Four Years On: Some Observations on the

Short-Term Assessment of Risk and Treatability

(START)

CHRISTOPHER D. WEBSTERNorthwest Forensic Academic Network

25 November 2008

Four Years On: Some Observations on the

Short-Term Assessment of Risk and Treatability

(START)

“Our disappointment may be alleviated if we accept that short-term “assessment” (which

permits the scanning of the subject’s present environment and associates, and his reactions to these) is likely to be much

more reliable than long-term assessment, which, especially in the present setting of a mobile and changeable society, is likely to be totally beyond

our reach.” (Scott, 1977)

“There is thus a pressing need to develop a predictive scheme involving temporally varying (dynamic)

predictors. Continuously varying predictors (e.g., an offender’s mood state) are useful in determining when an

offender may be more or less likely to reoffend in the immediate future, but because of their very nature, they

are not relevant to long-term predictions.” (Quinsey, 1997)

Monahan et al. (2001) 

“The factors related to more serious violence may or may not be the same ones associated

with less serious violence”.

Webster and Hucker (2007) 

“to yield statistically significant effects summarized across large numbers of people, particular factors seen in isolation or even

limited combinations, have to be very powerful to ‘show through’.

Researchers have sometimes failed to realize that their studies rest on what they are presently

able to measure, that a good deal of hard-to-index information necessarily remains crucial in

the making of individual release decisions”.

Original Scoring System

Strengths Vulnerabilities2 1 0 1 2

Failing:•Has to either/or•No recognition that a client may have both a vulnerability and a strength •0 can end up as a “default”

Current Scoring System

Strengths Vulnerabilities 2 1 0 0 1 2

Note: Can score all strengths first, then all vulnerabilities or score item-by item.

Note: The authors did not include space for summing risk and vulnerability scores [though of course, this can be done by users]

Note: “Strengths” seems to comingle “protective” and “promotive” functions [see Loeber and Farrington]

MacArthur (2001)

“This complexity is no doubt one of the principal reasons why

clinicians relying on a fixed set of individual risk factors have had

such difficulty making accurate risk assessments. It suggests the

need to take an interactional approach to violence risk

assessment. In this approach, the same variable could be a

positive risk factor for violence in one group [or one person],

unrelated to violence in another, and a protective factor against

violence.”

2. Separated Strength and Vulnerability Scales

1. T.H.R.E.A.T.

4. Signature Risk Signs

3. Key and Critical Items (for Theory and Planning) 5. Risk

Specificity Statement (of RSVP)

THREATHARMREALENACTABLEACUTETARGETED

[self or others]

THREAT

HISTORICAL

DYNAMIC

START

HospitalForensic/

Civil

Community

Community/courts, etc.

EMERGENCY[24 HOURS]

SHORT-TERM[WEEKS]

LONG-TERM[YEARS]

© Carla Dassinger, 2005

Historical Factors which may bear on START Assessments

Social 1. Skills 2. Relationships [T.A.]Necessities 11. Social support [P.P.S.]12. Material Resources Attitudes/Conduct13. Attitudes15. Rule Adherence16. ConductPlans18. Plans10. External Triggers*9. Impulsivity* e.g., associates, firearms, access to substances, etc.

States 6. Mental 7. Emotional 8. Substance Abuse17. InsightHealth/Self Care 5. Self Care14. Medication AdherenceOccupational 3. Occupational 4. RecreationalTransitions19. Coping20. Treatability

MNEMONIC SIMPLIFICATIONSTART Items: 20 scored separately as risks and strengths…SNAPSHOT

Idea is that a properly completed START gives a SNAPSHOT of the person’s state and their “present environment and associates and their reaction to these”.

RISK: 20/20

1 2 3 4 5 6 7 8 9 10

-2

-1

0

HISTORICAL SCALE OF THE HCR-20 (H-10)

ITEM

RISK: -35/40 STRENGTH: +3/40

1 2 3 4 5 6 7 8 9 10

11 12 13 14 15 16 17 18 19 20 21 22 23

* Denotes Critical Item

START ITEMS

ITEM

RIS

KST

RE

NG

TH

RIS

KST

RE

NG

TH

1

2

-2

-1

0

2

0

1

ITEM

-2

-1

X START

* *

* * *

*

RISK: -8/40 STRENGTH: +23/40

1 2 3 4 5 6 7 8 9 10

11 12 13 14 15 16 17 18 19 20

START ITEMS

* Denotes Critical Item

ITEM

ITEM

RIS

KST

RE

NG

TH

-2

-1

0

RIS

KST

RE

NG

TH

2

1

2

-2

-1

0

1

X

***

IDEALIZED CASE

At Admission At Discharge

SPJ IN ACTION

Note the important concluding two sentences of Gray et al. (2008)

“…this study used the HCR-20 in an ‘actuarial’ manner (i.e., we

derived a score by adding together the item scores), whereas

the real strength of the HCR-20 [and, presumably, the

START] lies in its use to guide clinical judgment about

risk and therefore about risk management. We note there

is some evidence that structured risk assessments are even

more effective when used in this clinical manner.” [p.286]

Predicting Violent Reconvictions using the

HCR-20

Nicola S. Gary, John Taylor & Robert SnowdenBrit. J. Psych, 2008, 192, 384-387

1. Help improve consistently or cross-disciplinary clinical language (defined terms) (consistency).

2. Help to ensure comprehensiveness of assessment (ensure “obvious”, well-grounded, factors enter consideration).

3. Help isolate key factors to form risk management plans.4. Help sharpen predictions (about violence and related issues)

(e.g. vignettes). 5. Help discern change in individual clients (and groups) over

time and according to circumstance.6. Help clinicians discuss risk issues with clients.7. Help improve communication among staff (especially at

transition points).8. Help in the design of new facilities and programs (or the

refurbishment of existing ones) [“snapshots”].

What are some of the possibly attractive features of SPJ?