Communicating the risk of violent and offending behavior: review and introduction to this special issue

Evaluating layperson interpretation of actuarial sexual violence risk data: A multi-method comparison of risk communication with attention to gender bias

Forensic clinicians are often called upon to help courts determine the likelihood that someone will continue to commit sexually violent acts in the future. The utility of these evaluations depends largely on how effectively the results are communicated to and understood by the trier of fact. Actuarial results, such as those commonly reported in sexual offense risk assessments, appear particularly challenging for laypersons to understand. Using a representative sample of 206 U.S. adults, this study examines three methods of communicating actuarial risk via simulated expert testimony on participants' ratings of a hypothetical evaluee's risk of sexual re-offending. The results suggested that all participants, regardless of how results were communicated, over-estimated the examinee's risk level relative to the expert's probabilistic findings, but tended to agree with the expert's categorical predictions. Participants who were only shown actuarial data consistently rated the evaluee as more dangerous and likely to commit future sexually violent acts. Additionally, it was found that gender significantly impacted participants' perceptions, such that women found the evaluee more dangerousness and desired greater social distance from him. This study has implications for best practices regarding expert communication of actuarial results in cases involving sexual violence.

Same Score, Different Audience, Different Message: Perceptions of Sex Offense Risk Depend on Static-99R Risk Level and Personality Factors of the Recipient

There are multiple ways to report risk scale results. Varela et al. (2014) found that Static-99R results were interpreted differently by prospective jurors based on risk level (high vs low) and an interaction between risk level and risk communication format (categorical, absolute estimate, and risk ratio). We adapted and extended Varela et al.'s (2014) study using updated Static-99R norms, recruiting a population-wide sample (n = 166), and adding variables assessing the personality factors 'cognitive motivation' (i.e., need for cognition) and 'attitudinal affect' (i.e., attitudes toward sex offenders, authoritarianism). We found a main effect of risk level and no effect of either communication format or the interaction between the two. Adding the personality variables increased explained variance from 9% to 34%, suggesting risk perception may be more about the personality of the person receiving the information than the information itself. We also found an interaction between attitudes toward sex offenders and risk level. Our results suggest risk perception might be better understood if personality factors are considered, particularly attitudes toward sex offenders. Because biases/personality of the person receiving the information are unknown in real world settings we argue that sharing multiple methods for communicating risk might be best and more inclusive.

Calibrating violence risk assessments for uncertainty

Psychiatrists and other mental health clinicians are often tasked with assessing patients' risk of violence. Approaches to this vary and include both unstructured (based on individual clinicians' judgement) and structured methods (based on formalised scoring and algorithms with varying scope for clinicians' judgement). The end result is usually a categorisation of risk, which may, in turn, reference a probability estimate of violence over a certain time period. Research over recent decades has made considerable improvements in refining structured approaches and categorising patients' risk classifications at a group level. The ability, however, to apply these findings clinically to predict the outcomes of individual patients remains contested. In this article, we review methods of assessing violence risk and empirical findings on their predictive validity. We note, in particular, limitations in calibration (accuracy at predicting absolute risk) as distinct from discrimination (accuracy at separating patients by outcome). We also consider clinical applications of these findings, including challenges applying statistics to individual patients, and broader conceptual issues in distinguishing risk and uncertainty. Based on this, we argue that there remain significant limits to assessing violence risk for individuals and that this requires careful consideration in clinical and legal contexts.

Privacy and safety: Issues of dual compliance in high-secure and other forensic psychiatric hospitals

Health care organizations are obligated to provide safe and effective treatment to their patients and also protect the safety of their workers. This paper analyzes the tensions arising from legislative regimes that, respectively, protect privacy and workplace safety, using a large, tertiary high-secure forensic psychiatric hospital in Ontario, Canada, as an example. In Ontario, the Personal Health Information Protection Act (PHIPA) prohibits personal health information (PHI) from being disclosed to individuals who fall outside the "circle of care," including nonclinical employees who have direct involvement with patients and may be at risk of violence. PHIPA permits the disclosure of information where there is a risk of violence, but the statute's scheme for privacy protection was not designed to address, and may not be compatible with, the operations and requirements of high-secure forensic and other psychiatric hospitals. At the same time, the Occupational Health and Safety Act (OHSA) creates a regulatory framework that sets health and safety standards, including an employer's duty to disclose the risk of violence. OHSA prosecutions and proceedings demonstrate how these duties have been enforced against psychiatric hospitals. We examine this regulatory backdrop, explaining that PHIPA provides little guidance to psychiatric hospitals, where the risk of violence is elevated. We also discuss issues of dual compliance that arise from a hospital's legal obligations under PHIPA and OHSA. Finally, we turn to the ongoing clinical and operational challenges, suggesting strategies for increasing staff safety. These include strengthening the therapeutic alliance and providing patients with the option of consenting to disclosure of PHI to those outside the circle of care.

Improving Risk Communication: Developing Risk Ratios for the VRAG-R

We developed a set of risk ratios for the Violence Risk Appraisal Guide-Revised (VRAG-R) to broaden the range of risk communication options available when using this tool and to provide information needed for future efforts to apply The Council of State Governments Justice Center's standardized five-level risk framework to the scale. A slightly reduced version of the VRAG-R normative data set was used for the analyses (N = 1,238). Contrary to previous research developing risk ratios, logistic regression provided a more accurate estimate of observed violent recidivism rates than Cox regression for both total VRAG-R scores and VRAG-R decile bins. Further analyses indicated the relationship between the VRAG-R and violent recidivism was consistent over a 15-year follow-up period. Due to the difficulties with interpreting odds ratios, the final risk ratios were computed using rate ratios derived from a logistic regression model using a 5-year fixed follow-up period. These risk ratios, and templates for how the ratios might be used in an assessment report, are presented in the appendices.

Evaluating Change in Men Who Have Sexually Offended: Linkages to Risk Assessment and Management

PURPOSE OF REVIEW

We provide a review and synthesis of the sexual offense treatment change literature with implications for dynamic sexual violence risk assessment and management. An argument is presented for the need for a dynamic approach in research and practice, and that for change to be prognostic, such changes need to be risk relevant and to come from credible change agents.

RECENT FINDINGS

Extant research demonstrates that changes on psychologically meaningful dimensions of risk and need (e.g., sexual deviance; attitudes and cognitions; anger, aggression, and hostility) tend to be associated with reductions in sexual and other forms of recidivism; however, changes in domains less germane to risk and need tend not to be (e.g., empathy, mental health and well-being). Formalized dynamic sexual offense risk measures can be administered at multiple time points to reliably measure changes in sexual violence risk. Change information can then be used systematically to adjust risk appraisals. The extant literature supports the dynamic nature of sexual violence risk. Working toward the routine assessment of change with psychometrically sound measures, and integrating this information into risk management interventions, can not only improve lives and reduce sexual violence but is an ethical and human responsibility.

Risk assessment communication difficulties: An empirical examination of the effects of categorical versus probabilistic risk communication in sexually violent predator decisions

Expert testimony concerning risk and its communication to the trier of fact has important implications for some of the most significant legal decisions. In a simulated sexual violent predator hearing, we examined how mock jurors interpret and use recidivism risk expert testimony communicated either categorically, using verbal labels, or probabilistically, using numeric values. Based upon the STATIC-99R, we compared mock jurors' decision-making and verdicts when we manipulated the style of risk communication across four different risk levels. In terms of verdict decisions, we found that higher risk levels were associated with more commitment decisions, but that this relationship only existed for the categorical risk-communication format. We also replicated previous research demonstrating that participants overestimate recidivism risk in general, especially when higher risk is communicated categorically. Finally, our participants did not differentiate well between the four levels of risk offered, instead apparently employing a more simplistic dichotomy between "low" or "high" risk for both their verdict decisions and their thresholds for commitment. The legal and policy implications of our findings are discussed, as well as suggestions for more effective presentation of expert risk testimony.

The case against categorical risk estimates

Risk estimates can be communicated in a variety of forms, including numeric and categorical formats. An example of the latter is "low/medium/high risk." The categorical format is preferred by judges and practitioners alike, and is mandated by the most commonly utilized forensic risk assessment instruments (the HCR-20 and the Static-99). This article argues against the practice of communicating risk in categorical terms on empirical and normative grounds. Empirically, there is no consensus about what level of risk corresponds to a particular category, such as "high risk." Moreover, recent studies indicate that categorizing an otherwise continuous risk estimate does not add incremental predictive validity to the risk estimate. Normatively, categorization obscures what is fundamentally a value judgment about the relative costs and benefits of correct (e.g., true positive) and incorrect (e.g., false positive) outcomes. Such a judgment is inherently non-scientific and invades the province of the jury. Indeed, categorical risk estimates are in principle no different than "dangerousness predictions," which are simply binary and which have been denounced by the field. The fact that alternative risk communication formats have limitations does not justify continuing the pervasive practice of communicating categorical risk estimates.

Sex Offender Risk Assessment: Where Are We and Where Are We Going?

PURPOSE OF REVIEW

Risk assessment is one of the most ubiquitous tasks in the criminal justice system, informing virtually every decision made about offenders. This review, intended for researchers and practitioners, outlines some of the most important recent advances, emerging issues, and recommendations in sex offender risk assessment.

RECENT FINDINGS

The underlying nature and purpose of risk scales is reviewed, with implications for how we should evaluate them. Limits of recidivism probability estimates are discussed, and efforts to advance a common language for describing risk levels are highlighted. Advances in risk communication and field validity are summarized. The utility of protective risk factors in risk assessments is debated. Emerging areas in assessing offender change and assessments with child pornography offenders are discussed. Despite critical advances in the last few years, there are still important gaps in knowledge, particularly for risk communication, field implementation, offender change, and child pornography offenders.

Preventative Services for Sexual Offenders

The role of primary prevention of sexual offences is an understudied area. The current study examined a sample ( N = 100) of men charged or convicted of a sexual offence to determine their interest in interventions that could be offered prior to offending, reasons for not seeking out interventions in the past, and demographic information including onset of deviant sexual fantasy and interests. The majority indicated that preventative interventions, including individual and group treatment, would have been beneficial, but inaccessibility of interventions and fear of arrest prevented them from seeking services. The findings suggest that men who progress to committing a sexual offence are interested in preventative interventions but require information regarding availability of accessible support and the development of primary prevention structures to fulfill society's desire to prevent sexual offending.

Diagnosing Crime and Diagnosing Disease: Bias Reduction Strategies in the Forensic and Clinical Sciences

Cognitive effort is an essential part of both forensic and clinical decision-making. Errors occur in both fields because the cognitive process is complex and prone to bias. We performed a selective review of full-text English language literature on cognitive bias leading to diagnostic and forensic errors. Earlier work (1970-2000) concentrated on classifying and raising bias awareness. Recently (2000-2016), the emphasis has shifted toward strategies for "debiasing." While the forensic sciences have focused on the control of misleading contextual cues, clinical debiasing efforts have relied on checklists and hypothetical scenarios. No single generally applicable and effective bias reduction strategy has emerged so far. Generalized attempts at bias elimination have not been particularly successful. It is time to shift focus to the study of errors within specific domains, and how to best communicate uncertainty in order to improve decision making on the part of both the expert and the trier-of-fact.

The biasing effect of the "sexually violent predator" label on legal decisions

Public fear has driven legislation designed to identify and exclude sexual offenders from society, culminating in sexually violent predator (SVP) statutes, in which a sex offender who has served his prison sentence is hospitalized indefinitely if a jury determines that he is likely to reoffend as a result of a mental disorder. Jurors rarely vote not to commit a previously-convicted sex offender as an SVP. This study tests whether the mere label of "sexually violent predator" affects these legal decisions. Venire jurors (n=161) were asked to decide whether an individual who had been incarcerated for 16years should be released on parole. The individual was either labeled as a.) a sexually violent predator or b.) a convicted felon, and all other information was identical between the conditions. Jurors were over twice as likely to deny parole to the SVP compared to the felon, even though they did not consider him any more dangerous or any more likely to reoffend. Demographic variables did not moderate this finding. However, jurors' desire to 'get revenge' and to 'make the offender pay', as measured by Gerber and Jackson's (2013) Just Deserts Scale, did significantly relate to decisions to deny parole. These findings suggest that jurors' decisions in SVP hearings are driven by legally impermissible considerations, and that the mere label of "sexually violent predator" induces bias into the decision making process.