Five Years Later: a Collision in the Making?
© Paul Quinnett, Ph.D.

In 2001 the Surgeon General’s National Strategy for Suicide Prevention was news. Fresh off the press, supported by both houses of congress, and full of promise, many of the goals set for 2005 have been approached if not fully realized. But on some fronts we appear stalled.

If we had enough research in 2001 to justify the goals set and recommendations made then, why haven’t we reached more of them? The definition of success was modest enough, “Promote awareness,” “Develop strategies” “Implement training,” and no one claimed we would be saving thousands of lives by 2005. Yes, states are writing and implementing plans, model programs are emerging, and a few evidence-based practices are being registered and disseminated.

But on one front, not much is happening. With few exceptions, the vast majority of our clinical institutions that admit, assess, manage and treat suicidal persons have yet to join the suicide prevention movement. Of more concern, the majority of colleges, universities, and advanced clinical training programs that prepare healthcare professionals appear unaware or unwilling to implement the recommended curriculum changes needed to shape professional practice for suicidal consumers in the decades to come.

This lack of involvement by our educational institutions does not bode well for the safety of suicidal patients. Absent recommended changes in how practitioners are trained today, next year’s graduating classes will be as perfectly ignorant about suicide and its prevention as I was the day I was awarded a Ph.D. in Clinical Psychology in 1970.

Ten years ago we might be permitted to blame death by suicide on shame, ignorance, stigma, lack of training, or even the patient, but who shall we blame next year? Didn’t the former Surgeon General, David Satcher, proclaim suicide our most preventable death? Don’t goals 6 and 7 of the strategy call for improved knowledge and practice in the identification and care of suicidal patients? And, if these goals were met, is there not an implied promise that suicidal consumers won’t die by their own hands while in treatment?

Having traveled widely both before and after the release of the National Strategy, I believe a collision is about to occur between public expectation and professional practice, and that this collision will force our institutions to change whether they want to or not.

The institutional resistance problem
From my parallax view, I do not see university-based training program directors accepting a direct, participatory role or responsibility in suicide prevention education. It is simply not on their radar screens -- otherwise we would see more seminars, classes, workshops and other knowledge and skill-building learning requirements for graduation. Perhaps program directors believe preventing suicide is a public health problem and not something clinicians need to learn about.

In discussions with clinical and educational leadership, I find the same antiquated myths and misconceptions about suicide as are held by the general public. These great flywheels of wrong beliefs appear to discourage change, or even the exploration that something other than current practice might be better. How else can five years pass without even a modest accommodation to life-saving National Strategy and Institute of Medicine policy and training recommendations?

Until these leadership beliefs change, a 21st century university degree will assure graduating healthcare professionals at least two things: 1) an opportunity to earn a good income, and 2) a spectacular lack of information about one of humanities leading causes of premature death and how it might be prevented.

The consumer awareness problem
While the time divide between research and practice is great and everyone is so busy we can’t reasonably expect clinicians and students to stay up with current scientific findings in a field as arcane as suicide prevention, the consumer is not likewise encumbered. Concerned for the welfare and treatment of their suicidal loved ones, consumers simply cut out the background noise raised by the din of tiny academic swords clashing and click on Google. After all, when you’re loved one is thinking suicide you don’t have time to enjoy the leisure of the theory class.

My, my, what consumers can learn with a two-second web search! What we professionals ought to know but don’t is the stuff of lawsuits. The predictable result is that consumers will believe the Surgeon General (that suicide is preventable) – even if professionals do not. And, it appears, this is already happening. My contacts inside the insurance risk management business tell me suicide malpractice claims are increasing and settlements are getting bigger.

Question: If I take my suicidal brother to a qualified practitioner and that practitioner doesn’t conduct a risk assessment and/or ask me to help remove my bother’s firearms to help manage risks, and my brother later shoots himself – and after Googling “suicide malpractice” I find, say, www.skipsimpson.com, who am I going to be angry enough to sue?

The educational resource problem
Attitudes, ignorance and wrong-beliefs aside, and even we set about to vigorously achieve the educational and clinical goals set for us, we have too few qualified teachers and trainers. We didn’t have them in 1970, and we don’t have them now. None of my otherwise excellent graduate school faculty taught me anything about suicide prevention for a very simple reason: they didn’t know anything. They still don’t.

Those who know the most (researchers) often do not teach at all, or teach very little. As a survey of the membership of the American Association of Suicidology some years ago confirmed, very few of our own subject matter experts are training others. If those who know this stuff don’t teach it, others can’t possibly learn it. And except for a few small efforts here and there, we are about to graduate a whole 2006 class of healthcare professionals this year without specific knowledge about suicide and how to prevent it.

Most clinicians learn about suicide after the death of their patient, not before, and often with unpleasant psychological consequences to themselves. With regard to suicide, fear-driven anxiety and denial remains a powerful anti-learning force. One possible way to confront this fear head on is to mandate suicide prevention training as part of healthcare licensing. We did it with HIV/AIDS, why can’t we do it with suicide prevention? Surely the stakes are not smaller.

The money problem
Currently there are no financial incentives to improve one’s professional practice or competence to serve suicidal patients. Some of my colleagues in private practice refuse service to suicidal patients out of hand. “Why take the risk?” they ask.

Unlike neurosurgery, no one pays you extra to take on critical life-threatening cases, and thus many suicidal patients are discriminated against except in our hospital emergency departments or public sector service providers. Without a boost to the bottom line, why on earth would a busy practitioner take time off from his or her practice to pay for and acquire the requisite knowledge and skill to competently treat suicidal patients?

But imagine what would happen if we paid premium fees to those practitioners trained and willing to treat those most at risk for premature death by suicide? If not more money, could we not at least convince managed care companies to award providers who seek extra training “preferred provider” status, thus netting them more referrals and more revenue?

Perhaps the only way to get the horse to drink is to make it thirsty. By salting every state healthcare licensing exam with enough evidence-based questions about suicide that the untrained and ill prepared fail the exam, training institutions would either change curricula or close up shop. To protect the public’s safety, we do this in medicine, pharmacy, dentistry, and many other fields, then why not for those professions serving the mentally ill and those with addictive disorders?

Having chaired a state licensing board for psychology I can assure you no one but a fool bothers to learn answers to questions they know they will never be asked. But assure them they will fail an exam if they don’t know something about suicide, and fear proves an excellent motivator.

Finally, until the matter of consumer death by suicide is framed as a patient safety issue which is at once knowable and manageable, and until there is wider acceptance that trained, knowledgeable professionals can, and should, be able to save lives through informed judgment and the application of “best practice” interventions, the life-saving goals set by National Strategy for Suicide Prevention will remain only promises of what might have been.

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QPR Staff and Faculty