While they are not a framework to determine the risks of reporting such a patient I would use a thorough suicidality and homicidality assessment (such as the Sheehan-Suicidality Tracking Scale or the Sheehan-Homicidality Tracking Scale [preferably the Clinically Meaningful Change Measure versions of these scales) and if the patient has had any suicidal or homicidal planning, I would then use a scale that tracks suicide or homicide planning (such as the Suicide Plan Tracking Scale or the Homicide Plan Tracking Scale).  Once you have a better picture of the patient's suicidality or homicidality from the scores to these assessments you will be better informed to then make a determination and you would have documentation to support your determination. 

The Sheehan-Suicidality Tracking Scale is available by contacting Dr. David V. Sheehan (https://www.researchgate.net/profile/David_Sheehan2?_sg=qC%2Bc3%2BMjtiYmRa%2BXRap9AbpoeyXGf9XCKaUyk3B7V0my6WTWPpmSUjmuG4HdArf6_lY6%2FlIzMf4jsY9ZESUlFzr5y86CO1qw1Y39LuwUkuY3f5HuS2K6gb%2BxbVAYiLtUG_jGIkvbn0INgR%2ByHp1ds5Pi9C9b27cXdoZu9%2FgGJM9K8GEtC4f9pBBjgtDD5PF3uW

The Sheehan-Homicidality Tracking Scale is available from either Dr. David V. Sheehan (see link above) or from Dr. Ivan Sascha Sheehan (https://www.researchgate.net/profile/Ivan_Sheehan?_sg=Q8v2Dsl79pI260apr%2BlQuF4mafmD53tR2U%2FNif%2BvgZDlVcN7YkFnHFYDY%2BtIQMD7HYrZTEt%2B2iLEe7utZcLlOA%3D%3D) or on his website at http://professorsheehan.com/scales/

Please feel free to contact me for a copy of the Suicide Plan Tracking Scale or Homicide Plan Tracking Scale.

My first question concerning anyone threatening to kill another person is "have they the capability to carry out the threat".  Basically if they talk of killing etc I would want to know how they plan to do so and have they the capability and is the plan realistic. Let me explain, if they threaten to kill ex-president George Bush, I would ask them where does he live, how are they going to do it  and if s/he has a gun. I would ask have you a gun (No then how do you propose to do shoot Bush?  Beside you would have to join a long queue of individuals whom have already made a serious threat.  The more distance between the proposed victim and the person making the threat the less likely the risk.  However your risk assessment has to be continuously upgrades especially in the light of new information. Compare this to say a husband who has a history of domestic violence, possible violence in the community, drug and alcohol abuse and is in possession of a shotgun and threaten to kill his partner as s/he is leaving him that day (I have used stereotypes just to make the argument).  He is quite capable of doing so and as such it is beholden on the psychologist to take drastic action to prevent an immediate risk .. Basically the more realistic the more you have to respond  however the issue of confidentiality needs to be considered..  

Psychologists and others have to think in terms of the possibility where as in the past they were less likely to do so or be legally responsible.  An example is identifying the risk to children from their parents, most clinicians do not automatically think of the taboo of killing ones' own children.  See our paper in Researchgate.   You are right to consider the issue of breach of confidentiality and then subsequent reduction of risk at the cost of loosing the patient.  While the breach of confidentiality is a concern it has to be balanced with the risk.  You also have to consider if the patient is playing games with the therapist regarding  confidentiality, especially in forensic institution..  Prison psychologists are contractually obliged to inform the authorities if a prisoner makes a threat to any person, the situation is less clear for say a psychologist in private practice. .The important issue is to discuss it with a professional colleague not involved to obtain an alternative interpretation and to react quickly and record everything.  Hope this is not too depressing for you but I have tackled it from a clinician's position rather than a purely academic position.  Good luck. Mike Berry Clinical Forensic Psychologist.

Given that the question involved threat assessment in a educational setting I have shared a summary of different threat assessment models that might apply when individuals with mental illness are being considered for out patient fitness restoration as opposed to inpatient.  I have what I wrote saved as a PDF if anyone would like the PDF just let me know and I will send it to you.

Assessment Method for Community Fitness Restoration Placement

Abstract

The purpose of this paper is to briefly review several different threat assessment models and threat assessment tools derived from different assessment models. Two threat assessment models, the Department of Justice’s Federal Bureau of Investigation (FBI) and the United States’ Treasury Department’s Secret Service, were developed by federal law enforcement organizations specifically to provide a reasonable model that could be used by individuals who work in an educational setting.  The third law enforcement mode developed by the US Marshal Service was not specifically designed for an educational setting, but clearly was applicable to the educational setting. 

Following the introduction of the law enforcement models, the History Clinical Risk Management – 20 (HCR-20) is presented. The History Clinical Risk Management – 20 model was developed for use with inpatient and outpatient forensic mental health patients. Since the publication of the HCR-20, the HCR-20 concept has been modified to meet the needs of several different risk assessment and risk management populations. This paper purposes a possible modification of the History Clinical Risk – 20 item threat assessment tool for use by the 17th Judicial Circuit Court. The goal would be to assist the 17th Judicial Circuit Court in determining placement for restoration to fitness for individuals found unfit to stand trial. Placement considerations would be binary with either inpatient or outpatient fitness restoration options

Threat Assessment Models Developed by Law Enforcement

There are two law enforcement based evaluation and classification methods for threat assessment used by individuals working in an educational setting.  First, the most popular, and for many in the educational field, the only threat assessment model was derived from the work completed by the FBI and has been commonly referred to as “The School Shooter: A Threat Assessment Perspective. A second significant but relativity unknown and seldom referenced model within the educational field was developed by The United States Secret Service. The US Secret Service reference was titled “Threat Assessment in Schools: A Guide to Managing Threatening Situations and to Creating Safe School Climates” (2002) U.S. Department of Education and the U.S. Secret Service. Both of these models have been employed as a framework for identifying and evaluating factors in a student’s life that may indicated that the student falls somewhere on a risk matrix.  Fitness restorations is essentially an educational instructive process for individuals who suffer from emotional disturbance. Therefore, a brief review of the FBI and US Secret Service models are offered.

The third law enforcement based threat assessment mode presented in this paper was developed by the United States Marshal Service.  The U.S. Marshal model was not specific to an educational setting, but included the educational setting as an arena were the model could be applied. 

The final risk assessment method to be presented is the HCR-20 method developed by the Mental Health, Law and Policy Institute Simon Fraser University through the British Columbia Forensic Psychiatric Service Communion. The HCR-20 is a threat assessment and risk management model developed for use with both inpatient and outpatient forensic mental health patients.

Threat Assessment Model Developed by Mental Health

The purpose of reviewing law enforcement models is to familiarize the reader with how law enforcement bureaus and agencies have conceptualization the behavioral concepts of: types of threats, factors in threat assessment, and risk classification.  Following the law enforcement models, the History Clinical Risk -20 (HCR-20) is presented.

The HCR-20 item model is used by mental health agencies. This author knows from reading forensic reports that Elgin State Hospital has staff who are familiar with the HCR-20 and have included an HCR-20 reference in a forensic evaluation read by this author. Thus, the History Clinical Risk -20 is presented as a possible model to use for determining appropriate placement in an outpatient setting. It is understood by this author that the individuals reading this paper are aware that the individual evaluated by Elgin using the HCR-20 later targeted a member of the court system, and thus, the US Marshal’s threat assessment and management model – presented later in this paper -could arguably substitute for the HCR-20 once a specific target is identified.

The author suggest that it might be beneficial to consider merging some of the risk management concepts developed by law enforcement and the concepts from forensic mental health. The merging of concepts would lead to the development of a model which would be a court base risk assessment and management model applicable to determining inpatient and outpatient fitness restoration placement.

We begin this process with a brief review of the FBI, Secret Service, and US Marshals models.

Federal Bureau of Investigation Method

Table 1.

The School Shooter:

A THREAT ASSESSMENT PERSPECTIVE (2002)

Critical Incident Response Group (CIRG)

National Center for the Analysis of Violent Crime (NCAVC)

FBI Academy

Quantico, Virginia 22135

What is a Threat?

A threat is an expression of intent to do harm or act out violently against someone or something. A threat can be spoken, written, or symbolic -- for example, motioning with one's hands as though shooting at another person.

2 Critical Questions of a Threat Assessment

1.       How credible and serious is the threat itself? And

2.       To what extent does the threatener appear to have the resources, intent, and motivation to carry out the threat?

2 Essential Principles

1.       All threats and threateners are not equal.

2.       All threats must be taken seriously and evaluated.

Motivation

Threats are made for a variety of reasons. A threat may be a warning signal, a reaction to fear of punishment or some other anxiety, or a demand for attention. It may be intended to taunt; to intimidate; to assert power or control; to punish; to manipulate or coerce; to frighten; to terrorize; to compel someone to do something; to strike back for an injury, injustice or slight; to disrupt someone's or some institution's life; to test authority, or to protect oneself. The emotions that underlie a threat can be love; hate; fear; rage; or desire for attention, revenge, excitement, or recognition.  Motivation can never be known with complete certainty, but to the extent possible, understanding motive is a key element in evaluating a threat.

                                                                  Types of Threats

Threats can be classed in four categories: Direct, Indirect, Veiled, or Conditional.

1.       A direct threat identifies a specific act against a specific target and is delivered in a straightforward, clear, and explicit manner: "I am going to place a bomb in the school's gym.

2.       An indirect threat tends to be vague, unclear, and ambiguous. The plan, the intended victim, the motivation, and other aspects of the threat are masked or equivocal: "If I wanted to, I could kill everyone at this school!" While violence is implied, the threat is phrased tentatively --"If I wanted to" -- and suggests that a violent act COULD occur, not that it WILL occur.

3.       A veiled threat is one that strongly implies but does not explicitly threaten violence. "We would be better off without you around anymore" clearly hints at a possible violent act, but leaves it to the potential victim to interpret the message and give a definite meaning to the threat.

4.       A conditional threat is the type of threat often seen in extortion cases. It warns that aviolent act will happen unless certain demands or terms are met: "If you don't pay me one million dollars, I will place a bomb in the school."

                                                                 Factors in Threat Assessment

1.       Specific, plausible details are a critical factor in evaluating a threat. Details can include the identity of the victim or victims; the reason for making the threat; the means, weapon, and method by which it is to be carried out; the date, time, and place where the threatened act will occur; and concrete information about plans or preparations that have already been made. Specific details can indicate that substantial thought, planning, and preparatory steps have already been taken, suggesting a higher risk that the threatener will follow through on his threat.

2.       Precipitating Stressors:  Incidents, circumstances, reactions, or situations which can trigger a threat. The precipitating event may seem insignificant and have no direct relevance to the threat, but nonetheless becomes a catalyst.

                                                                            Levels of Risk

Low Level of Threat: A threat which poses a minimal risk to the victim and public safety.

·                                                                 Threat is vague and indirect.

·                                                                 Information contained within the threat is inconsistent, implausible or lacks detail.

·                                                                 Threat lacks realism.

·                                                                 Content of the threat suggests person is unlikely to carry it out.

Medium Level of Threat: A threat which could be carried out, although it may not appear entirely           realistic.

·                                                                 Threat is more direct and more concrete than a low level threat.

·                                                                 Wording in the threat suggests that the threatener has given some thought to how the act will be carried out. There may be a general indication of a possible place and time (though these signs still fall well short of a detailed plan).

·                                                                 There is no strong indication that the threatener has taken preparatory steps, although there may be some veiled reference or ambiguous or inconclusive evidence pointing to that possibility -- an allusion to a book or movie that shows the planning of a violent act, or a vague, general statement about the availability of weapons.

·                                                                 There may be a specific statement seeking to convey that the threat is not empty: "I'm serious!" or "I really mean this!"

High Level of Threat: A threat that appears to pose an imminent and serious danger to the safety of others.

·                                                                 Threat is direct, specific and plausible.

·                                                                 Threat suggests concrete steps have been taken toward carrying it out, for example, statements indicating that the threatener has acquired or practiced with a weapon or has had the victim under surveillance. Example: "At eight o'clock tomorrow morning, I intend to shoot the principal. That's when he is in the office by himself. I have a 9mm. Believe me, I know what I am doing. I am sick and tired of the way he runs this school." This threat is direct, specific as to the victim, motivation, weapon, place, and time, and indicates that the threatener knows his target's schedule and has made preparations to act on the threat.

FOUR-PRONGED ASSESSMENT APPROACH

The Four-Pronged Assessment Model

This innovative model is designed to assess someone who has made a threat and evaluate the likelihood that the threat will actually be carried out. Anyone can deliver a spoken or written message that sounds foreboding or sinister, but evaluating the threat alone will not establish if the person making it has the intention, the ability, or the means to act on the threat. To make that determination, assessing the threatener is critical. ….The assessment is based on the "totality of the circumstances" known about the student in four major areas:

Prong One: Personality of the student

Prong Two: Family dynamics

Prong Three: School dynamics and the student's role in those dynamics

Prong Four: Social dynamics

**FROM:

U.S. Department of Justice Federal Bureau of Investigation (2002). The School Shooter: A Threat Assessment Perspective.

United States Secret Service Method

The document, “Threat Assessment in Schools: A Guide to Managing Threatening Situations and to Creating Safe School Climates” was published with strategies for setting a process for identifying, assessing, and managing students who may pose a threat of targeted violence in schools. The guide represents a modification of the Secret Service threat assessment process based upon findings from the Safe School Initiative. 

The Secret Service threat assessment is a process of identifying, assessing, and managing the threat that certain persons may pose to Secret Service protectees. The goal of threat assessment is to intervene before an attack can occur. The threat assessment process involves three principal steps, all before the person has the opportunity to attack:

Ø  Identifying individuals who have the idea or intent of attacking a Secret Service protectees:

Ø  Assess whether the individual poses a risk to a protectees, after gathering sufficient information from multiple sources, and

Ø  Managing the threat the individual poses in those cases where the individual investigated is determined to pose a threat.

Chapter IV, “Implications of Safe School Initiative Findings for the Prevention of Targeted School Violence” is derived for the study of 37 incidents of targeted school violence examined under the Safe School Initiative. The key findings are presented below. The interested reader can cross-reference this material with “The Final Report and Findings of the Safe School Initiative: Implications for the Prevention of School Attacks in the United States”.

Incidents of targeted violence at school rarely are sudden, impulsive acts.

Prior to most incidents, other people knew about the attacker (s) idea and/or plan to attack.

Most attackers did not threaten their targets directly prior to advancing the attack.

There is no accurate or useful profile of students who engage in targeted school violence.

Most attackers engage in some behavior prior to the incident that caused others concern or indicated a need for help.

Most attackers had difficulty coping with significant losses or personal failures.  Moreover, many had considered or attempted suicide.

Many attackers felt bullied, persecuted or injured by others prior to the attack.

Most attackers had access to and had used weapons prior to the attack.

In many cases, other students were involved in some capacity.

Despite prompt law enforcement responses, most shooting incidents were stopped by means other than law enforcement interventions.

For a discussion comparing risk assessment, threat assessment, and other approaches for school settings, the reader is referred to the article written by Reddy, Borum, Berglund, Vossekuil, Fein and Modzeleski, Evaluating Risk for Targeted Violence in Schools Comparing Risk Assessment, Threat Assessment, and other approaches Psychology in the Schools, Vol 38(2), 2001. 

Similar to the model provided by the FBI in Table 1, the Secret Service Model is provided in Table 2 below. The reader will note that the models are based on cases investigated or studied by the bureau and agency. Regardless of which law enforcement organization was involved, both law enforcement organizations used specific methods and specific sources to collect information regarding past and current behavior as well as current thoughts (ideations).

Table 2.

Threat Assessment in Schools:

A Guide to Managing Threatening Situations and to Creating Safe School Climates (2002)

U.S. Department of Education and the U.S. Secret Service

The Threat Assessment Process  and Continuum

·                     The primary objective of both a threat assessment inquiry and an investigation is to determine whether a particular student poses a threat of targeted school violence.

·                     The central question of a threat assessment is whether a student poses a threat, not whether the student is a threat.

Although some individuals who threaten harm may pose a real threat of targeted violence, many do not. The Safe School Initiative found that fewer than 20 percent of school shooters communicated a direct or conditional threat to their target before the attack. By contrast, individuals who are found to pose threats of violence frequently do not make threats to their targets. The study found that in more than 80 percent of the cases, school shooters did not threaten their targets directly, but they did communicate their intent and/or plans to others before the attack.

5 Types of Information to Be Sought in A Threat Assessment Inquiry

(1. The facts that drew attention to the student, the situation, and possibly the targets

(2. Information about the student

Three kinds of general information about a student should be gathered: identifiers, background information, and information about the student’s current life situation and circumstances.

A. Identifying information:

Name, Physical Description, Date of birth; and identification numbers (e.g., Social Security number, student ID, etc.).

B. Background information:

Residences, family/home situation, academic performance, social networks, history of relationships and conflicts, history of harassing others or of being harassed by others; history of violence toward self and others; history of having been a victim of violence or bullying; known attitudes toward violence; criminal behavior; mental health/substance abuse history; access to and use of weapons; and history of grievances and grudges.

C. Current Life Information:

Present stability of living and home situations; nature and quality of current relationships and personal support; recent losses or losses of status (shame, humiliation, recent breakup or loss of

significant relationship); current grievances or grudges; perceptions of being treated unfairly; known difficulty coping with a stressful event; any "downward" progression in social, academic, behavioral, or psychological functioning; (recent hopelessness, desperation, and/or despair, including suicidal thoughts, gestures, actions, or attempts) and, pending crises or change in circumstances.

(3. Information about "attack-related" behaviors

Examination of the thinking and behaviors of school shooters suggests that most attacks are preceded by discernible behaviors, as the student plans or prepares for the attack. These behaviors are referred to as attack-related behaviors.

Behaviors that should raise concern about potential violence include:

• ideas or plans about injuring him/herself or attacking a school or persons at school;

• communications or writings that suggest that the student has an unusual or worrisome interest in school attacks;

• comments that express or imply the student is considering mounting an attack

at school;

• recent weapon-seeking behavior, especially if weapon-seeking is linked to ideas about attack or expressions about interest in attack;

• communications or writings suggesting the student condones or is considering violence to redress a grievance or solve a problem;

 (4. Motives

Motives for actual school attacks have included:

• revenge for a perceived injury or grievance;

• yearning for attention, recognition, or notoriety;

• a wish to solve a problem otherwise seen as unbearable; and

a desire to die or be killed.

Knowledge of the motives of a student of concern may help the threat assessment team in evaluating the risk of targeted violence. Understanding the circumstances that may have prompted a student to consider attacking others may permit authorities to direct the student away from violence.

(5. Target Selection

Most school shooters identified their targets to friends and fellow students before advancing the attack. Almost half of school shooters had more than one target. Threat assessors should consider whether and how a potential attacker’s interest in a target may shift to another target over time. Information about a student’s targets may provide clues to the student’s motives, planning, and attack-related behaviors. Information about the student’s motives also may inform the question of whether there are additional targets.

Sources of information for the threat assessment inquiry

( 1. School Information

A school threat assessment inquiry should begin with what is known about the student from records, teacher interviews, and other information easily accessed at the school and from school officials. In utilizing information from school records in a threat assessment inquiry, the threat assessment team should follow school policies and relevant laws regarding information-sharing.20

Answers to the following questions may be drawn from information at school:

• Is the student well known to any adult at the school?

Has the student come to attention for any behavior of concern? If so, what? (email,

Web site, posters, papers, rule-breaking, violence, harassment, adjustment problems, depression or despair, acting-out behavior, etc.)

• Has the student experienced serious difficulties or been in distress?

• Is there anyone with whom the student shares worries, frustrations, and/or sorrows?

• Is there information that the student has considered ending his or her life?

• Has the student been a victim and/or an initiator of hostile, harassing, or bullying behavior directed toward other students, teachers, or other staff?

• Is the student known to have an interest in weapons? If so, has he or she made efforts to acquire or use weapons? Does the student live in a home in which there are weapons (whether or not the weapons are secured)?

(2. Collateral School Interviews

Students and adults who know the student who is the subject of the threat assessment inquiry should be asked about communications or other behaviors that may indicate the student of concern’s ideas or intent. The focus of these interviews

should be factual:

• What was said? To whom?

• What was written? To whom?

• What was done?

• When and where did this occur?

• Who else observed this behavior?

• Did the student say why he or she acted as they did?

(3. Parent/Guardian Interview

The parents or guardians of the student of concern usually should be interviewed. Parents may be protective of their children. They may be frightened and/or embarrassed about the inquiry and the possibility that their child may be contemplating a violent act. The threat assessment team therefore should make it clear to the student’s parents, or guardians that the objective of the threat assessment inquiry is not only to help prevent targeted school violence and diminish the chance that the student and possibly others would be harmed, but also to help their child. The threat assessment team should seek the help of the student’s parents in understanding the student’s actions and interests, recognizing that parents may or may not know much about their child’s thinking and behavior. Questions for parents should focus on the student’s behaviors and communications, especially those that might be attack-related. The student’s interest in weapons should be explored, as well as his or her access to weapons at home.

11 Key Questions of a Threat Assessment Inquiry:

(1. What are the student’s motive(s) and goals?

What motivated the student to make the statements or take the actions that caused him or her to come to attention?

Does the situation or circumstance that led to these statements or actions still exist?  Does the student have a major grievance or grudge? Against whom? What efforts have been made to resolve the problem and what has been the result? Does the potential attacker feel that any part of the problem is resolved or see any alternatives?

(2. Have there been any communications suggesting ideas or intent to attack?

What, if anything, has the student communicated to someone else (targets, friends, other students, teachers, family, others) or written in a diary, journal, or Web site concerning his or her ideas and/or intentions? Have friends been alerted or "warned away"?

(3. Has the subject shown inappropriate interest in any of the following?

School attacks or attackers; Weapons (including recent acquisition of any relevant weapon); Incidents of mass violence (terrorism, workplace violence, mass murderers).

(4. Has the student engaged in attack-related behaviors? These behaviors might include:

Developing an attack idea or plan; making efforts to acquire or practice with weapons; casing, or checking out, possible sites and areas for attack; rehearsing attacks or ambushes.

(5. Does the student have the to carry out an act of targeted violence?

How organized is the student’s thinking and behavior?  Does the student have the means, e.g., access to a weapon, to carry out an attack?

(6. Is the student experiencing hopelessness, desperation and/or despair?

Is there information to suggest that the student is experiencing desperation and/or despair?  Has the student experienced a recent failure, loss and/or loss of status?  Is the student known to be having difficulty coping with a stressful event?  Is the student now, or has the student ever been, suicidal or "accident-prone"? Has the student engaged in behavior that suggests that he or she has considered ending their life?

(7. Does the student have a trusting relationship with at least one responsible adult?

Does the student have at least one relationship with an adult where the student feels that he or she can confide in the adult and believes that the adult will listen without judging or jumping to conclusions? (Students with trusting relationships with adults may be directed away from violence and despair and toward hope.)   Is the student emotionally connected to–or disconnected from–other students?  Has the student previously come to someone’s attention or raised concern in a way that suggested he or she needs intervention or supportive services?

(8. Does the student see violence as an acceptable–or desirable–or the only–way to solve problems?

Does the setting around the student (friends, fellow students, parents, teachers, adults) explicitly or implicitly support or endorse violence as a way of resolving problems or disputes? Has the student been "dared" by others to engage in an act of violence?

(9. Is the student’s conversation and "story" consistent with his or her actions?

Does information from collateral interviews and from the student’s own behavior confirm or dispute what the student says is going on?

(10. Are other people concerned about the student’s potential for violence?

Are those who know the student concerned that he or she might take action based on violent ideas or plans? Are those who know the student concerned about a specific target?  Have those who know the student witnessed recent changes or escalations in mood and behavior?

(11. What circumstances might affect the likelihood of an attack?

What factors in the student’s life and/or environment might increase or decrease the likelihood that the student will attempt to mount an attack at school? What is the response of other persons who know about the student’s ideas or plan to mount an attack? (Do those who know about the student’s ideas actively discourage the student from acting violently, encourage the student to attack, deny the possibility of violence, passively collude with an attack, etc.?)

Thoughtful consideration of the answers to the above 11 questions will produce a sound foundation for the threat assessment team’s response to the overarching question in a threat assessment inquiry:

Does the student of concern pose a threat of targeted violence at school?

United States Marshal Service Model

The United States Marshal Service Model (USMS) is detailed in a book written by Frederick S. Calhoun and Stephen W. Weston, Contemporary Threat Management. The USMS model postulates that individuals intending to commit an act of violence must engage in specific attack-related behaviors.

The US Marshal Service model is based on the research, and the case experience of a number of law enforcement and private agencies who had security responsibilities involving a wide variety of different settings and different type of risk assessment and management needs.

A figure representing the US Marshal Service model is provided below. In essence along each step of the progression to violence the individual completing the assessment gathers information to determine if the individual being assessed would meet the criteria to be classified as falling in on that specific step. 

Figure 1

Each step of the stairs is subdivided into specific behaviors which generally fall within the domain of that specific step. An illustration of the specific variable in step one which is the Signs of Grievance has been provided below.

Figure 2

The reader will note that the Grievance step is divided into six possible variables to consider.  The US Marshal who developed this mode was clear that the risk assessment must consider the specific of the case – that is the individual factors unique to the individual being assessed and thus, which of the six variable were the most important are unknown until the investigative material is gathered.  In addition the model cautions the individual completing the risk assessment that it is unknown if there would be a seventh variable unique to the individual being assessed.

The assessment process is then repeated for the next step – Ideation – see figure below.

Figure 3

The individual assigned to the assessment works the case through each of the steps.

The US Marshal Service model is not an actuarial profile mode. The US Marshal Service model was clear that the assessment model was directed towards a specific individual and not a group of individuals such as a group of individual in a “profile group”. Thus, although statistical trends among individuals who threat court officers are acknowledged the risk manager is not bound to a general profile type but rather focuses on the specific behaviors of the individual in question.

The US Marshal Service model offers two risk management alternatives which are referred to as confrontational and non-confrontation.

Mental Health Model

The History Clinical Risk for Violence version two model was developed by Christopher D. Webster, Kevin s. Douglas, Derek Eaves and Stephen D. Hart and is published in a text titled HCR-20 Assessing Risk for Violence Version 2.  A second text, HCR-20 Violence Risk Management Companion Guide Kevin S. Douglas, Christopher D. Webster, Stephen D. Hart, Derek Eaves and James R. P. Ogloff (Eds) is a recommended second text.  

At the time that this paper was written, the HCR-20 Version 3 had been released. A comparison between version 2 and version 3 is available at http://www.oacbha.org/docs/Forensic_B_-_Stinson.pdf

For purposes of discussion, this paper will outline the concepts of the HCR-20 Version 2 until the Version 3 arrives. A benefit of HCR-20 version 3 is that additional research was added. In addition, some of the items were modified and additional material was added.  The items were expanded in that there was an additional breakdown of the individual items – see Version 3 Form page one and two attached at the end of this paper.

The HCR-2- Companion Guide contains information about the use of the HCR-20 with forensic psychiatric patients that would be of interest to the 17th Judicial Circuit Court judges.

A few notes from the HCR-20 manual

The HCR-20 was developed as a method for forensic mental health providers working in the British Columbia. The authors of the HCR-20 advised that British Columbia forensic clinicians responsible for both forensic inpatients and outpatients were asking for some means by which risk assessments could be performed in a systematic manner (p. v of manual).

The authors of the HCR-20 report that “the HCR-20 is, clearly, a work in progress. “Our primary purpose in this revision of the manual is to make it more “user friendly” by clarifying the administration and coding procedures. Our own research is evaluating the interrater reliability and predictive validity of the HCR-20. We are also collecting normative data concerning the prevalence of risk factors in various samples, including civil and forensic psychiatric patients and correctional offenders”. (p. vii).

“Another plan is to develop a comprehensive set of special-purpose risk assessment devices.  We have for example, already published the Spousal Assault Risk Assessment guide, Second edition (p. vii).” 

Manuals that are based on a HCR-2- model and not mentioned by the authors of the HCR-20 include the following; Manual for the Structured Assessment of violence Risk in Youth (SAVRY) by Randy Borum, Patrick Bartel and Adelle Forth; Early Assessment Risk List for Girls Version One (EARL – 21 G) by Kathryn s. Levene, Leena K. Augimeri, Debra J. Pepler, Margret M. Walsh, Christopher D. Webster, Christopher J. Koegl, and the Early Assessment Risk for Boys Version 2 (EARL – 20 B) by Leena K. Augimeri, Christopher J. Koegl, Christopher D. Webster and Kathryn S. Levene.

This author, Dr. Terrance G. Lichtenwald has used the Spousal Assault Risk Assessment as a method to collect, organize and analyze information in an evaluation for the 17th Judicial Circuit Court.

It is in the vein of using the HCR-20 framework as proposed by the authors of the HCR-20 that this author suggests that the 17th Judicial Circuit Court may benefit from modifying the HCR-20 into a format that meets its purposes – assigning individuals to either inpatient or outpatient fitness restoration programs.

The authors of the HCR reported that “the manual for the HCR-20 is a guide to assessment, and not a formal psychological test” (p.1).

The areas evaluated by the HCR-20 were broken down into what has happened in the past (Historical Items), what is happening now (Clinical Items), and what is likely to happen in the near future (Risk Management). The items divided by past, present, and future were presented in Figure 1 in the manual (p. 11) which was reproduced below.

Table 3

HCR-20 Items

Historical

(Past)

Clinical

(Present)

Risk Management

(Future)

H1 Previous violence

C1 Lack of Insight

R 1 Plans Lack Feasibility

H2 Young Age at first violent Incident

C2 Negative Attitudes

R2 Exposure to Destabilizers

H3 Relationship Instability

C3 Active Symptoms of Major Mental Illness

R 3 Lack of Personal Support

H4 Employment Problems

C 4 Impulsivity

R 4 Noncompliance with remediation attempts

H 5 Substance Use Problems

C 5 Unresponsive to Treatment

R 5 Stress

H 6 Major Mental Illness

H 7 Psychopathy

H 8 Early Maladjustment

H 9 Personality disorder

H 10 Prior Supervision failure

The worksheet provided by the HCR-20 manual which this examiner purchased from a vender – Parcor-cannot be reproduced. Thus, making it difficult at best to show how the HCR-2- coding sheet was created. However, the HCR-20 Version 3 now has worksheets that can be reproduced.  This author provided the HCR-20 coding system below.

For purposes of demonstration, the reader is advised that each section such as Historical was given its own table. Each item such as the first item in the Historical Factor was given a quick reference (i.e., Historical Item One was referenced as H1). Each item such as H1 was then coded with a 0, 1, or 2 with a key that 0 equal no/absent, 1 equal partially/possibly present and 2 equal yes definitely present.

Table 4

HCR-2- Coding Sheet

Historical

Code  0, 1, 2

H1 Previous Violence

Enter Score for this items here 0, 1, or 2

H2

H3

Total point out of 20 possible points (up to two points for each of the ten items)

The table above is then repeated for the Clinical Items – see Table 5. 

Table 5

HCR-2- Coding Sheet

Clinical Items

Code  0, 1, 2

C1 lack of Insight

Enter Score for this items here 0, 1, or 2

C2

C3

Total point out of 20 possible points (up to two points for each of the ten items)

The table format was again repeated for the Risk Management item –see Table 6

Table 6

HCR-2- Coding Sheet

Risk Management

Code  0, 1, 2

R 1 Plans Lack Feasibility

Enter Score for this items here 0, 1, or 2

R2

R3

Total point out of 20 possible points (up to two points for each of the ten items)

The reader of this report will note that the HCR-20 has no items in the Other Considerations factor. It is up to the individual working the risk assessment and risk management plan to place into the Other Considerations the variables that maybe relevant to that specific assessment.

.

Table 7

HCR-2- Coding Sheet

Other Considerations

Code  0, 1, 2

O1

Enter Score for this items here 0, 1, or 2

O2

O3

Total point out of 20 possible points (up to two points for each of the ten items)

Each of the three tables: Historical, Clinical and Risk Management as well as Other Considerations are then added together for a Final Risk Judgment of Low Moderate or High.

Of interest to the 17th Judicial Circuit Court

Of interest to the 17th Judicial Circuit Court is the modification of the Other Considerations Table. In essence, the examiner using the HCR-20 coding Sheet is allowed to define other items under the Other Considerations Table. Therefore, individual items in Table 7 could be specifically tailored to the needs of the 17th Judicial Circuit Court and the community agency which was providing the fitness restoration educational program

Table 5

Other Considerations

Code 0, 1, 2

01

01

03

The HCR-20 Other Considerations developed by the 17th Judicial Circuit Court considering the needs of Stepping Stones may look something like the table below.

Table 6

17th Judicial Circuit Court

Restoration Program

Other considerations

O1  Willingness to take medication

Code

0, 1, 2

O2 Transportation to restoration program

03 Housing

O 4 Social support which supports attendance and passing restoration

O 5 Sexual inappropriate behaviors

O 6  Physical violence to others

O 7

O 8

It is within the Other Considerations that the specific behaviors of concern to Stepping Stones are addressed. This author is aware that there may be some overlap between the Historical Items and the Other Considerations Items identified. However, with further participation with the community providing the fitness restoration education programing, the overlaps could be identified and resolved. For example, would sexual behavior be considered within the Previous Violence or would the court or Stepping Stones wish to have the sexual behavior variable listed and coded in the Other Considerations Items?

Summary

1.      Review of law enforcement risk assessment and risk management models rely on clearly defined definitions of current and past behavior in concert with present thought process. 

2.      Regardless of which law enforcement or forensic mental health organization model is considered, each use a variety of sources and methods to collect information.

3.      Once the information is collected, the information is then coded. The coding systems allow for an overall view of a case and the classification of a case falling into one of a number of possible classification.

4.      The HCR-20 is a model that could possibly be modified using the Other Considerations section and/or a clarification of specific items which are already listed within the Historical, Clinical, or Risk Management factors.

5.      Modification of the HCR-20 to meet risk assessment and management unique to specific groups have been previously developed. 

6.      Of interested are the specific groups related to assessment and management of forensic mental health patients. The individuals evaluated for the fitness restoration program have many similar characteristics as the forensic mental health individuals on which the HCR-20 was already developed. 

7.      The 17th Judicial Circuit Court HCR-20 model would allow for additional modification as the importance of specific Historical, Clinical, Risk Management, or Other Consideration items that proved to have predictive power gained providence in the assessment and those items that proved to have poor predictive power were subjugated.

References

American Academy of Child and Adolescent Psychiatry. (2005). Children’s Threats: When Are

They Serious?  Obtained from: Center for School Mental Health. Threat Assessment:   

Resources and Cautions. http://smhp.psych.ucla.edu/qf/threatassessment.html  

Lichtenwald, T.G.; Steinhour, M.H. & Perri, F.S. (2012). “A Maritime Threat Assessment of Sea   

Based Criminal Organizations and Terrorist Operations”. Homeland Security Affairs, 8, 13. Retrieved from http://www.hsaj.org/?article=8.1.13

Conduct and Behavior Problems in School Aged Youth (Introductory Packet). Retrieved from

             http://smhp.psych.ucla.edu/pdfdocs/conduct/CONDUCT.pdf

National School Safety and Security Services. School Safety Assessments. (2007). Retrieved

            from http://www.schoolsecurity.org/consultants/security-assessments.html 

Risk factors for school violence. (2001). Retrieved from

            http://archives.cnn.com/2001/US/03/05/fbi.shooter.profile/ .

School Violence Resource Center, Criminal Justice Institute. National Center for Rural Law  

            Enforcement.  School Violence FACT Sheets. Retrieved from: www.svrc.net .

Screening/Assessing Students: Indicators and Tools (Resource Aid Packet).  Retrieved from

            http://smhp.psych.ucla.edu/pdfdocs/assessment/assessment.pdf

U.S. Department of Education and the U.S. Secret Service. (2002). Threat Assessment in

Schools: A Guide to Managing Threatening Situations and to Creating Safe School Climates.

U.S. Department of Education and the U.S. Secret Service. (2002). The Final Report and

Findings of the Safe School Initiative: Implications for the Prevention of School Attacks in the United States.

United States Secret Service.  National Threat Assessment Center.  Retrieved from http://www.secretservice.gov

Violence Prevention and Safe Schools (Introductory Packet). Retrieved from      http://smhp.psych.ucla.edu/pdfdocs/violence/violence.pdf

American Psychological Association Database Search

HCR-20

There were 112 results for HCR-20: in peer review articles, chapters of text books and dissertations.

Abstracts

Violence risk assessment: The use of the PCL-SV, HCR-20, and VRAG to predict violence in mentally disordered offenders discharged from a medium secure unit in Scotland.

Ho, Hilda; Thomson, Lindsay; Darjee, Rajan

Journal of Forensic Psychiatry & Psychology. Vol 20(4), Aug 2009, 523-541.

1.      Risk assessment tools are increasingly used in the management of mentally disordered offenders in Scotland, but there has been limited research into their validity among this population. The aim of this study was to examine the validity of risk assessment tools in predicting violence following discharge from a Scottish medium secure unit. The PCL-SV, the VRAG, and the historical subset of the HCR-20 were completed on 96 patients. Follow-up information regarding postdischarge violence and clinical factors was collected for two years. Four (4.2%) patients from the sample committed five serious violent offences, while 38 (40.6%) patients committed more than 100 minor violent offences. The risk assessment tools were found to have moderate predictive accuracy for violent outcomes. Thus this study provides useful evidence supporting the validity of risk assessment tools in Scotland. Individual clinical factors such as substance abuse, personality disorder, treatment non-compliance, and symptom relapse are also relevant in risk assessment and management. (PsycINFO Database Record (c) 2009 APA, all rights reserved)

Database: PsycINFO

[Journal Article]

The effect of training on the quality of HCR-20 violence risk assessments in forensic secure services.

Reynolds, Kelly; Miles, Helen Louise

Journal of Forensic Psychiatry & Psychology. Vol 20(3), Jun 2009, 473-480.

1.      Training (full course: one and a half days; introductory course: half a day) on the HCR-20 risk assessment of violence in mentally disordered offenders was held for Kent Forensic Psychiatry Service (KFPS) staff in 2007 and 2008. KFPS inpatient files (n = 68) on 1 April 2008 were reviewed to locate completed HCR-20s. Overall and component parts (historical factors, clinical factors, risk management factors, and risk management plan) were rated for quality. Training significantly increased the quality of HCR-20 assessments. No significant differences in quality were found between those completed by qualified and by trainee staff. Training evaluations indicated that the most useful/helpful aspects of the training were the facilitator’s training style and the pace of the day, while the least was training venue. Confidence in completing HCR-20s was also reasonably low, possibly due to perceptions of the time involved. (PsycINFO Database Record (c) 2009 APA, all rights reserved)

Database: PsycINFO

[Journal Article]

Use and perceived utility of structured violence risk assessments in English medium secure forensic units.

Khiroya, Reena; Weaver, Tim; Maden, Tony

Psychiatric Bulletin. Vol 33(4), Apr 2009, 129-132.

1.      Aims and method: We surveyed the usage and perceived utility of standardised risk measures in 29 forensic medium secure units (a 62% response rate). Results: The most common instruments were Historical Clinical Risk–20 (HCR–20) and Psychopathy Checklist—revised (PCL–R); both were rated highly for utility. The Risk Matrix 2000 (RM2000), Sex Offender Risk Appraisal Guide (SORAG) and Static-99 were the most common sex offender assessments, but the Sexual Violence Risks–20 (SVR–20) was rated more positively for its use of dynamic factors and relevance to treatment. Clinical implications: Most medium secure units use structured risk assessments and staff view them positively. As HCR–20 and PCL–R/PCL–SV (Psychopathy Checklist—Screening Version) are so widely used they should be the first choices considered by other services. (PsycINFO Database Record (c) 2009 APA, all rights reserved)

Database: PsycINFO

[Chapter]

Understanding and assessing aggression and violence. Oxford handbook of personality assessment.

Megargee, Edwin I.

Butcher, James N. (Ed). (2009). Oxford handbook of personality assessment. Oxford library of psychology. (pp. 542-566). New York, NY, US: Oxford University Press. xvii, 750 pp.

1.      This chapter discusses the issues pertinent to defining and understanding these problems in society. Dr. Megargee discusses the factors leading to aggressive behavior and violence and provides an overview of contemporary methods being used to assess and predict aggressive behavior and violence. He describes the types of assessments and deals with referral questions and assessment contexts such as not guilty by reason of insanity defense, treatment planning, and needs assessments. He details useful information on assessment tools and techniques that are effective for retrospective and prospective predictions. In his chapter, he provides an overview of violent crimes—assault and murder, domestic violence, forcible rape and sexual battery, kidnapping and hostage taking arson, bombing, and terrorism—and describes the types of violent offenders delineated in the literature. He also highlights a conceptual framework for the analysis of aggression and violence including his "algebra of aggression" for predicting violence. He describes some personal factors that decrease the likelihood of aggression and discusses situational factors influencing the likelihood of aggression. (PsycINFO Database Record (c) 2009 APA, all rights reserved)

Database: PsycINFO

[Journal Article]

Risk assessment in forensic patients with schizophrenia: The predictive validity of actuarial scales and symptom severity for offending and violence over 8 - 10 years.

Thomson, Lindsay; Davidson, Michelle; Brett, Caroline; Steele, Jonathan; Darjee, Rajan

International Journal of Forensic Mental Health. Vol 7(2), Fal 2008, 173-189.

1.      Assessment of risk of violence is essential in the management of patients with schizophrenia admitted to secure hospitals. The present study was conducted to test the validity of actuarial measures and psychotic symptoms in the prediction of further violence and offending in this group. The H-10 scale of the HCR-20, Violence Risk Appraisal Guide and Psychopathy Checklist-Revised were scored retrospectively. Symptom severity was rated at interview and persistence from notes. Outcome was measured using criminal records and recorded incidents of aggression over an 8-10 year period. Seventy-six percent of patients were involved in more than 1800 incidents defined as physical contact with a victim or damage to property, and 28% in a serious incident defined as injury to a victim requiring hospital treatment, a contact sexual incident or fire setting. Fifteen percent of patients were convicted of any offense and 5% of a violent offense. The risk scales had moderate to high predictive accuracy for offenses and violent offenses but failed to predict incidents or serious incidents. Symptom severity and persistence predicted incidents but not offenses. Violence within this population is common. Actuarial measures of risk assessment are valid predictors of offending and violent offending but psychotic symptoms are more relevant to the prediction of violent incidents. Assessments of likely inpatient aggression must emphasize symptoms. (PsycINFO Database Record (c) 2009 APA, all rights reserved)

Database: PsycINFO

[Journal Article]

Predicting violent reconvictions using the HCR-20.

Gray, Nicola S.; Taylor, John; Snowden, Robert J.

British Journal of Psychiatry. Vol 192(5), May 2008, 384-387.

1.      Background: Risk assessment of future violent acts is of great importance for both public protection and care planning. Structured clinical assessments offer a method by which accurate assessments could be achieved. Aims: To test the efficacy of the Historical, Clinical and Risk Management Scales (HCR-20) structured risk assessment scheme on a large sample of male forensic psychiatric patients discharged from medium secure units in the UK. Method: In a pseudo-prospective study, 887 male patients were followed for at least 2 years. The HCR-20 was completed using only pre-discharge information, and violent and other offending behaviour post-discharge was obtained from official records. Results: The HCR-20 total score was a good predictor of both violent and other offences following discharge. The historical and risk sub-scales were both able to predict offences, but the clinical sub-scale did not produce significant predictions. The predictive efficacy was highest for short periods (under 1 year) and showed a modest fall in efficacy over longer periods (5 years). Conclusions: The results provide a strong evidence base that the HCR-20 is a good predictor of both violent and non-violent offending following release from medium secure units for male forensic psychiatric patients in the UK. (PsycINFO Database Record (c) 2009 APA, all rights reserved)

Database: PsycINFO

[Journal Article]

Assessing living skills in forensic mental health care with the behavioural status index: A European network study.

Ross, Thomas; Woods, Phil; Reed, Val; Sookoo, Susan; Dean, Anne; Kettles, Alyson; Almvik, Roger; Ter Horst, Paul; Brown, Ian; Collins, Mick; Walker, Helen; Pfäfflin, Friedemann

Psychotherapy Research. Vol 18(3), May 2008, 334-344.

1.      Assessment of living skills and violence risk in forensic psychiatric patients is a priority for clinicians. Suitably fine-grained instruments are rare. The goal of this study was to compare a norm-based psychometric assessment battery (the Behavioural Status [BEST] Index) with known valid instruments. Parallel cohort studies were undertaken in four European countries. Inpatients from 24 forensic psychiatric clinics were assessed three times using five instruments measuring living skills, psychological symptoms, aggression, and violence risk. Positive clinical changes were noted in insight, empathy, and some behaviors related to communication and living skills, with little change in violence risk, which was low to medium for most patients. Clinical congruence was observed between logically cognate items of the BEST Index and comparison instruments. Evidence for the scientific and clinical utility of the BEST Index as an effective tool for forensic psychiatric practice is discussed. (PsycINFO Database Record (c) 2009 APA, all rights reserved)

Database: PsycINFO

[Journal Article]

Measuring progress in hospital order treatment: Relationship between levels of security and C and R scores of the HCR-20.

Müller-Isberner, Rüdiger; Webster, Christopher D.; Gretenkord, Lutz

International Journal of Forensic Mental Health. Vol 6(2), Fal 2007, 113-121.

1.      Although it is generally presumed that there will be an association between the levels of security at which clients are held in a forensic hospital and the formal ratings of violence risk ascribed to them, such a relationship is seldom demonstrated. One measure in this study was the security level of 218 inpatients held in a German forensic hospital. The other measure was the C- and R-score of the HCR-20 (CR-10). The results were clear in showing an orderly correspondence between the two measures (C-scale: r = .37; R-scale: r = .52). The CR-10 part of the HCR-20 seems to be a useful measure to gauge progress in forensic psychiatric inpatient treatment. (PsycINFO Database Record (c) 2009 APA, all rights reserved)

Database: PsycINFO

[Journal Article]

The validity of violence risk estimates: An issue of item performance.

Mills, Jeremy F.; Kroner, Daryl G.; Hemmati, Toni

Psychological Services. Vol 4(1), Feb 2007, 1-12.

1.      Typically, research conducted on the cross-validation or generalization of risk assessment schemes focuses on the aggregate score accuracy of the schemes within the new sample or population. Often overlooked when the schemes are examined in their aggregate form is the performance of the individual items. This study looks at the association between the items of the HCR-20 (C. D. Webster, K. S. Eaves, D. Douglas, & S. D. Wintrup, 1995) and the Violence Risk Appraisal Guide (VRAG; C. D. Webster, G. T. Harris, M. E. Rice, C. Cormier, & V. L. Quinsey, 1994) and violent recidivism in a sample of predominantly violent offenders. The results show that a number of the items from each scale do not distinguish between violent recidivists and nonrecidivists and that the presence of these items potentially reduces the predictive accuracy of the instruments. In addition, the inclusion of items that do not discriminate between recidivists and nonrecidivists potentially undermines the validity of the risk assessment process. Discussion centers on the application of prediction schemes and their individual risk factors in forensic practice. (PsycINFO Database Record (c) 2009 APA, all rights reserved)

Database: PsycINFO

[Letter]

Use of HCR-20 in routine psychiatric practice.

Pyott, J.

Psychiatric Bulletin. Vol 29(9), Sep 2005, pp. 352.

1.      This letter reports the use of the HCR-20 in routine psychiatric practice. I would like to suggest that the HCR-20 may be of particular value in clarifying the interface between generic and forensic services and in directing the allocation of resources. I would therefore support the call to incorporate the HCR-20 into standard risk assessment procedures. There are obvious advantages in using a tool based on empirically derived information. At the service level the HCR-20 may be useful in stratifying services according to the level of risk they should manage, such that an H-scale score could provide an initial indicator of the suitability for supervision by a community forensic team or a generic team. The HCR-20 may also be useful in demonstrating to those who fund forensic services that expensive services such as assertive outreach or intensive case management are being directed to an appropriately 'forensic'and high-risk client group. (PsycINFO Database Record (c) 2009 APA, all rights reserved)

Database: PsycINFO

[Journal Article]

Predicting violence in a medium secure setting: A study using the historical and clinical scales of the HCR-20.

McKenzie, Brian; Curr, Helen

British Journal of Forensic Practice. Vol 7(3), Aug 2005, 22-28.

1.      This study examined the ability of the HCR-20 Scale (version 2) to predict incidents of inpatient violence during a stay on a medium secure ward. The study was carried out retrospectively on a sample of 94 admissions, using reports pre-existing at the time of admission and nursing observations of behaviour in the two weeks that followed admission. The sample group was made up of mentally disordered offenders and patients with challenging behaviour. Their episodes of care averaged two years. The H and C scores, singly or combined, did not show powerful predictive capacity for the sample as a whole, which had a high base rate for violence. Insufficient variance and poor inter-rater reliability precluded use of the R variable. For purposes of analysis, violent patients were also grouped on the number of incidents committed during their episode of care. Here the C Scale items showed strong predictive capacity for patients with more than 10 incidents during their stay. The paper argues that the latter finding supports a method of predicting admissions at risk of frequent incidents of violence. (PsycINFO Database Record (c) 2009 APA, all rights reserved)

Database: PsycINFO

[Journal Article]

Ethnic Differences in Prediction of Violence Risk With the HCR-20 Among Psychiatric Inpatients.

Fujii, Daryl E. M.; Tokioka, Abe B.; Lichton, Alex I.; Hishinuma, Earl

Psychiatric Services. Vol 56(6), Jun 2005, 711-716.

1.      Objective: This study examined ethnic differences in assessment of violence risk among psychiatric inpatients by using the Historical Clinical Risk Management-20 (HCR-20). Methods: The HCR-20 was administered to 169 consecutive psychiatric inpatients. Individual items and total scores on the HCR-20 were compared between patients of Asian- American (N=51), Euro-American (N=46), and Native-Hawaiian (N=38) heritage. Receiver operating characteristic (ROC) and stepwise regressions were calculated for each ethnic group with HCR-20 scores as predictor variables and violent event reports of significant threats and assaults as the outcome measure. Results: Similar rates of overall violence were found between ethnic groups, and the HCR-20 was found to have predictive validity as measured by ROC analysis. Differences in scores on individual HCR-20 items were found, including young age at first incident of violence, psychopathy, early maladjustment, personality disorder, and past supervision failure, as well as total HCR-20 score, with Asian Americans scoring lower (less risk) than Euro-Americans and Native Hawaiians. Stepwise multiple regressions indicated a different pattern of predictor variables for each ethnic group, with impulsivity salient for the Asian-American group, young age at first incident of violence salient for the Euro-American group, and young age at first incident of violence, relationship instability, and risk-management plans' lacking feasibility as salient predictors for the Native-Hawaiian group. Conclusions: The findings provide preliminary support for the crosscultural validity of the HCR-20 while at the same time identifying unique ethnic differences in prediction of violence risk among psychiatric inpatients. (PsycINFO Database Record (c) 2009 APA, all rights reserved)

Database: PsycINFO

[Journal Article]

Violence, mental disorder and risk assessment: Can structured clinical assessments predict the short-term risk of inpatient violence?.

Grevatt, Michelle; Thomas-Peter, Brian; Hughes, Gary

Journal of Forensic Psychiatry & Psychology. Vol 15(2), Jun 2004, 278-292.

1.      This study considered the ability of items on the HCR-20 and VRS, structured clinical risk assessments, to predict inpatient violence within the first 6 months of admission to a secure forensic service. A retrospective file review of information available at time of admission was used to complete the Historical and Clinical scales of the HCR-20 and VRS for a sample of 44 male inpatients. The ability of these risk assessments to predict recorded incidents of violent behaviour, as measured by official incident reports, was then assessed. The predictive validity of individual scale items was also considered. The HC composite and VRS did not predict inpatient violence within the first 6 months of admission. However, the clinical sub-scale of the HCR-20 was predictive of violence, abuse or harassment. When considering repetitiveness there was some indication across the scales that static factors predicted isolated incidents and dynamic factors repetitive violence. A number of individual items within the scales appeared to act as predictive or protective factors for inpatient violence. Despite the poor predictive validity of the scales overall, this study provides some indication of the differential utility of these structured clinical assessments for predicting short-term risk of violence in inpatients. In particular the use of dynamic clinical factors in identifying those likely to engage in imminent repetitive violence. (PsycINFO Database Record (c) 2009 APA, all rights reserved)

Database: PsycINFO

[Dissertation]

Making structured clinical decisions about violence risk: Reliability and validity of the HCR-20 violence risk assessment scheme.

Douglas, Kevin Stewart

Dissertation Abstracts International: Section B: The Sciences and Engineering. 64(8-B),2004, pp. 4032.

1.      Violence risk assessment has been reconceptualized in recent years, away from passive one-time prediction toward the ongoing assessment of dynamic or changeable risk. The complex and multifaceted nature of risk has been emphasized, and the development of violence risk assessment schemes under various decision making models has taken place. The HCR-20 violence risk assessment scheme is one application of the structured professional judgment model of risk assessment. Although there have been numerous studies of the HCR-20 items and scales, there had yet to be an evaluation of its central intended clinical use-structured clinical judgments of low, moderate, and high risk for violence. Using file ratings of 100 released forensic psychiatric patients, this dissertation evaluated the interrater reliability and validity of these existing structured judgments, as well as of experimental judgments not included in the HCR-20 but suggested by recent developments in the literature (i.e., short-term judgments; judgments of differing severities of violence; ratings of likelihood of item change). Chance-corrected agreement was good to substantial for existing HCR-20 structured judgments, but less consistent for experimental judgments. HCR-20 structured judgments consistently were related to violence, and added incrementally to the HCR-20 used in an actuarial fashion. Experimental HCR-20 structured judgments performed more variably, tending to have significant univariate effects with violence but not maintaining significance in multivariate models. It is concluded that the use of HCR-20 judgments currently contained in the manual is supported, but that most experimental judgments need refinement prior to adoption in clinical practice. Implications for practice, research, theory, and training are discussed. (PsycINFO Database Record (c) 2009 APA, all rights reserved)

Database: PsycINFO

[Journal Article]

Predictive validity of the HCR-20 Violence Risk Assessment Scheme within a maximum security special hospital.

Macpherson, Gary J. D.; Kevan, Ian-Mark

Issues in Forensic Psychology. Vol No 5,2004, 62-80.

1.      The predictive validity of the HCR-20 violence risk assessment scheme was assessed with respect to in-patient violence during admission within a maximum-security forensic mental health facility. The HCR-20 was completed on admission with 86 consecutive patients detained under the Mental Health (Scotland) Act 1984 and Criminal Procedures (Scotland) Act 1995 and compared with subsequent threatening behaviour and physical violence within the hospital. Historical, Clinical and HCR-20 Total indices were found to be differentially predictive of different types of violence during admission, with Receiver Operating Characteristics (ROC) analyses yielding a AUC's ranging from 0.65 to 0.72. Only the clinical scale of the HCR-20 was significantly predictive of physical violence, with an AUC of 0.65. Implications for the clinical utility of the HCR-20 in predicting inpatient violence in maximum-security forensic psychiatric settings are discussed. (PsycINFO Database Record (c) 2009 APA, all rights reserved)

Database: PsycINFO

[Journal Article]

Assessing risk for violence among male and female civil psychiatric patients: The HCR-20, PCL:SV, and VSC.

Nicholls, Tonia L.; Ogloff, James R. P.; Douglas, Kevin S.

Behavioral Sciences & the Law. Vol 22(1),2004, 127-158.

1.      This study evaluated the predictive validity of violence risk assessments conducted using the HCR-20, the Psychopathy Checklist: Screening Version (PCL:SV), and by the Violence Screening Checklist (VSC) in a sample of 268 involuntarily hospitalized male and female psychiatric patients. Information pertaining to violence and crime was coded from medical charts and correctional records. The HCR-20/PCL:SV evidenced modest non-significant associations in postdictive assessments of inpatient violence among men. Moderate to strong significant associations were found between the HCR-20/PCL:SV and inpatient violence among women. Pseudo-prospective assessments using the HCR-20 and PCL:SV resulted in moderate to large relationships with violence and crime in men and women following community discharge. It is concluded that the VSC is a promising tool for assessing acute inpatient violence risk with men. Findings offer preliminary validation of the predictive validity of the HCR-20 and PCL:SV with female civil psychiatric patients. (PsycINFO Database Record (c) 2009 APA, all rights reserved)

Database: PsycINFO

[Dissertation]

Exploring differences in clinical judgments of dangerousness of North Carolina psychiatric inpatients: Utility of the HCR-20 Risk Assessment Scheme.

Stribling, Adeirdre Lacheryl

Dissertation Abstracts International: Section B: The Sciences and Engineering. 65(1-B),2004, pp. 454.

1.      The purpose of this study is to assess the efficacy of clinician ratings of dangerousness among psychiatric inpatients by utilizing the structured HCR-20 Risk Assessment Scheme. The study is based on archival records of patients committed to a North Carolina psychiatric hospital due to being found incompetent to proceed to trial, not guilty by reason of insanity, or detained due to exhibiting exceptional dangerous behavior in the community or while hospitalized. The individuals were chosen for the study because they had at least two completed HCR-20 risk assessments of historical, clinical, and risk management factors of dangerousness. Patients (N = 52) were assessed with the HCR-20 at one hospital before being referred to the increased security forensic treatment program at Dorothea Dix Hospital (DDH) where they were again assessed for risk of violence at intake. The differences in mean total scores on the HCR-20 were compared. Behavioral data was also gathered for the patients hospitalized for one year (N = 39) for the interim between the DDH risk assessment and one-year post DDH risk assessment. Patients' total number of "physical assaults" (criterion 1) and "verbal threats" (criterion 2) were summed. Individuals were deemed "physically violent" (criterion 3) if at least one physical assault was made and "verbally aggressive" (criterion 4) if at least one verbal threat was made. For each clinician rating, the HCR-20 items and subscale totals were used as predictors of the four criteria over the course of one year. The study lends support to the hypothesis that the referring clinicians' ratings of dangerousness are higher than the ratings by a clinician at DDH. Also, supportive of ongoing research using the HCR-20 was the finding that historical factors best predict future dangerousness. Suggestions are offered to improve the process of risk communication among mental health professionals in North Carolina. (PsycINFO Database Record (c) 2009 APA, all rights reserved)

Database: PsycINFO

[Journal Article]

Evaluation of a Model of Violence Risk Assessment Among Forensic Psychiatric Patients.

Douglas, Kevin S.; Ogloff, James R. P.; Hart, Stephen D.

Psychiatric Services. Vol 54(10), Oct 2003, 1372-1379.

1.      This study tested the interrater reliability and criterion-related validity of structured violence risk judgments made by using one application of the structured professional judgment model of violence risk assessment, the HCR-20 violence risk assessment scheme, which assesses 20 key risk factors in three domains: historical, clinical, and risk management. The HCR-20 was completed for a sample of 100 forensic psychiatric patients who had been found not guilty by reason of a mental disorder and were subsequently released to the community. Violence in the community was determined from multiple file-based sources. Structured final risk judgments were significantly predictive of postrelease community violence, yielding moderate to large effect sizes. Event history analyses showed that final risk judgments made with the structured professional judgment model added incremental validity to the HCR-20 used in an actuarial sense. The findings support the structured professional judgment model of risk assessment as well as the HCR-20 specifically and suggest that clinical judgment, if made within a structured context, can contribute in meaningful ways to the assessment of violence risk. (PsycINFO Database Record (c) 2009 APA, all rights reserved)

Database: PsycINFO

[Chapter]

Violence risk assessment in American law. Adversarial versus inquisitorial justice: Psychological perspectives on criminal justice systems.

Monahan, John

van Koppen, Peter J. (Ed); Penrod, Steven D. (Ed). (2003). Adversarial versus inquisitorial justice: Psychological perspectives on criminal justice systems. Perspectives in law & psychology, Vol. 17. (pp. 81-89). New York, NY, US: Kluwer Academic/Plenum Publishers. x, 437 pp.

1.      In this chapter, I address two topics relevant to the use of violence risk assessment in American law. First, I review the state of the science of violence risk assessment, concentrating on recent moves in the United States toward augmenting clinical prediction with statistical approaches to assessment. Second, I review the current state of American law on the admissibility of clinical and statistical risk assessments of violence as evidence in court proceedings. Topics discussed included: the validity of clinical risk assessments, the move toward actuarial risk assessment, The Violence Risk Appraisal Guide, The HCR-20, The Iterative Classification Tree, Constitutional issues, and evidentiary issues. (PsycINFO Database Record (c) 2009 APA, all rights reserved)

Database: PsycINFO

[Journal Article]

Actuarial versus clinical assessments of dangerousness.

Litwack, Thomas R.

Psychology, Public Policy, and Law. Vol 7(2), Jun 2001, 409-443.

1.      In their book, Violent Offenders, V. L. Quinsey, G. T. Harris, M. E. Rice, and C. A. Cormier (1999) proposed the "complete replacement" of clinical assessments of dangerousness with actuarial methods, such as the Violence Risk Appraisal Guide (VRAG). In this article, the author argues that (a) research to date has not demonstrated that actuarial methods of risk assessment are superior to clinical methods; (b) because most clinical determinations of dangerousness are not "predictions" of violence, as well as for other reasons, it is very difficult to meaningfully compare clinical and actuarial assessments of dangerousness; and (c) even the best researched and validated actuarial tool for assessing dangerousness to date, the VRAG, has not yet been validated in a manner that would make it appropriate for use in determining when individuals should be confined on the grounds of their dangerousness. Therefore, although clinicians who engage in risk assessments certainly should be knowledgeable about arguably relevant actuarial assessment schemes and other assessment guides (e.g., the HCR-20), it is premature, at best, to replace clinical risk assessments with actuarial assessments. (PsycINFO Database Record (c) 2009 APA, all rights reserved)

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HCR-20 Version Three Form

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In my role as Forensic Clinical Specialist at a civil mental health service I am routinely asked to assess the risk of people acting on threats of violence.  The standard tool I use to guide my advice is the HCR-20, currently version 3, although version 2 also has good validity.  See http://hcr-20.com/ . Terrance Lichtenwald has already provided a summary of these and some supporting references.  From my perspective the huge advantage of structured professional judgement tools such as the HCR-20 is that in addition to providing a sound understanding of the type, severity and imminence of risk of violence, by identifying the evidence based dynamic risk variables for interpersonal violence they provide guidance as to interventions that can reduce the risk of violence.  Surely this is one of the key goals of any clinical engagement? 

Having said that, in the Australian context, if a person makes a threat to harm that is targeted and enactable a clinician would be on very dangerous ground if they did not provide clear warning.  “Tarasoff v. Regents of the University of California – decided by the California Supreme Court in 1976” is generally referred to as providing guidance for clinicians. https://scholar.google.com/scholar_case?case=263231934673470561  There are numerous references easily found elaborating upon this, e.g. http://nationalpsychologist.com/2009/03/tarasoff-%E2%80%9Cduty-to-warn%E2%80%9D-clarified/101056.html . 

Your professional body will also undoubtedly have extensive material on this issue and the steps to be taken if confidentiality is to be breached.

I currently assess clients in the ED for Suicide homicide. The Emergency Nurses Association has an evidence based tool called the VASA assessment.