The Myth of Suicide Risk and Protective Factors


 

HummingbirdMyths are fascinating, resilient ideas that openly defy reality.

Some people say, “All myths are based in truth.” Well, maybe so, but tracking down the myth’s truthful origins reminds me of my friends back in high school who used to take their dates snipe hunting. Maybe the idea that all myths are based in truth is a myth too?

Suicide is a troubling problem (this is an obvious understatement). To deal with this troubling problem, one of the tools that most well-intended prevention programs advocate is to watch for suicide risk factors and warning signs, and when you see them, intervene. This would be great guidance if only useful or accurate suicide risk factors and warning signs existed. Sadly, like the snipe, you can look all night for useful or accurate risk factors and still come up empty.

I’m writing about mythical risk factors and warning signs today because I just covered this content in our suicide assessment and treatment manuscript. In the following excerpt, we’re writing about suicide competencies for mental health professionals:

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Cramer and colleagues (2013) noted, “One of the clinician’s primary objectives in conducting a suicide risk assessment is to elicit risk and protective factors from the client” (p. 6). As we’ll discuss in greater detail later, this competency standard is problematic for at least three reasons. First, in an extensive meta-analysis covering 50-years of research, the authors concluded: “All [suicide thoughts and behavior] risk (and protective factors) are weak and inaccurate. This general pattern has not changed over the past 50 years” (Franklin, et al., 2017, p. 217).

Second, the number of potential risk and protective factors that counselors should be aware of is overwhelming. Granello (2010a) reported 75+ factors, we have a list of 25 (Sommers-Flanagan & Sommers-Flanagan, 2017), and even Cramer and colleagues lamented, “It would be impossible for clinicians to be familiar with every risk factor” (p. 6). Jobes (2016) referred to suicidology as “a field that has been remarkably obsessed with delineating countless suicide ‘risk factors’ (that do little for clinically understanding acute risk)” (p. 17).

Third, prominent suicide researchers have concluded that using risk and protective factors to categorize client risk is ill-advised (McHugh, Corderoy, Ryan, Hickie, & Large, 2019; Nielssen, Wallace, & Large, 2017). For example, even the most common suicide symptom and predictor (i.e., suicide ideation), is a poor predictor of suicide in clinical settings; this is because suicide ideation occurs at a very high frequency, but death by suicide occurs at a very low frequency. In one study, 80% of patients who died by suicide denied having suicidal thoughts, when asked directly by a general medical practitioner (McHugh et al., 2019). Even the oft-cited risk factor of previous suicide attempt has little bearing whether or not individuals die by suicide.

When AAS (2010) and Cramer and his colleagues (2013) described the risk and protective factor competency, eliciting risk and protective factors from clients was standard professional practice. However, in recent years, researchers have begun recommending that practitioners avoid using risk and protective factors to categorize client risk as low, medium, or high—principally because these categorizations are usually incorrect (Large, & Ryan, 2014). In a review of 17 studies examining 64 unique suicide prediction models, the authors reported that “These models would result in high false-positive rates and considerable false-negative rates if implemented in isolation” (Belsher et al., 2019, p. 642).

To summarize, this suicide competency boils down to four parts:

  1. Competent practitioners should still be aware of evidence-based suicide risk and protective factors.
  2. Competent practitioners are aware that evidence-based suicide risk and protective factors may not confer useful information during a clinical interview.
  3. Instead of over-relying on suicide risk and protective factor checklists, competent practitioners identify and explore client distress and then track client distress back to individualized factors that increase risk and enhance protection.
  4. Competent practitioners use skills to collaboratively develop safety plans that address each client’s unique risk and protective factors.

Although risk and protective factors don’t provide an equation that tell clinicians what to do, knowing and addressing each unique individual’s particular risks and strengths remains an important competency standard.

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As always, even though getting feedback on this blog is yet another mythical phenomenon,  please send me your thoughts and feedback!

 

 

 

6 thoughts on “The Myth of Suicide Risk and Protective Factors”

  1. Thanks for this post John! I wasn’t sure if a simple reply would work so I used your other email as well☺. This is helpful info. You and I corresponded a while back and I’m a clinical supervisor in Edmonton. I appreciate you trying to balance the tension between saying these factors don’t add any predictive value but they’re important on an individual scale in terms of understanding your client and safety planning. It still feels very abstract and I know a lot of my clinicians will still feel confused. I wonder if a concrete example would be helpful? I hope you’re healthy and well.

    Mark

    Mark Nicoll, Ph.D., RPsych
    Clinical Supervisor
    Children, Youth and Families
    Addictions & Mental Health – Edmonton Zone
    Northgate Health Center
    Edmonton, AB
    Phone: 780-342-2920/780-919-2020 Fax: 780-413-4728

    This message, and any documents attached hereto, is intended only for the addressee and may contain privileged or confidential information. Any unauthorized disclosure is strictly prohibited. If you have received this message in error, please notify us immediately so that we may correct our internal records. Please then delete the original message. Thank you.

    1. Hi Mark,

      Great comment and question. I’ve got some concrete examples in the upcoming book and will try to pull them out and feature them here to help make the abstract idea of individualizing risk and protective factors clearer.

      I hope all is well for you in Edmonton.

      John

  2. As you know John, I have no experience in your field other than being bereaved by suicide (with no involvement with the Mental Health Services.) However, like a lot of people in my postion I am picking this subject to pieces -in my attempt to try to make that lightening does not strick twice with my two surviving adult child. I would also say that our family our not as “grounded” as some familes so you can understand why.

    As a lay person I am fortunate to be involved with a National Health Service suicide prevention steering group. The papers that are coming out over here are saying the same as you are. Thank goodness this is all becoming centered around individuals and not an assessment set in stone.

    Thank you

    1. Hi Carol,

      Your perspective is very important and valuable. I’m glad you take time to comment here and appreciate your input. It’s good to hear that you’re getting a consistent message from NHS. Please keep up your concern and good work.

      Sincerely,

      John

  3. Hi John After years and years of practice I don’t think I ever said or even thought ” Well I saw that coming” after learning of a suicide I rely on advice given by you and Rita at a workshop many years ago ” It doesn’t matter if you think they will do it, Act like they might” Tha’ts still what I say to family members who express fears of a potential suicide Hope I run into you guys one of these days

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