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Behavioral Emergencies Update

Volume 1, Issue 1
Spring/Summer 2004
Section on Clinical Emergenices and Crises
American Psychological Assn.
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In this issue...

The President's Column:
Who is teaching our youth?

Letter from the Editor

Ideas for Moving Forward

Assessment of Firearm Access

The Lack of Graduate School Training in Suicide Assessment and Management

APA Program Summary


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THE LACK OF GRADUATE SCHOOL TRAINING IN SUICIDE ASSESSMENT AND MANAGEMENT

Elizabeth Dexter-Mazza, MS
Montefiore Medical Center

     
Treating suicidal patients has been identified as an “occupational hazard” for psychologists based on the statistic that 22% of psychologists will experience the death of a client by suicide during their career (Chemtob, Hamada, Bauer, Torigoe, & Kinney,1988). Further, almost all psychologists will treat a suicidal client at some point. Given the high probability of working with suicidal patients, shouldn’t it be mandatory that all psychologists receive adequate training in how to manage a suicidal client?

According to psychology program directors only 40% of graduate psychology programs are offering formal training in the management of suicidal clients (Bongar & Harmatz, 1991). Further, between 11% and 54% of mental health trainees experience a client suicide (Courtenay & Stephens, 2001; Dewar, Eagles, Klein, Gray, & Alexander, 2000; Kleespies, Penk, & Forsyth, 1993; McAdams & Foster, 2000). Dexter-Mazza and Freeman (2003) surveyed 238 predoctoral psychology interns and found that only 50% reported that they had received formal training in managing suicidal clients during their preinternship experiences. This leaves half of psychology trainees receiving no formal training on how to work with suicidal clients. Furthermore, approximately 5% of participants indicated that they had a client suicide, and more over, 99% indicated that they had treated at least one suicidal client during the course of their graduate school years. Based on this data, it is clear that psychologists are not receiving sufficient training regarding how to deal with high-risk suicidal clients.

In 2003, Dexter-Mazza completed a preliminary evaluation of a brief training model in suicide risk assessment and intervention developed by the American Association of Suicidology Education and Training Committee. Participants included 63 first year graduate students; 36 received the brief training module and 27 received training as usual (TAU). Five areas of suicidology were covered in the training module; the areas included prevalence rates, theoretical model of suicide, suicide assessment, suicide intervention, and risk management/liability issues. The TAU group received a general lecture on suicide risk assessment from the course professor. The lecture included a true-false suicide quiz on myths and facts of suicide, a review of the SAD Persons Scale (Patterson, Dohn, Bird, & Patterson, 1983), and a review of the Specificity, Lethality, Availability, Proximity (SLAP) suicide assessment model. Results indicated that the Training group showed an increase in both knowledge and clinical skill (e.g., assessment and intervention skills) over the TAU group. Specifically, in videotaped interviews with pseudo-clients, students in the Training group conducted a more thorough suicide risk assessment and intervention procedures.

Notably, significant concerns arise when the majority of students from both groups at pre-test rated themselves at a “moderate level” regarding their ability to assess and manage suicidal clients, as well as their overall knowledge about suicide. It is alarming to think that students feel competent in this area when in actuality only one-third of the students reported receiving training in managing behavioral emergencies prior to starting graduate school. At post-test, differences were notable between the Training and TAU groups with regard to knowledge base. There was a significant difference in the increase of self-ratings for the Training group in all three areas, which included assessment skills, ability to work with suicidal clients, and knowledge about suicide. The TAU group only reported an increase in self-ratings in the area of suicide assessment, however.

These findings are consistent with previous ones (Dexter-Mazza & Freeman, 2003). Students are generally more likely to feel comfortable with suicide assessment (as was observed with the TAU group) since the majority of training programs address this specific area, albeit briefly. Trainees often expect to be receiving adequate training in the management of suicidal clients and may believe that the informal review of suicide assessment is enough to be able to effectively manage this type of patient in ongoing treatment, leaving them with a false sense of self-confidence.

The inconsistencies among graduate programs with regard to the type of training provided in managing suicidal clients may result in an ethical dilemma for many trainees, especially if they do not receive any type of formal training during their predoctoral internship. According to APA Ethical Guidelines (1992), “[psychologists] recognize the boundaries of their particular competencies and the limitations of their expertise. They provide only those services and use only those techniques for which they are qualified by education, training, or experience” (p. 1599). This statement could cause ethical dilemmas for new psychologists who have not received appropriate training in suicide as research suggests that it is highly unlikely that a psychologist will never treat a suicidal patient.

Overall, graduate programs need to do a better job of providing formal training to students in working with suicidal clients. Students should be provided with opportunities to receive formal training through special topic courses, lectures, workshops, and practicum experiences. Additionally, suicidal clients should not be screened out and referred to other agencies due to a student’s lack of training. By “screening out” suicidal patients, trainees miss opportunities early on to manage high-risk patients in ongoing treatment while they are receiving direct supervision and support. Otherwise, trainees may not experience working with their first suicidal patient until internship or after they graduate when minimal supervision may be available.

REFERENCES

American Psychological Association. (1992). Ethical principles of psychologists and code of conduct. American Psychologist, 47, 1597-1611.
Bongar, B., & Harmatz, M. (1991). Clinical psychology graduate education in the study of suicide: Availability, resources, and importance. Suicide and Life Threatening Behavior, 21, 231-244.
Chemtob, C. M., Hamada, R. S., Bauer, G., Torigoe, R. Y., & Kinney, B. (1988). Patient suicide: Frequency and impact on psychologists. Professional Psychology: Research and Practice, 19, 416-420.
Courtenay, K. P., & Stephens, J. P. (2001). The experience of patient suicide among trainees in psychiatry. Psychiatric Bulletin, 25, 51-52.
Dexter-Mazza, E. T., & Freeman, K. A. (2003). Graduate training and the treatment of suicidal clients: The students’ perspective. Suicide and Life Threatening Behavior, 33, 211-218.
Dewar, I., Eagles, J., Klein, S., Gray, N., & Alexander, D. (2000). Psychiatric trainees’ experiences of, and reactions to, patient suicide. Psychiatric Bulletin, 24, 20-23.
Kleespies, P. M., Penk, W. E., & Forsyth, J. P. (1993). The stress of patient suicidal behavior during clinical training: Incidence, impact, and recovery. Professional Psychology: Research and Practice, 24, 293-303.
McAdams, C. R., & Foster, V. A. (2000). Client suicide: Its frequency and impact on counselors. Journal of Mental Health Counseling, 22, 107-122.
Patterson, W M., Dohn, H. H., Bird, J., & Patterson, G. A. (1983). Evaluation of suicidal patients: The SAD PERSONS scale. Psychosomatics, 24, 343-349.