Sovereign Citizens comprise an understudied right-wing extremist movement in the United States who have grown in notoriety in recent years due to several high-profile instances of violence. Despite this, little empirical research has been conducted on Sovereign Citizens, including research on assessing their risk for violence. In this study, we sought to replicate and extend a prior study on Sovereign Citizen violence. Using open-source data, we added several new cases to a pre-existing dataset of violent and non-violent Sovereign Citizen incidents, yielding a total sample of 107 cases, 69 of which were scored using the HCR-20V3 , and 83 of which were scored using the TRAP-18. Our findings indicated that higher scores on both instruments were significantly associated with greater odds of cases being violent. We also observed that several risk factors occurred with significantly more frequency among violent cases than non-violent ones. Implications for future research and professional practice are discussed.

The Historical-Clinical-Risk Management Scale 20 (HCR-20) is a structured tool to assess the risk of violence and assist in its management. French professionals are reluctant to use it because only a few studies have shown its psychometric qualities with French samples. The objective of this study is to test the psychometric qualities of the HCR-20 with samples of violent detainees in France. The HCR-20 and Level of Service/Case Management Inventory (LS/CMI) were administered to 128 violent offenders with an average age of (44.16±12.30) years. We evaluated the reliability, internal consistency and validity of the HCR-20 and conducted an exploratory factor analysis. The results show that the HCR-20 has good psychometric qualities with a sample of French prisoners. Only the Risk domain presents weak results due to the data collection locations and the participants\' age. Correlations were observed between certain factors. The exploratory factor analysis shows four factors explaining 44% of the variance. The continuation of this work will enable French professionals to use sound tools to assess the risk of recidivism.

In 2011 Mrs A assaulted two people, one who died. In the hours prior to the attack she made multiple attempts to gain help including attending accident and emergency, contact with an inpatient service and the police. Subsequent investigation highlighted that her risk was not well documented or understood.
This quality improvement project aimed to improve knowledge and awareness of HCR-20 risk assessments amongst mental health professionals.
The Quality Improvement approach was taken and various initiatives were introduced to improve knowledge of the location and purpose of the HCR-20 and to ensure that these risk assessments were regularly updated.
The results indicated that knowledge relating to the HCR-20 significantly improved amongst staff and breaches of deadlines for updating these risk assessments dramatically declined after the induction of the interventions.
Including the \'risk formulation\' and \'scenarios\' from the HCR-20 in clients\' crisis plans, introducing training relating to the HCR-20, and including discussions relating to the HCR-20 at the beginning of CPA meetings resulted in improved MDT awareness and knowledge of the HCR-20. A broader understanding and awareness of risk factors enabled the service to move towards a culture of risk being everyone\'s business.

BACKGROUND: Treatment completion difficulties are common in forensic mental health settings and may have a profound impact on recidivism rates.
OBJECTIVE: To test for associations between measures of risk and of security needs on the one hand and treatment non-completion on the other among male offender-patients in one medium security hospital.
METHODS: We conducted a retrospective file study in a Flemish medium security hospital. A random sample of 25 treatment non-completers was compared to a random same-size sample of completers, each rated, blind to outcome, on the DUNDRUM-1 security needs scale from data recorded at the time of admission to the unit. \'Non-completion\' was defined as any failure to complete treatment, whether staff-terminated or self-terminated; in Flanders, failure to comply with the judicial conditions of placement can result in re-imprisonment. We used binary logistic regression to test relationships between treatment completion/non-completion and security need, measured with the DUNDRUM-1, together with a range of possible confounding variables.
RESULTS: Most patients had psychosis and/or personality disorder and often substance use disorders also. Treatment non-completion was invariably staff ordered because of security breaches. DUNDRUM-1 and PCL-R Facet 4 scores at the time of admission and HCR-20 scores during admission were significantly higher among non-completers than completers, but after binary logistic regression, only the DUNDRUM-1 rating was independently associated with non-completion.
CONCLUSIONS: Our study showed that an admission DUNDRUM-1 rating, indicating levels of security need, co-varies only to a small extent with the historical items of the HCR-20, so may be regarded as measuring complementary domains. While conditions in Flanders at the time of the study complicated it in that medium security hospital units offered the highest level of hospital security available, the finding that non-completion of treatment was particularly likely when the DUNDRUM-1 indicated a higher security need than facilities could provide may have implications for all secure hospital services.

The HCR-20, a widely used method of assessing and managing risk, relies on the structured professional judgement approach. This paper reports a narrative literature review of the HCR-20 studies to explore the applicability of the study results to the use of the HCR-20 in clinical practice. From a literature search using terms \"HCR-20\" and \"HCR 20\", 206 papers were included. Of studies using the HCR-20 version 2 (n = 191), 92% (n = 176) relied on variables based on scores derived by adding item scores, and 50% (n = 95) tested the HCR-20 using predictive validity methodology. Of the HCR-20 version 3 studies (n = 21), the \"presence of risk factors\" step was the most commonly examined (n = 18, 86%), but 2 of the 7 steps (\"scenario planning\" and \"management\") were not examined at all. Amongst those studies whose primary focus was on the HCR-20, 67% (n = 64/95) did so by assessing the predictive validity of the tool. Only one employed a design to test whether the use of the HCR-20 affected violence rates. The predominant study design provides support for the use of the HCR-20 as an actuarial tool, and there is limited empirical evidence in support of its effectiveness as a structured professional judgement approach to the assessment and management of the risk of violence.

CONCLUSIONS: The HCR-20 has taken on a life of its own. In forensic services it has been elevated from helpful aide-mémoire into a prophetic tool worthy of Nostradamus himself. Almost every outcome is interpreted through it. Despite the evidence of its limited utility, the difficulties of predicting rare events, the narrative fallacies and other heuristic biases it creates, and the massive opportunity costs it entails, commissioners and services alike mandate its use. Yet in routine practice the problems are not acknowledged, multiple conflicts of interest lie unobserved and other opportunities are neglected.

The link between schizophrenia spectrum disorders (SSD) and violence is a core issue for most forensic psychiatric services. However, the drivers of violence in this population remain unclear, and, to date tools to predict violence risk have a range of limitations. Perhaps because of this uncertainty about the nature of violence risk, treatment programmes and care pathways for mentally disordered offenders vary substantially across the European Union, and differences in legal and policy frameworks are highly relevant.
The three-year EU-VIORMED project (Grant Number PP-2-3-2016, November 2017-October 2020) involves forensic centres in Italy, Austria, Germany, Poland, and the U.K. It aims to: (a) identify and compare violence risk factors, clinical needs, and decision making capacity in violent (N = 200, \"cases\") and nonviolent patients with SSD (N = 200; \"controls\") using a case-control design; (b) test the predictive validity of the HCR-20v3, OxMIS and FoVOx among cases alone (N = 200), using a prospective cohort study; and (c) compare forensic-psychiatric care pathways across the EU, in a continent wide service mapping study.
Data collection started in September 2018 and continues. By September 2019, 333 participants have been enrolled (201 cases and 132 controls were recruited). Experts from 23 countries provided data for the service mapping exercise.
Retrospectively registered on January 2, 2019 as researchregistry4604 January 2, 2019.

BACKGROUND: Patients suffering from severe mental disorders and who have an increased risk of violent behavior, tend to be insufficiently cared for until committing a violent offense leads to compulsory placement in a forensic psychiatric clinic.
OBJECTIVE: The concept of the preventive outpatient clinic has been recently published in this journal. The aim of the study was to evaluate whether treatment in the outpatient clinic is preventive with respect to violence and whether there is a positive therapeutic outcome.
METHODS: The study design was quasi-experimental and longitudinal. The control group consisted of comparable patients from an adjacent healthcare catchment area. Measurements were taken on admission (t0) and after 6 and 12 months of treatment (t1 and t2, respectively). Dynamic risk factors, i.e. subscales C and R of the history clinical risk-20 version 2 (HCR-20 V2) scale and global assessment of functioning (GAF) scale were used as indicators of treatment success, involving both clinician ratings and self-reports. Multiple imputed data for 70 subjects in the experimental group and 51 in the control group were analyzed by mixed effects models with group as a fixed effect.
RESULTS: The interaction effect between time and group was statistically significant for the R (risk management) subscale and the GFA values but not for the C (clinical risk) value (after Bonferroni correction), whereby controls were made for multiple testing.
CONCLUSIONS: The hypothesis with respect to the efficacy of the treatment could be maintained regarding risk markers and global assessment of functioning. With respect to clinical parameters there was a positive tendency in the expected direction. The data therefore indicate a positive effect of the preventive outpatient clinic for the patients treated.

The present study featured an investigation of the predictive properties of risk and change scores of two violence risk assessment and treatment planning tools-the Violence Risk Scale (VRS) and the Historical, Clinical, Risk-20, Version 2 (HCR-20)-in sample of 178 treated adult male violent offenders who attended a high-intensity violence reduction program. The cases were rated on the VRS and HCR-20 using archival information sources and followed up nearly 10 years postrelease. Associations of HCR-20 and VRS risk and change scores with postprogram institutional and community recidivism were examined. VRS and HCR-20 scores converged in conceptually meaningful ways, supporting the construct validity of the tools for violence risk. Receiver operating characteristic curve analyses demonstrated moderate- to high-predictive accuracy of VRS and HCR-20 scores for violent and general community recidivism, but weaker accuracy for postprogram institutional recidivism. Cox regression survival analyses demonstrated that positive pretreatment and posttreatment changes, as assessed via the HCR-20 and VRS, were each significantly associated with reductions in violent and general community recidivism, as well as serious institutional misconducts, after controlling for baseline pretreatment score. Implications for use of the HCR-20 and VRS for dynamic violence risk assessment and management are discussed.

This study examined the predictive validity of the Spanish version of the Suicide Risk Assessment Manual (S-RAMM) and the Historical-Clinical-Risk Management-20 (HCR-20) in a sample of violent offenders with schizophrenia and other psychosis, who had committed violent crimes and had been sentenced to compulsory psychiatric treatment by the criminal justice system. Patients were prospectively monitored within the institution for 18 months. During the follow-up period, 25% of offenders were involved in any suicidal behavior including acts of self-harm, suicidal ideation and suicide attempts and 34% were physically or verbally violent. The S-RAMM and HCR-20 risk assessment tools were strongly correlated and were able to predict suicidal behavior and violence with a moderate-large effect size (AUCs = 0.81-0.85; AUCs = 0.78-0.80 respectively). Patients scoring above the mean on the S-RAMM (>20-point cut-off) had a five times increased risk of suicide related events (OR = 5.05, 95% CI = 2.6-9.7) and sevenfold risk of violence in the HCR-20 (>21-point cut-off) (OR = 7.13, 95% CI = 2.0-21.2) than those scoring below the mean. Offenders at high risk for suicide and violence had significantly more suicide attempts (p < 0.001) and more prior sentences for violent crimes (p < 0.001). These results support the use of the S-RAMM and HCR-20 for clinical practice by providing evidence of the utility of these measures for predicting risk for suicidal and violent behavior in mentally disordered offenders.