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= Historical, Clinical, Risk Management-20, HCR-20 = The HCR-20 is structured professional judgement (SPJ) tool used in the fields of forensic psychology and forensic psychiatry with the aim of violence risk assessment and management. The HCR-20 is the most widely used violence risk assessment tool and has been translated into multiple languages. Rating sheets of the current version are available from the publishers for non-commercial purposes.

Introduction
Violence risk assessment is a core part of forensic mental health practice and the

== History == The first edition dates from 1993, and was updated in 1995. A second edition followed in 1997. The current version, the HCR-20v3 was published in 2013. original version was presented as an 'aide memoir', a checklist for factors of violent behaviour to be used by clinicians to systematically demonstrate consideration of the range of factors included. As now 20 factors consisted of 10 Historical (H), 5 Clinical (C) and 5 Risk Management (R) items. The second version then required assessors to make a judgement as to the presence of the item (absent, possibly / partially presnet and present) and then the significance of that factor towards violence risk (high, medium, low).

Evidence
== Criticisms ==

Risk Factors
The risk factors included in the HCR-20 are arguably arbitrary and do not include the strongest predictors of violence: age and sex. Of the factors included many lack evidence from large scale studies of violence recidivism such as the MacArthur Study or more recent large scale epidemiological research and many do not predict violence. Other findings show that random combinations of risk factors, whether or not items in the HCR-20 can produce tools with broadly similar predictive powers.

Publication Bias and Declarations of Interest
There is significant evidence of publication bias in relation to the reporting of findings of risk assessment tools in general, with one meta-analysis finding that no authors of risk assessment tools declared a financial conflict of interest in their publications

Cost- training, licensing, time
There is a significant opportunity cost, with estimates that each HCR-20 takes in the region of 16 hours to complete. Institutions and independent practitioners currently pay approximately $500 for online training.

Lack of RCT evidence
There is no grade 1 or 2 evidence for the effectiveness of the HCR-20 in either predicting or preventing violence. The same applies for all SPJ tools. The only RCT of an SPJ tool, of the START, showed a negative result, using the START resulted in no significant effect and incidents of violence were more frequent in the intervention group than in the control, although without this being statistically significant.

Research vs Clinical Validity
Although the HCR-20 authors suggest that the validity of the HCR-20 is high, this may not be true in clinical as opposed to research settings when assessed in psychiatric inpatient settings in both Flanders and Scotland. Similar difficulties exist with other tools such as the PCL-R which are used in violence risk assessment.

Lack of Validity for Violence in Schizophrenia
Although the HCR-20 is commonly used in forensic mental health settings, where the majority of inpatients have serious psychotic illnesses such as schizophrenia, the HCR-20 has been shown to lack validity when used in this diagnostic group and 'young age at first violent incident', whilst a risk factor in the HCR-20 is negatively correlated with future violence in people with schizophrenia.

Lack of Superiority Against Actuarial Assessments
Evidence from from both individual studies and large meta-analyses show no significant difference between actuarial tools such as the VRAG and SPJ violence risk assessments, with some studies, such as one from Ashworth High Secure Hospital in the UK showing the VRAG to be superior.

Heuristic Biases
The HCR-20 now requires the generation of a narrative explanation. One dimensional. B iases orientation and experience of the author as well as all the heuristic biases found in professional judgements .Given the difficulties experienced by mental health teams following serious untoward incidents, such as homicides committed by discharged patients, there is the possibility that authors may exaggerate risk to avoid conclusions that might in hindsight be consider erroneous .Rater Bias High media profile paper.

Group ratings
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High, Medium and Low Risk Categories
In the HCR-20 predictions of future risk are expressed adjectivally; high, medium and low. But these terms have no objective meaning and are not correlated with actual risk when expressed as a percentage risk of reoffending. The 'high' risk category has been fond to be associated with annualised violence rates ranging from 5-100%.