1. Assessing Risk for Violence Dr Lorraine Johnstone Consultant Clinical Forensic Psychologist Honorary Research Fellow Accredited Risk Assessor Lorraine.Johnstone@ggc.scot.nhs.uk

2. Perspectives RESEARCH PRACTITIONER ORGANISATIONAL

3. Process of evaluating the characteristics of offenders and their environment to estimate the likelihood and the nature of a negative outcome (in this case, violence) What is Risk Assessment?

4. “Prediction of dangerousness is particularly difficult because: dangerousness is the resultant of a number of processes which occasionally may be synergistic amounting to more than the sum of the parts, some within the individual and some in society; it is not static; key factors are the individual’s adaptiveness, resistance to change, and his intentions…” Scott (1977, p. 128)

5. False errors

6. Risk Factors Offence Analysis Risk Scenarios Risk Management Offender Background Protective Factors RMA Standards: Assessment

7. Assess Formulate Scenarios Communicate Risk Management Management Drive Disinhibit Destabilise Background

8. Unstructured Clinical Judgement Actuarial (Prediction) Structured Clinical Judgement Risk Assessment: Approaches

9. Which method is best?

10. Research Perspective PREDICTIVE VALIDITY

11. Unstructured Clinical Judgement Unstructured Clinical Judgement

12. “…relies on an informal, ‘in the head,’ impressionistic, subjective conclusion, reached (somehow) by a human clinical judge” Grove and Meehl (1996)

13. PREDICTIVE VALIDITY ACTUARIAL SCJ

14. Methodologies

15. Assessing Risk for Violence A Framework for Practice David Farrington Darrick Jolliffe Lorraine Johnstone RMA Scotland May 2008

16. Aims and objectives CHARACTERISE AND QUANTIFY THE EVIDENCE PREDICTIVE VALIDITY

17. ROC Analysis and studies reported AUC (or these could be derived) Overall ES Method

18. Inclusion Criteria Prospective Violence AUC for ROC N= 50 or more Males

19. Terms: Violen*, Aggressiv*, Serious*, Crim*, Assessment, HCR-20, VRAG, Etc. Strategy: Contact leading researchers, electronic database, internet and citation searches Search Terms and Strategy

20. 145 31 Studies Retrieved & Included

21. DeviceNAUCLower CIUpper CI GSIR40.730.680.79 OGRS40.710.660.75 HCR-20130.700.660.74 PCL180.690.660.73 VRAG180.690.670.72 LSI-R70.640.630.66 Results: Overall ES

22. From the Group to the Individual....

24. Illustration Violence Risk Assessment Guide

25. Psychopathy Checklist Score Elementary school maladjustment DSM-III diagnosis of Personality Disorder Age at index offence Separated from parents under age 16 Failure on prior conditional release +VE –VE +VE VRAG Variables - 1

26. Non-violent offence history Never married DSM-III diagnosis of Schizophrenia Victim injury Alcohol abuse Female victim index offence +VE –VE +VE –VE VRAG Variables - 11

28. Probability of Violent Recidivism Seven Year Follow-up VRAG CATEGORY

29. -20-1001020 VRAG 0.0 0.2 0.4 0.6 0.8 1.0 Probability Probability of Violent Reconviction after Two Years 95% CI Group 95% CI Individual

30. “The ARAIs cannot be used to estimate an individual’s risk for future violence with any reasonable degree of certainty and should be used with great caution or not at all.”

31. Assess Formulate Scenarios Communicate Risk Management Management Drive Disinhibit Destabilise Background

32. METHOD: DESIGN

33. Standards and Principles 1. User Manual 2. Specified User Qualifications, Competencies and Skills 3. Accessible Training 4. Ease of Use 5. Uses a Comprehensive Information Source 6. Appropriate Administration Time 7. Social History 8. Offence Analysis 9. Appropriate Number of Risk Factors 10. Appropriate Emphasis on Static Factors

34. Standards and Principles 11. Appropriate Emphasis on Dynamic Risk Factors 12. Well Defined Risk Factors 13. Ease of Scoring/Rating Procedures 14. Describes and Identifies Protective Factors 15. Assists in Risk Formulation 16. Assists in Identifying Plausible Risk Scenarios 17. Assists in the Development of a Risk Management Plan 18. Assists in the Identification of Treatment Needs 19. Assists in the Identification of Monitoring Needs 20. Concordance with Other Risk Assessment Tools/Guidelines 21. Confidence in Risk Judgement

35. METHOD: Sample

36. Respondents

38. HCR-20RAG-F /RA1-4 LSI/ LS-CMI PCL Standards (Max = 22) 21182018 Perceived Utility

39. Which tool is best?

40. But.....Organisational Issues Violence Expertise Suicide Time intensive Labour Intensive High Cost On-going Training & Development

41. Senior Management Directive to develop RA policy Legislative and Policy Drivers MWC Inquiry 2 Dedicated Posts MDT Risk Policy Group Framework for Practice, Training and Documentation 2004 2006 2006/07 March 2007 Draft Policy: Presentation and Consultation

42. Model and Format – SCJ Model as per RMA standards – Psychiatrist or psychologist co- ordinates but strong emphasis on MDT involvement DFMH Risk Policy (NHSGG&C)

43. Aims 1) to have at least a preliminary formulation of the person’s risk available to inform management; 2) to have a full risk assessment with all specialist assessments completed DFMH Risk Policy (NHSGG&C)

44. 1) Risk Screen for Risk Identification 2) Risk assessment Pathway and Process

45. Limited Information used to inform HCR-20 Preliminary formulation Additional information used to update HCR-20 Re-formulation Specialist Assessment (e.g. Personality disorder) Re-formulation

46. ( 1) Lead Posts (x2) (2) On-going training Strategy for MDT staff on: Awareness training Risk Policy HCR-20 PCL-R and other specialist assessments (START) * internal and external trainers Implementation

47. raining Strategy for MDT staff Risk Policy HCR-20 PCL-R (START) Does it work? More of the same... Back to before... Something entirely new

48. Assessing Risk for Violence is a complex and controversial task Priorities differ depending on perspective Common question: Which model is best? Summary and Conclusions

49. Meta-analysis indicated that the empirical research supports HCR-20 (and OGRS) in terms of predictive validity Practitioners prefer the HCR-20 in terms of risk assessment standards Challenge for organisations to promote and support the widespread use of the SCJ approach in a way that is time and cost effective: Models need to be tried and tested Summary and Conclusions