Exploring differences in clinical judgments of dangerousness of North Carolina psychiatric inpatients : utility of the HCR-20 risk assessment scheme

The purpose of this study is to assess the efficacy of clinician ratings of dangerousness among psychiatric inpatients by utilizing the structured HCR-20 Risk Assessment Scheme. The study is based on archival records of patients committed to a North Carolina psychiatric hospital due to being found incompetent to proceed to trial, not guilty by reason of insanity, or detained due to exhibiting exceptional dangerous behavior in the community or while hospitalized. The individuals were chosen for the study because they had at least two completed HCR-20 risk assessments of historical, clinical, and risk management factors of dangerousness. Patients (N=52) were assessed with the HCR-20 at one hospital before being referred to the increased security forensic treatment program at Dorothea Dix Hospital (DDH) where they were again assessed for risk of violence at intake. The differences in mean total scores on the HCR-20 were compared. Behavioral data was also gathered for the patients hospitalized for one year (N = 39) for the interim between the DDH risk assessment and one-year post DDH risk assessment. Patients' total number of "physical assaults" (criterion 1) and "verbal threats" (criterion 2) were summed. Individuals were deemed "physically violent" (criterion 3) if at least one physical assault was made and "verbally aggressive" (criterion 4) if at least one verbal threat was made. For each clinician rating, the HCR-20 items and subscale totals were used as predictors of the four criteria over the course of one year. The study lends support to the hypothesis that the referring clinicians' ratings of dangerousness are higher than the ratings by a clinician at DDH. Also, supportive of ongoing research using the HCR-20 was the finding that historical factors best predict future dangerousness. Suggestions are offered to improve the process of risk communication among mental health professionals in North Carolina.