Assessment of suicidal thoughts and other related behaviors may be one of the most difficult areas for mental health professionals, both because this area can create feelings of anxiety and fear in the clinician and because many may feel they do not have adequate training in this area. Research suggests that psychologists are less likely to accept for treatment individuals who present with suicide risk factors (Groth & Boccio, 2018). Some recent journal articles have highlighted ethical considerations for psychologists that touch on important questions related to training and competence. For example, what are the ethical responsibilities of practicing psychologists in terms of being aware of and using evidenced informed assessment and care for suicide? Should suicide prevention be a considered an element under intervention and assessment competencies in the field? Given that the majority of mental health professionals will work with at least one individual who experiences suicidal ideation, should there be a minimal level of competence necessary for practicing psychologists?
A recent article by Cho, Martell, and Cramer (2024) discussed the importance of suicide prevention training for both students and practicing psychologists and raised the question of whether it should be mandated education for all mental health professionals. This column will explore some of the barriers and possible considerations for psychologists in risk assessment and feature comments from an interview with one of the authors (Dr. Christopher Martel, University of Massachusetts Amherst). A separate article by Jobes and Barnett (2024) explored issues related to ethical responsibilities of psychologists in terms of evidence-based approaches to suicide assessment, prevention, and related care, and will also be discussed.
Barriers to Asking About Suicide
Several barriers in terms of asking about suicide and working with individuals who report suicidal thoughts and behaviors have been cited in the literature. It seems clear that provider concerns about perceived competence may be an important barrier. An empirical study by Groth and Boccio (2018) indicated that concerns about professional skill levels were frequently cited by participants who expressed unwillingness to accept a hypothetical patient/client who expressed suicidal ideation. Practicing within the boundaries of one’s competence is a core ethical standard but, as Groth and Boccio noted, there can be difficult dilemmas, such as providing treatment in rural areas where there are few available providers or providing services in emergency situations. Both Cho et al. (2024) and Jobes and Barnett (2024) discussed the relationship between competence in terms of professional services related to suicide prevention. Professional competence maps onto several APA Ethics Code principles and standards, including 2.01 Boundaries of Competence, 2.03 Maintaining Competence and 2.04 Bases for Scientific and Professional Judgment (American Psychological Association, 2017).
As Jobes and Barnett (2024) noted in their review of the research, studies suggest several barriers in effective suicide assessment, including clinicians avoiding asking about suicide (Roush et al., 2018) and patients/clients not reporting suicidal ideation because of fears of being hospitalized involuntarily (Blanchard & Farber, 2020). Cho et al. (2024) suggested several possible reasons clinicians may avoid asking, including fear and stigmatized beliefs about suicide among mental health providers. Concerns about professional liability have also been cited as a potentially important barrier that may lead to not asking about suicide (Jobes & Barnett, 2024). Lack of experience, particularly among early career psychologists who may not have had training experiences where they had opportunities to assess for risk, may also be a contributing factor. Finally, fears related to one’s perceived incompetence can lead to avoidance in terms of asking or working with individuals who experience suicidal thoughts or behaviors. Dr. Martell explained, “I think people can be afraid of clients when they’re suicidal. It brings up fears of incompetence. I also think sometimes the response from professionals can be anger and frustration because of that fear. None of us want to feel incompetent. A lot of people may be really afraid that they’re sort of walking on thin ice if they have clients who express at least more than passive ideation.”
Fear and anxiety may contribute to avoidance in asking about suicide, which, as Dr. Martell noted, can lead to potential missed opportunities to intervene and unintentionally place the clinician at more risk. He noted, “I think the way when the way people cope with it is to not ask. Avoidance is never a good coping strategy, you know, can lead to worse things and ironically, not asking, I think leads to more could lead to more liability.”
What Can We Do to Improve Suicide-Related Assessment and Care?
Given many mental health professionals may not feel competent in suicide assessment and treatment, there have been calls for increased education and training in risk factors as well as evidence-based assessment tools and treatment. Most graduate programs don’t adequately cover evidence-based suicide prevention and assessment in their graduate programs and there’s an acknowledged need for dedicated didactics in this area. Indeed, a recent survey of program and internship directors suggest strong support for mandated suicide training for trainees (Kleespies et al., 2023). There are also valuable opportunities to provide instruction and training (including in how to assess for risk) in practica, coursework, and internship. Adding to an already full list of competencies is not without its challenges; however, as Dr. Martell noted the importance of this topic overall in clinical psychology and the need to address not only student knowledge but also attitudes, in terms of “…training students to not be afraid of people who have suicidal thoughts and behaviors.”
For practicing psychologists, filling training gaps and staying up to date with the latest methods in assessment and treatment may be addressed through education and training programs, including continuing education requirements through licensing boards. In fact, as Cho et al. (2024) discussed, several states have introduced requirements for training in suicide prevention. There is also a growing body of research on empirically supported training programs for professionals (e.g., Cramer, Long, Gordon, & Zapf, 2019; Stuber et al., 2023).
There are some important self-assessment considerations for psychologists working with individuals who experience suicidal thoughts or engage in related behaviors. One is to recognize one’s own feelings about suicide and working with individuals who may be at higher risk. Are our feelings and beliefs contributing to an already-significant stigma around suicide and, importantly, do they lead to behaviors such as avoidance in terms of assessing risk?
Another consideration is to evaluate our training and competence in this area. This can be difficult for psychologists to evaluate one’s competence in specific areas. Is being familiar with the literature and best practices to be able to effectively conduct a risk assessment and knowing how to respond to risk factors (which could include referrals and involving others in care) considered a baseline competence for practicing psychologists? Psychologists looking to learn more can draw upon the growing body of research in the area of prevention, assessment and intervention to learn more about which methods have empirical support and which do not. In their article, Jobes and Barnett (2024) provided an excellent overview of evidence-based assessment and treatment of suicide-risk behaviors and argued that understanding and using evidenced-based practices is both good care and serves as a risk management strategy. As Martell noted, “Suicide, suicidal ideation, and suicidal behaviors need to be treated directly. We learn how to treat depression. We learn how to treat anxiety disorders. Suicide, from the experts, is not just something tacked on to those things… There are direct interventions and we need to at least learn how to directly address this. Not being afraid in addressing this with clients, I think, validates for clients that they’ve come to a safe place.” Finally, Jobes and Barnett (2024) described how specific risk management strategies, such as informed consent about limits in confidentiality and legal responsibilities, detailed documentation, and consultation with colleagues can be both effective risk management and beneficial for care.
Conclusion
These articles and discussion underscore the value for psychologists to identify and address their own feelings (including fears) and level of knowledge in working with individuals who may experience suicidal thoughts. It’s interesting to think about how, in response to fears related to liability or lack of competence, we can sometimes engage in avoidance behaviors, which can actually worsen the situation, both for clinicians and potentially for those with whom we work. Identifying the reasons for and addressing our own avoidance in terms of learning more about effective assessment management techniques is also critical for practicing psychologists. As Dr. Martell concluded about individuals who may experience suicidal ideation, “They may feel hopeless but being in a therapist’s office and having a therapist who’s not freaking out as soon as you say something can, I think, begin to instill a little more hope that there can be a better life ahead.”
by Adam Fried, PhD
References
American Psychological Association (2017). Ethical principles of psychologists and code of conduct. Retrieved October 28, 2024. https://www.apa.org/ethics/code
Blanchard, M., & Farber, B. A. (2020). It’s never okay to talk about suicide”: Patients’ reasons for concealing suicidal ideation in psychotherapy. Psychotherapy Research, 30(1), 124–136. https://doi.org/10.1080/10503307.2018.1543977
Cho, G. Y., Martell, C. R., & Cramer, R. J. (2024). Ethical and practical considerations for mandating suicide prevention training for mental health professionals. Professional Psychology: Research and Practice, 55(4), 375–383. https://doi.org/10.1037/pro0000568
Cramer, R. J., Long, M. M., Gordon, E., & Zapf, P. A. (2019). Preliminary effectiveness of an online-mediated competency-based suicide prevention training program. Professional Psychology: Research and Practice, 50(6), 395–406. https://doi.org/10.1037/pro0000261
Groth, T., & Boccio, D.E. (2019). Psychologists’ willingness to provide services to individuals at risk of suicide. Suicide and Life-threatening Behavior, 49(5), 1231–1254. https://doi.org/10.1111/sltb.12501
Jobes, D. A., & Barnett, J. E. (2024). Evidence-based care for suicidality as an ethical and professional imperative: How to decrease suicidal suffering and save lives. American Psychologist. Advanced online publication. https://doi.org/10.1037/amp0001325
Kleespies, P. M., Feinman, A., AhnAllen, C. G., Hausman, C., Thach, T., Woodruff, J., Loomis, S., & Bongar, B. (2023). A national survey of doctoral psychology education and training in suicide risk and violence risk assessment and management. Suicide and Life-Threatening Behavior, 53(4), 666–679. https://doi.org/10.1111/sltb.12972
Roush, J. F., Brown, S. L., Jahn, D. R., Mitchell, S. M., Taylor, N. J., Quinnett, P., & Ries, R. (2018). Mental health professionals’ suicide risk assessment and management practices: The impact of fear of suicide-related outcomes and comfort working with suicidal individuals. Crisis: The Journal of Crisis Intervention and Suicide Prevention, 39(1), 55–64. https://doi.org/10.1027/0227-5910/a000478
Stuber, J., Massey, A., Payn, B., Porter, S., & Ratzliff, A. (2023). Training health care professionals in suicide assessment, management, and treatment. Psychiatric Services, 74(1), 88–91. https://doi.org/10.1176/appi.ps.202100571