Thanks for the discussion! Take care, Tony. – Wade

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.

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.

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…

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