Spring/Summer 2004 Newsletter Section 7

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, correct?
Psychologist: Yes.
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 psychopathology.
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 90’ lecture 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?
Psychologist: Yes.
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?
Psychologist: Yes,
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 in practice?
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.
Psychologist: No.
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 the findings?
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.

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