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A Review of Violence Risk Assessment for Mentally Disordered Patients in Mainland of China Yan Gu, Jay P. Singh, Libing Yun and Zeqing Hu Criminal Justice and Behavior published online 27 August 2014 DOI: 10.1177/0093854814547950 The online version of this article can be found at: http://cjb.sagepub.com/content/early/2014/08/22/0093854814547950

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CJBXXX10.1177/0093854814547950Criminal Justice and BehaviorGu et al. / Violence Risk Assessment in China

A Review Of Violence Risk Assessment For Mentally Disordered Patients In Mainland Of China Yan Gu Sichuan University

Jay P. Singh Molde University College Global Institute of Forensic Research, LLC

Libing Yun Zeqing Hu Sichuan University

The Chinese research literature on violence risk assessment is small compared with Western countries. However, violence by mentally disordered populations is an area of considerable importance in China, given major legal developments in recent years. The aim of the present article was to provide an overview of the current state of violence risk assessment practices in China, focusing on the role that such assessments play in forensic and non-forensic hospitals as well as in community treatment settings. The Chinese evidence base on currently available approaches to violence risk assessment was also explored. Further research on risk assessment, formulation, communication, and management is needed before it can be argued that practitioners in China charged with making risk-based decisions are using the most scientifically defensible procedures. Keywords:  violence; risk assessment; China; mental illness; forensic

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ith more than 1.3 billion residents, China is the most populous country in the world. Despite a stably low annual incidence of violent crime in recent years (0.004%), interpersonal violence remains a major public health concern (Law Yearbook of China, 2012). Hence, the assessment of violence risk has become an important role tasked to mental health professionals working in both institutional and community settings. Considerable advances have been made over the past several decades in the accurate prediction of future violence in mentally disordered populations (Fazel, Singh, Doll, & Grann, 2012; Skeem & Monahan, 2011). Such advances are welcome, as decisions influenced by violence risk assessments can have far-reaching civil rights and public safety implications. Despite the importance of this science, however, the violence risk assessment literature of China is small compared with that of Western countries such as the United

Authors’ Note: Correspondence concerning this article should be addressed to Zeqing Hu, Department of Forensic Psychiatry, Sichuan University, No.16. Section 3, RenMin Nan Road, Chengdu, Sichuan, People’s Republic of China; e-mail: [email protected]/ [email protected]. CRIMINAL JUSTICE AND BEHAVIOR, 201X, Vol. XX, No. X, Month 2014, 1­–8. DOI: 10.1177/0093854814547950 © 2014 International Association for Correctional and Forensic Psychology

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States, the United Kingdom, and Australia (Singh, Grann, & Fazel, 2011). By identifying important themes and knowledge gaps in the extant Chinese literature, it may be possible to influence the research and policy agenda of this influential nation. The aim of the present article is to provide an overview of the current state of violence risk assessment in China. Specifically, the role that such assessments play in forensic and non-forensic hospitals as well as in community treatment settings is examined and the evidence base on currently available approaches to violence risk assessment is explored. To identify relevant research studies for this review, a systematic search was conducted current to 2014 using the MEDLINE, CNKI, VIP, and WANFANG databases1 with combinations of Boolean keywords capturing the domains of mental illness (e.g., psych*) and violence (e.g., viol*). The search identified 2,290 publications, most of which explored the relationship between individual risk factors and violence rather than the performance of risk assessment instruments. An Overview Of Chinese Mental Health Law

In recent decades, the introduction of mental health legislation has become a political priority in China. In 1985, a committee of five senior psychiatrists wrote the first draft of the National Mental Health Law. After nine subsequent drafts and much debate, 1999 saw the adoption of modified versions of the law in Shanghai, Beijing, and other provinces. It was not until October 2012, however, that the National People’s Congress of China adopted the law, which officially went into effect nationally in May 2013(Eleventh National People’s Congress Standing Committee). The National Mental Health Law aims to promote citizens’ psychological well-being through the improvement of mental health services. The law not only protects the human rights of patients diagnosed with mental disorders but also specifies the conditions under which residential treatment can be given. The law stipulates that patients who have been diagnosed with a severe mental illness and who are judged to be at risk to themselves or others may receive such treatment. However, whether persons are at risk to themselves or others is currently open to broad interpretation under the law. Once admitted to residential care, patients judged to be at high risk of violence may be subject to restraint and isolation to prevent them from harming staff or their peers. Outside of the residential context, the National Mental Health Law places the responsibility of mental health care with patients’ families. The role of violence risk assessment in both institutional and community care settings will be discussed in the following section. The Current State Of Violence Risk Assessment In China Violence Risk Assessment In Forensic Psychiatric Hospitals

To protect the civil rights of mentally disordered offenders as well as to ensure public safety, mandatory medical treatment of forensic patients in China must be carried out in special maximum security facilities called “Ankang” hospitals, meaning “Peace and Health.” As of 2005, there were 25 Ankang hospitals with more than 7,000 beds and approximately 2,958 staff members in the 23 provinces in China (Hu, 2005). The violence risk of patients is assessed on admission to, throughout treatment in, and prior to discharge from Ankang hospitals by forensic psychiatrists. These assessments are conducted as part of a Downloaded from cjb.sagepub.com at SIMON FRASER LIBRARY on September 8, 2014

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battery of mental health evaluations, as the presence of psychotic symptoms such as active delusions and hallucinations or lack of insight are considered key indicators of violence risk. As such, instruments such as the Brief Psychiatric Rating Scale (Overall & Gorham, 1962) are often used in the risk violence assessment process (Kang, Qi, & Feng, 2009). Evaluating the predictive validity of such assessments is difficult, as forensic patients are rarely followed after having been discharged from Ankang hospitals into the community, regardless of their risk level. Violence Risk Assessment In General Psychiatric Hospitals

Patients newly admitted to general psychiatric hospitals in China are screened for violence risk by nursing staff. This screening usually does not involve risk assessment tools, but rather the scoring of observational scales such as the Nurses’ Observation Scale for Inpatient Evaluation (NOSIE; Zhong, 2011), with higher scores implying a higher likelihood of violence. These evaluations are conducted using medical files and consultation with patients’ family members and assigned social workers. Furthermore, violence risk is not routinely taken into consideration when making discharge decisions. Rather, the alleviation of symptoms is usually the determining factor. Due to the limited number of forensic beds in China, some high risk mentally disordered offenders have to be managed and treated in general psychiatric hospitals. However, these offenders do not receive different care programs than non-forensic patients in these settings. Accordingly, forensic patients are discharged to the community not contingent on lowered violence risk but rather the alleviation of symptoms. Hospital stays have been becoming dramatically shorter over the past two decades, with the introduction of managed health care and governmental emphasis on the provision of treatment in the least restrictive setting available; as such, even patients judged to have a high likelihood of violence are regularly treated in the community after a few days to several weeks in hospital. This may increase rates of community violence, especially in the short-term period after initial discharge (Gu & Hu, 2009). Violence Risk Assessment In The Community

The reliable and valid assessment of violence risk for mentally disordered patients being treated in the community is considered by Chinese practitioners to be a priority in serving patients’ relatives and society-at-large (Liu et al., 2011). In support, the recently introduced Chinese Managerial and Treatment Regulations for Severely Mentally Disordered Patients (2009) make explicit that violence risk should be frequently assessed for community-based patients who experience severe delusions and hallucinations as well as those who have committed an act of violence (verbal or physical) in the previous half year. Such risk assessments are routinely conducted by social workers and community physicians, unless an act of physical violence has been recently perpetrated, in which case a psychiatrist will be asked to participate in the assessment. At present, no studies have been conducted examining the psychometric performance of these violence risk assessments. Current Violence Risk Assessment Methods In China

There are two general approaches to violence risk assessment: unstructured and structured. The former refers to the reliance on clinical experience and instinct to determine risk Downloaded from cjb.sagepub.com at SIMON FRASER LIBRARY on September 8, 2014

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level, whereas the latter refers to the use of more objective techniques such as checklists of theoretically and empirically based risk and protective factors for violence. A preponderance of research over the past 60 years supports the structured approach over the unstructured approach when it comes to both reliability and validity (Hilton, Harris, & Rice, 2006). Two distinct forms of structured violence risk assessment appeared during the 1980s and 1990s in North America: actuarial evaluation and structured professional judgment. Actuarial evaluation involves the generation of probabilistic estimates of violence risk without the influence of clinical judgment, whereas structured professional judgment involves the consideration of a pre-determined set of factors to aid in clinical determinations of violence risk. Both actuarial and structured professional judgment tools appear to be growing in their use in forensic, non-forensic, and community settings in China. According to the Western literature (Singh & Fazel, 2010), no single risk assessment tool has been consistently shown to have superior ability to predict violence risk. Whereas in China, no study about the consistency of tools has been done yet. In the following sections, the use of unstructured clinical judgment and both actuarial and structured professional judgment instruments in China are detailed, and key research studies are discussed. Unstructured Clinical Judgment

Although Chinese mental health practitioners have come to acknowledge the importance of violence risk assessment tools, unstructured clinical judgments of dangerousness remain common. There are four key reasons for this: First, despite remarkable progress in the modernization of violence risk assessment practices in China, little guidance is available to Chinese practitioners who wish to use structured assessment instruments with their patients. Recent survey evidence confirms that lack of educational resources on violence risk assessment is a major obstacle to instrument implementation (Singh 2013). Second, mostly retrospective investigations of predictive validity have been conducted on violence risk assessment tools in China. Without the longitudinal collection of outcome information through prospective study designs, the practical utility of available instruments (especially those with dynamic item content) will remain in question (Caldwell, Bogat, & Davidson, 1988). Third, outcome information collected in China may differ systematically from that collected in Western countries. Because of the cultural values of tolerance and harmony, verbal and non-severe physical violence may not be reported, resulting in low base rates and insufficient statistical power to conduct research studies. Fourth and finally, psychiatric care is not widely available in China, meaning that most mentally disordered patients cannot receive regular treatment, let alone violence risk assessments. The general unavailability of mental health care combined with the complicated process involved with becoming licensed as a forensic specialist in China may be key contributors to the low number of practicing forensic psychiatrists in the country. There are more than 100 million mentally disordered patients in China, more than 16 million of which are diagnosed with a psychotic disorder (Qian, 2012). However, there are only approximately 20,500 practicing psychiatrists in China (Chinese Health Statistics Yearbook, 2011), resulting in a low practitioner-to-patient ratio of 1:840. Particularly rare are forensic psychiatrists, which numbered only 944 across all of China as of 2005 (Gu & Hu, 2007). To become a forensic psychiatrist in China, a medical doctor with at least 5 years of clinical experience

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who has passed a government examination must respond to a formal provincial announcement. The hospital at which the doctor practices must also obtain a provincial license to serve as a forensic institution (Hu, Yang, Huang, & Coid, 2011). At no point in this process is violence risk assessment training required. Actuarial Risk Assessment Tools In China

The most prominent actuarial risk assessment tool developed in China is the Chinese Risk Assessment Scale of Severe Psychiatric Patients in Community (C-RASSPPC; Li et al., 2010). A 10-item instrument composed of static risk factors, the C-RASSPPC measures a patient’s history of violence, treatment history, history of illicit substance use, recent mood, and recent psychotic symptomatology. Higher scores on the instrument imply higher risk of violence. The reliability of the C-RASSPPC was recently investigated by Li et al. (2010) in a randomly selected sample of 860 severe psychiatric patients from eight communities in the province of Beijing. The authors established excellent levels of internal consistency (Cronbach’s α = .86) and interrater reliability (R2 = .92). These findings are promising; however, studies exploring the predictive validity of the C-RASSPPC are needed. In addition to the C-RASSPPC, translated versions of actuarial violence risk assessment tools widely used in North America are beginning to appear in China. The primary example of this is the Violence Risk Scale (VRS; Wong & Gordon, 2009), a 26-item instrument composed of 6 static and 20 dynamic risk factors for violence that enables the administering practitioner to systematically track treatment progress and adjust risk estimates accordingly. A translation of the VRS, the Violence Risk Scale–Chinese Version (VRS-C; Zhang, Chen, Cai, & Hu, 2012) was recently introduced into forensic psychiatric settings. In a recent investigation by Zhang et al. (2012), 125 mentally disordered offenders from three facilities were administered the VRS-C. The authors found evidence of a good level of interrater reliability (intraclass correlation coefficient [ICC] = 0.80) and excellent levels of internal consistency (Cronbach’s α = .92) and split-half reliability (r = .91) for the VRS-C. However, our systematic search identified no published studies examining the predictive validity of the VRS-C. Structured Professional Judgment Risk Assessment Tools In China

Structured professional judgment risk assessment tools including the Historical, Clinical, Risk Management–20 (HCR-20; Webster, Douglas, Eaves, & Hart, 1997) and the Violence Risk Screening–10 (V-RISK-10; Hartvig et al., 2007) have recently been translated into Chinese and implemented in mental health settings. The HCR-20 is a 20-item instrument composed of 10 static and 10 dynamic risk factors for violence in mentally disordered populations. The Chinese translation of the HCR-20, the HCR-20–Chinese Version (HCR-CV; Xiao, Li, & Wang, 2010), is becoming one of the most popular violence risk assessment instruments in China. According to our systematic search, two studies have been published exploring the reliability and validity of the HCR-CV in China. In the first study, Xiao et al. (2010) investigated differences in HCR-CV total scores among 30 pairs of male non-forensic psychiatric patients diagnosed with schizophrenia either with or without a history of aggression. The authors found evidence of an excellent level of internal consistency (Cronbach’s α = .92) Downloaded from cjb.sagepub.com at SIMON FRASER LIBRARY on September 8, 2014

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and test–retest reliability (r = .90). Evidence of moderate convergent validity was found between the HCR-CV and the Barratt Impulsiveness Scale (r = .66; Patton, Stanford, & Barratt, 1995). Finally, using ratings on the Modified Overt Aggression Scale (Kay, Wolkenfeld, & Murrill, 1988) as the outcome, a strong level of predictive validity was found for institutional aggression (r = .84). In the second study, Lv, Han, and Wang (2013) also examined the reliability and validity of the HCR-CV in 156 male non-forensic psychiatric patients diagnosed with schizophrenia. The authors found evidence of fair to good levels of internal consistency (Cronbach’s α = .58-.78), good to excellent levels of interrater reliability (R2 = .82-.97), and fair to excellent levels of test–retest reliability (r = .52-.95) for total scores on the Historical, Clinical, and Risk Management subscales of the HCR-CV. Evidence of statistically significant convergent validity was found between the HCR-CV and the Psychopathy Checklist–Revised (Hare, 2003). Finally, using ratings on the Modified Overt Aggression Scale as the outcome, a moderate level of predictive validity was found for institutional aggression (area under the receiver operating characteristic curve; AUC = 0.72). The Xiao and Lv studies provide preliminary evidence of the clinical usefulness of the HCR-CV with psychiatric patients in China. However, future research on the utility of the HCR-CV is needed, as our systematic search found no published studies evidencing predictive validity of assessments made using this instrument in the community. Furthermore, more studies should also look at other mentally disordered patients in addition to schizophrenic patients. Whereas most violence risk assessment tools have been developed for use with forensic patients, the V-RISK-10 is one of the few instruments designed specifically for use with patients in general psychiatric settings. A 10-item instrument composed of four static and six dynamic risk factors for violence, the V-RISK-10, currently has two validated Chinese translations (Yao, Li, Arthur, Hu, & Cheng, 2012; Zhan, Yao, Yan, & Chao, 2013). After minor modifications to item content designed to make the instrument accord with local culture, the interrater reliability and predictive validity of the V-RISK-10–Chinese Version were examined by Yao et al. (2012) in two independent samples. First, they coded the instrument for 376 inpatients in a general psychiatric hospital. Using this sample, an excellent level of interrater reliability (ICC = 0.89) and a fair level of predictive validity (AUC = 0.63) were established. The cutoff score that produced the most balanced cost-ratio between sensitivity and specificity was +8 (sensitivity = 79.6%, specificity = 38.4%, positive predictive value = 34.3%, negative predictive value = 81.5%). Second, Yao, Li, Arthur, Hu, and Cheng (2014) followed 289 different patients discharged from the same psychiatric hospital for 6 months in the community. Similar to their previous study, the authors found an excellent level of interrater reliability (ICC = 0.89) and a fair level of predictive validity (AUC = 0.62). The cutoff score that produced the most balanced cost-ratio of sensitivity to specificity was +5 (sensitivity = 87.5%, specificity = 26.8%, positive predictive value = 9.8%, negative predictive value = 95.9%). Given these findings, it seems that this translation of the V-RISK-10 is better at predicting the likelihood of non-violence rather than violence, albeit this is a general trend in the risk assessment literature with low base rate populations (Singh et al., 2013). The translation team of Zhan et al. (2013), another team in Nanjing, translated V-RISK-10 into Chinese without modification in 2013. When coded for 109 non-forensic schizophrenic patients, Zhan’s V-RISK-10 translation produced a Cronbach coefficient of .83, interrater reliability of 66% to 90%, and test–retest reliability estimates of 54% to 100% depending Downloaded from cjb.sagepub.com at SIMON FRASER LIBRARY on September 8, 2014

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on the item. Most of the items of V-RISK-10 were significantly related to scores on the Modified Overt Aggression Scale (concordance coefficients from .30 to .56). Conclusion

Although a nascent research literature exists on violence risk assessment in China, the field has far to go. With the National Mental Health Law now in effect, reliable and valid risk assessment instruments are urgently needed, especially tools that incorporate dynamic item content that can help in the monitoring of future violence risk. Further research is needed not only on the assessment of violence risk, however, but also on risk communication, risk formulation, and risk management. Such research may lead to major public health advances for China, including a standardized system of delivering evidence-based interventions to reduce the likelihood of future violence. Until such research has been conducted, however, there will continue to be questions as to whether practitioners charged with making risk decisions are using the most scientifically defensible procedures. Note 1. CNKI, VIP, and WANFANG are the three largest citation databases containing Chinese publications.

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8  Criminal Justice and Behavior Liu, J., Ma, H., He, Y. L., Xie, B., Xu, Y. F., Tang, H. Y., . . .Yu, X. (2011). Mental health system in China: History, recent service reform, and future challenges. World Psychiatry, 10, 210-216. Lv, Y., Han, C., & Wang, X. P. (2013). 历史、临床、风险评估量表中文版信效度研究 [The validity and reliability of HCR-20-Chinese version]. Paper presented at the 11th Annual Meeting of the Chinese Society of Psychiatry, Beijing. Overall, J. E., & Gorham, D. R. (1962). The Brief Psychiatric Rating Scale. Psychological Reports, 10, 799-812. doi:10.2466/ pr0.1962.10.3.799 Patton, J. H., Stanford, M. S., & Barratt, E. S. (1995). Factor structure of the Barratt Impulsiveness Scale. Journal of Clinical Psychology, 51, 768-774. doi:10.1002/1097-4679(199511)51:63.0.CO;2-1 Qian, J. (2012). Mental health care in China: Providing services for under-treated patients. Journal of Mental Health Policy and Economics, 15, 179-186. Singh, J. P. (2013, June). International perspectives on the practical application of violence risk assessment tools: A survey of 16 countries. Paper presented at the Annual Conference of the International Association of Forensic Mental Health Services, Maastricht, The Netherlands. Singh, J. P., & Fazel, S. (2010). Forensic risk assessment: A metareview. Criminal Justice and Behavior, 37, 965-988. doi:10.1177/0093854810374274 Singh, J. P., Grann, M., & Fazel, S. (2011). A comparative study of risk assessment tools: A systematic review and metaregression analysis of 68 studies involving 25,980 participants. Clinical Psychology Review, 31, 499-513. doi:10.1016/j. cpr.2010.11.009 Skeem, J. L., & Monahan, J. (2011). Current directions in violence risk assessment. Current Directions in Psychological Science, 20, 38-42. doi:10.1177/0963721410397271 Webster, C. D., Douglas, K. S., Eaves, D., & Hart, S. D. (1997). HCR–20: Assessing Risk for Violence (Version 2). Burnaby, British Columbia, Canada: Mental Health, Law, and Policy Institute, Simon Fraser University. Wong, S., & Gordon, A. (2009). Manual for the Violence Risk Scale. Saskatoon, Canada: University of Saskatchewan. Xiao, Q., Li, C., & Wang, X. (2010). 暴力危险性评估-20对精神分裂症暴力危险性评估的信效度研究 [Study of the reliability and validity of HCR–20 for assessing violent risk of patients with schizophrenia]. Journal of Clinical Research, 27, 405-408. Yao, X., Li, Z., Arthur, D., Hu, L., & Cheng, G. (2012). 攻击风险评估工具在住院精神病患者中的初步应用 [The application of a violence risk assessment tool among Chinese psychiatric service users: A preliminary study]. Journal of Psychiatry and Mental Health Nursing, 19, 438-445. doi:10.1111/j.1365-2850.2011.01821.x Yao, X., Li, Z., Arthur, D., Hu, L., & Cheng, G. (2014). Validation of the Violence Risk Screening–10 instrument among clients discharged from a psychiatric hospital in Beijing. International Journal of Mental Health Nursing, 23, 79-87. doi:10.1111/j.1447-0349.2012.00890.x Zhan, M. X., Yao, H., Yan, J. H., & Cao, D. (2013). 暴力危险性筛查量表中文版在精神分裂症患者中的信度与效度研究 [Reliability and validity of Chinese version of the violence risk screening–10 in patients with schizophrenia]. Journal of Clinical Psychiatry, 23, 361-364. Zhang, X. L., Chen, X. C., Cai, W. X., & Hu, J. M. (2012). 暴力危险量表中文版的信度 [Reliability of the Violence Risk Scale Chinese version]. Fa Yi Xue Za Zhi, 28(1), 32-35. Zhong, W. (2011). 住院精神病患者攻击行为危险因素预测研究 [The prospective study of risk factors for aggressive behaviors of inpatients with mental illness]. Medical Journal of Chinese People’s Health, 23, 1352-1353. Yan Gu graduated from Sichuan University in 2008. She is currently practicing in forensic psychiatry and psychology at the Institute of Forensic Medicine at Sichuan University, People’s Republic of China. Her research is related to violence risk assessment in Chinese psychiatric patients, especially those diagnosed with schizophrenia. She also participates in forensic mental health practice, such as assessment of criminal responsibility, competence to stand trial, and other clinical services for mentally disordered offenders. Jay P. Singh is the internationally award-winning president and CEO of the Singh Institute of Forensic Research, LLC. Former Senior Clinical Researcher in Forensic Psychiatry and Psychology for the Department of Justice of Switzerland, he completed his graduate studies in psychiatry at the University of Oxford. Since this time, he has lectured at Harvard, Yale, Columbia, Cornell, Brown, Dartmouth, and UPenn. Libing Yun got his PhD from Sichuan University (Chengdu, PR China), where he has been a lecturer and taught several courses on forensic science since 2006. His main research interests are in the areas of forensic genetics and biological psychiatry, and he has published and presented on many topics related to risk gene for schizophrenia and Forensic DNA Typing. Zeqing Hu is a professor and PhD supervisor of the Forensic Psychiatry department at Sichuan University, where he has taught forensic psychiatry and psychology since 1982. He participated in drafting the first version of Chinese Mental Health Law in 1980s. Now, he is the chief editor of the textbook “Forensic Psychiatry,” which is the unified teaching materials for Chinese medical students.

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