Getting a START on Risk Assessment

1
Getting a START on Risk Assessment

• Mary-Lou Martin
• Clinical Nurse Specialist, St. Josephs
  Healthcare Hamilton
• martinm_at_stjosham.on.ca
• Christopher Webster, Connie Middleton
• St. Josephs Healthcare Hamilton
• Tonia Nicholls, Johann Brink
• Forensic Psychiatric Services Commission , B.C.
• May 2005

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Short Term Assessment of Risk and Treatability
(START)

• developed by staff at St. Josephs Healthcare
  Hamilton (SJHH) recently collaboratively
  re-developed by staff at SJHH Forensic
  Psychiatric Hospital in BC
• brief clinical guide for the dynamic assessment
  of risk, strengths treatability

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The Scientific Professional Challenge Has
Altered

• Past How do we predict possible future
  dangerousness?
• Current How do we assess the likelihood of
  possible future risk behaviors?

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Risk Assessment Management

• Risk assessment management are integral parts
  of the clinicians role in delivering the highest
  quality of care to the client, family community

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Limitations of Current Tools

• More attention to long term violence than acute
  violence
• Little effort to apply structured clinical guides
  to organize clinical interventions index
  possible improvement due to therapeutic
  intervention
• Limited attention to client strengths
• Few tools assess multiple risk to self others

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Key Concerns in Research Clinical Practice

• How do we aid interdisciplinary teams to work
  with maximal effectiveness?
• 2. How do we create efficient/effective
  interdisciplinary assessment intervention
  schemes?
• Where are the case reports that describe how risk
  was attenuated recovery was effected?

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Short-Term Assessment of Risk and Treatability
(START)

• Developed the STARTa structured clinical tool
  for the assessment of strengths risks of harm
  to self /or others, treatability
• Risk of violence to others
• Risk of self-harm
• Risk of suicide
• Risk of unauthorized leave
• Risk of substance use
• Risk of self-neglect
• Risk of being victimization

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STARTPurpose

• To provide mental health professionals with a
  structured guideline to organize mental health
  status evaluations treatment planning
• To inform decision-making regarding risk to self
  others
• To improve mental health risk assessments, risk
  communication risk prevention/management thru
  best practice

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STARTDescription

• Clinical-practice guide for the dynamic
  assessment of risk treatability
• Intended for interdisciplinary use
• Intended for use in clinical assessments repeated
  over time

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START Designed For

• Psychiatric forensic in-patients
• Psychiatric forensic out-patients

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STARTWhen To Use

• Assessment/acute cases once a week
• Rehab cases every 4-8 weeks
• Times of transition ie. discharge from hospital
  to community, change in caregivers

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The Process

• Completed by a professional(s) who knows the
  individual
• One member assumes responsibility for completion

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Organization of the START

• Three main parts
• Demographic diagnoses status
• 22 items rated for strengths/risks
• Signature risk signs, specific risk estimates,
  current management measures, community access,
  health concerns, risk specificity statement

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STARTStrength Risk

• 20 items are rated for strength (0, 1, 2) risk
  (0,1,2)item descriptions in Manual
• Comprehensive assessment using a set of terms
  with ascribed meanings
• Clinicians highlight any key/critical items
• There is value in using an assessment scale that
  can go in both directions

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STARTStrength Risk

• The identification scoring of client strengths
  encourages clinicians clients to think about
  positive factors or possibilities
• The Strength Scale the Risk Scale are
  considered independent of each other
• A high rating on the Strength Scale does not
  preclude a high rating on the Risk Scale
• ParadoxStrengths and Risks can exist
  simultaneously

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START 20 Items Scored for Risks Strengths

• Social Skills Material Resources
• Relationships Attitudes
• Occupational Medication Adherence
• Recreational Rule Adherence
• Self-Care Conduct
• Mental State Insight
• Emotional State Plans
• Substance Use Coping
• Impulse Control Social support
• External Triggers Treatability

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Risks Strengths

• May be more accurate to regard risk as a balance
  between risk protective (strengths) factors
• A client with multiple risk factors may not be at
  high risk if each is counterbalanced
• A client whose clinical condition is stable may
  become high risk b/c the care received is
  decreased (ex. when client is discharged to the
  community)

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Seeing Risk Seeing StrengthIllustrative Case
Example
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Signature Risk Signs

• Seemingly irrelevant symptoms represent a
• signature risk sign which is invariant for
• that person and may serve as a highly reliable
• predictor of impending relapse and elevated
• risk of violence toward the self and others
• START Guide (p. 29)

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Specific Risk Estimates

• Identifies specific types of risk such as
  threats, risk to others, crisis,
  suicide/self-harm, unauthorized leave, substance
  abuse self-neglect it describes the condition
  which may increase the likelihood of occurrence
  during a clearly stipulated period of time

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Current Management Measures

• Identify measures in use
• Current management plan

22
Community Access

• Level of supervision

23
Health Concerns/Medical Tests

• Health Issues others assessments or tests

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Risk Specificity

• Documents
• Any specific types of risk
• Describes the conditions
• Stipulates period of time

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Caution

• START Limitations
• START should be used with other tools as
  appropriate ex. Beck Depression Scale
• Patients at risk should be assessed using measure
  appropriate to the identified risk

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Relevance of the START

• Compliments existing Risk Assessment Tools
• Potential of becoming standard way of indexing
  risk
• Potential to help predict risk
• Potential to prevents violence to self/others
• Potential to be used as a framework for team
  meetings/case review

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Collaborating With Nicholls Brink at Forensic
Psychiatric Services Commission, B.C.

• Prospective pilot study (N138 pts) indicates
• Teams endorse the user-friendliness of guide
• START captured the identified risks
• Identified risks overlapped
• On average it required 8 minutes to complete
• Funding proposal submitted for further evaluation
  of START (June, 2005)

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Proposed Research

• To determine if START is able to identify
  patients who are at risk for violence to others,
  self-harm, suicide, self-neglect, substance use,
  unauthorized leave or being victimized
• To determine the STARTs psychometric properties,
  concurrent, discriminant, predictive
  incremental validity

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Translation of the START

• Norwegian
• French
• German
• Dutch

• Completed
• Underway
• Underway
• Underway

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Implementation of the START
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Concluding Remark

• A key assumption underlying the structured
• professional judgment approach is that
• professional discretion is potentially valuable
• and appropriate for the assessment of risk,
• although a degree of structure is necessary to
• reduce the complexity of the clinical task and
• guide the exercise of discretion
• Douglas et al. (2003, p. 1373)