Structured Support in Suicide Prevention with Jacinta Hawgood
Episode Description:
How do we move beyond clinical checklists to create meaningful care for those in crisis? Host Tony Pisani interviews Jacinta Hawgood, a clinical psychologist, lecturer, and researcher at Griffith University, whose groundbreaking work on STARS (Systematic Tailored Assessment for Responding to Suicidality) is changing the way professionals understand and respond to suicide risk.
In this episode, Jacinta explains how STARS combines structured tools with empathy, empowering clinicians and non-clinicians alike to truly hear and honor the stories of people in distress. From identifying protective factors to addressing professional fears of "getting it wrong," Jacinta challenges traditional approaches and offers practical insights for improving care.
Key Topics:
- How STARS (Systematic Tailored Assessment for Responding to Suicidality) bridges structured tools and personal stories.
- Why protective factors and client-driven care are essential for meaningful interventions.
- How suicide prevention is evolving, with new roles for non-clinical professionals and lived experience leaders.
- The biggest misconceptions about suicide, including fears around asking direct questions.
Note: This episode was originally released in 2023 through a collaboration with Aetna as “Practical Advice About Youth Suicide Prevention in Primary Care”. We loved this chat with Dr Dundas so much we wanted to share it again with our Never the Same Audience.
Guest:
- Jacinta Hawgood, MPsych (Clin), is a senior lecturer, clinical psychologist, and researcher at Griffith University. With nearly 25 years at the Australian Institute for Suicide Research and Prevention, Jacinta specializes in tailoring interventions to fit the unique needs of individuals, promoting both professional and community approaches to suicide prevention.
Host:
- Dr. Tony Pisani: Dr. Tony Pisani is a professor, clinician, and founder of SafeSide Prevention, leading its mission to build safer, more connected military, health, education, and workplace communities.
Referenced Resources (Timestamped):
Transcript
Tony: I had the opportunity to sit down with Jacinta Hawgood. Jacinta Hawgood is a faculty member at Griffith University in the Australian Institute for Suicide Research and Prevention. In this conversation, we explored Jacinta's learnings from a varied and interesting career as a psychologist, clinician and researcher. We discussed what we both learned as clinicians from people with lived experience, and we delved into Jacinta's work on a structured protocol for understanding people's stories related to suicide. A couple of production notes here. As you'll see, Jacinta and I recorded this on location at an international conference. It was in beautiful Piran, Slovenia. But because we were outside and just off the lobby of a hotel, there were a few moments where sound cut out or other distractions occurred. Finally, I'd like to note that while I'm a professor at the University of Rochester, this work is separate from my role there, but it is part of the same career mission I have as a clinician, teacher, and researcher to learn what I can and share what I learned toward the goal of suicide prevention. So without further ado, I'm pleased to bring to you highlights from this fascinating conversation with Jacinta Hawgood, a colleague and friend who offers valuable perspectives to the field.
Jacinta: My name's Jacinta Hawgood, and I work at the Australian Institute for Suicide Research and Prevention at Griffith University, where I have been for a very long, almost a quarter of a century. I absolutely love my job, so I started off as a senior researcher there. Um, I also had a clinical practice, and so I'm a clinical psychologist by profession. And then after several years, I went into the academic lecturing kind of side of academia and went to senior lecturer and I'm kind of moving from there. But basically my whole kind of position is a mixture of research, teaching and practice because of my clinical, so I have a clinical practice on the side, but it's very small.
Tony: Can you tell us what does STARS-P stand for? What is it? And kind of what's on the front burner for you related to STARS-P? STARS-P.
Jacinta: So STARS-P now stands for Systematic Tailored Assessment for Responding to Suicidality.
Tony: Systematic Tailored Assessment for Responding to Suicidality.
Jacinta: That's it. And we put a little P on the end to represent Protocol. So we have STARS-P- Protocol now. So it's kind of STARS-P- P. Um, because it's really a protocol. It's a structured professional judgment interview.
Tony: Okay, let's just pause there.
Jacinta: Tell me what that means. Ha ha. So, structural professional judgment has been used a lot in forensic settings, mostly, right, in the 90s, um, and onwards, um, to kind of describe the systematic process of conducting an interview that allows you to provide some level of objectivity, around your questioning, uh, and usually it's guided by empirical items or questions in your interview. So, empirically informed items. So for example, um, that approach in STARS-P means that we have lots of, that we have three sections in the protocol interview, but there's, there are items that represent empirically founded factors. For example, it could be, Psychosocial risk factors, it could be Protective factors, and it provides an element of structure so that the clinician doesn't use an unstructured, what we might refer to traditionally as just a clinical interview, uh, to, in our space of suicide is really important, to, that, that they don't provide subjectivity, and we all know about professional attitudes, fears, experiences, that kind of even unconsciously, but also even just semi- consciously, drive us to, or sway us in a particular area of the interview, um, and deny other areas.
Tony: It's, it's instilling sort of a discipline. Hmm. Uh, Yeah, yeah, very much. Um, um, making sure that, because it's, when suicide comes up, it can make us so anxious, or we want to avoid it, or maybe we, Uh, think some one thing is really important about it, and so we hyper- focus on that. Uh, this is trying to give a broader, a broader understanding.
Jacinta: Yeah, and it's, and it's very comprehensive. So you, so it does take time. Um, usually an hour and a half would be because it has safety planning in it as well. So the safety planning for us in regards to assessment, is essential. You can't finish an assessment, if it's a comprehensive one, without doing some sort of safety planning. So it's inherent in what we would conceptualise as, um, a psychosocial needs based assessment, which is STARS-P. So, the important thing not to forget is that, um, you can still, you can still be client- focused and hear the narrative of the client and they can certainly still be the expert in telling you exactly what's of concern to them in this process and STARS-P- P for that reason has built- in to all the questions a place for the client to tell you how much of a concern those factors are that they've said yes, they're experiencing or they're affecting them. How much of a concern none? Moderate concern? Or a severe concern to me? So I'm really concerned, for example, that a particular method, um, is accessible, that I have a lot of knowledge about it, it's part of my occupation, and it concerns me a lot. So what happens with regards to that piece of information interview is the training helps the worker to use anything that's of moderate or severe concern to the client to directly inform the commensurate care plan, the safety planning, and the management.
Tony: That seems like a really important concept. I don't know, and I've seen it actually crystallised like that before. But, um, you know, uh, I think a lot of times when you're doing any kind of a structure around different factors in a person's life to try to understand what's going on with them, um, I think there's sort of an assumption, uh, for people in kind of service providing roles that, we would decide which of those things was important. Sure. Right? Because, oh, well, this is a well known risk factor, or this is a whatever. But, uh, and you can, of course, keep that knowledge. You don't have to give that up but, but, um, really says, okay, something that might seem like the most important thing to me might not be, yeah. what's of most concern to the person? Yeah. Um, and there might be something that we think, I mean, do you ever find that there's something really concerning for you, but the person's like, no, I'm not too worried about it?
Jacinta: Definitely. It's an empirical risk factor that we believe, for example, is something that is, it heightens someone's propensity for suicide. For example, unemployment, uh, sexual abuse. Right? Particularly in females. We know that there's an increase, six fold at least, in literature for, for people to take their life because of that. So when these items appear in STARS-P- protocol, we have to be very careful, and the training supports this, when you're asking these questions, to really hear that person's story. Because unemployment for, for many people, particularly in a certain age range of the people that I've seen in my practice, is like, yeah, nah. I'm glad I'm not employed at the moment. I need time off work. I was being bullied or I want to just take time off. I don't need a job for the next six months. I'll go surf the waves down at the beach and live off Centrelink for a while, which is the Australian you know, social support system, and, um, and so, so it may not be of concern in contributing to that person wanting to take their life, but it is in the literature, of course, on population based studies, it represents a risk. Similarly, with sexual abuse, we find that some people, particularly older adults, um, have reported, yes, I've been abused, I've experienced trauma, but that's not of concern here. It's not, it's not relevant to my current experience of wanting to die. I've dealt with that, or I've accepted that that's going to be a part of my life, but it's not of concern. Um, another one is we have gender, um, identity and a sexual orientation as factors. For some people it's not an issue that they're maybe gay or bisexual or, or that even they've, they're transitioning. That may be nothing to it that they may have instead, relationship problems, financial problems. Gambling is another one. So for us, if we were sitting there traditionally, asking these questions, we'd be going, Oh, yes. Yes. And adding up like an additive effect, typical scales that pro formas from the past and you would result in a score that would inform allocation of resources, what response you had, but it's not, we have to really honestly really hear that story about what is of concern and encourage the person and it opens up a dialogue in fact. So to answer your question, that's important to proceed. The next part of STARS-P-P is we have another column. Next to the client rating of concern, where the therapist or worker rates their confidence.
Tony: You know, some, some of the innovation that you have here is that, you know, really, I mean, do we do that systematically and really understand? And I think that's what the S the S. To Systematically understand what's the person's concern level about the things that we're hearing, um, and not assuming that we know what it is and then, but it could be a focus of then, you know, further. You know, inquiry to understand.
Jacinta: Yeah.
Tony: So we have the the different sections that cover key areas to understand and and there are It's it's not giving people specific questions, but rather areas and then training fills in how these might be asked about there's the, um, the, uh, inquiry about, well, this in this area, how much of a concern is this for you? Um, and then there's some self reflection in a way, uh, there's some self reflection in a way of, of, uh, uh, how much of a concern is this for me? Do we, do we match up on this? Um, what else?
Jacinta: So, so there's those, so we have the suicide state inquiry, which is part A, part B is psychosocial factors, and then part C is protective factors. So we want to know from the person that doesn't have a concern rating, of course, because there's not really concern of having a protective factor, of course, um, because these are buffers. So we want to know from the prior storytelling that we've had around the other factors, you know, thinking of all those kinds of what stopped you? What are the things you think worked the most to alleviate the distress, the adversity, the, the pain, whatever? And, um, so we have, yes, empirically informed protective factors, but of course in our field, we don't know that much about it. We, we do it at a community level, but not so much individually. So we kind of take people by the hand through the training to, like, um, appreciate that people will probably have protective factors that aren't even listed there. So, but they're a start, they're a guide to the person then, it's an open ended commentary space for the worker or the client, they can fill it out if they want, but to write in different situations, and some factors might only work in some situations. So we, we get them to discuss that, write that information down, and primarily that's about using the protective factors to support safety planning, uh, and of course they never supersede what part A what you get from part A, right? So when there's there's what we call warning signs or situational experiences etc. that help us know when you're in distress. Yeah?
Tony: So one of the things that I'm often interested in is how people Uh, how people's ideas or thoughts change and evolve over time. Like, I feel like for me, as soon as I put something out there, you know, whether we release a new way of thinking about education, or as soon as I publish a paper, it's almost like by the time it's gotten out, I've already started thinking, maybe that's not what I think anymore. And I've kind of gone further from that at that point. So I'm curious about how this has evolved over time. What have you changed your mind about? Um, in regard to this process and, and, and what has changed about it and what might still.
Jacinta: Hmm. Okay. So, so certainly we talked before about questions, right? We have Example Questions in the protocol. So one of four studies that we've just finished over the last couple of years, um, which were part of my PhD, the final study was looking at, um, getting reflections from lived experience about how they would want us to ask that question. So language and safe language and language that allows them to further disclose. And we kind of in the past have left a lot of that to the worker to find a way to articulate the questions. And we do know that there are some techniques that can be used to ask questions from Sean Shea's great work, right, in our field.
Tony: There's an expert in Clinical Interviewing and, uh, and has, has approaches.
Jacinta: Very good yeah approaches for, for, and even for non- clinicians, so there's some quite simple techniques that have really worked in drug and alcohol field, et cetera, we can transfer. And, um, but apart from that, there's, we're learning that if we can listen to the experts, how they want to be asked about these things. Um, so we've done quite a bit on, and we've published on the different words that they want changed, um, how they prefer rewordings of different items. And, um, and basically we've, we've, trying to, trying to, the next adaption will probably be a 2024 protocol, uh, will consist of that wording, because in the past they were only example, they were never meant to be how you would literally ask a question in the protocol, but they're there as examples of, this is the area you need to investigate, sort of thing. But of course, now that we've opened it up, here's a change over time from clinical workforce to non- clinical. Because you've got to think about our non- clinical workforce, um, their literacy has increased phenomenologically, phenomenally. Yeah, a lot. But it has over the years.
Tony: Can you just say that for people who might not, um, understand what the clinical or non- clinical workforce is could you just make that distinction?
Jacinta: For people who are listening or watching? Sure. Um, in Australia, it's very much clinical is psychiatry, psychologists, social workers, occupational therapists, other allied health professionals who might be employed in what we refer to in the government as mental health worker or case worker. Um, and of course, they're also included in the clinical workforce is private practice community practitioners who are registered with an affiliative body, um, for their profession. But then we have non- clinical, and emerging in Australia is, is quite substantial growth in the past even four, three years, even of non- qualified, non- professional backgrounds, a lot lived experience, so we have a peer workforce emerging, um, and, and there's also a non- clinical workforce who are not peers with lived experience, um, that we have trained up into volunteer roles, but also getting into the paid workforce. We have to do something to meet the demand of health concerns, and we're recognising in suicide, I should say suicide prevention, that the human connection is, is a critical part of care and even if it was a step, if you look at the step to care sort of response that I think most countries use in their health systems at the very broadest level, um, when it's not a severe presentation or experience for the person, you can do a lot there with human connection. So our non- clinical workforce don't have to have, uh, you know, university qualifications. So they can use STARS-P. We've trained them with Beyond Blue, um, supported quite a big project that we did where we trained their, what we call as aftercare sites. So when people are discharged from hospital, which is the highest risk, um, for psychiatric patients, at least in Australia, is the area where care needs to be improved. So we found from our STARS-P training of this particular workforce that it really, it had a major impact, significant differences in people's knowledge. And their ability to actually conduct a structured professional judgment approach was, was really greater than we expected, in fact, um, because they're joining with a human.
Tony: Yeah. Yeah, I, I, I have found that time and time again. I mean, so many times I've, I've had people say, well, you know, but people who aren't, didn't go to school for that, they can't. And then yes, they. Like, unfortunately, I hate to say, I hate to break it to you, it doesn't take a PhD to actually connect and even, you know, understand a lot, make useful response, like, in fact, sometimes it gets in the way. I agree. I agree. So like, I don't want to, you know, like, oh, our, our whatever can't do that. So one of the things you've changed your mind on is providing examples that, that are informed by people of lived experience. Other ways that, that, um, that STARS-P is evolving, you would say, or has?
Jacinta: Yeah, definitely. The, the two other major changes, um, that we're going to make is, is shortening the protocol. So, As Bojay and Horowitz would say, for something to be able to be tested for its effectiveness, it's got to be feasible. People have to use it in the way in which it's intended. So STARS-P protocol is long, right? It's a long, because it takes time to sit with someone, right? I don't know what would be the alternative, honestly, myself. I often say to people like, okay, I know you only get 55 minutes in Australia with a client to get a rebate from the government. So you have 55 minutes. But what do you do at 55 minutes when you're with someone who you, who's in suicidal distress? So to me, but I, I do, I do get organisational system responses and this is why people screen out those who are experiencing or at least present immediately. It's a hard copy. It's a hard copy protocol interview where you write down your information, right, and you put it in the charts or your files, which, which is difficult because then when you see the person in the next session, you've got to date it. A different color pen or something, and most of the time, a lot of section B and C doesn't change, but you'll have slight changes elsewhere. And if we're using that each session to see where we're at, um, it's not feasible. So it's a bit old fashioned, basically.
Tony: So, okay. So yeah, so to make it fit with like, okay, well I have to document what I did today. today. Yeah. Another time, another time, I'll second a fit and maybe it's electronic or a whole bunch of different options.
Jacinta: Yeah. So we're doing, yeah, we're doing a digital based form and people can re enter stuff. And, but the, the, the query or the hesitancy around this is, um, the concern that we may disturb that relationship. So, I don't want to be typing stuff while I'm talking to someone. And you don't want to be entering data into a laptop or something when you're talking to someone. So, at some point, you're still going to have to be taking notes. And I, I can't imagine, and of course, this is where feasibility testing comes in, it would be important to see how that would work for, uh, people. And the, yeah.
Tony: You be interesting to study because I'm genuinely curious about whether Um, I know we often assume if you're typing, you can't be listening and attentive, and I get that. Uh, at the same time, I wonder if, if people would really be, if you actually like randomize people to a, somebody who's listening very well and not writing anything down or writing something in this way versus somebody who is typing. Um, would you actually get different ratings of the evolution? I don't know.
Jacinta: Excellent question. It's, it's such a good question. Um, I'm mostly, I certainly haven't tried it myself, but I'm mostly listening to people in training, their experiences of doing it. And there's, there's, there's a real sense of feeling disconnected if they themselves do it. But having not tried it. Yeah. A lot of the time, I don't know how many people have tried it and, um, I have, I have used Uh, a, a laptop with clients myself for different things and, and they haven't cared. And I just, I think it's part of the process of using your relationship to explain this is what I'm doing here.
He's got an extremely, an intelligent, clear thinking brain, um, with lots of experience in regards to suicide, the phenomenon and, and he really brought to Australia the whole notion of suicide as a behavior, not a mental illness. And all of the interpretations around Suicide that he had appreciated from historical interpretations right through to now. He used to ensure that we really brought into how we did research, our understanding, kind of very much was about a 360 degree perspective of the phenomenon. And for me, that meant trying to understand cultural interpretations and social determinants and, um, you know, economic and from Durkheim right through to medical interpretations. And they just didn't teach that at the time. Um, deep appreciation for the human experience. I think, I mean, that's what really informed his desire to set up this Life Promotion Clinic, which we opened in 2004, as an alternative to hospitalised based care. Appreciate that suicidality isn't just associated with mental illness. You know, and in the very moments of someone taking their life, perhaps there's a state of mind that's not quite The person's normal state, understandably, um, but not necessarily associated with some sort of full blown diagnostic.
Tony: Yeah, I think that's even still a common misconception.
Jacinta: It is, it really is, yeah. The Lived Experience, kind of just entering the sector in Australia, um, with Bronwyn's organisation, there was definitely lived experience already in mental health.
Tony: Sure.
Jacinta: There was, that had already been since I think the 80s, quite a movement, if you want to use the, the word, the shift of, of really listening to the consumer, as, as I referred to, people who use services, but not in suicide. And of course, when Diego entered the landscape of Australia, it was very much suicide is a behaviour. So you couldn't treat and respond in terms of prevention with regards to suicide, as we do with mental health. That was just not seen, so he really shifted the focus of policy and we had a separate strategy. You get to realise that these gaps that are in front of you that you can't fill, there's a reason for that and it's because we need to fill it with Lived Experience.
Tony: Yeah, that's, that's a really, um, interesting way of putting it. That, uh, as a clinician, you sensed that there was something that you couldn't provide. Yeah. But then it takes a while to realize like, oh, because there isn't. We need to do really well by the people who want as part of the support they get something from a professional. Yeah. Um. But no matter how much we develop our, our skills, our connection with people, our ability to respond, it seems like that's not going to fill a need that many people have, which is to really talk with somebody who's been through what they've been through.
Jacinta: Yeah, yeah, exactly.
Tony: As we close this conversation, I'd be curious to know if there are, like, misconceptions, um, out there about suicide, suicide prevention, the field, your right to basically the things that you would love to kind of correct out there, things that you think, I always hear this and it bugs me and I really wish we couldn't. Anything come to mind for you on, on, on that front?
Jacinta: Well, there's, there's two equal things, but one's from the community and one's from the profession. Okay. Um, So, from the community, it's a common one. We all hear that asking someone about suicide is going to lead them to take their life, right? To do it, if we ask. So, I think we don't heavily do enough work in the literacy side of prevention to debunk that. Um, and I always think that education with science provides the best way to debunk a myth, right? Present the facts. So, I think we've, training's moved a long way away from doing myths and facts as the first module of training, right? But I do believe that that's a really, it's a very, very important one. So, that's the first thing that obviously we have to then equip people in the ways to do that, to feel safe, right? And then from the profession, the biggest thing is the fear of litigation. Right. And it's not big in Australia, the litigation. Nowhere near as big in, probably as in the US. Nowhere near. So, but it's, yet, it remains there as a really high level rating, if you asked our profession to rate what is their biggest fear, it would be that. Right. litigation or the coroner. Yeah. Correct. And, um, we work quite closely with the coroners. In fact, they had a role in some of the STARS-P documentation sections. So it's all very, very minimum standard duty of care. So I would want to work with them to, to, to get them to get a real handle on your role is to keep someone safe.
Tony: So what is the misconception that you think people have about litigation? Or they just think it's more common than it is, or they just think everything is going to, they're just sort of a boogeyman.
Jacinta: Yeah,
Tony: that's just sort of out there, that not, what's the, what's the, what's?
Jacinta: Well, I mean, regulatory practices in professions such as psychology, psychiatry, even social work has also got their own separate regular regulation board, um, but it's very strict when you get registration. So in your training, I mean, I'm sure it comes back to training? We're trained to be hyper vigilant around risk. So everything has a risk kind of focus. I mean, even in Australia now, the most recent workplace code of conduct, or code, I should say, of practice is psychosocial injury, in the work place, hazards. And hazards, yeah. So, but it's still got the word risk in it. And risk mitigation is such an important part of everything we do. Um, so we're already, we're already hyper vigilant to any risk mitigation stuff. So when it comes to working with people in distress, that's first and foremost where we go, the fear factor. And of course fear is a result of not having factual information, right? So, but good information can be power, and good power, in a way, because you can, you can use knowledge to, well, yes, of course, develop myths, but to change a practice, effectively.
Tony: I wonder if the, like that word risk is, puts people in a, uh, defensive mindset. Um,
Jacinta: you
Tony: know, like having somebody, this person is at risk. Um, it's like you're already supposed to be scared.
Jacinta: Yeah, correct. And, and so imagine how our clients feel when they hear that they're going to have a risk assessment. So it's, I mean, we've had to really work hard, like I've had to really work hard in my quarter of a century here at AISRAP. It's, it's very, um, when it's in, it's a vocab, it's vocab, right, is to say risk assessment. Um, in fact, it was Nav Kapur who, um, was present and did a bit of mentoring with me around the, the name of STARS-P, because he said, you can't say. screening tool for assessing risk of suicide. That's what
Tony: it was originally called. It
Jacinta: was originally called.