The use of the HCR-20V3 in Dutch forensic psychiatric practice - De Vogel - 2014 - Article

What are violence risk assessment tools?

Violence risk assessment tools are an important aspect of forensic psychiatric practices. Adequate violence risk assessments provide insight into risk and protective factors and concrete guidelines for risk management and treatment.  This can help to determine the most appropriate security level and treatment strategies. In turn, this helps to prevent violent recidivism.  In the 1990s, the Structured Professional Judgment approach (SPJ) was developed in Canada. The SPJ approach is a way to collect, review, combine, weigh and integrate information on risk factors. It is widely used by mental health professionals around the world.

What is the Historical, Clinical, Risk management-20 Version 2 (HCR-20)?

The Historical, Clinical, Risk management-20 Version 2 (HCR-20) is the most widely used risk assessment instrument. This instrument is used for the assessment of risk for future violence. Many studies have demonstrated that the HCR-20 is reliable and valid in various general and forensic psychiatric settings and penitentiary institutions in different countries.

What is the HCR-20 Version 3?

The Historical, Clinical, Risk management-20 Version 3 is a revised version of the HCR-20 Version 2. The goal of this revision was to improve the applicability of the tool and to increase its usefulness for risk assessment and management in daily practice. However, in contrast to the HCR-20 Version 2, its psychometric properties and clinical value still needs to be established. The current study questions whether the revised version of the HCR-20 Version 2 has sound psychometric properties, substantial clinical value, and whether it is really an improvement compared to the earlier version.

Since 2005, all forensic psychiatric institutions in The Netherlands are mandated to perform risk assessment with the use of the HCR-20 or the HKT-30, which is a Dutch equivalent. They use these tools before deciding upon leaves or discharge of all forensic patients who have been sentenced to mandatory treatment. This paper uses the first research results and clinical findings on the HCR-20 Version 3 in the Netherlands to describe the psychometric properties of it.

What can be said about the use of the HCR-20 in the Netherlands?

In the Netherlands, one forensic psychiatric hospital is the Van der Hoeven Kliniek. This is a hospital that admits both male and female patients. The majority of the patients suffer from a personality disorder and are admitted because of a TBS-order, which is translated as ‘disposal to be treated on behalf of the state.’ The TBS-order is a Dutch court-order implying mandatory inpatient psychiatric treatment. The main goal of it is to reduce violence risk. Every one or two years, the necessity of prolonged treatment is re-evaluated, by means of an evaluation of treatment progress and risk for violence as assessed with the HCR-20 or other tools.

What are additional tools to the HCR-20?

Since 2001, the Dutch version of the HCR-20 is used in the Van der Hoeven Kliniek. The clinicians were also always looking for ways to improve their violence risk assessments. This lead to some developments. For example, there were two tools developed according to the SPJ approach which can be used in addition to the HCR-20 or HCR-20 Version 3.

Even though the knowledge on violence risk factors and violence risk assessment has increased, hardly any attention has been paid to factors that moderate or buffer risk factors. To achieve a balanced evaluation of risk, both risk and protective factors should be taken into account. Also, treatment aimed at reducing violent recidivism should not only be focused on diminishing risk factors, but also on reinforcing protective factors. Based on this reasoning, the authors of the article developed a tool to specifically assess protective factors in addition to risk assessment tools such as the HCR-20, which is called the Structured Assessment of Protective Factors for violence risk.

The second tool is based on the finding that even though many violence risk factors seem to be valid for both men and women, the assessment and formulation of violence risk differ at least to a certain degree between men and women. Therefore, there is a need for more gender-sensitive risk assessment. This lead to the development of the Female Additional Manual, which is an additional tool to the HCR-20 for assessing risk for violence in female offenders with the goal to provide mental health professionals with more concrete guidelines for gender-sensitive risk assessment and management for women in forensic psychiatry.

More recently, the HCR-20 Version 3 was implemented in the Van der Hoeven Kliniek.

What are the conclusions?

Based on research in the Van der Hoeven Kliniek, it seems that the interrater reliability and predictive validity for violent recidivism of the HCR-20 Version 3 was good and comparable to that of the HCR-20 Version 2. It also seems that the applicability of the HCR-2 Version 3 for daily practice is high. Therefore, the overall conclusion is that the HCR-20 Version 3 is a good improvement compared to the HCR-20, especially with regards to the practical applicability and the link with risk management strategies. It has maintained the strengths of the HCR-20 Version as a relatively straightforward, easy to use tool. According to the authors, the HCR-20 Version 3 is more widely usable for the Dutch practice compared to the HCR-20 Version 2. Therefore, the authors of this article recommend the use of the HCR-20 Version 3 for violence risk assessment and guidance of risk management. However, they do note that it is important to follow the guidelines that are provided in the manual. Also, evaluators are advised to use the manual at every risk assessment, even if they are very experienced! They are also advised to frequently consult with colleagues, and to keep up with new research findings and developments. The authors also advise evaluators to attend training before using the tool in clinical practice. They also encourage assessments to be carried out by multiple evaluators from different disciplines.

They also have some suggestions for the implementation of SPJ tools in clinical practice. According to the authors, the most important aspect of a successful implementation of a new risk assessment tool is that before the actual implementation starts, the practical relevance and clinical value of the tool needs to be well investigated and communicated. It is also important to keep the patients informed about the risk assessment procedures, and about the new developments and individual assessment results. This may provide a good opportunity to discuss risk and protective factors, and form shared opinions on treatment goals and trajectories.