Training Mental Health Professionals to Assess and Manage Suicidal Behavior: Can Provider Confidence and Practice Behaviors be Altered?

Remarkably little systematic research has studied the effects of clinical suicidology training on changing practitioner attitudes and behaviors. In the current study we investigated whether training in an empirically‐based assessment and treatment approach to suicidal patients administered through a continuing education workshop could meaningfully impact professional practices, clinic policy, clinician confidence, and beliefs posttraining and 6 months later. At the 6 month follow‐up we found that 44% of practitioners reported increased confidence in assessing suicide risk, 54% reported increased confidence in managing suicidal patients, 83% reported changing suicide care practices, and 66% reported changing clinic policy. These results suggest that a brief and carefully developed workshop training experience can potentially change provider perceptions and behaviors with a possible impact on clinical care therein.     

Collaborating to prevent suicide: a clinical-research perspective

It is argued that suicidality is essentially a relational phenomenon; the presence or absence of certain key relationships paradoxically can be both suicide causing and suicide preventive. The relational aspects of suicide are especially poignant in clinical work with suicidal patients. However, when suicidality is involved, there are a number of issues that can interfere with effective clinical practice. Fortunately, a new paradigm has begun to emerge in contemporary clinical suicidology, which objectifies suicidality and emphasizes the phenomenology of suicidal states. Moreover, from an increasingly empirical perspective, this approach is creating new and better ways to effectively assess and treat suicidal conditions.     

Primary care providers' views regarding assessing and treating suicidal patients

Primary care providers (PCPs) usually do not explore patient suicidality during routine visits. Factors that predict PCP attitudes toward the assessment and treatment of suicidality were examined via an online survey of 195 practicing PCPs affiliated with medical schools in the United States. PCPs who perceived themselves as competent to work with suicidal patients were more willing to assess and more willing to treat suicidal patients, with the perception of competency fully explaining the relationship between training and willingness to treat. Female gender predicted lower self-perceived competency, while in-office access to professional mental health (MH) consultation predicted greater self-perceived competency. Higher self-perceived general competence predicted lower subjective valuation of access to MH consultation. Multiple linear regression analysis indicated a three-way interaction between training, gender, and valuation of MH consultation as predictors of perceived competency, with training generally being associated with greater perceived competency to treat suicidality. Relative to their male counterparts, female PCPs have lower confidence in assessing and treating suicidality. Perceived competence in risk assessment should be given more attention in medical training because of its role in PCPs' willingness to treat suicidality.     

Suicidology: A Look Backward and Ahead

Using the metaphor of “a long run’ to describe our progress in suicidology, the author looks back to discuss important concepts that have become well established, such as clues to suicide, ambivalence, crisis services, suicide consultations, and psychological autopsies. An example is the psychological autopsy of Marilyn Monroe. Follow-up studies of crisis center clients have indicated that chronically suicidal clients are at the greatest risk of suicide. Recommendations for the long-term treatment of such patients are provided. Research on youth suicide is reported. Finally, the author looks ahead toward new developments in training and treatment.     

The anatomy of suicidology: a psychological science perspective on the status of suicide research. 2002 Shneidman Award Address

Suicidologists have made tremendous strides in advancing the knowledge of correlates of completed suicide and nonfatal suicidal behavior since the early 1960s. In order to move beyond the simple identification of risk factors, however, scientific suicidology needs to give greater attention to the critical role of theory in guiding inquiry and advancing the understanding of suicidal behaviors. In this article I argue the importance of theoretical grounding from the perspective of psychological science, provide examples of this perspective from my work, and discuss their implications for future research in the field.     

Suicide risk assessment: Clinicians’ confidence in their professional judgment

Suicide risk assessment is a critical component of mental health practice for which the stakes are high and the outcomes uncertain. This research examines the consistency with which clinicians make determinations of suicide risk and factors influencing clinical confidence. Seventy-one social workers interviewed two standardized patients performing in scenarios depicting suicidal ideation, judged whether the patient required hospitalization, and completed standardized suicide risk assessment measures. Self-ratings and qualitative interviews explored participants’ confidence in their judgment of risk. Participants had highly divergent views regarding whether or not the risk of suicide was sufficiently high to require hospitalization. However, regardless of the ultimate decision reached, participants were equally confident when recommending either clinical course of action. The variation in risk assessment appraisals in this study, despite at times high rates of confidence in risk appraisals, speaks to the need for ongoing training, consultation, and increased decision support strategies.     

Nonlinear dynamics: theoretical perspectives and application to suicidology

Despite decades of research, the prediction of suicidal behavior remains limited. As a result, searching for more specific risk factors and testing their predictive power are central in suicidology. This strategy may be of limited value because it assumes linearity to the suicidal process that is most likely nonlinear by nature and which can be more adequately described and analyzed with nonlinear dynamics. The goal of moving nonlinear dynamics from theory to practice and to real-world phenomena can now be realized with Internet-based monitoring systems such as the Synergetic Navigation System.     

A Functional Approach to the Assessment and Treatment of Non-Suicidal Self-Injury in Veterans: A Dialectical Behavior Therapy–Informed Perspective

Given that non-suicidal self-injury (NSSI) is related to increased odds of suicidal ideation and suicide attempts, treating NSSI in veterans is a key treatment priority to help reduce suicide risk and increase quality of life. Treating NSSI can be difficult for clinicians and training in addressing NSSI can enhance therapist empathy and decrease negative attitudes. The current paper describes prevalence of and risk factors for NSSI in veterans and presents a Dialectical Behavior Therapy (DBT)-informed approach for arriving at a functional understanding of NSSI in order to inform assessment and treatment. This DBT-informed approach is demonstrated with two case examples of veteran clients. While in many circumstances treatment of NSSI may be most effective in the context of full model DBT (i.e., individual therapy, group skills training, phone coaching, and therapist consultation team), many aspects of the functional approach discussed herein are not specific to DBT and could therefore be integrated into behavioral analyses and case formulations conducted within non-DBT therapeutic approaches.     

Rebuilding the tower of Babel: a revised nomenclature for the study of suicide and suicidal behaviors. Part 1: Background, rationale, and methodology

Since the publication of the O'Carroll et al. (1996) nomenclature for suicidology, there have been a number of published letters and articles, as well as an active e‐mail dialogue, in response to, and elaborating upon, this effort to establish a standard nomenclature for suicidology. This new nomenclature has been presented on a number of occasions at both national and international meetings. In this paper we provide the background, rationale, and methodology involved in the process of revising the O'Carroll et al. nomenclature, based on the feedback and discussions that have ensued over the past 10 years. Those who have written and studied the phenomenon of suicide have not defined the term so simply … how the word is defined has implications and large effects for statistics that are compiled on the official number of suicides, and for researchers, so that there is clear communication regarding what and who is being studied. Among writers in the field of suicidology there is no single common accepted definition … the term suicide refers not to a single action but more broadly to a great many varied behaviors. For example, one can speak of suicidal thoughts, intentions, ideation, gestures, attempts, completions, equivalents. Thus far, no single term, definition, or taxonomy has served to sufficiently represent the complex set of behaviors that have been suggested as suicidal. A standard set of terms and definitions are greatly needed to advance the science of suicidology and aid communication and understanding of the field. McIntosh (1985 , pp. 18–19)     

The Use of Consultation in Psychological Practice: Ethical,Legal, and Clinical Considerations

The importance of consulting with other professionals to maintain acceptable standards of care is well documented in many health care professions. However, evidence indicates that many psychologists fail to utilize consultation when needed, and that consultation use varies along dimensions such as the education and training of the consultee, the type of setting, number of years in practice, and proximity to available consultants. In this article, we review the research on the use of consultation by psychologists as well as other health care professionals. We discuss the clinical, ethical, and legal implications of seeking consultation as a professional psychologist. Finally, a detailed and practical model for the regular use of consultation is given to improve the routine use of consultation in clinical practice.     

The use of consultation in psychological practice: ethical, legal, and clinical considerations

The importance of consulting with other professionals to maintain acceptable standards of care is well documented in many health care professions. However, evidence indicates that many psychologists fail to utilize consultation when needed, and that consultation use varies along dimensions such as the education and training of the consultee, the type of setting, number of years in practice, and proximity to available consultants. In this article, we review the research on the use of consultation by psychologists as well as other health care professionals. We discuss the clinical, ethical, and legal implications of seeking consultation as a professional psychologist. Finally, a detailed and practical model for the regular use of consultation is given to improve the routine use of consultation in clinical practice.     

The Collaborative Assessment and Management of Suicidality (CAMS): An Evolving Evidence‐Based Clinical Approach to Suicidal Risk

The Collaborative Assessment and Management of Suicidality (CAMS) is an evidence‐based clinical intervention that has significantly evolved over 25 years of clinical research. CAMS is best understood as a therapeutic framework that emphasizes a unique collaborative assessment and treatment planning process between the suicidal patient and clinician. This process is designed to enhance the therapeutic alliance and increase treatment motivation in the suicidal patient. Central to the CAMS approach is the use of the Suicide Status Form (SSF), which is a multipurpose clinical assessment, treatment planning, tracking, and outcome tool. The original development of CAMS was largely rooted in SSF‐based quantitative and qualitative assessment of suicidal risk. As this line of research progressed, CAMS emerged as a problem‐focused clinical intervention that is designed to target and treat suicidal “drivers” and ultimately eliminate suicidal coping. To date, CAMS (and the clinical use of the SSF) has been supported by six published correlational studies and one randomized clinical trial (RCT). Currently, two well‐powered RCTs are under way, and various new CAMS‐related projects are also being pursued. The clinical and empirical evolution of CAMS—how it was developed and what are the next steps for this clinical approach–are described here.     

The suicidal mode: a cognitive-behavioral model of suicidality

This article discusses the theoretical foundation and potential clinical application of the suicidal mode, a cognitive behavioral theory of suicidality. The model presented represents a specific elaboration of Beck's modal theory of psychopathology. In addition to discussing the fundamental requirements of a theory of suicidality, the theoretical assumptions of the suicidal mode are identified, its component parts defined, its inherent strengths emphasized, and its application in clinical settings detailed. Definition of a modal theory of suicidality represents the growing influence of cognitive-behavioral theory in efforts at psychotherapeutic integration in clinical suicidology.     

A cultural look on suicide: the Yorùbá as a paradigmatic example

This conceptual review focuses on deepening the cultural perspective on suicidal behaviour and suicide prevention using a specific cultural group (the Yorùbá) as a paradigmatic example. We examine the social/cultural cognitions in Yorùbá that are ingrained in concepts of dishonour, shame, and masculine ethos, and the way these may contribute to the phenomenology of suicidal behaviours in Yorùbá communities. We also addressed the limitations of some widely accepted frameworks in suicide research, in particular, the emphasis on neurobiological conditions as risk factor for suicidal behaviour and the focus on hopelessness as a specific (social) cognition that leads to suicidal volition. Lessons learnt include the possibility of specific “culture-bound” cognitive motivators for suicidal behaviours among the Yorùbá which may be unrecognised but potentially rewarding focus of cognitive-behavioural therapy and other prevention strategies. A general need for contextualised application of universal suicidology research findings when working in specific socio-cultural milieu is emphasised.     

Rebuilding the tower of Babel: a revised nomenclature for the study of suicide and suicidal behaviors. Part 2: Suicide-related ideations, communications, and behaviors

A revised and refined version of the O'Carroll et al. (1996) nomenclature for suicidology is presented, with a focus on suicide‐related ideations, communications, and behaviors. The hope is that this refinement will result in the development of operational definitions and field testing of this nomenclature in clinical and research settings. This revision would not have been possible without the international collaboration and dialogue addressing the nomenclature of suicidology since the O'Carroll et al. nomenclature appeared in 1996. Although it is doubtful that we will ever be able to construct universally unambiguous criteria to comprehensively characterize suicidal behaviors (and, overall, firmly establish the intention behind them), for scientific clarity it would be highly desirable that the set of definitions and the associated terminology be explicit and generalizable. De Leo, Burgis, Bertolote, Kerkhof, & Bille‐Brahe, 2006 , p. 5)     

The clinical psychologist as program consultant: When is enough enough?

One of the most influential roles clinical psychologists play in health care settings is as consultant to medical colleagues. The psychologist consultant typically approaches either clinical or programmatic questions intending to tap both empirical research and clinical judgment perspectives in trying to answer them. This paper describes a specific “program consultation case,” a not atypical consultation situation in which graduate medical education directors asked for advice about their residency training program. The purpose is to use this example to generate ideas and provoke discussion about such consultation processes and their usefulness in the health care training and service delivery world. The psychologist may be faced with questions that have meaningful implications beyond the specific consultation. What if the concerns being posed by this particular program are concerns which have been raised before, have been researched before, and have generated reasonable suggestions, conclusions, and strategies for improvement? And what if no one has paid attention, so that the questions are being raised again? When empirical and clinical data consistently combine to identify problems within health-related training or service delivery systems, and when suggestions or alternatives for their solutions have been presented and, also presumably, ignored, what does the clinical psychologist consultant do next?     

The CAMS Approach to Working with Suicidal Patients

The Collaborative Assessment and Management of Suicidality (CAMS) is a novel clinical protocol designed to quickly identify and effectively engage suicidal outpatients in their own clinical care. The CAMS approach emphasizes a thorough and collaborative assessment of the patient's suicidality that then leads to problem-solving treatment planning that is coauthored by the clinician and the patient. This approach is specifically designed to launch a strong therapeutic alliance creating an effective treatment trajectory. The CAMS approach is designed to modify and change clinician behaviors in terms of how they initially identify, engage, conceptualize, assess, treatment plan, and manage suicidal outpatients. Critically, however, CAMS does not usurp clinical judgment or dictate treatment modality. Preliminary research has shown that CAMS leads to faster resolution of suicidality and may decrease nonmental health medical utilization. Given the challenges of clinical work with suicidality, increased concerns about malpractice liability, and the decreased use of inpatient hospitalization, CAMS provides a potentially important new approach to working with suicidal individuals on an outpatient basis.     

Clinical trials for rapid changes in suicidal ideation: Lessons from ketamine

Rapid‐acting treatments for suicidal thoughts are critically needed. Consequently, there is a burgeoning literature exploring psychotherapeutic, pharmacologic, or device‐based brief interventions for suicidal thoughts characterized by a rapid onset of action. Not only do these innovative treatments have potentially important clinical benefits to patient populations, they also highlight a number of methodological considerations for suicide research. First, while most clinical trials related to suicide risk focus on suicide attempts, new clinical trials that use suicidal thoughts as the primary outcome require a number of slight modifications to their clinical trial design. Second, the rapid onset of these new interventions permits an experimental therapeutics approach to suicide research, in which psychological and neurobiological markers are embedded into clinical trials to better understand the underlying pathophysiology of suicidal thoughts. The following review discusses these methodological innovations in light of recent research using the N‐methyl‐D‐aspartate (NMDA) receptor antagonist ketamine, which has been associated with rapid effects on suicidal thoughts. We hope that “lessons learned” from the ketamine literature will provide a blueprint for all researchers evaluating rapid‐acting treatments for suicidal thoughts, whether pharmacologic or psychotherapeutic.     

Suicide prevention in the genetic counseling context

Utilizing a case report, this paper explores psychosocial aspects of suicidal intent in a woman seeking prenatal diagnosis. Using knowledge and practice of appropriate assessment, referral, and intervention procedures, the therapy team of genetic counselor and psychotherapist facilitated successful identification and management of this potentially suicidal client. The main counseling goals for the genetic counselor are to assess the situation adequately, decrease the immediate danger, and, with supervision and/or consultation, stabilize the seriously suicidal person until that individual can be triaged to mental health or medical professionals for treatment. The prevalence of suicide issues in genetic counseling contexts is unknown and reports mentioning suicidal ideation unusual in the genetic counseling literature. Is this reported case a rarity among genetic counseling referrals? Systematically collected information on the prevalence and resolution of suicidal issues in genetic counseling contexts would be helpful for those setting curricula for genetic counseling training programs, standards for professional certification exams, and policy and procedures manuals for clinical units.