An evaluation of the understanding risk group programme in inpatient forensic psychological services
| Date | 02 December 2024 |
| Pages | 34-49 |
| DOI | https://doi.org/10.1108/JCRPP-06-2024-0045 |
| Published date | 02 December 2024 |
| Author | Kirsty M. Taunton,Hannah R. Cook,Stacey Eyers |
An evaluation of the understanding risk
group programme in inpatient forensic
psychological services
Kirsty M. Taunton, Hannah R. Cook and Stacey Eyers
Abstract
Purpose –Risk assessment and risk management planning are integral to reducing risk of future
violence in forensic settings. Over the past decade, emphasis has been placed on involving service
users in this process. Nonetheless, service user knowledge of violence risk assessments such as the
Historical-Clinical-RiskManagement-20,Version 3 (HCR-20v3) and collaborative risk assessmentis often
limited. This service evaluation aimed to assess the effectiveness of a pilot Understanding Risk
programme,on increasing knowledge of the HCR-20v3 and insightinto risk of violence.
Design/methodology/approach –The methodology used was a within-subjects design, collecting
quantitative data beforeand after intervention. Participants’ beliefs and attitudes supportive of violence,
and perceptions of theirrecovery, were assessed using a semi-structuredHCR-20v3 questionnaire, the
Maudsley ViolenceQuestionnaire and the Recovery Assessment Scale –Domainsand Stages. An HCR-
20v3 historical factor checklist was also completed. The final sample (n¼11) consisted of low and
mediumsecure forensic inpatients.
Findings –The results of this study indicated that after intervention, parti cipants had significantly greater
knowledge of the HCR-20v3 and more positive perceptions of their functional and personal recovery.
Significant changes were not observed on the Maudsley Violence Question naire total score; however, further
analysis indicated significantly lower scores on the ‘‘acceptance of violence’’ subscale after interventi on.
Practical implications –The Understanding Risk programme was associated with positive changes
across treatment domains in a small sample of forensic inpatients. Specifically, improvements were
observed for increasedknowledge of the HCR-20v3, attitudes towards recovery and non-acceptance of
violence.It would be of clinical benefit to replicate this studyacross different levels of security to increase
the generalisability of findings. This study shows promise for the efficacy of the Understanding Risk
programmeamong forensic inpatients.
Originality/value –This service evaluation provides preliminary support for the benefits of educating
and involvingservice users in violence risk assessment.
Keywords Risk assessment, Recovery
Paper type Research paper
Introduction
Forensic secure units are responsible for the effective assessment and treatment of
individuals with serious mental illness and a forensic history (Seppa
¨nen et al., 2018).
Studies investigating the prevalence of violence within forensic inpatient settings have
produced varied findings; this is partly because of differences in sample populations and
what constitutes violence (Bunce et al., 2023;Neumann and Klatt, 2022). For example,
some studies focus on distinct subtypesof violence, whereas others adopt a more inclusive
definition of violence (Dickens et al., 2013). Nonetheless, prevalence rates as high as 44%
have been evidenced in the literature (Ketelsen et al.,2007), with over a third of forensic
inpatients perpetrating a minimumof one physical assault during their admission (Broderick
Kirsty M. Taunton, Hannah
R. Cook and Stacey Eyers
are all based at Forensic
Psychological Services,
Essex Partnership
University NHS Foundation
Trust, Wickford, UK.
Received 25 June 2024
Revised 3 October 2024
Accepted 7 November 2024
The authors are grateful to staff
at Essex Partnership University
NHS Foundation Trust for their
support throughout the study
including Debra Easton, Dr
Emma Gray, Dr Kristoff Bonello,
and Pauline Young.
Disclosure statement: No
potential conflict of interest was
reported by the author.
Data availability statement: The
data that support the findings
of this study are available on
request from the corresponding
author [anonymised copy].
Anybody wishing to use the
semi-structured
HCR-20v3 questionnaire and/or
the HCR-20v3 Historical Factor
Checklist should contact the
corresponding author
[anonymised copy].
PAGE 34 jJOURNAL OF CRIMINOLOGICAL RESEARCH, POLICY AND PRACTICE jVOL. 11 NO. 1 2025, pp. 34-49, ©Emerald Publishing Limited, ISSN 2056-3841 DOI 10.1108/JCRPP-06-2024-0045
et al.,2015). Higher rates of inpatient violencehave also been observed in forensic inpatient
units compared to general psychiatric units (Neumann and Klatt, 2022), and future violence
is prevalent among individualsdischarged from forensic mental health services (Fazel et al.,
2016). The robust assessment and management of violence risk is, therefore, crucial to
enhance patient and staffsafety and to maximise public protection.
Numerous factors should be taken into account when assessing risk; specificall y, static,
dynamic and future factors (Coid et al., 2016). Historically, risk assessments adopted an
actuarial and unstructured clinical judgment approach (Hilton et al., 2006) . Structured
professional judgement is a third type of risk assessment that combi nes the use of a
structured template with clinical judgement (Royal College of Psychiatrists, 2016) and is
thought to be superior to alternative approaches (Monahan et al.,2001).Adopt ing a structured
professional judgement approach, the Historical-Clinical-Ri sk Management-20, Version 3
(HCR-20v3; Douglas et al., 2014) is composed of 20 risk factors known to predict future
violence. The “Historic” section consists of ten items, and the “Clinical” and “Ris k
Management” sections each contain five items. A formulation, risk scenarios and risk
management plan are also derived as part of the risk assessment process. Th e Female
Additional Manual (FAM) is an additional guideline used along side the HCR-20v3, to facilitate
the risk assessment of females (de Vogel et al., 2014). The HCR-20v3 FAM contains a n
additional eight items centred around pregnancy at a young age, childcar e responsibilities,
suicidal behaviour and/or self-harm, covert behaviour, self-esteem and prostit ution. In line with
best practice guidelines, the HCR-20v3 is the most frequently used t ool to assess risk of
violence in forensic settings in the UK (Beazley et al.,2017). Typically, it is completed within 12
weeks of a patient’s admission to hospital,after which it is updated every six months.
Completion of the HCR-20v3 varies across services, with regar ds to how it is completed and
who it is completed by. However, one factor that has received increasing attenti on of late is the
significance of service user involvement in the risk assessment process (Department of
Health, 2009;NHS England, 2013), which is thought to have many benefits. Whilst clini cians
often have access to patients’ medical records, obtaining further information fro m patients
themselves can allow for a more precise evaluation of risk, enhanci ng formulation (Beazley
et al., 2017) and the development of a positive therapeutic alliance (de Vries Robb
eet al.,
2011). Involving patients in the risk assessment process also promotes empowerment
(Deegan and Drake, 2006;Gough et al.,2015), self-deter mination and resilience (Royal
College of Psychiatrists, 2016), whilst instilling hope that there is life beyond hospital
(Henagulph et al.,2012). Moreover, collaborative ri sk assessment can provide patients with a
better understanding of why they are detained in hospital and how the y can progress to
discharge (Henagulph et al., 2012). Adopting an inclusive and recovery-based appro ach to
risk assessment has also been found to reduce incidents of restr aint and the number of
patients being nursed in seclusion (Ashcraft and Anthony, 2008).
Despite the clear benefits of collaborative risk assessment (Markham, 2020), patient
involvement in this process is often lacking (Dixon, 2012;Gough et al., 2015;Langan and
Lindow, 2004). In an early study by Langan and Lindow (2004), several patients were
unaware of the risks that they posed. Moreover, Dixon (2012) found that the majority of the
patients in their study had no awareness of an HCR-20v3 having been completed to
evaluate their risk. In addition in Gough et al.’s (2015) study, only 6% of patients were
actively involved in the completion of their HCR-20v3. Importantly, increasing insight into
risk of violence may lead to a reduction in violence perpetration (Bjørkly, 2006), and it has
been argued that interventions targeted at improving insight are needed (Buckley et al.,
2004). Nonetheless, to date, there is a distinct lack of psychological intervention targeting
this area, as well as empirical literature evaluating the effectiveness of such treatment. One
study details a psychoeducational programme called “The Safety Planning Group”, an
eight-week programme which provides information on risk assessment and management.
The effectiveness of this, however, was not evaluated. Only oneidentified study evaluated a
VOL. 11 NO. 1 2025 jJOURNAL OF CRIMINOLOGICAL RESEARCH, POLICY AND PRACTICE jPAGE 35
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