The Journal of Forensic Psychiatry & Psychology

ISSN: 1478-9949 (Print) 1478-9957 (Online) Journal homepage: https://www.tandfonline.com/loi/rjfp20

Assessing change in dynamic risk factors in

forensic psychiatric inpatients: relationship with
psychopathy and recidivism

Bianca Mastromanno, Delene M. Brookstein, James R. P. Ogloff, Rachel

Campbell, Chi Meng Chu & Michael Daffern

To cite this article: Bianca Mastromanno, Delene M. Brookstein, James R. P. Ogloff, Rachel
Campbell, Chi Meng Chu & Michael Daffern (2018) Assessing change in dynamic risk factors in
forensic psychiatric inpatients: relationship with psychopathy and recidivism, The Journal of
Forensic Psychiatry & Psychology, 29:2, 323-336, DOI: 10.1080/14789949.2017.1377277

To link to this article: https://doi.org/10.1080/14789949.2017.1377277

Published online: 11 Oct 2017.

Submit your article to this journal

Article views: 1143

View related articles

View Crossmark data

Citing articles: 3 View citing articles

Full Terms & Conditions of access and use can be found at

https://www.tandfonline.com/action/journalInformation?journalCode=rjfp20
The Journal of Forensic Psychiatry & Psychology, 2018
VOL. 29, NO. 2, 323–336
https://doi.org/10.1080/14789949.2017.1377277

Assessing change in dynamic risk factors in forensic

psychiatric inpatients: relationship with psychopathy
and recidivism
Bianca Mastromannoa, Delene M. Brooksteina, James R. P. Ogloffa,b,
Rachel Campbellb, Chi Meng Chuc and Michael Dafferna,b
a
Centre for Forensic Behavioural Science, Swinburne University of Technology, Melbourne,
Australia; bVictorian Institute of Forensic Mental Health (Forensicare), Melbourne, Australia;
c
Centre for Research on Rehabilitation and Protection, Rehabilitation and Protection Group,
Ministry of Social and Family Development, Singapore, Singapore

ABSTRACT
This study explored change in dynamic risk for violence using the Clinical and
Risk Management subscales of the Historical Clinical and Risk Management-20
version 3 (HCR-20 v3) and sought to determine whether change was associated
with violent recidivism. The association between the magnitude of change and
psychopathy was also assessed. Participants were 40 male (n = 32) and female
(n = 8) forensic psychiatric inpatients discharged from a secure forensic mental
health service. Results showed that participants significantly improved on the
HCR-20v3 Clinical subscale but significantly worsened on the Risk Management
subscale. Psychopathy was unrelated to change in Clinical and Risk Management
subscales. The hypothesis that changes in dynamic risk would predict recidivism
over and above total pre-treatment risk (HCR-20v3 Total score) and psychopathy
was not supported. These results suggest that improvements in mental state risk
factors alone are insufficient with regard to lowering violence risk.

ARTICLE HISTORY Received 13 December 2016; Accepted 5 September 2017

KEYWORDS Treatment; forensic mental health; violence; risk assessment

The third version of the Historical Clinical and Risk Management assessment
scheme (HCR-20 v3; Douglas, Hart, Webster, & Belfrage, 2013) guides assessment
of the presence and relevance of static and dynamic risk factors, in conjunction
with consideration of other contextual factors that may be relevant to their vio-
lent behaviour (Strub, Douglas, & Nicholls, 2014). Although the extant evidence
base is limited, reductions in dynamic risk factors, as measured with the HCR-20
and the Violence Risk Scale (VRS, Wong & Gordon, 2000) have been found to
be associated with reductions in violent recidivism (De Vries Robbé, de Vogel,
Douglas, & Nijman, 2015; Michel et al., 2013; Olver, Lewis, & Wong, 2013). The aim

CONTACT Michael Daffern mdaffern@swin.edu.au

© 2017 Informa UK Limited, trading as Taylor & Francis Group
324  B. MASTROMANNO ET AL.

of this study is to explore associations between changes in dynamic risk factors,

as measured by the HCR-20 v3 Clinical and Risk Management subscales, and
violent recidivism. It also explores the relationship between psychopathy and
change in dynamic risk. This research is important since the nature of desistence
from violence, whilst generally considered to be due to a reduction in dynamic
risk factors (Serin, Lloyd, Helmus, Derkzen, & Luong, 2013), is complex and not
yet entirely elucidated. Further, the extant literature exploring the relationship
between change in dynamic risk factors and recidivism is small, and results
of these studies are inconsistent. For example, using the HCR-20 v3 to assess
108 offenders who had spent an average of five years in a forensic psychiatric
hospital, de Vries Robbé and colleagues (2015) found that violence risk change
scores were predictive of violent recidivism at long-term follow up (an average
of 11 years). Those patients who made greater changes on the HCR-20 v3 were
significantly less likely to violently recidivate, suggesting that changes made
during treatment were sustained upon release into the community. Participants
who had improved by five points on their overall risk rating (out of 40) were
two times less likely to violently recidivate (De Vries Robbé et al., 2015). Hogan
and Olver (2016) also found significant reductions in HCR-20 v3 Clinical and
Risk Management scales from pre- to post-treatment in a sample of 99 forensic
psychiatric inpatients. Changes on both the Clinical and Risk Management scales
were associated with decreased inpatient aggression during hospitalisation.
Michel et al. (2013) assessed dynamic risk factors among violent offenders
diagnosed with Schizophrenia following discharge into the community from
inpatient treatment. Participants were assessed at six-month intervals over a
two-year period; 96 and 87% of participants experienced change on the Clinical
and Risk Management subscales of the HCR-20 version 2 (v2), respectively. For
each unit increase (worsening) in the Risk Management subscale of the HCR-20,
participants were nearly three times more likely to behave violently, although
changes on the Clinical subscale did not affect the likelihood of future violent
behaviour. This latter finding is important and consistent with the view that an
exclusive focus on treatment of psychiatric symptoms is insufficient to reduce
the risk of recidivism. This is because the main predictors of recidivism for men-
tally disordered and non-mentally disordered offenders are the same (Bonta,
Law, & Hanson, 1998), with the exception that some specific clinical symptoms
may also impact the likelihood of violence (Douglas, Guy, & Hart, 2009). Changes
in clinical risk factors alone are therefore insufficient for reducing recidivism risk
in all except those mentally disordered offenders whose offending is caused
exclusively and directly by their psychiatric symptoms.
Finally, individuals high in psychopathy have been the subject of consider-
able research interest due to their purportedly decreased responsivity (Berg et
al., 2013), greater likelihood of violence during treatment (Chakhssi, De Ruiter, &
Bernstein, 2010) and poorer compliance with treatment (Hildebrand & de Ruiter,
2012). They have also been found to demonstrate less improvement with regard
 THE JOURNAL OF FORENSIC PSYCHIATRY & PSYCHOLOGY  325

to violence risk than less-psychopathic offenders (Olver et al., 2013), although

contrasting findings are reported (Hildebrand & de Ruiter, 2012). Consistent
with previous studies investigating the effect of change in violence risk scores
on violent recidivism in non-psychopathic offenders, violence risk change scores
have also been associated with recidivism among highly psychopathic offenders
(Olver et al., 2013).

Aims and hypotheses

The aim of this study was to investigate whether forensic psychiatric patients
would show a reduction in dynamic risk scores between admission to inpatient
psychiatric care and discharge. It also sought to explore whether these changes
were associated with psychopathy, and whether changes were predictive of
violent and non-violent recidivism. Consistent with these aims, the following
hypotheses were made.
H1: Participants would show a significant decrease in total dynamic risk scores
from admission to discharge.
H2: Participants higher in psychopathy would experience less change in dynamic
risk.
H3: A greater reduction in dynamic risk between admission and discharge would
be negatively associated with violent and non-violent recidivism post-release, and
changes would add incremental predictive validity over and above total HCR-20
v3 pre-treatment risk scores, and psychopathy.

Method
Setting
Thomas Embling Hospital (TEH) is a high security forensic mental healthcare
facility located in Victoria, Australia. Patients are admitted as ‘security’, ‘invol-
untary’ or ‘forensic’ patients. Security patients are admitted under the Mental
Health Act 2014 (Vic) or the Sentencing Act 1991 (Vic), although participants
in this study were admitted under the 1986 version of the Mental Health Act
(Vic) as this was the Act governing admission at the time. These Acts allow for
mentally ill prisoners to be certified and transferred to the hospital, and for
mentally ill offenders to be sentenced to TEH as opposed to prison. Involuntary
patients include individuals detained following expiration of their sentence if
they are still deemed unwell and a risk to the community. Involuntary patients
also include civil psychiatric patients who cannot be managed by general psy-
chiatric facilities and so are transferred to TEH. Forensic patients have been
found Not Guilty by Reason of Mental Impairment or are considered to be unfit
to stand trial and so are ordered to remain at TEH under the Crimes (Mental
Impairment and Unfitness to be Tried Act) 1997 (Vic). The level of observation
326  B. MASTROMANNO ET AL.

and liberty of patients differs between units within TEH. Initially patients are
admitted to the acute units where access to the hospital grounds is limited
and there is more supervision of patients’ activities. Once patient’s risk towards
others and themselves lessens and there is improvement in mental state and
well-being the patients are transferred to sub acute and then rehabilitation units.
Some are returned to prison at this stage, if they are sentenced or remanded
prisoners who have been admitted for assessment and treatment of their mental
illness. Approaching release to the community, patients are usually graduated
to use escorted, followed by unescorted leave. Patients are often discharged
directly to the community although some are returned to prison to complete
their prison sentence.

Participants
Participants were 40 adult male (n = 32) and female (n = 8) forensic psychiatric
inpatients admitted to TEH for a period of at least four months (mean treatment
length = 744.4 days, SD = 976.50, range = 123–3641) between 2000 and 2002.
Participants’ mean age at admission was 30.3 years (SD = 9.20, range = 19.5–
55.7). Participants were predominantly of Caucasian Australian (n = 30), fol-
lowed by Asian (n = 4), European (n = 3), Aboriginal or Torres Strait Islander
(n = 1), British (n = 1), and Turkish (n = 1) backgrounds. Participants comprised
Involuntary (n = 5), Security (n = 31) and Forensic (n = 4) patients. All partici-
pants had a history of violence, either in their index offence or in prior criminal
convictions. Of the participants with a violent index offence, offences/offence
types were as follows: Assault (n = 20), Homicide (n = 7), Theft with Violence
(n = 5), Sexual (n = 2), Arson (n = 1), Threats to Kill (n = 1), and Stalking (n = 1).
For the three participants whose index offences were not violent, index offences
included theft, property offences and a breach.
Mental health diagnoses were extracted from discharge summaries made by
the treating psychiatrist. Diagnoses were as follows: Depression with Psychosis
(n = 1), Paranoid Schizophrenia, (n = 16), Schizoaffective Disorder (n = 3),
Schizophrenia (n = 17), Substance Use Disorder (n = 1), and no diagnosis (n = 2).
Seven participants had a single personality disorder diagnosis and three had
two personality disorder diagnoses recorded. Diagnoses of personality disorders
included Antisocial (n = 5), Borderline (n = 2), Paranoid (n = 2), Narcissistic (n = 1),
Avoidant (n = 1), Dependant (n = 1), and Personality Disorder Not Otherwise
Specified (n = 1). A history of substance abuse was present for 88% of partic-
ipants. At admission, 65% of participants had been previously admitted to a
forensic psychiatric hospital, and 75% had been previously hospitalised in a
non-forensic setting.
 THE JOURNAL OF FORENSIC PSYCHIATRY & PSYCHOLOGY  327

Procedure
HCR-20 v3 and PCL-R assessments were retrospectively completed for each
participant based on patient files. Although risk assessments were routinely
conducted during the time in which participants resided in TEH, such assess-
ments were conducted using the HCR-20 version 2. The purpose of this study
was to investigate change on the most recent, HCR-20 v3, thus retrospective
assessments were required. Different researchers scored the first two months
and the last two months’ HCR-20 v3 assessments for each participant. All raters
were formally trained in the administration of the HCR-20 v3 and the PCL-R.
Inter-rater reliability was assessed by both raters scoring the same six partici-
pants on the HCR-20 v3 dynamic subscales. The Intraclass Correlation Coefficient
(ICC) using a two-way random method with absolute agreement for the Clinical,
Risk Management, and combined Clinical and Risk Management presence and
relevance ratings were considered to be in the ‘good’ (.60–.74) or ‘excellent’ (.75
and above) range (Cicchetti, 1994). See Table 1 below for all HCR-20 v3 ICCs.
Two raters each scored thirty participants for the purposes of assessing inter-
rater reliability of the PCL-R. The ICC for the PCL-R prorated total score was ‘fair’
at .46 (Cicchetti, 1994). All ICCs were significant at p < .05. All assessments were
conducted blind to recidivism outcome. A four-month time period was chosen
as the minimum treatment time in which to assess change in risk from admis-
sion to release for participants, as the average length of stay for patients in
TEH according to the 2014/2015 Victorian Institute of Forensic Mental Health
(VIFMH) annual report, was 117 days (Victorian Institute of Forensic Mental
Health [VIFMH], 2015). As this equates to approximately four months, this time
frame was deemed a realistic one within which to explore inpatient change and
risk assessments were completed for participant’s first two months of treatment,
and their final two months of treatment.

Measures
HCR-20 v3 Douglas et al. (2013)
HCR-20 v3 comprises 10 static Historical risk factors (e.g. ‘History of Problems with
Violence’) and 10 dynamic risk factors for violence. Dynamic risk factors include

Table 1. Intraclass correlation coefficients for the purpose of inter-rater reliability.

ICC1 ICC2
C-Scale presence 0.85 0.92
C-Scale relevance 0.76 0.86
R-Scale presence 0.89 0.94
R-Scale relevance 0.74 0.85
C & R presence 0.93 0.96
C & R relevance 0.82 0.90
Notes: C-Scale = Clinical subscale total score, R-Scale = Risk Management subscale total score, C & R =
Combined Clinical and Risk Management subscale scores.
N = 40.
328  B. MASTROMANNO ET AL.

five Clinical (e.g. ‘Recent Problems with Insight’), and five Risk Management
(e.g. ‘Problems with Future Professional Services or Plans’) items. Although the
HCR-20 v3 is a non-numeric risk assessment instrument for the purposes of cal-
culating change scores the items were scored on a three-point scale (0 = absent,
1 = partial, 2 = present). Although in this study the scales were scored according
to presence, each item can also be rated according to its relevance to violence
(0 = low, 1 = moderate, 2 = high). For both Presence and Relevance scores for
static and both dynamic subscales, a total score out of 40 is generated. An
assessment can then be made regarding an individual’s case prioritisation, risk
for future violence, risk of serious physical harm, and risk of imminent violence
(0 = low, 1 = moderate, 2 = high). The HCR-20 v3 is typically coded following an
interview with the examinee although it can be reliably coded from file review
alone (Douglas et al., 2013).

PCL-R Hare (2003)

Psychopathy was assessed using the 20-items Psychopathy Checklist Revised
(PCL-R). Each item (e.g. ‘Glibness and/or superficial charm’) is coded on a three-
point scale (0 = absent, 1 = partial, 2 = present). Higher scores on an item reflect
higher levels of that trait, and higher total scores represent higher levels of
psychopathy. Psychopathy is typically assessed with the PCL-R by conducting
an interview and/or file review, however for research purposes the latter is suf-
ficient (Olver et al., 2013 ).

Outcome data
Recidivism data were obtained from Victoria Police’s Law Enforcement Assistance
Program (LEAP). LEAP is an online database that holds all information pertaining
to crimes bought to the attention of police in Victoria. Information was obtained
relating to the occurrence and nature of any violent or non-violent offending
by participants, and the dates of offending. See Table 2 for a description of
violent and non violent offences. Recidivism data were provided for the time
period of 1 April 2000 – 31 January 2013, allowing for a maximum follow-up
period of 12 years and 10 months. Although ten participants in this study were
returned to prison on discharge from TEH, all participants spent some time in
the community prior to the end of the follow-up period.

Ethical considerations
Ethics approval was granted by the Swinburne University Human Research Ethics
Committee (SUHREC), Department of Justice Human Research Ethics Committee
(JHREC), and the Victoria Police Research Coordinating Committee (RCC).
 THE JOURNAL OF FORENSIC PSYCHIATRY & PSYCHOLOGY  329

Table 2. Categories of violent and non-violent offences.

Violent Non-violent
Homicide offences Property offences
Sexual offences Drug offences
Assault offences Deception offences
Theft offences with violence Obstruction of justice
Kidnap offences Theft offences
Arson offences Legal order offences
Threat offences Public order offences
Stalking offences Driving offences
Other offences

Results
Data screening
Normality was violated for three variables; total dynamic risk scores and Clinical
subscale scores from the first two months of treatment, and Risk Management
subscale scores from the last two months of treatment. No significant univariate
or multivariate outliers were detected. A Mann–Whitney U test was performed to
assess any significant differences between males and females on PCL-R scores,
and on overall dynamic risk, Clinical subscale, and Risk Management subscale
scores at either time point. Results are shown below in Table 3.

Recidivism

The base rate for recidivism post-release was 50% (n = 20). Of these, one participant
violently reoffended, five non-violently reoffended, and 14 committed both violent
and non-violent offences. Of the total 15 participants who reoffended violently,
the categories of their first violent offences are as follows: Threat (n = 1), Arson
(n = 2), Theft with Violence (n = 2), Assault (n = 10). Out of the total 19 participants
who reoffended non-violently, the categories of their first non-violent offences are
as follows: Drug offences (n = 1), Property offences (n = 2), Obstruction of Justice
(n = 2), Aggravated Burglary with a Weapon Present (n = 2), Legal Order offences

Table 3. Differences in psychopathy and dyn amic risk scores between males and females.
Mean rank (Wilcoxon signed ranks test)
M F U z p
PCL-R Total 21.02 15.36 79.50 −1.19 .24
C & R Total FTM 21.00 18.50 112.00 −.54 .61
C Scale Total FTM 21.17 17.81 106.50 −.74 .48
R Scale Total FTM 20.53 20.38 127.00 −.03 .99
C & R Total LTM 21.02 18.44 111.50 −.56 .58
C Scale Total LTM 21.44 16.75 98.00 −1.03 .33
R Scale Total LTM 20.78 19.38 119.00 −.31 .78
Notes: M = Males, F = Females, C Scale Total = Clinical subscale total score, R Scale Total score = Risk
Management subscale total score, C & R = Combined Clinical and Risk Management subscale score, FTM
= First two months of treatment, LTM = Last two months of treatment, U = Mann–Whitney U statistic.
N = 40.
330  B. MASTROMANNO ET AL.

(n = 2), Theft (n = 10). During the follow-up period, 20 participants were incarcer-
ated, 24 were re-hospitalised in a forensic setting, and 22 were re-hospitalised in
a non-forensic setting.H1: Participants would show a significant decrease in total
dynamic risk scores from admission to discharge.

Total dynamic risk

Dynamic risk was measured by combining presence scores from the Clinical
and Risk Management subscales of the HCR-20 v3. The Wilcoxon-Signed Ranks
test was used to assess participant change. On average, participants did not
experience a significant change in total dynamic risk over the course of inpatient
treatment (z = -1.19, p = .23). Twenty participants experienced a decrease, 14
participants showed an increase, and six participants experienced no change
on total dynamic risk scores.

Clinical subscale
Participants, on average, significantly decreased in risk as measured by the
Clinical subscale (z = –4.34, p < .001). Thirty participants decreased, three
increased, and seven experienced no change in scores on the Clinical risk
subscale.

Risk management subscale

Participants, on average, significantly increased in risk on the Risk Management
subscale (z = −2.32, p = .02). Eleven participants decreased, 24 increased, and
five experienced no change.

Degree of participant change

Participants, on average, improved by 1.9 points on the Clinical subscale and
deteriorated by 1.6 points on the Risk Management Scale. On the Clinical sub-
scale, the most substantial amount of improvement and deterioration was six
and four points, respectively. On the Risk Management subscale, the most sub-
stantial improvement and deterioration was four and seven points, respectively.
Relevant descriptive statistics are shown in Table 4.
H2: Participants higher in psychopathy would experience less change in dynamic
risk.
Overall dynamic risk did not significantly change over the course of inpa-
tient treatment. Therefore, PCL-R scores were correlated with change scores
on the Clinical and Risk Management subscales separately, as these did change
significantly. Pearson’s correlation results indicated non-significant linear rela-
tionships between psychopathy and both Clinical (r (38) = .24, p = .14) and Risk
Management (r (38) = .07, p = .68) subscale change scores. Participants had a
mean PCL-R score of 13.41, with scores ranging between 1.1 and 24.7.
H3: A greater reduction in dynamic risk between admission and discharge would
be negatively associated with violent and non-violent recidivism post-release, and
 THE JOURNAL OF FORENSIC PSYCHIATRY & PSYCHOLOGY  331

Table 4. Mean dynamic risk scores from the first and last two months of inpatient treatment.
First two months Last two months
M SD Min. Max. M SD Min. Max.
C & R Total 12.33 3.43 5 17 11.58 4.53 1 20
C Scale Total 7.20 2.32 1 10 5.30** 2.45 0 10
R Scale Total 5.13 1.88 0 9 6.28* 2.71 1 10
Notes: C Scale Total = Clinical subscale Total score, R Scale total score = Risk Management subscale total
score, C & R = Combined Clinical and Risk Management subscale score.
**Score significantly differed from the first two months of treatment at p < .001; *Score significantly differed
from the first two months of treatment at p < .05.; N = 40.

changes would add incremental predictive validity over and above total HCR-20
v3 pre-treatment risk scores, and psychopathy.
Stepwise binary logistic regression analyses were first conducted to assess
whether total HCR-20 v3 risk scores at pre-treatment and PCL-R scores inde-
pendently affected the likelihood of violent and non-violent recidivism. Both
significantly increased the chances of reoffending violently and non-violently.
For each unit increase in HCR-20 v3 pre-treatment risk, participants were 26%
more likely to reoffend violently (OR = 1.26 [1.05, 1.51], p = .01), and 18% more
likely to reoffend non-violently (OR = 1.18 [1.02, 1.36], p = .02) during follow-up.
For each unit increase in PCL-R scores, participants were 28% more likely to reof-
fend violently (OR = 1.28 [1.07, 1.52], p = .01), and 15% more likely to reoffend
non-violently (OR = 1.15 [1.01, 1.23], p = .04).
HCR-20 v3 pre-treatment and PCL-R scores were then entered as simultane-
ous predictors to assess whether either added predictive validity above that
of the other. These variables were highly collinear (r (37) = .73, p < .001). When
entered together, although psychopathy approached significance (OR = 1.23
[.99, 1.53], p = .07), neither it nor HCR-20 v3 pre-treatment scores (OR = 1.07 [.85,
1.34] p = .58) remained significant predictors of violent recidivism. Similarly, for
non-violent recidivism, neither PCL-R (OR = 1.09 [.91, 1.29], p = .36) nor HCR-
20 v3 pre-treatment scores (OR = 1.09 [.89, 1.33], p = .40) remained significant
predictors.
As both psychopathy and HCR-20 v3 total pre-treatment scores were non-sig-
nificant predictors of recidivism when entered into the model together, psychop-
athy was removed from the logistic regression model prior to testing whether
either dynamic subscale added incremental predictive power. To avoid issues
of multicollinearity, Pearson’s correlations were first conducted to ensure that
neither Clinical nor Risk Management change scores were highly correlated with
HCR-20 v3 pre-treatment scores. Neither change score correlated significantly
with HCR-20 v3 scores at pre-treatment. Neither Clinical (OR = 1.05 [.72, 1.54],
p = .78) nor Risk Management change scores (OR = 1.06 [.81, 1.38], p = .67) added
predictive power above that of HCR-20 v3 scores at pre-treatment for violent
recidivism. Similarly, for non-violent recidivism, neither Clinical (OR = 1.09 [.77,
332  B. MASTROMANNO ET AL.

1.55], p = .61), nor Risk Management change scores (OR = .90 [.71, 1.15], p = .40)
added predictive power to HCR-20 v3 scores at pre-treatment.
Logistic regression analyses were conducted to assess whether Clinical and
Risk Management subscale change scores alone were predictive of violent or
non-violent recidivism. Clinical subscale change scores were not predictive of
violent recidivism (OR = 1.09 [.80, 1.49], p = .59), nor non-violent recidivism
(OR = .1.12 [.83, 1.52], p = .46). Similarly, Risk Management change scores were
not predictive of violent (OR = 1.05 [.83, 1.32], p = .70), or non-violent recidivism
(OR = .91 [.73, 1.14], p = .42). Hosmer and Lemeshow Goodness-of-fit statistics
indicated good model fits for all analyses.

Discussion
This study examined whether forensic psychiatric inpatients experienced a
decrease in dynamic violence risk during inpatient treatment, whether psychop-
athy was associated with the magnitude of change in dynamic risk factors, and
whether change in dynamic risk factors was associated with violent recidivism.
Participants significantly improved on the Clinical subscale of the HCR-20 v3 but
significantly deteriorated on the Risk-Management subscale. Psychopathy was
unrelated to change in both Clinical and Risk-Management subscales. Finally,
neither Clinical nor Risk-Management subscale change scores significantly pre-
dicted violent and non-violent recidivism.
The significant decrease in the Clinical subscale is consistent with previous
research (Michel et al., 2013; de Vries Robbé et al., 2014). However, against expec-
tations, participants tended to increase in the Risk Management subscale. By
contrast, participants in de Vries Robbé et al. (2014) experienced on average, a
decrease of 2.9 points on the Risk Management subscale during inpatient treat-
ment and Michel et al.’s (2013) participants experienced more improvements
than deteriorations on the Risk-Management subscale. The divergent findings
may be explained by treatment length. Participants in the De Vries Robbé et
al. study had a mean treatment length of six years, and those in Michel et al.
(2013) had a mean treatment length of approximately four years. Participants
in the present study spent two years, on average, in inpatient treatment. The
Risk Management subscale of the HCR-20 v3 contains items relating to future
problems with social support, professional services, living situation, employ-
ment, and stressors. It is possible that the time frame in this study may have
been insufficient to improve these risk factors to a degree where they would
generalise to the community.
Differences in the capacity for services to rehabilitate patients for community
living could contribute to the lack of improvement on the Risk Management
subscale. Participants in both Michel et al. and de Vries Robbé et al. (2013) were
recruited mainly from forensic psychiatric hospitals in Western Europe. Within
many Western European countries, both prison and forensic psychiatric systems
 THE JOURNAL OF FORENSIC PSYCHIATRY & PSYCHOLOGY  333

administer programs that heavily emphasise rehabilitation for life in the commu-
nity, and opportunities for education and work are often required and remuner-
ated. It may be that more comprehensive and targeted interventions delivered
over a longer period of time and encompassing a gradual reintegration to the
community are required to achieve improvement in the Risk Management sub-
scale items. Whilst services by psychologists, doctors, nurses, social workers, and
occupational therapists are provided to patients in TEH, intensive and sustained
rehabilitation and reintegration efforts are directed towards longer stay patients
who are hospitalised under the Crimes (Mental Impairment and Unfitness to be
Tried Act) 1997 (Vic). The focus for other patients who are admitted to TEH during
a prison sentence is primarily, and in some cases exclusively, on treatment of
mental illness. Such service delivery would therefore be expected to impact the
Clinical but not necessarily the Risk Management scale.

Psychopathy unrelated to change in dynamic risk

The hypothesis that participants higher in psychopathy would experience less
change in dynamic risk was unsupported, which is inconsistent with Olver et
al. (2013) but similar to Chakhssi et al. (2010) and Hildebrand and de Ruiter
(2012). The contrast in findings between the present study and those of Olver
et al. (2013) may be due to the way risk was assessed in both studies, which
has important implications for future research. Olver et al. assessed risk using
the VRS, which includes dynamic risk factors of a somewhat different emphasis
to those contained in the HCR-20 v3. The HCR-20 v3 dynamic risk items relate
primarily to mental disorder, and to their future risk management plans. The
VRS assesses similar risk factors (but to a lesser degree), although also contains
items relating to criminal personality, criminal attitudes, and other antisocial
lifestyle factors. Given that psychopathy comprises these same features, and that
psychopathy itself as a construct is difficult to change (Lynam & Gudonis, 2005),
the Olver et al. finding could be due to the relatively stable nature of attitude,
personality and lifestyle factors. The present results indicate psychopathy has
no impact on the treatment of risk factors related to symptoms of mental illness.

Change in risk as measured by the HCR-20 v3 is not predictive of violent

and non-violent recidivism
The hypothesis that change in dynamic risk as measured by the HCR-20 v3 would
be predictive of recidivism, above that of total risk scores at pre-treatment and
psychopathy scores, was unsupported. These findings are somewhat dissimilar
to de Vries Robbé et al. (2014), Hogan and Olver (2016) and Michel et al. (2013).
It was impossible to test whether either HCR-20 v3 pre-treatment scores or
psychopathy scores added predictive validity over and above the other due
to multicollinearity. Therefore, when testing to see whether Clinical and Risk
334  B. MASTROMANNO ET AL.

Management change scores would add incremental predictive validity to the

model, psychopathy was removed. It was deemed more important to assess
how change scores add predictive validity above that of pre-treatment HCR-20
v3 scores as opposed to PCL-R scores, due to the limited research in this area.
Neither changes in the Clinical nor Risk Management subscales added pre-
dictive validity over and above that of HCR-20 v3 pre-treatment scores for vio-
lent or non-violent recidivism. Few studies have examined whether changes in
violence risk are predictive of recidivism among mentally disordered offenders.
de Vries Robbé and colleagues did not examine the predictive validity of change
scores for total dynamic risk, or for each dynamic risk subscale. Michel et al.
(2013) revealed that changes in the Clinical subscale were not predictive of
violence, however, changes in the Risk Management subscale were; each addi-
tional point of worsening on the Risk Management subscale rendered partici-
pants in that study 2.8 times more likely to behave violently in the community.
Further, changes in specific items on these subscales were also associated with
recidivism. As the study conducted by Michel and colleagues is the only one to
examine how change scores on the dynamic subscales of the HCR-20 relate to
recidivism, it is difficult to draw generalisable conclusions from their results. It
may be that improvements to an individual’s mental state bears less importance
for destinance from future violence, as compared with improvements in other
risk factors, a finding consistent with Bonta and colleagues (1998) who reported
that the same major predictors of offending were similar for mentally disordered
and non disordered offenders. These findings are also consistent with Gray et al.
(2004) who suggest an exclusive focus on treating symptoms of mental illness
is insufficient to reduce offending.

Limitations and directions for future research

The limited sample of 40, predominantly male participants, mostly with a diag-
nosis of a psychotic disorder, and all sourced from the same psychiatric setting,
limits the generalisability of these findings, since rates of change have been
known to differ between demographically and clinically defined groups, as well
as between services (O’Shea & Dickens, 2015). The small sample also prevented
‘time at risk’ from being controlled for in any analyses; finally, the small sample
size limited statistical power and potentially obscured significant differences.
This study could be replicated with a larger and more gender- and diagnostically
diverse sample who have spent a longer average time in inpatient treatment.
Future research could consider examining changes in risk at an item level to
determine which risk domains change according to particular interventions.
Furthermore, assessing change at an individual level using the Reliable Change
(RC) Index or measures of Clinically Significant Change (CSC) and exploring the
relationship between CSC and RC, diagnostic group, and recidivism would be of
value to further examine how much change on which scales, subscales, or items,
 THE JOURNAL OF FORENSIC PSYCHIATRY & PSYCHOLOGY  335

for which patients, is required to reduce recidivism. It should also be noted that
the HCR-20 is a non-numeric tool and chance scores are not ordinarily used in
clinical practice to determine whether the individual has achieved significant
change. However, the use of numeric values is the most common, logical and
simplest methodology for research purposes.

Conclusions
Changes in dynamic risk factors pertaining to mental illness are possible among
forensic psychiatric inpatients. In this study, these changes were unrelated to
psychopathy, and to recidivism. Change in Risk Assessment scores and how this
relates to psychopathy and recidivism will depend on several factors, including
but not limited to, the composition of risk factors embedded in the risk assess-
ment tool used to appraise change. The small and homogenous sample in this
study means that the generalisability of findings is limited, and therefore further
research in this area is required. Whilst the anticipated relationships between
change, psychopathy and recidivism were not found in this study, it cannot
be concluded that changes in dynamic violence risk are not relevant to recidi-
vism, nor that psychopathy is irrelevant to responsivity. Previous findings have
highlighted that psychopathy can interfere with improvements on particular
risk assessment tools, and that changes on such tools have been predictive of
recidivism.

Disclosure statement
No potential conflict of interest was reported by the authors.

References
Berg, J., Smith, S., Watts, A., Ammirati, R., Green, S., & Lilienfeld, S. (2013). Misconceptions
regarding psychopathic personality: Implications for clinical practice and research.
Neuropsychiatry, 3, 63–74.
Bonta, J., Law, M., & Hanson, K. (1998). The prediction of criminal and violent recidivism
among mentally disordered offenders: A meta-analysis. Psychological Bulletin, 123,
123–142.
Chakhssi, F., De Ruiter, C., & Bernstein, D. (2010). Change during forensic treatment in
psychopathic versus nonpsychopathic offenders. Journal of Forensic Psychiatry &
Psychology, 21, 660–682. doi:10.1080/14789949.2010.483283
Cicchetti, D. V. (1994). Guidelines, criteria, and rules of thumb for evaluating normed
and standardized assessment instruments in psychology. Psychological Assessment,
6, 284–290. doi:10.1037/1040-3590.6.4.284
Crimes (Mental Impairment and Unfitness to be Tried) Act, (Vic) (Austl.), (1997).
De Vries Robbé, M., de Vogel, V., Douglas, K. S., & Nijman, H. L. (2015). Changes in dynamic
risk and protective factors for violence during inpatient forensic psychiatric treatment:
Predicting reductions in postdischarge community recidivism. Law and Human
Behavior, 39, 53–61. doi:10.1037/lhb0000089
336  B. MASTROMANNO ET AL.

Douglas, K., Guy, L., & Hart, S. (2009). Psychosis as a risk factor for violence to others: A
metaanalysis. Psychological Bulletin, 135, 679–706. doi:10.1037/a0016311
Douglas, K. S., Hart, S. D., Webster, C. D., & Belfrage, H. (2013). HCR-20V3: Assessing risk of
violence – User guide. Burnaby: Mental Health, Law, and Policy Institute, Simon Fraser
University.
Gray, N. S., Snowden, R. J., MacCulloch, S., Phillips, H., Taylor, J., & MacCulloch, M. J. (2004).
Relative efficacy of criminological, clinical, and personality measures of future risk of
offending in mentally disordered offenders: A comparative study of HCR-20, PCL:SV,
and OGRS. Journal of Consulting and Clinical Psychology, 72, 523–530. doi:10.1037/0022-
006X.72.3.523
Hare, R. D. (2003). Manual for the revised psychopathy checklist (2nd ed.). Toronto: Multi-
Health Systems.
Hildebrand, M., & de Ruiter, C. (2012). Psychopathic traits and change on indicators of
dynamic risk factors during inpatient forensic psychiatric treatment. International
Journal of Law and Psychiatry, 35, 276–288. doi:10.1016/j.ijlp.2012.04.001
Hogan, N. R., & Olver, M. E. (2016). Assessing risk for aggression in forensic psychiatric
inpatients: An examination of five measures. Law and Human Behavior, 40, 233–243.
doi:10.1037/lhb0000179
Lynam, D. R., & Gudonis, L. (2005). The development of psychopathy. Annual Review of
Clinical Psychology, 1, 381–407.
Mental Health Act, (Vic) (Austl.), (2014).
Michel, S., Riaz, M., Webster, C., Hart, S., Levander, S., Müller-Isberner, R., & Hodgins,
S. (2013). Using the HCR-20 to predict aggressive behavior among men with
schizophrenia living in the community: Accuracy of prediction, general and forensic
settings, and dynamic risk factors. International Journal of Forensic Mental Health, 12,
1–13. doi:10.1080/14999013.2012.760182
O’Shea, L. E., & Dickens, G. L. (2015). The HCR-20 as a measure of reliable and clinically
significant change in violence risk among secure psychiatric inpatients. Comprehensive
Psychiatry, 62, 132–140. doi:10.1016/j.comppsych.2015.07.009
Olver, M. E., Lewis, K., & Wong, S. C. (2013). Risk reduction treatment of high-risk
psychopathic offenders: The relationship of psychopathy and treatment change to
violent recidivism. Personality Disorders, 4, 160–167. doi:10.1037/a0029769
Sentencing Act, (Vic) (Austl.), (1991).
Serin, R. C., Lloyd, C. D., Helmus, L., Derkzen, D. M., & Luong, D. (2013). Does intra-individual
change predict offender recidivism? Searching for the Holy Grail in assessing offender
change. Aggression and Violent Behavior, 18, 32–53. doi:10.1016/j.avb.2012.09.002
Strub, D. S., Douglas, K. S., & Nicholls, T. L. (2014). The validity of Version 3 of the HCR-20
violence risk assessment scheme amongst offenders and civil psychiatric patients.
International Journal of Forensic Mental Health, 13, 148–159. doi:10.1080/14999013.
2014.911785
Victorian Institute of Forensic Mental Health. (2015). Annual report 2014–2015. Retrieved
from http://www.forensicare.vic.gov.au/assets/pubs/ReportofOperations20142015.
pdf
Wong, S., & Gordon, A. (2000). Violence risk scale. Saskatoon: Stephen Wong & Audrey
Gordon.