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1Mike Doyle, 2008
2Mike Doyle, 2008
The Classification of Violence Risk The Classification of Violence Risk
COVRCOVR
Development & EvaluationDevelopment & Evaluation
Michael DoyleMichael DoyleNurse Consultant & Honorary Research FellowNurse Consultant & Honorary Research Fellow
3Mike Doyle, 2008
Acknowledgements
• National Forensic R&D Programme
• Professor Mairead Dolan
• Stuart Carter
• Professor John Monahan
• Rebecca Rowles
• Jenny Vo
• Des Kelly
• Professor Jenny Shaw
4Mike Doyle, 2008
Aims of presentation
• Describe development of the COVR
• Highlight findings from recent European
studies
• Present findings from study of non-forensic
discharged psychiatric patients in Greater
Manchester, England
• Discuss future research considerations
5Mike Doyle, 2008
• Examined 134 dispositional, historical, clinical, and situational risk factors
• Compared factors assessed while inpatient with community violence
• 939 male and female civil psychiatric patients
• Comparison group of 519• Age 18 - 40 • Time at risk 20 weeks post-discharge
BackgroundMacArthur Violence Risk Assessment Study(Monahan et al. 2001)
6Mike Doyle, 2008
MacVRAS Big Predictors20 weeks post-discharge
Factor Pearsons r correlation coefficient *
Psychopathy (PCL:SV > 12) .26 Prior arrests since age 15 .24 Substance abuse .18 Anger (Novaco anger scale behaviour) .16 Father ever used drugs .16 Father ever been arrested .15 Victim of child abuse .14 Recent violent behaviour .14 Violent fantasies .13 *ALL SIGNIFICANT WHERE p < .001
7Mike Doyle, 2008
Iteration #1
Total sample
n=939; 18.7% violent
Seriousness of ArrestProperty, minor, drugs
n=306; 20.3%
Seriousness of ArrestRobbery, rape, assault, murder
n=208; 36.1%
Motor Impulsiveness
Lown=359; 7.0%
Motor
ImpulsivenessHigh
n=66; 21.2%
Father Used DrugsNo
n=255; 16.5%
Father Used DrugsYes
n=51; 39.2%
Recent ViolentFantasies
Non=134; 26.9%
Recent Violent Fantasies
Yesn=74; 52.7%
Seriousness of ArrestNone
n=425; 9.2%
High Risk Group
High Risk Group
Classification of Violence Risk
Monahan et al, 2005
8Mike Doyle, 2008
Risk Classes
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1
1 2 3 4 5
Classes
P
0
50
100
150
200
250
300
350
400
N
Probability of Violence N 95% Confidence Interval
36.5% 26.4%
19.5%10.9% 6.7%
9Mike Doyle, 2008
Monahan, J., Steadman, H., Appelbaum, P., Grisso, T., Mulvey, E., Roth, L., Robbins, P., Banks, S., & Silver, E. (2005). The classification of violence risk. Lutz, FL: Psychological Assessment Resources.
10Mike Doyle, 2008
Classification of Violence RiskDescription
• Interactive software programme
• Estimate risk of post-discharge violence
• Brief Chart review
• 5-10 minute interview with participant– Self-report option
11Mike Doyle, 2008
Categorical Risk Communication
• Category 1: very low risk – [corresponding to a risk of 1%/1 of 100]
• Category 2: low risk – [corresponding to a risk of 8%/8 of 100]
• Category 3: average risk – [corresponding to a risk of 26%/26 of 100]
• Category 4: high risk – [corresponding to a risk of 56%/56 of 100]
• Category 5: very high risk – [corresponding to a risk of 76%/76 of 100]
12Mike Doyle, 2008
COVR: Research Evidence• Construction study (Monahan et al., 2001; Banks et
al., 2004)– Estimated ten different risk assessment models – Different risk factors were chosen to be the lead variable upon
which a classification tree was constructed– Five risk groups - likelihood of violence to others ranged from 1% to
76%.
• Validation study (Monahan et al., 2005;2006)– Low Risk = 9% v High-Risk = 49%– Shrinkage in predictive power– “..validated only on samples of psychiatric inpatients in acute
facilities in the United States who would soon be discharged into the community”.
13Mike Doyle, 2008
Prospective Validation of COVRMonahan, Steadman, Robbins, Appelbaum, Banks, Grisso, Heilbrun, Mulvey, Roth, and Silver (2005)
1
9.0
64
49.0
0
10
20
30
40
50
60
70
% V
iole
nt
Low Risk High Risk
Predicted Observed
14Mike Doyle, 2008
Concerns
• McCusker, 2007– Clinical use questionable– ‘Shrinkage’ in predictive power as
construction study fit the data too specifically
– Unreliable responses in clinical setting– Environmental influences– Further validation required
15Mike Doyle, 2008
COVR: Research Evidence• Doyle et al. 2007
– COVR strong correlation with Historical, Dispositional & Clinical factors previously found to be correlated with violence risk.
– Good concurrent validity compared with established violence risk measures e.g. HCR-20, VRAG
• Snowden and Gray, 2008– 52 inpatients in 4 medium secure units in Wales over 6 months– COVR good predictor of verbal and physical aggression
• Lindqvist and Sturup, 2008– 352 civil psychiatric patients discharged into community– Only 3% high or very high risk– 5% committed violent act; base rate much lower than USA and
UK– Uncertain benefits of COVR in Swedish population
16Mike Doyle, 2008
Preliminary Evaluation in a UK SamplePreliminary Evaluation in a UK Sample
17Mike Doyle, 2008
Rationale
• Evidence supports structured professional judgement approach that combines static & dynamic factors (e.g. Doyle and Dolan, 2006)
• COVR untested in UK population
• Need for efficient decision support tool for use in clinical practice
18Mike Doyle, 2008
Hypotheses
• Participants with higher baseline rating on the COVR will be significantly more likely to be violent in the 20 weeks post discharge
19Mike Doyle, 2008
Procedure (1)
Baseline assessment
• Current civil psychiatric inpatients
– Interview
– Case note review
– Liaison with primary nurse
– Staff rated measures
• Administer COVR computerized programme
20Mike Doyle, 2008
Procedure (2)Follow-up assessment
• Violent behaviour in the community measured 20 weeks
post discharge.
• Interview with the participants, record review and
speaking to someone who knows the person well (e.g.
friend, relative, carer).
• Baseline measure then compared with violence in the
community post-discharge.
21Mike Doyle, 2008
Violence Definition
“ . . any acts that include battery that resulted in physical injury; sexual assaults; assaultative acts that involved the use of a weapon; or threats made with a weapon in hand.”
(Monahan et al, 2001)
22Mike Doyle, 2008
Sample
• Sample size: 93• Age: Mean – 40 years (Range - 18-60)• White Caucasian 92.5% (n = 86)• Male 58% (54) Female 42% (39)• Mean length of Stay: 36.2 days Med = 19 days• Involuntarily detained: 36.6% (34)• Previous Serious Violence: 20.4%• Definite/Serious Substance Use Problems
31.2%
23Mike Doyle, 2008
Primary Chart Diagnosis
29.1
19.4
25.8
5.4
10.8 9.5
0
5
10
15
20
25
30
35
Schizo
phrenia
Man
ia/ B
ipola
r
Depre
ssio
n PD
Substan
ce U
se
Other
Diagnosis
%
24Mike Doyle, 2008
Representativeness of Sample
29.119.4
4058
92.5
53.5
89.8
37.7
8.2
39.4
0
20
40
60
80
100
Schizo
phrenia
Man
ia/ B
ipola
r Age
Mal
e
White
Cau
casi
an
Diagnosis
% Sample
Norm
25Mike Doyle, 2008
COVR Risk Category50.5
32.3
4.3 1.1
11.8
0
10
20
30
40
50
60
Very
Low Ris
k
Low Ris
k
Avera
ge Ris
k
High R
isk
Very
High R
isk
Risk Category
%
26Mike Doyle, 2008
COVR Risk CategoryComparison with MacVRAS
50.5
32.3
4.31.1
19.5
10.96.7
11.8
36.5
26.4
0102030405060
Risk Category
%
Sample
MacVRAS
27Mike Doyle, 2008
Prevalence of Violence
30.8 (12)
18.5 (n=10)
23.7 (22)
0
5
10
15
20
25
30
35
Mal
e
Femal
e All
% 20 Weeks
28Mike Doyle, 2008
Frequency of Violence 40 incidents
1.9 1
15
25
5
0
5
10
15
20
25
30
Mea
n
Med
ian
Max
Mal
e
Femal
e
% 20 weeks
29Mike Doyle, 2008
COVR Risk CategoryViolence 20 Weeks
50.5
32.3
4.3 1.1
54.5
11.8
0 0
23.319.1
0102030405060
Very
Low Ris
k
Low Ris
k
Avera
ge Ris
k
High R
isk
Very
High R
isk
Risk Category
%Category
Violence
30Mike Doyle, 2008
MacVRAS Category & Violence at 20-weeks
36.526.4 26
56
76
6.710.919.5
18
01020304050607080
Very
Low Ris
k
Low Ris
k
Avera
ge Ris
k
High R
isk
Very
High R
isk
Risk Category
%
MacVRAS
Violence
31Mike Doyle, 2008
COVR Risk Category
Violence 20 Weeks x2 = 6.024, df, 2, p = 0.049*
50.5
32.3
54.5
11.8
23.319.1
0
10
2030
40
50
60
Risk Category
%Category
Violence
32Mike Doyle, 2008
Summary of Preliminary Findings
Insufficient sample size Lower risk scores compared to MacVRAS
Different sample characteristics e.g. nationality, age, diagnosis, length of stay
Self-report with no adjustment High-Very High risk participants identified and
managed
Predictive accuracy not replicated although trend
Women more likely to be violent in 20 weeks post-discharge
33Mike Doyle, 2008
Future Research
• Repeat with larger sample• Concurrent ‘clinical’ rating by 1 or more raters• ? Link with structured professional judgement• Examine integration in clinical practice• Investigate the relative contribution of COVR &
established tools in predicting violence • Examination of the validity of the tools based
on • (i) gender • (ii) treatment, support and supervision available
• Trial in forensic population
34Mike Doyle, 2008
“…there is an obvious conclusion, but we’re not
allowed to jump to it!”
Webster, 2008
35Mike Doyle, 2008C/O Coronation Street
36Mike Doyle, 2008
Final Thoughts
• ……We can never prove how many people We can never prove how many people we have prevented from being violent..we have prevented from being violent..
• Good judgement comes from experience, Good judgement comes from experience, and experience comes from bad and experience comes from bad judgementjudgement
• Tools and scales don’t make Tools and scales don’t make decisions...people do!!decisions...people do!!
37Mike Doyle, 2008
References• Banks, S., Robbins, P. C., Silver, E., Vesselinov, R., Steadman, H. J.,
Monahan, J., et al. (2004). A multiple-models approach to violence risk assessment among people with mental disorder. Criminal Justice and Behavior, 31, 324–340.
• McCusker, P. J. (2007) Issues regarding the Clinical Use of the COVR Assessment Instrument. International Journal of Offender Therapy & Comparative Criminology. Doi:10.1177/0306624x07299227
• Monahan, J., Steadman, H., Appelbaum, P., Grisso, T., Mulvey, E., Roth, L., Robbins, P., Banks, S., & Silver, E. (2005). The classification of violence risk. Lutz, FL: Psychological Assessment Resources.
• Monahan, J, Steadman, H., Robbins, P., Appelbaum, P., Banks, S., Grisso, T., Heilbrun, K., Mulvey, E., Roth, L., & Silver, E. (2005b). An actuarial model of violence risk assessment for persons with mental disorders. Psychiatric Services, 56, 810–815.
• Monahan, J., Steadman, H. J., Silver, E., Appelbaum, P. S., Robbins, P. C., Mulvey, E. P., et al. (2001). Rethinking risk assessment: The MacArthur study of mental disorder and violence. New York: Oxford University Press.
38Mike Doyle, 2008
Contact DetailsDr Michael DoyleNurse Consultant, Professional Lead, Hon Research
FellowAdult Forensic Mental Health ServiceEdenfield CentreGreater Manchester West NHS Mental Health TrustBury New RoadPrestwichManchesterEnglandM25 3BL Tel: 0161 772 4611/3879
Email: [email protected]
