How Do You Compare and Apply the SAVRY, START, and HCR-20-V3 in Violence Risk Assessment as a Forensic Psychologist Conducting Evaluations in a Forensic Hospital?

The HCR-20-V3 is among the world’s most used violence risk assessment instruments. With the third version bringing demonstrated improvements on a range of measures, it provides professional guidelines for assessing the risk of interpersonal violence by examining 20 items categorized into three domains: Historical (H), Clinical (C), and Risk Management (R).

The application of the HCR-20 V3 in forensic hospitals is built for long-term treatment planning and discharge evaluations. The Historical scale covers lifetime factors, while the Clinical scale focuses on the recent past, and the Risk Management scale speculates on the near future in both institutional and community settings. Research indicates that the HCR-20 V3 Clinical scale is well-suited for assessing risk within a psychiatric hospital, as it captures the dynamic mental health symptomatology most relevant to that setting.

A defining feature of the HCR-20 V3 is its move away from simple "presence" ratings toward relevance scores. A risk factor is deemed relevant if it has contributed to past violence, influences the decision to act violently, or is necessary to manage for risk mitigation. This rating system allows the evaluator to construct an individualized risk theory or "risk diagnosis," which serves as a starting point for treatment. However, psychologists should be aware that while the HCR-20 V3 performs well in research settings, its predictive validity in field studies can be mixed. One mitigating factor is that individuals who are judged to be at high risk of violent behavior often receive interventions that prevent the violence predicted by the HCR-20.

While the HCR-20 V3 is often used for broader dispositional decisions, the START is a guide developed to evaluate short-term risk for aggression and the likelihood of a patient responding well to treatment.

The START, unlike many other risk assessment tools, balances its scope by looking at both strengths and vulnerabilities. It requires clinicians to rate 20 clinical items, such as impulsivity, social support, and mental health, independently for their positive and risk-associated qualities. In a forensic hospital, identifying these "therapeutic levers" (strengths) is as crucial as identifying "red flags" (vulnerabilities) for well-informed treatment.

One of the primary benefits of the START is its sensitivity to change over time. Because it focuses on dynamic variables, it can monitor a patient’s progress as they move through a hospital continuum, for example, from maximum security to minimum security. START dynamic scores demonstrate incremental predictive validity for inpatient aggression even after controlling for static historical factors. The tool also addresses multiple risk domains, including externalizing (violence toward others), internalizing (suicide, self-harm), and high-risk behaviors (unauthorized absences, self-neglect).

For forensic psychologists working with adolescent populations (typically ages 12 to 18), the SAVRY is the designated SPJ tool. Modeled after the HCR-20, the SAVRY focuses on 24 risk items drawn from research on adolescent development and youth violence. These items are clustered under Historical, Social/Contextual, and Individual/Clinical domains.

The SAVRY is notably different from adult tools in its emphasis on the social and contextual environment, such as peer delinquency, parental management, and community disorganization. Like the START, the SAVRY incorporates protective factors, such as strong social support, resilient personality traits, and commitment to school, that are notable for their presence rather than their absence.

In forensic hospitals, the SAVRY is particularly useful for dispositional planning, such as evaluating an adolescent for transfer to adult court, civil commitment, or discharge from a residential facility. Studies have shown that the SAVRY differentiates between low- and high-risk reoffending with good predictive capacity. However, longitudinal studies suggest it may not be as sensitive as adult tools for measuring distinct changes in offending patterns over time.

The details of the person being assessed and the most salient timeframe for the situation are key factors in considering which test to use. The HCR-20 V3 is best for general violence potential over longer follow-up periods and for making broad legal/clinical decisions. The START is superior for day-to-day practice and managing immediate acuity within the hospital.

While all SPJ tools theoretically allow for the consideration of protective factors, the START and SAVRY provide formal, structured mechanisms to rate them, which is often beneficial for fostering a rapport with the patient.

Forensic psychologists should remain cautious when using these tools with women or ethnic minorities, as the evidence base is often heavily weighted toward Western male samples. For example, the SAVRY’s protective factors may yield different results in non-Western cultures.

For forensic psychologists, the HCR-20 V3, START, and SAVRY are indispensable instruments that provide a common language for discussing risk and intervention across disciplines. By selecting the tool that best fits the patient's developmental stage and current acuity, and by anchoring the assessment in a robust, collaborative formulation, psychologists can provide higher-quality work that informs effective treatment and protects public safety. Mastery of these skills transforms a practitioner from a generalist into a specialist capable of navigating the complex demands of the forensic hospital and the courtroom.

Training

• Violence Risk Assessment Certificate
• Evaluations for High Stakes Sentencing: Capital and Juvenile Murder Cases
• Evaluation of Mental State at the Time of the Offense (Insanity/Criminal Responsibility)
• Foundations of Violence Risk Assessment and Management
• Assessing Psychopathy using the Hare Scales (PCL-R and PCL-SV)
• Advanced Issues in the Assessment of Risk for Violence: Formulation

Blog Posts

• An Introduction to Violence Risk Assessments
• General Violence Risk: A Structured Professional Judgment Approach
• Violence Risk Assessment Case Study: Dangerousness Evaluation using the START
• A New Perspective on SAVRY in Youth Violence Assessments
• Predictive Validity of the SAVRY Differs Across Ethnic Subgroups
• What Are the Roles and Responsibilities of the Forensic Psychologist?