Risk Assessment and Management

Question 1

Receiver Operating Characteristics

Answer 1

Used to express how many good predictions we are making

Use extensive file history to conclude on Yes or No predictions - yes = violent, no = not violent

Follow up later to see what happened, Yes/no

Difficult to know how well we predicted as our risk assessments indicating violence prediction often try to stop from happening - don’t actually know what would have happened

Expressed in a ROC graph - plot hits against false positives

Question 2

Hit

Answer 2

Predicted to be violent = Yes
Was violent = yes

Question 3

False positive

Answer 3

Predicted to be violent = yes
Was violent = no

Question 4

Correct rejection

Answer 4

Predicted to be violent = no
Was violent = no

Question 5

Misses

Answer 5

Predicted to be violent = no
Was violent = yes

Question 6

ROC curve

Answer 6

How much the curve bulges from the centre line is how good we are at making hits - called the AUC

Question 7

AUC

Answer 7

0.50- chance performance – same number as hits and false positives
0.56 - weak
0.65 - moderate
0.71 - strong effect
0.90 - best possible

Question 8

Pros of ROC

Answer 8

Immune to baseline changes
Can compare with very different base rates

Question 9

Cons of ROC

Answer 9

Lose quality of an event - e.g. severity, type of violence

Question 10

Predictive factors for violence

Answer 10

Previous violence
Unemployment
Poor relationships
Victim of abuse
Negative attitudes
Poor temper control

Question 11

Types of risk assessment

Answer 11

Clinical judgement
Actuarial measured
Structured professional judgement

Question 12

Unstructured clinical judgement

Answer 12

Based on impression, intuition and experience
Administered by clinicians
Most widely used
Allows for idiographic analysis - intensive study of one person
Allows clinician bias

Question 13

Unstructured clinical judgement - reliability

Answer 13

Very poor interrater reliability when assessing risk

Poor predictivity

Question 14

Why are they unreliable?

Answer 14

Clinicians are blind to outcomes - if they actually become violent or not
The tendency to weigh bizare or unusual factors more heavily (e.g. grand delusions) rather than the more actually correlative crimiogenic factors
There are too many variables for a clinician to substantially keep track of
We tend to make judgements quickly and later seek support for them

Question 15

Actuarial Assessment

Answer 15

A preordained way of coming to a conclusion
Uses factors thought to be predictive of risk using a pre-ordained method - decide if people show these risks or not to inform of what to do next – can add up to a score or lead to a path
Avoids individual bias only to an extent - still subjective if people fit into risk or not
Quick
Lack in idiographic information - possibly reductionist

Question 16

VRAG - Quinsey et al.

Answer 16

Example of an actuarial assessment
Developed from men who left a Canadian psychiatric unit - released to community, minimum secure units or halfway houses
Measured a range of potential predictors
Highly correlated predictors were used to make 12 items of risk
Scoring 12 items add up to put people into 1 of 9 risk categories

Question 17

VRAG predictive validity / reliability - Snowden et al.

Answer 17

Pseudo-prospective study - only looked at case notes to review VRAP score (when blind to outcomes) and later checked accuracy by using home office records
High predictive accuracy over 1 year, lasted for around 3 years but went down slightly
Rates lower than Canadian sample but still sig.

Question 18

Clinician individual differences

Answer 18

Different levels of competence and experience
Tend to focus on short-term outcomes, rather than long-term
Tend to focus on more obviously dangerous patients - can miss others less apparent (part of weighing bizarre factors more heavily)

Question 19

Harris - AUC of clinician vs. VRAG

Answer 19

Clinicians gave risk rating for patients they knew well and compared with VRAG - prediction of homicides
Clinician AUC - .59
VRAG AUC - .80
– VRAG much better for predicting homicides

Question 20

Why have actuarials not been widely adopted?

Answer 20

May de-individualise the patient
Clinician belief that their status is at-risk
Clinician belief that risk assessment is not a priority of their job but rather treating
Broken leg problem - actuarials do not account for new factors (such as a broken leg) that would greatly reduce ability/chances of violence
Atheoretical - only provides a number of risk but doesn’t actually give us any idiographic information or why the risk is that

Question 20

Why have actuarials not been widely adopted?

Answer 20

May de-individualise the patient
Clinician belief that their status is at-risk
Clinician belief that risk assessment is not a priority of their job but rather treating
Broken leg problem - actuarials do not account for new factors (such as a broken leg) that would greatly reduce ability/chances of violence
Atheoretical - only provides a number of risk but doesn’t actually give us any idiographic information or why the risk is that

Question 21

Structured Clinical Assessment

Answer 21

Combines clinical judgement and actuarial measures
A clinician scores a set of pre-set items and makes a decision of risk based off that score
Avoids bias to an extent - still slightly interpretative
Contains idiographic information
But is time consuming and need clinical skills to interpret

Question 22

HCR-20

Answer 22

10 historical items (derived from VRAG)
5 present clinical items
5 future risk management items

Question 23

HCR-20 efficacy in predicting violence + self-harm

Answer 23

Followed for 3 months
Noted all incidences of violence through nursing and incident reports/forms
– very good as not relying on inconsistent crime stats that miss a lot of unreported crime
Classified violence by type - verbal, physical, property
HCR was highly predictive of violence on all 3 types of violence
– AUC of .79 - .83

Question 24

Prospective studies

Answer 24

Measure from present to future - highly predictive and can confirm/deny our predictions of risk
Can measure confounds and how they change/influence over time
Violence risk is long-term, good as it reflects this

Question 25

Prospective studies

Answer 25

Measure from present to future - highly predictive and can confirm/deny our predictions of risk
Can measure confounds and how they change/influence over time
Violence risk is long-term, good as it reflects this

Question 26

HCR-20 and type of MI

Answer 26

Most effective predictor for learning disabilities and schizophrenia
Least effective predictor for personality disorders - perhaps not very strong against manipulation/malingering?

Question 27

HCR-20 limitations

Answer 27

Hasn’t been tested thoroughly in diverse populations
Doesn’t specify specific forms of violence, e.g. sexual, domestic