Psychotherapy Bulletin

Psychotherapy Bulletin

Education in Suicide Prevention Should Be Required in the Training of All Healthcare Psychologists

Over the last 20 years, the rates of suicidal ideation, suicide attempts, and suicides have rapidly increased in the United States (Garnett & Curtin, 2023). At the same time, evidence has developed that interventions can effectively reduce the risk of suicide (Calati et al., 2018). Given these changes, it is time for APA to require competence in suicide prevention for all graduates of programs that train healthcare psychologists and in all APA-accredited internships and postdoctoral residency programs.  

The American Psychological Association (APA) Commission on Accreditation (CoA) has identified nine profession-wide competencies in the Standards of Accreditation required for all students who graduate from doctoral and internship programs accredited in health service psychology. Postdoctoral residency programs have a separate list of competencies. Programs must provide opportunities for all of their students to achieve and demonstrate each required profession-wide competency. Each competency listed in the Standards of Accreditation is considered critical for graduates in programs accredited in health service psychology (APA, 2015). If competence in suicide prevention was added to the list of profession-wide competencies required for accreditation, every graduate of an accredited program would receive this training.      

Health Care Psychologists Will Encounter Suicidal Patients

All psychologists delivering health care will likely encounter patients with suicidal thoughts. Suicide is the 11th most common cause of death in the United States (National Center for Health Statistics, 2021). A survey by Leitzel and Knapp (2021) found that 88% of the members of the Pennsylvania Psychological Association had encountered at least one patient with suicidal thoughts in the last year. The survey included all psychologists, including those not delivering health care services. If the results were limited to healthcare psychologists, the percentage would likely be closer to 100%.  

Not only will psychologists encounter patients with suicidal thoughts, but they also risk having a patient die from suicide. We could not find recent data on the percentage of psychologists who experienced a patient suicide throughout their careers. However, Leitzel and Knapp (2021) found that 6% of the members of the Pennsylvania Psychological Association had at least one patient die from suicide in the last year. Even 30 years ago, before suicide rates began dramatically climbing, 11% of psychology trainees had a patient die from suicide (Kleespies, 1993). Although patient suicides are very upsetting for all psychologists, they may be especially traumatic for trainees or early career psychologists who have not yet developed a solid professional identity (Gill et al., 2012). Nonetheless, conversations with and studies concerning doctoral students and interns in psychology indicate that many feel unprepared to treat suicidal patients and reduce their risk of suicide (see, for example, Cramer et al. [2023], Hagwood et al. [2021], and Jahn et al. [2017]). 

Suicidal thoughts and attempts have recently increased by about 35% from 2001 to 2023 (Garnett & Curtin, 2023). The increase in suicidal thoughts is exceptionally high among adolescents. According to the latest Youth Risk Behavior Survey, in 2021, more than 14% of high school boys and almost 30% of high school girls had serious thoughts of suicide in their lifetimes (Gaylor et al., 2023). One would be hard-pressed to find a psychologist who works with adolescents who does not need to have proficiency in assessing and treating suicide.  

Psychologists frequently treat disorders, such as depression, anxiety, or trauma where suicidal thoughts are common (about 85% of psychologists frequently or very frequently treat anxiety, 84% frequently or very frequently treat depression, and 57% frequently or very frequently treat trauma; Stamm et al., 2018). According to APA’s practice guidelines for depression, for example, the prevalence of suicidality among depressed adults “underscores the need for adequate assessment of the presence and degree of suicidality when working with depressed adults” (APA, 2019, p. 23). Suicide prevention is so important that several state boards of psychology now require continuing education in it as a condition of licensing renewal.  

Training in Suicide Prevention Will Improve Public Health

Training all healthcare psychologists in suicide prevention will benefit the public because it would be an important step in reducing the number of persons who live with suicidal thoughts, make suicide attempts, or die from suicide. Various interventions have shown effectiveness in reducing suicidal thoughts and behaviors, such as safety plan-type interventions, lethal means counseling, dialectical behavior therapy, cognitive behavior therapy, the collaborative assessment and management of suicide, and others (Calati et al., 2018).  

It is true that no one, not even the most competent psychologist, can guarantee they can prevent suicide (Jobes et al., 2023). Nonetheless, those who implement evidence-supported treatments for suicide prevention using sound clinical judgment and recognizing patient preferences and needs will significantly reduce the likelihood of a patient suicide. This is especially important since many psychotherapists still use unproven or potentially iatrogenic interventions (Rozek et al., 2023).   

Mandating competence in treating suicidal patients will help increase the public’s confidence in the ability of psychologists to deliver good care. Many patients do not reveal their suicidal thoughts to their psychotherapists (Hom et al., 2017). Some have realistic fears- based on past experiences- that their psychotherapists will shame them for their thoughts or impose unwanted interventions such as a non-consensual disclosure of their suicidal thoughts to loved ones or seeking hospitalization against their will (Hom et al., 2020). Unfortunately, many psychotherapists use less-than-optimal interventions with suicidal patients, including those prioritizing external control of the patients as opposed to the more effective interventions that make patients partners in treatment and motivate them by accommodating treatment to their personal needs and goals. If training in suicide prevention was mandatory for all healthcare psychologists, then the workforce would be less likely to use outdated and sometimes iatrogenic interventions.  

In addition, requiring training in suicide prevention may help to reduce the stigma associated with suicidal thoughts, as it would convey to those with suicidal thoughts that having suicidal thoughts does not make them abnormal or deviant. Finally, psychologists who are more knowledgeable about suicide prevention can influence others in their work environment to become aware of the importance of identifying and responding to suicidal thoughts and behaviors.   

Fortunately, resources exist for psychology trainers to use in guiding their educational program, such as Cramer et al.’s (2023) curriculum or Rudd et al.’s (2008) core competency model, and in evaluating the outcomes (Sandford et al., 2023).   

Addressing Arguments Against Mandating Suicide Training

Opponents of mandating suicide prevention may argue that the doctoral program requirements are designed to address general issues, such as assessment or interventions, without identifying specific diagnoses or symptom patterns. Identifying suicidal behaviors as a target of doctoral program training may, they could argue, open the door for other groups to advocate for specific training in their areas of interest, leading to an endless proliferation of requirements that would ultimately water down all of them. Furthermore, they could argue that targeting specific categories would limit the flexibility of doctoral programs to tailor their curriculum to emerging societal needs. Finally, they could argue that training programs are already moving toward including suicide prevention within their curriculum, so why should we fix a problem that is already fixing itself?   

However, one has to look at the purpose of accreditation. APA states that one of its accreditation goals is to ensure “outstanding, evidence-based clinical services to ensure the wellbeing of the public” (APA, n.d.). If APA wants to ensure public well-being, it should ensure adequate instruction in healthcare issues of high social importance, such as the prevention of suicide, which is the third leading cause of death among Americans aged 14 to 18 (Gaylor et al., 2023). Flexibility in standards is important, but flexibility should not be revered so much that it undercuts accreditation goals or minimizes crucial social needs.  

Of course, a line has to be drawn on what doctoral programs must require. However, the burden of mandating suicide training might not be as high as some might suspect. Most programs already teach suicide prevention to some extent. Indeed, the number of doctoral programs that include suicide prevention in their curriculum has increased to more than 90% in 2023 (Kleespies et al., 2023), far ahead of the 40 to 50% three decades ago (Bongar & Harmatz, 1991).  

The problem is that the quality of the training varies from minimal and likely inadequate (only a few lectures) to exemplary (an entire semester course including skills training and supervised experience). Monahan and Karver (2021) found that doctoral students in psychology received an average of less than 11 hours of training in suicide assessments, and many students did not feel adequately prepared to work with suicidal patients. It would be better if the students received more extensive education, including skills-based training (Bryan, 2021). Mandating competence for all doctoral programs could upgrade the quality of education in those programs that currently provide only minimal instruction.  

Conclusions

Suicide is a significant health concern within the United States, and the prevalence of suicidal behavior continues to increase. Psychologists regularly encounter suicidal patients, yet many have not had the training needed to treat them adequately. To promote public well-being, the APA CoA should include proficiency in identifying and treating suicidal persons as one of the competencies necessary for accreditation. Although most programs offer at least some training in suicide prevention, the training requirements could be upgraded to ensure sufficient competence in assessing and treating suicidal patients.  

Samuel Knapp is a retired psychologist who formerly worked as the director of professional affairs for the Pennsylvania Psychological Association.

Cite This Article

Knapp, S., Knauss, L. J. (2023). Education in suicide prevention should be required in the training of all healthcare psychologists. Psychotherapy Bulletin, 58(4), 22-26.

References

American Psychological Association. (2019). APA Clinical practice guideline for the treatment of depression across all three age cohorts. Retrieved from https://apa.org/depression-guideline”https://apa.org/depression-guideline 

American Psychological Association. (2015). Standards of Accreditation. Retrieved from https://apa.org/ed/accreditation 

American Psychological Association. (n.d.). Why accreditation matters. Retrieved from https://r.search.yahoo.com/_ylt=AwrjYBcqZSVl42wQtwsPxQt.;_ylu=Y29sbwNncTEEcG9zAzEEdnRpZANSRUZDTFJfMQRzZWMDc3I-/RV=2/RE=1696978347/RO=10/RU=https%3a%2f%2faccreditation.apa.org%2fwhy-accreditation-matters/RK=2/RS=mi0tw3e_N3s1jPue8WtrclE3Vjc- 

Bongar, B., & Harmatz, M. (1991). Clinical psychology graduate education in the study of suicide: Availability, resources, and importance. Suicide and Life-Threatening Behavior, 21(3), 231-244. 

Bryan, C. J. (2021). Rethinking suicide. Oxford.  

Calati, R., Courtet, P., & Lopez-Castroman, J. (2018). Refining suicide prevention: A narrative review on advances in psychotherapeutic tools. General Psychiatry Research, 20(2) http://doi.org/10.1007/s11920-018-0876-0 

Cramer, R. J., Hawgood, J., Kaniuka, A. R., Brooks, B., & Baker, J. C. (2023, September 25). Updated Suicide Prevention Core Competencies for Mental Health Professionals: Implications for Training, Research, and Practice. Clinical Psychology: Science and Practice. Advance online publication. https://dx.doi.org/10.1037/cps0000172 

Garnett, M. F., & Curtin, S (2023). Suicide mortality in the United States, 2002-2021. NCHS Data Brief no 464. National Center for Health Statistics. https://doi.org/10.10.15620/cdc.125705 

Gaylor, E. M., Krause, K. H., Welder, L. E., Cooper, A. C., Ashley, C., Mack, K. A., Crosby, A. E., Trinh, F., Ivey-Stephenson, A. Z., & Whittle, L. W. ( 2023). Suicidal thoughts and behaviors among high school students—Youth Risk Behavior Survey, United States, 2021. Morbidity and Mortality Weekly, 72(1), 45-54. http://doi.org/10.15585/mmwr.su7201a6 

Gill, I. J., (2012). An identity theory perspective on how trainee clinical psychologists experience the death of a client by suicide. Training and Education in Professional Psychology, 6(3), 151–159. http://doi.org.10.1037/a0029666 

Hawgood, J., Krysinska, K., Mooney, M., Ozols, I., Andriessen, K., Betterridge, C., De Leo, D., & Kõlves, K. (2021). Suicidology post graduate curriculum: Priority topics and delivery mechanisms for suicide prevention education. International Journal of Environmental Research and Public Health, 18(18), Article 9926. https://doi.org/10.3390/ijerph18189926 

Hom, M.A., Stanley, I. H., Podlogar, M. C., & Joiner, T. E. (2017). “Are you having thoughts of suicide?” Examining experiences with disclosing and denying suicidal ideation. Journal of Clinical Psychology, 73(10), 1382-1392. http://doi.org/10.1002/jclp.22440 

Hom, M., Albury, E. A., Christensen, K., Gomez, M. M., Stanley, I. H., Stage, D. R. L., & Joiner, T. E. (2020). Suicide attempt survivors’ experiences with mental health care services; A mixed method study. Professional Psychology: Research and Practice, 51 (2), 172-183. http://doi.org:10.1037/pro0000265 

Jahn, D. R., Drapeau, C. W., Wacha-Montes, A., Grant, B. L., Nadorff, M. R., Pusateri, M. J., Jr., Hannah, D. J., Bryant, G., & Cukrowicz, K. (2017). Characteristics of and barriers to suicidology training in undergraduate and clinically-oriented graduate-level psychology programs. Suicidology Online, 8, 104–113. 

Jobes, D. A. (2023). The collaborative assessment and management of suicide. (3rd Ed.). Guilford. 

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(3), 293-303. https://doi.org/10.1037/0735-7028.24.3.293 

Kleespies, P. M., Feinman, A., AhnAllen, C. G., Hausman, C., Thach, T., Woodruff, J., Loomis, S., & Bongar, B. (2023). A national survey of doctoral psychology education and training in suicide risk and violence risk assessment and management. Suicide and Life-Threatening Behavior, 53(4), 666-679. http://doi.org/10.1111/sltb.12972 

Leitzel, J., & Knapp, S. (2021). Annual survey of the members of the Pennsylvania Psychological Association. Unpublished data.  

Monahan, M. F., & Karver, M. S. (2021). Are they ready yet? A theory-driven evaluation of suicide risk assessment trainings in psychology graduate programs. Journal of Clinical Psychology, 77(7), 1614-1628. http://doi.org/10.1002/jclp.23171 

National Center for Health Statistics. (2022). Leading causes of death. Retrieved from https://wonder.cdc.gov 

Rozek, D. C., Tyler, H., Fina, B. A., Baker, S. N., Moring, J. C., Smith, N. B., Baker, J. C., Bryan, A. O., Bryan, C. J., & Dondanville, K. S. (2023). Suicide prevention practices: What is being used by mental health clinicians and mental health allies? Archives of Suicide Research, 27(3), 1034-1046. http://doi.org/10.1080/13811118.2022.2106923 

Sandford, D. M., Kirtley, O. J., Thwaites, R., Dagnan, D., & O’Connor, R. C. (2023). The adaptation of a measure of confidence in assessing, formulating, and managing suicide risk. Crisis, 44(1), 70-77. http://doi.org/10.1027/0227-5910/a000830 

Stamm, K., Lin, L., & Christidis, P. (2018). Mental disorders most frequently treated by psychologists. Monitor on Psychology, 49(3), 19. 

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