Four Years On: Some Observations on the Short-Term Assessment of Risk and Treatability (START)

1. Four Years On: Some Observations on the Short-Term Assessment of Risk and Treatability (START) Four Years On: Some Observations on the Short-Term Assessment of Risk and Treatability (START) CHRISTOPHER D. WEBSTER Northwest Forensic Academic Network 25 November 2008

2. “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)

3. “There is thus a pressing need todevelop 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)

4. Monahan et al. (2001) “The factors related to more serious violence may or may not be the same ones associated with less serious violence”.

5. 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”.

6. Original Scoring System Strengths Vulnerabilities 2 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”

7. 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]

8. 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.”

9. 1. T.H.R.E.A.T. 2. Separated Strength and Vulnerability Scales 4. Signature Risk Signs 3. Key and Critical Items (for Theory and Planning) 5. Risk Specificity Statement (of RSVP)

10. START Hospital Forensic/ Civil Community/courts, etc. H I S T O R I C A L D Y N A M I C THREAT THREAT HARM REAL ENACTABLE ACUTE TARGETED [self or others] Community EMERGENCY [24 HOURS] SHORT-TERM [WEEKS] LONG-TERM [YEARS]

11. Historical Factors which may bear on START Assessments © Carla Dassinger, 2005

12. MNEMONIC SIMPLIFICATIONSTART Items: 20 scored separately as risks and strengths…SNAPSHOTIdea 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”. • States • 6. Mental • 7. Emotional • 8. Substance Abuse • 17. Insight • Health/Self Care • 5. Self Care • 14. Medication Adherence • Occupational • 3. Occupational • 4. Recreational • Transitions • Coping • Treatability Social 1. Skills 2. Relationships [T.A.] Necessities 11. Social support[P.P.S.] 12. Material Resources Attitudes/Conduct 13. Attitudes 15. Rule Adherence 16. Conduct Plans 18. Plans 10. External Triggers* 9. Impulsivity * e.g., associates, firearms, access to substances, etc.

13. RISK: -8/40STRENGTH: +23/40 RISK: -35/40 STRENGTH: +3/40 IDEALIZED CASE At Admission At Discharge RISK: 20/20

14. SPJ IN ACTION

15. 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]

16. Predicting Violent Reconvictions using the HCR-20 Nicola S. Gary, John Taylor & Robert Snowden Brit. J. Psych, 2008, 192, 384-387

17. What are some of the possibly attractive features of SPJ? • Help improve consistently or cross-disciplinary clinical language (defined terms) (consistency). • Help to ensure comprehensiveness of assessment (ensure “obvious”, well-grounded, factors enter consideration). • Help isolate key factors to form risk management plans. • Help sharpen predictions (about violence and related issues) (e.g. vignettes). • Help discern change in individual clients (and groups) over time and according to circumstance. • Help clinicians discuss risk issues with clients. • Help improve communication among staff (especially at transition points). • Help in the design of new facilities and programs (or the refurbishment of existing ones) [“snapshots”].