Historical, Clinical, Risk Management-20
The Historical, Clinical, Risk Management-20 (HCR-20) is an assessment tool that helps mental health professionals estimate a person's probability of violence.
The HCR-20's results help mental health professionals determine best treatment and management strategies for potentially violent, mentally disordered individuals, including parolees, forensic mental health patients, and others. For example, if an individual is standing trial for a violent offense, a judge might order that assessments (such as the HCR-20, as well as others) be performed. The results of the evaluation could be used to determine the person's future potential for violence, how the court should proceed, and which kind of facility the person might require.
A professional trained in conducting individual assessments and in the study of violence should administer the HCR-20. The test administrator should have a background in using assessment tests or should consult a mental health professional. The HCR-20 is not intended to be a stand-alone measure, and it does not cover all risk factors. When possible, the test administrator should use supplemental test measures and investigate any unique patterns of violence and its triggers in the person's history. The HCR-20 is not meant to be administered just once; the nature of risk assessment requires ongoing reassessment as circumstances change. Final interpretation of HCR-20 results should be in the context of several factors, including the reason for the person's test referral, base rates of violence in populations with similar characteristics, and assessment of future risks in the person's environment.
The HCR-20 is an assessment tool. It consists of a list of 20 probing questions about the person being evaluated for violence. The clinician gathers qualitative information about the person being assessed, guided by the HCR-20, and the results are used to make treatment decisions.
The HCR-20 provides significantly improved valid predictions over previous testing methods. Earlier testing methods tended to be more subjective, less well-focused, and based on the loosely supported judgment of test administrators, or on comparing characteristics of the person being tested with base rates of violent behavior in populations with similar characteristics. The HCR-20 extends the methods of earlier tests and supplements them with a review of dynamic variables, such as stress and lack of personal support— both factors important to the person's future adjustment. This review adds to the accuracy of the HCR-20, and increases its practicality.
The HCR-20 consists of three main areas: historical, clinical, and risk management. The HCR-20 domains are coded with a rating of 0 (not present), 1 (possible/less serious), or 3 (definite/serious).
To rate historical areas, the test administrator must do an exhaustive review of background documents, interview people who know the person being assessed, and complete the Hare Psychopathy Checklist , a useful instrument in its own right. The historical area is considered by many to anchor the instrument. It includes 10 domains:
- previous violence
- young age at first violent incident
- relationship instability
- employment problems
- substance use problems
- major mental illness, such as schizophrenia or bipolar disorder
- psychopathy, which can be defined as personality traits that deviate from social norms, such as manipulating and exploiting others for personal gain
- early maladjustment, or exposure to family and social disruptions during childhood that lead to coping problems (could be abuse or divorce, for example)
- personality disorder, such as paranoia
- failure to respond to clinical supervision or treatment in the past—may be related to noncompliance to treatment, such as refusing to take medications or attend therapy sessions
The rating of the clinical area requires a clinical interview between the person being assessed and the mental health professional. The professional will also use his or her judgment, as well. The clinical area consists of five domains:
- Lack of insight, or difficulty understanding cause and effect. For example, people with poor insight might not understand why they do what they do and why their actions matter.
- Negative attitudes.
- Active symptoms of major mental illness.
- Unresponsiveness to treatment.
The third area, risk management, includes five domains:
- the person's plans lack feasibility
- exposure to destabilizers, which means that family or social supports are missing, or that alcohol and drugs are available
- lack of personal support
- refusal to attend counseling sessions or take medications
The HCR-20 does not allow for a definite prediction of violence. Predictions based on the HCR-20 are estimates of the likelihood of violence, and should be presented in terms of low, moderate, or high probability of violence. Probability levels should be considered conditional, given short- and long-term time frames, and should be considered in relation to relevant factors the individual may encounter. These factors include situations and states of being that may dispose a person to violence or help insulate them against it. Consideration of such factors can aid in reporting the type and extent of risk presented by a person and in selecting intervention strategies intended to reduce the probability that an individual will demonstrate violence. These strategies when taken as a whole are called a risk management plan.
Ultimately, HCR-20 results are intended to provide information for decision-makers, so that criminal and mental health-related decisions can be based on the best available estimates of risk of violence.
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Geoffrey G. Grimm, Ph.D., LPC