Winter 2024 Issue

Education in Suicide Prevention
By Kathryn Miller-Procknal, LCSW
Social Work Today
Vol. 24 No. 1 P. 18

Suicide, or the act of intentionally causing one’s own death, is among the top 10 leading causes of death in the United States and the second leading cause of death for individuals ages 10 through 14 and 20 through 34. In 2022, the overall suicide rate increased by 2.6% nationally.1 The COVID-19 pandemic appears to have increased death by suicide rates for youth, specifically over the first several months of the pandemic.2 During the last 10 years, rates of suicide have fluctuated slightly but have not seen dramatic declines despite a multitude of interventions aimed at reduction.

There are many theories that aim to explain the occurrence of suicide and the variables influencing suicidal behaviors. These theories include, but are not limited to, the cognitive behavioral theory of suicidality, the interpersonal theory of suicide, the schematic appraisals model of suicide, the biological model (circuits implicated) of suicide, the theoretical model of suicidal behavior in borderline personality disorder, the rational theory of suicide, and the integrated-motivational-volitional model of suicidal behavior.3 Although these theories are supported by current research evidence, no single theory can fully explain the occurrence of suicide or explain its persistence over time.

Suicide: A Wicked Problem
Suicide, then, is not a single factor problem but a wicked social problem. Wicked problems are defined by their complexities, often being difficult to define, difficult to frame, and even more difficult to solve. These problems often have multiple solutions, and no single solution is able to solve the problems entirely.4 Solving wicked problems like suicide requires the efforts of multiple stakeholders from across various professions and disciplines.

In the field of mental health, social workers play a critical role in the prevention of suicide. They make up a substantial percentage of the workforce across community, outpatient, and in-patient settings. Therefore, they have significant access to clients presenting with suicidal ideation and crisis. In one study, 55% of clinical social workers had a client on their caseload who had attempted suicide. In that same study, 31% of social workers reported that they worked with a client who ultimately died by suicide.5 Additional research indicates that one-third of victims of suicide had contact with mental health services within one year of their death.6 Yet, social work students are not well prepared to address suicidal ideations with their clients due to lack of suicide-specific courses and content in their graduate work.7-9

Challenges in Teaching and Training
In 2022, of the CSWE-accredited social work programs in the United States, only 6% of programs require a suicide-specific course, 13.9% offer an elective specific to suicide-related content, and 25.2% offer courses that report a “substantial” amount of suicide-related content.10 In a web-based survey of 598 social workers, 79% of social workers reported they did not receive formal training in suicide-related content in their MSW programs.8 Additional research indicates that MSW students typically receive less than four hours of education about suicide in their graduate studies.9

Lack of exposure to didactic lectures, role-play, and simulation experiences related to working with suicidal clients is detrimental to MSW students’ ability to serve clients struggling with thoughts of suicide or suicide-related behaviors. This lack of education is in part due to barriers identified by faculty within MSW programs. Faculty report that there are significant obstacles to teaching suicide-specific content, such as lack of faculty expertise, crowded curricula, and other educational priorities.9 Additionally, some faculty report that there are few supports for teaching students about suicide, beliefs that suicide content was covered in other courses, and a general lack of time in the semester to teach suicide-specific content. Lack of expertise and resources are also barriers to teaching up-to-date suicide-related content. In some instances, faculty were found to be teaching students to complete outdated and ineffective “no suicide” contracts to prevent suicide.11 These “no suicide” contracts are a relic of treatments of the past, which are known to be ineffective in preventing suicide. Teaching outdated or ineffective interventions can be explained in part by a general lack of research being conducted by social workers in the field of suicidology and the scarcity of articles addressing the development of effective antisuicide interventions. 12 When students and faculty are not focusing on suicide-related content in the classroom, less interest is generated by students and faculty in the subject, and less research is being focused on suicide within the profession.12

In the instances when faculty are reporting levels of confidence and ability in suicide prevention and intervention-related content, didactic/lecture-based education is most common among MSW faculty, and assessment of skills is less common.13 Although didactic lecture can help students gain a basic understanding of theories, risk factors, protective factors, and statistics about suicide, it cannot provide assessment of skill development among students. Students are not often tested or graded on their actual skills in suicide risk assessment, safety planning, or crisis prevention. This is a significant barrier to students feeling confident and capable in the assessment of suicide risk.

Due in part to limited comprehensive educational opportunities in suicidology at the MSW level, social work students have limited knowledge about suicide assessment, intervention, and prevention. In one study surveying students about their knowledge of suicide prevention and attitudes toward working with clients with suicidal ideation, students rated an average of 77% on declarative knowledge of suicide, and a majority of students reported they would prefer not to work with clients who have suicidal ideation.14 MSW students report being open and receptive to suicide-related content/materials within the curricula and wonder why students are not required to take suicide-related content in their studies.15

Social work students frequently report that they experience high levels of anxiety related to working with clients who have suicidal ideation.16 When professionals are not prepared or ill prepared for work with clients with suicidality, stress increases for the professional/student, ultimately increasing provider anxiety and negatively affecting clients.17 This anxiety is exacerbated when students do not have adequate training in the assessment, treatment, and prevention of suicide.

Psychology programs at the graduate level are also struggling to adequately address the issue of suicide. Evidence from several studies over the last decade continues to identify that suicide-related content is covered on a limited basis across programs.18 Within the programs that are teaching content about suicide, didactic lectures remain the most common form of education about suicide prevention, assessment, and intervention.19 Although didactic lecture can be a good starting point in exposing students to the warning signs, protective factors, and theory of suicide, it does little in the way of preparing students to do formal suicide risk assessments. When suicide content is not covered in lecture, many programs rely on the practicum and internship experiences of their students to provide suicide-specific training. This can be counterproductive for both students and clients, as they report feeling unprepared to work with these clients in practice. Psychology students, therefore, continue to report significant need for additional skill development at the graduate level in working with clients experiencing suicidal ideation and crisis.20

Social work and psychology students are key stakeholders in the fight against suicide due to their relationship with the mental health field, but there are several other disciplines that need to be included in the efforts to prevent, assess, and intervene against suicide. Medical professionals, including doctors, nurses, and physical therapists, are on the front lines of service, often working with people who experience suicidal ideation. Since the COVID-19 pandemic, these professions have seen an increasing number of individuals in acute crisis with significant unmet basic needs.

Due to these increasing needs, primary care, physician assistant, nursing, and physical therapy students are critically important persons in the suicide prevention community. In one report, 50% of those who die by suicide will have seen their primary care physician in the month before their death.6 This highlights that a significant number of individuals struggling with suicidal ideation have contact with a medical professional prior to their attempt. Yet, there are serious gaps in the training of primary care specialties, nursing, and other physical health professions. Students report a lack of preparedness in how to work with and intervene on behalf of clients experiencing a suicidal crisis.21,22 There’s little evidence that medical providers are being adequately trained while in their graduate school programs to assess and intervene in a suicide crisis, despite working with high-risk populations (the chronically ill, individuals with chronic pain, and those with comorbid health and mental health disorders).23

Of those clinical social workers, psychologists, and medical professionals who do address suicide, many work on a micro- or individual level. This can include counseling, medication support, substance use treatment, and many other personalized treatments aimed at addressing underlying medical or mental health concerns contributing to suicidal thoughts and behaviors. Micro-level interventions typically support a single client or family who is struggling. This level of intervention is critically important to decrease suicide rates but cannot tackle the problem completely.

Mezzo- and macro-level interventions are also necessary for suicide prevention. Mezzo- and macro-level interventions include groups, communities, and state or national initiatives. These are often aimed at public health campaigns, community means reduction measures, procurement of necessary funding for mental health, and other suicide prevention initiatives on the community, state, national, and global scale. When considering mezzo- or macro-interventions, mental health and physical health professionals cannot be the only individuals addressing suicide. Educators, behavior analysts, persons in politics and government, and public health officials play a critical role in suicide prevention in our schools and communities. Unfortunately, while in their graduate level education, professional students in these areas are not well trained to address the issue of suicide. Suicide can often be seen as out of the scope of their profession, but wicked problems like suicide will take new ideas to solve. These new ideas cannot be isolated to the field of mental health or medicine and must include the insights of persons looking at the problem from new perspectives and in new ways.

Simulation-Based Learning for Suicide Prevention
As the rates of suicide are increasing nationally, it’s more imperative than ever to build multidisciplinary teams to tackle this wicked problem. Exposing students to suicide specific content in graduate level courses can help significantly in diversifying the types of professionals engaging in dialogue, research, scholarship, and practice in this area. Yet, this exposure must go beyond didactic/lecture-based training and bring new and emerging technologies and practices into the classroom.

Simulation-based learning has been shown to improve student outcomes in suicide assessment and prevention, increase the likelihood of skill acquisition, and improve student perspectives on preparedness to conduct risk assessments.24 In simulation-based learning exercises, students have the opportunity to work with actors or fellow classmates to simulate real life scenarios they will experience when actively working with clients, groups, or communities. These opportunities, when done well, allow students to practice suicide assessment and intervention and receive feedback on their interactions. Students have reported finding these exercises helpful in skill acquisition and decreasing anxiety when working with clients who are reporting thoughts of suicide.24 Increasing access to simulation-based learning opportunities is not only helpful for each discipline independently but is also an innovative way to begin meaningful dialogue and collaboration between students from different backgrounds.25 In this type of educational format, students from different disciplines can work together to use skills and tools from each of their respective backgrounds to address suicide.

Simulation-based learning opportunities have the benefit of allowing students to work with clients, groups, and communities from diverse backgrounds and experiences. Working with actors in a simulation allows students to explore working with persons and groups that are different from them in terms of race, religion, gender, sexual orientation, gender expression, age, or ability status. This then allows for critical feedback and dialog in their work with diverse groups. In professions like social work, psychology, medicine, education, and public office, cultural competence and cultural humility are essential to effective practice. Simulation-based learning opportunities allow students to work with diverse groups and client populations and then receive feedback from each other and their professors on how to improve their communication and interventions with these groups.26 This practice is essential for students to grow and learn in suicide prevention. Students can explore suicide assessment, intervention, and prevention from a place of cultural humility. It also allows students to reflect and correct potential bias, prejudice, or faulty beliefs about how persons or groups may experience suicide crisis.

Wicked problems like suicide are complex, and addressing them will require the minds of persons from diverse perspectives. Interdisciplinary collaboration can help students see the complexities of suicide more clearly and work together to identify risk factors, protective factors, key assessment needs, and, ultimately, treat suicide more holistically.27 Exposure to this type of interdisciplinary work while in graduate programs can also increase skill and ability to engage in interdisciplinary work in practice. To grow a workforce competent in suicide prevention and intervention requires a conscious and committed effort in training new generations of professionals across disciplines. Targeted content about suicide in graduate level courses and opportunities for cross discipline simulation-based learning can be just one way to tackle the wicked problem of suicide.

— Kathryn Miller-Procknal, LCSW, is an assistant professor of social work and sociology at Daemen University in Buffalo, New York. Her research interests include suicidology, the use of behavior analytic tools in social work practice, and interdisciplinary collaborations. She continues to work as a licensed clinical social worker in crisis prevention and intervention programs in her community.

References
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