Douglas Flemons & Leonard M. Gralnik
Reviewer Julia Denington
Relational Suicide Assessment (RSA) is written by Douglas Flemons, family therapist and Leonard Gralnik, psychiatrist, both working in Florida, USA. It is an easy read, consisting of five chapters that are well structured and progress logically. It is however important not be misled by the title – the relational aspect does not refer to the therapeutic relationship, but rather the significance of the client’s intra and interpersonal world of relationships. Theoretically, RSA is based mainly on systemic principles, while also considering the importance of empathy, in order to establish a safe and trusting relationship. In addition, it seems to consider ideas from cognitive behavioural therapy and solution-focused work.
RSA provides a step-by-step approach for assessing suicidal clients. It is grounded in research findings regarding both risk and protective factors. Research data is referred to throughout in order to back up evidence for the assessment process, rather than as a focus for understanding suicide risk. The authors have devised a thorough semi-structured interview, the ‘Risk and Resource Interview Guide’ (RRIG), which enables clinicians to conduct a free-flowing interview. The structure and questions of the interview are based on the ‘client’ and their ‘significant others’, and considers in detail risk factors and resources for both.
Chapter 1 covers the “Foundations” for RSA. It refers to methods and assessment scales used for assessing suicide, some of which the authors incorporate into, yet also differ from, in RSA; it generally sets the tone for the book. Chapter 2 outlines the “Therapeutic Principles” that inform RSA. In particular, it considers the world of relationships we live in, dynamic processes, the client’s interpersonal and intrapersonal world, and the importance for the therapist to communicate empathically. Chapter 3, “Risks and Resources”, covers what information the therapist needs to gather and how to go about it (RRIG). It takes the reader through all the possible questions and issues to be covered. This is helped by references to many clinical examples. Chapter 4 is about the client’s “Safety” and the importance of making a safety plan following assessment. Chapter 5 shows us the “RSA In Action”, giving a transcript of an assessment with Douglas Flemons and Steve, a client who was seen in a student counselling centre. It brings all the earlier thinking and ideas into action in an accessible way.
Throughout the book, emphasis is on a collaborative approach, encouraging empathy, curiosity and acknowledging the client as their own ‘expert’ in understanding their behaviour, thought patterns, relationships and experiences.
This book is not about “therapy” per se, but focuses on assessment, which in itself may be therapeutic. The clinician (with the client’s agreement) may decide to invite the client’s ‘significant others’ to sessions as well as involve them in the client’s safety plan.
The RRIG is on the one hand rather straightforward and makes good sense. However it also requires a level of skill and expertise for the clinician to be competent in and to implement with ease. It is an aid that identifies the many areas the clinician should cover, and is not recommended for use as a questionnaire.
For whom this book is intended is unclear, and it would have been helpful to include possible differences in how to use RSA, depending on the work context for clinicians. For example, for those working in Child and Adolescent Mental Health Services, Student Counselling Services, Community Mental Health Teams or IAPT Services, it is a helpful guide to considering how to conduct suicide assessments. For the private practitioner working in isolation it may be more complex. It is important that the reader/clinician is open and responsive to working systemically in order to find RSA a helpful resource. Working in isolation, without ready access to other team members, may create complications. Implementing the RSA requires regular practice and for those who are not routinely seeing suicidal clients it could be difficult to become proficient.
A chapter on supervision would have been beneficial as I noticed only a couple of brief references. Given the complex and evocative nature of working with suicidal clients, I would have liked to read more explicitly about the importance of safe and solid supervision, and for examples to be included.
Overall this is a comprehensive book, which should be welcomed by systemic practitioners and clinicians who are routinely undertaking suicide assessments.
Julia Denington is joint Head of First Year at The Minster Centre, and teaches Skills and Object Relations. She also supervises second year students and runs weekend trainings on Eating Disorders and Self-harm and Suicide for finalists. She worked for many years in a CAMHS service in Richmond, specialising in treating adolescents with eating disorders and self-harming behaviours. Julia has a private practice in Kew, Surrey.