Reflections on the role of graduate training in suicide prevention efforts within clinical psychological science
Ilana Gratch, M.A.
As a graduate student in a lab focused on youth suicide, I spend a great deal of time thinking about the fact that it is the second leading cause of death among young people in the United States and the tenth leading cause of death overall (Hedegaard et al., 2018). Many may be familiar with the recent discovery that 50 years of research has not markedly improved our ability to predict suicide (Franklin et al., 2017), nor have we managed to meaningfully improve the efficacy of our treatments over time (Fox et al., 2020). There is, of course, no silver bullet, and likely no one-size-fits-all approach that will resolve what has become such an intractable problem in our field.
But in my view as a trainee, one possible piece of the puzzle lies in graduate training. A shift in our training approach may have potential to yield strong clinical and empirical effects.
First, with regards to clinical care: those who die by suicide are three times more likely to have had a hard time accessing healthcare than those who died another way (Miller & Druss, 2001). Why might this be? A recent examination of psychologists in private practice in the United States found practitioners to be less receptive to providing care to suicidal patients than patients with no explicit suicidal ideation (Groth & Boccio, 2019). The authors then explored the psychologists’ beliefs about the sources of this ambivalence; chief among them was concern about the adequacy of their own skills and training in the assessment and treatment of suicidal patients. Another study similarly found mental health professionals less likely to demonstrate willingness to treat suicidal adolescents than depressed non-suicidal adolescents (Gvion, Rozett, & Stern, 2021).
While troubling, these findings are not especially surprising. Research suggests that psychotherapists consistently consider treating patients with suicidal ideation to be one of the most stressful aspects of their work (e.g., Deutsch et al., 1984; Farber, 1983). This may be due, in part, to a lack of perceived self-competency as well. Indeed, graduate training does not seem to provide a robust education in working with suicidal patients. A study published earlier this year found that clinical psychology doctoral students report spending just 11 hours on average learning about suicide risk assessment throughout their graduate training (Monahan & Karver, 2021), and only 51% of students from PhD programs report that their graduate program provided formal suicide training (Dexter-Mazza & Freeman, 2003). Moreover, applied and informal training opportunities (i.e., through clinical supervision of cases) appears to be lacking as well; one study found that only 20% of students received direct supervision on their work with suicidal patients, despite the fact that 50% reported treating them (Mackelprang et al., 2014).
In my own experience, my most extensive training opportunities thus far have come somewhat indirectly and through experiences I explicitly sought out: volunteering on a suicide prevention hotline for LGBTQ youth for 4 years, working as a research coordinator on a randomized controlled trial of the safety planning intervention for suicidal patients in a psychiatric emergency room, and joining a lab that focuses on youth suicide. These experiences, for which I am immensely grateful, are still qualitatively different from, and do not make up for the lack of, the accumulation of many hours of supervised clinical experience, including in an outpatient treatment setting.
Finally, with regards to research: I cannot help but wonder whether providing trainees more direct and in-depth experience working with suicidal patients may have downstream effects on our research efforts as well. Indeed, if direct observation is a fruitful pathway towards the development of ideas and hypotheses – in this instance, perhaps, as it relates to what might be effective from a treatment standpoint – then it stands to reason that the more experience trainees have, the more promising ideas they might generate; and we are very much so in need of promising ideas and research.
It is true that there are some important factors to weigh in the consideration of implementing the shift for which I am advocating – ranging from concerns about trainees’ clinical and psychological readiness, to concerns about supervisors’ and training directors’ tolerance for certain risks. However, it is also true that we have an ethical obligation as a field to produce clinicians and researchers who are equipped to work with all kinds of patients, including, perhaps especially, those who are in enough pain to consider ending their lives.
Ultimately, any “solution” is of course likely to be multi-pronged and beyond the scope of graduate training programs. But it is my hope that graduate training is not overlooked as one of the many possible avenues of change worthy of pursuit.
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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.