Violence Risk Appraisal Guide Research Articles

Static and dynamic predictors of forensic mental health decision-making.

In Canada, individuals found not criminally responsible on account of mental disorder (NCR) fall under the supervision of a jurisdictional review board (RB) per the Criminal Code. Limited research has examined whether RB decisions balance the needs of public safety with social reintegration as intended by federal legislation. To fill this gap, the present study determined whether forensic decisional outcomes in one provincial RB system accounted for information relevant to violence risk. Study instruments included the Level of Service/Case Management Inventory (LS/CMI), Historical Clinical Risk Management-20 Version 3, and the Revised Violence Risk Appraisal Guide. A retrospective longitudinal design was employed to examine an NCR cohort (N = 109) that entered the RB system between 2005 and 2010 and their respective RB hearings (N = 327) until 2015. Results indicated that risk-relevant information was supplied to the RB by forensic professionals; however, key criminogenic risk and need factors as defined by the LS/CMI were absent in clinical reports. RB decisions were still strongly predicted by empirically supported risk factors linked to violent recidivism. Higher release likelihoods corresponded to a proportionally greater reliance on dynamic risk factors to enact dispositions. Forensic risk instruments are central aspects of correctional rehabilitation, and the results demonstrated their relevance to forensic tribunals. It is recommended that information from a forensic risk instrument be routinely delivered to RBs to support evidence-based decision-making. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Violence risk assessment instruments in forensic psychiatric populations: a systematic review and meta-analysis

Although structured tools have been widely used to predict violence risk in specialist mental health settings, there is uncertainty about the extent and quality of evidence of their predictive performance. We aimed to systematically review the predictive performance of tools used to assess violence risk in forensic mental health, where they are routinely administered. In our systematic review and meta-analysis, we followed PRISMA guidelines and searched four databases (PsycINFO, Embase, Medline, and Global Health) from database inception to Nov 1, 2022, to identify studies examining the predictive performance of risk assessment tools in people discharged from forensic (secure) mental health hospitals. Systematic and narrative reviews were excluded from the review. Performance measures and descriptive statistics were extracted from published reports. A quality assessment was performed for each study using the Prediction Model Risk of Bias Assessment Tool. Meta-analysis was conducted on the performance of instruments that were independently externally validated with a sample size greater than 100. The study was registered with PROSPERO, CRD42022304716. We conducted a systematic review of 50 eligible publications, assessing the predictive performance of 36 tools, providing data for 10 460 participants (88% men, 12% women; median age [from 47 studies] was 35 years, IQR 33-38) from 12 different countries. Post-discharge interpersonal violence and crime was most often measured by new criminal offences or recidivism (47 [94%] of 50 studies); only three studies used informant or self-report data on physical aggression or violent behaviour. Overall, the predictive performance of risk assessment tools was mixed. Most studies reported one discrimination metric, the area under the receiver operating characteristic curve (AUC); other key performance measures such as calibration, sensitivity, and specificity were not presented. Most studies had a high risk of bias (49 [98%] of 50), partly due to poor analytical approaches. A meta-analysis was conducted for violent recidivism on 29 independent external validations from 19 studies with at least 100 patients. Pooled AUCs for predicting violent outcomes ranged from 0·72 (0·65-0·79; I2=0%) for H10, to 0·69 for the Historical Clinical Risk Management-20 version 2 (95% CI 0·65-0·72; I2=0%) and Violence Risk Appraisal Guide (0·63-0·75; I2=0%), to 0·64 for the Static-99 (0·53-0·73; I2=45%). Current violence risk assessment tools in forensic mental health have mixed evidence of predictive performance. Forensic mental health services should review their use of current risk assessment tools and consider implementing those with higher-quality evidence in support. Wellcome Trust.

Adverse Childhood Experiences and Offending as a Function of Acquired Brain Injury Among Men in a High Secure Forensic Psychiatric Hospital.

Acquired brain injury (ABI) is a serious problem that disproportionately affects individuals in correctional services, but relatively little is known about ABI risks and correlates in forensic psychiatric services. We conducted a retrospective chart review of all admissions to a high secure forensic hospital in Ontario, Canada from January 2009 to December 2012 (n = 637) and collected data on ABI, psychiatric diagnoses, developmental disadvantage, criminal offending, and in-hospital aggression. A k-means cluster analysis was employed to assess risk factors by which men with ABI could be identified and multivariate general linear models were used to identify ABI-related differences in offending history and in-hospital aggression. One-fifth of the men had a documented ABI indicator. Based on our cluster analysis, ABI was more likely to be identified by greater adverse childhood experiences (ACEs), more health problems from pregnancy to childhood, and lower socioeconomic status, suggesting that ABI within the forensic context is associated with greater developmental disadvantage. Men with ABI had more serious pre-admission offences, but not more serious admission offences or in-hospital aggression. Men with ABI were more likely than those without to have higher scores on the Violence Risk Appraisal Guide or to be diagnosed with mood and personality disorders, and less likely to have a schizophrenia diagnosis, suggesting an association between ABI and general mental health pathologies but not with psychotic illness. The disadvantage of ABI among men in forensic psychiatric hospitals is most likely evinced in antisocial behaviour rather than serious mental illness. Given that ACEs are likely to precede or co-occur with ABI, strategies that mitigate ACEs hold promise for ABI prevention.

Forecasting Stalking Recidivism Using the Guidelines for Stalking Assessment and Management (SAM).

We examined the long-term risk for stalking recidivism and the predictive validity of ratings made using the Guidelines for Stalking Assessment and Management (SAM) in 100 stalking offenders from a forensic clinic. Overall, 45 offenders were convicted of, charged with, or the subject of police investigation for stalking-related offenses during a potential time at risk that averaged 13.47 years. Survival analyses using the Cox proportional hazards model indicated that a composite score of the presence of SAM risk factors was significantly predictive of recidivism and had significant incremental validity relative to total scores on two scales commonly used in violence risk assessment, the Screening Version of the Hare Psychopathy Checklist-Revised (PCL:SV) and the Violence Risk Appraisal Guide (VRAG). Overall ratings of risk made using the SAM, however, were not significantly predictive of recidivism. We discuss the potential uses of the SAM in stalking risk assessment and provide recommendations for future research.

Resistance to Antisocial Peers in Adolescents Found Not Criminally Responsible on Account of Mental Disorder: Predictive and Incremental Validity With the VRAG-R

There has been a recent theoretical shift toward the inclusion of protective factors within risk assessment. However, there is a lack of empirical evidence surrounding this practice in unique forensic populations. Using a long-term retrospective design, we examined the predictive and incremental validity of the protective factor resistance to antisocial peers and the Violence Risk Appraisal Guide—Revised in 119 individuals who were found Not Criminally Responsible on Account of Mental Disorder (NCRMD) as adolescents. The results indicated that resistance to antisocial peers significantly predicted general nonrecidivism (area under the curve [AUC] = .647) and violent nonrecidivism (AUC = .654) in the long term (maximum 35-year follow-up). Incorporation of resistance to antisocial peers into the Violence Risk Appraisal Guide—Revised did not significantly increase the incremental validity for general or violent recidivism. Using logistic regression, adolescents’ age at their NCRMD start date had no significant relationship with recidivism and was unrelated to the protective effect of resistance to antisocial peers.

Static and Dynamic Assessment of Violence Risk Among Discharged Forensic Patients

This study evaluated the predictive validity of structured instruments for violent recidivism among a sample of 82 patients discharged from a maximum security forensic psychiatric hospital. The incremental predictive validity of dynamic pre–post change scores was also assessed. Each of the Historical-Clinical-Risk Management-20 Version 3 (HCR-20V3), Psychopathy Checklist–Revised, Short-Term Assessment of Risk and Treatability, Violence Risk Scale (VRS), and Violence Risk Appraisal Guide–Revised was rated based on institutional files. The study instruments significantly predicted community-based violent recidivism (area under the curve [AUC] = 0.68-0.85), even after controlling for time at risk using Cox regression survival analyses. Dynamic change scores computed from the HCR-20V3 Relevance ratings and from the VRS also demonstrated incremental predictive validity, controlling for baseline scores. The findings provided support for the use of the study instruments to assess violence risk and for the consideration of dynamic changes in risk—provided that valid means of assessment are employed.

Cross-Validation of the Revised Version of the Violence Risk Appraisal Guide (VRAG-R) in a Sample of Individuals Convicted of Sexual Offenses.

The aim of the present study was to examine the psychometric properties of the German version of the revised Violence Risk Appraisal Guide (VRAG), the VRAG-R. Therefore, VRAG-R ratings were made retrospectively in an Austrian sample of 534 individuals convicted of a sexual offense who were followed up with an average of 7.62 years. The VRAG-R showed large effect sizes for the predictive accuracy of violent (AUC = .75) and general recidivism (AUC = .78) and significant but rather small effect sizes (AUC = .63 and .61, respectively) in predicting any sexual and sexual contact recidivism. Furthermore, for the prediction of violent recidivism but not for sexual recidivism the VRAG-R was incrementally predictive beyond the Sex Offender Risk Appraisal Guide (SORAG) and the Static-99. Finally, the VRAG-R absolute recidivism rates for the risk bins showed satisfactory calibration properties. Taken together, the results of the present study support the cross-national utility of the VRAG-R and its use in applied risk assessment settings also in German-speaking countries.

The validity of risk assessment instruments for transition-age youth.

There is increasing recognition in the justice system that transition-age youth (TAY) are in a unique developmental period that may require tailored policies and practices. This study investigated the differential predictive validity and potential for disparate impact of both juvenile (the Structured Assessment of Violence Risk for Youth and Youth Level of Service/Case Management Inventory) and adult risk assessment instruments (the Historical-Clinical-Risk Management-20 [HCR-20] and the Violence Risk Appraisal Guide [VRAG]) with this age group (ages 16-24), relative to adolescents (ages 12-15) or older adults (ages 25-40). The authors obtained secondary data sets for the 4 instruments totaling 3,353 cases. The final samples for each instrument after exclusions ranged from 1,181 cases for the VRAG to 290 cases for the HCR-20. Age group generally did not moderate the prediction of any recidivism or of violent recidivism. The only exception was on the HCR-20, which significantly predicted recidivism regardless of age but operated better for TAY than adults. The VRAG was the only instrument with significant mean age-related differences in risk scores. The potential for an unfair impact of risk assessments on TAY is minimal regardless of whether they are processed in the juvenile or adult justice systems. This preliminary evidence suggests well-validated instruments used in either system should accurately quantify the likelihood of recidivism for TAY; however, this does not necessarily translate into effective risk management for this developmental period. More research using study designs developed specifically for examining age-related differences is needed. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

An update and expansion on the role of the Violence Risk Appraisal Guide and Historical Clinical Risk Management‐20 in United States case law

An individual's risk for future violent behavior may be considered in various legal contexts, including civil commitment, criminal sentencing, or suitability for parole. Among the assessment tools forensic evaluators use to assess violence risk are the Violence Risk Appraisal Guide (VRAG; Quinsey, Harris, Rice, & Cormier, ) and the Historical Clinical Risk Managment-20 (HCR-20)/Historical Clinical Risk Management-20, Version 3 (HCR-20V3 ) (Webster, Douglas, Eaves, & Hart, and Douglas, Hart, Webster, & Belfrage, , respectively). Previous surveys and case law research suggest that these measures are widely used and perceived to be useful in aiding forensic clinicians. This study provides an update to Vitacco, Erickson, Kurus, and Apple () and examines the use of the HCR-20 and VRAG in United States case law. A LexisNexis review revealed 134 cases decided between 1 January 2010 and 21 December 2016 that included the HCR-20, VRAG, or both. Results revealed that these measures are typically introduced by the prosecution to inform opinions regarding general violence risk. In addition, consistent with previous research, these data suggest the introduction of the HCR-20 and VRAG is rarely challenged and, when challenged, these challenges are rarely successful. However, data suggest that courts and parole boards may focus on specific risk factors (e.g., lack of insight) at the expense of other, more objective factors. Finally, we offer suggestions for clinicians who have transitioned to the newest version of the HCR-20.

Cross-Validation of the Discrimination and Calibration Properties of the VRAG-R in a Treated Sexual Offender Sample

The present study featured an examination of the predictive properties of the Violence Risk Appraisal Guide–Revised (VRAG-R) in a treated sample of sexual offenders, using modern risk metrics. The Sex Offender Risk Appraisal Guide (SORAG) and the original Violence Risk Appraisal Guide (VRAG) were examined for comparison purposes. The three measures were rated archivally on 296 treated sexual offenders followed up 17.6 years. VRAG-R scores demonstrated good discrimination of recidivists from nonrecidivists for sexual (area under the curve [AUC] = .60-.67) and violent (AUC = .70-.78) recidivism, and were incremental in the prediction of violent, but not sexual, recidivism after controlling for baseline sexual violence risk and treatment change. The VRAG-R bin structure demonstrated good calibration, although the present sample generated lower 5-year estimates of general violence compared with the normative sample. Application of the VRAG-R in the assessment and management of violence risk, via integration with dynamic risk assessment information, is discussed.

A Prospective Examination of the Predictive Validity of Five Structured Instruments for Inpatient Violence in a Secure Forensic Hospital

ABSTRACTThis prospective study investigated the predictive validity of five structured risk/forensic instruments for inpatient violence risk in a secure forensic hospital. Episodes of inpatient violence and the following instruments were each coded from hospital files: Historical Clinical Risk Management 20 – Version 3 (HCR-20V3), Psychopathy Checklist Revised (PCL-R), Short-Term Assessment of Risk and Treatability (START), Revised Violence Risk Appraisal Guide (VRAG-R), and Violence Risk Scale (VRS). The dynamic/clinical instruments (HCR-20V3, START, and VRS) predicted inpatient violence, even after controlling for the static measures. The results indicated that structured risk instruments may be applied to the assessment of inpatient violence risk.

A cross-validation of the Violence Risk Appraisal Guide-Revised (VRAG-R) within a correctional sample.

The Violence Risk Appraisal Guide-Revised (VRAG-R) was developed to replace the original VRAG based on an updated and larger sample with an extended follow-up period. Using a sample of 120 adult male correctional offenders, the current study examined the interrater reliability and predictive and comparative validity of the VRAG-R to the VRAG, the Psychopathy Checklist-Revised, the Statistical Information on Recidivism-Revised, and the Two-Tiered Violence Risk Estimate over a follow-up period of up to 22 years postrelease. The VRAG-R achieved moderate levels of predictive validity for both general and violent recidivism that was sustained over time as evidenced by time-dependent area under the curve (AUC) analysis. Further, moderate predictive validity was evident when the Antisociality item was both removed and then subsequently replaced with a substitute measure of antisociality. Results of the individual item analyses for the VRAG and VRAG-R revealed that only a small number of items are significant predictors of violent recidivism. The results of this study have implications for the application of the VRAG-R to the assessment of violent recidivism among correctional offenders. (PsycINFO Database Record

Usage exploratoire d’outils d’évaluation structurée du risque de récidive en France

This communication shows the demographic and legal characteristics and statistics levels of risk of recidivism of a sample of 55 criminal offenders sentenced to lengthy prison terms. Assessments of risk levels were conducted on an exploratory basis, using the Hare Psychopathy Check-List-Revised (PCL-R), the Violence Risk Appraisal Guide (VRAG), the Sex Offender Risk Appraisal Guide (SORAG) and STATIC 99-R. We report the average result, the distribution of scores into risk categories, inter-correlation of tools and several statistical analyzes.

Violence risk assessment: A brief review, current issues, and future directions.

A little over 11 years ago, the Journal of Interpersonal Violence invited its contributors to provide a brief response to questions for a special edition on the 20th anniversary of the journal (Mills, 2005). One of the questions was, What is the most important thing we need to learn in the next 10 years? Given my opportunity to review the literature for this article and the relative time that has passed, I revisited my answers to those questions, and they will serve to frame this brief review. Topics I identified then included (a) the identification that unstructured clinical methods were grossly inaccurate in risk assessment and that there was an emerging debate between structured clinical judgment (now referred to as structured professional judgment [SPJ]) and actuarial approaches to risk assessment, (b) the need to advance our knowledge of risk communication and risk management within the risk assessment process, (c) the importance of measuring dynamic change in risk assessment, and (d) the need to recalibrate frequently used risk instruments to meet specific population needs.The field of criminal and violence risk assessment has grown considerably over the past decade, as evidenced by a surge in risk assessment instruments. In a study involving 2,135 mental health professionals drawn from around the world, respondents reported over 400 instruments being used in violence risk assessment within the past 12 months of the survey (Singh et al., 2014). Among the most commonly used methods, approximately half were actuarial and half were SPJ. Although it is self-described as a measure of a personality construct, also included in the list was the Psychopathy Checklist-Revised (PCL-R; Hare, 2003). During these intervening years, the field has benefited from numerous meta-analytic investigations related to criminal and violence risk assessment that have served as sign posts of the underlying scientific findings over the years. For example, Yang, Wong, and Coid (2010) compared nine commonly used risk instruments and found they predicted recidivism equally well for the most part (with the exception of Factor 1 of the PCL-R); however, there was considerable heterogeneity between studies. For example, only 25% of the heterogeneity in the effect sizes found for the analysis was attributed to differences between the risk instruments whereas the majority of variance was accounted for by the methodological differences between the studies. In another meta-analysis that compared a number of instruments, Campbell, French, and Gendreau (2009) examined 88 studies and found that the effect sizes related to various instruments generally did not significantly differ. The Violence Risk Appraisal Guide (VRAG; Quinsey, Harris, Rice, & Cormier, 2006) was the measure that was most predictive of violent recidivism and those measures containing dynamic risk factors performed better than measures based solely on static risk factors.In their systematic review, Singh, Grann, and Fazel (2011) reported that the median area under the curve values for many of the commonly used risk instruments examined were well within the moderate to high range of predictive accuracy. A more recent meta-analysis by Fazel, Singh, Doll, and Grann (2012) included 73 samples and found that measures that were specifically designed to predict violence were more accurate in their predictions than instruments designed to predict general or sexual reoffending. Taken together, these meta-analyses indicate that the predictive accuracy for most instruments are generally in the moderate to high range and are similar across instruments and samples.Other meta-analyses have examined instruments related to specific types of violence. For example, in a meta-analytic study of risk assessment methods used to predict recidivism among sexual offenders Hanson and Morton-Bourgon (2009) found that actuarial instruments were more accurate than SPJ, and further that clinically adjusting actuarial risk resulted in significantly poorer predictive accuracy. …

Predicting Institutional Aggression in Offenders with Intellectual Disabilities Using the Violence Risk Appraisal Guide.

One of the most extensively tested risk assessment instruments in offenders with an intellectual disability (OIDs) is the Violence Risk Appraisal Guide (VRAG). The purpose of this prospective study was to test the ability of this instrument to predict institutional aggression in OIDs. VRAG scores were collected for 52 OIDs, and staff registered aggressive incidents during a period of 6months. Predictive accuracy was analysed using several performance indicators. The VRAG was not able to significantly predict aggressive behaviour, although a trend towards significance was found for interpersonal physical aggression. Furthermore, the VRAG was only accurate in prospectively identifying low-risk individuals. Compared to other studies, demonstrating good predictive validity for institutional aggression in OIDs, the VRAG performed poorly in this study. The usefulness of this instrument in identifying high-risk offenders is questioned. Until further evidence is available from studies using multiple performance indicators, clinicians have to be very careful in relying on the results of a risk assessment tool.

Interrater reliability of Violence Risk Appraisal Guide scores provided in Canadian criminal proceedings.

Published research suggests that most violence risk assessment tools have relatively high levels of interrater reliability, but recent evidence of inconsistent scores among forensic examiners in adversarial settings raises concerns about the "field reliability" of such measures. This study specifically examined the reliability of Violence Risk Appraisal Guide (VRAG) scores in Canadian criminal cases identified in the legal database, LexisNexis. Over 250 reported cases were located that made mention of the VRAG, with 42 of these cases containing 2 or more scores that could be submitted to interrater reliability analyses. Overall, scores were skewed toward higher risk categories. The intraclass correlation (ICCA1) was .66, with pairs of forensic examiners placing defendants into the same VRAG risk "bin" in 68% of the cases. For categorical risk statements (i.e., low, moderate, high), examiners provided converging assessment results in most instances (86%). In terms of potential predictors of rater disagreement, there was no evidence for adversarial allegiance in our sample. Rater disagreement in the scoring of 1 VRAG item (Psychopathy Checklist-Revised; Hare, 2003), however, strongly predicted rater disagreement in the scoring of the VRAG (r = .58). (PsycINFO Database Record

The predictive validity of the Two-Tiered Violence Risk Estimates Scale (TTV) in a long-term follow-up of violent offenders.

Over the past few decades many structured risk appraisal measures have been created to respond to this need. The Two-Tiered Violence Risk Estimates Scale (TTV) is a measure designed to integrate both an actuarial estimate of violence risk with critical risk management indicators. The current study examined interrater reliability and the predictive validity of the TTV in a sample of violent offenders (n = 120) over an average follow-up period of 17.75 years. The TTV was retrospectively scored and compared with the Violence Risk Appraisal Guide (VRAG), the Statistical Information of Recidivism Scale-Revised (SIR-R1), and the Psychopathy Checklist-Revised (PCL-R). Approximately 53% of the sample reoffended violently, with an overall recidivism rate of 74%. Although the VRAG was the strongest predictor of violent recidivism in the sample, the Actuarial Risk Estimates (ARE) scale of the TTV produced a small, significant effect. The Risk Management Indicators (RMI) produced nonsignificant area under the curve (AUC) values for all recidivism outcomes. Comparisons between measures using AUC values and Cox regression showed that there were no statistical differences in predictive validity. The results of this research will be used to inform the validation and reliability literature on the TTV, and will contribute to the overall risk assessment literature. (PsycINFO Database Record

The increasing influence of risk assessment on forensic patient review board decisions.

Previous studies of decisions about forensic patients' placement in secure hospitals indicate some changes over time in the use of empirically supported risk factors. Our aim was to investigate whether, in more recent cases, risk assessment instruments were cited by a forensic patient review board or by the clinicians who made recommendations to the board and whether there was evidence of an association between risk assessment results and either dispositions or recommendations. Among review board hearings held in 2009-2012 pertaining to 63 different maximum security patients found not criminally responsible on account of mental disorder in Ontario, Canada, dispositions were most strongly associated with psychiatrists' testimony, consistent with previous studies. However, dispositions were associated with the scores on the Violence Risk Appraisal Guide (VRAG), such that transferred patients had a lower risk of violent recidivism than detained patients. An association between clinical opinions and risk assessment results was also evident and significantly larger than in previous research. There was no evidence that risk assessment was cited selectively in higher risk cases or when scores were concordant with the review board decision. This research may provide a baseline for studies of the effect of 2014 legislation introducing a high-risk designation for forensic patients in Canada. We recommend further efforts to measure the effect of nonpharmacological treatment participation and in-hospital security decisions on forensic decision-making. (PsycINFO Database Record

The predictive validity of common risk assessment tools in men with intellectual disabilities and problematic sexual behaviors

This CIHR-funded study examined whether certain current risk assessment tools were effective in appraising risk of recidivism in a sample of sex offenders with intellectual disabilities (ID). Fifty men with ID who had engaged in problematic sexual behavior (PSB) were followed for an average of 2.5 years. Recidivism was defined and measured as any illegal or problematic behavior, as well as any problematic but not necessarily illegal behavior. At the beginning of the study, each participant was rated on two risk assessment tools: the Violence Risk Appraisal Guide (VRAG) and the Sex Offender Risk Appraisal Guide (SORAG). During each month of follow-up, participants were also rated on the Short-Dynamic Risk Scale (SDRS), an assessment tool intended to measure the risk of future problematic behaviors. Data was analyzed using t-tests, Cohen’s d and area under the curve (AUC) to test predictive validity of the assessment tools. Using the AUC, results showed that the VRAG was predictive of sexual (AUC=0.74), sexual and/or violent (AUC=0.71) and of any criminally chargeable event (AUC=0.69). The SORAG was only significantly predictive of sexual events (AUC=0.70) and the SDRS was predictive of violent events (AUC=0.71). The t-test and Cohen’s d analyses, which are less robust to deviations from the assumptions of normal and continuous distribution than AUC, did not yield significant results in each category, and therefore, while the results of this study suggest that the VRAG and the SORAG may be effective tools in measuring the short term risk of sexual recidivism; and the VRAG and SDRS may be effective tools in appraising long term risk of sexual and/or violent recidivism in this population, it should be used with caution. Regardless of the assessment tool used, risk assessments should take into account the differences between sex offenders with and without ID to ensure effective measurement.

Validity and reliability of the VRAG in a forensic psychiatric medium security population in Flanders

ABSTRACTSince the development of the Violence Risk Appraisal Guide (VRAG), one of the most widely used actuarial risk assessment instruments, numerous replication studies have shown its usefulness in predicting (violent) recidivism among various offender populations. It is not clear, however, whether these findings can be generalized to forensic psychiatric patients admitted to a medium security forensic psychiatric unit in the Flemish part of Belgium. Therefore, the main aim of this study was to test the predictive validity and reliability of the VRAG in a sample of 191 Flemish medium security patients. The mean follow-up period was 2.4 years. Contrary to the expectations, the VRAG was unable to significantly predict any kind of outcome. Possible explanations are discussed and further research with the VRAG in Flanders, and its recently revised version, is recommended.