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HCR-20 shows poor field validity in clinical forensic psychiatry settings
  1. John Tully
  1. Department of Forensic and Neurodevelopmental Sciences, Institute of Psychiatry, Psychology and Neuroscience, London, UK; john.tully{at}kcl.ac.uk

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ABSTRACT FROM: Jeandarme I, Pouls C, De Laender J, et al. Field validity of the HCR-20 in forensic medium security units in Flanders. Psychology, Crime & Law 2017;23:305–22.

What is already known about this topic

Assessment and prediction of violence risk is central to forensic psychiatry practice. From the 1970s, increasing awareness of the limitations of clinical judgement alone meant services began to employ actuarial risk assessment tools, which were shown to significantly improve predictive accuracy.1 However, these tools soon came under criticism for their own limitations, including focus on relatively static factors that are immutable and lack of applicability to specific real-world scenarios.1 This led to the development of structured professional judgement (SPJ) tools, which have largely replaced purely actuarial tools as the gold standard of risk assessment and management. Such instruments combine actuarial and dynamic components and are thought to be yet practically relevant and encourage use of professional discretion, while having a solid empirical basis.2

The most widely used SPJ tool in forensic psychiatry settings in the UK is the Historical Clinical Risk Management-20 (HCR-20), which is currently in its third version (HCR-20V3).3 Both retrospective and prospective research has suggested that the HCR-20 is predictive of future violence, across a range of settings.3–5 Hence, the HCR-20 has become the first choice instrument for risk assessment of violence in forensic psychiatry practice in the UK. In recent years, however, the basis of this practice has been challenged. Further studies have suggested that SPJ tools, including the HCR-20, lack validity for certain key diagnoses in forensic psychiatry such as schizophrenia6 and psychopathy7 and that the standard method of reporting validity of the HCR-20—area under the curve (AUC)— is flawed if used without other performance measures.6 Other work has suggested that most of its individual factors do not predict …

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