The Impact of a Suicide Training Program on Master’s Level Counseling Students’ Level of Perceived Self-Efficacy

by

Nicole L. Black, MEd, LPC, LCDC

A Dissertation

In

Counselor Education

Submitted to the Graduate Faculty of Texas Tech University in Partial Fulfillment of the Requirements for the Degree of

DOCTOR OF PHILOSOPHY

Approved

Charles Crews, PhD Chair of Committee

Bret Hendricks, EdD

Stacy Carter, PhD

Mark Sheridan Dean of the Graduate School

May, 2017

Copyright, 2017, Nicole L. Black

Texas Tech University, Nicole L. Black, May 2017

DEDICATION

This dissertation is dedicated to my mother and all others who have been lost to

suicide. Mom, this is my meaning-making chapter for you.

ii Texas Tech University, Nicole L. Black, May 2017

ACKNOWLEDGEMENTS

First, I would like to thank my Heavenly Father for instilling me with a tenacious heart and the strength to withstand everything this life has handed me. Thank you for providing me with the resilience and perseverance to make meaning out of my life’s struggles. Thank you for carrying me through the past year. It is my life’s work to make meaning out of all the hardships that I have experienced. To You I give the glory.

To my late husband Trevor, you were my rock and my soft place to land. You helped push me through this dissertation and encouraged me every step of the way.

Thank you for the love that you gave me and the strength that it created. To our beautiful son Hayes, know that everything I have done in life has been with you in mind, even before you came into existence. You are my source of strength when life proves to be too heavy. When life becomes too much for you, remember how strong you are. You have already proven to be such a strong soul even in your tender infancy. To my niece, Olivia,

I love you, Baby Girl. I am fighting for you and I am here for you always. You will always have me here to support you and love you. I am thankful that you are here as our reminder of your mother.

I would also like to thank my professors who helped me through this academic endeavor. To my chair, Dr. Crews, thank you for making yourself available to be a mentor throughout this process and throughout my higher education. Dr. Hendricks, thank you for your leadership and for showing me how to be a leader in our profession.

The assistance from both of you has been tremendous. Dr. Carter, thank you for stepping in and being the methodologist on my dissertation and for your guidance. Dr. Froeschle-

Hicks, thank you for your guidance, kindness, and mentorship throughout my higher iii Texas Tech University, Nicole L. Black, May 2017 education. Also, thank you to the staff at the Dissertation Support Center. Dr. Lancaster,

Dr. Schmidt, and Ms. Shelton, I could not have done this without you. It is a daunting task to write a dissertation, and your support was invaluable through the process. I would have been utterly lost without each of you.

Lastly, I would like to thank my tribe; you know who you are. The last year has been unreal. Each of you has carried me through and strengthened me through a year full of trials, grief, and loss. Thank you to my in-laws, Louis and Laura, and my uncle Allan.

You stepped into a parental role and are invaluable to me. Thank you to my grandparents, Richard and Doris Hickner. You invested in my education at a young age and always encouraged me to pursue a higher education. My education has been my saving grace in so many ways. Thank you.

iv Texas Tech University, Nicole L. Black, May 2017

TABLE OF CONTENTS

DEDICATION...... ii ACKNOWLEDGEMENTS ...... iii ABSTRACT ...... ix LIST OF TABLES ...... x LIST OF FIGURES ...... xi I. INTRODUCTION ...... 1 Overview of the Study ...... 1 Statement of the Problem ...... 1 Significance of the Study ...... 3 Purpose of the Study ...... 5 Null Hypotheses ...... 6 Definitions of Terms ...... 7 Summary ...... 9 II. REVIEW OF THE LITERATURE ...... 10 Crisis Theory ...... 10 Psychological First Aid ...... 11 Crisis of Suicidality ...... 12 History of Suicide ...... 12 Theoretical Models ...... 13 Suicide Prevention ...... 13 Suicide Intervention ...... 15 Suicide Postvention ...... 16 Suicide Risk Assessment ...... 16 Checklists ...... 17 Frameworks ...... 18 Models ...... 22 Core Competencies for Suicide Risk Assessment ...... 26 Domain 1: Attitudes and Approaches ...... 26 Domain 2: Understanding Suicide ...... 27

v Texas Tech University, Nicole L. Black, May 2017

Domain 3: Collecting Accurate Assessment Information ...... 27 Domain 4: Formulating Risk ...... 27 Domain 5: Developing a Treatment and Service Plan ...... 28 Domain 6: Managing Care ...... 28 Domain 7: Documenting ...... 28 Domain 8: Understanding Legal and Regulatory Issues Related to Suicide ...... 29 Suicide Assessment Training Programs ...... 29 Self-Concept ...... 38 Self-Efficacy ...... 39 Enactive Mastery Experience ...... 40 Vicarious Experiences ...... 40 Verbal Persuasion ...... 41 Psychological and Affective State ...... 41 Counselor Self-Efficacy ...... 42 Counseling Skills ...... 42 Counselor Self-Efficacy and Suicide Assessment ...... 45 Counselor Education and Self-Efficacy ...... 46 Summary ...... 48 III. RESEARCH METHODOLOGY...... 50 Overview ...... 50 Null Hypotheses ...... 50 Setting up the Study ...... 51 Participants ...... 52 Materials ...... 52 Instrumentation ...... 53 Counselor’s Self-Efficacy Scale ...... 53 Demographic Survey ...... 55 Qualitative Question ...... 55 Design ...... 56 Procedure...... 56 Recruiting ...... 56

vi Texas Tech University, Nicole L. Black, May 2017

Suicide Educational Training ...... 57 Data Analysis ...... 62 Potential Limitations ...... 63 Delimitations ...... 63 Assumptions ...... 64 Summary ...... 64 IV. RESULTS ...... 65 Research Design ...... 65 Descriptive Statistics of Demographic Data ...... 66 Level of Comfort ...... 67 Prior Experience ...... 68 Prior Education ...... 70 Descriptive Statistics of the Counselor’s Self-Efficacy Scale ...... 73 Scoring Scale ...... 73 Null Hypothesis Testing ...... 73 Results ...... 77 Qualitative Data ...... 80 Qualitative Question A ...... 81 Qualitative Question B ...... 85 Summary ...... 87 V. FINDINGS ...... 89 Summary ...... 89 Discussion of the Findings ...... 90 Descriptive Statistics of Demographic Data ...... 91 Null Hypotheses ...... 92 Qualitative Questions ...... 96 Implications for Delivery of Information ...... 97 Implications for CACREP ...... 98 Implications for Counselor Education ...... 102 Ensuring Student Competency ...... 102 Ensuring Student Comfort ...... 106 vii Texas Tech University, Nicole L. Black, May 2017

Content of Suicide Training ...... 107 Limitations of the Study ...... 109 Delimitations ...... 111 Recommendations for Future Research ...... 111 Conclusion ...... 116 REFERENCES ...... 117 APPENDICES ...... 124 Counselor’s Crisis Self-Efficacy Scale ...... 124 Demographic Form ...... 129 IRB Approval ...... 130 Module References...... 131 Risk Assessment Form ...... 135 Visual Representations of Null Hypotheses Results ...... 137

viii Texas Tech University, Nicole L. Black, May 2017

ABSTRACT

Counselors are faced with the risk of client suicide frequently throughout their careers.

The skills needed to assess a suicidal client are imperative for future counselors. This study focused on determining changes in self-efficacy amongst master’s level counseling students based on a training program that educated them on how to assess suicide. This study aimed to analyze changes in self-efficacy among participants as measured by the

Counselor’s Self-Efficacy Scale (CSES) and participants’ changes in comfort assessing suicidal clients. Data obtained from a treatment and control group were analyzed using a

Mixed Design ANOVA and showed significant changes on the CSES for the treatment group. Two qualitative research questions supplemented quantitative research findings to provide further understanding. Findings from this study have implications for the education of suicide assessment within counseling programs. This study provided a foundation for educating future counselors on suicide assessment through in person and online educational means.

Keywords: Counselor Education, suicide, counseling, counselor, suicide

assessment, self-efficacy, counselor self-efficacy, crisis

ix Texas Tech University, Nicole L. Black, May 2017

LIST OF TABLES

1: Comfort Assessing Suicidal Client ...... 68

2: Demographic Data ...... 71

3: Master’s Courses that Taught Suicide Assessment ...... 71

4: Chi Square of Comfort and Formal Education on Suicide ...... 72

5: Treatment Group Descriptives ...... 75

6: Control Group Descriptives ...... 76

7: Test of Within Subject Effects ...... 77

8: Theme 1 - Questions to Ask ...... 81

9: Theme 2 - How to do Risk Assessment ...... 82

10: Theme 3 - Risk Factors ...... 83

11: Theme 4 - Documentation ...... 84

12: Theme 5 - Laws and Ethics...... 84

13: Theme 6 - Resources...... 85

x Texas Tech University, Nicole L. Black, May 2017

LIST OF FIGURES

1: Means for CSES Subscale 1 ...... 137

2: Means for CSES Subsale 2...... 137

3: Means for CSES Subscale 4 ...... 138

4 Means for CSES Subscale 3 ...... 138

5: Means for CSES Total Scale ...... 139

xi Texas Tech University, Nicole L. Black, May 2017

CHAPTER I INTRODUCTION

Overview of the Study

The World Health Organization reported that suicide rates have increased by 60% in the past 50 years (2007). In addition, the Center for Disease Control (CDC) 2015 statistics indicated that suicide was the tenth leading cause of death among all ages; however, it is the second leading cause of death for those ages 10-34 (CDC, 2015,

Suicide). Statistics released by the American Association of Suicidology indicated that someone completes suicide every thirteen minutes in the United States; furthermore, there is a ratio of 25 attempted suicides for every one completed suicide in the United

States (2014c).

Statement of the Problem

Because the number of suicides and attempted suicides in the United States has increased over the past 50 years, counselors in all settings, whether clinical mental health or school, have an increased likelihood of working with clients who may experience suicidal ideations. In fact, a high percentage of counselors have reported experiencing this likelihood of clients with suicidal ideations. In a random sample of members of the

American Mental Health Counselors Association, 71% of counselors reported that they have worked with a client who has attempted suicide, and 28% of counselors had a client who completed suicide (Rogers, Gueulette, Abbey-Hines, Carney, & Werth, 2001).

There is an additional concern for clinical mental health and school counselors who are working with youths because the CDC reported that suicide is the second leading cause of death in those ages 10-34 (CDC, 2015). Because suicide is such a concern with the 1 Texas Tech University, Nicole L. Black, May 2017 youth population, school counselors should be as equally concerned as clinical mental health counselors. In a study on school counselors, only 52% of the counselors knew to ask a student why he or she was feeling suicidal (King, Price, Telljohann, & Wahl, 2000).

As these examples suggest, there is a growing need for the increased education on suicide statistics and appropriate interventions for counselors both in the community and in schools.

To address the need for better and more training in suicide intervention, the

Council for Accreditation of Counseling and Related Educational Programs (CACREP) called for the infusion of crisis education into counseling program curriculum in their

2016 CACREP Standards. In their standards, they require that CACREP accredited programs teach about suicide within “Counseling and Helping Relationships” and

“Assessment and Testing.” The standards state that CACREP programs must include

“suicide prevention models and strategies,” “crisis intervention, trauma informed, and community-based strategies, such as Psychological First Aid,” and “procedures for assessing risk of aggression or danger to others, self-inflicted harm, or suicide” into their programs (“2016 CACREP Standards”, 2016, p.12). Furthermore CACREP standards for

Clinical Mental Health Counseling programs dictate that curriculum should cover the

“impact of crisis and trauma on individuals with mental health diagnoses”, “legislation and government policy” and “legal and ethical considerations specific to clinical mental health counseling” (“2016 CACREP Standards”, 2016, p.23). All of these topics are important aspects of suicide assessment education for counselor students.

Despite these new standards by CACREP, many counselors are still ill-prepared in crisis preparation including suicide intervention, as Morris and Minton’s study has 2 Texas Tech University, Nicole L. Black, May 2017 shown: In a study of 193 professional counselors who had completed their counseling degree within two years and who were currently employed, only 20.73% of participants reported completing a crisis intervention course (Morris & Minton, 2012). Of the population assessed, 26.95% of participants reported “no preparation” or “minimal preparation” in suicide assessment, and 36.27% reported “no preparation” or “minimal preparation” in suicide management and intervention. Furthermore, 82.90% of participants reported a client experiencing suicidal ideations, and 59.07% reported a client experiencing suicidal behavior during this field experience as a master’s student

(Morris & Minton, 2012). As stated by the authors, this level of preparation is

“unacceptably low” when preparing future counselors on suicide intervention (Morris &

Minton, 2012). Currently (as of December 21, 2016), only seventeen different university locations in this southern state offer a counseling program that is CACREP accredited

(“Directory,” 2016). All other programs within the state do not have to abide by the

CACREP standards that require education on crisis and suicide intervention because these programs are either not accredited at all or have some accreditation other than

CACREP. Currently these CACREP standards call only for the infusing of crisis education and do not prescribe a specific method or procedure for implementation. There is a need for a program that will inform counseling students on suicide intervention that is based on best practice and research. Furthermore, this intervention program should be accessible and evidenced based.

Significance of the Study

Currently, counseling students may access a variety of resources (not all accredited, however) to educate themselves on suicide intervention. The resources are 3 Texas Tech University, Nicole L. Black, May 2017 available in a variety of mediums, including online trainings, books, conferences, workshops, and continuing education opportunities. However, it may be difficult for students to navigate all of these resources and locate one that is evidenced-based and relevant to their roles as future mental health counselors within certain states. Two primary resources for evidenced-based information on suicide include the American

Association of Suicidology and the Suicide Prevention Resource Center. Both of these programs have expanded educational opportunities available to the public; however, they are not accessible to students in the classroom and would require participants to attend often-expensive face-to-face programs.

The American Association of Suicidology offers a suicide intervention-training program for clinicians that includes a two-day, in-person workshop, web-based assessment, evidenced-based curriculum, and manuals that are presented in a live face-to- face training format (2014b). However, this training is costly and not time efficient for students enrolled in their master’s programs (American Association of Suicidology,

2014b). Likewise, the Suicide Prevention Resource Center offers a suicide intervention training program (“SPRC Training Institute,” 2014). However, it requires students to pay to host a trainer to come to them and is not cost effective for counseling programs to be able to provide the training to each of their students.

Pisani, Cross, and Gould (2011) conducted a review of the literature on current programs that provided suicide intervention education to mental health professionals.

Interventions discussed in this literature review included the “Air Force Guide for

Managing Suicidal Behavior (AF’s MSB),” “Question, Persuade, Refer, Treat (QPRT),” and “Risk Assessment Workshop” (Pisani, Cross, & Gould, 2011). These programs were 4 Texas Tech University, Nicole L. Black, May 2017 offered in a variety of settings with various learning formats. Each provided a different set of benefits or weaknesses. However, each of these programs covered all eight domains of Suicide Core Competencies ascribed by the Suicide Prevention Resource

Center.

Other options for training may be found through educational videos online through various providers such as PESI, Inc. (2014). However, these online videos do not allow for synchronous interactions with the participants, such as a face-to-face class would, nor do they provide evidence of validity obtained through pretest and posttest assessments. Lastly, these programs cannot be updated and do not reflect the mental health codes within each individual state (PESI, Inc., 2014).

Due to the current lack of access to up-to-date, evidence-based suicide intervention, there is a need to develop a training course that may fill this void. Based on a review of the suicide intervention trainings available, a training program that is based on best practices and current statistics is missing and needed. In addition, this training course should be available for students in class and should be assessed for effectiveness and validity by completing pretest and posttest assessments.

Purpose of the Study

To address the need for better and increased training in suicide intervention and the constraints of access to existing accredited CACREP programs, this current study examined the changes in self-efficacy amongst participants. An in-class training course on suicide intervention was provided for master’s level students who are enrolled in a counseling program either through a 60-hour clinical mental health counselor tract or a

5 Texas Tech University, Nicole L. Black, May 2017

48-hour school counseling tract program. This current study examined any changes related to perceived self-efficacy for the following: crisis situations, basic counseling skills, therapeutic response to crisis and post-crisis, and unconditional positive regard. In addition, the current study examined differences in abilities among counseling students with varying levels of educational and practicum or internship experience. This current study may provide further understanding of education for master’s level counseling students and may lead to the development of an educational training course on suicide intervention that can be accessed by students within their master’s level program.

Null Hypotheses

Null Hypothesis A. There will be no significant difference between the mean pretest and mean posttest scores of students in the experimental group and control group in self-efficacy in crisis situations, measured by the Counselor’s Self-Efficacy Scale.

Null Hypothesis B. There will be no significant difference between the mean pretest and mean posttest scores of students in the experimental group and control group in self-efficacy in basic counseling skills, as measured by the Counselor’s Self-Efficacy

Scale.

Null Hypothesis C. There will be no significant difference between the mean pretest and mean posttest scores of students in the experimental group and control group in self-efficacy in therapeutic response in crisis and post crisis, as measured by the

Counselor’s Self-Efficacy Scale.

Null Hypothesis D. There will be no significant difference between the mean pretest and mean posttest scores of students in the experimental group and control group

6 Texas Tech University, Nicole L. Black, May 2017 in self-efficacy in unconditional positive regard, as measured by the Counselor’s Self-

Efficacy Scale.

Null Hypothesis E. There will be no significant difference between the mean pretest and mean posttest scores of students in the experimental group and control group in self-efficacy, as measured by the total score of the Counselor’s Self-Efficacy Scale.

Qualitative Question A: What have you learned about suicide risk factors?

Definitions of Terms

The following terms are used in this dissertation and are defined as follows:

Comfort: “A state or feeling of being less worried, upset, frightened, etc., during a time of trouble or emotional pain” (Merriam-Webster, 2016a).

Intervention: “A strategy or approach that is intended to prevent an outcome or to alter the course of an existing condition (such as providing Lithium for Bipolar

Disorders, educating providers about suicide prevention, or reducing access to lethal means among individuals with suicide risk)” (U.S. Department of Health and Human

Services, 2012, p.14).

Means: “The instrument or object used to carry out a self-destructive act (e.g., chemicals, medications, illicit drugs)” (U.S. Department of Health and Human Services,

2012, p.14).

Protective factors: “A characteristic at the biological, psychological, family, or community (including peers and culture) level that is associated with a lower likelihood

7 Texas Tech University, Nicole L. Black, May 2017 of problem outcomes or that reduces the negative impact of a risk factor on problem outcomes” (National Research Council and Institute of Medicine, 2009, p. xxvii).

Risk factors: A characteristic at the biological, psychological, family, community, or cultural level that precedes and is associated with a higher likelihood of problem outcomes” (National Research Council and Institute of Medicine, p. xxviii).

Self-efficacy: “Beliefs in one’s capabilities to organize and execute the courses of action required to produce given attainments” (Bandura, 1997, p. 3).

Suicidality: “The likelihood of an individual completing suicide” (“Suicidality,”

2012).

Suicide: “Death caused by self-directed injurious behavior with any intent to die as a result of that behavior” (U.S. Department of Health and Human Services, 2012, p.14).

Suicide attempt: “A nonfatal, self-directed, potentially injurious behavior with any intent to die as a result of that behavior. A suicide attempt may or may not result in injury” (U.S. Department of Health and Human Services, 2012, p.14).

Suicidal gesture or behaviors: “Acts and/or preparation toward making a suicide attempt, suicide attempts, and deaths by suicide” (U.S. Department of Health and Human

Services, 2012, p.14).

Suicidal ideations: “Thoughts of engaging in suicide-related behavior” (U.S.

Department of Health and Human Services, 2012, p.14).

8 Texas Tech University, Nicole L. Black, May 2017

Suicidal intent: “Evidence (explicit and/or implicit) that at the time of injury the individual intended to kill him or herself or wished to die and that the individual understood the probable consequences of his or her actions” (U.S. Department of Health and Human Services, 2012, p.14).

Suicidal plan: “A thought regarding a self-initiated action that facilitates self- harm behavior or a suicide attempt; often including an organized manner of engaging in suicidal behavior such as a description of a time frame and method” (U.S. Department of

Health and Human Services, 2012, p.14).

Summary

This dissertation will include a review of the pertinent literature on suicide assessment and intervention in Chapter 2 followed by a description of the methods used for this study. Chapter 4 will describe the testing results for the research null hypotheses analyzed during this process, and Chapter 5 will include a discussion of the findings and their implications for the practice and education in the field of counseling as well as limitations and recommendations for future research.

9 Texas Tech University, Nicole L. Black, May 2017

CHAPTER II REVIEW OF THE LITERATURE

The assessment of suicidality is a complex and imperative skill for professional counselors to obtain. It is of the utmost importance that counselor educators promote a sense of self-efficacy within students when it comes to their suicide assessment skills.

This is imperative because suicides are so prevalent, and counselors must feel capable of intervening effectively with suicidal clients. Suicide assessment is complicated because it takes into account crisis and suicide theories and is then ultimately guided by various factors and statistics. First, the literature review will explore crisis theory and crises of suicidality. Second, it will cover the theoretical basis for suicide intervention as a whole and this review of the literature will focus on exploring current research and findings in the field of suicide intervention and will cover the current literature that discusses evidence-based programs currently provided on the topic of suicide assessment. It will also cover the statistics and research that influence and guide suicide assessment. Third, the literature review will also cover a discussion of the Suicide Prevention Resource

Center’s eight domains for suicide intervention core competencies and how they are impactful and necessary components for training future Licensed Professional

Counselors. Fourth, the literature review will discuss self-concept, self-efficacy, and counselor self-efficacy. Lastly, this literature review will discuss effective counseling skills.

Crisis Theory

Crises have been explained in various ways over the years, whether they are crises of suicide or not (Caplan, 1964; Lindemann, 1944; Slaikeu, 1990). The origins of crisis

10 Texas Tech University, Nicole L. Black, May 2017 theory is generally traced back to the writing of Eric Lindemann after he described the effects of the Coconut Grove nightclub fire that took the lives of 493 people (1944). In his writings, he described symptomatology of patients who had experienced some sort of traumatic grief in relation to a crisis and described it as a “definite syndrome”

(Lindemann, 1944). His research and finding led the way for the current day understandings of crisis and how to conceptualize an appropriate response to individuals that have had a traumatic experience.

Gerald Caplan also made efforts to describe the characteristic of a crisis at its most basic level. He reported that a crisis is a situation when there is an imbalance between the individual’s problem at hand and the resources that the individual has

(Caplan, 1964). He also stated that this situation overwhelms the individual’s problem- solving skills resulting in ineffective coping. Caplan described four phases of crisis development in which the individual experiences increased tension and uses previously effective techniques to solve the situation. In the final phase of the crisis, Caplan reported that the tension may grow to a breaking point causing “major disorganization” and “drastic results” (Caplan, 1964, p. 41). The fundamental aspects of crisis theory have led the way to understanding how to handle various types of crises; one way is

Psychological First Aid (Slaikeu, 1999).

Psychological First Aid

Karl Slaikeu stated that a crisis is “a temporary state of upset and disorganization, characterized chiefly by an individual’s inability to cope with a particular situation using customary methods of problem solving” (1990, p. 15). Within his book, he established a basic plan for individuals to follow in order to aid professionals in the resolution of 11 Texas Tech University, Nicole L. Black, May 2017 various types of crises. These are laid out in the “Five Components of Psychological

First Aid” in his book (1990, p. 107). He reported that when working with an individual in any crisis situation, the intervener needs to follow five steps: 1) “make psychological contact,” 2) “explore dimensions of the problem,” 3) “examine possible solutions,” 4)

“assist in taking concrete action,” and 5) “follow up” (Slaikeu, 1990, p. 108-109).

Psychological First Aid today is widely held as a fundamental structure for handling crisis situations and is a required teaching in CACREP accredited programs (2016

Standards, 2016). It is also utilized when working with crisis of suicide. However, there must be a deeper understanding of the phenomenology of suicide.

Crisis of Suicidality

History of Suicide

Suicide has occurred for ages and is even noted in the Bible. One of the most notable suicides in the Bible is that of Judas after he betrayed Jesus for thirty pieces of silver (Matthew 27:5). In that day, there was no available help to keep Judas from his actions. In recent decades, though the public has increased efforts to learn more about suicide and has developed suicide prevention. These suicide prevention efforts started in the United States in the 1950s (U.S. Department of Health and Human Services, 2012) and were expanded by the development of the American Association of Suicidology in

1968. In 1983 the Center for Disease Control began taking further steps in suicide prevention by bringing youth suicides to the attention of the public (Office of the Surgeon

General, 2012) and have been expanded by a plethora of research in the field of suicide that focuses on suicide prevention, intervention, and postvention (Burns & Patton,

2000; Cox, Robinson, Williamson, Lockley, Cheung, & Pirkis, 2012; Debski, Spadafore, 12 Texas Tech University, Nicole L. Black, May 2017

Jacob, Poole, & Hixson, 2007; Gibbons & Studer, 2008; Jobes, Lento, & Brazaitis, 2012;

Pisani, Cross, & Gould, 2011). Each of these areas of suicide work holds different meanings and purposes, starting with suicide prevention.

Theoretical Models

In the clinical process of working with individuals that are suicidal, there are three major components of suicide work (Robinson, Cox, Malone, Williamson, Baldwin,

Fletcher, & O’Brien, 2013). These areas are concentrated into the domains of suicide prevention, suicide intervention, and suicide postvention. Chronologically, prevention is the first line of defense against suicides. The discussion is then followed by intervention, which is provided to the already suicidal client. Lastly, postvention occurs when someone has already completed suicide. A brief description of each phase is discussed with close attention paid to suicide intervention. Specific detail is given to the intervention portion of this model due to clients presenting to students in a state of crisis and potentially actively suicidal.

Suicide Prevention

Suicide prevention takes many forms. The literature in the field is tremendous therefore; a focused review of prevention programs follows. Suicide prevention is the first line of suicide work. It is generally aimed at accomplishing three different goals

(Cusimano & Sameem, 2011). The first of these goals is to increase awareness of suicide. The second of these goals is to educate laypersons on how to recognize warning signs of suicide for the safety of themselves and others. The last goal is to provide individuals with information on resources available in the community or within schools or whatever setting is applicable (Cusimano & Sameem, 2011). These efforts promote 13 Texas Tech University, Nicole L. Black, May 2017 the overarching goal of reducing the number of suicidal individuals who come into a state of crisis that needs immediate intervention.

There are a multitude of different suicide prevention programs that are available for use in various settings (Robinson et al., 2013). These are particularly popular in school settings because teenagers are at increased risk for thinking about or attempting suicide (CDC, 2015). Two of these suicide prevention programs include Signs of Suicide

(SOS) and the Zuni Life Skills Development Curriculum.

Signs of Suicide (SOS) is a school-based program that is aimed at prevention of suicide risk with middle school and high school-aged students (Aseltine & DeMartino,

2004). The program focuses on teaching students about indicators and risk factors for depression and suicide. It provides a video for students to watch, and role models appropriate ways to talk with others that may be depressed. It also models how to seek help from school professionals (Aseltine & DeMartino, 2004).

Another program that is focused on suicide prevention is the Zuni Life Skills

Development Curriculum developed by LaFromboise and Howard-Pitney (1995). This program is specifically designed to work with Native American youth and is administered over a period of 28-56 lessons. This program focuses on reducing feelings of hopelessness and reducing risk factors of suicide for Native American youth. It also teaches suicide prevention skills (LaFromboise & Howard-Pitney, 1995).

Both of these programs are examples of suicide prevention tools that are useful in reducing the number of individuals that become suicidal. Individuals that become suicidal ultimately need suicide intervention. Suicide intervention is the next step in the effort to prevent loss of life. Suicide prevention is beneficial in many settings; however,

14 Texas Tech University, Nicole L. Black, May 2017 mental health counselors must be trained in suicide intervention due to their increased contact with this population.

Suicide Intervention

Suicide intervention is the focus of this dissertation. A brief introduction to suicide intervention is discussed focused on the directly relevant literature. The information is covered in this paragraph and will be expanded upon further in the literature review. Once an individual becomes suicidal, there is a need for suicide intervention rather than prevention. Suicide intervention is completed on a continuum

(Joiner, Walker, Rudd, & Jobes, 1999; Rudd, Joiner, & Rajab, 2011).

Suicide intervention is the process of actively preventing an individual from completing suicide and describes the continuum of those efforts. Suicide intervention may include clinical interviews, measures, assessments, or referrals to outside resources

(Jobes et al., 2012; Joiner et al., 1999; Rudd et al., 2001). Suicide intervention is most often initiated by assessing the level of need of the suicidal person; this process is known as suicide assessment. Once the individual’s level of suicidality is assessed, the intervener can continue with other intervention efforts. Other intervention efforts include therapy, Psychological First Aid, medications, hospitalization, or safety planning (Bryan

& Rudd, 2006; Joiner et al., 1999; Slaikeu, 1990; Stanley & Brown, 2008). However, these interventions are not always provided in time, resulting in suicide. This leads to a need for suicide postvention.

15 Texas Tech University, Nicole L. Black, May 2017

Suicide Postvention

Suicide postvention takes many forms. The literature in the field is tremendous therefore, a focused review of postvention programs is discussed. Unfortunately, not all suicidal people receive needed intervention. Suicide postvention is the process of providing services to the survivors after an individual completes suicide (Cox, Robinson,

Williamson, Lockley, Cheung, & Pirkis, 2012). These services are provided in order to prevent future suicides and also to mitigate the impact of suicide in communities because suicides can often be epidemic in nature (U.S. Department of Health and Human

Services, 2012). Suicide postventions provide organizational response plans, debriefings, group counseling, screening for others who are at high risk, and assistance with reporting suicides in the media (Cox et al., 2012). All of these efforts are aimed at reducing future suicides that are a direct effect of the original suicide. Suicide risk assessment is one method of reducing suicides.

Suicide Risk Assessment

As previously stated, crises of suicide are experienced at various degrees and require skill, knowledge, and assessment by practitioners (Joiner et al., 1999; Oordt,

Jobes, Fonseca, & Schmidt, 2009; Pisani et al., 2011). In fact, there are numerous ways to calculate the risk of a client’s completing suicide and various measurements or assessments to determine that level of risk (Granello & Granello, 2007). Many experts in the field have sought to establish the best practices for assessing suicidal clients and have sought to teach current and future professionals how to conduct suicide assessments skillfully (Bryan & Rudd, 2006; Joiner et al., 1999; Oordt et. al., 2009; Pisani et al., 2011;

Reis & Cornell, 2008; Rudd et al., 2001). These assessment strategies include 16 Texas Tech University, Nicole L. Black, May 2017 algorithms, screening measures, and even whole books written on specific models of risk assessment (Bryan & Rudd, 2006; Joiner et al., 1999; Rudd et al., 2001). For this reason, several of the models and methods for risk assessment warrant discussion, including those developed by physicians and psychiatrists as they too have elevated chances for contact with suicidal clients. This literature review documents the different checklists, frameworks, models, core components, assessment forms, and mnemonics for suicide assessment.

Checklists

Historically, suicidal assessment has been done through the use of checklists.

These checklists focused on asking the client about a series of risk factors (Range &

Knott, 1997). These risk factors were determined by the Center for Disease Control

(CDC) who, for years, has kept track of various risk factors associated with different public health crises (2015). These checklists can be completed either by the client who is suicidal or by the clinician. Various professions, including physicians, use checklists as a means of screening clients for suicidal ideations. Two examples of such checklists include the Lethality of Suicide Attempt Rating Scale and the Self-Rated Scale for

Suicide Ideation.

The Lethality of Suicide Attempt Rating Scale is an 11-point scale that is used by the clinician to assess the severity of a suicide attempted based on lethality (Smith,

Conroy, & Ehler, 1984). Suicide attempts with a low level of lethality would be rated closer to a zero while suicide attempts that are guaranteed to be lethal would be rated a

10. This type of scale may be useful to clinicians when evaluating the level of lethality in prior suicide attempts among clients (Smith, Conroy, & Ehler, 1984). 17 Texas Tech University, Nicole L. Black, May 2017

The Self-Rated Scale for Suicide is another checklist that practitioners may utilize in assessment. It is comprised of 19 different items that ask questions about the client’s suicidal ideations with a focus on desire and preparation for suicide attempts (Beck,

Steer, & Ranieri, 1988). This assessment may be useful to clinicians because it can be administered via pen and paper or on the computer.

Oftentimes, these checklists are short and lack the direction and guidance needed to assist clinicians in effective suicide intervention and safety planning. They are also not a substitute for clinical judgment (Range & Knott, 1997). These checklists should be utilized as a supplement for clinical judgment to help guide the clinician through a series of questions or risk factors in order to determine the level of suicidality in the client. The checklists may be utilized to help the clinician navigate through a framework of suicide interventions.

Frameworks

It is often helpful to consider using a framework when working with such a convoluted and anxiety-provoking clinical skill such as suicide assessment. Joiner et al.

(1999) created such a framework to follow and identified seven domains of suicide assessment. These domains were developed through a review of the literature and were based on standard of care for suicide assessment within the profession. These domains include “previous suicidal behavior; the nature of the current suicidal symptoms; precipitant stressors; general symptomatic presentation, including the presence of hopelessness; impulsivity and self-control; other predispositions; and protective factors”

(Joiner et al., 1999, p. 447).

18 Texas Tech University, Nicole L. Black, May 2017

Previous suicidal behavior. Joiner et al. stated that the previous suicidal behavior is the most important of all the domains to consider (1999). This domain focuses on whether an individual has ever attempted suicide or if they have ever had suicidal ideations. Joiner et al. stated that there is a significant difference between suicidal people and that they fall into three different groups -“suicide ideators, single attempters, and multiple attempters” (Joiner et al., 1999, p. 447).

Nature of current suicidal symptoms. Joiner et al. (1999) considered it of high importance to factor in the differing nature of suicidal symptoms presented by a client and theorized that these symptoms fall into two different categories: “suicidal desire and ideation” and “resolved plans and preparation” (p. 448). The suicidal desire and ideations factor or category focuses on the clients expressed desire to die, thoughts they have regarding death or dying, and their expectations for the suicide attempt.

Conversely, the resolved plans and preparation category or factor focuses on the clients resolve to complete suicide or behaviors that increase the chances of their completing suicide, such as the frequency of suicidal ideations, how specific their suicide plan is, how intense their suicidal ideations are, or their access to means for suicide. Joiner et al. reported that the factors from the “resolved plans and preparation” category cause clients to be at a higher risk of suicide and stressed the clinical significance of these two factors when considering how suicidal a client may be (Joiner et al. 2009, p. 448).

Precipitant stressors. Crises of suicide often are spurred as a result of other crisis situations that happen in people’s lives. This is echoed by the current statistics for suicide risk factors published by the CDC. The CDC reports that various types of risk factors can increase the risk of and precipitate suicidal ideations and attempts in 19 Texas Tech University, Nicole L. Black, May 2017 individuals. For that reason, these CDC-reported risk factors are utilized as a part of suicide assessment. Some of the most common stressors that increase suicidal ideations include recent loss (of job, relationships, house, etc.); physical, sexual, or emotional abuse; illness; or major life-changing events (such as moving or isolation) (CDC, 2015).

These stressors must be considered and factored into the assessment of suicidal clients and are easily considered by including a clinical checklist of the relevant most common risk factors of suicide published by the CDC (2015).

General symptomatic presentation. The next important domain of suicide assessment that must be considered according to Joiner et al. is the domain of general symptomatic presentation. This domain refers to the general mental health symptoms that the client is exhibiting and the diagnosis from which these symptoms originate.

Several different mental health conditions are known to be associated with suicidality.

These mental health conditions include Bipolar Disorder, Major Depressive Disorder,

Schizophrenia, and Personality Disorders such as Borderline Personality Disorder (CDC,

2015). Because these conditions are often a risk factor for suicide, it is important to evaluate for symptoms that are associated with these conditions (Joiner et al., 2009).

Impulsivity and self-control. Another important aspect of suicide assessment is that of determining the client’s level of impulsivity and self-control. These qualities are important they qualities either increase or decrease the likelihood of an individual’s following through on suicidal ideations. Impulsivity is associated with several different mental health diagnoses that are connected to suicide, such as Bipolar Disorder and

Personality Disorders (American Psychiatric Association, 2013). In addition, impulsivity

20 Texas Tech University, Nicole L. Black, May 2017 and self-control should be noted when evaluating the previous suicide attempts of the client because they predict potential future behaviors (Joiner et al., 2009).

Other predispositions. Other predispositions to suicide should also be considered during the assessment process. Some of these predispositions include family conflict, sexual abuse, parental separation or divorce, and changes in living situations

(Joiner et al., 2009). It would be beneficial to include an assessment for these predisposing factors in any crisis assessment.

Protective factors. Lastly, Joiner et al. believed that protective factors, just as much as risk factors, should be considered in the suicide risk assessment (2009).

Protective factors help predict the likelihood that a client is protected from the ill effects of risk factors. In addition, protective factors provide a source of information to help spur discussions between the client and the clinician about safety planning.

Researchers also postulate that a client’s risk for suicide could be ranked based on the aforementioned factors into one of five categories. These categories revealed the level of risk that a client had for completing suicide and include nonexistent, mild, moderate, severe, and extreme (Joiner et al., 2009; Wingate, Joiner, Walker, Rudd, &

Jobes 2004). These factors and ranking system have merit and were utilized in the suicide training program developed for this study. Still, there are other methods of determining the level of suicidality with a client, including models of risk assessment and intervention. The following section will discuss models of suicide assessment.

21 Texas Tech University, Nicole L. Black, May 2017

Models

Some examples of the assessments include the Collaborative Assessment and

Management of Suicidality (CAMS) developed by Jobes, Lento, and Brazaitis (2012) and

The Substance Abuse and Mental Health Services Administration Suicide Assessment

Five-Step Evaluation and Triage (SAFE-T) developed by the American Psychiatric

Association’s Practice Guidelines (2003).

The CAMS is a “therapeutic framework” that the counselors follow while working with a client that is suicidal. This therapeutic framework is followed over the course of many therapy sessions until the suicidal ideations are resolved (Jobes et al.,

2012). The CAMS utilizes the Suicide Status Form to assess clients that are suicidal.

This thorough assessment is an asset to counselors. However, as thorough as the CAMS may be, the training does not include education on the 24 Core Competencies and does not educate users on important competencies such as ethical requirements. These are necessary components that will likely influence student’s self-efficacy when he or she is assessing suicidal clients.

The (SAFE-T) developed by the American Psychiatric Association’s Practice

Guidelines is another assessment guide (2003). This guide provides an outline for counselors to assess clients that are suicidal, and it walks them through two factors that must be considered: risk factors and protective factors for suicide. In addition, it reminds clinicians to assess for suicidal ideations, plans, or intent and to rank how suicidal the client is on a level system. This also appears to be a beneficial asset to clinicians; however, it does not educate counseling students on the various risk factors that they must know to complete the checklist. Furthermore, it also does not teach the necessary 22 Texas Tech University, Nicole L. Black, May 2017 competencies that are likely needed to make counseling students feel efficacious in suicide assessment.

Core components. The literature on suicide assessment generally agrees that suicide risk can be assessed by including certain core components. These components include risk factors, protective factors, and suicide warning signs (American Psychiatric

Association, 2003; Brown, 2001; Bryan & Rudd, 2006; Goldston, 2000; Granello &

Granello, 2007). Risk factors and protective factors are provided by research in the field of suicide and by the statistics produced each year by the CDC (2015). These statistics and research are ascertained by evaluating common factors between suicide attempters and suicide completers (CDC, 2015).

Assessment forms. An array of assessments has been developed in order to assess for the risk of suicide assessment (Goldston, 2000). Each of these different assessments has various merits and is useful when working with various populations. In fact, Goldston has published a catalog of different assessments focused specifically on youth: “Assessment of Suicidal Behaviors and Risk Among Children and Adolescents”

(2000). This catalog contains over fifty different assessments that can be utilized for suicide assessment. In addition, it provides a review of the instruments, their purposefulness, and their reliability and validity (2009). Brown also published a catalog of assessments for adults: “A Review of Suicide Assessment Measures for Intervention

Research with Adults and Older Adults” (2001). This catalog, too, provides a description of each assessment, its purposefulness, and its reliability and validity.

23 Texas Tech University, Nicole L. Black, May 2017

Various assessment forms provide a formulary to follow for risk assessment. One such is the SAD PERSONS Scale discussed further later in this literature review. Others provide simple information to follow and then allow the clinician to use his or her best clinical judgment in determining the risk of the client. The literature and publications are so great that it can be overwhelming for counseling students to navigate. There is a need to provide not only evidenced-based tools for counseling students but also to provide the competencies they need in order to complete effective suicide intervention.

Mnemonics. Other assessment models follow mnemonics for remembering specific risk factors. The SAD PERSONS Scale is one such mnemonic developed by

Juhnke (1996). The SAD PERSONS Scale is a mnemonic for different risk factors that place a person at increased risk for suicide based on data provided by the CDC. The mnemonic stands for Sex, Age, Depression, Prior History, Ethanol (Alcohol) Abuse,

Rational Thinking Loss, Support System Loss, Organized Plan, No Significant Others, and Sickness (terminal illnesses). The user is able to “score” the participants based on how many risk factors they trigger for within each of the categories in the SAD

PERSONS mnemonic. For each category present in the individuals’ lives, they receive a point. Individuals with 0-2 points are deemed to have no major problems and need only continued monitoring. Individuals with a score of 3-4 should be sent home and monitored often. If individuals score 5-6, the counselor should consider hospitalizing the client either through voluntary or involuntary hospitalization. Lastly, for individuals with a score of 7-10, the clinician should seek hospitalization for the client whether it is on a voluntary or involuntary basis (Juhnke, 1996). This mnemonic may be helpful but is lacking several necessary components for a counselor because it does not educate the 24 Texas Tech University, Nicole L. Black, May 2017 counselor on ethics, documentation, treatment planning for suicide, or safety planning. It is simply a reminder of risk factors and does not encompass all the necessary steps of suicide risk assessment that counselors must know and follow.

The IS PATH WARM is another mnemonic developed by the American

Association of Suicidology (2014c). This mnemonic stands for Ideations (suicidal ideations), Substance Abuse, Purposelessness, Anxiety, Trapped, Hopelessness,

Withdrawal, Anger, Recklessness, and Mood Changes (American Association of

Suicidology (2014c). Like the mnemonic developed by Juhnke, this model focuses on warning signs or risk factors but fails to include several risk factors highly associated with suicide, such as a history of prior attempts, age, sex, and lack of social support.

Additionally, this mnemonic does not provide education on ethics, laws, documentation, or safety planning for suicide, which are all necessary components for counselor training.

Each of the various measures or mnemonics have benefits and strengths because they are grounded in best practices and research that guides the assessment of suicide risk. However, these assessments do not necessarily educate mental health professionals on all of the necessary facts and knowledge for suicide assessment. In addition, they do not educate clinicians on the statistics, research, and information that influence the line of questioning necessary for effective suicide assessment. There is a need to go beyond basic education and to ensure that counselors are educated in the core competencies of suicide assessment.

25 Texas Tech University, Nicole L. Black, May 2017

Core Competencies for Suicide Risk Assessment

Competency is defined as “the ability to do something well” (Merriam-Webster,

2017b). Furthermore, competency is not just the ability to perform well but to perform actions in an ethical and consistent manner. Core competencies are needed throughout the field of counseling and especially when it comes to suicide assessment. Within the counseling profession, core competencies encourage counselors to be self-reflective and seek to refine their practices (Drake, 2013).

The American Association of Suicidology sought to establish a list of competencies needed for current and future practitioners to follow when assessing suicidal clients and commissioned the Suicide Prevention Resource Center (SPRC) to do just that through a board of experts in the field. These nine experts conducted a review of the suicide literature, interviewed experts, collected information on other related core competencies in the field, and collected information on “relevant instructional materials” in order to establish a general consensus on the necessary core competencies for suicide assessment (American Association of Suicidology, 2014b). This committee, organized by the SPRC, then published “Core Competencies for Suicide Risk Assessment” and developed assessment implications for counselor supervision (American Association of

Suicidology, 2014a). The authors established 24 competencies within eight domains, which were published in 2006 and are described in this section.

Domain 1: Attitudes and Approaches

This domain focuses on ensuring that counselors are aware of the personal attitudes, beliefs, and values that they hold about suicide and those that are suicidal. The competencies also ask counselors to be aware of any prejudice they may hold. These 26 Texas Tech University, Nicole L. Black, May 2017 competencies aim to prime the therapist to be self-aware and open minded before ever interacting with a client that is suicidal (American Association of Suicidology, 2014a).

Domain 2: Understanding Suicide

Understanding suicide focuses on ensuring that counselors are familiar with suicide-related statistics, basic terms surrounding suicide, the different risk and protective factors related to suicide, and “understanding the phenomenology of suicide” (American

Association of Suicidology, 2014a). This set of competencies is written in general terms and does not specify which terms, statistics, or risk and protective factors should be taught to counselors in order to ensure the counselors’ competency.

Domain 3: Collecting Accurate Assessment Information

Collecting accurate assessment information focuses on ensuring that counselors are competent in eliciting the information necessary to complete fully an accurate suicide assessment. These competencies focus on ensuring that the counselors know how to

“elicit risk and protective factors,” suicidal ideations, plan, behaviors, attempts, and how to elicit specific indicators of imminent risk with patients (American Association of

Suicidology, 2014a).

Domain 4: Formulating Risk

The domain of formulating risk aims to ensure that the counselor is able to determine the likelihood that a client will complete suicide in the short and long term and the various risk factors that lead to the imminent risk of a client. In addition, this domain focuses on ensuring that the counselor is competent in documenting these factors in the client’s file (American Association of Suicidology, 2014a).

27 Texas Tech University, Nicole L. Black, May 2017

Domain 5: Developing a Treatment and Service Plan

This domain focuses on ensuring that the counselor is skilled in creating a treatment plan for the client that focuses on promoting protective factors, reducing or eliminating risk factors, and exploring and correcting various stressors that lead to the client’s suicidal ideations. This domain also focuses on identifying various services that the client may benefit from and coordinating the care through a multidisciplinary team when appropriate (American Association of Suicidology, 2014a).

Domain 6: Managing Care

Managing care focuses on ensuring that there are specific policies and procedures in place to manage the care of a client that is suicidal. Several of these core competencies focus on ensuring that there are specific plans of action in place prior to the counselor’s interacting with a suicidal client. This domain also focuses on ensuring that the counselor has an effective plan of action in place to manage suicidal client’s by following up with them, providing referrals, and providing various aspects of care throughout a crisis of suicide (American Association of Suicidology, 2014a).

Domain 7: Documenting

Ensuring the counselor is competent in completing all appropriate documentation for the suicidal client is the focus of this domain. This includes documenting informed consent, as well as contacts with the client, family, or other professionals, documenting treatment plans and safety plans, and documenting clinical notes (American Association of Suicidology, 2014a).

28 Texas Tech University, Nicole L. Black, May 2017

Domain 8: Understanding Legal and Regulatory Issues Related to Suicide

This domain focuses on ensuring the counselors are competent in various legal requirements that they must follow, including the Health Insurance Portability and

Accountability Act of 1996, state and local laws, and national and state level ethical codes of conduct. In addition, this domain focuses on ensuring that counselors are competent in understanding the impact of failure to follow these various regulations and the legal repercussions that may result from or as a result of this action (American

Association of Suicidology, 2014a).

All eight of these domains encompass the 24 Core Competencies but do not include specific information that should be taught to clinicians in order to ensure competency. There is some latitude for professionals to infuse their input into the educational content of each domain, making various trainings unique and varied. Some of these trainings are discussed in the literature; some training programs have been developed specifically in order to fulfill the educational requirements of these domains.

Suicide Assessment Training Programs

As previously discussed in this literature review, various types of trainings focus on how to conduct a suicide assessment, and each offers its own method. Each of the methods has merits and is based on best practices or evidenced-based research.

However, there is a need to explore suicide assessment trainings that teach participants how to do suicide assessment based on the 24 Core Competencies for suicide risk assessment. This section will explore the current literature of suicide assessment training programs that are aimed at mental health professionals and that teach components of the

24 Core Competencies. 29 Texas Tech University, Nicole L. Black, May 2017

A search for suicide training programs was conducted using EBSCO. The search was conducted with keywords “suicide assessment” and “training”. The inquiry returned a multitude of suicide assessment training tools. The results were refined by exploring which of these reference the SPRC’s 24 Core Competencies for suicide assessment. This section discusses the suicide training programs that met these criteria.

Two primary resources that utilize the 24 Core Competencies for suicide risk assessment include the American Association of Suicidology and the Suicide Prevention

Resource Center. Both of these programs have expanded educational opportunities available to the public; however, they are not accessible to students in the classroom and would require participants to attend often-expensive, face-to-face programs. These programs are discussed for additional insight.

The American Association of Suicidology offers a suicide intervention training program for clinicians that includes a two-day, in-person workshop, web-based assessment, evidenced-based curriculum, and manuals that are presented in a live face-to- face training format (2014b). Although this curriculum is based on the 24 Core

Competencies for the Assessment and Management of Individuals at Risk for Suicide, it comes with limitations. This particular training costs $75 dollars per participant, $3,500 for a trainer fee, $1,000 for a “training service fee,” a 23% “indirect fee,” plus the cost of travel and lodging for the trainer (American Association of Suicidology, 2014b).

Although this training is comprehensive, it is costly, not accessible on a solitary basis, and requires that the individual set aside two days for training. These limitations are burdensome for counseling students who may also work or have financial or scheduling limitations. 30 Texas Tech University, Nicole L. Black, May 2017

The Suicide Prevention Resource Center offers a suicide intervention training program (“SPRC training institute,” 2014). This workshop consists of a one-day training session for mental health professionals and is also based on the 24 Core Competencies for the Assessment and Management of Individuals at Risk for Suicide (Suicide Prevention

Resource Center, 2014). The training is 6.5 hours in duration and offers a manual for attendees. The fees for this training include $115 per participant, a trainer fee of approximately $1,500 that “varies,” travel costs, and the cost of continued education credits (L. Morales, personal communication, January 14, 2015). Although these trainings are based on best practice and research, they are costly and available only to those who can afford to host a trainer and pay for expenses.

A review of the literature conducted by Pisani et al. (2011) revealed a group of twelve workshops that were aimed mainly at mental health professionals, with at least one peer-reviewed publication on the workshop and with the primary objective of the workshops’ being “clinical competence in the assessment and management of risk for suicide” (p. 256). The authors completed a thorough literature review and solicited creators of these trainings in order to compile current and relevant data. Developers of eleven workshops provided information about their program, and this was included in the literature review. Interventions discussed in this literature review included the “Air Force

Guide for Managing Suicidal Behavior (AF’s MSB),” “Question, Persuade, Refer, Treat

(QPRT),” and “Risk Assessment Workshops.” These programs were offered in a variety of settings with various learning formats. Each provided a different set of benefits or limitations. It should be noted that no educational intervention in the literature review by

Pisani et al. (2011) covered all eight domains of Suicide Core Competencies ascribed by 31 Texas Tech University, Nicole L. Black, May 2017 the Suicide Prevention Resource Center. However, these interventions were included in the literature review of this study and influenced the educational content of the suicide training program.

The AF’s MSB training was developed through collaborative efforts from the

U.S. Air Force and was focused on training mental health personnel on how to assess and treat suicidal ideations for military personnel (Oordt, Jobes, Fonseca, & Schmidt, 2009).

This training was administered over a one-and-a-half-day period for Air Force mental health personnel. The program spent four hours discussing assessment, four hours discussing management and treatment, and four hours discussing working with military personnel through lecture format. Eighty-two mental health professionals participated in a study conducted by Oordt et al. to evaluate this program. Participants were asked to attend the suicide training developed by the Air Force and complete a pretest and two posttests. Pretesting and posttesting were done with an anonymous questionnaire that asked how participants felt about their comfort assessing suicidal clients and questioned their beliefs about clinician liability when a client completes suicide.

This assessment form was developed by Oordt et al. and was not tested for reliability or validity. However, only 50% of the participants returned measures utilized to determine efficacy and changes in knowledge in follow-up. A single sample t test was used to analyze the data. Out of the respondents, 14% reported that they felt more hesitant to ask a client if they were suicidal after receiving this training, and researchers concluded from the data that “participants did not report increased confidence in assessing suicidal risk immediately following training but did show a statistically significant change at a 6-month follow up” (Oordt et al., 2009, p. 27). This training was 32 Texas Tech University, Nicole L. Black, May 2017 specially designed to focus on training mental health professionals working with military personnel and did not address the educational requirements and state specific laws that impact future Licensed Professional Counselors. However, this training did produce a beneficial resource for mental health professionals entitled the “Air Force Guide for

Managing Suicidal Behavior,” and this document was examined and referred to within this current study’s training program.

The study by Oordt et al. (2009) has several merits. The study was developed specifically for mental health professionals working with military populations and is comprehensive and includes multiple resources. In addition, it is an evidence-based program. However, the research by Oordt et al. lacked an assessment that was reliable or valid. Furthermore, they evaluated for other measures of change and did not assess for changes in self-efficacy.

The Question, Pursued, Refer, Treat (QPRT) training was also covered in the literature review by Pisani et al. (2011). QPRT is considered an evidence-based treatment according to the Substance Abuse and Mental Health Services Administration

(SAMHSA) National Registry of Evidence-based Programs and Practices. However, it appears that the evidence-based status is based on evaluation of the original training called Question, Pursued, Refer, which was developed for lay persons. QPRT is considered an approved, evidence-based variation of QPR according to the developers

(QPR Institute, 2014). For this literature review, research on QPR will be assessed.

QPR training has been tested for effectiveness with school counselors (Reis &

Cornell, 2008). Their researchers focused on a population of elementary, middle, and

33 Texas Tech University, Nicole L. Black, May 2017 high schools in Virginia and divided participants into a treatment and control group. One hundred seventy-two participants were in the control group, including 74 counselors.

The treatment group was comprised of 403 participants, 73 of whom were school counselors. These treatment group participants took the QPR training and then were asked questions from The Student Suicide Prevention Survey to measure change. This measure was developed by the researchers to ascertain information about how many students the counselors had assessed, how confident they felt in assessing, and how much knowledge they had gained. It should be noted that this assessment tool was not tested for internal reliability or validity. Statistical analysis for this study was done by using a 2 x 2 multivariate of covariance (MANCOVA).

This study by Reis and Cornell (2008) showed that school staff who attended

QPRT training showed greater knowledge of suicide intervention. However, these participants went through the gatekeeper (clinician) version of Question, Persuade, and

Refer, which is only a one-to-three-hour program. Furthermore, researchers reported that

“[t]rainees reported questioning fewer potentially suicidal students than did control group participants and they reported referring fewer students to mental health services than did control participants” (Reis & Cornell, 2008, p. 390). This is of great concern due to the fact that mental health professionals, based on their increased knowledge and training, should be more inclined to assess suicidal clients.

According to the QPR website, QPRT is available online and is designed for

“primary healthcare professionals, counselors, social workers, psychiatrists, psychologists, substance abuse treatment providers” and more (QPR Institute, 2014, para.

1). This course is available online and is approximately eight to ten hours long, costing 34 Texas Tech University, Nicole L. Black, May 2017

$149 per person. However, according to the literature review by Pisani et al. (2011), the

QPRT training does not include three of the SPRC Core Competencies of Suicide:

“attitudes and approaches,” “formulating risk,” and “legal and regulatory issues” (p. 261).

Although the QPRT training offers an easily accessible learning format and good educational content, it does not fulfill all of the suicide risk assessment needs of a master’s level counseling student because it is missing three whole domains from the

SPRC Core Competencies of Suicide.

The training provided by QPRT has several benefits, including the fact that it is accessible online and can be viewed at the pace of the participant (asynchronous). It is also an evidence-based intervention. However, QPRT does not include three of the eight domains of the 24 Core Competencies for suicide assessment, and Reis and Cornell

(2008) focused their research on school counselors, excluding Community Mental Health

Counselors from the study.

Pisani et al. (2011) also discussed the Risk Assessment Workshop. The Risk

Assessment Workshop consisted of a five-hour workshop that taught participants how to assess and determine risk of suicide in clients. This training was assessed using a sample of 45 participants who attended the training. This sample consisted of 43 psychiatric residents and two clinical psychology interns (McNeil, Forwood, Weaver, Chamberlain,

Hall, & Binder, 2008). The comparison group was comprised of ten psychiatric residents who attended a different workshop on medicine and not suicide assessment. Both groups completed pretesting and posttesting of a 7-item scale that rated their “perceived ability to accurately assess patients’ risk of suicide, their ability to manage patient’ risk of suicide, and their knowledge about suicide and working with suicidal patients” (McNeil 35 Texas Tech University, Nicole L. Black, May 2017 et al., 2008, p.1463). There was no significant difference between the treatment and control group on pretesting; however, it should be noted that these groups were not comparable in size. Participants who received the suicide assessment training showed higher scores on the 7-item assessment as compared to the control group after data was analyzed using multiple regression analysis. This training was conducted in person by

“12 faculty psychiatrists and psychologists” (McNeil et al., 2008, p.1463). Their lecture format had obvious limitations due to the number of presenters being utilized in person.

Furthermore, this particular program did not include the SPRC Core Competencies of

Suicide of “attitudes and approaches” or “legal and regulatory issues,” which are all necessary components for future Licensed Professional Counselors (Pisani et al., 2011, p.

261). Additionally, McNeil et al. did not include a precise research design aimed at reducing confounds or statistical error. Lastly, the study by McNeil et al. (2008) included uneven comparison groups, did not use a true control group, and utilized measures that were not tested for reliability but only face validity.

Although the programs covered in the literature review by Pisani et al. (2011) have various notable qualities, not one fulfills all of the Suicide Core Competencies set forth by the SPRC. Each of these components is deemed necessary in order to ensure counselor competency in the area of suicide assessment. Furthermore, none of these programs is available in the classroom for master’s level students at a nominal fee, and none of these programs includes the legal and ethical standards that are specific to each state (Pisani et al., 2011).

Other options for training may be found online through various providers such as

PESI, Inc. (2014). However, these online videos do not allow for synchronous 36 Texas Tech University, Nicole L. Black, May 2017 interactions with the participants, as a face-to-face class would, nor do they provide evidence of validity obtained through pretest and posttest assessments. Lastly, these programs cannot be updated and do not reflect the mental health codes within each individual state (PESI, Inc., 2014).

In addition to the dearth of suicide training programs based on the 24 Core

Competencies, there is a lack of research that examines the impact of suicide assessment programs on the self-efficacy of counselors. A review of the SAMHSA National

Registry for Evidenced-based Programs and Practices (NREPP) was conducted. This database is important for researchers to review because it maintains a list of evidence- based interventions with information on each program available to review. This search reveals only two different evidenced-based programs that were assessed in terms of influencing self-efficacy. All other evidence-based programs focused their research on other measures, such as knowledge of suicide risk factors or outcome measures having to do with suicidal clients (SAMHSA, 2017). Two of the suicide training programs that influence self-efficacy are the QPRT program that was previously described in the literature review and the “Suicide Options, Awareness, and Relief (SOAR)” program.

The SOAR program was developed for the Dallas, Texas, Independent School

District and provides school counselors with eight hours of education on how to effectively assess students that are suicidal. This program was evaluated to determine if it influenced participants’ knowledge of suicide and self-efficacy. Researchers assessed the effectiveness of this model using scales that they designed and tested for face and content validity. 186 participants responded to this survey after receiving the SOAR training as a part of district requirements (King & Smith, 2000). There was no control 37 Texas Tech University, Nicole L. Black, May 2017 group in the study. The study showed that as a result of the training, three fourths of attendees felt knowledgeable in suicide assessment. Unfortunately there was less of an impact of self-efficacy. Fifty-six percent of counselors strongly thought they could recognize a possibly suicidal student (King & Smith, 2000). While the results are promising, they indicate that nearly half of participants did not feel efficacious in identifying potentially suicidal students. Lastly, it should be noted that the SOAR program was developed prior to the 24 Core Competencies’ being released by the SPRC.

As will be discussed further in the next section, self-efficacy is an integral part of education and counselor development. There is a need for further understanding of how self-efficacy influences counselor education and competency. Furthermore, research has been lacking in this area of suicide intervention. This literature review will discuss the importance of self-efficacy and its role in the study.

Self-Concept

The construct of “self” is multifaceted. It includes a variety of different constructs as well. The following section will discuss these various constructs in order to form a better picture of self-efficacy, which was utilized in this study. The self-beliefs pertinent to this study include self-concept and self-efficacy. However, counselors and other mental health practitioners use self-esteem, the universal self and self-concept to assist suicidal clients. To facilitate a better understanding of self-beliefs as they pertain to suicide assessment, prevention, intervention and postvention, the self-beliefs of self- concept and self-efficacy are discussed below briefly.

38 Texas Tech University, Nicole L. Black, May 2017

To influence the views students possesses about themselves, it is important to understand how those views and opinions are formed. Self-concept is defined as “the individual’s belief about himself or herself, including the person’s attributes and who and what the self is” (Baumeister, 1999). Often individuals see themselves differently based on the situation. Carl Rogers theorized that self-concept was comprised of three different pieces: self-image, self-esteem, and the ideal self (1959). Merriam-Webster defines self- image as “one’s conception of oneself or one’s role” (2017d). Self-esteem is defined as

“a confidence and satisfaction in one’s self” (Merriam-Webster, 2017c). Rogers expands on this definition by adding that an individual also has the “ideal self,” who is the self that he or she wish they were (1959). Each of these personal views of the self is important in understanding personal development. The concept of the self have been studied in the field of education and are important in counselor education (Bandura,

1997, Meyer, 2015). While self-concept is a holistic view of self, self-efficacy pertains to specialized skills, or beliefs that are discussed below. When studying the self in regards to counselor education, it is important to examine and understand the idea of self- efficacy.

Self-Efficacy

Self-efficacy has been a widely studied theory by Albert Bandura (1997,

1982,1977, 1986). He defined self-efficacy as “beliefs in one’s capabilities to organize and execute the courses of action required to produce given attainments” (Bandura, 1997, p. 3). In other words, self-efficacy is the “self” belief that one is capable of achieving a specific goal or task. In his book, he described the various types of self-efficacy that individuals have and how they are attained. He reported that individuals who perceive 39 Texas Tech University, Nicole L. Black, May 2017 themselves as being self-efficacious in a particular skillset tend to be more likely to attempt that skill and succeed versus individuals who had a low sense of self-efficacy in the same skill. In addition, the individual’s self-efficacy was more predictive of successful outcomes over the individual’s level of knowledge on the topic at hand.

Conversely, if individuals do not feel that they are likely to be successful, they tend to put less effort into an activity, attempt the activity for less time, and experience more anxiety about their ultimate failure at the activity (Bandura, 1986). Bandura reported that self- efficacy is crafted through four major methods: enactive mastery experience, vicarious experiences, verbal persuasion, and psychological and affective states (1997).

Enactive Mastery Experience

Bandura identified “enactive mastery experiences” as the “most influential source of efficacy information because they provide the most authentic evidence of whether one can muster whatever it takes to succeed” (1997, p. 80). Furthermore, Bandura stated that individuals need to be provided with clear rules and strategies to follow in order for them to practice new skills and cultivate a sense of self-efficacy. This would be achieved in an academic setting by providing didactic lecture to educate students on the nuances of suicide assessment and then allowing them the opportunity to practice the skills that they had learned. This study aimed to provide these self-efficacy building experiences to master’s level counseling students by allowing them the opportunity to role play suicide assessment techniques within the suicide training program.

Vicarious Experiences

In addition to enactive experiences, Bandura reported that individuals obtain a sense of self-efficacy through vicarious experiences. He wrote that people are able to 40 Texas Tech University, Nicole L. Black, May 2017 self-measure their abilities and level of self-efficacy by watching the skill level of those around them and comparing themselves to others that already have a level of skill mastery. Bandura highlighted that this learning mechanism is particularly effective when individuals have almost no prior experience in certain skills (1997). This could be achieved in the context of suicide assessment by allowing students to watch suicide assessment role-plays. This study achieved this by utilizing a skilled practitioner to demonstrate suicide assessment, allowing students to ask questions, and then having students practice their skills.

Verbal Persuasion

Bandura identified the third method of developing self-efficacy to be through verbal persuasion. He reported that individuals obtain a sense of self-efficacy by learning, through the feedback from others, that they are capable (1997). Persuasive feedback from educators or those that already have mastery in the desired skill help learners achieve this. This study facilitated this skill in the classroom for students by providing specific and genuine feedback on student’s suicide assessment skills as they practiced through role-plays and answered questions during lecture.

Psychological and Affective State

Lastly, Bandura stated that individuals gain a sense of self-efficacy by listening and tuning into their internal psychological and affective states (1997). In essence, students are listening to what their bodies are telling them. If they feel anxious and tense, they perceive that they are less capable of the skill they are trying to master. Conversely, students that feel calm and confident when learning and practicing new skills are more likely to increase their self-efficacy in a desired task. This study facilitated this skill in 41 Texas Tech University, Nicole L. Black, May 2017 the classroom by having the instructor spend time easing student’s anxieties and providing reassurance and facilitating a relaxed and positive learning environment.

Counselor Self-Efficacy

Counseling self-efficacy is defined as the counselor’s belief that they are capable of effectively counseling a client in the near future (Larson & Daniels, 1998, Larson,

Suzuki, Gillespie, Potenza, Bechtel, & Toulouse, 1992). Promoting self-efficacy in master’s level counseling students is imperative because it is instrumental in their ability to perform counseling-related skills (Meyer, 2015). Counselor self-efficacy has five dimensions that include “confidence in executing microskills, attending to process, dealing with difficult client behaviors, behaving in a culturally competent way, and being aware of one’s values” (Larson et al., 1992, p. 117). This literature review will discuss the fundamental counseling skills that are important to suicide assessment.

Counseling Skills

Unconditional Positive Regard. At the core of counseling is the concept of unconditional positive regard. This concept is taught as a core component of counseling theory in counseling courses and is derived from Person Centered Therapy developed by

Carl Rogers (1959). Rogers defined the concept of positive regard first, explaining that it is a basic need of individuals to feel that another human has a generally positive view of them. This is characterized by the person’s feeling love and affection from another person (Rogers, 1959). He then goes on to state, “to perceive oneself as receiving unconditional positive regard is to perceive that of one's self-experiences[,] none can be discriminated by the other individual as more or less worthy of positive regard” (Rogers,

1959). In other words, unconditional positive regard is the experience of someone’s 42 Texas Tech University, Nicole L. Black, May 2017 feeling love and affection from another person without any reservations, conditions, or qualifications.

This concept of unconditional positive regard forms the basis of the counseling relationship. This relationship is the basis for all interactions in therapy between the client and the counselor. Once counselors are able to display unconditional positive regard, they are able to utilize their counseling skills to help influence change in the client

(Young, 2013).

Basic Counseling Skills. In the field of counseling, counselors and related professionals employ several techniques at the very basis of their conversation that help the ebb and flow of the therapeutic counseling relationship between a client and clinician.

These techniques or skills are basic conversation skills used by professionals to help clients further explore their thoughts and feelings in order to enhance the client’s ability to explore topics of concern and health within the counseling relationship. These basic counseling skills build upon themselves and form a hierarchy of clinical skills that are used throughout the session to benefit the client. These basic counseling skills include the following major categories and are described below in further detail: Listening,

Empathy, Genuineness, Unconditional Positive Regard, Open Questions, (Young, 2013).

Listening or attending skills are basic things that listeners do to show they are paying attention. This includes making eye contact, nodding the head, mirroring body language, and not giving into distractions in the room. Listening is the act of catching the verbal and nonverbal states of the client (Young, 2013). The “Empathy” category comprises another portion of the skills that clinicians use in a counseling session. These

43 Texas Tech University, Nicole L. Black, May 2017 skills include attending, paraphrasing, rephrasing, and perception checking. Attending behaviors are as defined above. Paraphrasing is done so that the clinician can summarize what the client is saying and further direct the conversation in a direction that will be more beneficial to the client. Rephrasing is similar to paraphrasing and is a basic skill that allows the clinician to clarify what a client is saying or trying to convey. Lastly, perception checking is usually done by asking a short question of the client, such as “I heard you say that you feel betrayed by your friend, is that correct?” (Young, 2013)

The last three basic counseling skills are genuineness, unconditional positive regard, and open questions. Genuineness includes the ability of the counselors to be true versions of themselves in the counseling relationships and for them to have congruence between their feelings and behaviors. Unconditional positive regard is defined by the counselor’s exhibiting the conduct described above. Counselors are also required to practice asking open-ended questions that collect information such as who, what, when, and where instead of asking closed-ended questions that could be answered with a “yes” or “no.” This skill helps facilitate opening the conversation without the therapist’s needing to drill the client for information (Young, 2013). Each of these skills is practiced in counseling programs by future counselors and are the basic skills that counselors learn.

These basic skills comprise the core of a counselor’s statements in the therapy session.

These basic counseling skills, including unconditional positive regard are imperative in the suicide assessment process because they are the fundamentals of the counseling relationship and therapeutic rapport (Slaikeu, 1990). However, basic counseling skills are not enough to handle crisis situations. There is a need to promote

44 Texas Tech University, Nicole L. Black, May 2017 the self-efficacy of master’s level counseling students when they are completing suicide assessments.

Counselor Self-Efficacy and Suicide Assessment

Suicide assessment appears to be an area that causes anxiety for counselors because they do not feel efficacious in completing suicide assessment (Douglas &

Morris, 2015; Larson & Daniels, 1998). In an effort to measure self-efficacy as it relates to suicide, Douglas and Morris created an assessment called the Counselor Suicide

Assessment Efficacy Survey (CSAES). They created the CSAES to measure participant’s self-efficacy in completing suicide-assessment-related skills such as inquiring about suicide risk level or suicide risk factors. Testing of the CSAES indicate that the measure has good reliability (Douglas & Morris, 2015). Lastly, the researchers completed a factorial analysis of the measure and determined that it is comprised of four factors including “General Suicide Assessment, Assessment of Personal Characteristics,

Assessment of Suicide History, and Suicide Intervention” (Douglas & Morris, p. 63).

This measure has several merits and would be useful in the future assessment of the efficacy of a suicide-training program. Unfortunately, this measure was not utilized because it was not published until after the beginning of the study.

Self-efficacy research holds several implications for the field of counseling and for counselor education. Research indicates that self-efficacy of suicide assessment is often low for counselors (Douglas & Morris, 2015). For this reason, there is a need for a suicide training program that boosts the self-efficacy of students and that incorporates the fundamentals of counseling.

45 Texas Tech University, Nicole L. Black, May 2017

Counselor Education and Self-Efficacy

According to Larson et al., the higher the level of self-efficacy that counselors have, the more likely they are going to attempt specific counseling skills, exert more effort in counseling, and persist in their efforts; all of which help them experience a decrease in anxiety (Larson, et al., 1992). Research also indicates that an increase in self- efficacy can occur over a short time period and that training is associated with a higher level of self-efficacy in students. Furthermore, monitoring self-efficacy levels in students is a rational way of monitoring their educational progress (Kozina, Grabovari, De

Stefano, & Drapeau, 2010). However, some research shows that some student’s may over-endorse self-efficacy when they haven’t completed a significant amount of education or training (Goreczny, Hamilton, Lubinski, & Pasquinelli, 2015).

Goreczny et al. conducted research on the development of self-efficacy with counseling students throughout the course of their academic careers, starting in their undergraduate programs and going through their master’s programs (2015). Their research findings indicated that counseling students develop self-efficacy in a nonlinear pattern. Undergraduate students indicate a higher level of self-efficacy than those students that were in the beginning of their master’s level coursework. In addition, those at the end of the master’s education reported the highest level of self-efficacy (Goreczny et al, 2015). The authors cited that this may be because new master’s level students are experiencing an increase in anxiety due to being new to the field of counseling.

However, it is also possible that undergraduate students are overly confident in their abilities and knowledge and, therefor, their self-efficacy (Goreczny et al, 2015). It is

46 Texas Tech University, Nicole L. Black, May 2017 important to explore if there are possible difference in the self-efficacy of students from

CACREP accredited or non-CACREP accredited universities.

CACREP. Research has been conducted on the level of counseling student’s self-efficacy and any differences that may be present between CACREP accredited and non-CACREP accredited universities (Tang, Addison, LaSure-Bryant, Norman,

O’Connell, & Stewart-Sicking, 2004). Tang et al. explored the differences of self- efficacy by comparing three CACREP accredited programs to three non-CACREP programs using 116 participants. Participants were assessed using the Self-Efficacy

Inventory, which includes five subscales that assess for counseling skills. However, this inventory also provides scores for the participants’ self-efficacy in individual tasks named in each question. For example, students may feel efficacious in providing referrals or diagnosing. Data was analyzed using a multivariate analysis of variance (MANOVA).

The results of the study indicate that there was no significant difference in self- efficacy between CACREP and non-CACREP accredited universities based on total scores of the Self-Efficacy Inventory. However, CACREP accredited programs did show higher levels of self-efficacy over non-CACREP accredited programs in the following individual tasks: “counseling anxiety reactions, assessing using a clinical interview, counseling adjustment reactions, and counseling affective disorders” (Tang et al., 2004, p. 77). The author cited that this difference in self-efficacy may be due to the fact that

CACREP accredited programs require more practicum and internship hours over non-

CACREP programs (Tang et al., 2004).

47 Texas Tech University, Nicole L. Black, May 2017

Of further interest to CACREP programs is research conducted by Wozny (2005).

Wozny conducted an analysis of different CACREP accredited programs to determine the prevalence of courses that taught suicide assessment. Data was collected by randomly selecting 50 CACREP accredited programs from the CACREP accredited national registry. Identified programs were reviewed based on their curriculum and coursework descriptions provided online via program websites (Wozny, 2005). This research method found that CACREP accredited programs offered suicide assessment training at an extremely rare rate (2%) (Wozny, 2005).

There are obvious potential limitations with this research design. Programs were assessed only on online descriptions, and it is possible that coursework included discussion of suicide assessment, even though it was not explicitly stated in the description. Furthermore, the 2009 CACREP standards focused more than prior standards on the emphasis of crisis education and infused higher standards for the education of crisis. This article was written prior to this wave of focus on crisis education. It is possible that more programs are prudent in training students on suicide assessment.

Summary

There is currently a void in suicide assessment education for master’s level counseling students (Schmitz et al., 2012). These students are in need of an educational program that will teach them the necessary competencies of suicide assessment. There are a few training programs that fulfill the educational demands established by the

SPRC’s 24 Core Competencies for Suicide Assessment. However, even these programs have limitations. They are either expensive or inaccessible to students. Other programs 48 Texas Tech University, Nicole L. Black, May 2017 are insufficient because they do not cover all the domains of the 24 Core Competencies for Suicide Assessment.

Additionally, there is a dearth of research on suicide assessment training programs that influence the participants’ self-efficacy. Counseling students are in need of a program that will be accessible to them through their schooling platforms and that will educate them on suicide theory, assessment, and resources. This program will need to be grounded in research and best practice and needs to be evidence-based through rigorous assessment. The study aims to explore the effects of such a program based on the

SPRC’s 24 Core Competencies that will influence the self-efficacy of counseling students.

49 Texas Tech University, Nicole L. Black, May 2017

CHAPTER III RESEARCH METHODOLOGY

Overview

This study investigated the ability to impact participants’ perceived self-efficacy concerning handling crisis situations by examining the impact of an educational training program on suicide assessment to influence the dependent variables. The dependent variables of this study include self-efficacy in crisis situations, self-efficacy in basic counseling skills, self-efficacy in therapeutic response in crisis and post crisis, and self- efficacy in unconditional positive regard. This chapter discusses the methods used to explore these null hypotheses. The methodology used in this study is described in the following sections: Overview, Null Hypotheses, Setting of the Study, Participants,

Material, Instrumentation, Design, Data Collection Procedures, and Analysis. This was a mixed methods study comprised of primarily a pre-post control experimental design with two qualitative case study question added for additional understanding.

Null Hypotheses

Null Hypothesis A. There will be no significant difference between the mean pretest and mean posttest scores of students in the experimental group and control group in self-efficacy in crisis situations, as measured by the Counselor’s Self-Efficacy Scale.

Null Hypothesis B. There will be no significant difference between the mean pretest and mean posttest scores of students in the experimental group and control group in self-efficacy in basic counseling skills, as measured by the Counselor’s Self-Efficacy

Scale. 50 Texas Tech University, Nicole L. Black, May 2017

Null Hypothesis C. There will be no significant difference between the mean pretest and mean posttest scores of students in the experimental group and control group in self-efficacy in therapeutic response in crisis and post crisis, as measured by the

Counselor’s Self-Efficacy Scale.

Null Hypothesis D. There will be no significant difference between the mean pretest and mean posttest scores of students in the experimental group and control group in self-efficacy in unconditional positive regard, as measured by the Counselor’s Self-

Efficacy Scale.

Null Hypothesis E. There will be no significant difference between the mean pretest and mean posttest scores of students in the experimental group and control group in self-efficacy, as measured by the total score of the Counselor’s Self-Efficacy Scale.

Qualitative Question A: What have you learned about suicide risk factors?

Participants were asked this qualitative question to obtain a rich explanation of what knowledge they had obtained from the training program. This qualitative question was provided to also fulfill a question that could not be answered through quantitative means due to there not being any assessment that measures knowledge of suicide risk factors documented in the literature.

Setting up the Study

For the convenience of students, the intervention was completed in the classroom.

Students were divided between either the control group or the treatment group by randomly drawing participant slips out of a bowl. Students that were randomly placed in the control group were sent home after they completed the pretest. During the second

51 Texas Tech University, Nicole L. Black, May 2017 phase of the study, all students came back to their assigned classroom, and again, control group participants completed the pretest and then were dismissed from the room. If students were enrolled in distance education courses, they were provided with the intervention via an online live synchronous teaching platform. This allowed distance students to view the information and see the presenter discussing slides in a live format where they could interact and ask questions as if in a physical classroom. Students who participated in the study via distance were provided with the pretest and posttest via

Qualtrics, an online survey website.

Participants

For the purpose of this study, a sample of students in a counseling program at a public university in the southern region of the United States was utilized. Students were enrolled in different stages of their program but had to be currently enrolled in or have previously taken one of the following courses: Ethics, Addictions,

Dysfunctional/Abnormal Behavior, Techniques, Practicum, or Internship. These classes are generally taken towards the end of a student’s master’s program and allowed for a better comparison of the treatment and control group and more uniformity of the sample.

Participants were incentivized with the potential to receive one of five $25 Amazon gift cards. These gift cards were extended to students who elected to participate in the drawing, and they were selected at random at the conclusion of the study.

Materials

During the recruiting period of the study, students and professors in charge of the classroom were provided with recruiting material for the study, which included an emailed invitation to participate in the study as well as an information sheet about the 52 Texas Tech University, Nicole L. Black, May 2017 study and resources for counseling, if needed. The information sheet also included information on the gift card incentive for completing the program.

During the intervention, participants were provided with a paper copy of the

Counselor’s Self-Efficacy Scale (Appendix A) and the demographic form (Appendix B) to complete pretesting prior to the study. At the conclusion of the study, the participants were again provided with the CSES and the demographic form to complete for post testing. The post-testing demographic form also included the qualitative question “What have you learned about suicide risk factors?”

During the training, the researcher provided material via a PowerPoint presentation; copies of the Power Point were not distributed. However, participants were encouraged to write down notes or take down resources that they felt would benefit them in the future. During the training, participants were provided with two handouts. The first handout was a crisis assessment form developed by the researcher based on best practice and research on suicide assessment. Students were also provided with a safety plan outline developed by Stanley and Brown (2008).

Instrumentation

Counselor’s Self-Efficacy Scale

The Counselor’s Self-Efficacy Scale (CSES) was developed by adapting the Social

Work Self-Efficacy Scale (Sawyer, Peters, & Willis, 2013). The Social Work Self-

Efficacy Scale was developed for Social Workers and contained items in a question form about clinical experience as well as several items that focused on finding community resources, a central duty for Social Workers (Holden, Cuzzi, Rutter, Rosenberg,

53 Texas Tech University, Nicole L. Black, May 2017

Chernack, 1996). Several of the original items were modified and amended to be more appropriate for counselors. Five items were added after a review of the literature and consultation with experts in the field (Sawyer, Peters, & Willis, 2013). Once the final format of the CSES was completed, it was normalized on a purposive sample of master’s level counseling students.

The scale is comprised of 42 questions that fall into four different subscales: “(a)

Crises Situations (13-items), (b) Basic Counseling Skills (15-items), (c) Therapeutic

Response to Crisis and Post-Crisis (8-items), and (d) Unconditional Positive Regard (6- items)” (Sawyer et al., 2013, p. 34) (Appendix A). The Crises Situations subscale asks participants about how confident they feel working with a variety of crisis situations such as suicide, murder, or sexual assault. The Basic Counseling Skills subscale asks participants how confident they feel with accomplishing several basic skills required of counselors in crisis situations, such as being empathetic, maintaining professional boundaries, or helping clients develop treatment goals. The Therapeutic Response to

Crisis and Post-Crisis subscale is comprised of questions that ask participants how confident they feel with various clinical skills necessary during and after a crisis. The

Unconditional Positive Regard subscale asks questions about participants’ level of confidence with showing behaviors that exhibit unconditional positive regard such as exhibiting empathy and validating clients. These questions are answered on a Likert scale with 0= No Confidence at all to 5= Complete Confidence. The four subscales together comprise the total scale for the CSES by adding up the values of each subscale.

The CSES was sent out to ten different counseling professors for feedback and comments on face validity. The survey was then revised and reviewed by “a university 54 Texas Tech University, Nicole L. Black, May 2017

Program Coordinator of Counseling and a measurement expert” before being administered to students (Sawyer et al., 2013). Lastly, a Cronbach’s alpha reliability coefficient was shown to be .96 for the whole instrument. Cronbach’s alpha is a score that predicts the reliability of a scale, and a score of .96 shows that the CSES has a high level of reliability (Field, 2013).

Demographic Survey

Students were requested to complete a demographic form (Appendix B) that collects information on their previous experience working with clients that have experienced suicidal ideations and what, if any, training they have received on suicide intervention. In addition, the demographic survey collected information on how far they are in their master’s program and if they have received any in-school education or out-of- school education on the topic of suicide. Lastly, the demographic survey asked participants to rate their level of comfort on a scale of 1-10 in assessing a suicidal client.

Comfort is defined as “a state or feeling of being less worried, upset, frightened, etc., during a time of trouble or emotional pain” (Merriam-Webster, 2016a). Students were asked about their level of comfort because it is an indicator of reduced anxiety and an important aspect of ensuring participant self-efficacy, which is shown to promote counselor self-efficacy (Douglas & Morris, 2015; Kozina, Grabovari, Stefano, &

Drapeau, 2010; Larson & Daniels, 1998; Larson et al., 1992).

Qualitative Question

Students in the treatment groups were asked one qualitative question in the posttest questionnaire: “What have you learned about suicide risk factors?” This question was posed to obtain information about students’ perceived change in knowledge on 55 Texas Tech University, Nicole L. Black, May 2017 suicide risk factors. There is currently no valid and reliable assessment for the knowledge of suicide risk factors. In addition, posing a qualitative question to students allowed for a rich and full response on the topic that deepened the understanding of the research (Jick, 1979).

Design

This was a mixed methods study comprised primarily of a pretest-posttest randomized control group design with one qualitative question added for additional understanding. A control group with a pretest and posttest was utilized in order to help ascertain that the suicide training program was the source of change for the treatment group and was unrelated to outside confounds. Both groups of the study completed the pretest and posttest, and only the treatment group received the intervention during the study. Participants that were assigned to the control group were provided with the option of taking the treatment at the completion of the study if it proved to be efficacious.

Procedure

Recruiting

After receiving IRB approval from the Texas Tech Office of Human Research

Protection Program (Appendix C), the researcher recruited students to participate in this study by emailing professors within the Counseling Department at a public university in the southern United States and asking if the researcher could recruit students in person for the study. The researcher then read the recruitment script to students and provided them with a participation slip to designate whether or not they wanted to participate in the study. Students were not penalized for not participating in the study and were notified

56 Texas Tech University, Nicole L. Black, May 2017 through the information sheet and in person that their participation was voluntary and that they could quit at any time. In order to be considered for the study, students had to be currently enrolled in classes for their Master’s in Counseling. In addition, the study was limited to students who had previously taken or were currently enrolled in one of the following courses: Ethics, Addictions, Dysfunctional/Abnormal Behavior, Techniques I or II, Practicum, or Internship. These classes are generally taken towards the end of a student’s master’s program and allowed for better comparison of the treatment and control group and more uniformity of the sample.

Suicide Educational Training

The suicide educational intervention created from the literature of this study was provided in a live format in the classroom or via distance education to students off campus through Blackboard Collaborate. The intervention was provided over the course of two sessions in two-hour time segments provided anywhere from two weeks apart to three weeks apart. The course outline for each segment was based on the Suicide

Prevention Resource Center’s 24 Core Competencies and was augmented by appropriate topic-related statistics and research in the area of suicide assessment and intervention as described in the following section. The 24 Core Competencies are available online and were retrieved from http://www.suicidology.org/Portals/14/docs/Training/RRSR_Core_Competencies.pdf

(American Association of Suicidology, 2014a).

The first thirteen competencies were taught in module one, which was two hours in length, and the remaining eleven competencies were taught over the course of two hours in module two. The training modules complemented and augmented the 57 Texas Tech University, Nicole L. Black, May 2017 educational goals of the 24 Core Competencies. A full list of references for the modules is provided in Appendix D. A description of the course content is provided below under each domain:

Domain One: Attitudes and Approaches

Information provided in this domain included recommendations by Rudd et al.,

(2008) for methods of ensuring that a clinician has an appropriate and receptive attitude towards suicide assessment. This content enumerated the importance of being culturally competent and exploring one’s own beliefs and feelings about suicide before a counselor assesses a suicidal client. This was done through the use of reflective questioning and challenging questions surrounding suicide beliefs: “Ask yourself what your beliefs are about suicide. How do these beliefs impact your work with suicidal clients?”

Domain Two: Understanding Suicide

The information provided in this domain focused on ensuring that participants were educated in understanding the basics of suicide, including definitions, terms, and the phenomenology of suicide. Preliminary definitions used in suicide assessment were included; also, the most recent statistics for suicide attempts and completions were provided by the CDC (2015). Crisis theory was discussed in this domain, and participants were educated on Caplan’s Crisis Theory as well as Psychological First Aid.

Participants also learned about the 12 Core Principles of Suicide Assessment that were published by Granello (2010). Participants also explored risk factors and protective factors for suicide that were provided by the CDC (2015). Risk factors include a myriad of constructs, from sexual identity, to mental health issues, to having someone in the family who attempted suicide.

58 Texas Tech University, Nicole L. Black, May 2017

Domain Three: Collect Accurate Assessment Information

In this domain, participants learned the importance of including a suicide risk assessment early on during the therapeutic relationship. Participants were taught how to integrate suicide assessment from the intake with a client and throughout the counseling relationship. Participants were educated on what information should be obtained during the intake assessment for counseling and during a crisis assessment (in the event that a client is suicidal). They were taught how to elicit risk and protective factors based on the

CDC statistics in order to help determine the level of suicidality with a client.

Participants were taught about which risk factors are more indicative of a higher level of suicide risk and how to rank the level of suicidality as determined by Joiner et al,

(1999). Participants were also provided with the appropriate verbiage to elicit accurate information about suicidal ideation. They were provided with the Risk Assessment Form that is provided in Appendix E, and time was spent with participants practicing the form and discussing how to utilize it in a clinical setting. Participants were then educated on the process of hospitalizing client that are suicidal, when this process is necessary, and how to achieve this process. Participants were educated on local resources that assist in achieving hospitalization for suicidal clients and how to determine whether a client would benefit from hospitalization or whether he or she would better benefit from continued outpatient monitoring and care. Participants were also educated on the legal concept of

Foreseeability and how to ensure that they are caring for suicidal clients in an ethical manner and how to safeguard against malpractice and litigation. Participants were educated on how to work collaboratively with other practitioners and family members in order to ensure the best interest of the client. Lastly, in this domain, participants explored

59 Texas Tech University, Nicole L. Black, May 2017 a vignette and how to apply Psychological First Aid. They also learned from this example how to conduct assessment, including how to identify risk and protective factors.

Domain Four: Formulating Risk

In this domain, participants learned how to apply the information they learned in the previous domains. They also learned of various resources or measures that they can utilize in order to supplement their own clinical judgment. These include “Twenty suicide assessment instruments: evaluation and recommendation” published by Range and Knott (1997), “A review of suicide assessment measures for intervention research with adults and older adults” published by Brown (2001), and “Reviews of measures of suicidal behavior: assessment of suicidal behaviors and risk among children and adolescents (2000). Participants were also told how to document their clinical judgment in the file for clients. They then finished this domain with another vignette followed by a discussion of the risk factors and clinical decision-making process for the example.

Domain Five: Developing a Treatment and Service Plan

This domain included information on how to create a safety plan for clients and how to develop a treatment plan for a suicidal client throughout the course of the counseling relationship. Participants were provided with a handout for a safety plan developed by Stanley and Brown (2008). This domain included information by the

American Psychiatric Association on how to complete treatment planning with suicidal clients (2013). This domain also included a discussion of local resources for suicide assessment and how to work collaboratively with other professionals including local crisis teams that provide suicide assessment through state funding.

60 Texas Tech University, Nicole L. Black, May 2017

Domain Six: Managing Care

This domain focused on implementing different policies and procedures in order to ensure that suicidal client are handled effectively within clinical settings. It also reminded participants to follow a crisis intervention model as previously discussed in other modules. Lastly, this domain discussed the various strategies and mnemonics for suicide assessment as discussed by Granello and Granello (2007).

Domain Seven: Documenting

Domain seven focused on teaching participants the proper method of documenting suicide risk and assessment. Participants were educated on the various aspects that should be included in the progress note when documenting suicide assessment. Furthermore, they were educated on what items to include in the client’s file, including the crisis assessment form, notes on contact with collaterals, the treatment plan, any safety plan, and documentation of follow up conversations or the results.

Domain Eight: Understanding Legal and Ethical Issues Relating to Suicidality

This last domain focused on covering the laws and ethics necessary to participants for conducting proper suicide assessment and intervention. This domain included a discussion of the American Counseling Association's Code of Ethics, the state’s LPC

Code of Ethics, the state’s Health and Safety Code, the state’s Family Code, the state’s

Education Code, and a discussion of the case law that dictates Duty to Warn. This domain ended by discussing pertinent case law that discussed the actions of practitioners that either prevented or led to malpractice.

Participants were provided with two handouts. One handout was a crisis assessment form developed by the researcher based on her clinical experience as a

61 Texas Tech University, Nicole L. Black, May 2017 suicide risk assessor for a local mental health authority. The primary researcher has completed over one thousand suicide assessments during her clinical experience and included questions and a checklist deemed necessary for risk assessment based on suicide research (American Association of Suicidology, 2014c; American Psychological

Association, 2013; CDC, 2015, Montague et al., 2016; Truant, O’Reilly, & Donaldson,

1991;). A copy of the risk assessment form is found in Appendix E. The researcher also provided copies of the “Patient Safety Plan Template” published for public access by

Stanley and Brown (2008). The “Patient Safety Plan Template” was provided to participants because it is a safety plan tool that was developed based on the research and best practices in the field of counseling (Stanley & Brown, 2008).

Data Analysis

For this study, 30 participants were required for each group based on the Central

Limit Theorem (Siegrist, 2015). The Central Limit Theorem establishes that a sample size of 30 participants or larger will produce a normal distribution (Field, 2013).

Quantitative questions were assessed using pretests and posttests that were analyzed using a Mixed Analysis of Variance (ANOVA) design. A Mixed Design ANOVA was deemed appropriate for this study because it analyzes the differences between groups and repeat measures (Field, 2013). For this study, the Counselor’s Crisis Self-Efficacy Scale

(CSES) and a demographic form were employed to collect data for pretest and posttest assessments of the research variables. This design allowed for the analysis of the variables. Data were displayed within the dissertation using suitable charts to reflect pertinent data and statistics. Results from the different variables were compared to one another to display any relevant causal effects. 62 Texas Tech University, Nicole L. Black, May 2017

Potential Limitations

Several statistical limitations to this study existed. Assessment of effect size is limited to changes that can be measured with available instruments that exhibit reliability and validity (Field, 2013). Due to geographical restrictions, the results of this study may be generalized only to students within this particular southern state. In addition, results of this study were limited to master’s level counseling students. These results are not to be extended to students of psychiatry, psychology, social work, chemical dependency counseling, or marriage and family counseling at this time because the study did not include participants from these disciplinary fields.

Delimitations

This study was delimited to a convenience sample of master’s students enrolled at a public university in the southern United States in either a School Counseling track or in the Clinical Mental Health Counseling track. In addition, students were selected to participate only if they had taken, or were currently enrolled in, one of the following courses: Counseling Ethics, Addictions, Dysfunctional Behavior, Techniques of

Counseling, Counseling Practicum, or Counseling Internship. This delimitation existed due to the numerous educational differences that exist among students enrolled in various stages of their master’s level program. In addition, this sample included participants who are being educated to practice within one particular southern state and who were trained on appropriate state specific mental health laws. Finally, the sampled population was graduate students from a program that has an ethnic breakdown of 59% Caucasian and

41% Minorities. The gender breakdown is 61% female and 39% female according to

CACREP’s reported statistics for this program. 63 Texas Tech University, Nicole L. Black, May 2017

Assumptions

The researcher made the following four assumptions about participants within the study:

1. It is assumed that participants in this study answered their assessments in a

complete and truthful manner.

2. It is assumed that the participants completed pretest and posttest assessments

within the required time frame.

3. It is assumed that participants were motivated to participate by a chance of

winning one of five $25 Amazon gift cards.

4. It is assumed that the results of this study might be generalized to other

universities in the state that was studied.

Summary

In summary, this study aimed to look at the impact of a suicide training module and its ability to change the self-efficacy of counseling students in the master’s level program. This study aimed to accomplish this goal by completing pre-and-post testing using the Counselor’s Self-Efficacy Scale and observing differences between a randomly assigned treatment group and control group using a mixed design ANOVA paired with triangulation for the qualitative question to provide additional understanding of the research null hypothesis.

64 Texas Tech University, Nicole L. Black, May 2017

CHAPTER IV RESULTS

This chapter discusses the statistical analysis for this study. The results are reported in the following sections: descriptive statistics of the demographic data, descriptive statistics from the Counselor’s Self-Efficacy Scale (CSES), results on null hypothesis testing, and a summary of the statistical analysis.

Research Design

The purpose of this study was to explore the effects of a suicide assessment- training module on the counselor’s crisis self-efficacy of masters level students. This was done by using a pretest-postest treatment control group design with random assignment.

Pretesting and post-testing was done utilizing the CSES (Appendix A) and a demographic form (Appendix B). Pretesting and posttesting were administered at different time intervals based on how frequently the class met. The minimum time in between pretesting and posttesting was one week, and the greatest time between pretesting and posttesting was three weeks. Additionally, two qualitative questions were included in order to obtain richer understanding of the participant’s experiences with the suicide educational program. One qualitative question was included on the demographic form, and the other qualitative question was included at the end of the CSES by the developers of the CSES instrument. The demographic form included questions about how many times participants had assessed suicidal clients, if they had prior education within their schooling on suicide assessment, or if they had any education obtained outside of their formal education. If respondents did report prior education in suicide assessment, they were asked for the names of the courses that taught them these skills and how many hours

65 Texas Tech University, Nicole L. Black, May 2017 of education were spent on the topic. Lastly, participants were also asked about their level of comfort with assessing a client who is suicidal.

Participants in this study were comprised of a convenience sample of master’s level students currently enrolled in either a Clinical Mental Health Counseling Program or a School Counseling Program at a public university in the southern United States.

Students were recruited from the following courses: Ethics, Addictions,

Dysfunctional/Abnormal Behavior, Techniques, Practicum, or Internship. These classes were chosen because they were pertinent to the educational content of the training and are more frequently taken towards the end of a students’ courses in the master’s program.

Participants were randomly assigned to either the treatment group or the control group and provided with the pretest. Participants in the treatment group received a four-hour training that was provided over the course of two different days. These two-hour sessions were provided anywhere from one week apart to one month apart, based on when the participants were scheduled to be trained. Participants in the treatment group participated either in person or in a live streaming session over Blackboard Collaborate if they were recruited to participate through a counseling course provided online.

Participants in the control group did nothing in between the pretest and posttest.

Descriptive Statistics of Demographic Data

A total of 62 individuals participated in the study, with a response rate of 60%.

The participants were randomly assigned into a treatment or control. This random assignment resulted in having 32 individuals in the treatment and 30 in the control. All participants completed their pretest and posttest. All questions were answered with the

66 Texas Tech University, Nicole L. Black, May 2017 exception of a couple, which will be discussed with the corresponding data analysis below.

Demographic data regarding participant age, gender, or ethnicity were not obtained. Demographic data focused on collecting information in regards to participants’ prior experience or education of suicide assessment and their level of comfort assessing a suicidal client. Information on participants’ prior education and experience as well as comfort was included to better understand educational implications for counseling programs and supervisors in the field of counseling.

Level of Comfort

Students were asked during their pretest and posttest to report their level of comfort assessing a client that was suicidal. This was done to measure if participants showed any change in comfort after receiving the suicide assessment training program.

They were asked to do this on a Likert scale ranging from 1 (being the lowest level of comfort) to 10 (being the highest level of comfort). The participants’ levels of comfort were analyzed by three categories: “low comfort” included scores of 1-3, “medium comfort” included scores of 4-6, and “high comfort” included scores from 7-10. This information was analyzed using a t-test. The data met criteria for analysis using a paired- sample t-test because the data was obtained from the same participants under two different experimental conditions (Field, 2013).

Control group participants reported on the pretest experiencing feeling “low comfort” (n = 15) and “medium comfort” (n = 14) more often than feeling “high comfort” (n = 1). On the posttest, the control group had similar results with the majority

67 Texas Tech University, Nicole L. Black, May 2017 expressing “low comfort” (n = 13) and “medium comfort” (n =14) over “high comfort”

(n = 2). Treatment group participants also reported on the pretest “low comfort” (n =17) and “medium comfort” (n =10) more frequently than “high comfort” (n =5). However, the treatment group showed a significant increase of those reporting “high comfort” (n

=26) in suicide assessment over those who felt “medium comfort” (n =6) and “low comfort” (n =0). These results are displayed in Table 1. Participants who received the treatment reported a higher level of comfort (M=7.46, SE=.38) on their posttest as compared to their pretest (M=3.94, SE=.20) denoting an increase in 3.46 points after the treatment, t(31)=-8.64, p<.05. This difference had a large effect size (d=1.62), according to Cohen (1988). These results suggest that there was an effect of training on the students’ level of comfort in assessing clients who are suicidal.

Table 1: Comfort Assessing Suicidal Client

Level of Comfort Control Control Treatment Treatment Group Group Group Group Pretest (n) Posttest (n) Pretest (n) Posttest (n) Low (score 1-3) 15* 13* 17 0 Medium (score 4-6) 14 14 10 6 High (score 7-10) 1 3 5 26 *Two control group participants indicated a score of 0 on the pretest; 1 reported a score of 0 on the posttest

Prior Experience

Within both the treatment and control group, all participants answered the question about whether or not they had ever assessed a client who was suicidal. Students typically obtain experience assessing suicidal clients only during their field experience unless they have an outside job in which they interact with clients who are suicidal.

Counseling students obtain their clinical field experience through working with clients in

68 Texas Tech University, Nicole L. Black, May 2017 their Practicum and Internship courses. Only 19 (31%) participants reported ever assessing a client who was suicidal. Participants, excluding one outlier, reported having assessed an average of ten suicidal clients. Sixty-nine percent (n=43) of the total sample of participants reported that they had never assessed a suicidal client. One participant in the control group reported having assessed 100 clients. Due to this being an extreme outlier, this response was substituted with the mean response number (Field, 2013).

Data from both the control group and the treatment group regarding past experiences with assessing suicidal clients was then compared to their level of comfort assessing a suicidal client as measured on a Likert scale ranging from 1-10 using a

Pearson’s Chi Square for Association. A Pearson’s Chi Square test was deemed appropriate for this statistical analysis because it tests to see if there are any relationships between different categorical variables (Field, 2013). This analysis was conducted to determine if there was a relationship between the participants’ past experiences and the participants’ level of comfort in assessing individuals who are suicidal. The participants’ level of comfort was analyzed by three categories: “low comfort” included scores of 1-3,

“medium comfort” included scores of 4-6, and “high comfort” included scores from 7-10.

The Pearson’s Chi Square test was found to be significant, ( λ2 (2)= 10.90, p<.05, with an effect size of .43. Cramer’s V was run in order to determine the strength of the association between two variables (Field, 2013). This effect size, according to Cramer’s

V, represents a large effect size, showing that there is a strong association between the two groups (Field, 2013). Roughly half of participants (n=30) reported that they had a low level of comfort assessing a suicidal client. Sixteen participants (26%) reported

69 Texas Tech University, Nicole L. Black, May 2017 medium or high levels of comfort assessing a suicidal client even though they had never assessed a suicidal client.

Prior Education

Treatment and control group participants were also asked about whether or not they had received education on how to assess a client who was suicidal either through formal education in their master’s level program or through outside education. Half of all participants (n =31) reported that they had not received any education on suicide assessments either within their master’s program or through outside educational opportunities. Out of all participants (n =11) in the study, only eleven participants reported having had been educated on suicide assessment in their master’s program.

Thus, 82% of participants had never received any education on suicide assessment in their master’s program.

Of participants who responded yes to this experience, they reported receiving this education through the following classes: Introduction to Clinical Mental Health

Counseling, Ethics, Crisis, Abnormal/Dysfunctional Behavior, Internship, Addictions, and Assessment. Four participants reported having learned about suicide assessment in their Crisis course, three participants reported for Addictions, and two people reported learning suicide assessment in their Assessments course. The following courses were reported only one time as being a source of knowledge about suicide assessment:

Clinical Mental Health Counseling, Ethics, Abnormal/Dysfunctional Behavior, and

Internship. Twenty-two participants reported having received outside education on how to assess suicidal individuals, so roughly 62% of participants had not received any

70 Texas Tech University, Nicole L. Black, May 2017 training on suicide assessment from any source outside of their formal education through the master’s program. These results are displayed in Table 2 and Table 3.

Table 2: Demographic Data

Independent Participants Average Participants Average Variable with Prior number of with Prior number of Education in Hours of Outside Hours of Master’s Education in Education Outside Program Master’s Education Program Control Group 6 1.05 7 2.43 (N=30) Treatment Group 5 1.43 15 1.06 (N=32)

Table 3: Master’s Courses that Taught Suicide Assessment Course* Frequency Percentage No Course 51 82.2% Intro to Clinical Mental Health 1 1.61% Counseling Addictions 3 4.84% Ethics 1 1.61% Crisis 5 8.06% Assessment 2 3.23% Internship 1 1.61% Abnormal/Dysfunctional 1 1.61% Behavior Nonspecific (professors, class) 2 3.23%

*Some participants reported more than one course

The relationship between students’ prior education on suicide assessment through their master’s level program and participants’ perceived level of comfort assessing a client who is suicidal was examined. Data was analyzed using a Pearson Chi Square for

71 Texas Tech University, Nicole L. Black, May 2017

Association. A Pearson’s Chi Square test was deemed appropriate for this statistical analysis because it tests to see if there are any relationships between different categorical variables (Field, 2013). The test was found to be significant, ( λ2 (2)= 3.28, p<.05. with an effect size of .23, which, according to Cramer’s V, represents a medium effect size, showing that there is a medium association between the two groups (Field, 2013). Of these participants, 35% reported having medium to high levels of comfort assessing a suicidal client even though they never had any formal education on suicide assessment in their master’s level program, while roughly 48% (n =30) of all participants reported low levels of comfort assessing suicidal clients. Results from the Pearson Chi Square are displayed in Table 4.

Table 4: Chi Square of Comfort and Formal Education on Suicide

Comfort Frequency and Frequency and percentage of No percentage of Formal Education Formal Education on Suicide on Suicide Low (1-3) 27 (90%) 3 (10%) Medium (4-6) 17 (70.8%) 7 (29.2%) High (7-10) 5 (83.3%) 1 (16.7%)

The statistics for prior education, comfort, and prior experience were used to complement the statistical analysis of the Counselor’s Self-Efficacy Scale. These results are analyzed and available for review in the next section.

72 Texas Tech University, Nicole L. Black, May 2017

Descriptive Statistics of the Counselor’s Self-Efficacy Scale

Scoring Scale

The Counselor’s Self-Efficacy Scale (CSES) was scored based on a participant’s answers provided during pretesting and posttesting. The CSES contains 4 subscales and a total scale that are scored on a Likert scale ranging from 0-5 (0=No Confidence,

5=Complete Confidence). The scale is comprised of 42 questions that fall into four different subscales: “(a) Crises Situations (13-items), (b) Basic Counseling Skills (15- items), (c) Therapeutic Response to Crisis and Post-Crisis (8-items), and (d)

Unconditional Positive Regard (6-items)” (Sawyer et al., 2013, p. 34). The internal consistency of the CSES has been reported with a Cronbach’s alpha coefficient of .96, which indicates that the measurement has a high level of reliability (Sawyer et al., 2013).

The CSES was scored by the researcher and research assistant. The research assistant is a retired professional educator. The scores were double checked for accuracy.

Scoring was completed by the primary researcher totaling each subscale and then adding all subscales in order to obtain the value of the total CSES scale.

Null Hypothesis Testing

This section discusses the results of the five null hypotheses tests examined within this study. This study examined whether an educational program on suicide assessment was effective in influencing the student’s self-efficacy as measured by the CSES. This section contains the results of a mixed design ANOVA used to test these null hypotheses.

A mixed design ANOVA was deemed appropriate for analysis of this study due to the

73 Texas Tech University, Nicole L. Black, May 2017 fact that there was a treatment group and a control group from which data was obtained during pretest and posttest (Field, 2013).

Prior to conducting the analysis, the researcher ensured there was no missing data.

The dependent variables of the four self-efficacy subscales are measured by the CSES at the continuous level. The assumptions for each of the five ANOVAs conducted were met.

The assumption for normality was met by analyzing data for range, skewness, kurtosis, mean, and medians. The assumptions of normality indicate that the data between the control group and treatment group were relatively normal to one another (Field, 2013).

Homogeneity of variance was examined with a Levin’s test. Levin’s test ensures that the variance between two groups is equal (Field, 2013). The assumption of homoscedasticity was met using Box’s Test of Equality of Covariance Matrices and showed no significance for the CSES and also each of the subscales of the CSES. The assumption of homoscedasticity indicated the score for each group was spread relatively evenly around the mean (Field, 2013). Participants were evenly and randomly divided into treatment and control groups. The data met the assumptions for Independence, meaning that the two groups were comprised of different participants. Tables 5 and 6 show the values for the mean, standard error, median, mode, standard deviation, sample variance, kurtosis, skewness, and range for the treatment group and control group. A summary of the estimated marginal means and standard deviations for each subscale and the total subscale are reported in Table 7. Listed are the results of the null hypotheses tested using the mixed design ANOVA.

74 Texas Tech University, Nicole L. Black, May 2017

Table 5: Treatment Group Descriptives

CSES CSES CSES CSES CSES CSES CSES CSES CSES CSES Subscale Subscale Subscale Subscale Subscale Subscale Subscale Subscale Total Total 1 Pretest 1 Posttest 2 Pretest 2 Posttest 3 Pretest 3 Posttest 4 Pretest 4 Posttest Pretest Posttest

Mean 18.41 28.41 35.78 49.41 19.72 26.16 17.22 21.94 91.13 125.91 Standard Error 1.55 1.98 2.76 2.44 1.32 1.29 1.06 1.10 5.75 6.0

Median 15.5 26 34.5 54 20.5 27 16.5 24 90.5 133

Mode 15 21 29 60 23 32 24 24 90 149 Standard Deviation 8.79 11.18 15.63 13.80 7.45 7.30 5.98 6.24 32.55 33.93 Sample Variance 77.227 124.96 244.31 190.51 55.56 53.23 35.72 38.96 1059.34 1150.93

Kurtosis 0.64 -0.57 -0.34 -0.38 -0.58 -0.96 -0.95 -0.67 -0.47 -0.69

Skewness 0.55 0.53 -0.27 -0.75 -0.34 -0.10 -0.21 -0.40 -0.11 -0.53

Range 41 40 62 53 27 27 22 22 131 129

75 Texas Tech University, Nicole L. Black, May 2017

Table 6: Control Group Descriptives

CSES CSES CSES CSES CSES CSES CSES CSES CSES CSES Subscale 1 Subscale 1 Subscale 2 Subscale 2 Subscale 3 Subscale 3 Subscale 4 Subscale 4 Total Total Pretest Posttest Pretest Posttest Pretest Posttest Pretest Posttest Pretest Posttest

Mean 18.13 20.13 34.03 35.43 17.93 20.13 17.2 17.03 87.3 92.73 Standard Error 1.40 2.04 2.36 2.84 1.46 1.67 1.11 1.20 5.56 7.06

Median 19 19.5 33 32.5 16.5 18 18.5 18 82 83.5

Mode 24 28 42 24 16 32 12 24 73 54 Standard Deviation 7.66 11.17 12.94 15.54 7.97 9.15 6.10 6.58 30.46 38.65 Sample Variance 58.74 124.67 167.41 241.50 63.58 83.71 37.27 43.27 927.73 1494.06

Kurtosis 0.11 1.59 0.96 -0.79 -0.75 -1.33 -1.10 -1.40 -0.43 -0.97

Skewness -0.06 0.99 0.68 0.25 0.21 -0.02 -0.08 -0.06 0.13 0.15

Range 35 51 59 60 29 28 21 21 123 136

76 Texas Tech University, Nicole L. Black, May 2017

Table 7: Test of Within Subject Effects

Independent Variable Pretest Mean, SD Post Test Mean, SD CSES Subscale 1 Control Group 18.13, 7.66 20.13, 11.16 Treatment Group 18.41, 8.76 28.41, 11.17 CSES Subscale 2 Control Group 34.03, 12.94 35.43, 15.54 Treatment Group 35.78, 15.63 49.41, 13.80 CSES Subscale 3 Control Group 17.93, 7.97 20.13, 9.15 Treatment Group 19.72, 7.45 26.16, 7.30 CSES Subscale 4 Control Group 17.20, 6.11 17.03, 6.58 Treatment Group 17.22, 5.98 21.94, 6.24

CSES Total Control Group 87.30, 30.46 92.73, 38.65 Treatment Group 91.13, 32.55 125.91, 33.93

Results

Each of the null hypotheses for this study was examined and tested using appropriate statistical measures. The results of these null hypotheses are listed. A review of the null hypotheses is reviewed as well as an explanation of the analysis and results as follows.

Null Hypothesis 1. There will be no significant difference between the mean pretest and mean posttest scores of students in the experimental group and control group in self-efficacy in crisis situations, as measured by the Counselor’s Self-Efficacy Scale. A

2 by 2 mixed design ANOVA with repeated measures on the CSES for crisis situations was conducted. The Levene’s test of homogeneity of variance was not significant for the pre-test F(1,60) =.66, p =.42 nor for the posttest F(1,60) = .20, p =.67. The Box test of

77 Texas Tech University, Nicole L. Black, May 2017 homogeneity of covariance matrices was non-significant, Box’s M=.96, p=.82. The test showed that there was a statistically significant interaction effect between the treatment group and the level of self-efficacy in crisis situations, F(1, 60) =13.75, p<.05, η2=.18.

The interaction effect shows the suicide training program increased the reported self- efficacy of students in crisis situations as measured by the CSES. A visual representation of the differences in mean is provided in Figure 1 (Appendix F).

Null Hypothesis 2. There will be no significant difference between the mean pretest and mean posttest scores of students in the experimental group and control group in self-efficacy in basic counseling skills, as measured by the Counselor’s Self-Efficacy

Scale. A 2 by 2 mixed design ANOVA with repeated measures on the CSES for basic counseling skills was conducted. The Levene’s test of homogeneity of variance was not significant for the pre-test F(1,60) =1.06, p =.31 nor for the posttest F(1,60) = .55, p =.46.

The Box test of homogeneity of covariance matrices was non-significant, Box’s

M=13.99, p=.004. Testing for this null hypothesis showed that the suicide training program did in fact have a statistically significant effect on students within the treatment group’s reported self-efficacy in self-efficacy in basic counseling skills as measured by the CSES, F(1, 60) =13.63, p<.05, η2=.18. This effect shows that the suicide training program increased the reported self-efficacy of students in basic counseling skills. It was also noted that this subscale had noticeably higher scores than those of the other subscales when comparing the pretest and posttest score of both the treatment and control group. A visual representation of the differences in mean is provided in Figure 2

(Appendix F).

78 Texas Tech University, Nicole L. Black, May 2017

Null Hypothesis 3. There will be no significant difference between the mean pretest and mean posttest scores of students in the experimental group and control group in self-efficacy in therapeutic response in crisis and post crisis, as measured by the

Counselor’s Self-Efficacy Scale. A 2 by 2 mixed design ANOVA with repeated measures on the CSES for therapeutic response in crisis and post crisis was conducted. The

Levene’s test of homogeneity of variance was not significant for the pre-test F(1,60)

=.21, p =.65 nor for the posttest F(1,60) = 3.48, p =.07. The Box test of homogeneity of covariance matrices was non-significant, Box’s M=2.29, p=.53. Testing for this null hypothesis showed that the suicide training program had a statistically significant effect on students within the treatment group’s reported level of self-efficacy in therapeutic response in crisis and post crisis situations, F(1, 60) =15.60, p<.05, η2=.20. This effect shows that the suicide training program increased the reported self-efficacy of students in therapeutic response in crisis and post crisis situations. A visual representation of the differences in mean is provided in Figure 3 (Appendix F).

Null Hypothesis 4. There will be no significant difference between the mean pretest and mean posttest scores of students in the experimental group and control group in self-efficacy in unconditional positive regard subscale, as measured by the Counselor’s

Self-Efficacy Scale. A 2 by 2 mixed design ANOVA with repeated measures on the

CSES for unconditional positive regard was conducted. The Levene’s test of homogeneity of variance was not significant for the pre-test F(1,60) =.06, p =.82 nor for the posttest

F(1,60) = .49, p =.49. The Box test of homogeneity of covariance matrices was non- significant, Box’s M=.08, p=.99 Testing for this null hypothesis showed that there was a statistically significant interaction between the treatment group and the self-efficacy of 79 Texas Tech University, Nicole L. Black, May 2017 students in the self-efficacy of unconditional positive regard F(1, 60) =13.75, p<.05,

η2=.18. This effect shows that the suicide training program increased the reported self- efficacy of the student’s unconditional positive regard. A visual representation of the differences in mean is provided in Figure 4 (Appendix F).

Null Hypothesis 5. There will be no significant difference between the mean pretest and mean posttest scores of students in the experimental group and control group in self-efficacy, as measured by the total score of the Counselor’s Self-Efficacy Scale. A

2 by 2 mixed design ANOVA with repeated measures on the CSES was conducted. The

Levene’s test of homogeneity of variance was not significant for the pre-test F(1,60)

=.02, p =.90 nor for the posttest F(1,60) = .82, p =.37. The Box test of homogeneity of covariance matrices was non-significant, Box’s M=2.95, p=.42. Testing for this null hypothesis showed that there was a statistically significant interaction between the treatment group and their overall self-efficacy as measured by the CSES F(1, 60) =20.54, p<.05, η2=.26. This effect shows that the suicide training program increased the reported overall self-efficacy of students. A visual representation of the differences in mean is provided in Figure 5 (Appendix F).

Qualitative Data

Two qualitative questions were asked in order to complement and supplement information obtained through quantitative measures. The first qualitative question was provided to participants at the end of the demographic form. The second qualitative question was included in the original version of the CSES, which was provided to students and analyzed. The qualitative data was analyzed using a triangulation method in order to compare if the qualitative data supported the findings from quantitative research 80 Texas Tech University, Nicole L. Black, May 2017 or if these findings were conflictual in any way (Jick, 1979). The questions are discussed below.

Qualitative Question A

Participants were asked on the demographic form for the posttest, “What have you learned about suicide risk factors?” Of the 32 participants in the treatment group, only two participants did not provide a response to this question. Responses were coded for key terms, and the researcher was able to identify six major themes. The vast majority of participants provided multiple responses to this question in incomplete sentences, which fell into assorted categories for thematic purposes. A description of each of the themes and the responses of participants within each theme is listed as follows.

Questions to ask. The first theme identified was one of participants’ learning

“what questions to ask” in an assessment. Out of the 30 participants who responded, fifteen reported that they had learned what questions to ask during a suicide assessment through the training.

Table 8: Theme 1 - Questions to Ask

Participant Number Response 1 “questions to ask” 2 “questions to ask” 5 “ask follow up questions” 6 “what to ask” 7 “ask direct, pointed questions during psychological first aid” 8 “questioning the client is necessary” 10 “what to ask the client” “suicide risk assessment follows a certain line of questioning for 14 every suicidal individual” 81 Texas Tech University, Nicole L. Black, May 2017

Participant Number Response 15 “how to ask questions about their suicidal thoughts and ideations” 17 “questions to ask” “it is important to ask the appropriate questions to receive 21 information on how severe risk is” “the questions to ask (and to use a risk assessment when you suspect 22 a person/client is suicidal” 24 “what questions to ask” 25 “what questions to ask” 28 “questions to ask”

How to do risk assessment. The second theme was one of participants’ learning

“how to do risk assessment” with thirteen out of 30 participants reporting this theme.

Table 9: Theme 2 - How to do Risk Assessment

Participant Number Response 1 “steps to assess suicide” 9 “how to administer a suicide risk assessment” 14 “suicide risk assessment follows a certain line of questioning” “I learned how to assess the client’s initial thoughts of suicide, how 15 to ask questions about their suicidal thoughts and ideations, the level and frequency of and intensity of the suicidal ideations” “I have learned about what factors to look for as different risk for a 16 person while visiting with them about suicide. I am confident I could rate a client as none, mild, medium, or high level of risk.”

18 “how to assess” 19 “assessing” “I learned it’s very important to follow the assessment steps in 20 order to measure a client’s suicidality.” “The questions to ask (and to use a risk assessment) when you 22 suspect a person/client is suicidal.”

24 “how to perform an intake and assessment” 27 “Become familiar with crisis procedures and resources.” 31 “How to assess for suicide.”

82 Texas Tech University, Nicole L. Black, May 2017

Participant Number Response “Proper steps to take to insure [sic] the safety of everyone 32 involved.”

Risk factors/protective factors. The third theme identified was that students reported learning “how to identify risk factors and protective factors” when doing crisis assessments. Twelve out of 30 participants reported this skill.

Table 10: Theme 3 - Risk Factors

Participant Number Response 2 “signs of suicide attempts” 5 “to read the client” 6 “risk factors” 9 “to evaluate for risk factors” “I did not think there were so many factors that potentially could 13 lead to suicide risk. I think I might need more training to feel more comfortable doing it on a client.” “I have learned about what factors to look for as different risk[s] for 16 a person while visiting with them about suicide.”

17 “Signs to look for, questions to ask, protective factors” 19 “risk factors” 23 “I have learned about risk factors” 24 “what the risk factors are, suicidal ideations” 26 “Reading the signs by what the client says” “There are many risk factors, just because a person had risk factors 29 does not mean they are suicidal. Risk factors are not something to ignore, but to use as a guide.”

Documentation. The fourth theme identified was that participants’ obtained knowledge on how to do “documentation” with seven out of 30 participants reporting knowledge gained in this area. 83 Texas Tech University, Nicole L. Black, May 2017

Table 11: Theme 4 - Documentation

Participant Number Response 4 “documentation” 7 “cover your ass through documentation” 10 “documentation of suicide risk” 12 “always document to protect yourself” 15 “the extreme importance of documentation” 19 “how to document” 27 “Document everything.”

Laws and ethics. The fifth theme identified was one of participants learning about the applicable “laws” and “ethics” that relate to suicide and that are specific to their

State. Seven out of 30 participants indicated that they had learned about this.

Table 12: Theme 5 - Laws and Ethics

Participant Number Response 6 “what we can be held liable for” 10 “protection against lawsuits” 19 “laws” 22 “The laws and codes counselors must follow with suicidal clients.” 25 “Laws pertaining to practice.” “It is critical to abide by all ethics codes and laws in the city and 27 state that you live in.”

31 “I have learned when I am and am not liable.”

Resources. Lastly, another five out of 30 participants reported the sixth and final theme of learning about “resources” for clients who are in crisis.

84 Texas Tech University, Nicole L. Black, May 2017

Table 13: Theme 6 - Resources

Participant Number Response 1 “who to call” 12 “call the crisis team for help” 17 “who to call” 22 “when to refer to MCOT or when to use a safety plan” 27 “Become familiar with crisis procedures and resources.”

Qualitative Question B

Participants were asked, “How do you feel about your capabilities to successfully support a client in crisis?” This question was provided on the CSES and was included in triangulation analysis by the primary researcher because the responses being available responses were complementary to the research goals of this study. Out of the 32 participants in the treatment group, only two participants did not respond to this question.

Responses were then coded for key terms, and the researcher was able to locate four major response themes.

Increased confidence. The first theme identified was one of participants’ feeling more confidence in their abilities to support a client in crisis. Of the 30 participants who responded, fourteen reported this theme. Some participants who reported this stated,

Participant 6: “[This s]eries of lectures better equipped us as practitioners to deal

w[ith] a client who is having suicidal ideations or who has had suicide attempts.

We really don’t get that education in our master’s program. Good informative

series of lectures. I feel confident moving forward w[ith] a suicidal client.”

85 Texas Tech University, Nicole L. Black, May 2017

Participant 14: “I feel more confident in assessing suicide risk in individuals. I

have a copy of an assessment form I can go through for every client.”

Participant 9: “I feel fairly confident in my capabilities as long as I remain calm

and utilize the techniques that I have been taught.”

Increased knowledge and skills. The second major theme identified was one of participants’ reporting more knowledge or specific skills that they have learned during the course of the suicide intervention program. Out of the 30 participants who responded, fourteen reported this theme. Participants who indicated this change stated things such as

Participant 16: “I feel much more confident about my ability to support a client

in crisis because now I know where to start the conversation. I know to jump

right in about suicidal thoughts or attempts in the past, immediate, or long term

risk and setting a plan for crisis [sic].”

Participating 15: “The instructions that were given during the training were

incredibly helpful. I feel that I have gained a better understanding and knowledge

on approaching a crisis situation than I did before the training.”

Participant 11: “I feel like I have more knowledge that will help me successfully

support a client in crisis. I know what steps to take to help clients when they are

in crisis, or others who can help keep the client safe if it is out of my scope.”

More capable. The third major theme identified from this qualitative question was a theme of participants’ feeling more capable or being “better equipped” to handle a client in crisis. Of the 30 participants who responded, seven reported this theme and made comments such as

86 Texas Tech University, Nicole L. Black, May 2017

Participant 24: “I feel fairly capable because I know what signs to look for, what

risk factors to assess, and the process of helping someone in crisis was explained

to me.”

Participant 19: “I feel a lot more positive about my capabilities to successfully

support a client in counseling because now I know what steps to take, but I would

feel even more confident with real experience.”

More comfort. Lastly, participants reported the theme of feeling more comfort in their ability to assess a client who was in crisis. Of the 30 participants who responded to this question, five reported this theme. Participants with this theme made comments such as

Participant 2: “I feel comfortable in helping clients in crisis because I feel I

know better questions to ask someone who is going through a crisis.”

Participant 4: “Again I feel that personality wise I feel comfortable with crisis

situations but after the class (intervention/treatment)[,] I feel that the confidence

in myself went up due to being through further information on the subject of crisis

and suicide.”

Summary

In summary, this chapter provided an analysis of the quantitative and qualitative data analysis for the dissertation. Quantitative data was analyzed using a mixed design

ANOVA and showed statistical significance for each null hypothesis proposed in this study. Qualitative data was also analyzed for better understanding of research questions.

The combination of the two research methods provided for greater understanding of

87 Texas Tech University, Nicole L. Black, May 2017 participants’ experiences and changes in self-efficacy as it relates to the suicide training program. These mixed methods procedures provided richer understanding and implication for the field. Chapter 5 will provide a discussion of the findings for this study as well as limitations and implications for future research.

88 Texas Tech University, Nicole L. Black, May 2017

CHAPTER V FINDINGS

The following chapter provides a summary and discussion of the findings for this study. These findings have implications for counseling programs with the Council for the

Accreditation of Counseling and Related Educational Programs (CACREP) accreditation, as well as for counselor education and supervision. Limitations, and recommendations for future research are discussed in the chapter and concluding comments tie together this study as a reason to pursue suicide intervention to save needlessly lost lives.

Summary

The purpose of this study was to develop and examine, for change, a training program that instructs master’s level counseling students on how to effectively to intervene with a client who is suicidal. The review of the literature in Chapter 2 demonstrates there is not currently a known training program that fulfilled this need for students in a timely and cost-effective manner. Nor was there a training program that educated students on all eight domains of the Suicide Prevention Resource Center’s Core

Competencies for Suicide Assessment (Pisani et al., 2011). This was especially of concern because the core competencies include a call for professionals to understand their state’s laws and ethics pertaining to suicide intervention. A need for such training was further echoed by the 2016 CACREP standards (CACREP, 2016). This study showed significance in creating such a training program, as indicated by the data analysis discussed in Chapter 4.

This study fulfilled a previously existing gap in research. This dissertation highlighted the fact that suicide training programs are currently available, but none of 89 Texas Tech University, Nicole L. Black, May 2017 them studies changes in self-efficacy among master’s level counseling students.

Furthermore, these previously published studies also contain several limitations. For example, the study published by McNeil et al. (2008) lacked three of the eight domains for the 24 Core Competencies and did not utilize valid and reliable measures for pre/posttesting. The study conducted by King and Smith (2000) focused on changes in self-efficacy but also used assessments that were not valid or reliable and that were used only by school counselors in their study. Lastly, the study by Reis and Cornell (2008) did not include three of the eight domains for the 24 Core Competencies for suicide assessment. It also did not utilize a valid and reliable assessment for self-efficacy. This dissertation filled a gap in the literature by conducting an assessment on changes of self- efficacy among master’s level counseling students that received training on suicide assessment based on the 24 Core Competencies. Discussions of the implications are included below.

Discussion of the Findings

The following section provides a review of each of the research analyses conducted. These include a discussion of the findings for the descriptive statistics of demographic questions. This section also reviews the null hypotheses that were selected for this study. Null hypotheses were used in order to validate the statistical value of a pre/post test experimental design. In addition, this section discusses the results of the tested null hypotheses and an interpretation of the results. Lastly, the qualitative questions will be reviewed and discussed.

90 Texas Tech University, Nicole L. Black, May 2017

Descriptive Statistics of Demographic Data

Demographic data aimed at collecting information about the clinical and educational experiences of participants prior to their participating in the study. This was done to better ascertain how much education participants had received on suicide assessment and how comfortable they felt. Participants in the treatment and control group were asked about what type of education they had received, and this was compared using a Pearson’s Chi Square of Association to determine the level of association between these two factors. These results showed that a staggering 82% of study participants had not received any type of suicide training in their master’s program.

Furthermore, 62% of all participants had not received training of suicide assessment either in their master’s program or through some outside source of education. These findings hold great implications for the field and will be discussed more in depth further in this chapter.

Participants who received the treatment were asked during the pretest and the posttest about their level of comfort assessing a client that was suicidal. This question was posed to better understand the level of comfort that these participants had when asked to participate in a task that is often anxiety provoking for counselors (Douglas &

Morris, 2015). This study found that participants in the treatment group had a significantly higher level of comfort in assessing suicidal clients after receiving the suicide training program. This holds great implications for the field of counseling as it relates to suicide assessment, and these finding will be discussed in more depth later in the chapter.

91 Texas Tech University, Nicole L. Black, May 2017

Null Hypotheses

Null Hypothesis 1. There will be no significant difference between the mean pretest and mean posttest scores of students in the experimental group and control group in self-efficacy in crisis situations, as measured by the Counselor’s Self-Efficacy Scale.

This null hypothesis was rejected, indicating that there was a significant difference between the control group and the treatment group when the data was analyzed using a

Mixed Design ANOVA.

This study focused on influencing the self-efficacy of master’s level counseling students as it pertains to crisis situations. This study attempted to influence student self- efficacy by educating participants in the treatment group on how to effectively intervene with a client that is suicidal. This education consisted of familiarizing students on the 24

Core Competencies for Suicide Assessment and the information required to be educated in each of the competencies. This subscale assessed how efficacious participant felt when working with a variety of crisis situations such as suicide, murder, and sexual assault. This study indicates that participants felt an increase in self-efficacy with working through these types of crisis situations after having received the suicide assessment training provided by the researcher. This holds implications for the field because the suicide training program positively influenced how efficacious future counselor’s felt when working with difficult counseling situations and crises.

Null Hypothesis 2. There will be no significant difference between the mean pretest and mean posttest scores of students in the experimental group and control group in self-efficacy in basic counseling skills, as measured by the Counselor’s Self-Efficacy

Scale. This null hypothesis was rejected, indicating that there was a significant difference 92 Texas Tech University, Nicole L. Black, May 2017 between the control group and the treatment group when the data was analyzed using a

Mixed Design ANOVA.

This study aimed to influence the self-efficacy of participants’ basic counseling skills. As previously discussed in Chapter 2, basic counseling skills are at the foundation of counseling and form the basis of every therapeutic relationship that counselors have with the client. These findings hold positive implications for the field because this suicide training program showed to increase counseling students’ self-efficacy in basic counseling skills. Not only will this benefit future counselors when handling crisis situations but also in their everyday therapeutic conversations with clients.

The 24 Core Competencies includes several different goals that likely helped influence the significant change on this subscale for the treatment group. Several of the skills listed in the basic counseling skills subscale were taught throughout the different domains of the core competencies. These skills were covered in various domains, including the Attitudes and Approaches domain, the Formulating Risk domain, and the

Developing and Implementing a Treatment Plan domain.

Null Hypothesis 3. There will be no significant difference between the mean pretest and mean posttest scores of students in the experimental group and control group in self-efficacy in therapeutic response in crisis and post crisis, as measured by the

Counselor’s Self-Efficacy Scale. This null hypothesis was rejected, indicating that there was a significant difference between the control group and the treatment group when the data was analyzed using a Mixed Design ANOVA.

93 Texas Tech University, Nicole L. Black, May 2017

This study aimed to influence the self-efficacy of participants in regard to their skills to have a therapeutic response to crisis and post-crisis situations. This was analyzed by the crisis and post crisis subscale, and the suicide training program proved to have a significant impact on the treatment group’s self-efficacy when working with these situations. This was addressed in the training program by teaching participants about

Psychological First Aid; the training positively changed clients’ views and thinking during crisis situations. This holds implications for the field because it shows that the suicide training program equipped future counselors to be more self-efficacious in their response to crisis situations. Research shows that counselors’ self-efficacy is vital in predicting how they deal with difficult client situations (Douglas & Morris, 2015).

Null Hypothesis 4. There will be no significant difference between the mean pretest and mean posttest scores of students in the experimental group and control group in self-efficacy in unconditional positive regard, as measured by the Counselor’s Self-

Efficacy Scale. This null hypothesis was rejected, indicating that there was a significant difference between the control group and the treatment group when the data was analyzed using a Mixed Design ANOVA.

As previously discussed in Chapter 2, unconditional positive regard is a basic component of the counseling relationship between a therapist and client and is taught as a standard of care in counseling programs. These findings hold implications for the field and show that future counselors feel more efficacious in providing a safe and warm environment for their clients. This is a necessary skill not only during crisis situations but also in all therapeutic conversations and relationships. These findings indicate that

94 Texas Tech University, Nicole L. Black, May 2017 participants gained an enhancement in their day-to-day counseling abilities by participating in this study.

Of additional interest, this subscale had noticeably higher scores when compared to the other subscales for both the pretest and posttest scores of the treatment and control group. This subscale had two questions more than the first subscale, but even this difference in the number of questions does not account for the overall difference in subscale scores. This higher level of self-efficacy in basic counseling skills may be due to the fact that these skills are core components and are taught heavily in counseling programs. These counseling skills are taught by using skills training where counselor educators focus on ensuring that students are using specific skills in their counseling sessions. This holds implications for the teaching of suicide assessment skills and encourages the justification for suicide assessment skills training for master’s students.

Null Hypothesis 5. There will be no significant difference between the mean pretest and mean posttest scores of students in the experimental group and control group in self-efficacy, as measured by the total score of the Counselor’s Self-Efficacy Scale.

This null hypothesis was rejected, indicating that there was a significant difference between the control group and the treatment group when the data was analyzed using a

Mixed Design ANOVA. The rejection of the fifth null hypothesis shows that the suicide training program was efficacious in impacting the self-efficacy of participants in the treatment group in their overall level of self-efficacy as measured by the CSES. These findings hold implications for the field of counseling by showing that this suicide training program, which includes all domains of the 24 Core Competencies, increases the self- efficacy of future counselors. 95 Texas Tech University, Nicole L. Black, May 2017

Qualitative Questions

This study aimed at answering two different qualitative questions to gain a richer and fuller understanding of participants’ experiences and knowledge. These qualitative questions included “What have you learned about suicide risk factors?” and “How do you feel about your capabilities to successfully support a client in crisis?”

When asked, “What have you learned about suicide risk factors?” participants responded within six major themes:

1. Questions to ask

2. How to do risk assessment

3. Risk factors/protective factors

4. Documentation

5. Laws and ethics

6. Resources

These themes correspond with the 24 Core Competencies and hold implications for the field of counseling and counselor educators. The implications for the field will be discussed further in this chapter.

When participants were asked, “How do you feel about your capabilities to successfully support a client in crisis?” they responded with the following major themes:

1. Increased confidence

2. Increased knowledge and skills

3. More capable

4. More comfortable 96 Texas Tech University, Nicole L. Black, May 2017

The qualitative analysis of this question bolsters the quantitative findings of this study that participants felt a higher level of confidence, comfort, and capability when assessing suicidal clients leading to a higher level of self-efficacy in suicide assessment. These findings hold implications for counselor education and will be discussed in greater detail later in this chapter.

Implications for Delivery of Information

One of the obstacles of other programs developed for suicide prevention training around the 24 Core Competencies for suicide assessment is that researchers were restricted by available delivery methods of information. This was either because course developers required in-person training with an instructor that had specialized training in his or her specific model or had a cost for delivery and travel to sites. This created more obstacles for participants to attend their trainings in a cost-effective manner. However, the program developed for this study provided a great amount of information that was accessible to students through live in-person lectures as well as through synchronous distance lecture.

This study fulfilled a need for online accessible training that was previously missing in the field of counseling. Research indicates that distance education formats do not reduce the self-efficacy of counseling students and this study complements this prior research (Meyer, 2015). In fact, one study found that counseling students enrolled in online courses felt more self-efficacy than those enrolled in traditional face-to-face courses (Watson, 2012). The findings of this study hold promise for the field of counseling that there is the ability to provide students with an impactful synchronous distance suicide training program. In addition, the results of this study appear to be 97 Texas Tech University, Nicole L. Black, May 2017 generalizable to other states because of the commonality of standards of care among

LPCs in different states. All states in the US have professional licensure credentialing requirements. With minor adaptation for state specific codes of ethics and laws, this study could be efficacious in other states.

Furthermore, this training was done during four hours while other programs taught their information over the course of five to fifteen hours. It should be noted that providing this program over the course of four hours proved to be efficacious in influencing the self-efficacy of participating students and increased their self-reported levels of comfort, knowledge, and capability as reported through both quantitative and qualitative data.

Implications for CACREP

As previously stated in Chapter 2, CACREP requires that certain aspects of suicide assessment and crisis intervention be infused within the curriculum of CACREP accredited programs. Unfortunately, a method for assuring compliance is not prescribed in the 2016 CACREP Standards, nor was it prescribed in the 2009 CACREP Standards.

Most programs have crisis counseling built into numerous courses or have a stand-alone

Crisis counseling course. The Standards communicate that CACREP accredited programs should teach about suicide within the foundational knowledge areas of “Counseling and

Helping Relationships” and “Assessment and Testing.” Furthermore, CACREP states that these topics should include “suicide prevention models and strategies,” “crisis intervention, trauma informed, and community-based strategies, such as Psychological

First Aid,” and “procedures for assessing risk of aggression or danger to others, self- inflicted harm, or suicide” into their programs (“2016 CACREP Standards,” 2016). 98 Texas Tech University, Nicole L. Black, May 2017

However, programs are free to determine where and how they infuse these required standards, leading to a lack of guidance or adherence to the standards. This concern is echoed in the findings of this study.

The counseling program where the participants were recruited is currently

CACREP accredited under the 2009 standards and does include these suicide-and-crisis- related learning objectives in their course syllabi. The program also has a stand-alone

Crisis counseling course that addresses suicide as part of a larger focused crisis context.

However, the participants reported, at an alarming rate, not having been provided education on suicide assessment. This could be due to a variety of factors. First, students may not have taken the Crisis counseling course yet. The students may not have effectively remembered the material from crisis counseling, or the students may have received suicide knowledge, but not how to intervene, like this program includes.

Surprisingly, half of the students in this study (n=31) reported not receiving any education on suicide assessment techniques. This could be due to the reasons above, or because they had not yet enrolled in a course that provided such training, or because their professors struggled to include dedicated lecture and practice time to the topic of suicide assessment amidst all the other important topics to be covered. Lastly, it is possible that professors covered the topic of suicide assessment but did not dedicate time in class for the practice of these skills, thus resulting in incomplete curricular experience for some students.

Morris and Minton (2012) and Wonzy (2012) found that CACREP programs lacked class time dedicated to the discussion of suicide assessment techniques. Morris and Minton (2012) found that master’s students reported not learning about suicide 99 Texas Tech University, Nicole L. Black, May 2017 assessment in their Master’s program. Only 20.73% of participants in their study reported completing a crisis intervention course (Morris & Minton, 2012). Of the sample assessed, 26.95% of participants reported “no preparation” or “minimal preparation” in suicide assessment, and 36.27% reported “no preparation” or “minimal preparation” in suicide management and intervention (Morris & Minton, 2012). In Wonzy’s (2012) study, it was discovered that as low as 2% of master’s programs explicitly included suicide assessment in the course curriculum based on online program and course descriptions. When the findings of this study are considered in addition to the finding of

Morris and Minton (2012) and Wonzy (2015), there is evidence that CACREP may need to take additional steps towards ensuring that suicide assessment is more explicitly covered in their accreditation standards.

This study’s findings suggest that CACREP should explicitly state the courses that should infuse the required standards for suicide assessment. It is recommended that these standards be mandated and covered within an appropriate class prior to master’s level students’ participating in actual counseling with real clients. This could be accomplished by requiring suicide assessment to be covered within Techniques, or pre- practicum courses that must be completed prior to the students’ working with real clients.

Covering this topic in a crisis counseling course would be logical, but because CACREP does not require programs to have a stand-alone crisis course, this may not be possible for all institutions.

Furthermore, it would be beneficial for CACREP to establish a required timeframe for the topic of suicide assessment to be covered in a counseling program.

This study gives credence to a four-hour training dedicated to the topic provides enough 100 Texas Tech University, Nicole L. Black, May 2017 time for students to experience an increase in self-efficacy, knowledge, and capability.

Lastly, CACREP and counselor educators could benefit from establishing a guideline to follow to ensure that suicide assessment training is covered in a thorough manner during the student’s master’s program. It is recommended that CACREP require programs to ensure student proficiency in the 24 Core Competencies of suicide assessment. The suicide training program developed for this study could be a recommended tool in accomplishing this goal because it is statistically significant in increasing the self- efficacy of students and is based on the 24 Core Competencies. In addition, the training increased participants’ self-reported levels of comfort, knowledge, and capability of students as reported through both quantitative and qualitative data.

In addition, counselor educators could implement an experiential classroom exercise for these skills by providing an additional hour of live roleplaying and practice in the classroom after each two-hour portion of the suicide training program. This could last two-to-three hours of a course meeting. Counselor educators could also choose to provide suicide assessment practice in shorter periods over the course of several classes after both sessions of the suicide training program are provided. This could be done by including examples of suicidal clients in the roleplays done throughout the semester or by providing case examples for students to review and complete case conceptualization.

Finally, it is recommended that counselor educators provide specific time for students to practice suicide assessment skills immediately after the educational sessions and also throughout the course of their class semester. Counselor educators should focus on students practicing their skills heavily for suicide assessment and suicide safety planning. This is of the utmost importance due to the fact that suicidal clients are 101 Texas Tech University, Nicole L. Black, May 2017 presenting in the field of counseling (Rogers et al, 2001). This extra practice could easily be facilitated by providing students with the Crisis Assessment form (Appendix E) and the Safety Plan form developed by Stanley and Brown (2008) to practice these skills in class by roleplaying with one another or by working through a vignette using the forms.

These would be effective methods of developing students’ self-efficacy based on

Bandura’s research (1997).

Implications for Counselor Education

Ensuring Student Competency

The researcher asked questions to assess whether students had received any formal education on suicide assessment either through their master’s level program or through educational opportunities outside of their master’s program. As stated earlier in the section covering CACREP standards, half of all participants reported that they had not received any education of suicide assessment either within their master’s program or through outside sources of education. Furthermore, it should be noted that 82% of all participants reported not receiving any education on suicide during their master’s level education thus far. This could have been the case due to various reasons but is of concern for several reasons. Research indicates that counselors are highly likely to interact with a suicidal client (Rogers et al., 2001). However, counselors often feel anxious about their ability to intervene with a suicidal client (Douglas & Morris, 2015). It stands to reason that this anxiety will be worsened when counselors do not have experience or education on suicide intervention.

102 Texas Tech University, Nicole L. Black, May 2017

The researcher also analyzed data related to students’ perceived level of comfort assessing a client that was suicidal and the students’ history of ever assessing a client for suicidality. The Pearson Chi Square for Association showed that there was a significant effect between these two constructs. Almost half of all participants between the treatment group and control group (n=30) reported on the pretest a low level of comfort assessing a client that was suicidal and indicated that they had never assessed a client before. This is to be expected, as these participants have never completed a suicide assessment.

Research indicates that 71% of counselors will experience a client that is suicidal

(Rogers et al, 2001). Counseling programs must ensure student competency in suicide assessment by ensuring that the topic is covered in a clear and explicit manner during a master’s level program. This should be done before students have interactions with real clients. Based on the aforementioned information, counseling programs must be prudent in ensuring content mastery on the topic of suicide assessment. Programs may ensure content mastery by implementing mock assessment procedures to gauge students’ level of comfort or level of competency, comfort, or self-efficacy as it relates to the suicide assessment of an actively suicidal client.

Of serious concern, sixteen participants (26%) reported, on their pretest, medium or high levels of comfort assessing a suicidal client even though they had no prior experience assessing a suicidal client. This is of great concern to counseling programs that may be producing clinicians that have an overinflated belief in their abilities to intervene with suicidal clients despite no real-world experience or education. In order to prevent an over-inflated sense of self-efficacy, it is recommended that counselor 103 Texas Tech University, Nicole L. Black, May 2017 education program take steps to ensure that student’s competency is solid and is not fleeting. Since the training teaches suicide knowledge to participants, it is logical to have the students practice the skills taught, and be able to apply those skills in a clinical setting with a qualified supervisor.

Though counseling programs cannot ensure that a student can interact and intervene with a suicidal client prior to graduation, they can ensure that students practice these suicide assessment skills after students are educated on the proper intervention techniques. This could be done effectively by infusing roleplaying scenarios that allow students to practice intervention strategies. These role-plays would be appropriate in the following courses: Crisis, Techniques, Pre-Practicum, Practicum, and Internship.

Another area that should be addressed by CACREP and counseling programs is who is responsible for ensuring competency in suicide assessment. Counselor educators are often burdened with teaching many different topics in course work and may expect practicum and internship site supervisors to carry the burden of teaching suicide assessment skills. Practicum and Internship site supervisors are required to have an hour of contact with students each week according to the 2016 CACREP Standards (CACREP,

2016). However, the site supervisor may assume that the burden of suicide assessment education falls on the counselor educator.

The 2016 CACREP Standards require that practicum and internship sites have access to “orientation, consultation, and professional development opportunities”

(CACREP, 2016, p.15). Furthermore, there should be “written supervision agreement” that defines the roles and responsibilities of the faculty supervisor, site supervisor, and

104 Texas Tech University, Nicole L. Black, May 2017 student during practicum and internship (CACREP, 2016, p.15). The findings of this study highlight a need for those areas of CACREP standards to be reviewed by both counselor educators and practicum and internship site supervisors to ensure that suicide assessment is being taught to students in an effective and comprehensive manner.

Both counselor educators and practicum and internship site supervisors should consider implementing testing procedures to ensure that students are, in fact, competent in suicide assessment. This could be done by administering a test over the educational content provided in this suicide training module. However, competency could also be measured by evaluating the self-efficacy of the students based on the Counselor Suicide

Assessment Efficacy Scale.

Lastly, this study holds implications for ensuring student competency with multicultural issues related to suicide. The Center for Disease Control (CDC) statistics indicate that certain populations are at increased risk of attempting and completing suicide. These populations include those with mental illnesses, Hispanic populations,

Native American populations, the elderly, and those who identify as lesbian, gay, bisexual, transgender, or queer (LGBTQ) (CDC, 2015). It is imperative that crisis intervention and suicide assessment are taught as components of working with these multicultural populations in various aspects of the counselor education program in order to ensure the highest level of student competency. By ensuring student competency in this area, the field of counseling can effectively address the mental healthcare needs of these multicultural populations.

105 Texas Tech University, Nicole L. Black, May 2017

Ensuring Student Comfort

As discussed in Chapter 4, the researcher included questions on the demographic form in order to assess participants’ levels of comfort in assessing a suicidal client before and after the training. Analysis of this data using a t-test showed a significant effect on the treatment group participants’ levels of comfort after they received the suicide training program, and this significance had a large effect size. These reports are further enhanced by qualitative data. Students in the treatment group were asked on the posttest how they felt about their capabilities to successfully support a client in crisis. Analysis of qualitative data revealed the following themes: increased confidence, increased knowledge and skills, more capable, and more comfort.

This analysis gives additional credence to the suicide training program and highlights students’ experiences of feeling more comfortable in their abilities to assess suicidal clients. It is important that counseling programs seek out programs that bolster the confidence and competency of students prior to their graduation and clinical experience. Furthermore, it is incumbent upon programs to provide practical and efficacious programs that provide practical knowledge to future practitioners.

The findings of this study indicate that this suicide training program increased the level of comfort for participants. This study showed that students felt more efficacious in their suicide assessment skills, which is related to a lower level of anxiety (Larson, et al.,

1992). Furthermore, the findings of this study indicate that this program will lead to higher levels of counselor self-efficacy and will boost the efficacy of students with counseling-related skills.

106 Texas Tech University, Nicole L. Black, May 2017

Content of Suicide Training

The focus of this study was to study the ability of a suicide training program to influence the perceived self-efficacy of master’s level students when it comes to assessing clients for suicide risk. Prior to this, there was no such training documented in the literature (Pisani et al., 2011). Other programs based on the SPRC’s 24 Core

Competencies for suicide assessment focused on teaching these competencies to fully licensed clinicians and neglected future practitioners. Furthermore, these programs did not cover all eight domains of the 24 Core Competencies (McNeil et al., 2008, Oordt,

Jobes, Fonseca, & Schmidt, 2009, Pisani et al., 2011, Reis & Cornell, 2008).

The training program developed for this study aimed to provide content coverage of each of these domains and was specifically structured around each of the 24 Core

Competencies and the components that would need to be covered for students to master each competency. Unfortunately, there is not a current quantitative measure that assesses an individual’s knowledge of how to conduct suicide risk assessments because there are many components that are required to master this skill. Therefore, the researcher asked a qualitative conclusion question to gain a better understanding of participants’ experiences. This question asked what participants have learned about suicide risk assessment. Participants responded within six major themes

1. Questions to ask

2. How to do risk assessment

3. Risk factors/protective factors

4. Documentation

5. Laws and ethics 107 Texas Tech University, Nicole L. Black, May 2017

6. Resources

Based on this information, it appears that students identified learning an impactful amount of information that fell into the following domains of the SPRC’s 24 Core

Competencies for suicide assessment:

Domain 2: Understanding Suicide

Domain 3: Collecting Accurate Assessment Information

Domain 4: Formulating Risk

Domain 7: Documenting

Domain 8: Understanding Legal and Regulatory Issues Related to Suicide.

It is important to note that participants also reported learning information from the domains one, fix, and six, but that not enough participants reported this information for it to be considered a significant theme in qualitative data.

Other programs based on the SPRC’s 24 Core Competencies for suicide assessment often neglected to cover Domain 8 of the 24 Core Competencies, which covers “understanding legal and regulatory issues related to suicide.” This is a major concern for licensed practitioners because they must follow the ethical and legal requirements of the licensing boards and national associations and must also comply with local and state laws. By not addressing these needs, practitioners are left alone to navigate many different regulatory bodies that often provide conflicting rules and regulations.

For example, Licensed Professional Counselors (LPC) in the state studied in this study must comply with the following regulatory bodies and laws: Health Insurance 108 Texas Tech University, Nicole L. Black, May 2017

Portability and Accountability Act of 1996 (HIPPA), The Board of Examiners of

Professional Counselors, and the American Counselor Association Code of Ethics. LPCs dealing with a suicidal client in this state must also comply with the following State legal codes that pertain to suicide, Health and Safety Codes and Family Codes. Those practicing in a school setting must comply with the Education Code. Lastly, this southern state does not have a law that supports a “Duty to Warn,” and this is cited in case law handed down by the State’s Supreme Court. There is an overwhelming amount of information for any new practitioner, much less a master’s level student. However, this training program could present all this information to future practitioners in a succinct manner and bring about a discussion of how these different codes and laws may be conflictual at times and how a counselor may abide by these in order to prevent legal risk.

Counseling programs should consider implementing a program like the one developed in this study’s research because it covers all aspects of the 24 Core

Competencies for suicide and meets the educational needs of master’s level students in a timely, effective, and comprehensive manner. Participants not only reported an increase in all areas of self-efficacy measured by the CSES, but they also provided qualitative feedback that indicates they learned about important aspects of suicide assessment and intervention. Lastly, this information provided in the training program is applicable not only to those focused on Clinical Mental Health Counseling but also to those focused on

Professional School Counseling.

Limitations of the Study

This study focused on statistically significant change in self-efficacy of students who received a suicide training program versus control group students who did not 109 Texas Tech University, Nicole L. Black, May 2017 receive any interventions. One limitation of this study was the time that was taken to provide the intervention to the students. This study was limited to two two-hour sessions of lecture and practice, which did not allow for more instructional time with students.

Furthermore, due to class schedules, some students received the two sessions over the course of three weeks. It is possible that these students may have experienced a small maturation effect if they learned anything about suicide assessment in their regular classes or field placements.

The current study was conducted at various times of the year. Some student cohorts completed the intervention in the spring semester, while others received the intervention in Summer II or in the fall. Additionally, information was not obtained on whether or not they had taken a Crisis counseling-specific course, which should include curriculum on suicide. This particular CACREP accredited program includes 3 hours of education on suicide within the Crisis course; however, some students may not have taken this course yet or may not have recalled the educational content. Lastly, half of the study’s total participants took this training at the beginning of their Techniques course.

Other participants received this training at the end of the Practicum, Internship, Ethics, or

Abnormal/Dysfunctional Behavior Course. This may have impacted the participants’ reports on how much suicide assessment education they received in their Master’s program.

Finally, this study was limited to analyzing the perceived self-efficacy of students and their qualitative experiences about what they learned. The study utilized the CSES instead of the Counselor Suicide Assessment Efficacy Survey (CSAES) because the

CSAES was not available at the time, which is another limitation. No assessments were

110 Texas Tech University, Nicole L. Black, May 2017 found to evaluate for knowledge of suicide assessment skills; thus, this is a limitation of the study.

Delimitations

This study was delimited to a convenience sample of master’s students enrolled at a public university in the southern United States either in a School Counseling track or in a Clinical Mental Health Counseling track. In addition, students were selected to participate only if they had taken, or were currently enrolled in one of the following courses: Ethics, Addictions, Dysfunctional Behavior, Techniques, Practicum, or

Internship. This delimitation existed due to time constraints and the various educational differences that exist among students enrolled in various stages of their master’s level program. The findings of this study cannot be generalized to other mental health professions, such as a Licensed Marriage and Family Therapist, Psychologist,

Psychiatrist, or Licensed Chemical Dependency Counselor.

Recommendations for Future Research

This study answered the aforementioned research questions but leaves open the opportunity for recommendations for future research. Future research spurred by this study could bring about a great deal of knowledge for the counseling profession. The following recommendations are made for the field of counseling and counselor education:

This study focused on a sample from one counseling program. It is recommended to conduct a study with multiple counseling programs. This would make results more

111 Texas Tech University, Nicole L. Black, May 2017 generalizable in the future. Increasing the sample size would help ensure the reliability of this study’s findings.

This study recruited participants in a counseling program that is CACREP accredited. It is recommended to evaluate the effectiveness of this intervention with non-CACREP accredited programs and possibly compare those programs to CACREP accredited programs. This would provide insight into the difference in how CACREP and non-CACREP accredited programs prepare future counselors for suicide assessment.

These findings would be beneficial to CACREP and help inform future versions of their accreditation standards that pertain to crisis education. More clearly written CACREP standards would in turn benefit the profession of counseling by providing guidance on suicide assessment education to counselor education programs.

This training was conducted in four hours, which proved to influence the self- efficacy of participants. It would be recommended to conduct this study again with additional classroom time dedicated to practicing and role-playing the skills learned within the suicide educational program. The results of this new research that includes increased classroom practice could be compared to the results of the current study. These findings would bring greater impact to counselor education by highlighting differences in how practicing and role-playing suicide assessment techniques may boost students’ self- efficacy.

If this study were to be duplicated, it would be beneficial to assess the self- efficacy of students over a longer period of time to ensure that the changes to self- efficacy are maintained over extended periods. This could be done by completing 3, 6, 9, and 12-month posttests. This would help ensure that the program effects of self-efficacy

112 Texas Tech University, Nicole L. Black, May 2017 continue to last. These findings would bring credence that the program is efficacious in boosting counselors’ self-efficacy even after they complete their master’s programs and continue into the field of counseling.

If this study were to be conducted again, it would be beneficial to have participants evaluate what they learned in the course. This could be done via a checklist of items based on the 24 Core Competencies for suicide assessment. This evaluation would help ascertain that the program is ensuring student competency. Furthermore, this method of participant evaluation could provide formative information and be utilized for feedback to counselor educators on what areas of suicide assessment need to be reinforced for students.

Future research should look at evaluation of the suicide intervention program developed for this study based on measures other than self-efficacy. This can be conducted once measures of suicide assessment knowledge are developed and would further the research impact for the field. Assessing this program on knowledge-based measures would help counselor education programs produce more students that are knowledgeable about suicide assessment. Furthermore, once this training is adapted for continued education, other professionals could utilize a knowledge-based assessment in order to monitor their own suicide assessment knowledge and capabilities.

Future research should look at evaluating the effectiveness of this program with doctoral-level students, Licensed Professional Counselor Interns, and Licensed

Professional Counselors. Furthermore, this research could be extended to other professionals, such as Licensed Clinical Social Workers, Licensed Chemical Dependency

Counselors, and Psychologists. This would provide greater impact to the mental health

113 Texas Tech University, Nicole L. Black, May 2017 profession because each of these professionals work in different settings where suicidal clients are found.

Future research should look at adapting this suicide training program so that it may be recorded and uploaded online for distance education, allowing for greater dissemination of the program without requiring one specific instructor to provide the course via a live format. Online training would provide more educational opportunities for distance students. This training format would also be advantageous for providing continued education opportunities for fully licensed professionals, such as Licensed

Professional Counselors, Licensed Chemical Dependency Counselors, Licensed Clinical

Social Workers, and Psychologists.

Future research should look at adapting this program into a standardized manual that could be used by Counselor Education Programs to teach suicide assessment to students, allowing for greater dissemination of the program, and give greater impact on the counseling profession. This standardized manual would provide a teaching outline for professors to administer this training program for their students. It could include a professor’s manual with important tips and strategies for teaching suicide assessment to students. It could also include handouts and presentation material for the training program. Student booklets or manuals could be included as well so that students can keep these for personal references, much like textbooks.

Future research should look at evaluating this program’s influence on participants’ self-efficacy using the Counselor’s Suicide Assessment Efficacy Survey.

This may give greater credence to the program’s influence on students’ self-efficacy as it specifically relates to suicide assessment. Furthermore, this research would help

114 Texas Tech University, Nicole L. Black, May 2017 determine how quickly a counselor’s suicide assessment self-efficacy is influenced by a program provided over a succinct period of time. These findings would hold promise for influencing future teaching methods aimed at cultivating higher levels of student self- efficacy.

Future research should look at developing an assessment to test students’ knowledge and competencies in suicide assessment, which would be impactful to the profession by ensuring student knowledge and competency prior to graduation. The assessment is an important component needed for the future of counselor education to help ensure that programs are producing students that are competent. This assessment could be utilized as a way to measure student competency of suicide skills during

Practicum or Internship courses and could be utilized as a benchmark assessment to measure improvement in knowledge and competency. Furthermore, this measure could be utilized as a method of feedback to both CACREP and non-CACREP accredited counselor education program on how efficacious they are in teaching suicide assessment skills.

Future research should look at the development of a counseling course specially dedicated to educating counseling students about suicide assessment and the competencies surrounding suicide. This would be impactful to the counseling profession by ensuring student knowledge and competency in suicide assessment. This course could cover the training program developed for this study. Each of the eight domains covered by the 24 Core Competencies for suicide assessment could be covered in greater detail.

Class time could be dedicated to case conceptualization and applying suicide assessment theory and practice to suicide in different situations. This could include educating

115 Texas Tech University, Nicole L. Black, May 2017 students on how to conduct suicide assessment within various multicultural contexts and how to handle crisis situations in various clinical settings. Course material for this class would also include suicide prevention and suicide postvention (after suicide) techniques.

Conclusion

The topic of suicide has been widely studied. Yet, historically there has been an inadequacy of research that focused on efficacious models for teaching master’s level counseling students about suicide assessment. This lack of research has left counseling students without access to an evidence-based suicide-training program that is accessible.

This study fulfilled its purpose of developing an educational program that is based in best practices and evidenced-based research, including suicide competencies. This educational program proved to be efficacious in positively influencing the perceived self- efficacy of students who received the intervention. It also positively influenced the levels of knowledge, comfort, competency, and confidence of counseling students.

Furthermore, this study has created an opportunity to explore the conversation for methods of future training for suicide intervention and holds tremendous potential for impacting the field of counselor education.

116 Texas Tech University, Nicole L. Black, May 2017

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APPENDICES

Appendix A Counselor’s Crisis Self-Efficacy Scale

1

1 Used with permission granted by Dr. Cheryl Sawyer granted via personal correspondence on September 7, 2014.

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Appendix B Demographic Form

Please create a unique code so that your pretest and posttest can be matched. You should write this code down so that you can remember it for your posttest. Please make your code your favorite number, your favorite color, and name of your first pet (i.e. 13bluespot): ______

1. How many times have you had to intervene with a client who was suicidal?

______

2. On a scale of 1-10 (1 being lowest level of comfort and 10 highest level of

comfort), how comfortable do you feel intervening with a client who is actively

suicidal? ______

3. Have you received formal education on how to intervene with a suicidal client

while completing your graduate program? Yes No

4. If “yes” to question 3, which class(es) taught you how to intervene with a suicidal

client? ______

5. If “yes” to question 3, how many hours were spent covering the topic of suicide?

______

6. Have you completed any outside trainings, workshops, or educational sessions on

suicide intervention strategies? Yes No

7. If “yes” to question 6, how many hours of training or education have you received

on suicide intervention strategies? ______

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Appendix C IRB Approval

December 16, 2015

Dr. Charles Crews Educ Dean's Ofc Mail Stop: 1071

Regarding: 505282 Evidenced-Based Online Education of Suicide Intervention for Master's Level Counseling Students in Texas

Dr. Charles Crews:

The Texas Tech University Protection of Human Subjects Committee approved your claim for an exemption for the protocol referenced above on December 15, 2015.

Exempt research is not subject to continuing review. However, any modifications that (a) change the research in a substantial way, (b) might change the basis for exemption, or (c) might introduce any additional risk to subjects must be reported to the Human Research Protection Program (HRPP) before they are implemented.

To report such changes, you must send a new claim for exemption or a proposal for expedited or full board review to the HRPP. Extension of exempt status for exempt protocols that have not changed is automatic.

The HRPP staff will send annual reminders that ask you to update the status of your research protocol. Once you have completed your research, you must inform the HRPP office by responding to the annual reminder so that the protocol file can be closed.

Sincerely,

Kelly C. Cukrowicz, Ph.D. Chair, Institutional Review Board for the Protection of Human Subjects Associate Professor, Dept. of Psychological Sciences

Box 41075 | Lubbock, Texas 79409-1075 | T 806.742.3905 | F 806.742.3947 | www.vpr.ttu.edu

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Appendix D Module References

American Association of Suicidology. (2014). Core competencies for the assessment and management of individuals at risk for suicide. Retrieved from http://www.suicidology.org/Portals/14/docs/Training/RRSR_Core_Competencies. pdf

American Association of Suicidology. (2012). U.S.A. Suicide: 2012 official final data. Retrieved from http://www.suicidology.org/Portals/14/docs/Resources/ FactSheets/2012datapgsv1d.pdf

American Counseling Association (2014). ACA Code of Ethics. Alexandria, VA: Author.

American Psychiatric Association. (2008). Practice guideline for the assessment and treatment of patient with suicidal behaviors. Retrieved from http://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/ suicide.pdf

Baerger, D. (2001). Risk management with the suicidal patient: Lessons from case law. Professional Psychology Research and Practice, 32(4), 359-366.

Barber, M., Marzuk, P., Leon, A., & Portera, L. (2001). Gate questions in psychiatric interviewing: The case of suicide assessment. Journal of Psychiatric Research, 35(1), 67-69.

Beck, A., Kovacs, M., & Weissman, A. (1979). Assessment of suicidal intention: The scale for suicidal intention. Journal of Consulting and Clinical Psychology, 47(2), 343-352.

Brown, G. (2001). A review of suicide assessment measures for intervention research with adults and older adults. Retrieved from http://www.sprc.org/sites/sprc.org/ files/library/BrownReviewAssessmentMeasuresAdultsOlderAdults.pdf

Bryan, C. & Rudd, M. (2006). Advances in the assessment of suicide risk. Journal of Clinical Psychology, 62(2), 185-200.

Caplan, G. (1964). Principles of Preventative Psychiatry. New York: Basic Books.

Center for Disease Control (2015). Suicide: Facts at a glance. Retrieved from http://www.cdc.gov/violenceprevention/pdf/suicide_datasheet-a.pdf

Center for Disease Control (2015). 10 leading causes of death, United States, 2015, all races, both sexes. Retrieved from http://webappa.cdc.gov/cgi-bin/broker.exe

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Department of Veteran Affairs. (2012). Suicide Data Report. Retrieved from http://www.va.gov/opa/docs/suicide-data-report-2012-final.pdf

Gliatto, M. & Rai, A. (1999). Evaluation and treatment of patients with suicidal ideations. American Family Physician, 59(6), 1500-1506.

Goldston, D. (2000). Reviews of measures of suicidal behavior: assessment of suicidal behaviors and risk among children and adolescents. Retrieved from http://www.sprc.org/sites/sprc.org/files/library/GoldstonAssessmentSuicidalBeha viorsRiskChildrenAdolescents.pdf

Granello, D. (2010). The process of suicide risk assessment: twelve core principles. Journal of Counseling & Development. 88(3), 363-370.

Granello, D. & Granello, P. (2007). Suicide assessment: Strategies for determing risk. Counselling, Psychotherapy, and Health. 3(1), 42-51.

Jobes, D. (2006). Managing suicidal risk: A collaborative approach. New York: Guilford Press.

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Appendix E Risk Assessment Form

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Appendix F Visual Representations of Null Hypotheses Results

Figure 1: Means for CSES Subscale 1

Figure 2: Means for CSES Subscale 2

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Figure 3: Means for CSES Subscale 4

Figure 4 Means for CSES Subscale 3

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Figure 5: Means for CSES Total Scale

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