Founding President Phil Kleespies set the tone from the beginning
of Section VII. Ever since, he has been our town crier. Steadfastly
he has called for the APA to be more ethically responsible for
the systematic and formal training of psychologist-practitioners
in behavioral emergencies. He has authored papers and reports;
he has gone to board meetings; he figuratively has stood on his
head to get attention from anyone in position to listen. To this
day he has maintained hope and has not wavered in his commitment
to make change happen. Yet, to date, his voice had only minimal
impact. To be fair, as we well know, change is slow, particularly
when there is not any acute psychic pain (at the APA) commanding
that something be done. Progress on his goal is best measured
in years, I trust not millennia, but surely not measured during
single year section presidencies.
I’ve chosen to do something that few subsequent
presidents (of organizations, no less countries) have done, i.e.
to sustain his vision and mission, rather than to shift to some
alternative pet project. A change in political will, concurrent
with new presidencies, only has narcissistic payoff; it rarely
moves a difficult process ahead. Changes in political will simply
destroy momentum and slow true progress toward elusive goals. This
is an easy decision for me, as education and training have been,
for years, my pet project, as well. I am not deluded to believe
that we will be there in but one more year; but I wholeheartedly
believe this is a goal we must reach and I will do all possible
to pressure future section presidents to stay the course until
our goals are met.
Having some reasonable amount of experience
offering forensic testimony in cases alleging negligence in the
assessment and treatment of an at-risk for suicide patient, I have
had significant opportunity to read depositions of defendant psychologists.
Let me share with you a paraphrasing of the typical scripting of
these scenes. Imagine a garden variety psychologist, pre- or post-licensure,
facing a hostile attorney after a complaint has been filed regarding
the suicide of the psychologist’s patient. Here’s how
this deposition might go, in a severely shortened and kinder form
than the reality I wish on none of my colleagues:
Attorney: Dr. Smith, I see from your resume that you have been in
practice some 20 years. Is that correct?
Psychologist: Yes, I graduated with my Ph.D. in 1984.
Attorney: And you graduated from X University with a Ph.D. in clinical psychology,
Attorney (stalking for his prey): X University is a most prestigious university.
I understand that the graduate clinical program there is quite renowned.
Psychologist (not resisting the baiting of his narcissism): The program is
one of the oldest in the country and it is quite competitive.
Attorney: Now, Dr. Smith, can you recall what course work you had during your
years at X University?
Psychologist: Well, it has been quite a while, but for the most part, yes.
Attorney: During your graduate years, before receiving your Ph.D., did you
have an academic course on the assessment and treatment of the suicidal patient?
Psychologist: Well, not a course, per se. This was covered in my course on
Attorney: Could you estimate how much was covered? That is, did you, perhaps,
have several lectures on the subject, for example?
Psychologist: Well, I do not recall exactly; probably at least a lecture.
Attorney: So would it be fair to state that your pre-licensure
training in assessing and treating suicidal patients amounted to perhaps a
on the subject?
Psychologist (beginning to feel some tension): Well, no. Perhaps that would
be it for formal didactic, I mean classroom, education; but I got my training
on externship and internship, when I was doing intensive clinical work and
was seeing at-risk patients.
Attorney (setting up for kill #2): Fair enough, doctor. Let’s
talk about your internship a bit. I note that it was at VA Hospital Z, correct?
Attorney: And this was a full-year, full-time training program with supervision
from staff psychologists, correct?
Psychologist: yes, and psychiatrists.
Attorney: Were any of your supervisors, as best you know, experts in working
with suicidal patients; that is, do you know if any had special expertise or
training to further train you in working with this type of patient?
Psychologist: Well, I do not know that for sure, but my supervisors were excellent
and taught me a great deal about what to look for, how to evaluate patients,
and how to design treatment strategies based on these evaluations.
Attorney: But, you can not tell the court for sure how well
trained your supervisors were, whether they were current in their reading of
the literature regarding suicidal patients, whether they were giving you sound
teaching, building your skills based on valid information…can you?
Psychologist: I believe my training was excellent.
Attorney: Now, Doctor Smith, let’s shift to your years of practice. You
told me earlier that you see an average of about 25 patients per week and that
this would be a fair estimate of how many patients, on average, you’ve
seen weekly over the years of your practice. Correct?
Attorney: Doctor, could you estimate – I know this is a rough estimate – how
many different patients you have seen in total over the 20 years you have been
Psychologist: Well that would be almost impossible,
but I would guess I’ve seen an average of maybe 50 different patients
per year, give or take; so I guess something like 1,000 patients.
Attorney: That’s fine, I understand you are
estimating. Now, could you tell me, on average, what proportion of
your current patients have suicidal thoughts or, from your best guess,
are at some non-zero risk of being suicidal?
Psychologist (trying to look experienced and knowledgeable): I would
say that, perhaps, 10 of mycurrent patients have some varying degree
of suicidal risk.
Attorney: Dr. Smith, that would be about 40%, if my math is correct.
Might that proportion be fairly applied over all the years of your
practice? That is, could we guesstimate that over the years of your
practice you have seen something like 400 suicidal patients?
Psychologist: Well, I might guess that, perhaps, somewhere between
250 and 400 over my 20 years.
Attorney: Now, Dr. Smith, can you tell me, during the course of your
professional career, have you attended a full-day workshop on the
assessment and treatment of the suicidal patient.
Attorney: Can you tell me the name or authors of a textbook or practice guideline
on this subject that you have read in the past 5 years?
Psychologist: Well, I have read some, but I can’t recall
the authors or name of the book, as I speak.
Attorney: How about in the past year, have you read a research article on these
subjects that you can cite or, at least, tell us what you recall relevant to
Psychologist: I read 2-3 journals every month and there are frequent articles
on the topic, but I can not tell you any specific article for the moment.
Attorney: Well, Dr. Smith, you have seen some 250 or more
at-risk patients, the preparation for which amounts to 90’ of didactic
lecture in graduate school and supervision by probably equally unprepared psychologists.
You have not taken a full-day training workshop. Moreover, you can not specifically
cite for the court that you are current in the literature on the topic…
I trust the reader gets the gist of what is ultimately a torturous
process for any psychologist to endure. The rationale for competency-based
training should not have to rely on the threat of litigation (although
this makes for a strong enough argument). It should rest on common
sense and on our ethical responsibility to be competent at what we
do. Few, if any, psychologists can ever know in advance that no at-risk
patient will walk in their office as a next patient. We need not
sell the notion that better training will mean fewer suicidal deaths.
We need only sell the idea that we must do better. I invite you to
join with us to make competency-based training in behavioral emergencies
a reality for future generations of psychologists.