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The Classification of Violence Risk COVR Development & Evaluation Michael Doyle Nurse Consultant & Honorary Research Fellow. Acknowledgements. National Forensic R&D Programme Professor Mairead Dolan Stuart Carter Professor John Monahan Rebecca Rowles Jenny Vo Des Kelly

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The Classification of Violence Risk

COVR

Development & Evaluation

Michael Doyle

Nurse Consultant & Honorary Research Fellow

acknowledgements
Acknowledgements
  • National Forensic R&D Programme
  • Professor Mairead Dolan
  • Stuart Carter
  • Professor John Monahan
  • Rebecca Rowles
  • Jenny Vo
  • Des Kelly
  • Professor Jenny Shaw
aims of presentation
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
background macarthur violence risk assessment study monahan et al 2001
BackgroundMacArthur Violence Risk Assessment Study(Monahan et al. 2001)
  • 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
slide7
Iteration #1

Total sample

n=939; 18.7% violent

Seriousness of Arrest

Property, minor, drugs

n=306; 20.3%

Seriousness of Arrest

Robbery, rape, assault, murder

n=208; 36.1%

Seriousness of Arrest

None

n=425; 9.2%

Father Used Drugs

No

n=255; 16.5%

Father Used Drugs

Yes

n=51; 39.2%

High Risk Group

Motor

Impulsiveness

High

n=66; 21.2%

Recent Violent

Fantasies

No

n=134; 26.9%

Recent Violent

Fantasies

Yes

n=74; 52.7%

Motor

Impulsiveness

Low

n=359; 7.0%

High Risk Group

Classification of Violence Risk

Monahan et al, 2005

slide8
36.5%

26.4%

10.9%

6.7%

19.5%

slide9
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.
classification of violence risk description
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
categorical risk communication
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]
covr research evidence
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”.
slide13
Prospective Validation of COVRMonahan, Steadman, Robbins, Appelbaum, Banks, Grisso, Heilbrun, Mulvey, Roth, and Silver (2005)
concerns
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
covr research evidence15
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
rationale
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
hypotheses
Hypotheses
  • Participants with higher baseline rating on the COVR will be significantly more likely to be violent in the 20 weeks post discharge
procedure 1
Procedure (1)

Baseline assessment

  • Current civil psychiatric inpatients
    • Interview
    • Case note review
    • Liaison with primary nurse
    • Staff rated measures
  • Administer COVR computerized programme
procedure 2
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.
violence definition
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)

sample
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%
summary of preliminary findings
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
future research
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
final thoughts
Final Thoughts
  • …We can never prove how many people we have prevented from being violent..
  • Good judgement comes from experience, and experience comes from bad judgement
  • Tools and scales don’t make decisions...people do!!
references
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.
contact details
Contact Details

Dr Michael Doyle

Nurse Consultant, Professional Lead, Hon Research Fellow

Adult Forensic Mental Health Service

Edenfield Centre

Greater Manchester West NHS Mental Health Trust

Bury New Road

Prestwich

Manchester

England

M25 3BLTel: 0161 772 4611/3879

Email: Mike.Doyle@gmw.nhs.uk

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