Short-Term Assessment Of Risk And Treatability Research Articles

Reducing Risk for Future Violence From Forensic Psychiatric Patients by Using Critical Factors of the Short-Term Assessment of Risk and Treatability as a Caring Tool.

The dual task for forensic mental health care is community protection and treatment of mental disorders. The Short-Term Assessment of Risk and Treatability (START) has become an established tool for risk assessment and care planning in forensic psychiatry. When using the START, items judged as critical factors are chosen to be addressed in the care plan. However, it is not known which critical factors that are of special interest need to be addressed to reduce the risk for future violence. The main aim of this study was to explore how staff's choice of critical factors in the care planning influences risk for future violence. The study is based on 787 START assessments from 285 convicted and involuntary admitted inpatients at the Forensic Psychiatric Clinic of Stockholm County, Sweden. The influence on risk for future violence by selecting a certain item as a critical factor in the care plan was measured by comparing patients' sum of vulnerabilities at the time this certain critical factor was selected with this sum at the next assessment. The results show that a patient's overall risk for future violence decreases significantly when the items "insight," "attitudes," "mental state," "coping," and "drug use" were addressed as critical factors in the care planning. The importance of specified critical factors differs between diagnostic groups and time after admission. When staff select certain specified items as critical factors in the care planning, the patients' risk of relapse into acts of violence was significantly reduced.

Assessing the Alignment of Short-Term Assessment of Risk and Treatability (START) with NANDA-I Taxonomy in Forensic Care Settings

Purpose. To investigate the alignment of START with NANDA-I in forensic psychiatric care. Design. A quantitative design was chosen to compare the START instrument with the NANDA-I taxonomy and analyze their alignment. Each item of the START was attempted to be matched with potentially relevant NANDA-I diagnoses, and the matched diagnoses were extracted and presented. Findings. The study demonstrated a strong alignment between START coding and NANDA-I diagnoses, with 99% of the START diagnoses finding a match within NANDA-I. These results support the use of NANDA-I in forensic psychiatric care, which facilitate providing comprehensive care and avoiding sole focus on psychiatric problems. Practice Implications. It is recommended to use a structured nursing taxonomy, such as NANDA-I, in forensic psychiatric care.

Investigating the dynamic nature of multiple risk assessment instruments in a forensic mental health hospital.

Readministration of multiple risk assessment instruments to determine the risk of aggression over the short, medium, and long term is common practice in many forensic mental health settings. Justification for the repeated administration and use of multiple instruments is based on purported differences in discriminative validity of risk factors according to whether they are characterized as static, stable, or acute, and the composition of these tools, in terms of the relative balance of different types of risk factors, which can impact the discriminative validity of these instruments over different follow-up periods. However, research has yet to determine whether the use of multiple and repeated administration of risk assessment instruments improves identification of risk, and it may be the case that the heavy burden on service providers to administer multiple instruments is unwarranted. In this study, time-dependent cox regression with repeated assessments and recurrent events was used to investigate the dynamic nature and incremental validity of the dynamic appraisal of situational aggression (DASA), short-term assessment of risk and treatability (START), and HCR-20v3, which were repeatedly rated on a sample of forensic mental health inpatients (N = 240) over a 2-year period. Results suggest that using the rolling mean or the most recent risk assessment yielded the most accurate characterization of change in aggression risk. Repeated administration of dynamic risk instrument instruments improved the identification of aggression beyond the initial risk assessment. Although static, stable, and acute factors were significantly related to aggression, the combination of data from multiple risk assessment instruments may not result in clinically meaningful improvements in risk identification. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Effects of Implementing the Short-Term Assessment of Risk and Treatability for Mechanical Restraint in a Forensic Male Population: A Stepped-Wedge, Cluster-Randomized Design.

The assessment and formulation of the risk of violence and other unwanted behaviors at forensic psychiatric facilities have been attempted for decades. Structured professional judgment tools, such as the Short-Term Assessment of Risk and Treatability (START), are among the recent attempts to overcome the challenge of accomplishing these goals. This study examined the effect of implementing START in clinical practice for the most serious adverse events among the target group of severely mentally ill forensic psychiatric inpatients. Results were based on the use of mechanical restraints as an outcome. This study is a pragmatic, stepped-wedge, cluster-randomized controlled trial and was conducted over 5 years. It included eight forensic psychiatric units. Fifty out of 156 patients who had a basic aggression score of more than 0 were included in the study. We found that the rate of mechanical restraint use within the START period were 82% [relative risk (RR) = 0.18], lower than those outside of the START period. Patients evaluated within the START period were also found to have a 36% (RR = 0.64) lower risk of having higher Brøset Violence Checklist scores than patients evaluated outside the START period. Previous studies on START have primarily focused on validation, the predictive capability of the assessment, and implementation. We were only able to identify one study that aimed to identify the benefits and outcomes of START in a forensic setting. This study showed a significant reduction in the chance for inpatients in a forensic psychiatric facility to become mechanically restrained during periods where the START was used as risk assessment.

Unidimensionality of the Strengths and Vulnerabilities Scales in the Short-Term Assessment of Risk and Treatability (START)

The Short-Term Assessment of Risk and Treatability (START) is a 20-item structured professional judgment instrument for assessing dynamic risk in mental health services. Much of the START research literature examines the relationship between Strengths and Vulnerabilities sub-scale total scores and various adverse outcomes including violence. This assumes that the two sub-scales have the psychometric property of unidimensionality i.e. all the items cluster together as a measure of a single construct. Such assumed unidimensionality is a necessary condition for any analyses based on scale “total score” and the widespread use of scores summated in this way in research studies may obscure more specific clusters of items within each sub-scale. This multinational study examined START assessments (n = 685) conducted in four forensic services in Scandinavia and the UK using principal component analysis. It was found that all but three Strengths items (Substance Use, Social Support and Material Resources) and all but four Vulnerabilities items (Substance Use, Social Support, Material Resources and Self care) loaded >0.5 on the expected component. This indicates a unidimensional structure underlying the START and provides empirical support from a large multinational sample for the widespread use of summated Strengths and Vulnerabilities scores in forensic psychiatric risk research.

Validity of Short-Term Assessment of Risk and Treatability in the Japanese Forensic Probation Service.

This study aimed to evaluate the predictive validity and reliability of the Short-Term Assessment of Risk and Treatability (START) in the context of the Japanese forensic probation service. START is a structured professional judgement guide for risk domains concerning negative behaviors such as violence, self-harm, suicide, substance abuse, unauthorized leave, victimization, and self-neglect. In this study, rehabilitation coordinators evaluated community-dwelling patients who were treated under the Medical Treatment and Supervision Act at baseline and followed-up for 6 months. The results revealed that START vulnerability scores significantly predicted self-harm, suicide, physical aggression, substance abuse, and self-neglect. START strength scores predicted physical violence and unauthorized leave. Specific risk estimates predicted physical violence and self-neglect. Risk judgement for future substance use may require adjustments for cultural differences, because of the lower prevalence in Japan. These results suggest that START offers a feasible and valid tool that allows clinicians to plan treatment and promote recovery of forensic patients in Japan.

Assessing the risk of self-harm: the impact of safety interventions on the predictive validity of risk assessment in secure care

PurposeSelf-harm is a cause of concern for health-care professionals. The Short-Term Assessment of Risk and Treatability (START) is a short-term assessment instrument used to rate the likelihood of risk behaviours, including self-harm. As result of the assessment, interventions that are implemented to reduce the risk of self-harm may reduce the strength of the predictive validity of a risk assessment tool. The aim of this study was explore the impact of risk management interventions on the capacity of START to predict self-harm. It was predicted that the interventions would weaken the ability of START to predict self-harm in patients who received the intervention.Design/methodology/approachSecondary analysis of routinely collected data in a large sample of women in an inpatient secure care setting. Demographic and clinical information, self-harm episodes, safety management interventions and START assessments were extracted and used to build an anonymous database.FindingsSTART significantly predicted self-harm in those with and without the safety management intervention. However, the strength of the predictive validity was smaller in those who received the intervention compared to those without.Practical implicationsThe results suggest that the implementation of safety management interventions needs to be taken into account when assessing future risk of self-harm.Originality/valueTo the best of the authors’ knowledge, this is the first study to explore the impact of safety management interventions on the predictive validity of START in a large sample of women.

Assessing the confidence-accuracy relationship in risk assessments using the START: introducing calibration analysis

ABSTRACT A risk assessor’s confidence has been shown to influence both the rater as well as those evaluating the risk assessment. It is important to consider the impact of confidence on accuracy in the risk assessment field given the significant implications of risk assessments for the assessed (e.g. available treatment options vs. restrictions of liberties) and the safety of the public. While prior research in the risk assessment field has used correlations to investigate the confidence-accuracy (C-A) relationship, a number of fields in psychology have introduced additional techniques, including calibration analysis, to understand this relationship. In this study, we examined the C-A relationship across various adverse clinical outcomes using the Short-Term Assessment of Risk and Treatability (START) and compared and contrasted the C-A relationship using conventional methods (i.e. correlations/ROC analysis) and calibration. Raters completed START assessments for a sample of 106 civil psychiatric inpatients. Overall, calibration provided greater detail into the C-A relationship compared to correlations/ROC analysis. Our results also suggested that the C-A relationship varied as a function of the outcome assessed (e.g. violence, substance abuse, unauthorized leave). These results provide insights into the C-A relationship in medico-legal settings and can inform best practices for risk assessment training and implementation.

Healthy emotions, lower risk? The relationship between emotional states and violence risk among offenders with Cluster B personality disorders

ABSTRACT Personality disorders (PDs) are ingrained dysfunctional patterns of cognition, emotion, and behavior. PDs, especially Cluster B PDs, are related to an increased violence risk and are highly prevalent in offender populations. Patients with PDs may suffer from dysregulated affect in a sense that they experience many maladaptive emotional states and relatively few healthy emotional states. It was therefore hypothesized that violence risk can be predicted by emotional states. It was expected that a decrease in maladaptive emotional states or an increase in healthy emotional states would precede a decrease in violence risk. The study sample consisted of 103 male offenders with a Cluster B PD, hospitalized in the Netherlands. We used the Schema Mode Inventory-Revised (SMI-R) to assess healthy and maladaptive emotional states and the Short-Term Assessment of Risk and Treatability (START) to assess short-term violence risk and to monitor changes thereof. Assessments were repeated after 6 months, 12 months, and 18 months. We conducted hierarchical regression analyses with START Risks or Strengths as outcome variables, predicted by START scores, SMI healthy, and maladaptive total scores at an earlier time point and the change over time. Results show that all models were highly significant, but neither the healthy and maladaptive emotional states nor the change over time was a significant predictor. The exception was at 6 and 12 months of START Strengths, where an SMI healthy score was a significant predictor in the model. Our hypothesis was only partially supported, which is likely explained by limitations of the study.

A retrospective study on risk assessment and management of forensic psychiatric inpatients in Hong Kong.

The Department of Forensic Psychiatry of Castle Peak Hospital is the only facility in Hong Kong that provides territory-wide forensic psychiatric services for patients with criminal involvement. This retrospective study aimed to explore whether the rehabilitation programs provided by the department could significantly reduce the risks of forensic psychiatric inpatients as measured by the Short-Term Assessment of Risk and Treatability (START). START ratings of inpatients who were hospitalized in the department for more than 3 months and were discharged to the community during the period from 11 April 2015 to 31 March 2019 were analyzed. A total of 79 patients were assessed, of whom 61 (77.2%) were males. Fifty-four (68.4%) patients suffered from schizophrenia. START scores upon admission (strength score = 5.67; vulnerability score = 17.43) and upon discharge (strength score = 6.87, vulnerability score = 11.18) indicated significant reduction of risks among inpatients (p < 0.05).

Single-item predictive validity of the Short-Term Assessment of Risk and Treatability (START) for violent behaviour in outpatient forensic psychiatry

ABSTRACTThe single-item predictive validity of the Short-Term Assessment of Risk and Treatability (START) has not been thoroughly investigated, although this has great clinical relevance for the selection of treatment targets. Furthermore, it remains unclear whether the characteristic START additions of scoring strengths next to vulnerabilities and selecting key items, add incremental predictive validity. Finally, predictive validity has primarily been studied in inpatient settings and included mainly patients with a psychotic disorder. We analysed data from a mixed diagnostic sample of 195 forensic psychiatric outpatients with a 3-month and 170 patients with a 6-month follow-up period, using logistic regression analysis. The occurrence of violent or criminal behaviour was established based on the case manager’s recordings in the patient’s file. Only 5 of the 20 START items were found to have predictive validity: Impulse Control, Attitudes, Material Resources, Rule Adherence and Conduct. The last three were the only items for which incremental predictive validity was found with respect to scoring it as a strength and a vulnerability. Selection of key items did not add to the predictive validity. While possibly having therapeutic significance, the scoring of strength next to vulnerability and the selection of key items, may not be beneficial for risk assessment.

Gender-Sensitive Violence Risk Assessment: Predictive Validity of Six Tools in Female Forensic Psychiatric Patients

Most violence risk assessment tools have been validated predominantly in males. In this multicenter study, the Historical, Clinical, Risk Management–20 (HCR-20), Historical, Clinical, Risk Management–20 Version 3 (HCR-20V3), Female Additional Manual (FAM), Short-Term Assessment of Risk and Treatability (START), Structured Assessment of Protective Factors for violence risk (SAPROF), and Psychopathy Checklist–Revised (PCL-R) were coded on file information of 78 female forensic psychiatric patients discharged between 1993 and 2012 with a mean follow-up period of 11.8 years from one of four Dutch forensic psychiatric hospitals. Notable was the high rate of mortality (17.9%) and readmission to psychiatric settings (11.5%) after discharge. Official reconviction data could be retrieved from the Ministry of Justice and Security for 71 women. Twenty-four women (33.8%) were reconvicted after discharge, including 13 for violent offenses (18.3%). Overall, predictive validity was moderate for all types of recidivism, but low for violence. The START Vulnerability scores, HCR-20V3, and FAM showed the highest predictive accuracy for all recidivism. With respect to violent recidivism, only the START Vulnerability scores and the Clinical scale of the HCR-20V3demonstrated significant predictive accuracy.

Assessing Risk for Victimization in a Forensic Psychiatric Setting Using the Short-Term Assessment of Risk and Treatability.

Although a growing literature on community-based victimization of people with mental illness exists, victimization within institutional settings is comparatively understudied. The current study seeks to fill this gap by exploring factors related to risk of victimization in a male forensic psychiatric sample using a relatively new risk assessment measure. The Short-Term Assessment of Risk and Treatability (START) is a short-term risk assessment measure that compiles information about several clinically relevant risk factors to evaluate risk of victimization, among other adverse outcomes. Nearly one-third (31.3%) of the sample experienced some type of victimization during their hospitalization. The summary risk judgment and subsets of select START items effectively predicted risk of victimization in this sample with a fair degree of accuracy over a 2-month period.

Inter-rater reliability of the Short-Term Assessment of Risk and Treatability (START)

ABSTRACTEmpirical evidence supports the reliability and validity of the Short-Term Assessment of Risk and Treatability (START) completed in the context of research studies as well as field implementation. However, one limitation is that the body of literature is not fully representative of the range of services where the tool is applied, highlighting the paucity of UK-based research into the START. The primary aim of this study was to assess the inter-rater reliability (IRR) of the START and to examine whether IRR varies across professional disciplines who routinely complete the assessments as part of the integrated multi-disciplinary teams in the field of male mental health within an independent provider of healthcare services. Further aims were to look at the internal consistency of IRR and the test re-test reliability. Findings overall indicated better IRR for START items, between disciplines, across different cases and time, than for risk estimates. Therefore, outcomes are discussed in relation to applied practice for professionals within the service, but also the implications this may have for general risk management based on risk estimation.

Risk prediction using natural language processing of electronic mental health records in an inpatient forensic psychiatry setting.

Instruments rating risk of harm to self and others are widely used in inpatient forensic psychiatry settings. A potential alternate or supplementary means of risk prediction is from the automated analysis of case notes in Electronic Health Records (EHRs) using Natural Language Processing (NLP). This exploratory study rated presence or absence and frequency of words in a forensic EHR dataset, comparing four reference dictionaries. Seven machine learning algorithms and different time periods of EHR analysis were used to probe which dictionary and which time period were most predictive of risk assessment scores on validated instruments. The EHR dataset comprised de-identified forensic inpatient notes from the Wilfred Lopes Centre in Tasmania. The data comprised unstructured free-text case note entries and serial ratings of three risk assessment scales: Historical Clinical Risk Management-20 (HCR-20), Short-Term Assessment of Risk and Treatability (START) and Dynamic Appraisal of Situational Aggression (DASA). Four NLP dictionary word lists were selected: 6865 mental health symptom words from the Unified Medical Language System (UMLS), 455 DSM-IV diagnoses from UMLS repository, 6790 English positive and negative sentiment words, and 1837 high frequency words from the Corpus of Contemporary American English (COCA). Seven machine learning methods Bagging, J48, Jrip, Logistic Model Trees (LMT), Logistic Regression, Linear Regression and Support Vector Machine (SVM) were used to identify the combination of dictionaries and algorithms that best predicted risk assessment scores. The most accurate prediction was attained on the DASA dataset using the sentiment dictionary and the LMT and SVM algorithms. NLP, used in conjunction with NLP dictionaries and machine learning, predicted risk ratings on the HCR-20, START, and DASA, based on EHR content. Further research is required to ascertain the utility of NLP approaches in predicting endpoints of actual self-harm, harm to others or victimisation.

A Prospective Examination of the Predictive Validity of Five Structured Instruments for Inpatient Violence in a Secure Forensic Hospital

ABSTRACTThis prospective study investigated the predictive validity of five structured risk/forensic instruments for inpatient violence risk in a secure forensic hospital. Episodes of inpatient violence and the following instruments were each coded from hospital files: Historical Clinical Risk Management 20 – Version 3 (HCR-20V3), Psychopathy Checklist Revised (PCL-R), Short-Term Assessment of Risk and Treatability (START), Revised Violence Risk Appraisal Guide (VRAG-R), and Violence Risk Scale (VRS). The dynamic/clinical instruments (HCR-20V3, START, and VRS) predicted inpatient violence, even after controlling for the static measures. The results indicated that structured risk instruments may be applied to the assessment of inpatient violence risk.

Implementation of the Short-Term Assessment of Risk and Treatability over two phases.

BackgroundOver the last decade, the Short-Term Assessment of Risk and Treatability (START) has provided a strong evidence base to predict a range of problem behaviors. The implementation of START and adaptation of the services to the use of START have so far been sparsely described in the literature. The purpose of this study was to describe the continuation and the interdisciplinarity of risk assessments through the two phases.MethodsOver a period of 10 years, the forensic mental health services at Brøset has implemented START in two phases: initially with implementing the instrument (2005–2009) and secondarily by customizing the instrument to everyday treatment and planning (since 2009). This implementation was based on data from 887 START assessments for 181 patients over a decade (2005–2015).ResultsThe results showed that the number of START assessments has been stable throughout the past 10 years and the interval between the ratings has decreased significantly (p<0.05). The involvement by diversity of professionals has increased significantly over the two implementation phases.ConclusionThis study also addressed the continuity and organization of the implementation process and presented an overview of how START has been widespread in the service through treatment. The results showed an increased multidisciplinary participation and a continuing rate of assessments as the implementation progressed from assessment to a combined assessment–treatment phase.

Predictive validity of the Short-Term Assessment of Risk and Treatability (START) for multiple adverse outcomes: The effect of diagnosis

The Short-Term Assessment of Risk and Treatability (START) assists risk assessment for seven risk outcomes based on scoring of risk and protective factors and assignment of clinically-informed risk levels. Its predictive validity for violence and self-harm has been established in males with schizophrenia, but accuracy across pathologically diverse samples is unknown. Routine START assessments and 3-month risk outcome data of N = 527 adult, inpatients in a UK secure mental health facility were collected. The sample was divided into diagnostic groups; predictive validity was established using receiver operating characteristics regression (rocreg) analysis in which potential covariates were controlled. In most single-diagnosis groups START risk factors ('vulnerabilities'), protective factors ('strengths'), and clinically-informed estimates predicted multiple risk outcomes with effect sizes similar to previous research. Self-harm was not predicted among patients with an organic diagnosis. The START risk estimates predicted physical aggression in all diagnostic groups, and verbal aggression, self-harm and self-neglect in most diagnostic groups. The START can assist assessment of aggressive, self-harm, and self-neglect across a range of diagnostic groups. Further research with larger sample sizes of those with multiple diagnoses is required.

Structured risk assessment for reduction of multiple risk outcomes in a secure mental health setting: Use of the START.

Structured risk assessment is commonly used in secure settings to aid prediction and prevention of risky behaviours; the expected benefits have rarely been investigated. The aim of the study is to determine whether adverse outcomes (physical and verbal aggression, self-harm, victimisation, self-neglect, unauthorised leave and substance abuse) reduced after patients were assessed with the Short-term Assessment of Risk and Treatability (START). In a naturalistic study, anonymised demographic and clinical information was collected from 50 male patients. Data included START assessment and frequency of target behaviour for 3months before and after first assessment. Chi-square and linear mixed models analyses were used to determine whether there was any change in the behaviours of interest. There were no significant changes in physical or verbal aggression over time, although a tendency towards fewer incidents was apparent. Other adverse behaviours were very infrequent at baseline, precluding adequate analysis. In this small sample, START did not achieve its primary purpose of significant reduction in adverse behaviours. Although our sample size was informed by a power calculation, we may have over-estimated the size of anticipated change. Further, the 3-month comparison periods before and after the assessment follow-up period were rather short. Accordingly, we recommend more research on the value of this tool in practice rather than discontinuing its use. Copyright © 2017 John Wiley & Sons, Ltd.

Models of Protection Against Recidivism in Justice-Involved Adults With Mental Illnesses

Protective factors may play an important role in the assessment, treatment, and supervision of adult offenders with mental illnesses. However, little is known regarding associations between protective factors, risk factors, and recidivism in this population. In research with adolescents, five models describing these associations have been proposed and tested: (a) Compensatory, (b) Buffer, (c) Challenge, (d) Protective-Protective, and (e) Mediation. This study evaluated these models of protection against recidivism in a sample of justice-involved adults with mental illnesses ( N = 550). Risk and protective factors were operationalized using Short-Term Assessment of Risk and Treatability (START) assessments. Results showed consistent evidence for the Compensatory model, where risk and protective factors were independently associated with recidivism. In contrast, results failed to provide evidence supporting the other four models. Findings underscore the importance of both risk and protective factors in the assessment, treatment, and supervision of adult offenders.