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Risk Assessment: START Manuals

The Short-Term Assessment of Risk and Treatability (or START) is a concise, clinical guide used to evaluate a client's or patient’s level of risk for aggression and likelihood of responding well to treatment.

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Approaches to risk assessment

Health care professionals are often asked to assess the risk for aggressive or adverse events among their patients and clients. They make decisions and provide recommendations about the admission, discharge and management of people who may be a safety risk through suicide, self-harm, victimization of others, substance use, and more.

This is a challenging task, and there are conflicting approaches and tools available to help with these decisions. Traditional approaches in risk assessment have focused mainly on long-term, individual risk factors that were either based on unstructured clinical opinions or static, historical information (for example, prior criminal history or age at first offence). These approaches neglect patients' and clients' strengths as well as the changing factors and circumstances that contribute to their risk level.

START: A balanced perspective on risk

With these limitations in mind, clinicians and researchers at BC Mental Health and Substance Use Services, in close collaboration with academics and colleagues at St. Joseph's Health, developed the START Manual, a structured clinical assessment tool designed to provide a more balanced and accurate snapshot of the client's or patient's risk for self-harm and aggression, and how well they respond to treatment.

It is different from other assessment tools as it focuses entirely on dynamic (changing) variables as well as the person's strengths, and not just their vulnerabilities. It also allows for the recording of other unique, client-specific risks (called "case-specific" factors) based on the person's recent level of functioning.

Who is the START Manual for?

The START Manual was developed for use with adults with mental, personality and substance-related disorders, and will be helpful for correctional, forensic and other patients and clients in both inpatient and community settings.

What to expect

The START instrument is made up of 20 dynamic items relevant to treatment and risk management, such as substance use, mental state, social skills, and coping, among others. Each item is rated as both a vulnerability and a strength on a three-point Likert scale from zero to two to yield an overall risk estimate for each of the following outcomes:

  • Violence to others
  • Suicide
  • Self-harm
  • Self-neglect
  • Unauthorized absence (failure to return from a day pass)
  • Substance use
  • Risk of being victimized
  • General offending

Once the assessment is complete, treatment planning begins and may be further refined with subsequent assessments. Administering this assessment repeatedly is a convenient way of tracking changes in clients' and patients' functioning, including their vulnerabilities, strengths and risk of self-harm or aggression.

What others are saying about the START Manual 

  • The START has been subject to more than 63 empirical validations
  • START has been incorporated into clinical practice and large-scale research programs in 22 countries
  • Over 1,500 mental health professionals have been trained by the START authors through workshops held around the world
  • Over 6,700 START manuals have been sold to civil psychiatric, forensic psychiatric and correctional organizations around the world
  • The manual has been translated into eight languages, with additional translations currently underway
  • START has been recognized as a Validated Risk Assessment Tool by Scotland's Risk Management Authority, and is included in their Risk Assessment Tool Evaluation Directory
  • START has been recognized as a Leading Practice by Accreditation Canada
  • START Program won a 2011 Quality Award in the "Living with Illness" category from the BC Patient Safety and Quality Council
  • START is one of two recommended tools to support clinical judgment by the Quebec Ministry of Health

"Several participants felt that the process of completing the START itself was helpful in terms of organizing information. […] Overall, our evaluation suggests that it could usefully aid a process of making risk judgements." (Doyle et al., 2008).


"The START is highly compatible with notions of person-centredness and recovery-oriented practice." (Dickens, 2015).


"START received the highest utility rating amongst staff on 29 forensic medium secure units." (Khiroya et al., 2009)


"START seems to fulfill the criteria of being user-friendly and useful for the practicing nurse, psychologist, and psychiatrist in the planning of treatment aimed at reducing risk of violence towards others." (Kroppan et al., 2011).

Dickens (2015). Re-focusing risk assessment in forensic mental health nursing. Journal of Psychiatric and Mental Health Nursing, 22, 461-462.


Doyle, M., Lewis, G., & Brisbane, M. (2008). Implementing the Short-Term Assessment of Risk and Treatability (START) in a forensic mental health service. Psychiatric Bulletin, 32, 406-408.


Khiroya, R., Weaver, T., & Maden, T. (2009).Use and perceived utility of structured violence risk assessments in English medium secure forensic units. Psychiatric Bulletin, 33, 129-132.


Kroppan, E., Nesset, M.B., Nonstad, K., Pedersen, T.W., Almvik, R., & Palmstierna, T. (2011).Implementation of the Short Term Assessment of Risk and Treatability (START) in a forensic high secure unit. International Journal of Forensic Mental Health, 10(1), 7-12.

Purchase a START Manual

The START guide is available for purchase for $60 CAD plus delivery charges.

Order a START Manual (PDF)

Request training

Staff should feel confident when they use a new tool, and have a solid understanding on how it should be applied. We offer customized half-day, full-day and two-day training sessions (PDF), including phone consults The recommended length of training will depend on the expertise of your audience (for example, experience using structured professional risk assessment measures) and the size of the group you plan to train. We recommend keeping groups to 30-50 people to allow for more interactive discussion.

Contact us at if you are interested in organizing a training workshop.

START for adolescents

If your client population consists of adolescents you may be interested in the adolescent version (PDF).

SOURCE: Risk Assessment: START Manuals ( )
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