative Attitudes.82 C4. Impulsivity.59 C5. Unresponsive to Treatment.80 R4. Noncompliance.82 F1 F2 F3 R1. Plans Lack Feasibility.83 R2. Exposure to Destabilizers.76 R3. Lack of Personal Support.65 R5. 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

 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 R3. Lack of Personal Support.65 R5. Stress.54 F4

 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/Caregiving H9. 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 re case conceptualization and formulation  Relevance rating  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)

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.

 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

 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

 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

 Clinical › Beta-testing › Consumer satisfaction  Analytic › Read and critique  Empirical › Reliability and validity

Kevin Douglas