Behavioral Sciences and the Law

Behav. Sci. Law 32: 557–576 (2014)

Published online 2 October 2014 in Wiley Online Library
(wileyonlinelibrary.com) DOI: 10.1002/bsl.2134

Version 3 of the Historical-Clinical-Risk

Management-20 (HCR-20V3): Relevance to
Violence Risk Assessment and Management in
Forensic Conditional Release Contexts
Kevin S. Douglas, LL.B., Ph.D.*

The conditional release of insanity acquittees requires decisions both about community
risk level and the contextual factors that may mitigate or aggravate risk. This article
discusses the potential role of the newly revised Historical-Clinical-Risk Management-20
(HCR-20, Version 3) within the conditional release context. A brief review of the structured
professional judgment (SPJ) approach to violence risk assessment and management is pro-
vided. Version 2 of the HCR-20, which has been broadly adopted and evaluated, is briefly
described. New features of Version 3 of the HCR-20 with particular relevance to condi-
tional release decision-making are reviewed, including: item indicators; ratings of the rel-
evance of risk factors to an individual’s violence; risk formulation; scenario planning; and
risk management planning. Version 3 of the HCR-20 includes a number of features that
should assist evaluators and decision-makers to determine risk level, as well as to antici-
pate and specify community conditions and contexts that may mitigate or aggravate risk. Re-
search on the HCR-20 Version 3 using approximately 800 participants across three settings
(forensic psychiatric, civil psychiatric, correctional) and eight countries is reviewed.
Copyright # 2014 John Wiley & Sons, Ltd.

The insanity defense exists in most legal systems that are derived from the English common
law system. Essentially, and formally starting with the English case of M’Naghten (1843),
Western common law jurisprudence has determined that it is unacceptable to convict and
punish a person who, due to mental disease or defect, is incapable of appreciating the nature
and quality of his or her actions, or that they were wrong (Melton, Petrila, Poythress, &
Slobogin, 2007; see Chapter 8, pp. 205–209). Although there are iterations on this theme
across time and jurisdictions, this basic premise has held since the mid-1800s.
A major question arises, then, once a person has been found not guilty by reason of
insanity (NGRI), as it is often called in the United States, or not criminally responsible
on account of mental disorder (NCRMD), as it is called in Canada. Most states, and
Canada, follow the least restrictive alternative doctrine (Melton et al., 2007; see p. 340)
in requiring that insanity acquittees should be subjected to the least restrictive placement
option possible, so long as they do not pose an undue risk to society. Most people found to
be NGRI or NCRMD start their supervision in a secure forensic hospital, but must be
discharged absolutely or conditionally if the state cannot demonstrate that hospitalization
is required to keep the public safe. As such, if a person can live in the community, with
conditions, and not pose an undue risk to others, then she or he must be allowed to do so.

*Correspondence to: Kevin S. Douglas, LL.B., Ph.D., Department of Psychology, Simon Fraser University,
8888 University Drive, Burnaby, BC, Canada, V5A 1S6. E-mail: douglask@sfu.ca

Copyright # 2014 John Wiley & Sons, Ltd.

558 K. S. Douglas

As such, there are several fundamental questions facing decision-makers. What level
of risk does an insanity acquittee pose if released to the community? Can a person be
released to the community under certain conditions, and not pose an undue risk? If
so, what exactly are those conditions, and will the person be compliant with them?
These questions are at the heart of violence risk assessment and management. Under
criminal responsibility law, it is necessary for risk evaluators and decision-making
authorities to have a clear understanding of the potential ways in which various com-
munity placement options and contexts might, or might not, affect a person’s risk.
These are inherently forward-looking questions. Not only must risk be estimated from
what is already known about a person (i.e., past violence, presence of violent ideation),
but decisions must be made that take into account how a person will fare in the com-
munity under a specified set of conditions (i.e., treatment, supervision), and whether
this combination does, or does not, present an undue risk to public safety.
In this article, the potential utility of the newly revised third version of the Historical-
Clinical-Risk Management-20, Version 3 (HCR-20V3; Douglas, Hart, Webster &
Belfrage, 2013) for conditional release decisions will be discussed. The HCR-20V3
and its predecessors (HCR-20 Version 1, Webster, Eaves, Douglas, & Wintrup,
1995; HCR-20 Version 2, Webster, Douglas, Eaves, & Hart, 1997) were all developed
to assist evaluators and decision-makers within conditional release and other settings
(i.e., correctional; civil psychiatric) to answer the types of questions posed here.
The HCR-20V3 is an example of the structured professional judgment (SPJ) approach
to violence risk assessment and management. Along with its predecessors, it contains 20
risk factors dispersed across three scales (see Tables 1 and 2). The historical (H) scale has
10 risk factors that focus primarily on past behaviors, features of mental disorder, and life
challenges that have been demonstrated in the literature to elevate the risk for violence.
The clinical (C) scale contains five risk factors dealing with the recent past (up to 12
months) that focus primarily on an evaluee’s emotional, cognitive, and behavioral func-
tioning, as well as compliance with and responsivity to intervention and risk reduction
strategies. Finally, the risk management (R) scale pertains to functioning in the future
(up to the next 12 months). The R scale can be rated for continued living within an
institution (i.e., prison, hospital), for community discharge planning, or for continuing
community supervision.

Table 1. Historical-Clinical-Risk Management-20 (HCR-20) Version 2 risk factors

Historical Clinical Risk management

H1. Previous violence C1. Lack of insight R1. Plans lack feasibility
H2. Young age at first violent C2. Negative attitudes R2. Exposure to destabilizers
incident
H3. Relationship instability C3. Active symptoms of major R3. Lack of personal support
mental illness
H4. Employment problems C4. Impulsivity R4. Noncompliance with remediation
attempts
H5. Substance use problems C5. Unresponsive to treatment R5. Stress
H6. Major mental illness
H7. Psychopathy
H8. Early maladjustment
H9. Personality disorder
H10. Prior supervision failure

Note. Reprinted with permission of the Mental Health, Law, and Policy Institute, Simon Fraser University.

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Table 2. Historical-Clinical-Risk Management-20 (HCR-20) Version 3 risk factors

Historical scale (History of problems with…)

H1. Violence
a. As a child (12 and under)
b. As an adolescent (13–17)
c. As an adult (18 and over)
H2. Other antisocial behavior
a. As a child (12 and under)
b. As an adolescent (13–17)
c. As an adult (18 and over)
H3. Relationships
a. Intimate
b. Non-intimate
H4. Employment
H5. Substance use
H6. Major mental disorder
a. Psychotic disorder
b. Major mood disorder
c. Other major mental disorders
H7. Personality disorder
a. Antisocial, psychopathic, and dissocial
b. Other personality disorders
H8. Traumatic experiences
a. Victimization/trauma
b. Adverse child-rearing experiences
H9. Violent attitudes
H10. Treatment or supervision response

Clinical Scale (Recent problems with…)

C1. Insight
a. Mental disorder
b. Violence risk
c. Need for treatment
C2. Violent ideation or intent
C3. Symptoms of major mental disorder
a. Psychotic disorder
b. Major mood disorder
c. Other major mental disorders
C4. Instability
a. Affective
b. Behavioral
c. Cognitive
C5. Treatment or supervision response
a. Compliance
b. Responsiveness

Risk management scale (Future problems with…)

R1. Professional services and plans
R2. Living situation
R3. Personal support
R4. Treatment or supervision response
a. Compliance
b. Responsiveness
R5. Stress or coping

Note. Reprinted with permission of the Mental Health, Law, and Policy Institute, Simon Fraser University

The remainder of this article will begin with a brief review of SPJ principles. Version
2 of the HCR-20, and its evaluation and use within conditional release settings, will be
briefly reviewed. Then, version 3 of the HCR-20 will be described, including changes

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560 K. S. Douglas

between versions 2 and 3, but focusing on those aspects of version 3 that may be most
relevant to common conditional release questions. A review of initial published research
on HCR-20V3 will then be presented, prior to concluding.

STRUCTURED PROFESSIONAL JUDGMENT APPROACH

TO VIOLENCE RISK ASSESSMENT

The SPJ approach to violence risk assessment and management has been described in
detail in numerous previous publications and will not be covered in depth here (for
reviews, see Douglas, in press; Douglas, Hart, Groscup, & Litwack, 2014; Guy, Hart &
Douglas, in press; Heilbrun, Yasuhara, & Shah, 2010). It differs from the unstructured
clinical approach, in which there are essentially no rules for risk assessment. It also differs
from actuarial approaches, which typically apply algorithms or equations to provide
numeric estimates of future risk, and which tend not to emphasize risk management.
Instruments developed under the SPJ approach select risk factors based on their
broad support in the scientific and professional literatures, so as to promote compre-
hensiveness of content coverage. Risk factors (typically 20–30) are usually rated using
a three-level system (not present; possibly or partially present; definitely present), and
evaluators are encouraged to determine which of the risk factors that are rated as pres-
ent are most important or relevant in a given case. SPJ instruments use a categorical,
narrative approach to risk assessment, in which evaluators decide whether a person is
low, moderate, or high risk, based on the number of risk factors that are present and
relevant, and the anticipated degree of intervention required to mitigate risk. Ulti-
mately, SPJ approaches structure the entire assessment system, from gathering infor-
mation, making risk factor ratings, determining why a person has acted violently in
the past, specifying the conditions under which violence might occur in the future,
and guiding the selection and implementation of risk management plans that will mit-
igate risk.
Meta-analytic studies of the violence risk assessment field have been reviewed in de-
tail elsewhere (Douglas, Hart, et al., 2014; Guy et al., in press). The basic findings are
that SPJ and actuarial measures tend to produce approximately comparable effect sizes
vis-à-vis violence, and both are more accurate than unstructured clinical judgment
(Campbell, French, & Gendreau, 2009; Guy, 2008; Hanson & Morton-Bourgon,
2009; Olver, Stockdale, & Wormith, 2009; Singh, Grann, & Fazel, 2011; Viljoen,
Mordell, & Beneteau, 2012; Yang, Wong, & Coid, 2010). Some meta-analyses have
shown that the summary risk ratings used by the SPJ model are as accurate as, or more
accurate than, the use of such instruments numerically, or the use of actuarial instru-
ments (Guy, 2008; Singh et al., 2011). Other meta-analyses have shown that instru-
ments designed to assess risk for more specific outcomes – such as violence – have
fared better than those designed to assess risk for more general outcomes, such as
any recidivism (Fazel, Singh, Doll, & Grann, 2012; Singh et al., 2011). Meta-analyses
have tended not to find differences in effect sizes as a function of setting (i.e., inpatient
violence vs. community recidivism) or legal context (i.e., forensic psychiatric vs. cor-
rectional vs. civil psychiatric).
As such, based on meta-analytic studies, whether an evaluator uses one approach
or the other will have more to do with their intended purposes and perceived benefits

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(i.e., clinical utility; relevance to management). However, there is a line of research – as

yet not well captured by published meta-analytic studies – focusing on the use of
summary risk ratings within SPJ instruments. A number of studies have compared
summary risk ratings of low, moderate, and high risk to the total or subscale numeric
scores that can be derived from these measures. A number of these studies also com-
pare summary risk ratings to actuarial instruments, or to the Psychopathy Checklist
family of measures (Hare, 2003; Hart, Cox, & Hare, 1995).
Douglas, Hart, et al. (2014) reported that 30 out of 34 published studies that have
investigated summary risk ratings have found support for them. In 15 out of 17 studies,
summary risk ratings added incremental predictive validity vis-à-vis the numeric use of
SPJ instruments, actuarial instruments, or psychopathy instruments. These findings
have been observed in numerous settings, including conditional release. Two meta-
analyses touch on this issue as well. Guy (2008) reported that SPJ summary risk ratings
and actuarial instruments had similar effect sizes (AUCs = 0.69 and 0.67, respec-
tively).1 Singh and colleagues (2011) included 27 SPJ studies in their meta-analysis,
22 of which included categorical risk estimates based on summary risk ratings. These
SPJ ratings were as accurate as actuarial estimates, and indeed the largest effect size
was for an SPJ instrument, the Structured Assessment of Violence Risk in Youth
(SAVRY; Borum, Bartel, & Forth, 2006).
The essential point is that there is support for an SPJ approach to violence risk
assessment. Of the SPJ instruments available, the HCR-20 Version 2 has been most fre-
quently evaluated and adopted within conditional release and other settings. We briefly
review this instrument and its literature base next.

HCR-20 VERSION 2

HCR-20 Version 1 was published early in 1995 (Webster et al., 1995), and, along with
the Spousal Assault Risk Assessment Guide (SARA; Kropp, Hart, Webster, & Eaves,
1994), which was published in late 1994, was one of the first SPJ instruments. Version
2 was published just two years later, after initial feedback on Version 1. As shown in
Table 1, Version 2 contains 20 risk factors distributed across three scales intending
to capture past, present, and future functioning and context. Consistent with the SPJ
approach, risk factors are weighted equally (each rated 0, 1, or 2), reflecting the “robust
beauty of improper linear models” (Dawes, 1979, p. 571). That is, variables with unit
(“improper”) weighting perform just as well as variables with cross-validated sample-
derived statistical weights. As described earlier and in more detail in the following
section, HCR-20 risk factors are “weighted” by evaluators depending on their in any
given case. There is not a presumption that all risk factors are equally important for
all people.

1
An AUC is the “area under the curve” of a receiver operating characteristic (ROC) analysis. It is derived
from plotting sensitivity against 1 – specificity for all possible cut-points on a given instrument. It is used with
dichotomous outcomes, and gives an overall index of predictive strength across the entire range of scores on
an instrument. AUCs can range from 0 to 1, with 0 being perfect negative prediction, and 1 being perfect pos-
itive prediction. An AUC of 0.50 is equivalent to chance prediction, or a Pearson r or Cohen’s d of 0. Using
transformational formulae found in Dunlap (1999) and Rice and Harris (2005), AUC values ranging from
0.70 to 0.75 would be comparable to Cohen’s d values ranging approximately from 0.74 to 0.95 (or, of mod-
erate to large magnitude).

Copyright # 2014 John Wiley & Sons, Ltd. Behav. Sci. Law 32: 557–576 (2014)
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The HCR-20 Version 2 contains detailed instructions on how to rate risk factors,
and a modest amount of instruction on how to come to summary risk ratings of low,
moderate, or high risk. In addition, the manual includes guidance on assessment prac-
tices likely to produce good quality assessments. Shortly after Version 2 was published,
an edited companion guide was published that focused on risk management (Douglas
et al., 2001).
Version 2 of the HCR-20 has been adopted broadly within forensic contexts to assist
with release decision-making. Based on a survey of 2,135 clinicians from 44 countries,
Singh (2013) reported that the HCR-20 Version 2 was the most commonly used vio-
lence risk assessment instrument for both conducting risk assessments and for develop-
ing and monitoring risk management plans. Although precise numbers are not
available, it is commonly used within US forensic systems for conditional release plan-
ning, as well as for institutional risk assessment and management.
Much of the HCR-20 research has been conducted in forensic/conditional release
contexts. As of January 2014, there were 178 entries in the HCR-20 annotated bibliog-
raphy under “forensic settings” for Versions 1 and 2, about 90% of which are based on
Version 2 (Douglas, Shaffer, et al., 2014). Given meta-analytic findings reported
earlier, that legal context does not moderate the predictive validity of the HCR-20, in
conjunction with the fact that a high proportion of all HCR-20 studies have taken place
in forensic contexts, the meta-analytic findings reviewed earlier should be applicable to
the use of the HCR-20 for conditional release decision-making.
Some meta-analytic studies have been able to draw conclusions about specific
instruments, including the HCR-20. Some of these have reported that the HCR-20 and
other instruments do not differ significantly in terms of predictive validity (Campbell
et al., 2009; Guy, 2008). Others, as reviewed earlier, have reported that instruments
focusing on specific outcomes such as violence (i.e., HCR-20; VRAG; SARA; SAVRY),
whether in SPJ or actuarial format, performed better than instruments designed to assess
risk for general recidivism (i.e., Level of Service instruments; see Andrews, 2012) (Fazel
et al., 2012; Singh et al., 2011). In Guy’s (2008) meta-analysis, AUC values for HCR-20
using violence as the outcome were 0.76 (summary risk ratings), 0.73 (total scale),
0.70 (H scale), 0.69 (C scale), and 0.71 (R scale).
Yang and colleagues (2010) compared several instruments against the Psychopathy
Checklist – Revised (PCL-R; Hare, 2003) as a benchmark, asking whether any instru-
ments could improve upon the PCL-R. Of those tested, only the HCR-20 (based on 16
samples) and the Offender Group Reconviction Scale (OGRS; Copas & Marshall,
1998), based on two samples, added significantly to the PCL-R. Guy, Douglas, and
Hendry (2010) conducted a focused meta-analysis that compared the HCR-20 and
PCL-R (and its screening version, the PCL: Screening Version, or PCL:SV; Hart
et al., 1995) specifically in all studies in which the two were both included. Although
bivariate effect sizes were the same for both instruments (AUCs = 0.69), in meta-
analytic multivariate logistic regression analyses, with the psychopathy item removed
from the HCR-20, the HCR-20 added incrementally to the PCL-R/SV, whereas the
converse was not true. With both instruments included in the model, the odds ratio
for the HCR-20 was 1.23 (23% increase in violence for every one step increase on
the HCR-20) and for the PCL-R/SV it was 0.99 (1% decrease in violence for every step
increase on the PCL-R/SV).
O’Shea, Mitchell, Picchioni, and Dickens (2013) conducted a meta-analysis of 20
HCR-20 studies, focusing on inpatient violence within psychiatric samples. Using

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Cohen’s d as effect sizes, they compared the summary risk ratings and scale scores for a
variety of types of outcome (any violence, physical violence, verbal violence, and “vio-
lence” against objects). They reported that mean weighted d values were consistently
larger for the summary risk ratings, C and R scales compared with the H scale. Most
effect sizes for the summary risk ratings, C and R scales were in the moderate to large
range (d-values of 0.42–1.17), with the majority above 0.70. Effect sizes for the H scale
were smaller (0.30–0.42), suggesting that for inpatient violence, summary risk ratings
and dynamic risk factors might be more predictive than historical factors. In a small-
scale quantitative summary of forensic psychiatric inpatient violence (4–6 effect sizes),
Hogan and Ennis (2010) reported that the HCR-20 total score and C scale score had
higher average correlations with violence (r-values of 0.33 and 0.35, respectively) than
did the H scale (0.19) or the PCL measures (0.21–0.26). These findings are consistent
with those of O’Shea et al. (2013).
A good deal of the research alluded to earlier regarding the performance of summary
risk ratings has been conducted with the HCR-20, and tends to show incremental va-
lidity of these indices. For example, de Vogel and de Ruiter (2006) reported in a sample
of 127 Dutch male forensic patients followed prospectively after release that adding the
summary risk ratings on the second block of a Cox regression analysis added signifi-
cantly to the HCR-20 subscales. Douglas, Ogloff, and Hart (2003) reported a similar
finding in a Canadian sample of discharged forensic patients. Once the three HCR-20
scales and the summary risk ratings were in the logistic regression model, only the sum-
mary risk ratings remained significant. For a review of other such studies, both for the
HCR-20 and other SPJ instruments, see Douglas, Hart, et al. (2014).
Several studies have investigated whether changes in the C and R items – which are
intended to be dynamic – predict changes in violence. Early research showed generally
that scores on the C and R items decrease over the course of forensic or civil psychiatric
treatment (Belfrage & Douglas, 2002; Douglas & Belfrage, 2001). In a sample of 248
patients with schizophrenia (98 civil psychiatric and 150 forensic psychiatric patients),
Michel and colleagues (2013) reported that changes in most C and R items over two
years (measured four times) were predictive of subsequent changes in violence. That
is, when these items worsened, violence was more likely to occur, and vice versa.
Blanchard and Douglas (2014) reported similar findings at the scale level in a sample
of civil psychiatric patients and correctional offenders. Douglas, Strand, and Belfrage
(2011) reported that changes in the C scale over six months of forensic treatment were
associated with corresponding changes in violence in the following six months. In a sam-
ple of 108 Dutch forensic patients, reductions on the C and R items during hospital
treatment were predictive of lower violent recidivism in the community after discharge,
controlling for baseline age and H scale scores (de Vries Robbé, de Vogel, Douglas, &
Nijman, 2014). This study also showed support for changes (increases) in protective
factors (measured with the Structured Assessment of Protective Factors, or SAPROF;
de Vogel, de Ruiter, Bouman, & de Vries Robbé, 2012), and the combination of re-
duced risk and increased protection, being predictive of lower violent recidivism post-
discharge.
In summary, the HCR-20 Version 2 has been broadly applied within conditional re-
lease and other contexts, and research indicates that it performs at least as well as other
approaches in terms of predictive validity. Its summary risk ratings of low, moderate,
and high risk tend to add incrementally to actuarial and numeric estimates of risk,
and it adds incrementally to the PCL family of instruments. There is also evidence that

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its clinical and risk management scales are susceptible to change, and that such change
is related to subsequent change in violence. Nonetheless, the authors of the HCR-20
Version 2 determined that it was in need of revision, and its revision was published
in 2013 (Douglas, Hart, Webster, & Belfrage, 2013). The remainder of this article will
focus on the reasons for this revision; changes between Versions 2 and 3; the main el-
ements of Version 3; the elements of Version 3 of particular potential relevance to the
conditional release context; and initial empirical evaluation of Version 3.

HCR-20 VERSION 3 AND ITS RELEVANCE TO CONDITIONAL

RELEASE
Version 3 of the HCR-20 was developed to enhance decision-making about individ-
uals, while remaining rooted in a solid empirical foundation. There was an attempt
to achieve continuity of concept between Versions 2 and 3, so that core principles were
preserved, and hence perhaps some of the strengths of Version 2 would be maintained.
For instance, it retains its focus on past, present, and future domains through its three
scales (historical, clinical, and risk management). The system for rating items is highly
similar (no, possible or partial, or yes, as compared with 0, 1, or 2). A summary risk
rating of low, moderate, or high is still required, although additional options have been
added (risk for serious physical violence; risk for imminent violence).
The HCR-20 has always been intended to foster decision-making about release, be it
from forensic, civil or correctional settings (see Douglas & Webster, 1999, for an early
review). Additionally, it was also intended to assist decision-making for institutional
violence, although that is not the focus of the present article or special issue. One of
the shortcomings of Version 2 of the HCR-20 was the sparse attention paid to how to
approach release decisions. When Versions 1 and 2 of the HCR-20 were developed,
in the mid-1990s, much of the focus in the risk assessment field broadly was on
selecting the “right” risk factors. Much less attention was devoted to what to do with
these risk factors, once identified.
In the intervening 15–20 years, the conceptual literature on violence risk assessment
has accrued at an increasing rate. Concepts such as dynamic risk, risk management,
risk formulation, and scenario planning are much more at the forefront of thought than
heretofore. It is these concepts that may provide enhanced assistance to decision-makers
as they contemplate who ought to be released, and under what conditions. It is also these
concepts that are now embodied by the HCR-20V3. In the next section, a brief overview
of the changes between Versions 2 and 3 is presented. Following that, a more thorough
discussion of the new elements of Version 3 that may be of particular relevance for
conditional release will be offered.

Summary of Changes between Versions 2 and 3 of the HCR-20

Although an attempt was made to preserve core aspects of the HCR-20 in its revision,
changes were made in several areas. A comparison of Tables 1 and 2 indicates that
several items were changed in terms of their scope, and a small number were either
dropped or added. For most items, there were at least small modifications to definitions.
For a smaller number of items, substantive modifications were made. For instance, H3

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now includes a focus on non-intimate relationships in addition to intimate relationships,

whereas it previously only captured problems in intimate relationships. H8 was
narrowed in one respect, excluding content related to antisocial behavior as a child or
adolescent because this content is now captured on H1 and H2 in Version 3. It was
broadened in another respect by including trauma across the lifespan, whereas previ-
ously trauma was only captured if it occurred during childhood or adolescence. C2
was narrowed to focus solely on violent ideation or intent, whereas it previously in-
cluded much broader concepts such as pessimism or negative attitudes about treatment.
Certain items were either dropped or added. For instance, H9 from Version 2 was
dropped because, under Version 3, H7 contains both psychopathy and personality
disorders contained within official nomological systems. In addition, for H7, evaluators
are no longer required to use a PCL measure, but can still do so if they choose. H2 was
dropped as a standalone item because young age at first violent act is captured entirely
now by sub-items of the new H1 item.
One of the more noticeable changes is the addition of sub-items for some of the
more broad or complex risk factors. Evaluators should still rate the over-arching risk
factor, but can now choose to specify more precisely where the nature of the risk
resides. For example, if a person has past violence, he or she would receive an overall
rating on H1. If the evaluator chooses, she or he can specify the developmental periods
during which past violence transpired through the sub-items of child, adolescent, or
adult.
In addition to the omnibus summary risk rating of low, moderate, or high risk that is
also contained in the HCR-20 Version 2, Version 3 now includes summary risk ratings
for serious physical violence, and for imminent violence. Moreover, there are options to
indicate when re-evaluations should be conducted, and whether any risks other than vi-
olence have presented themselves. More guidance is provided for determining evalua-
tion windows for the clinical and risk management scales (i.e., how far back or forward
should evaluators be looking in terms of making these ratings?). Some of the changes
are of particular relevance to a conditional release context, and hence will be reviewed
in more detail in the next section.

HCR-20V3 Features of Particular Relevance to Conditional Release

Conditional release decisions are highly context-dependent. In addition to the funda-

mental estimate of risk level, and whether this is acceptable in terms of public safety,
decision-makers must estimate the conditions that will mitigate or reduce risk (so as
to foster these), and must also anticipate the conditions that would aggravate risk (so
as to avoid these). Some of the features of Version 3 that were intended to address such
issues are discussed. Each may possess pragmatic value to professionals charged with
the task of release decision-making, and specifying optimal release conditions. Further,
each is intended to inform the others sequentially. That is, consideration of the rele-
vance of risk factors follows the identification of the presence of risk factors, and how
these manifest at the individual level. Formulation integrates risk factors deemed to
be relevant by evaluators. Scenario planning looks to the future and constructs viable
scenarios of concern, based on previous steps. Finally, risk management attempts to
specify plans that will account for relevant risk factors, address why a person has been
violent (identified through formulation), and put mechanisms into place to prevent
scenarios from unfolding.

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Risk Factor Indicators

One of the first basic steps in using Version 3 (and pretty much any risk assessment in-
strument) is the identification of which risk factors are present. The HCR-20V3 is not
novel in this regard. However, it has always been the case in the use of the HCR-20
(or any SPJ instrument) that, once risk factors are identified, their manifestation for
the given evaluee ought to be described and worked into the risk assessment (Douglas,
Blanchard & Hendry, 2013). The same general risk factor does not necessarily look the
same for different people. Although the HCR-20 Version 2 was not explicit on this
point, subsequent commentary was, and Version 3 provides considerable guidance
on this point.
In addition to general instruction on the importance of considering the individual
manifestation of risk factors, Version 3 includes item indicators. For each risk factor,
there is a set of indicators presented to provide guidance for evaluators if they choose
to individualize their descriptions of risk factors for an evaluee. They are not intended
to be rated (although they could be, if so desired), but rather they are intended to serve
as prompts for the investigation into how the risk factors manifest for any given person.
An example is provided.
Figure 1 presents one of the risk management factors from HCR-20V3. An evaluator
would first code whether this risk factor is present, according to the general definition
that appears at the top of the risk factor description. Then, the evaluator could consult
the indicators, which appear next, if she or he wanted to describe more specifically how
the risk factor manifests for the given person with whom she or he is working. The
indicators are not intended to be comprehensive, but rather to provide some guidance
for a more detailed consideration of the risk factors, beyond merely indicating whether
it is present. Several of the coding notes are presented for R2 as well. In general, coding
notes either define key terms used within the definition or indicator set, or address
specific coding requirements for the items.
Using the example provided, it would be fairly easy to determine whether a person
might face difficulties upon release in their immediate residence, or in their broader en-
virons. For one person, the residence and/or environs might be chaotic and provide
easy access to weapons. However, for a different person, other problems might be more
prominent, such as a poorly secured or supervised residence, or a high-crime neighbor-
hood. Consideration of these indicators might help evaluators and decision-makers to
determine whether a current release plan is satisfactory, or whether it needs to be
revised. The general intent of the indicators is to prompt evaluators and decision-
makers to contemplate what a risk factor “looks like” for an individual person, and to
provide guidance in terms of shaping specific risk management plans and avoiding
problem areas.

Individual Relevance of Risk Factors

Once risk factors have been identified and described, HCR-20V3 recommends that
evaluators and decision-makers rate which risk factors are most relevant at the individual
level in terms of understanding why a person has acted violently in the past, and why they
may act violently in the future. As Monahan and colleagues (2001) pointed out, not all
risk factors are equally relevant for all people. For one person, substance use problems
might be tightly linked to violence, whereas for another it could be quite irrelevant. At

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Figure 1. Item R2 (future problems with living situation) on Historical-Clinical-Risk Management-20,

V3
Version 3 (HCR-20 ).

sample and population levels, validity estimates (i.e., beta coefficients; odds ratios) de-
scribe the average association between a risk factor and violence. Yet, there is variation
around the average effect size, and the clinical task is to identify for whom the risk factor
is important, and for whom it is less important (Douglas, Hart, et al., 2013). As such, in
HCR-20V3, evaluators are encouraged to consider which of the risk factors that are pres-
ent also play an important role in understanding a person’s violence.

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568 K. S. Douglas

The manual provides detailed instructions for making relevance ratings. Essentially,
evaluators should consider whether risk factors materially contributed to past violence,
whether they might influence future decision-making in a manner that promotes vio-
lence, whether they might interfere with decision-making, or whether they are other-
wise critical to address within risk management plans. A thorough accounting and
description of past violence are crucial in this regard, perhaps by using an anamnestic
approach (see Melton et al., 2007), and by considering the functional roles that vio-
lence has played for an individual (Daffern, Howells, & Ogloff, 2007).

Formulation

As Hart and Logan (2011) have described, the purpose of formulation is to synthesize
information from previous steps into a coherent story that explains, as best as possible,
why a person has acted violently. It is intended to simplify and reduce information. In a
conditional release context, this step may be crucial to appropriate case management
planning and the setting of conditions, because it is geared toward facilitating the under-
standing of violence at the individual level. Even for two persons who are at the same
risk level (be that determined through an SPJ instrument like the HCR-20V3, or by
other means such as an actuarial instrument), their motivations and reasons for acting
violently may be vastly different. Indeed, even for two people with similar risk factors,
and similar relevant risk factors, reasons for violence may vary considerably. One set of
conditions and intervention plans likely will not work equally well for both.
Consider a simplified example of two people who share common risk factors: sub-
stance use problems (H5); stress (R5); employment problems (H4); instability (C4);
and relationship problems (H3). Based on a thorough evaluation, both people are con-
sidered to be high risk. Ostensibly, they should receive the same levels and types of
management. However, such an arrangement might be sub-optimal because the risk
factors might work together in different ways for the two people. For one person, rela-
tionship problems with a spouse might lead to instability (i.e., short temper, agitation,
reactive decisions) and stress. This state of negative emotionality might lead to drink-
ing, which could lead to problematic work performance, including, say, arguments
and physical conflicts with co-workers.
Consider a person with the same risk factors, but which act together in a very differ-
ent manner. This person could be chronically unemployed due to low education, and
so decide to make a living selling cocaine. He might be estranged from family because
of his lifestyle, which could cause stress. Instability may arise due both to the tense fa-
milial situation and to the drug lifestyle, which includes frequent high-risk encounters
with buyers and sellers of drugs, and a not infrequent use of violence as a part of that.
Would the same management strategy work the same way for both people? Perhaps,
but it would seem sensible to shape the risk management plan to capture the primary
reasons for violence. For one person, perhaps marital treatment is called for, whereas
for the other, educational and vocational skills training would be more appropriate.
In both instances, the role of substance use would need to be addressed, but the under-
lying reasons for problems in this sphere differ as well. The basic point is that without a
mechanism to integrate and understand how risk factors work together, and how the
resultant amalgam spurs violence, management attempts may be sub-optimal.
The HCR-20V3 does not require that a certain type of formulation be used. Rather, it
presents a number of viable approaches that evaluators can consider, and leaves open the

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possibility that different approaches can be used as well. This approach is consistent with
the SPJ model – to provide structure, but allow for appropriate professional judgment.

Scenario Planning

Scenario planning may be highly relevant within a conditional release context because
both inherently focus on what future contexts or conditions would either mitigate or
aggravate risk. As Hart and Logan (2011) have described, scenario planning is not new.
It has a long history in fields where decisions must be made in the face of uncertainly, such
as health care, the military, and business (Ringland, 1998; Schwartz, 1990; van der
Heijden, 1997). However, it is fairly new in the risk assessment field, introduced in
2003 in the Risk for Sexual Violence Protocol (RSVP; Hart et al., 2003).
Ultimately, the purpose of constructing risk scenarios is to estimate what a person
might do in the future, so as to implement monitoring systems and risk reduction strat-
egies. Scenarios are best estimates of the chain of events that could lead to violence, the
motivations for violence, the conditions under which it would be more or less likely to
happen, against whom it might be perpetrated, and how soon, often and serious it
might be. Importantly, evaluators should specify whether there are any case-specific
warning signs that would signal that a scenario might be unfolding. In principle, this
would permit intervention before any violence actually occurs; that is, in scenario plan-
ning, part of the task is to specify what the warning signs might be, and what intervening
steps should be taken if they appear.
Scenarios are based on reasoned concerns that evaluators have constructed from
case facts and their integration through previous steps outlined on the HCR-20V3
(i.e., relevance; formulation). Commentators both within (Hart et al., 2003) and outside
of the risk field (van Notten, Rotmans, van Asselt, & Rothman, 2003) have recommended
that evaluators consider whether reasonable, logical scenarios exist within each of the
following categories: repeat, twist, escalation, optimistic. In a repeat scenario, as the name
suggests, a person will engage in a similar type of violence as in the past, for similar rea-
sons, against a similar victim type. In the twist scenario, some element may change, such
as the victim type or nature of violence. However, there are similarities to past instances of
violence. Escalation occurs if violence becomes substantially worse – more frequent or
severe in terms of harm. In the optimistic scenario, violence is less harmful.

Risk Management

Version 3 of the HCR-20 provides substantially more information on risk management,

although it is not a treatment or management guide per se. It provides guiding principles
in terms of constructing management plans. Persons responsible for management
should ensure that management plans adequately address the relevant risk factors,
formulations, and scenarios derived from previous steps. Intensity of services should
correspond to degree of risk, a principle established long ago within the risk–need–
responsivity (RNR) approach commonly used for general recidivism within correctional
settings (Andrews, 2012; Andrews, Bonta, & Wormith, 2010). Risk management strat-
egies contemplated by the HCR-20V3 cover a broad array of approaches, from supervi-
sion and monitoring, to treatment and victim safety planning.

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Risk Management Items

Although all of the HCR-20V3 risk factors are of importance in terms of assessing, for-
mulating, and managing risk, the Risk Management items pertain specifically to future
conditions and functioning. Hence, they may be of particular relevance to conditional
release, in particular the task of arranging risk-mitigating conditions, and avoiding risk-
enhancing contexts. For this reason, the content of the risk management items is
reviewed. The risk factor names can also be found at the bottom of Table 2. The em-
pirical literature in support of the broad constructs underpinning each risk factor, and
hence supporting their inclusion on the instrument, is summarized in some detail else-
where (Guy & Wilson, 2007; Guy et al., in press). Each of the item labels is preceded by
“Future problems with….”

R1: Professional Services and Plans

The essence of this item is whether an evaluee’s plans for use of professional services
are adequate to mitigate risk. It is important that professional services are linked to
relevant risk factors, and that the overall intensity of services are commensurate with
a person’s risk level. These principles are in accord with empirically validated (for a re-
view, see Andrews, 2012; Andrews et al., 2010) RNR principles of risk (higher risk
cases warrant higher intensity services), need (services should target criminogenic
needs or dynamic risk factors), and responsivity (services should be delivered in man-
ner that is most responsive to a person’s learning style and any other needs that could
impact responsivity to services). Example indicators from the HCR-20V3 manual in-
clude “[p]lans regarding professional services fail to target one or more critical risk fac-
tors” and “[p]lans rely on inappropriate professional and other services” (p. 94).

R2. Living Situation

Readers can read the full item in Figure 1. To summarize, this item asks evaluators to
determine whether there will be any features of a person’s residence and environs that
could reasonably destabilize a person and hence elevate risk. The “destabilizers” listed
in the item definition, such as affiliations (i.e., antisocial peers), substances, or risk-
enhancing neighborhoods (chaotic; high crime rates) have broad support in social sci-
entific literatures (Guy et al., in press).

R3. Personal Support

This risk factor focuses on the extent to which a person will, or will not, benefit from
the personal support of people in their social (i.e., non-professional) network. A person
can receive a rating on this item if they have no support, poor support in certain do-
mains (i.e., emotional, material, problem-solving) or if there are persons in their net-
work with whom they have conflict, or would be subjected to negative influences.
Example indicators include “[s]ocial network does not include people who are likely
to have a positive impact on the person’s psychological adjustment” and “[i]nadequate
problem-solving support” (p. 96).

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R4. Treatment or Supervision Response

This risk factor captures both compliance problems and refractoriness, in response to
services designed directly to reduce risk (i.e., violent offender programming), or to
ameliorate conditions of relevance to risk (i.e., behavioral problems such as impulsivity
or substance use; emotional problems such as anger; mental health problems such as
psychotic symptoms; housing, vocational or employment problems). It is important
to note that both human service (i.e., medical, psychological, social work) and legal su-
pervision (i.e., parole, conditional release) are relevant to this item. Persons can be given
a rating on this item for a variety of reasons, including, inter alia, outright rejection of
services, not benefiting from services, or engaging in behaviors that counter the aim of
services (i.e., using drugs during substance use treatment). Example indicators include
“[d]emonstrates little motivation for future intervention” and “[d]oes not accept or
cooperate with plans regarding professional services formulated by others” (p. 99).

R5. Stress or Coping

The essential aspect of this item is the ability of persons to cope with minor and major
stressors. Ratings on this item can stem from either the presence of formidable life
stressors, the inability to cope with minor stressors such as daily hassles, or both. Exam-
ple indicators include “[l]iving circumstances are likely to be very stressful” and “[u]
nlikely to use coping strategies that will avoid stressors or minimize their conse-
quences” (p. 102).

Summary of Research on HCR-20V3

A series of evaluative projects was conducted in parallel with the development of

HCR-20V3 in order to ensure that there was at least initial evidence for its reliability
and validity. Studies or beta-testing projects were conducted in eight countries (Canada,
England, Germany, the Netherlands, Norway, Sweden, Wales, the USA), with over 800
cases spanning correctional, forensic psychiatric, and civil psychiatric settings.
In addition to beta-testing including roughly 30 clinicians with 50 patients in three
settings (de Vogel, van den Broek, & de Vries Robbé, 2014; Douglas & Belfrage,
2014; Kötter et al., 2014), research areas that have been subjected to peer review to date
include interrater reliability (IRR; de Vogel et al., 2014; Douglas & Belfrage, 2014;
Doyle et al., 2014; Kötter et al., 2014; Smith et al., 2014), concurrent validity between
HCR-20 Versions 2 and 3 (Bjørkly, Eidhammer, & Selmer, 2014; de Vogel et al., 2014;
Douglas & Belfrage, 2014; Strub, Douglas, & Nicholls, 2014), predictive validity of risk
factor and/or summary risk ratings (de Vogel et al., 2014; Doyle et al., 2014; Strub et al.,
2014), incremental validity of summary risk ratings and relevance ratings vis-à-vis pres-
ence ratings (Strub et al., 2014), and the influence of relevance and presence ratings in
terms of influencing summary risk ratings (Smith et al., 2014).

Interrater Reliability

Several studies have evaluated the IRR of HCR-20V3 indices. Douglas and Belfrage
(2014) tested IRR in a sample of 32 Swedish forensic psychiatric patients. At least three
clinicians interviewed patients and reviewed their files, and completed the HCR-20V3

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independently. Single rater intraclass correlation coefficients (ICC1) for total and scale
scores ranged from 0.69 to 0.94 (averaging 0.85), and for relevance ratings, from 0.60
to 0.80 (averaging 0.70). IRR for summary risk ratings was 0.81 (risk of institutional
violence) and 0.75 (risk for community violence). Across a total of 138 paired ratings,
86.15% were in perfect agreement (i.e., low-low; moderate-moderate; high-high), and
in only one out of 138 paired ratings (0.65%) was there a low-high disagreement. Most
items had ICC1 values that were 0.75 or greater.
Doyle and colleagues (2014) reported the IRR for the total and scale scores using
four raters and 20 forensic patients from England and Wales. ICC1 values were as fol-
lows: total (0.92), H (0.91), C (0.90), and R (0.93). In de Vogel et al. (2014), three raters
competed ratings for 25 Dutch forensic patients, and reported ICC1 values of 0.72 for
the summary risk ratings, and 0.84 for total scores. Smith and colleagues (2014) had
two graduate student raters complete 15 overlapping cases amongst jail detainees in
Texas. Despite a small sample, they reported ICC1 values as follows: H scale (0.92),
C scale (0.67), and R scale (0.68 institutional; 0.88 community). Kötter and colleagues
(2014) had five clinicians who were previously unacquainted with the HCR-20 rate 30
patients, after having undergone training. The ICC1 value for summary risk ratings
was 0.86. Average item-level ICC1 values were 0.65 (H items), 0.66 (C items), and
0.73 (R items). Using general guidelines for interpreting item-level IRR, these values
would be considered “good” (Fleiss, 1981) to “substantial” (Landis & Koch, 1977).

Concurrent Validity

Several studies have reported the correlations between Versions 2 and 3 of the HCR-20.
In a sample of 86 Dutch forensic patients, de Vogel and colleagues (2014) reported a
correlation of 0.93 between respective total scores. This was consistent with Strub and
colleagues. (2014) observed correlation of 0.91 between total scores amongst 106 Cana-
dian civil psychiatric and correctional offenders. In this study, correlations between
summary risk ratings was 0.98. For the scales, it was as follows: H (0.89), C (0.76),
and R (0.81). Douglas and Belfrage (2014) reported intercorrelations as follows in their
IRR study of 32 Swedish forensic patients: total (0.85 institutional, 0.90 community),
H (0.87), C (0.76), R (0.67 institutional, 0.82 community). In a sample of 20 Norwegian
forensic patients, Bjørkly and colleagues (2014) reported correlations between versions
as follows: total (0.84), H (0.85), C (0.59), and R (0.81).

Predictive and Incremental Validity

Several studies have investigated the association between HCR-20V3 and subsequent
violence. de Vogel and colleagues (2014) evaluated a draft of HCR-20V3 in a retrospec-
tive follow-up study of 86 Dutch male forensic psychiatric patients discharged from a
secure forensic facility into the community. They reported significant AUC values at
1, 2, and 3 years post-discharge for the total score as 0.77, 0.75, and 0.67 respectively.
For summary risk ratings, the AUC values were 0.72, 0.67, and 0.64. These values
were not significantly different than for Version 2 of the HCR-20.
Doyle and colleagues (2014) were able to follow an entire cohort of forensic patients
released from medium-secure forensic facilities into the community in England and
Wales over the course of a year. They prospectively followed these 387 male and female
patients for a year, and measured violent outcomes from multiple sources at 6 and 12

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months. Focusing on scale scores, the authors reported significant AUC values for
total, H, C, and R scales at 6 months (0.73, 0.63, 0.75, and 0.67, respectively) and
12 months (0.70, 0.63, 0.71, 0.63, respectively).
Strub and colleagues (2014) prospectively followed 106 male and female Canadian
civil psychiatric patients (n = 50) and correctional offenders (n = 56) from discharge
into the community both for short-term (4–6 weeks) and longer-term (6–8 months)
violence. Initial analyses indicated that subsample neither moderated nor confounded
(i.e., as a covariate) the association between the HCR-20V3 and violence, and hence,
although bivariate associations between HCR-20V3 and violence were reported across
samples, multivariate analyses used to test incremental validity were conducting
collapsing across subsamples.
At the bivariate level, point biserial correlations between HCR-20 total and scale
scores and violence ranged from 0.26 to 0.46, and averaged 0.36. AUC values averaged
0.74. Relevance ratings for the items ranged from 0.21 to 0.32, and averaged 0.27.
AUC values averaged 0.68. Correlations for summary risk ratings ranged from 0.33
to 0.53 and averaged 0.42. AUCs averaged 0.76. At the 4–6 week follow-up, 2%,
16%, and 44% of the people rated low (1/46), moderate (5/32), and high risk (10/23)
were violent. At the 6–8 month follow-up, 16%, 36%, and 67% of the people rated
low (8/49), moderate (12/33), and high risk (16/24) were violent. In incremental valid-
ity analyses (hierarchical logistic regression), summary risk ratings added incrementally
to both the HCR-20V3 item scores and relevance ratings. Gender did not moderate any
of the associations between the HCR-20V3 and violence. The performance of Version 3
and Version 2 was highly comparable (r-values within 0.02). Because Version 2 and 3
were highly correlated (r-values > 0.90), multivariate analyses were not conducted.

CONCLUSION
Version 2 of the HCR-20 has been evaluated in over 200 disseminations, conducted
across 25 countries. It was translated into 20 languages, and adopted broadly in foren-
sic agencies and facilities in numerous countries. Version 3, of course, is young, and
will benefit from the same extensive evaluation by independent researchers as did Ver-
sion 2. Initial evidence, based on studies with ~ 800 participants from eight countries
and three primary applied settings, suggests that there is support for the interrater reli-
ability and predictive validity of Version 3. Correlations between Versions 2 and 3 have
been substantial, suggesting similar content between versions. This continuity between
versions is important in terms of transitioning from Version 2 to Version 3, in that per-
sons with many (or few) risk factors, or judged to be high (or low) risk on Version 2 will
not unexpectedly change risk level or risk profile on Version 3.
Predictive validity appears to be at levels comparable to meta-analytic averages.
Summary risk ratings, in line with studies on Version 2 as well as other SPJ instru-
ments, added incrementally to the rating of risk factors. Some of its newer features,
such as formulation and scenario planning, are in need of evaluation, but may serve a
useful heuristic and pragmatic purpose at the individual decision-making level.
Conditional release, as stated at the outset, is inherently contextual. Decision-
makers must go beyond the relatively straightforward task of estimating risk level, to
the more complex task of understanding violence at the individual level, and designing
risk management plans that link logically to a person’s motivations for violence. The

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HCR-20V3 was designed to assist in this process. Future research should continue to
focus on basic but crucial issues such as reliability and validity, and expand to evaluate
the role of formulation and scenario planning.

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