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]
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
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?