CTL Blog

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ommitment to Living (CTL) is a practical and compassionate approach for responding to suicide risk. Dr. Anthony R. Pisani developed and tested CTL as a three-hour workshop geared toward busy clinicians in challenging clinical environments. The workshop teaches core competencies in suicide risk assessment, documentation, and decision-making. This weblog originated in 2007 in response to interest from participants in ongoing education and interaction. At the present time, Dr. Pisani posts to the blog intermittently, and uses it as a repository for commentaries and links that might be helpful to workshop participants, as well as to clinicians around the world who visit and comment.

Core principles in treating suicidal patients

James Fowler does it again. He has just published another terrific and useful paper, "Core principles in treating suicidal patients." This makes a terrific companion piece to his previous paper describing "guidelines for imperfect assessments" which I have raved about and recommend all the time. The current paper is elegant and straightforward. Dr. Fowler provides a rationale, evidence, and a treatment example for three core principles:

  • alliance building
  • enhancing curiosity about the function of suicidal thoughts and urge
  • enhancing experience and epxression of intense emotions

Voila! What more do you want? You have to put Dr. Fowler's name on your search engine alert list! I just added it to the reference list that I will distribute at my next Commitment to Living workshop.

Fowler, James Christopher. (2013). Core principles in treating suicidal patients. Psychotherapy, 50(3), 268-272. doi: 10.1037/a0032030

 

Is post-diagnosis suicide risk in cancer patients related to psychological or physical factors?

I have been thinking and learning a lot about suicide risk in cancer patients because I am working with some colleagues in cancer control and prevention to identify and respond to educational needs among cancer care professionals. Related to this topic, readers might be interested a nice article by Kendal & Kendal published last year in the journal Crisis (abstract linked below). This article titled, Comparative Risk Factors for Accidental and Suicidal Death in Cancer Patients makes a number of insightful observations about risk in cancer patients based on statistical analyses of a large and impressive NCI dataset (SEER, 1973-2000).

Among the observations I found most interesting was that the well-documented increased risk of suicide in the year following cancer diagnosis, which is commonly attributed to psychological factors, may in fact be more closely related to physical factors, i.e. rapid deterioration of symptoms in rapidly progressing disease. Because many of the candidate psychological factors were not measured in this study, the question cannot be studied directly, but I found the findings compelling enough–and their treatment in the article careful enough–to warrant consideration. In the end, it may be very difficult to tease apart psychological distress from physical suffering, but I appreciate this article drawing attention to the question.

Citation: Kendal WS & Kendal WM (2012). Comparative risk factors for accidental and suicidal death in cancer patients. Crisis: The Journal of Crisis Intervention and Suicide Prevention. 33(6):325-34. doi: 10.1027/0227-5910/a000149.

Affective and behavioral dysregulation are key in adolescent suicide attempts

In a 6-month follow-up study of 119 hospitalized adolescents, Yen and colleagues found that many traditional risk factors including psychiatric diagnoses and past attempts failed to prospectively predict suicidal behavior. Other factors, which the authors called "cross-cutting" (because they cut across many disorders) were more potent. 

These findings have direct clinical implications and indirect prevention implications. From a clinical perspective, clinicians must be cautious in applying population-generated risk factors to clinical risk formulation. Clinical training in risk formulation should emphasize dynamic factors over diagnoses and history and involve thoughtful synthesis of a wide range of factors and individual circumstances.  From a broader prevention perspective, the study provides additional building blocks in the argument for focusing on cross-cutting constructs such as emotion self-regulation in suicide prevention (see our recent population-based study identifying emotion self-regulation as a critical construct for youth suicide prevention). This emphasis on "cross-cutting" constructs has interesting intersections with NIMH's effort, represented by the Research Domain Criteria (RDoC) to shift research away from DSM diagnostic categories toward dimensional assessment of more fundamental and biologically verifiable constructs. These findings are also congruent with (though they do not directly support) strategies that reach further "upstream" in adolescent development to build core "cross-cutting" protective factors.

Yen, S., Weinstock, L. M., Andover, M. S., Sheets, E. S., Selby, E. A., & Spirito, A. (2012). Prospective predictors of adolescent suicidality: 6-month post-hospitalization follow-up Psychological Medicine. Advance online publication. doi:10.1017/S0033291712001912

Thanks to the SPRC Weekly Spark for bringing this article to my attention.

Health Affairs: Dr. Ashley Clayton reflects on care she received as a teenager

If my recent post on Patient and Family Centered Responses to Suicide Risk interested you–or if it didn't–I highly recommend an article by Dr. Ashley Clayton published this month in Health Affairs:  How ‘Person-Centered’ Care Helped Guide Me Toward Recovery From Mental Illness.

Thanks to Dr. Yeates Conwell for pointing me to the article.

Emotion Regulation Difficulties, Youth– Adult Relationships, and Suicide Attempts Among High School Students in Underserved Communities

My colleagues and I conducted a study examining associations between self-reported suicide attempts, emotion regulation difficulties, and trusted youth–adult relationships among 7,978 high-school students. The results have been pre-published online in the Journal of Youth and Adolescence. Our findings point to adolescent emotion regulation and relationships with trusted adults as complementary targets for suicide prevention that merit further intervention studies. We argue that reaching these targets in a broad population of adolescents will require new delivery systems and “option rich” (OR) intervention designs. Print publication will follow later this year.

NY Times article based on Nock study causing a stir

The New York Times published an article this week that readers of this blog should be aware of. The article is titled, Study Questions Effectiveness of Therapy for Suicidal Teenagers. The article reports on results from a study published in JAMA Psychiatry (the new name for Archives of General Psychiatry) by Matthew Nock and a team of outstanding scientists. The NYT headline is based mostly on the finding that:

...suicidal adolescents typically enter treatment before rather than after the onset of suicidal behaviors. This means that mental health professionals are not simply meeting with adolescents in response to their suicidal thoughts or behaviors, but that adolescents who are clinically severe enough to become suicidal more typically enter treatment before the onset of suicidal behaviors. There is no way to know from the NCS-A data how often this early intervention prevents the occurrence of suicidal behaviors that would otherwise have occurred but were not observed in our data. It is clear, though, that treatment does not always succeed in this way because the adolescents in the NCS-A who received treatment prior to their first attempt went on to make an attempt anyway. This finding is consistent with recent data highlighting the difficulty of reducing suicidal thoughts and behaviors among adolescents.  (Nock et al, (2013) Prevalence, Correlates, and Treatment of Lifetime Suicidal Behavior Among Adolescents, JAMA Psychiatry, ePub ahead of print, p. E9)
The Nock article is hefty and I have not yet fully digested it. So I will withhold judgement about the article's conclusions, and about whether the NYT article reported them fairly and accurately. However, I am pleased about the discussions that this study and the Times article have the potential to stimulate. One conversation is about how to improve the quality and effectiveness of treatment for at-risk adolescents. This is not a new conversation, but continues to be an important one. Another conversation I hope this NYT article will stimulate relates to broadening our view of what suicide prevention is. With some important exceptions (including some here in New York State), the dominant strategy in suicide prevention has been to identify youth who are suicidal and get them into treatment. As my mentor, Peter Wyman has demonstrated (Wyman et al, 2008) and this Nock article brings to the surface, these 'identify and refer' strategies are limited by a number of factors, including availability and acceptability of services, the length of time adolescents remain in services, the effectiveness of therapy, and adolescents' tendency not to disclose suicide concerns to adults (Pisani et al 2012). While I am committed as ever to improving the quality of screening, assessment, and treatment for at-risk adolescents (and help to train hundreds of clinicians each year), I do not expect that treatment services alone will be sufficient for reducing suicide in the population. For this reason, in my research I am pursuing youth suicide prevention strategies aimed at addressing risk and protective processes further "upstream" (a term I learned from Dr. Wyman). In an article soon to be published, I argue that we need new interventions that can flexibly reach a broader population of adolescents further upstream and that these will require making use of new delivery systems, designs, and technologies.
I look forward to studying the Nock article and to participating a discussion that could help stimulate the field to re-examine what "prevention" really means. Substance abuse prevention does not start with finding kids who are already taking drugs. Fire prevention doesn't start with the fire department. We need great fire departments and well-trained fire fighters, but fire protection engineering and public education make major conflagrations rare. Likewise, youth suicide prevention must focus more broadly then on adolescents who are already suicidal.

Suicidal High School Students’ Help-Seeking and Their Attitudes and Perceptions of Social Environment

Clinicians, school personnel, parents and other adults share at least one thing in common: none of us can read minds. The only way we're going to know if an adolescent is considering suicide is if they tell us. My colleagues and I conducted a study examining some key correlates of help-seeking among adolescents who had seriously considered suicide. The results have been published in the Journal of Youth and Adolescence.

What matters to patients in an assessment interview

Assessments are human encounters, a chance to demonstrate compassion and instill hope. A small qualitative study by colleagues in Manchester, England illustrates the importance of caring assessments and of considering the social and family context of the individual in planning. Hunter et al conducted 13 initial interviews and 7 follow-up interviews with individuals who had been hospitalized related to some form of self-injurious behavior. Their findings are highly congruent with the hallmarks of patient and family-centered response to suicide risk that  I have proposed. The article (linked below) outlines a number of lessons about what matters to patients, which boils down to having meaningful interactions with clinicians who: convey empathy, understand problems from their perspective, inspire hope, and develop plans/referrals that match their preferences and social context. None of this is rocket science; it's harder than that. Hearing how much it matters to patients should encourage all of us with a commitment to living to continually refine our approach to assessment.

Hunter, C., et al., Service user perspectives on psychosocial assessment following self-harm and its impact on further help-seeking: A qualitative study. Journal of Affective Disorders (2012), http://dx.doi.org/10.1016/j.jad.2012.08.009

Study investigating an educational program for nurses to educate family caregivers

Apropos of my post on needing more family-centered work, I came across this study out of Taiwan just published in Nurse Education Today: A suicide education programme for nurses to educate the family caregivers of suicidal individuals: A longitudinal study. It is good to see this kind of work being done, and refreshing to see people trying to test their work with controlled designs. I'm not sure I agree with how all of the concepts are laid out (and I really don't like the heavy-handed first line of the abstract: "Family members lack the ability to care for suicidal relatives"), but this is a helpful example of the kind of attention to families that is needed. 

Patient and Family-Centered Responses to Suicide Risk

Over the past few years, many mental health care systems have adopted useful strategies and technologies to reduce risk across their systems. In my consultations with health systems, I have seen enormous advances in terms of consistent nomenclature, universal screening, documentation standards, assessment procedures, and crisis response planning. A lot of interest has coalesced around certain helpful tools such as the Columbia Suicide Severity Rating Scale and Safety Planning, which help with key tasks that are part of the overall competent care of suicidal patients.

Competent implementation of suicide prevention technologies in clinical care depends on the attitudes and approach with which the professional applies them. Even as we make progress on systematic care for suicidal individuals, have we invested enough attention to fostering the attitudes and approaches that undergird effective care for suicidal individuals and their families? Evidence-based assessment and response to suicide risk includes forming cordial and collaborative relationships, conveying human compassion, building on natural strengths and supports, and promoting dignity and hope. Many major therapeutic interventions for suicidal individuals share common foundations in this regard--DBT and CAMS are good examples--and most clinicians are highly capable of forming bonds of caring with their patients and their families. However, the well-documented challenges (uncertainty, powerlessness, time burden, anxiety) of clinical work with suicidal individuals can interfere with authentic expressions of empathy, commitment, and respect, potentially reducing the yield from other measures taken to assess and reduce suicide risk, such as well-timed screening and safety planning. These challenges also tend to narrow clinicians’ focus on the patient alone, sometimes to the exclusion of interested family and friends. As a result, continuing professional education is needed to empower clinicians with a conceptual framework for understanding and responding to suicide risk that will promote desirable attitudes and behavior across treatment modalities, prevention technologies, and episodes of care.

Patient and family centered care (PFCC) provides a useful framework for developing attitudes and behaviors consistent with best-practices in the compassionate care of suicidal patients. PFCC is a movement that is re-centering healthcare on the experience of the patient and family as a key factor in health care quality and safety. PFCC encourages envisioning all aspects of a health-care system from the patient's perspective, from policies and facility lay-out down to specifics of the clinical encounter. PFCC is a major focus across  my home institution, with expertise coming from the Institute for the Family with which I am affiliated. I am not aware of any broad application of this term to the care of patients who present with suicide risk, but I have recently been thinking about CTL in these terms. I have been trying to boil down the PFCC approach I teach in CTL. This remains a work in progress. So far, I have generated these six hallmarks of patient and family-centered response to suicide risk:

  1. Elicit the experience and function of suicidal thinking from the perspective of the person at risk and their family members.
  2. Convey empathy for suffering, a desire to help relieve it, and confidence that recovery is possible.
  3. Invite individuals and their families to make decisions about addressing suicide risk based on their ideas, expectations, and preferences, providing informed consent about risks and benefits of various options. 
  4. Explore how plans and decisions for responding to suicide risk will affect and be affected by the person's family, social network, interests, and responsibilities.
  5. Express personal and institutional commitment to alleviating current distress and supporting  the life and happiness of the person and their family members.

These clinical principles are not unique or original to CTL. The SPRC/AAS Core Competencies (pdf) include these skills from a different vantage point and vernacular. There are also a host of constituent skills and attitudes that are part of specific treatment modalities. Nevertheless, I have seen a clear need for a direct and transtheoretical focus on these core points.

Because these five points are at the heart of CTL education and consultation, I have been considering re-wording the subtitle of the CTL workshop, and of this blog. For some time, the tagline for CTL has been "Understanding and Responding to Suicide Risk." I settled on that broad moniker at the advice of colleagues who thought the original title was too cumbersome: "Assessment and Decision-making for Competent and Caring Clinicians." They were right; however, as my thinking has evolved and my assessment of needs in the field has sharpened, I may want CTL to reflect the patient-centered focus more directly, perhaps with the title, “Commitment to Living: Patient and Family-Centered Response to Suicide Risk.”

Whatever the title of CTL, the time has certainly come to incorporate the helpful and empowering concepts from the PFCC movement into the way we work with individuals at risk for suicide.

Thanks to Susan H McDaniel, PhD, Dr. Laurie Sands Distinguished Prof. of Families & Health at the University of Rochester Institute for the Family, for her input on this article.

Longitudinal analysis of SAD PERSONS scale

As readers here know, I’m not a fan of using SAD PERSONS as a “scale.” Some clever colleagues in Manitoba, Canada studied over 4,000 consecutive emergency department referrals for two years in two large hospitals in their province. Study conclusion: “In their current form, SAD PERSONS and MSPS do not accurately predict future suicide attempts.”

Find the article here.

Pragmatic guidelines for imperfect assessments

I love the title of J. Christopher Fowler's article that was published in the current issue (vol 49, issue 1) of Psychotherapy, "Suicide Risk Assessment in Clinical Practice: Pragmatic Guidelines for Imperfect Assessments." This practice review is thorough and wise. Fowler strikes just the balance between encouraging completeness and responsibility, and acknowledging the limits inherent in assessments of risk. Dr. Fowler also masterfully weaves in the importance of self-awareness on the part of the clinician, and gives constant attention to maintaining a caring, compassionate stance. Some selected quotations to whet your appetite for this article:

"Knowing that patients frequently deny suicidal thoughts before suicide attempt and death, clinicians should remain appropriately circumspect regarding declarations of safety when a patient recently expressed suicidal ideation, feelings of hopeless, desperation, and/or affective flooding. This does not mean we should adopt a suspicious or adversarial stance—on the contrary, curiosity, concern, and calm acceptance of the patient’s emotional and cognitive states may serve to enhance the therapeu- tic alliance, encourage the patient to directly explore her or his current distress, and aid in the accurate evaluation of current functioning."
"Before conducting a formal suicide assessment, clinicians should conduct an introspective review of recent stressful life events facing the patient, including recent ruptures in the thera- peutic alliance, and disturbances in social relationships (Truscott, Evans, & Knish, 1999). Maintaining a therapeutic stance of curiosity and concern (while simultaneously remaining open to the possibility that an alliance rupture may be a precipitant to the crisis) is difficult to sustain when anxieties are running high; however, communicating genuine curiosity and concern about the causes for their unbearable suffering is critical."
"When clinicians face a potential suicide crisis, they are multi- tasking and are usually in a state of heightened alert and anxiety. Under such stressful circumstances, it is easy to get swept up in personal emotional reactions and lose sight of the patient’s suffering and their efforts to communicate distress."

My only critique involves the absence of family system context. I would have liked to see some attention to the positive role that family members can play in the assessment process. The article does mention that the quality of family relationships is an important modifiable risk factor, which should be considered and may be the focus of clinical intervention. But most of the article, and the clinical approach advocated, has a decidedly individualistic bent. The article doesn't address how to involve friends and family members in the interview process, how to build their participation into the decision-making process, how the relational context influences decisions about how to respond to identified risk. For me this is an important gap, and a contribution that is still needed.

This gap notwithstanding, this article will instantly join the Bryan et al. means restriction article on my Top 10 Most-recommended List. In fact, the Fowler article could become my primary go-to reference when clinicians ask for reading on the subject.

Fowler, J. C. (2012). Suicide risk assessment in clinical practice: Pragmatic guidelines for imperfect assessments. Psychotherapy, 49(1), 81–90. doi:10.1037/a0026148

Thorough and practical article about means-restriction counseling (finally!)

I am a huge fan of Craig Bryan. He, Sharon Stone, and David Rudd (another person whose work I really admire) have just published an article titled, "A Practical, Evidence-Based Approach for Means-Restriction Counseling With Suicidal Patients." I know I will be recommending this article a lot. Questions about means restriction come up just about every time I teach or consult with mental health professionals about managing suicide risk. This will be my go-to resource from now on. The authors carefully present the evidence for means restriction, and provide a clear and immediately useful guide for conducting means restriction counseling. Highly recommended:
A practical, evidence-based approach for means-restriction counseling with suicidal patients.

Bryan, Craig J.; Stone, Sharon L.; Rudd, M. David

Professional Psychology: Research and Practice, Vol 42(5), Oct 2011, 339-346. doi: 10.1037/a0025051

Interesting qualitative study about military mental health professionals on deployment

A group of US and UK colleagues have published an interesting qualitative study about the challenges and resiliency of military mental health professionals (MMHPs). They had a small non-representative sample of British MMHPs who had completed a period of deployment in Iraq between 2003-2005. For the study, they participated in detailed interviews about their experiences practicing in a deployment setting. The authors did a nice job pulling together themes from the interviews in order to develop a conceptual model for the goals, challenges, and resources, and to draw out some recommendations about training and planning. Recommended:McCauley, M., Liebling-Kalifani, H., & Hughes, J. H. (2011). Military Mental Health Professionals On Operational Deployment: An Exploratory Study. Community Mental Health Journal. doi:10.1007/s10597-011-9407-8

Helping at-risk patients who rarely show up

From early on in my quest to understand the unique challenges mental health professionals face in working with patients at risk for suicide, I've wondered aloud about the things that make us the most nervous. I'm still working my way through a  list of questions I posted based on my notes from a series of trainings I delivered across New York State. One that has kept coming up since that time is this one:
How do we handle individuals at risk who are only marginally involved in treatment-they miss more appointments than they make, but still come enough that they remain on our caseloads?

Mental health care was not organized to fit the way many people at risk utilize services. Much of outpatient mental health is organized around a fantasy that most patients will (1) Make an appointment ahead of time for an evaluation; (2) come to that appointment at the specified time; (3) make another appointment; (4) come to that appointment; (5) work on a signed treatment plan in between.

Now, that model probably does work well for some people. But for many individuals at risk, that level of organization and consistency is not congruent with their lives. If it were, they wouldn't need us! The situations that make professionals the most nervous are the ones where the patient (1) Makes an appointment.  (2) Comes to the appointment later in the day or the next day crying and upset, hoping to be seen. (2) Misses the next appointment.  (3) Makes it to one appointment with the psychiatrist. (4) Misses 2 of the next 3 appointments with the primary therapist (5) can't recall the treatment plan when asked about it. Naturally, clinicians get frustrated and wish the person would either sign-up or drop out.

But of course it's not the fault of the individual at risk that we're set up the way we are, or that all the empirically supported treatments assume the patient is actually in treatment. I've addressed this issue here, here, and here when I've talked about how to manage patients who violate the "social contract" of being a patient. But there's something distinctly anxiety-provoking about someone who is loosely connected to mental health services, compared with someone who actively refuses plans we suggest.  It can be especially hard if the loosely-connected person only shows up when in crisis.

This won't be a surprise to those who have followed my posts, but my approach to the loosely connected person hinges on two core clinical tasks: connection, compassion, and documentation.

Connection means that we should have the bias of keeping people involved to the level they are able.  I know that this is difficult in the context of productivity demands and limited resources.  You can't have 80 people on your caseload who all miss 75% of appointments.  But I think we should condition ourselves (and set up services) to have a least a few people like that because the resources might be well spent in being a bridge to life for the person.

Compassion is always core. It can be hard to feel and show compassion to someone in crisis when they haven't taken the least first step to try ideas you've given. It's easy to find yourself thinking, "Maybe if you came a little more often, you wouldn't be in this position." It's especially hard to find compassion for someone who is at-risk for suicide and not showing up because it feels like they could take us down with them. All of those thoughts are natural, and it shouldn't end there. Instead, we have to summon the courage to enter in to the suffering one more time, offering the main thing we can offer under these circumstances: a caring commitment to living.

Documentation is one way I get to that place. One barriers to compassion is fear.  It takes courage to keep working with someone who has only one foot in the room--especially when they present with suicide risk. Part of every clinician's brain is occupied with worry under these circumstances--worry about losing a patient, worry about being blamed, worry about being sued. It's hard to have compassion for someone if you think they could ruin your life. Having an unassailable risk assessment and other supporting documentation can put the fearful part of the clinicians brain to rest and make way for the kind of compassionate connection the hurting patient really needs. In other words, one of the key purposes of documentation is to quiet fears that might interfere with caring--and with doing the right thing. Once you're confident about documentation, you can focus on doing what's best for the patient, instead of feeling cornered into defensive courses of action.

Connection, compassion, and documentation share at least one thing in common: they are easier said than done. Their importance is so obvious that it may be tempting for an experienced clinician to speed passed these concepts. Anyone NOT think connection, compassion and documentation are important? Of course not. But, as with most simple good ideas, there are complex barriers to implementing them. Each person has to identify his or her own barriers and find a way to build these principles in to every day practice.

Preparing my presentation for AAS 2010

I'm preparing my presentation for the April 2010 American Association of Suicidology annual conference, which will be held in Orlando, Florida.   My presentation is titled "Evaluation of Commitment to Living: a brief training to address suicide risk assessment and management."  I'm enjoying the preparations because I'm planning to present entirely using mindmaps on my curriculum which relies heavily on mindmaps!  There's a very pleasing symmetry about it.   And I'm impressed all over again with how much the maps aid the conceptual organization of the material I want to present.  I'm sure it's not for everybody, but I find it so helpful.

If you're going to be in Orlando on April 24, please come by and say hello.

Related posts:

Visual maps and guides in high stress situations

Mindmapping coping strategies

Mindmanager Customer Vignette

Possible implications of findings re: visual memory

Newsmap illustrates power of mapping/visualization

New on the Web: Suicide Prevention News and Comment

Franklin Cook has started a suicide prevention news blog that looks very promising.   Suicide Prevention News and Comment (SPNAC) is still young-- less than a month old--but already has some valuable information and insights.  As the site's name suggests, most of the posts (several each week) are stimulated by news in the suicide prevention arena which Mr. Cook passes on, along with helpful and thoughtful commentary.   The webiste has a three-column newspaper-style format, which could be welcoming and familiar to readers who are less experienced with blogs.   I have added SPNAC to my blogroll, and look forward to reading more from this site.

Speaking of nomenclature...what about "protective factors"?

Speaking of nomenclature, I'm increasingly growing mistrustful of the term "protective factors."   It sounds very "evidence-based" to refer to "risk and protective factors" when discussing one's approach to risk assessment.   However, I've noticed a subtle misunderstanding that has creeped in along with the popularity of these terms.  Often, it sounds like some clinicians are thinking of risk and protective factors are two sides of the same coin or--better put--two sides of the same scale and you arrive at a formulation of risk by weighing one against the other.   The potential mistake is to think that protective factors "cancel out" risk factors.

Although I have a section called "protective factors" in the map I use to teach about risk formulation and documentation, I am increasingly finding myself replacing these words in workshops with the awkward phrase, "Launching off point factors."  What I mean to convey is that it is probably best to think of "protective factors" as factors that increase the likelihood of success for crisis and treatment planning, rather than factors that technically "protect" against risk previously identified.  A distraught, intoxicated individual with suicidal ideation and a gun can have all the protective factors in the world and that doesn't change the risk one bit.   These factors may, however, present opportunities to engage in crisis planning, develop a therapeutic relationship, and engage a supportive system, all of which create conditions in which risk can be addressed, and which could ultimately influence decisions about the most appropriate level of care.

In our next revision of risk-related documentation, I'm considering recommending that we get rid of the term "protective factors" altogether because of the danger that it can be misleading.  I don't have a great substitute, unfortunately.  Best I can come up with right now is "Opportunities for Crisis and Treatment Planning," but I wonder if an ordinary person coming to a section so-labelled would know what it meant.  Needs more work.

A better term for "high risk"?

At a recent workshop I presented, a senior colleague commented that our clinical vernacular needs a more apt phrase than "high risk" to describe individuals whose clinical and historical presentation suggests risk for suicide.   "High risk for suicide," he pointed out, sounds like suicide is probable, when in fact the likelihood of suicide in any given "high risk" case is still low in absolute terms.    So, I've been struggling to think about an alternative.  "Elevated risk?"  "Multiple indicators of risk?"   I don't know.   This is not the only area in clinical suicidology with nomenclature problems, but it's the one I need to figure out right now in order to make some recommendations for documentation standards in our department.   If you have any ideas, please leave them in the comment section or use the contact page to email me.