Risk assessment and risk management of violent reoffending among prisoners (original) (raw)
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Causal inference for violence risk management and decision support in forensic psychiatry
Decision Support Systems, 2015
The purpose of Medium Secure Services (MSS) is to provide accommodation, support and treatment to individuals with enduring mental health problems who usually come into contact with the criminal justice system. These individuals are, therefore, believed to pose a risk of violence to themselves as well as to other individuals. Assessing and managing the risk of violence is considered to be a critical component for discharged decision making in MSS. Methods for violence risk assessment in this area of research are typically based on regression models or checklists with no statistical composition and which naturally demonstrate mediocre predictive performance and, more importantly, without providing genuine decision support. While Bayesian networks have become popular tools for decision support in the medical field over the last couple of decades, they have not been extensively studied in forensic psychiatry. In this paper we describe a decision support system using Bayesian networks, which is mainly parameterised based on questionnaire, interviewing and clinical assessment data, for violence risk assessment and risk management in patients discharged from MSS. The results demonstrate moderate to significant improvements in forecasting capability. More importantly, we demonstrate how decision support is improved over the well-established approaches in this area of research, primarily by incorporating causal interventions and taking advantage of the model's ability in answering complex probabilistic queries for unobserved variables.
2004
Background: The assessment of risk of violence among mentally disordered offenders has been a controversial and well-researched area in forensic psychology and psychiatry in the last decades. The main focus of this research has been on the predictive validity of various risk factors and methods of combining risk factors to gain the highest possible predictive accuracy. In the present thesis, risk assessment is defined more broadly than predictive accuracy, and also includes process factors, riskmanagement and the communication and decision-making associated with risk of violence. The overall aim of this thesis was to study was to explore the process of structured risk assessment in its naturalistic clinical setting. Method: Four different samples were included in the 5 studies. A guideline for structured clinical risk assessment, Historical-Clinical-Risk assessment (HCR-20), was used in the first 4 studies. The first study used a 6 raters x 6 patients design to establish inter-rater reliability and validity of the HCR-20. 54 forensic patients were followed over time and monitored for inpatient violence and violence after discharge during three risk-management conditions in study 2. A sample of 40 nurses, assessing the same 8 patients, was included in studies 3 and 4. Finally study 5 included a sample of 88 decision-makers, divided into 3 groups; Clinicians, Criminal law professionals and Controls. Results: The HCR-20 was found to have reasonable reliability and validity in study 1. The main finding in study 2 was that the predictive accuracy of the HCR-20 was influenced by the intensity of risk management (AUC .64 compared to .82). In study 3 we found that structured clinical risk assessment was not "immune" to emotional bias in the assessment process. 43% of the variance in risk-scores could be attributed to the assessors' emotions towards the patient. The information utilised to make the assessment and how the assessor values it, also influenced the assessments in study 4. Placing value on personal interaction was more associated with inpatient violence than with recidivism. In study 5 we found that the inclination of making release decisions was greatly influenced (η= .58) by the prospect of making false negative error of judgement. Conclusions: Structured clinical risk assessments can be undertaken in a reliable and valid way in forensic clinical settings. Attention needs to be paid to factors that might influence the outcome of the assessments and the risk-management decisions that are the consequence of risk assessment. These factors can be emotional biases, evaluation of different kinds of information that form the basis for the process. There also needs to be an awareness of other factors than probabilities that influence decisions about risk. It is suggested that future descriptive, as opposed to prescriptive, research is needed on the processes and influences on risk assessments as they are actually done by clinicians in forensic, psychiatric and correctional settings.
Clinical Risk Assessment-Organizing Information Using Criminological Theory Seems to Work
Forensic Science & Addiction Research, 2018
Background: Risk assessment and management is a necessary and integrated part of clinical work. Risk assessment methods developed in the legal context differ from those traditionally used in clinical work but have been used to an increasing degree in such contexts. Aim: In general, traditional clinical assessment methods can be improved by using structured instruments. With respect to risk management, wellestablished criminological theory is worth testing. EuRAX is a comprehensive and structured clinical risk management tool which integrates concepts from current criminological theories. Method: 139 forensic psychiatric patients (stratified selection) were scored according to EuRAX. Results: Scoring was rather problem-free given the rich documentation in Swedish forensic case history files. Construct and discriminant validity was good. The patients displayed a wide array of problems assumed to be associated with criminal propensity. The concepts of "social bonds" and "poor self-control", as operationalized in EuRAX, displayed meaningful and discriminant patterns with respect to the other EuRAX variables, and to HCR and PCL scores. Conclusion: The use of well-established high-order criminological concepts, rated in a structured way, seems to provide important information relevant to the task of clinical risk management.
In the present study, we examined the predictive utility of the Brockville Risk Checklist (BRC), a structured assessment tool for clinical care planning, using a semi-parametric regression technique. We examined BRC scores and the frequency and type of incidents (aggression, noncompliance, etc.) over 13 assessments for 121 psychiatric patients at a medium-secure forensic unit. Most patients were male (95%), on average 40.9 (SD = 13.0) years old, and diagnosed with a psychotic disorder (78%). Generalized estimating equation (GEE; Liang & Zeger, 1986) modeling was used in this study to determine if changes in dynamic risk scores over time predicted outcomes (presence or absence of an incident) during the approximately six-week follow-up period. Results showed that scores on the Harm to Others scale assessed at one case conference significantly predicted changes in aggressive and total incidents recorded in the subsequent case conference. The BRC shows promise as a dynamic measure of inpatient aggression, predicting verbal or physical incidents an average of six weeks later. sion occurring on inpatient wards also poses a significant problem for the safety of other patients, staff, and psychiatric treatment. Nicholls and colleagues (2009) found that 60% of forensic psychiatric patients engaged in at least one act of aggression (verbal, physical aggression against property, physical aggression against others, or inappropriate sexual behavior) over the course of one year. Similarly, reported that 45% of forensic psychiatric patients were aggressive on at least one occasion over the course of one year. Thus, it is equally important to identify risk factors that identify patients who are aggressive during a hospitalization and that are amenable to intervention. The best clinical interventions need to integrate information from risk assessment to create treatment and risk management plans .
Risk Assessment for Future Offending: The Value and Limits of Expert Evidence at Sentencing
2017
1. Jerrod Brown & Jay P. Singh, Forensic Risk Assessment: A Beginner’s Guide, 1 ARCHIVES OF FORENSIC PSYCHOL. 49, 49 (2014). 2. KIRK HEILBRUN, EVALUATION FOR RISK OF VIOLENCE IN ADULTS 12 (2009). 3. Id. 4. GARY B. MELTON ET AL., PSYCHOLOGICAL EVALUATIONS FOR THE COURTS: A HANDBOOK FOR MENTAL HEALTH PROFESSIONALS AND LAWYERS 299 (6th ed. 2007). 5. JOHN MONAHAN, PREDICTING VIOLENT BEHAVIOR: AN ASSESSMENT OF CLINICAL TECHNIQUES (1981). 6. Mairead Dolan & Michael Doyle, Violence Risk Prediction: Clinical and Actuarial Measures and the Role of the Psychopathy Checklist, 177 BRITISH J. PSYCH. 303, 303 (2000). 7. MELTON ET AL., supra note 4. 8. Id. 9. Barefoot v. Estelle, 463 U.S. 880 (1983). 10. Id. at 884-85. 11. Id. at 885. The question of a criminal defendant’s risk for future offending may be of interest to courts in a variety of contexts. Courts may request or consider information from forensic mental health professionals regarding risk assessment, which is the formal appraisal of th...
Shared Risk Formulation in Forensic Psychiatry
The Journal of the American Academy of Psychiatry and the Law, 2019
Patients in forensic mental health care have a difficult journey through inpatient rehabilitation and re-integration into the community. Risk assessment guides this progress, usually with clinician-based processes that use structured risk-assessment tools. Patients' understanding of their own risk is important to inform risk assessment and the chances of successful rehabilitation. The emergence of shared decision-making approaches provides an opportunity to consider shared risk assessment and formulation. We reviewed the literature to explore models of patients' involvement in risk assessment and the impact on outcomes in forensic mental health care. We conducted searches of three databases (Medline, PsychINFO, and EMBASE) to identify papers that employed shared risk understanding for violence risk. Additional records were identified through review of citations, with articles being selected using a predetermined set of inclusion and exclusion criteria. We found five studies ...
A Clinical Feasibility Study of the Forensic Psychiatry and Violence Oxford (FoVOx) Tool
Frontiers in Psychiatry, 2019
Background: Risk assessment informs decisions around admission to and discharge from secure psychiatric hospital and contributes to treatment and supervision. There are advantages to using brief, scalable, free online tools with similar accuracy to instruments currently used. We undertook a study of one such risk assessment, the Forensic Psychiatry and Violence Oxford (FoVOx) tool, examining its acceptability, feasibility, and practicality. Methods: We completed the FoVOx tool on all discharges from six secure psychiatric hospitals in one region in England over two years. We interviewed 11 senior forensic psychiatrists regarding each discharge using a standardized questionnaire. Their patient's FoVOx score was compared to clinical risk assessment, and the senior clinicians were asked if they considered FoVOx scores accurate and useful. A modified thematic analysis was conducted, and clinicians were surveyed about current risk assessment practice on discharge. Results: Of 90 consecutive discharges, 84 were included in the final analysis. The median FoVOx probability score was 11% risk of violent recidivism in two years after discharge. We estimated that 12 (14%) individuals reoffended since discharge; all were in the medium or high risk FoVOx categories. Clinical assessment of risk agreed with the FoVOx categories in around half the cases. Clinicians were more likely to provide lower risk categories compared with FoVOx ones. FoVOx was considered to be an accurate representation of risk in 67% of cases; clinicians revised their view on some patient's risk assessment after being informed of their FoVOx scores. Completing FoVOx was reported to be helpful in the majority of cases. Reasons included improved communication with other agencies, reassurance to clinical teams, and identifying additional factors not fully considered. 10 of the 11 respondents reported that FoVOx was practical, and seven of 11 reported that they would use it in the future, highlighting its brevity and speed of use compared to existing risk assessment tools. Conclusions: Senior clinicians in this regional forensic psychiatric service found the FoVOx risk assessment tool feasible, practical, and easy to use. Its use addressed a lack of consistency around risk assessment at the point of discharge and, if used routinely, could assist in clinical decision-making.
Assessment of risk for violent recidivism through multivariate Bayesian classification
Psychology, Public Policy, and Law, 2010
Bayesian reasoning has already been applied in the area of assessing recidivism risk. Based on single predictors for re-offending, various authors have pointed out that Bayesian analysis was suited to the problem because the base rate of recidivism could be accounted for in terms of a prior probability. The present paper extends this argument towards the multivariate case. The result is a case-specific probabilistic assessment that allows judges and juries to reach informed decisions. The present paper illustrates the method through the combination of offender's age with data from a structured professional risk assessment instrument, the Psychopathy Checklist-Revised (PCL-R), for a sample of N ϭ 393 German convicts. The combination of these two criteria emerged as optimal from all available subsets of predictors (including the History Clinical Risk-20 and its components). The effect size for the Bayesian combination measure with regard to violent offense recidivism was large and significantly higher than the predictive value for each of its constituents. The study design was retrospective, average time at risk was 6.5 years.
British Journal of Psychiatry, 2013
BackgroundForensic psychiatry aims to reduce recidivism and makes use of risk assessment tools to achieve this goal. Various studies have reported on the predictive qualities of these instruments, but it remains unclear whether their use is associated with actual prevention of recidivism in clinical care.AimsTo test whether an intervention combining risk assessment and shared care planning is associated with a reduction in violent and criminal behaviour.MethodA cluster randomised controlled trial (Netherlands Trial Register number NTR1042) was conducted in three outpatient forensic psychiatric clinics. The intervention comprised risk assessment with the Short Term Assessment of Risk and Treatability (START) and a shared care planning protocol formulated according to shared decision-making principles. The control group received usual care. The outcome consisted of the proportion of clients with violent or criminal incidents at follow-up.ResultsIn total 58 case managers and 632 of the...