Currently, there is a plethora of screening tools and questionnaires to assess suicide risk. However, none of the existing instruments seem to constitute a reliable aid for suicide prediction. Fluctuations in suicide ideation represent a clear obstacle to evaluation through a ‘static’ tool. In addition, suicide risk prediction is not necessarily synonymous with risk assessment and formulation, which we argue reflects a systematic acquisition of understanding about a person’s momentary state of suicidality. Within the profession of psychology and importantly, the training of psychologists, there is little direction on specialised and scientific understandings about suicidal behaviour, even less about clinical assessment of such client presentations.
This article focuses primarily on the concept of suicide risk assessment and the recent arguments surrounding it, in order to educate about state-of-the-art practice in this domain. We pay attention to some of the core concepts that are not well understood within the profession of psychology as well as guiding clinicians on more caring approaches to suicidal persons. This discussion becomes the context for introduction of Hawgood and De Leo’s (2015) recently published Screening Tool for Assessing Risk of Suicide (STARS). The development and use of STARS is informed by a holistic and patient-centred conceptualisation of risk assessment which (due to word constraints) is discussed in-depth elsewhere (rationale, construction and utilisation) (see www.griffith.edu.au/health/australian-institute-suicide-research-prevention/publications/stars). We also make conclusions that probe further clinician education on alternate ‘standard of care’ approaches to risk assessment.
Momentary suicidal states
It is well known that suicide cannot be predicted (Clarke & Fawcett, 1992; Pokorny, 1983). The most commonly referred reasons for this relate to its low base rate phenomenon, the lack of reliable and systematic methods sensitive enough to detect changing suicidal states (within a short period of time), and importantly, the difficulty in accessing true suicide intent from clients whose shame and secrecy about their suicidality prevents this self-disclosure. Authors have argued against use of suicide risk assessment scales which are made up of risk factors derived from large population studies and associated with a final score or categorisation of suicide risk as low, medium or high (such as Beck Hopelessness Scale, Beck Suicide Intent Scale, the SAD PERSONS Scale). In fact, a recent systematic review of instruments for suicide risk assessment concluded that out of 22 identified tools (13 assessing risk of subsequent attempt behaviour and 9 assessing risk of future suicide), no instruments met the defined requirements for sensitivity and specificity (at least 80% sensitivity and 50% specificity) (SBU 2015). Further, large-scale studies from the United Kingdom have focused on prediction of repeat self-harm behaviour and have also demonstrated the inability of suicide risk assessment to predict subsequent self-harm (Kapur et al., 2005; Bolton, Gunnell & Turecki, 2015).
Long-term versus short term vulnerability
The premise against use of assessment tools comes largely from knowledge that statistical analysis of population based risk factors results in weak statistical power applied at the individual level of assessment. The empirical basis of population based risk factors is derived from longer term studies with time frames ranging between one to twenty years in follow-up (Brown et. al., 2000). Given the changing state of suicidality, measurement of these risk factors, while useful for establishing longer term vulnerability, does not provide applicability for suicide risk in the short term.
To date, little empirical attention has been given to capturing the short-term or proximal indicators of suicide risk in assessments. This is mostly due to the difficulty associated with their investigation (e.g., short-time frame of observation and disentangling their unique contributions towards and interplay with risk and protective factors). As such, traditional risk assessment tools do not seek information on warning signs or acute indicators of suicidality, and consequently, little attention has been given to their importance in education. The implications of this omission may mean the difference between saving a life and loss of life to suicide, since warning signs are the best immediate indication that a person wishes to die now (Rudd et al., 2006).
Do we really wish to throw away the baby with the bath water?
Some authors have cautioned strongly against suicide risk assessment procedures altogether, claiming that the practice itself may even do harm (Large, et al., 2011). Large et al (2011) refer to the potential detrimental outcomes that may arise from inaccurate restrictive management of those classified incorrectly as ‘high-risk’, but also to the squandering of resources spent on those that may benefit least (since they are not believed to be the majority of the population who will go on to suicide or attempt suicide subsequently). Conversely, the incorrect outcome (or false-negative result) which sees those who are at high suicide risk being inaccurately classified as at low or no risk can result in sub-optimal care or worse, suicide. Nevertheless, we disagree with the proposal to do away with risk assessment practice altogether.
Clearly, the [risk assessment] process is much more sophisticated than administration of psychometric scales and must focus on the ‘here and now’ needs and situation of the individual rather than on populations of individuals (Draper, 2012). Our conception of the practice of undertaking a systematic understanding of a client’s risk of suicide refers to making determinations about the person’s current level of distress and psychache (referring to intolerable psychological pain; Shneidman, 1993) and to respond to the identified needs accordingly; not to predict subsequent suicidal behaviour.
Need for clinician education on alternate contemporary conceptions of risk assessment
Despite long-standing awareness that suicide cannot be predicted, mental health services continue to rely on traditional tools for determination of client risk and management. Overcautious results obtained from their use often relates to anxiety about litigation and lack of competency (see Hawgood & De Leo, 2015b). On the other hand, the widespread lack of reliance on assessment tools in place of clinical interview (despite lack of evidence for its predictive capability) is related to lack of knowledge about their meaning, administration, and the failure of tools to capture the unique peculiarities of the suicidal state (Jobes et al., 2004). Clearly, a need exists to address knowledge gaps in this domain, and in particular in relation to psychologist education. Understanding what suicide risk assessment is and what it is not is an essential starting point to such education (see text box below). In sum, suicide risk prediction should not be synonymous with risk assessment and formulation as traditionally conceived.
The client’s narrative as central
Understanding the client’s unique experience of suicidality has gained momentum in the clinical research domain for some decades now. Suicidologists formally introduced working guidelines for more personalised assessment and treatment of suicidal persons in 2000 when the Aeschi Working Group was founded (Michel & Jobes, 2011). This group is responsible for development of what is considered the ‘gold standard’ approach to assessing and working with suicidal persons. In essence, the approach emphasises gaining a shared understanding of the client’s inner psychache in a non-judgemental and supportive way starting with his/her self-narrative. The consequent trusting therapeutic alliance may then facilitate more honest and less shameful disclosures of suicidality, leading ultimately to a lifesaving connection between the client and therapist.
The STARS protocol was developed in recognition of the centrality of psychache and contextual experiences associated with the suicidal status, and in recognition of its unique and changing state over time (Hawgood & De Leo, 2015). It includes example clinician probes or questions to facilitate exploration of suicidal status (and contextual, situational, relational risk and protective indicators) to reduce clinician anxiety that often accompanies approaching this domain of assessment. It also has a ‘traditional’ categorical severity-rating system against individual assessment indicators of the tool to guide clinician response to those most important to the client; as opposed to provision of a global risk rating. Finally, the tool provides for documentation of client needs and suicidal status, and commensurate actions proposed or undertaken by the clinician for demonstration of standard of care (see www.psychology.org.au/suicideprevention to download the STARS assessment tool).
Risk assessment has evolved from its original aim to predict future suicide to now estimating and identifying current suicidality and associated client needs. Some have recently coined this paradigm shift as moving from prediction- to prevention-oriented assessment (Pisani, Murrie & Silverman, 2015). We prefer to conceive suicide risk assessment as a compassionate, client-oriented (as opposed to clinician oriented) yet systematic exploration of the client’s current suicidal status and needs which informs a commensurate management care and safety plan.
Suicide risk assessment is….
Suicide risk assessment is not…..
- ‘Here and now’ determinations of risk – where clinical usefulness diminishes over time (Simon & Hales, 2006)
- A multifaceted process for learning about a person (client narrative should be central), recognising his or her needs and stressors, and working with him or her to mobilize strengths and supports (protective factors) (Perlman, et al., 2011)
- A systematic data gathering method for identifying modifiable and treatable risk and protective factors to inform safety, management and treatment (Simon & Hales, 2006; Rudd, Joiner & Rajab, 2001)
- A gateway to patient treatment and management (Simon, 2011)
- A process, not an event (Simon & Hales, 2006)
- A treatment map that answers questions critical to the individual patient’s treatment and ongoing care (Rudd, Joiner & Rajab, 2001).
- A prediction of suicide or suicidal behaviour (Simon & Hales, 2006)
- Calculation of a single or final score or category based on population based risk factors (Rudd, Joiner & Rajab, 2001)
- A check-list on presence of: Suicidal ideation, History of attempts, Diagnosis of mental illness, Other risk factors for suicide
- Relying on your gut feeling or your own opinion
- An outcome that remains valid or meaningful over time.
- Bolton, J. M., Gunnell, D. & Turecki, G. (2015). Suicide risk assessment and intervention in people with mental illness. British Medical Journal, 351: h4978.
- Brown, G. K., Beck, A. T., Steer, R. A., & Grisham, J. R. (2000). Risk factors for suicide in psychiatric outpatients: A 20- year prospective study. Journal of Consulting and Clinical Psychology, 68, 371-377.
- Clarke, D. C. & Fawcett, J. A. (1992). Review of empirical risk factors for the evaluation of the suicidal patient. In B. Bongar (Ed.), Suicide: Guidelines for Assessment, Management and Treatment (pp. 16-48). New York: Oxford University Press.
- Draper, B. (2012). Isn’t it a bit risky to dismiss suicide risk assessment? Australian and New Zealand Journal of Psychiatry, 46 (4), 385-386.
- Hawgood, J. & De Leo, D. (2015). STARS: Screening Tool for Assessing Risk of Suicide. Australian Institute for Suicide Research and Prevention, Brisbane: Griffith University.
- Hawgood, J. & De Leo, D. (2015b). Working with suicidal clients: Impacts on psychologists and the need for self-care. InPsych, 37(1), 9-11.
- Jobes, D. A., Nelson, K. N., Peterson, E. M., Pentiuc, D., Downing, V., Francini, K., & Kiernan, A. (2004). Describing suicidality: an investigation of qualitative SSF responses. Suicide Life Threatening Behavior, 34(2), 99-112.
- Kapur, N., Cooper, J., Rodway, C., Kelly, J., Guthrie, E., & Mackway-Jones, K. (2005). Predicting the risk of repetition after self harm: Cohort study. BMJ, 330(7488), 394-395. doi: 10.1136/bmj.38337.584225.82
- Large, M., Sharma, S., Cannon, E., Ryan, C., & Nielssen, O. (2011). Risk factors for suicide within a year of discharge from psychiatric hospital: A systematic meta-analysis. Australian and New Zealand Journal of Psychiatry, 45(8), 619-628.
- Michel, K., & Jobes, D. (2011). Building a therapeutic alliance with the suicidal patient. Washington, DC: American Psychological Association.
- Perlman, C. M., Neufeld, E., Martin, L., Goy, M., & Hirdes, J. P. (2011). Suicide Risk Assessment Inventory: A resource guide for Canadian health care organizations. Toronto, ON: Ontario Hospital Association and Canadian Patient Safety Institute.
- Pisani, A. R., Murrie, D. C., & Silverman, M. M. (2015). Reformulating suicide risk formulation: From prediction to prevention. Academic Psychiatry, 14, 1-7.
- Pokorny, A. D. (1983). Prediction of suicide in psychiatric patients. Report of a prospective study. Archives of General Psychiatry, 40(3): 249–257.
- Rudd, M. D, Berman, A. L., Joiner, T. E., Nock, M. K., Silverman, M. M., Mandrusiak, M., Orden, K., & Witte, T. (2006). Warning signs for suicide: Theory, research, and clinical applications. Suicide and Life Threatening Behaviour, 36 (3), 255-62.
- Rudd, M. D., Joiner, T., & Rajab, M. H. (2001). Treating suicidal behavior: An effective, time limited approach. New York: Guilford.
- Simon, R. I. & Hales, R. E. (2006). American Psychiatric Publishing textbook of suicide assessment and management. Arlington, VA: American Psychiatric Publishing, Inc.
- Simon, R. I. (2011). Improving suicide risk assessment. Psychiatric Times, 28(11), 16-21.
- Shneidman, E. S. (1993). Suicide as psychache. Journal of Nervous and Mental Disease, 181, 145-147.
- SBU – The Swedish Agency for Health Technology Assessment and Assessment of Social Services. (2015). Instruments for suicide risk assessment: A systematic review. Sweden: The Swedish Agency for Health Technology Assessment and Assessment of Social Services.