In recent years it has become somewhat fashionable for people in the field of suicide prevention to utterly dismiss the value of suicide risk assessment as a critical first step to saving lives because of the lack of predictive validity. In other words, using a suicide risk assessment (that typically focuses on suicide risk factors) is a waste of time because our ability to accurately predict a future suicide attempt or completion is frankly abysmal.
My colleague and friend Dr. Greg Carter, an eminent suicidologist in Australia, has been perhaps the most prominent and vocal critic of clinical suicide risk assessment. But many others have boldly dismissed clinical risk assessment as an entirely fruitless pursuit in various editorials and op-eds. And from a research perspective, the entire field of suicide prevention was stunned a few years ago by a rigorous meta-analysis conducted by Dr. Joe Franklin (at Florida State University) concerning 50 years of suicide risk factor research. In their big study of studies, Joe’s team decisively showed that all our efforts to study suicide risk factors actually does remarkably little to help us understand who might go on to engage in suicidal behaviors, or even more critically, die by suicide.
For my part, I do not share this enthusiasm to summarily dismiss the value of clinical risk assessment of suicide. From my perspective there are a few different ways to think about this topic and I ultimately come to a different set of conclusions than do contemporary suicide risk assessment naysayers.
On the one hand, I generally agree that too much has been made of suicide risk factors over the years because the literature details so many possible risk factors—hundreds really—that they come to lose meaning or potential clinical utility. I am however more enthusiastic about the clinical value of so-called suicide “warning signs” which tends to be a shorter list of acute variables that indicate increased near-term temporal risk.
Consider for example heart disease. There are many general risk factors for heart disease such as obesity, high cholesterol, hypertension, and being a smoker. But even though heart disease is the #1 killer, millions of people carry on living full natural lives with sometimes many of these risk factors on board. But warning signs of an acute myocardial infarction (aka a heart attack) is a different thing altogether. Acute chest pains, radiating pain in the left arm, and shortness of breath should prompt a 911 call to help save a life!
While suicide warning signs are not so dramatic, they tend to focus on highly agitated and dysregulated emotional states, with ready access to lethal means, and acute psychological distress that makes the person feel that suicide is the only solution to their exquisite suffering. And of course, within CAMS we think of suicidal “drivers”—those problems or concerns that are the “straw that breaks the camel’s back,” setting off an acute suicidal crisis that could be lethal. As described in one useful paper, patient-articulated drivers are idiosyncratic warning signs of what may put someone in an acutely suicidal state. Needless to say, I find these practical notions of suicidal warning signs and patient-defined suicidal drivers quite valuable within potential life-saving clinical care, which is why they are fundamentally “baked” into the CAMS approach.
But I digress. Let us return to the abject dismissal of suicide risk assessment that has become de rigueur in some quarters. First, there is nothing new in this contemporary critique. Indeed, years ago when I was in graduate school, I saw the imminent psychiatrist Dr. George Murphy present on this very topic. Dr. Murphy wrote the definitive paper encouraging the field to give up on the holy grail of predicting suicide, but in turn he emphasized the clinical utility of talking about relative risk. His seminal paper was published in 1983—over 37 years ago! (Hmm…am I now becoming the senior guy who relishes pointing out to contemporaries that we have been there and done that? Perhaps. But this hot idea is not new.)
I would further note the potential merits of suicide risk assessment, at least as we do it within the CAMS Framework. We know from our decades of clinical research that the collaborative process of working our way through the Suicide Status Form (SSF) risk assessment sections is both powerful and effective. In fact, in another meta-analysis that investigated 17 different clinical assessments across a range of mental health issues (not just suicide), the assessment experience within CAMS was seen to function as a “therapeutic assessment”. In other words, patients find the assessment experience embedded within every CAMS session as a therapeutic experience in and of itself (i.e., separate from the actual treatment of suicidal drivers). Moreover, because the CAMS SSF suicide assessment experience emphasizes empathy and collaboration, we believe it is part of the “secret sauce” which is fundamental to initially forming and then strengthening the clinical alliance, which treatment researchers know is at the heart of any successful clinical treatment experience.
It is for these reasons that we emphasize suicide risk assessment so often within CAMS. Notably, a variation of the SSF suicide risk assessment is used at the start of every session—from the first session, across all interim sessions, and finally in the outcome-disposition session that marks the end of using CAMS. We find it tremendously valuable in checking on suicide risk since it reveals important and quite dynamic information to both the clinician and the patient regarding where the patient is within their suicidal struggle and their CAMS treatment journey.
Upon reflection, perhaps I am being too dismissive of the risk assessment critique that has become so popular of late. I too share a concern that a mere checklist of many suicide risk variables may be worthless, and perhaps even iatrogenic. But I nevertheless still believe in the merits of risk assessment done in a collaborative manner as a means of validating the patient’s experience, forging the alliance, and orienting the dyad to the work that we must undertake if we are to find a way to help each person not only survive suicide risk but ultimately realize a life worth living with both purpose and meaning.