Report 2014-125 Summary - March 2015
California Department of State Hospitals:
It Could Increase the Consistency of Its Evaluations of Sex Offenders by Improving Its Assessment Protocol and Training
Our audit of the California Department of State Hospitals' (State Hospitals) evaluation process for determining whether offenders meet the criteria of a sexually violent predator (SVP) highlighted the following:
- It has not ensured that it conducts these evaluations in a consistent manner.
- Although state law requires evaluators to use a standardized assessment protocol when conducting evaluations, State Hospitals' existing protocol lacks detail.
- None of its reviews of SVP evaluations at headquarters focus on ensuring the quality of the evaluations from a clinical perspective.
- The quality assurance team provides guidance to less experienced evaluators but does not provide supervisory review.
- Coalinga State Hospital (Coalinga) has not established a process to document its clinical reviews of evaluations.
- It could better use data related to court outcomes to identify areas to strengthen its evaluations.
- Its training for SVP evaluators has been inconsistent—between August 2012 and May 2014 it offered no training at all.
- Coalinga has a significant backlog of annual SVP evaluations—it had 261 annual evaluations that were due to courts as of December 2014.
Results in Brief
The Legislature created the Sex Offender Commitment Program (program) in 1996 to target a small but extremely dangerous subset of sexually violent offenders who present a continuing threat to society because their diagnosed mental disorders predispose them to engage in sexually violent criminal behavior. Through this program, the California Department of Corrections and Rehabilitation (Corrections) refers certain sex offenders (offenders) to the California Department of State Hospitals (State Hospitals) for psychological evaluations when those offenders are nearing their scheduled release dates. State Hospitals' evaluators determine whether the offenders meet the criteria for being a sexually violent predator (SVP). If State Hospitals determines that offenders meet the SVP criteria, it requests the county counsels to petition for the offenders' commitments to a state hospital. If the county counsels concur with the request, the counties will submit a petition to the court, which decides whether the individuals should be committed. State law designates Coalinga State Hospital (Coalinga) as the hospital for SVPs unless unique circumstances exist. For example, one female SVP is held at another state hospital. As of June 2014 approximately 930 individuals were either residing at Coalinga pending trials for commitment or were committed as SVPs.
Despite the critical role State Hospitals' evaluations play in the SVP commitment process, it has not ensured that it conducts these evaluations in a consistent manner. State law requires that evaluators consider a number of factors about offenders, such as their criminal and psychosexual histories, when determining whether they meet the SVP criteria. However, of the 29 evaluations we reviewed—23 conducted by evaluators at State Hospitals' headquarters in Sacramento and six conducted by evaluators at Coalinga—we noted instances in which evaluators did not demonstrate that they considered all relevant information. For example, one evaluation did not indicate that the evaluator used a certain kind of instrument to gauge the risk that the individual would commit another sexual crime, and eight did not note that the evaluators had reviewed a report from Corrections that identifies any communication challenges or disabilities the individuals might have that could affect their assessments. In fact, we noted one instance in which differences in the documentation that evaluators indicated they reviewed led evaluators to reach very different conclusions about an individual: One evaluator noted that the individual had experienced suicidal thoughts, while the other stated that he did not have any mental health issues.
When evaluators do not consider all relevant information, it is possible that State Hospitals may recommend that courts commit individuals who do not pose a danger to the public, or they may not recommend commitment of individuals who do. Further, when evaluators do not fully document how they reached their conclusions, they may not be able to adequately defend those conclusions if challenged in court. To avoid such situations, we would expect State Hospitals to provide its evaluators with significant guidance regarding how they should perform evaluations. State law requires evaluators to use a standardized assessment protocol when conducting evaluations. However, State Hospitals' existing protocol lacks detail. For example, the protocol does not give guidance on specific risk assessment approaches or list specific risk assessment instruments evaluators may choose to use. In contrast, the former protocol State Hospitals used in 2007 covered approaches to risk assessment and risk assessment instruments. However, State Hospitals revised and simplified this protocol in 2008 because the Office of Administrative Law determined that certain provisions of the protocol met the definition of regulations but had not gone through the required regulatory process.
Additionally, evaluators did not always consider all three criteria for determining whether offenders might be recommended for commitment; however, this decision created some efficiency. Specifically, in three evaluations we reviewed the evaluators noted that they did not diagnose a mental disorder—the second of three criteria that must be met for commitment—and therefore chose not to evaluate the third criterion, which is whether the diagnosed mental disorder makes the offenders likely to engage in sexually violent, predatory criminal behavior in the future without treatment and custody. State Hospitals has directed evaluators to complete evaluation of all three criteria regardless of the outcome of one. However, if the evaluator determines that an offender will not meet the criteria, we believe stopping the evaluations is both appropriate and efficient.
Given that State Hospitals recently hired many of its evaluators and that evaluating SVPs requires highly specialized skills, we also would expect State Hospitals to have established certain quality control measures, such as supervisory reviews, to ensure that its evaluators complete adequate and consistent evaluations. However, none of State Hospitals' reviews of SVP evaluations at headquarters focus on ensuring the quality of the evaluations from a clinical perspective. Further, in October 2013, State Hospitals established a quality assurance and training team (quality assurance team) to provide guidance to State Hospitals' less-experienced evaluators at headquarters; however, the quality assurance team does not provide supervisory review. At Coalinga—where evaluators conduct annual evaluations of individuals whom the State has already committed as SVPs—hospital managers stated that evaluators receive multiple levels of clinical review. However, Coalinga has not established a process to document these reviews. Without evidence of adequate supervision and review, State Hospitals' evaluations may fail to effectively demonstrate the need to recommend or not recommend commitment of an individual.
Further, State Hospitals could better use data related to court outcomes to identify areas to strengthen its evaluations. High-quality evaluations are important because courts use them to decide whether individuals are SVPs and should be committed to a state hospital. However, State Hospitals has not consistently tracked the disposition of SVP court cases, and the courts do not always agree with State Hospitals' recommendations. For example, in one of the 23 evaluations we reviewed at State Hospitals' headquarters, a court chose to release an offender even though evaluators determined that he met the SVP criteria. A November 2014 change to State Hospitals' court scheduling process for evaluators may help State Hospitals better track case outcomes and evaluate trends for court decisions; however, it is too soon to conclude whether this new process is successful. Unless it tracks the dispositions of its SVP court cases, State Hospitals is missing an opportunity to improve its evaluation process and potentially strengthen its training and supervision of evaluators.
Besides providing guidance and supervisory reviews to evaluators, providing ongoing technical training is important to ensure the competence of those conducting evaluations of potential and current SVPs. However, State Hospitals has not consistently offered training to SVP evaluators. In 2009 and 2010 State Hospitals offered its evaluators—at the time, mostly contractors—training on a variety of topics, including sex offender risk assessment tools, statistics on sexual recidivism, the effect of aging on recidivism, and the violence-risk scale. In anticipation of hiring evaluators, State Hospitals developed its own training, which it provided in 2011 and part of 2012. However, between August 2012 and May 2014, it offered no training at all.
More recently, State Hospitals began taking steps to provide more robust training to its evaluators at its headquarters, though it has yet to take similar steps for the evaluators at Coalinga. In 2014 State Hospitals' chief psychologist and the quality assurance team developed a training plan for evaluators at headquarters. Specifically, in May 2014, State Hospitals offered comprehensive SVP training for all consulting psychologists, who currently represent 33 of 45 evaluators on staff. The training focused on the background of the SVP statutes, the various criteria under which State Hospitals evaluates potential SVPs, and a specific type of risk assessment tool. State Hospitals has a tentative plan to offer additional training but has yet to schedule it. Coalinga's evaluators receive fewer training opportunities than the evaluators at headquarters. Coalinga's forensic senior psychologist supervisor designed a training plan for fiscal year 2014-15 to help new evaluators at the hospital develop a basic understanding of state law affecting forensic evaluations, forensic report writing, and risk assessment. She indicated that Coalinga is also in the process of developing an ongoing training plan for experienced evaluators and has some trainings scheduled for 2015.
Compounding the inconsistent training offered to evaluators, State Hospitals has not offered training on dynamic risk assessment instruments until recently. A dynamic risk assessment may consider factors that change slowly, such as personality disorders or sexual preference, to help predict long-term risk, and may consider acute, rapidly changing factors, such as negative mood or intoxication, that could signal the possible timing of a reoffense. However, in two trainings on forensic assessment in 2012, State Hospitals' instructors provided a high-level overview of dynamic risk factors but did not provide instructions on how to use specific assessment instruments. State Hospitals' chief psychologist stated that a dynamic risk assessment tool strengthens an evaluation by providing a higher degree of certainty when estimating the risk of a reoffense. As a result, State Hospitals provided training on dynamic risk assessment instruments in December 2014 and January 2015.
Finally, Coalinga has a significant backlog of annual SVP evaluations it has not completed. State law requires State Hospitals to evaluate at least annually SVPs committed to it. However, according to Coalinga's tracking log of overdue annual reports, it had 261 annual evaluations that were due to courts as of December 2014. According to the acting chief of forensic services at Coalinga, State Hospitals briefly required Coalinga's evaluators to complete another type of evaluation in addition to the annual evaluations, creating additional work. Further, he stated that Coalinga has found it difficult to hire staff. When State Hospitals does not complete annual evaluations on time, it is not fulfilling its statutory obligation to consider whether an SVP is a candidate for release.
To promote efficiency, the Legislature should change state law to allow State Hospitals the flexibility to stop an evaluation once the evaluator determines that the offender does not meet one of the SVP criteria.
To improve the consistency of its evaluations, by June 2015 State Hospitals should create a written policy that requires its evaluators to include the following documentation in their evaluations:
- Detail describing all the documentation they reviewed.
- A description of the risk assessment instruments the evaluator used.
- Acknowledgement of their review of a form from Corrections that identifies any communication challenges or disabilities the offenders might have that could affect their assessments.
To promote consistency and ensure that it provides sufficient guidance to evaluators, State Hospitals should update its assessment protocol by March 2016 to include more specific instructions on how to conduct evaluations, such as what assessment instruments evaluators should use and what documents they should consider.
To improve the consistency and completeness of its evaluations, by December 2015 State Hospitals should develop a plan for the formal, supervisory review of evaluations from a clinical perspective.
To ensure that it has the data necessary to inform its training and supervision of evaluators, State Hospitals should identify the most efficient means for obtaining the outcomes of past trials—at least three years of past trials if possible—and should ensure that it includes such outcomes in its database by March 2016. It should use this information to provide training and supervision where they are most needed.
To ensure that its evaluators have the necessary training to conduct evaluations effectively and consistently, State Hospitals should complete the development of its comprehensive training plan for all evaluators by June 2015. In addition, by September 2015 it should provide training on risk assessment instruments to all new evaluators and those who have not yet received such training.
To reduce its backlog of annual evaluations at Coalinga and to reduce the number of days these evaluations are overdue, State Hospitals should continue its efforts to hire enough evaluators to meet its workload.
State Hospitals generally agreed with our recommendations, described the steps it would take to implement them, and provided estimated implementation dates.