01 | Introduction to PROTECT: Novel Solutions to Suicide Risk Management

A person with suicidal ideation is often trapped in an overwhelming sense of despair (Beck, 1986). Stemming from entrapment, suicide may become the salient solution to life circumstances (O’connor, 2011) and intense psychological pain (Shneidman, 1993). Suicide is a major public health problem, with over 800,000 people dying annually worldwide, and for each completed suicide, there may have been 20 other attempts (World Health Organization, 2014). To support those in suicidal distress, professionals, families and friends strive to establish new and alternative ways of coping (Jobes, 2006, p. 122; Owens et al., 2011). However, there is a dissonance between the reality of those experiencing a crisis, for whom suicide is the perceived solution, and those that are caring, who view suicide as the problem (Duffy, 2006). Reconciling these positions is difficult as professionals have to understand the person’s pain before they can form a collaborative partnership on the road to recovery (Michel & Jobes, 2011). In a serious suicidal crisis, recovery-oriented practice is often sacrificed on the altar of safety, and care becomes prescriptive. In our previous work in reducing coercion in care in the acute setting (PROMISE), staff and patients highlighted the difficulties in striking this balance. They described the restrictive practice as “it never is very nice… but it is a necessary evil” (Wilson, Rouse, Rae, & Kar Ray, 2017). 86% of study participants highlighted the importance of enhancing relationships through empathic communication as a way of overcoming the challenges posed (Wilson, Rouse, Rae, & Kar Ray, 2018).

This was the most common theme that emerged and formed the foundation of the PROMISE programme, which showed that with the right care, the person has more control (Lombardo et al., 2018). This way of working calls for compassion and a deeply empathic value set amidst professionals who need to be skilled at identifying and supporting people at risk, sometimes in high-pressure environments like inpatient wards and emergency departments (Canner, Giuliano, Selvarajah, Hammond, & Schneider, 2018). Although suicide prevention training to gatekeepers, primary care physicians, emergency department staff and mental health professionals has been rolled out (Albright, Timmons-Mitchell, & McMillan, 2018; Gryglewicz et al., 2019; Hodges, Inch, & Silver, 2001), reducing suicide rates remains a challenge (Arensman, 2017).

Most packages focus on assessment skills, risk screens and risk factor tools (Mortensen, Agerbo, Erikson, Qin, & Westergaard-Nielsen, 2000) but do not address tensions between divergent views of people in distress and professionals involved and how to build empathic partnerships (Downes, Gill, Doyle, Morrissey, & Higgins, 2016) in time and resource-poor environments. Risk assessments may become a tick box exercise and fail to capture the narrative of the person’s distress (Cole-King & Lepping, 2010). Also, most training programmes focus on which information to collect and do not address biases in thinking and attitudes (Owens et al., 2011), which may considerably influence the outcome.