October 23, 2008
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 helpful colleague emailed this response to me, and said I could catalog it here:
I…don’t like this “Opportunities of Jumping off Factors Facilitating Treatment Planning and Treatment Engagement in the Future if the Person Sticks with Therapy” wording. A bit awk-ward. You need to have Factors or Variables in the term to correspond with Risk Factors yet without implying that they cancel risk factors out. Moderating Factors can do this, since Moderating is more ambiguous in meaning than Protective. You could call them Engagement Factors, but is that too narrow? Though it has the focus on Treatment that you’re going for. Strengths? as in Risk factors and Strengths? Still pulls some for thinking that the Strengths offset the Risk factors, perhaps…
Risk Factors and Factors that predict treatment engagement? Ugh.
Factors that are predictive of suicide and factors that are predictive of treament engagement without minimizing the risk factors cuz they still might off themselves regardless? There, finally, THAT has a nice ring to it, eh? A bit wordy, maybe, but balanced and clear.
Another colleague also emailed me this response, which I like quite a lot. She gave me permission to post it here with her first name:
I’d like to offer “Relevant Resources” as an alternative term for “Protective Factors.” Although “resources” are often conceptualized by lay-people as external to the pt., most mental health professionals understand this to include internal as well as external attributes that can increase the likelihood of a person engaging and benefiting from treatment, etc. I think that meaning would be clear in the context of an assessment. For example, “Pt.’s risk factors include X, Y, and Z. Her relevant resources are: a supportive spouse, a job she enjoys, a history of good treatment engagement with her previous therapist, and demonstrated ability to access professional help when feeling distressed.”
Thanks,
Cindy
We are on the same page –see my column in the latest issue of NEWSLINK!
Lanny Berman
Thank you for visiting the site, Lanny. I’ll check out your column. Glad to be in good company!
This is a great topic to discuss! As I thought of my own candidate terms, I realized that the question really has to do with your conceptualization of what these “factors” are.
I’m not sure I agree with you totally that these “factors” don’t cancel out risk, at least to some degree. To take your example of a distraught, intoxicated individual with a gun. You say that so-called “protective factors” don’t mitigate risk. Is that true. If you added some detail here, say history of multiple high lethality attempts, dysthymia, lack of social support, lack of employment, and poor coping skills OR you had an individual with no past psych history who just lost his best friend, is happily married, gainfully employed in a rewarding career, has three well adjusted children with whom he is very involved, would you consider both of these at equal risk? Perhaps so, I’m open to the possibility – I agree with your reference to evidence, I’m not sure we have good evidence that these factors in any way mitigate the risk…. The question really is, in what way do these factors influence the likely course of behavior of the individual (true?)
Thanks for promoting critical thinking…
Thanks for your comment, Steven, and for the challenge to define terms and purposes more clearly. I think to decide whether the term “protective” is useful or not we need to ask “useful for what?”
For me, risk assessment is highly context-dependent and the most effective language for risk will often depend upon what decision you have to make. For the purposes of immediate intervention, it’s probably best not to think of “protective factors.” In the example you used (two drunk depressed men with guns–one with a bunch of “protective factors” one without), I would say that in the context of a decision about immediate intervention, I do not see much difference in terms of their risk. They are both at high acute risk, and both need someone to ask them about their suicidal thinking, keep them away from their gun, and probably stay with them constantly. And my fear about how I have seen “protective factors” used in the clinical setting where I practice is that the term can mislead and blur the decision-making process, especially when the risk is not as drastic and clear-cut as the caricature we’re using for the purposes of discussion.
But I can imagine another context that involves more long-term planning where it does make sense to think of the kids, the marriage, the rewarding job as being “protective,” as you point out.
The term “protective” factors probably also makes sense in an epidemiological or other research context. In fact, I haven’t researched the history of the term, but I suspect both “risk factors” and “protective factors” are terms that come out of research about relative risk that has to do with odds ratios and other ways of thinking that are highly useful for their own purposes. My contention is, however, that these terms don’t end up being used in clinical settings the way they are used in epidemiology and that the questions epi’s are addressing are not the same questions that a clinician assessing risk in an individual is.
As always with this blog, I put these ideas forward tentatively because the aim is developmental not summative. I’m thankful for great questions and comments like yours, Steven, for challenging me to think carefully about these issues and how I teach about them.
Important topic for discussion. Good Stuff!
With regard to potential confusion over the term protective, I am not so concerned about mental health professionals who are experienced and knowledgeable, as I would be for the “layman”. But then, a layman won’t be doing a professional assessment nor exercising professional judgement and would not be left to make a critical (potentially life and death) decision concerning a suicidal person. If there is confusion in the mind of a mental health professional, that risk and protective factors may just cancel each other out, there is cause for concern. Keep up the great work.
That’s a good point. The risk of misunderstanding is greater among layperson. My experience has been that the confusion among professionals is probably more subtle. I just hear it creep in to conversations or documentation. Sometimes I think I’m making to much of the terms. In some recent trainings, I think I’ve caused more confusion by trying to “clarify” this point than there would have been if I just left well enough alone! In any event, thanks for your thoughtful comment, Brian.
Tony, Nice website you have here. I too use the term protective factors in both my clinical practice and in my workshops. In my teaching and supervision I have seen your concerns in action. There certainly is some cause for concern, or at least a clarification in training novice practitioners (and maybe the not-so-novice as well). I wonder if the term/phrase “resiliency and recovery factors” might be more accurate and less risky? Resilience is the capacity to cope with stress, pain, and catastrophe. Recovery refers to the ability to return to a health baseline again. Both terms suggest a long-term component and may alleviate the inherent risk of using the “calculate” or “canceling out” approach associated with the term “protective”. Both in teaching and in documenting, we could use the phrase Resiliency and Recovery Factors to note clients strengths such as engagement in therapy, a supportive family, and certain religious beliefs, for example.
Thanks for the discussion! Take care, Tony. – Wade
Hi, Wade. Thanks for your comments. I like your “resiliency and recovery” idea a lot. I think it would make intuitive sense to most clinicians and resiliency is a concept that has a nice foundation in the research literature as well. Thanks so much for sharing that. That’s the best language I’ve heard yet. Tony
Tony, I have a couple of workshops in September. I think I’ll give “Resiliency and Recovery Factors” a test drive and see what the audience thinks about it. I’m thinking that from a teaching standpoint a helpful mnemonic device may be “The Four Rs” of Risk Assessment: Risk Factors, Recent Events (precipitating events/sufficient conditions), Resiliency and Recovery Factors. It doesn’t cover everything, but it may be a helpful tool in learning. Food for thought… – Wade