General Violence Risk : A Strength-Based Approach

Violence is not rare; it is a pervasive social problem that takes many distinct forms. Diverse professions are commonly tasked with identifying situations with increased violence and the individuals who may pose this risk. Then, professionals are tasked with identifying the necessary and appropriate steps to protect public safety.

The field of risk assessment has evolved from focusing mainly on risk prediction to more significant consideration of risk formulation and understanding of risk and risk management and reduction. The Short-Term Assessment of Risk & Treatability (START) is a guide that was developed to evaluate an individual’s risk for aggression and their likelihood of responding well to treatment. The START moves the assessment from assessing an individual’s vulnerability to violence and aggression to intervening and informing clinical interventions and the development of treatment plans. This tool guides the assessor in performing repeated evaluations and documenting treatment and management modifications as needed. Completing the START helps identify who is at risk from which person(s), under what circumstances, with what likely adverse effect(s), and over what period. The START unites research with clinical practice by relying on clinical expertise with a structured application.

• Identify risk(s)
• Inform treatment and risk management
• Describe individual clinical profiles
• Monitor progress and treatment outcomes
• Improve management of transitions
• Provide common language across disciplines

The START is coded to evaluate short-term risk by considering historical functioning coupled with the individual's recent and current functioning. The assessment is focused on a person’s attitude, functioning, and behavior. Administration requires users to rate 20 clinical items for strength and vulnerability independently. Individuals can be high or low on strength and vulnerability for any item.

Research suggests that once familiar with the START, the time for administration is approximately 30 minutes. Research has also supported the assertion that information coded on the START is information that clinicians can readily locate or solicit - rarely, a start can not be completed in its entirety. Therefore, if a clinician cannot complete a START due to missing information, it indicates that the assessor should obtain collateral or meet with the person again, as these items reflect information that should be known about the patient for well-informed treatment.

Using a risk-needs-responsivity approach, assessors identify which items on the START are particularly relevant to the evaluee. For example, if an item is either presently or historically a particular strength that can be used in treatment (e.g., therapeutic lever), it is indicated as a key item. Similarly, if an item is a particular vulnerability that requires increased supervision and treatment planning, it would be marked as a critical item (e.g., a red flag).  While there is no hard and fast rule, key and critical item ratings should be done parsimoniously.

These 20 strengths and vulnerabilities are rated to evaluate the risk of externalizing (violence towards others), internalizing (suicide, self-harm, and substance use), and high-risk behaviors (self-neglect, being victimized by others, and unauthorized absences) on a three-point scale (Low, Moderate, High). This step promotes an understanding of what factors are relevant to specific types of risk and what factors could be helpful to reduce or mitigate risk.

For use among adults (18 years & older) with:

• Mental disorders
• Substance use disorders
• Personality disorders
• Criminal justice involvement

1. It includes dynamic variables, which are beneficial to informing shorter-term decision-making.
2. Short-term assessments can inform daily practice. 
3. Professionals who conduct risk assessments can make recommendations or provide comprehensive care. The START does not just look at an individual's risk for violence. It also incorporates items that can improve mental and physical health. 

• Mental Health Diversion Programs - to keep individuals out of jails can be used as a referral tool and a tool for care planning. 
• Forensics Psychiatric Hospitals - help guide treatment to eventually transition individuals out of what is otherwise seen as a very static setting.
• Civil Psychiatric Hospitals - can be completed during intake while gathering other relevant information. It is beneficial to have a plan in place for patients and baseline data to evaluate changes in stability.
• Correctional Facilities - beneficial for transitioning back to the community to understand what resources an individual needs to keep them and others safe. 

Pros

• Comprehensive: The START can improve client care and enhance community safety.
• Transparent: When completing the START, the assessor identifies how long the estimates are valid.
• Sensitive to change over time: Individuals' risk ratings change as they move through a hospital continuum (e.g., from max to minimum security).
• Good psychometrics
  • Across professions, individuals tend to get the same rating using the START.
  • Changes in dynamic risk factors are reliably associated with institutional violence.
  • Strong demonstration of convergent and divergent validity with other risk assessment measures.
  • User satisfaction: User-friendliness and clinical utility.
• Common language: During transitional points, professionals who regularly use the START can garner a comprehensive and concise picture of the patient.
• Identification of treatment targets
  • Provides a framework to ensure consistent and comprehensive evaluations and interventions.
  • Allows for the prioritization of care.
• Translated into ten different languages and used in 22 countries

Cons

• An assessor would need to administer the START several times to see an individual’s change.
• The dynamic factors may have a shorter shelf life as the dynamic factors constantly change. Regularly completing a START for all patients on an individual caseload can be time-consuming.