Chris Ryan, a psychiatrist, writes about the futility of risk assessment in a group of patients admitted in emergency. He shows that they are more then likely to score high on quite a number of risk factors, so it is futile to take them into account, as most of them are unlikely to take their lives. His blog, on the excellent Imperfect cognitions, is in tune with a recent paper in which he and his co-authors write in the abstract:
No interpretation of the current requirements for suicide risk categorisation of psychiatric inpatients can lead to information that might usefully guide clinical decision-making.
But Ryan ends the blog with a cliff-hanger – he hints there might actually be a way. So I am going to help him (well, sort of, not really).
You see, I’m no psychiatrist (I am not even a proper psychologist, though one of my degrees is in psychology), and my reaction to what he wrote was: ‘Obviously!’. And it is more meant as a moan of resignation, rather than a gloat. There are two interrelated reasons for this. I would label them – meaning and context. I am not entirely certain, it makes sense to split the two, but I am going to have a go anyway.
However, let me offer a bit of background. Over the last few decades suicidology has told us quite a lot about suicide, its prevalence, its risk factors, stigma and much more. Without a shadow of a doubt, all these things are very important. But suicidology has not told us much about why I might take my life. Moreover, it has not told us much about why I might not take my own life, or what suicide might mean to me. In other words, as suicidology discovers another set of risk factors, putting them into another model of suicidal behaviour (and I do not want these words to be taken as disparaging at all), it still offers no insight into how to predict a suicide. Not suicide, but a suicide. Put differently, suicidology is still none the wiser as to why an individual might take their life.
Context. Why is it? Well, it is so because suicidology is not very good at dealing with context. Risk factors are not translated into the individual living their own life, making their own decisions. Let me give you an example. My collaborator, Justyna Ziółkowska, told me of an interview with a man after a suicide attempt, who told her that he had tried to kill himself because of a pack of cigarettes. Basically, his daughter promised to bring him the cigarettes, but was detained for some reason, and he just had enough. That was the last straw – he tried to kill himself. If we take this story at face value, and there is no reason why we shouldn’t, we must accept that had the daughter come in time, the man would not have tried to kill himself. You can have all the risk factors in the world figured out, yet, how do you factor in a delayed pack of fags! Predict this!
Indeed, I talked to a number of men who attempted to take their lives, who told me of a decision to kill themselves as thin as a ‘sheet of paper’. There was no time to consider, to think. One told me of talking to his girlfriend on the phone and on the spur of the moment, turned and walked under an oncoming car.
In my view, suicidology is unable to change large-scale risk factors into here-and-now situation. But let’s take a look at the other problem.
Meaning. By that I mean that current suicidology is very good at looking at groups or populations. But suicides are not carried out by populations, but by individual people. The individual perspective on suicide, its – you guessed it – meaning is not something that suicidology is very good at.
The example Ryan gives is that of suicide ideation, to which suicidology (and clinical practice) responds with a question of existence. In other words, are there suicidal thoughts, or not? And yet, there is precious little on what it actually means to have suicidal thoughts, what it means to the person who has them. I would go even further – I actually think there aren’t any ‘suicidal thoughts’, at least not from the point of view of a researcher/clinician. What the researcher has, are stories of those ‘thoughts’, and those stories are actually pretty heterogeneous, as Justyna Ziółkowska and I showed in a recent article. So what exactly are we talking about when you are refer to ‘suicidal thoughts’ or ‘suicidal ideation’?
I am currently interested in men’s suicide notes. And those notes paint a very complex picture of suicide. Take for example three fragments of three different notes (the men who wrote them, killed themselves).
- Maybe I’ll wake up.
- Throw my body into a swamp.
- I will love her till she dies.
At least judging by the notes themselves, I think suicide meant different things to their authors. And yet, it will have been recorded as suicide (for today’s suicidology they are ‘the same’ kind of event), while the three would have been (and probably will be) assessed for their risk factors. But who cares about the risk factors – these are different suicides in the sense that they are more than likely to have meant different things for the three men.
And yet, there are practically no studies of ‘meanings’. Suicide notes are predominantly studied for their authenticity, while suicide attempts for risk factors.
Now, the question that Chris Ryan might ask me is whether what I am writing here can help him in his clinical work. This is an important question, after all he must, probably almost daily, take a decision – is this person going to kill themselves or not. My answer is, unfortunately, that I don’t know.
I don’ t know because there needs to be much more work on ‘contexts and meanings’. And so here is time for a plea. Suicidology (and clinical practice) needs qualitative research – research into ‘contexts and meanings’. As it obsesses (do forgive me) with ‘objectivity’, I think it misses the actual individual who here and now is taking a decision to kill themselves. And at the moment it has very little to say about this individual.