Preventing Suicide Through Improved Training in Suicide Risk Assessment and Care: an American Association of Suicidology Task Fo

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292 Suicide and Life-Threatening Behavior 42(3) June 2012 2012 The American Association of Suicidology DOI: 10.1111/j.1943-278X.2012.00090.x Preventing Suicide through Improved Training in Suicide Risk Assessment and Care: An American Association of Suicidology Task Force Report Addressing Serious Gaps in U.S. Mental Health Training

WILLIAM M. SCHMITZ JR., PSYD, MICHAEL H. ALLEN,MD,BARRY N. FELDMAN,PHD, NINA J. GUTIN,PHD, DANIELLE R. JAHN,MA,PHILLIP M. KLEESPIES,PHD, PAUL QUINNETT,PHD, AND SKIP SIMPSON,JD

There are twice as many suicides as homicides in the United States, and the suicide rate is rising. Suicides increased 12% between 1999 and 2009. Mental health professionals often treat suicidal patients, and suicide occurs even among patients who are seeking treatment or are currently in treatment. Despite these facts, training of most mental health professionals in the assessment and management of suicidal patients is surprisingly limited. The extant literature regarding the frequency with which mental health professionals encounter suicidal patients is reviewed, as is the prevalence of training in suicide risk assessment and management. Most importantly, six recommendations are made to address the longstanding insufﬁcient training within the mental health professions regarding the assessment and management of suicidal patients.

WILLIAM M. SCHMITZ Jr., Southeast Loui- siana Veterans Healthcare System, Baton Rouge, BACKGROUND LA, USA; MICHAEL H. ALLEN, Department of Psychiatry, University of Colorado Depression In 2009, suicide was the tenth leading cause Center and the VISN 19 Suicide MIRECC, Den- of death overall and the third leading cause ver, CO, USA; BARRY N. FELDMAN, Department of Psychiatry, University of Massachusetts Medi- of death for youth aged between 15 and 24 cal School, Worcester, MA, USA; NINA J. GUTIN, (Centers for Disease Control and Prevention Didi Hirsch Mental Health Services, Pasadena, [CDC], 2012); the number of suicides in the CA, USA; DANIELLE R. JAHN, Department of Psy- nation (36,909) was more than double the chology, Texas Tech University, Lubbock, TX, number of homicides (16,799; CDC, 2012). USA; PHILLIP M. KLEESPIES, VA Boston Health- care System and Department of Psychiatry, Bos- Approximately one third of people who die ton University School of Medicine, Boston, MA, by suicide have had contact with mental USA; PAUL QUINNETT, Department of Psychiatry, health services within a year of their death, University of Washington School of Medicine, and 20% have had mental health contact Seattle, WA, USA; SKIP SIMPSON, Law Offices of Skip Simpson and University of Texas Health Sci- within the last month of their life (Luoma, ence Center, San Antonio, TX, USA. Martin, & Pearson, 2002). The views expressed in this article are When a mental health professional solely those of the task force and do not necessa- sees a patient who is at risk for suicide, he or rily represent the views of the Department of she is faced with the need to make decisions Veterans Affairs or the U.S. government. Address correspondence to William M. about patient care that can have serious life- Schmitz Jr., 7850 Anselmo Lane, Baton Rouge, or-death consequences. If a patient dies by LA 70810; E-mail: [email protected] suicide, there is a significant emotional SCHMITZ ET AL. 293 impact on the patient’s family, his or her hospital that caused serious injury or death; social network, and the clinician or clinician- Joint Commission, 2010b); insufficient or in-training treating the patient (Calhoun, absent patient assessment is reported as the Selby, & Faulstich, 1980; Cerel, Roberts, & root cause in over 80% of suicide deaths in Nilsen, 2005; Chemtob, Hamada, Bauer, these reported sentinel events (Joint Com- Torigoe, & Kinney, 1988b; Kleespies, Penk, mission, 2011). & Forsyth, 1993; Veilleux, 2011). When a Mental health professionals in outpa- patient of a mental health professional dies tient settings also encounter suicidal patients by suicide, clinical, ethical, and legal ques- with great regularity. A survey of psycholo- tions may arise about the adequacy of the cli- gists-in-training found that 97% of respon- nician’s evaluation and about the sufficiency dents had provided care to at least one of his or her training to perform such evalua- patient (and often several) with some form of tions. suicidal behavior or suicidal ideation during In this article, we establish that mental their training (Kleespies et al., 1993). In health professionals regularly encounter addition, social workers encounter suicidal patients who are suicidal, that patient suicide patients on a regular basis, with 87% of social occurs with some frequency even among workers in a random nationwide sample patients who are seeking treatment or are reporting that they had worked with a sui- currently in treatment, and that, despite the cidal patient within the past year (Feldman & serious nature of these patient encounters, Freedenthal, 2006). Other research has found the typical training of mental health profes- that 55% of clinical social workers reported sionals in the assessment and management of that at least one of their patients had suicidal patients has been, and remains, woe- attempted suicide during their professional fully inadequate. We follow this with a careers (Sanders, Jacobson, & Ting, 2008). review of the current state of training and Mental health professionals not only competence among mental health profes- treat suicidal patients, but also sometimes sionals regarding suicide assessment and lose patients to suicide, leading some authors interventions. We conclude with recommen- to refer to suicide as an ‘‘occupational haz- dations to address the longstanding insuffi- ard’’ (Chemtob, Bauer, Hamada, Pelowski, cient response of the mental health & Muraoka, 1989, p. 294). Ruskin, Sakinof- disciplines to the issue of appropriate train- sky, Bagby, Dickens, and Sousa (2004) found ing in the assessment and management of that 50% of psychiatrists and psychiatry resi- suicidal patients. dents in their sample had experienced at least one patient suicide. This finding was consistent with the 51% rate noted in an earlier THE INCIDENCE OF PATIENT national survey, which also indicated that a SUICIDAL BEHAVIOR IN majority of psychiatrists who reported hav- CLINICAL PRACTICE ing a patient die by suicide had more than one patient die by suicide (Chemtob, Almost all mental health professionals Hamada, Bauer, Kinney, & Torigoe, 1988). encounter patients who are suicidal. Psychia- Research has found that psychologists, social trists and other clinical staff who work on workers, and counselors experience some- inpatient psychiatry units see patients at risk what lower rates of patient suicide. Between for suicide daily. Multiple agencies (e.g., the 22% and 30% of psychologists report expe- Joint Commission) have made it clear that riencing a patient suicide (Chemtob, suicides in inpatient settings should not hap- Hamada, Bauer, Torigoe, & Kinney, 1988; pen, and yet they occur with some frequency. Pope & Tabachnick, 1993), and investiga- In fact, suicide has regularly been among the tions of patient suicides among social work- five most frequently reported sentinel events ers and counselors reveal numbers similar to in recent years (i.e., an unexpected event in a those of psychologists (Jacobson, Ting, 294 IMPROVED SUICIDE-SPECIFIC TRAINING

Sanders, & Harrington, 2004; McAdams & by the colleges, universities, clinical training Foster, 2000). sites, and licensing bodies that prepare mental health professionals.

CURRENT STATUS OF THE FIELD THE PREVALENCE OF TRAINING There have been numerous calls from IN SUICIDE RISK ASSESSMENT national and international public, private, AND MANAGEMENT and governmental organizations to improve training in the assessment and management The lack of training available in the of suicide risk (e.g., Institute of Medicine institutions that prepare mental health pro- [IOM], 2002; Joint Commission, 2010a; fessionals has been documented for decades. U.S. Department of Health and Human Multiple studies have found that only approx- Services [USDHHS], 2001); World Health imately half of psychological trainees had Organization 1996). In 1999, Dr. David Sat- received didactic training on suicide during cher, then Surgeon General of the United their graduate education, and the training States, issued The Surgeon General’s Call to provided was often very limited (Dexter- Action to Prevent Suicide. In this document, Mazza & Freeman, 2003; Kleespies et al., Satcher provided a vision that would lead to 1993). It is critical to note that didactic train- a cohesive and comprehensive national sui- ing is not necessarily synonymous with effec- cide prevention strategy (U.S. Public Health tively building the skills needed to conduct Service [USPHS], 1999). The strategy adequate suicide risk assessments and treat included having mental health professionals suicidal patients. Providing information to achieve competence in suicide risk assess- trainees is necessary but not sufficient as ment and management. trainees must also be given opportunities to Competence has been defined by vari- translate this information into competent ous authors in a number of different ways. practice by assessing and treating suicidal When discussing competence in suicide risk patients with proper supervision. Nearly assessment and management, we refer to 76% of responding directors of graduate pro- Quinnett’s (2010) definition, in which compe- grams in psychology indicated that they tence is defined as the capacity to conduct: wanted to include more suicide-specific training in their programs, but encountered a vari- [A] one-to-one assessment/intervention ety of barriers to doing so (Jahn et al., 2012). interview between a suicidal respondent in Training has been similarly sporadic a telephonic or face-to-face setting in among social work training programs. Less which the distressed person is thoroughly than 25% of a national sample of social work- interviewed regarding current suicidal ers reported receiving any training in suicide desire/ideation, capability, intent, reasons prevention, with a majority of the respon- for dying, reasons for living, and espe- dents reporting that their training had been cially suicide attempt plans, past attempts inadequate (Feldman & Freedenthal, 2006). and protective factors. The interview leads Faculty and deans–directors of graduate to a risk stratification decision, risk miti- social work programs reported that most stu- gation intervention and a collaborative dents receive 4 hours or fewer of suicide- risk management/safety plan, inclusive of related education (Ruth et al., 2009). The documentation of the assessment and lack of training is even more pronounced interventions made and/or recommended. among professional counseling and marriage and family therapy training programs. Competence in the assessment of Wozny (2005) found that suicide-specific suicidality is an essential clinical skill that has courses were present in 6% of accredited consistently been overlooked and dismissed marriage and family therapy programs and in SCHMITZ ET AL. 295

2% of accredited counselor education pro- or promote competencies in depression grams. assessment and management and suicide pre- Only the field of psychiatry seems to be vention’’ by 2005 (USDHHS, 2001, p. 86). attempting to ensure that their trainees are, at In late 2010, two organizations (the a minimum, exposed to the skills required to Suicide Prevention Resource Center [SPRC] properly conduct a suicide risk assessment and the Suicide Prevention Action Network and address suicidality in treatment. Ellis, [SPAN]) collaborated on the publication of Dickey, and Jones (1998), in a national survey 2010 Progress Review of the National Strategy. of directors of training in psychiatry, found This document provided a detailed analysis that 94% of the responding directors of how, and to what degree, the original reported some form of training in suicide risk NSSP (USDHHS, 2001) had been imple- assessment and intervention in their residency mented. The 2010 Progress Review of the programs. However, the majority of directors National Strategy (SPRC & SPAN, 2010) reported that most of the training occurred in findings regarding the current standards for passive formats (e.g., therapy supervision, clinical training were disheartening. After general seminar), and only 27.5% reported reviewing the standards for 11 different men- training via skill development workshops. tal health professional groups, ‘‘[o]nly the A more recent national survey of chief Council for the Accreditation of Counseling psychiatry residents by Melton and Cover- and Related Educational Programs … had dale (2009) found that, despite 91% of the increased attention on suicide in its 2009 residency programs offering some teaching standards compared to the previous version’’ on the care of suicidal patients, the average (SPRC & SPAN, 2010, p. 23). number of seminar sessions or lectures was Moreover, state licensing boards for only 3.6 and the specific content that was clinical social workers and psychologists, covered by the different programs was often whose mission is to protect the public’s vague and nondescript. Many of the respon- health and safety from untrained and unqual- dents were of the opinion that the focus on ified providers, do not require exam items on suicide intervention was insufficient (Melton the assessment and management of suicidal & Coverdale, 2009). patients. Again, only psychiatry has made The lack of training requirements some efforts in this regard. The American stands in stark contrast to the ongoing calls College of Psychiatrists Psychiatry Resident- for improvement in this area. The original in-Training Examination, which is com- National Strategy for Suicide Prevention (NSSP; pleted by nearly everyone who will be board USDHHS, 2001) outlined critical objectives eligible during their residence, includes sui- that would address the oft-cited, and previ- cide-specific questions within the emergency ously discussed, deficiency in training regard- psychiatry domain (American College of Psy- ing suicidality. Objective 6.3 of the NSSP chiatrists, 2011). In addition to the lack of specifically stated that the goal was to, ‘‘[b]y items on licensure examinations, not a single 2005, increase the proportion of clinical social state or mental health licensing body requires work, counseling, and psychology graduate continuing education addressing suicide, sui- programs that include training in the assess- cide risk, or other behavioral emergencies.1 ment and management of suicide risk, and the identification and promotion of protective 1Our review of state continuing education factors’’ (p. 82). There was a similarly stated (CE) requirements found eight states having no objective (6.2) directing that the same goals CE requirements for psychologists, three states be addressed in medical residency and physi- having no requirements for social workers, and six cian assistant educational programs. Further- states having no requirements for physicians, including psychiatrists. Among states that main- more, objective 6.9 called for an ‘‘increase [in tain CE requirements for licensure, our review the] number of recertification or licensing indicated that none require any suicide-specific programs in relevant professions that require CE credits. 296 IMPROVED SUICIDE-SPECIFIC TRAINING

However, continuing education on other suicide risk significantly improved the ability topics is mandated in a majority of states for of psychiatry residents and psychology licensure renewal. In fact, 27 states require interns to identify risk factors for suicide and continuing education in ethics for licensure also improved their specificity about the sig- renewal for psychologists, 27 states require nificance of risk and protective factors when continuing education in ethics for licensure developing plans for intervention. Allgaier, renewal for social workers, and 21 states Kramer, Mergl, and Hegerl (2009) found require continuing education in ethics for that training improved attitudes regarding licensure renewal for addictions counselors. the treatability of older adult suicide risk and This mandatory education ensures that men- increased knowledge about pharmacotherapy tal health professionals are informed about for depression and suicide risk among geriat- the current issues in ethics, yet there is no ric nursing staff. Moreover, Slovak and similar requirement to ensure that mental Brewer (2010) found that licensed social health professionals are using current infor- workers had more positive attitudes toward mation to assess and treat suicidal patients. using firearm assessment and safety counsel- The evidence clearly suggests that ing when they had received training on the there has been negligible progress in improv- use of firearm counseling for suicide preven- ing the competence of mental health profes- tion. While Pisani et al. (2011) had some res- sionals in evaluating, managing, and treating ervations about the efficacy of continuing suicidal patients. However, it is not a lack of education programs in changing clinical effective training materials that has ham- practices, they noted that there is strong sup- pered such progress. port for the effectiveness of evidence-based training workshops in transferring knowl- Training is Available and Accessible edge and shifting attitudes. The scientific literature is beginning There have been concerns raised in to demonstrate that empirically based skills the past regarding the effectiveness of taught in a brief continuing education format continuing education programs in impacting can change clinic policy, confidence in risk providers’ behaviors or changing patient- assessment, and confidence in management related outcomes (Davis et al., 1999). Recent of suicidal patients, with changes sustained at research has suggested that interactive a 6-month follow-up (McNiel et al., 2008; continuing medical education training pro- Oordt, Jobes, Fonseca, & Schmidt, 2009). grams, especially those that included super- Findings such as these, in conjunction with vised skill demonstration and rehearsal, the known elements that facilitate the trans- significantly affected health care providers’ lation of continuing education training into behavior (Bloom, 2005). However, a recent clinical practice (Bloom, 2005), suggest that review has raised questions about the efficacy suicide-specific continuing education can of training in workshop formats for improv- ‘‘meaningfully impact professional practices, ing the clinical care of the suicidal patient clinic policy, clinician confidence, and (Pisani, Cross, & Gould, 2011). Despite this beliefs’’ (Oordt et al., 2009, p. 21). review, studies have shown improvements in At the present time, there are several knowledge and skills because of continuing training programs that have been recognized education programs. for disseminating content that is consistent Sockalingam, Flett, and Bergmans with the core competencies that have been (2010), for example, found that training in referenced earlier and have been demon- suicide intervention for psychiatry residents strated to be effective in increasing suicide- increased comfort in treating suicidal specific knowledge and skills. The depth and patients and improved self-reported clinical breadth of these evidence-based training pro- practice. McNiel et al. (2008) reported that a grams vary in length from 6 hours (i.e., workshop on evidence-based assessment of Assessing and Managing Suicide Risk: Core SCHMITZ ET AL. 297

Competencies for Mental Health Profession- cidal students. In addition, there is an inher- als; SPRC, 2011) to 16 hours (i.e., Recogniz- ent danger in referring suicidal people to ing and Responding to Suicide Risk; AAS, mental health professionals who are not ade- 2011). Outcome data regarding behavior quately trained; if these suicidal people do change in response to these trainings is not feel that treatment has been effective emerging, with changes documented up to (which is likely the case with mental health 4 months after training (Jacobson & Berman, professionals who have not received proper 2010). training in treating suicidal patients), they may drop out of treatment, become discour- Systems-Level Problems Affecting aged about treatment with mental health Training professionals, and never return to treatment, leaving them at even higher risk for suicide. Despite the numerous ‘‘calls to action’’ The lack of training required of men- and sternly worded ‘‘recommendations’’ to tal health professionals regarding suicide has increase training and ensure the competence been an egregious, enduring oversight by the of practitioners in the area of suicide assess- mental health disciplines. On an individual ment and intervention noted earlier (e.g., level, one could argue that mental health USDHHS, 2001; USPHS, 1999), virtually professionals have an ethical obligation to nothing has been done by licensing boards, provide only those services that fall within training programs, and professional organi- their area of competence. Few, however, zations. In fact, certain professional organi- have attained specific competence in the zations have lobbied against efforts to assessment, management, and treatment of include suicide assessment and intervention individuals who are suicidal. In fact, over the training as a mandatory continuing educa- years, numerous authors have specifically tion requirement (J. Linder-Crow, President called into question the ethics of mental of the California Psychological Association, health professionals who, without adequate personal communication, December 6, training, provide service to suicidal patients 2010). (e.g., Bongar & Harmatz, 1991; Feldman & While the mental health field has Freedenthal, 2006; Jacobson et al., 2004; remained stagnant regarding the dissemina- Rudd, Cukrowicz, & Bryan, 2008). Each of tion of improvements in training regarding the mental health disciplines has ethical suicide assessment and treatment, there has codes which stipulate, in slightly different been growing pressure from community and verbiage, that mental health professionals grassroots organizations to ensure that sui- should not provide services that are beyond cide prevention education is provided in spe- their area of competence (American Psychi- cific settings. For example, schools, where atric Association, 2010; American Psycho- the issue of youth suicide has prompted logical Association, 2002; National action, have begun requiring mandated train- Association of Social Workers, 2008). Yet, a ing in suicide prevention in many states majority of mental health professionals will (SPAN, 2011). Virtually all of these gate- provide services to potentially suicidal keeper trainings that are required for school patients for whom they are ill-equipped, and, employees recommend referral to mental most importantly, potentially incompetent to health professionals for potentially at-risk treat. youth. Ironically, there is no such mandatory This issue, however, goes beyond the training for the mental health professionals. individual level and is perhaps more appro- It is incomprehensible that, in many states, a priately addressed as an issue in systemic teacher is now required to have more train- ethics. The system of training mental ing on suicide warning signs and risk factors health professionals has, generally, not pre- than the mental health professionals to pared them to function in the best interests whom he or she is directing potentially sui- of their patients in regard to the crucial 298 IMPROVED SUICIDE-SPECIFIC TRAINING issue of assessing and managing patient su- longstanding reluctance of these groups to icidality. Thus, the glaring deficiency in the implement meaningful change, the addi- mental health educational and training sys- tional presence of vested parties and patient tem creates an ethical values conflict for safety organizations, such as the National practitioners that needs to be addressed. Action Alliance for Suicide Prevention, the National Alliance on Mental Illness, the Leapfrog Group for Patient Safety, and sui- SUMMARY cide survivors, would also be encouraged to actively participate in this dialog. The Amer- Now is the time to make changes to ican Association of Suicidology is a willing policy and practice to improve the compe- and capable host to such a summit that will tence of mental health professionals and the aid in ensuring that the longstanding gap in quality of care provided to suicidal patients. the training of mental health professionals is This task force of the American Association finally closed. of Suicidology strongly endorses the follow- This proposed summit is the ideal ing recommendations to ensure that mental platform for the leaders from each of the health professionals are properly trained and mental health disciplines to initiate the competent in evaluating and managing sui- change process that is necessary to address cidal patients, the most common behavioral issues such as how to implement certification emergency situation encountered in clinical or programmatic recognition for those men- practice. This task force makes these recom- tal health professionals who have completed mendations based on the empirical literature requisite training in the core competencies of and based on the task force members’ collec- suicide assessment and management. We tive administrative, clinical, and forensic recognize that this summit is a starting point experience. It is this task force’s belief that for a change process that will continue to the implementation of the following general evolve. and specific recommendations will be a first step toward ensuring that mental health pro- Recommendation #1: Accrediting fessionals are competent to recognize, assess, organizations must include suicide- manage, and treat suicidal patients. specific education and skill acquisi- tion as part of their requirements Recommendations to Improve Training for postbaccalaureate degree program accreditation. General Recommendation: A summit comprised of the national leaders in Organizations such as the American mental health should be convened Psychological Association, the Council on to formulate plans for implement- Social Work Education, and the Liaison ing the following recommenda- Committee on Medical Education, among tions. others, have stringent accreditation requirements to ensure the competence and profes- The mental health disciplines have, to sional readiness of trainees that graduate date, failed to meet the National Strategy for from their programs. These accrediting Suicide Prevention (USDHHS, 2001) goals of bodies for each mental health discipline have increasing the availability of suicide-specific similar explicit goals to ‘‘protect the interests training. However, collaborative work by the of students, benefit the public, and improve various mental health professions (i.e., the the quality of teaching, research, and profes- American Psychiatric Association, American sional practice’’ (American Psychological Psychological Association, and National Association, 2007, p. 2) by ‘‘establishing Association of Social Workers) can facilitate thresholds for professional competence’’ efforts to address this failure. Given the (Council on Social Work Education, 2008, SCHMITZ ET AL. 299 p. 1). To meet these goals, accredited pro- vices to the public (American Psychological grams that aspire to train the mental health Association, 2009). As noted above, however, professionals of tomorrow must ensure that no states currently require suicide-specific specific training in the detection, assessment, continuing education for any mental health treatment, and management of suicidal professionals. Yet, a majority of states patients is included in the formal education require ethics training, which mental health of these future mental health professionals. professionals are compliant and from which Specifically, these programs should they presumably benefit. Thus, it has been incorporate the core competencies that have demonstrated that a required continuing been identified in the scientific literature and education area is feasible to implement with- are considered essential for assessing and out being overly burdensome to mental managing suicide risk (SPRC, 2006). To aide health professionals. in the process, Rudd et al. (2008) have provided detailed guidelines for facilitating the Recommendation #3: State and fed- adequate education of mental health trainees eral legislation should be enacted regarding these competencies. These guide- requiring health care systems and lines offer information for supervisors and facilities receiving state or federal instructors to ensure that trainees master the funds to show evidence that mental content and acquire the skills related to each health professionals in their systems domain. have had explicit training in suicide The core competencies have been risk detection, assessment, manage- determined and operationalized. It is now ment, treatment, and prevention. necessary to require training programs to utilize these core competencies in their train- Because of the noted failure of the ing of future mental health professionals. mental health field to implement changes Ideally, these abilities would be demon- that have been recommended and necessary strated through supervised training with a for over 10 years in response to the NSSP competent supervisor and suicidal patients, (USDHHS, 2001), the assistance of the state but at a minimum, would require some mea- and federal government is now needed to sure of skills-based demonstration (e.g., protect the American public and save the supervised role plays). lives of suicidal patients. It is incumbent on health care facilities that receive state and Recommendation #2: State licensing federal funds to ensure that they have appro- boards must require suicide-specific priately trained mental health professionals continuing education as a require- who can conduct thorough suicide risk ment for the renewal of every men- assessments and provide appropriate, compe- tal health professional’s license. tent care to those in suicidal crises. Medical centers, hospitals, and health care institu- Mental health professionals currently tions that receive federal or state funding providing care have generally not received should be required to hire only mental health the necessary training in suicide assessment professionals who have evidence of training and treatment. Practicing mental health pro- specifically addressing suicide risk assessment fessionals must improve and maintain their and suicidal patient care. Documentation of knowledge of suicide risk and develop their such training can be met through a variety of skills in assessment and treating suicidal paths: through a mental health professional’s patients. Continuing education is essential to graduate training, through continuing educa- ensure that providers remain current in their tion programs, or through a standardized understanding of emerging issues while also certification program. maintaining, developing, and increasing their The development of a national certifica- overall competencies, thereby improving ser- tion program for mental health professionals, 300 IMPROVED SUICIDE-SPECIFIC TRAINING possibly discipline specific, that is skills- (e.g., the Centers for Medicare and Medicaid based and empirically driven would greatly Services, the Joint Commission, the Com- increase the overall competence of mental mission on Accreditation of Rehabilitation health professionals in the assessment and Facilities) and state regulatory bodies will care of suicidal patients. This is not a novel motivate facilities to address this problem recommendation, as Knesper et al. (2010) area. Thus, requiring accredited facilities to have proposed such a program. A mandate have documented evidence that their staff for such certification was drafted in a bill has been adequately trained can address the submitted by then U.S. Representative Pat- longstanding patient safety issue of improper rick Kennedy (D-RI; H.R. 5040, 2010). assessment and management of suicidal While the bill was not enacted prior to the patients. Such documentation could easily be conclusion of the legislative session, had it reviewed as part of regularly conducted passed, agencies that provide health care accreditation inspections. would have been required to show evidence that their staff members had been properly Recommendation #5: Individuals trained in suicide prevention strategies in a without appropriate graduate or manner consistent with the Institute of Med- professional training and supervised icine (2002) report and the NSSP (US- experience should not be entrusted DHHS, 2001). with the assessment and management of suicidal patients. Recommendation #4: Accreditation and certification bodies for hospital and This task force is aware of instances emergency department settings must in which organizations regularly place indi- verify that staff members have the viduals with only bachelor-level preparation requisite training in assessment and or less in situations where they are expected management of suicidal patients. to conduct suicide risk assessments without appropriate supervision and to make man- Hospitals and emergency departments agement recommendations without prior cannot be considered safe havens from sui- supervisory review or, in some instances, no cide. The Joint Commission (2010a) has supervisory review. Given their lack of pro- noted the presence of systemic shortcomings fessional-level education and training, we that contribute to suicide in the hospital and find this practice irresponsible and egre- emergency department setting, specifically gious. As this document has clearly demon- noting problem areas of ‘‘inadequate screen- strated, even the most educated of mental ing and assessment, care planning and obser- health professionals have generally been vation; insufficient staff orientation and exposed to minimal formal training in this training; poor staff communication; inade- critical, specialized skill. Thus, anyone with- quate staffing; and lack of information about out formal training who has not been taught suicide prevention and referral resources’’ the requisite skills embodied in the core (p. 2). competencies as recognized and embodied To protect the health and safety of sui- in those programs designated best practices cidal patients who are in hospital, medical by SPRC referred to above and has not center, and emergency department settings, demonstrated these competencies in practice health care facilities must be responsible for settings under proper supervision should not ensuring that their clinical staff members be responsible for potentially suicidal have been specifically trained in the assess- patients. The task force stresses the goal of ment and intervention skills necessary to enabling and facilitating quality training to work effectively with suicidal patients. Rules current providers and providers-in-training or standards implemented by any or all of which should, ultimately, save lives. By rec- the institutional accreditation organizations ommending competence-based training, we SCHMITZ ET AL. 301 do not intend to deter professionals from ther elucidates the crisis in training that has engagement with the topic of suicidality, far continued to be overlooked and dismissed. from it. As previously noted, such training is The American Association of Suicidology easily accessible, not excessively time-con- considers this a critical problem, and this suming, and is available from a variety of task force strongly supports the implementa- excellent sources. tion of the recommendations in this report Graduate and residency programs that and those included in the NSSP (USDHHS, adequately train their graduates consistent 2001). with Recommendation #2 are the logical and The recommendations that have been most qualified venues to ensure that mental articulated will require national leaders from health professionals obtain these skills. the various mental health disciplines, legislative powers, and accrediting and certifying organizations to come forward promptly and CONCLUDING REMARKS move swiftly to address this longstanding deficit. Unfortunately, the research over the Improving the training and compe- past 30 years has clearly demonstrated that tence of mental health professionals is one of those within the mental health disciplines the most logical ways to prevent suicide and have been reluctant to address the oft-cited save lives. The current state of training insufficient training in the assessment and within the mental health field indicates that management of suicidal patients. This task accrediting bodies, licensing organizations, force concurs with and reinforces Jobes and training programs have not taken the (2011) assertion that ‘‘a huge challenge to numerous recommendations and calls to clinical suicide prevention is the actual com- action seriously. The recommendations petency of clinical practitioners’’ (p. 389). given earlier, if implemented, would address Now is the time to act. Those responsible the deficits in training documented in this for ensuring the competence of mental report. The positions presented here are health professionals have overlooked the consistent with those of other organizations topic of suicide for far too long. (e.g., IOM, 2002; USDHHS, 2001), but fur-

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