Short-Term Assessment of Risk and Treatability (START)

The Short-Term Assessment of Risk and Treatability (START) is a concise clinical guide for the dynamic assessment of short-term (i.e., weeks to months) risk for violence (to self and others) and treatability. START guides the assessor toward an integrated, balanced opinion to evaluate the client’s risk across seven domains: violence to others, suicide, self-harm, self-neglect, unauthorized absence, substance use, and risk of being victimized. This structured professional guide is intended to inform clinical interventions and index therapeutic improvements or relapses.

START represents a refinement in the risk assessment field, in that it comprises dynamic variables that are responsive to treatment and management efforts and because each of the 20 items is scored both as a vulnerability and as a strength, from 0 (no evident risk or strength) to 2 (high risk or strength). It also allows for the recording of historical and case-specific factors. Once the 20 items are coded, the assessor completes a summary judgment of risk (low, moderate, or high) on the seven domains (i.e., violence to others, suicide, etc.); other client-specific risks may also be added. A potentially useful aspect of START is that it facilitates the identification, recording, and communication of individually determined “critical” vulnerability items, “key” strengths, and “signature risks” (i.e., early but reliable, unique, and invariant signals of impending relapse and elevation in risk) deemed to be especially relevant to the particular client’s functioning, responsivity to treatment, and the likelihood of adverse outcomes.

START is devoted to the systematic assessment of the strengths and vulnerabilities of the individual client with the ultimate goal of enhancing mental health functioning and preventing adverse events. It is intended to assist in day-to-day monitoring, treatment planning, and risk communication. Repeated administrations are a convenient method of tracking changes in mental health status, vulnerabilities, strengths, and violence potential (against self/others). START is anticipated to be an effective means of reducing the cycling of mentally disordered persons through the civil psychiatric and criminal justice systems. It was developed for use with adults with mental, personality, and substance-related disorders, with relevance to correctional, civil, and forensic clients in the community and institutional settings. This new scheme is particularly applicable to forensic assessments requiring a consideration of violence risk. Where possible, START should be completed by multidisciplinary treatment teams.

START  Reliability

The interrater reliability of START has been assessed across multiple mental health disciplines. The inter-rater reliability for three assessor professions using the intraclass correlation coefficient was ICC2 = .87, p = .001. The internal consistency (Cronbach’s alpha) of the total START scores for diverse raters is also good (a = .87) and is relatively consistent across disciplines: psychiatrists (a = .80), case managers (a = .88), and social workers (a = .92). Item homogeneity measured using the mean interitem correlation exceeds .20, generally agreed to reflect a unidimensional scale.

START Validity

Content validity of START is demonstrated by the measure emerging from a perceived need by frontline mental health professionals. The items and content reflect the collaboration of a multidisciplinary group of researchers and mental health professionals. It grew out of repeated consultation with multiple treatment teams and reflects a comprehensive consideration of existing risk assessment devices and the literature. Professionals report that the items are easily applied to their clients’ circumstances, that START provides a comprehensive risk summary, and that signature risk signs are useful when evaluating their patients. It is also noteworthy that assessors identify more strengths than vulnerabilities in their clients, suggesting that the inclusion of strengths in START is an important advance over previous instruments.

Construct validity has been demonstrated by prospectively examining the relationship between START item scores and Review Board hearing outcomes; results indicate a weak positive relationship. Further evidence of convergent validity has been demonstrated through an examination of START scores by ward security levels in a forensic psychiatric hospital. Findings demonstrated significantly lower total scores among patients in open units than among patients in closed and locked units (F = 15.64, p < .001). Patients in open units were also found to have lower risk scores and higher strength scores than patients in closed and locked units.

Predictive validity has been examined in prospective research, which demonstrates a moderate association between START total scores and future self-harm, aggression against others, and attempted unauthorized leave, as measured by a modified Overt Aggression Scale (e.g., physical aggression rpb = .23, p < .001; AUC = .65, CI = .57-.72, p < .001). There is substantial overlap between the risk domains evaluated on START. For instance, patients who aggress against others are also significantly more likely to engage in self-harm (9 = .37). These findings suggest that joint assessment and treatment of these diverse needs is appropriate.

Future Research

Research examining the hierarchical organization and construct validity of START, as well as its utility for monitoring progress and planning for effective interventions, is needed. Prospective studies demonstrating START’s capacity to measure change in offenders, forensic, and civil psychiatric patients are required, as are projects to demonstrate whether that change is reflected in decreased future risk. In particular, future research should examine to what extent START’s dynamic variables add incremental validity to established static (more or less unchanging) risk markers and for what time frames static versus dynamic variables are most relevant. START research should focus on comparing and contrasting the importance of considering clients’ strengths in combination with their vulnerabilities and the relevance of those variables for predicting and reducing risk. START has been translated into several languages, though a pressing need remains for studies demonstrating its utility in English- and non-English-speaking populations and across cultures and settings.

References:

  1. Webster, C. D., Martin, M. L., Brink, J., Nicholls, T. L., & Middleton, C. (2004). Manual for the Short-Term Assessment of Risk and Treatability (START) (Version 1.0, Consultation ed.). Hamilton, ON, Canada: St. Joseph’s Healthcare/Port Coquitlam, British Columbia, Canada: Forensic Psychiatric Services Commission.
  2. Webster, C. D., Nicholls, T. L., Martin, M. L., Desmarais, S. L., & Brink, J. (2006). Short-Term Assessment of Risk and Treatability (START): The case for a new violence risk structured professional judgment scheme. Behavioral Sciences and the Law, 24, 747-766.

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