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Abstract
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We thank Matthew M Large and colleagues for their interest in our Personal View. However, we are concerned that they might have misconstrued our main message.
In our Personal View, the inclusion of factors within both the text and the figure was not because these factors are clear markers of suicide risk, but because they might contribute to distress, can lead to a suicidal crisis, and can cause general psychological suffering. As the majority of mental health patients present with psychological distress, and some present with suicidal thoughts, targeting potentially changeable factors therapeutically might help reduce patients' distress and risk of suicide. This targeted approach is likely to benefit all mental health patients. The figure was included to remind clinicians of the complex and dynamic nature of factors that can contribute to patients' distress and possible risk of suicide. The main focus of therapeutic risk management is reducing distress, including by collaboratively identifying factors with the patient that could produce some relief if changed. By doing this, the clinician and patient work together to identify factors that require more sustained therapeutic intervention. Positive outcomes (eg, reduction in distress and plans to address modifiable factors) come from establishing a therapeutic alliance, helping a patient feel understood and destigmatised, and instilling hope in the patient that their feelings of being trapped can be alleviated. There is increasing evidence of the benefits of therapeutic alliance in reducing suicidal thoughts and behaviour. The process and recording of a safety plan is another positive outcome from this alliance, reinforcing any short-term reduction in distress by providing the patient with tools to manage their next crisis and, potentially, their thoughts of suicide.
We also thank Stephanie R Penney and Alexander I F Simpson for their comments. We agree that there are substantial parallels between issues regarding risk assessment of violence and risk assessment of suicide. That some violence risk prediction tools seem to measure risk of violence more accurately than equivalent measures for suicide prediction is interesting, although their predictive ability in individual patients is unsatisfactory. Penney and Simpson rightly emphasise that the societal expectations of predicting risk of both suicide and violence are an unrealistic burden on clinicians. These unrealistic expectations might deflect their attention away from therapeutic risk management, in which interventions can reduce risk of suicide by enhancing the wellbeing of patients.
Language: en |