From suicide risk factors to ‘Drivers’ – what are you relying on in your risk assessments?
Article in Review: Tucker, R., Crowley, K., Davidson, C. & Gutierrez, P. (2015). Risk factors, warning signs and drivers of suicide: what are they, how do they differ, and why does it matter? Suicide & Life Threatening Behaviour, 45(6), 679-689
Summary: Exploring the work of David Jobes and the evidence based intervention, Collaborative Assessment and Management of Suicidality.
Research continues to identify risk factors and warning signs for suicide, for which we as clinicians respond with the hope to keep our clients safe and move with them to a place of hope. Indeed, understanding and identifying risk factors for suicide has been a critical clinical process. However, do assessment processes working only from a risk/protective basis yield enough information to allow for accurate understanding of risk? Which assessment measures or processes are more successful, and in what way are they important?
Risk factors are characteristics, processes or features that correlate with an increase in risk for suicidality (be that ideation, behaviour or death by suicide) (Simon 2006; Tucker et al. 2015). Suicide Risk Assessment Australia works with practitioners across disciplines, settings and roles with respect to mental health. The reality is that all clinicians working in mental health are likely to see clients where they can identify several (and often copious) risk factors for suicide. Indeed, protective and moderating factors are also critical in understanding an individual’s potential level of risk. The question is – How do we differentiate between clients presenting with similar risk/moderating/protective factors to discern those clients at greatest risk?
Risk factors are determined through statistical analysis of deaths by suicide/suicidal behaviour and key features presenting/relevant for the person. These risk factors are extremely important to us, yet fail to acknowledge the story of the individual. The evidence is that mental health clinicians need to be more savvy and critical in their ability to examine the whole individual, their circumstances and how the person perceives these factors when considering their risk, not just “tick the box” or gather data on their client.
It’s not “tick the box”
After recognising that we need to work beyond just risk factor identification, researchers and clinicians identified warning signs as useful indicators – those behaviours, signs or features that indicate a potential increase in risk – notably that the risk may be more acute or imminent. Again, clinicians have been educated to look out for key warning signs, often in the absence of understanding that warning signs are not a hard and fast rule that will ensure accurate risk assessment. Referrals to a Psychologist, Psychiatrist, the Emergency or other mental health practitioner may have been in response to an identified warning sign or constellation of signs… Indeed, this is a population who are at higher risk for suicidal and self injurious behaviour, but we remain somewhat struck that still, understanding who is likely act over another is extremely difficult.
Rethink our approach
As such, Tucker and colleagues (2015) challenged a rethink on suicide “drivers” – a concept introduced by Jobes (2006) where the person’s perception and interpretation of their problems (acute risk factors) need personal attention and consideration. Tucker, Crowley, Davidson and Gutierrez (2015) demonstrated that very little research had qualitatively examined how some risk factors impacted individuals driving them to act when others did not. It would appear that much of the research and practice continues to focus on statistical, demographic and population based evidence without the collaborative engagement with the client.
Suicide risk assessment is a collaborative process to be undertaken “with” the client rather than “to” the client
It is critical that as clinicians we accept that some clients do “tick the box” when it comes to risk factors, but if we fail to understand what it means to the individual or recognise the “drivers” in fluctuations in suicidality, we cannot make a difference in how the person see’s themselves or their recovery. Publications by researchers, clinicians and organisations have emphasised the importance of seeing suicide risk assessment as a process, rather than a static measure (see Hawgood & De Leo 2016). We must recognise that despite the anxiety that comes to a practitioner that there are no hard and fast rules in suicide risk assessment, we have a framework and process that guides us towards a personal intervention approach. Such a perspective supports movement away from a static interpretation of risk, towards a process of better understanding and working with a client in a collaborative manner.
Jobes, D. (2006). Managing suicidal risk; A collaborative approach. New York: Guilford Press.
Hawgood, J. & De Leo, D. (2016) Reconceptualising suicide risk assessment: A person-centred approach needs-based exploration of current suicidality, Inpsych, 38(1), 10-11.
Simon, R. (2006). Suicide risk: Assessing the unpredictable. In R. Simon & R. Hales (Eds), The American Psychiatric Publishing Textbook of Suicide Assessment and Management (pp.1-32), Arlington; American Psychiatric Publishing.
Tucker, R., Crowley, K., Davidson, C. & Gutierrez, P. (2015). Risk factors, warning signs and drivers of suicide: what are they, how do they differ, and why does it matter? Suicide & Life Threatening Behaviour, 45(6), 679-689.
First published 3 March 2016
By Carmen Betterridge