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The purpose of this paper is to explore how raters combine constituent components of Historical Clinical Risk-20 (HCR-20) risk assessment, and how relevant they rate the tool to different diagnostic and demographic groups.

A cross-sectional survey design of n=45 mental health clinicians (psychiatrists, psychologists, and others) working in a secure hospital responded to an online survey about their risk assessment practice.

HCR-20 Historical and Clinical subscales were rated the most relevant to violence prediction but four of the five items rated most relevant were Historical items. A recent history of violence was rated more important for risk formulation than Historical and Risk management items, but not more important than Clinical items. While almost all respondents believed predictive accuracy would differ by gender, the tool was rated similarly in terms of its relevance for their client group by people working with men and women, respectively.

This was an exploratory survey and results should be verified using larger samples.

Clinicians judge recent violence and Clinical items most important in inpatient violence risk assessment but may overvalue historical factors. They believe that recent violent behaviour is important in risk formulation; however, while recent violence is an important predictor of future violence, the role it should play in SPJ schemes is poorly codified.

It is important that risk assessment is accurate in order to both protect the public and to protect patients from overly lengthy and restrictive detention.

Despite the vast number of studies examining the predictive validity of tools like HCR-20 very little research has examined the actual processes and decision-making behind formulation in clinical practice.

The assessment and management of risk towards others is an integral part of clinical practice, particularly in forensic and other psychiatric settings. Version 3 of the HCR-20 is the latest version of a comprehensive set of professional guidelines based on the Structured Professional Judgement model. It is the most widely used and best validated tool available to assess risk of violence; however, clinicians perceive it as an additional task with limited clinical usefulness, which requires undergoing expensive training and takes considerable time to implement. The paper aims to discuss these issues.

Training was delivered to 148 clinicians to improve perceptions with regard to risk formulation and the HCR-20v3 as an effective and clinically useful tool in generating individual and robust care plans to minimise risk of violence.

Results indicated significant score increase post-training, indicating higher regard for the HCR-20 in terms of its usefulness, anticipated impact upon working, anticipated impact upon managing risk, ease of completion and perceived relevance to clinical practice. This was also consistent with qualitative feedback indicating improved risk management and care planning with reference to how learning would support respective roles. Feedback also highlighted the added value of certain aspects of the training provided, which may be useful to consider when designing HCR-20 training packages.

This study demonstrates the importance of engaging clinicians in bespoke training on the practicalities of HCR-20 completion and the fundamentals of risk formulation.

This study highlights the importance of incorporating a training package for staff of all disciplines in changing perceptions of risk management tools and thus their use in the practical management of violence. The useful aspects of training may assist changing perceptions of the role that risk formulation and the HCR-20v3 play in the assessment and management of violence.

This research suggests that if this can be done successfully, it may lead to a change in the perception of the role that the HCR-20v3 can play in assessing risk of violence and generating meaningful management plans to reduce the future likelihood of violence.

Evidence has shown associations between personality disorder (PD) and poor treatment outcomes. The purpose of this paper is to: first, establish which risk assessment method (i.e. structured professional judgement or actuarial) is most reliable for predicting treatment outcomes for individuals with PD. Second, determine whether individuals identified as high risk are more likely to have poorer treatment outcomes. Third, determine if engagement in treatment helps to reduce risk assessment scores.

In total, 50 patients were recruited from a medium secure forensic PD service. Their risk was assessed using one structured professional judgement instrument (the HCR-20) and one actuarial instrument (the RM2000). The study used a retrospective cohort design.

Overall, the HCR-20 was a better predictor of treatment outcome than the RM2000. Personality-disordered offenders with high HCR-20 scores are at an increased risk of adverse treatment outcomes.

This investigation used a small, non-randomised sample of male patients with PD at one South East England medium secure unit. The data were over-represented by white British males. Future research should compare PD offenders with non-PD offenders to investigate what factors best predict poorer treatment outcomes.

The findings indicate that structured professional judgement approaches are more effective predictors of risk than actuarial measures for assessing patients with PD. This study therefore adds value to forensic services and to the risk assessment debate.

This study examined the ability of the HCR‐20 Scale (version 2) to predict incidents of in‐patient 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.

The purpose of this study was to explore the predictive validity of the revised Problem Identification Checklist (PIC‐R) in predicting inpatient and community violence using a retrospective design. The Historical Scale (H‐Scale) of the HCR‐20 was employed to control for static risk factors. The predictive accuracy between predictors and outcome measures was evaluated using Receiver Operating Characteristics (ROC) analysis. The PIC‐R significantly predicted inpatient violence (AUC range 0.77‐0.92) over a 12‐month follow‐up period but did not predict community violence. Conversely, the H‐Scale significantly predicted community violence (AUC 0.82) but did not predict inpatient violence over a 12‐month follow‐up period. The findings offer preliminary validation for the predictive accuracy of the PIC‐R for violence in a UK inpatient population. Additionally, the findings suggest that short‐term risk of violence within a psychiatric inpatient population may be more related to dynamic and clinical risk variables rather than to static ones.

The use of violence risk assessment measures within intellectual disabilities (ID) services is now the norm and a growing target for research. The purpose of this paper is to examine the clinical utility of the historical and clinical factors of the HCR-20 in predicting violence.

The study took place within a national low secure service for adults with ID examining all completed admissions over a six-year period, (N=22). Clinical records covering the first three months of admission were examined along with historical reports and incident data recorded at three, six, nine and 12 months admission using the Modified Overt Aggression Scale (MOAS).

Significant positive relationship between Historical score and total number of incidents was established. Patients with challenging behaviour less likely to have a previous history of violence, and more likely to be older at first violent incident than patients without challenging behaviour. Incidents involving patients with autism were less severe and those with no additional psychiatric diagnosis were significantly more likely to have substance misuse problems than those with a diagnosis.

The study found the Historical section was predictive of violent incidents and whilst the study is too small to draw any firm conclusions, the significant positive relationship between the Historical Score and number of incidents for those without additional diagnosis needs to be investigated further as well as the potential positive clinical impact of using the HCR-20 in routine clinical practice.

Integral to the process of formulating and managing the difficulties of mentally disordered offenders is the assessment of risk. However, the opinion held by many clinicians who work with offenders with an autism spectrum disorder (ASD) is that most conventional risk assessment tools fail to capture the underlying reasons why such individuals may offend. This needs to be explored.

The paper presents a screening study of the HCR 20 risk assessment tool and some other characteristics of ‘high risk’ individuals with an ASD. Also presented is a brief literature review supported by clinical experience of the assessment of psychopathy in ASD and highlighting potential key factors to be included in a risk assessment of offenders with an ASD.

It was found that nine out of the 20 risk items contained in the HCR 20 are present in 50 per cent or less of the sample. Whilst some conventional risk factors are present, clinical experience and the literature suggests that it is the specific difficulties associated with having an ASD that contribute towards an individual's vulnerability to offend.

Although further examination is required, provisional findings from this small screening study of the HCR 20 profiles of high risk individuals with an ASD questions the usefulness of some conventional risk factors in understanding the difficulties within this population. It is proposed that there is a need for good practise guidelines for assessing risk in individuals with an ASD.

The purpose of this paper is to conduct a preliminary evaluation of a Violent Offender Treatment Program (VOTP) adapted for use in a medium secure unit (MSU). The patient population is adult male mentally disordered offenders.

Patient outcomes are explored using the Reliable Change Index and Clinical Significance Criterion. Outcomes are assessed using VOTP facilitators violence risk assessment (VRS), multi-disciplinary team violence risk assessment (HCR-20 and GAS-V), and patient self-report using two measures (FAVT and STAXI-2).

There was evidence of improved outcomes for some participants in some areas related to risk of violence.

Consideration is given to using varied risk assessments to evaluate outcomes of an adapted VOTP for a MSU.

There is limited development and evaluation of psychological treatment programmes that aim to reduce risk of violence for male offenders within MSUs. Outcomes of this evaluation could influence treatment delivery and evaluation in other services.

The purpose of this paper is to outline the initial development of a framework to assist in clinical case formulation for individuals diagnosed with autistic spectrum disorder (ASD) who have been convicted of violent and other offences.

The proposed framework obtains information on the presence of ASD features from an individual’s developmental history, index offence and offence paralleling behaviours. Through obtaining information across these three domains the framework helps the practitioner make an informed assessment of the possible contribution of ASD to offending.

The framework aims to assist the practitioner to develop a clinical formulation based on hypothesised linkages between these domains for use in forensic assessment reports and to aid treatment planning. The use of the proposed framework is illustrated through a reference formulation based on a fictive case example.

The framework is still in the early stages of development and has not been tested. The next stage is to utilise case information data to assess the validity of the items. This does not preclude the use of the framework by practitioners as an aid to generating clinical hypotheses about the possible link between autism and offending as the development of the tool has been informed by research on ASD and offending.

The framework may be used in conjunction with structured professional judgement tools. For example, the recently published third version of the HCR-20 includes pervasive developmental disorders as a historical risk item. This possible relevance of this item in terms of forensic risk could be presented using information obtained from the framework outlined in this paper. This in turn could be used to inform the formulation section of the HCR-20 and in the generation of treatment plans. In the longer term, the framework may help inform our understanding of possible relationships between violence risk and ASD and therefore aid effective assessment and treatment planning.

In the longer term, the framework may help inform our understanding of possible relationships between violence risk and ASD and therefore aid effective assessment and treatment planning.

Although there is an emergent body of research on ASD and offending this has not yet been translated into a tool to help practitioners. This paper sets out an approach to do this and therefore makes an original contribution to the literature.

This article describes an initiative undertaken by a clinical team in a medium secure unit to manage their workload by offering training in structured violence risk assessment to local mental health professionals. The HCR‐20 violence risk assessment tool was used in this context. A number of half‐day training sessions were offered to a multidisciplinary audience in three local areas in the West Midlands covered by the team. This initiative was evaluated by feedback from participants, which suggested that the training was well‐received and considered broadly useful.