Research insights and the evidence base
The literature on working with suicide is extensive, but also limited too. Extensive insofar as the search for a definitive answer to the question, who is most likely to end their life through suicide seems to lead to an insatiable quest and endless studies. In writing this chapter I undertook a brief literature search of academic papers related to the search terms “suicide risk assessment”, since 2019, and returned in the region of 17,200 papers. Of those reviewed, the majority attended to one of the following predominant themes:
- • The broad identification of specific risk factors
- • The delivery of suicide intervention programmes
- • Understanding suicide across different demographic and cultural
groups
- • The epidemiology of suicide
- • Models of suicide thinking and pre-suicidal process
- • The development, implementation and evaluation of suicide risk
assessment tools
Space does not allow for a meaningful account of the extent of literature here; rather, and perhaps more importantly, is a consideration of what might be missing. In that context it is helpful to consider the meta-analysis, conducted by Large et al. (2016), cited in Reeves (2017), who stated,
that 95% of high-risk patients do not die through suicide, and that there had been no meaningful increase in the accuracy of prediction of suicide over the last 40 years.
Reeves (2019, p. 3) goes on to state that suicide risk assessment tools,
may contribute to an understanding [of suicide risk] and may give
permission for more of an exploration, but the problem is that too many
view them as the ‘start and stop’ of working with suicide, rather than simply a starting point. We place so much trust in their predictive accuracy that, too often, we forget to turn back to the client.
The Zero Target for suicide in the UK in National Health Service (NHS) settings (Deputy Prime Minister’s Office, 2015) is predicated on the assumption that enough is known of the who and how of suicide that such targets become not only aspirational, but instead achievable. Whereas, looking back at Large et al’s assertion, the who and how continue to be elusive concepts that set up false expectations for policy makers, researchers, practitioners, and, perhaps, clients too.
Related to these epistemological and ontological conundrums with respect to suicide, is the place of communication. As asserted elsewhere in this chapter, we too often rely on the efficacy of risk assessment tools for fear of going to a more frightening place. I offer a personal reflection here.
Reflections on the science
I mentioned previously the death of my client early on in my career and the traumatic impact that had on me. By traumatic impact, I refer to trauma with a capital T, as opposed to it simply being distressing. I became hy- pervigilant to potential risk, experienced flashbacks, nightmares etc., and stepped away from practise for a while to allow for a period of recovery. Embarking on my own doctoral studies in this area, my research proposal to an established UK university was the development of a short-risk assessment tool for humanistic counsellors that would, when completed with clients, definitively tell the practitioner whether the client was going to kill themselves. Needless to say, the University enthusiastically bit my hand off and invited me to study there.
It was only during my doctorate that the reflective penny finally dropped: such a tool did not exist, but I had wanted it to because of my trauma following my client’s death and, simply, never wanting to go there again. I had lost the capacity of working with uncertainty, which remains the cornerstone of practice with suicide potential. On this realization my research took a very different turn - a turn to discourse - and looked at ways in which practitioners might be supported, through training, to sit with uncertainty too, while building confidence and capacity to talk to clients about suicide. My anxiety, which drove me initially to undertake the development of a risk assessment tool was neatly captured by one of my latter participants, who insightfully said as part of a feedback session,
“/ was wondering, is this a personal journey, are you Sir Galahad on his horse riding out to save the nation because you felt such a failure in yourself. And I wondered about that. I didn't in any way feel judgmental I just felt, oh, what’s that about. This poor man has to tell the nation, to protect the nation...”. She continued, ‘‘What I was left with was the fact that it was something that you were passionate about... which is a strange use of words ... but from your experience you had been through with your client, you didn't want any of us ... you were quite protective ... you didn't want any of us going through what you had been through. ”
That sense of “failure in yourself’ poignantly captured that fear of getting it wrong. As one therapist once said to me, the feared perception from others is that “good enough therapists keep their clients alive”; even acknowledging the ridiculous nature of this comment, deep down the fear might be of it being a truth.
