Minding Mental Health: Clinicians’ Engagement with Youth Suicide Prevention
2. Materials and Methods
2.1. Sampling Design and Data Collection
2.2. Data Management and Analysis
3.1. Professional Preparation: Becoming a Practitioner
3.1.1. Educational Background
There were some professors that were very candid about their own experiences in the field. And I think that was the most beneficial and the most helpful, there were some professors that were definitely more focused on the literature than the real-life application. And so, it was definitely a mixed bag. I think where I have learned the most is by doing. Just because you can read as many books as you can, and it tells you, oh, I can get this kind of patient or this kind of client, this is what you need to do. What if they don’t want to do that? And still having to navigate that and realize that they’re real people, they’re not just robots, a case study.(Kaitlin)
So, I haven’t been required to participate in any suicide prevention trainings, but that’s a real important part of the work that we do. So, we are required to get 24 CPU’s over the course of two years before license renewal. And early on I actually did a training that comes in a book for social workers. I did it just because it was interesting. And it was very impactful in the sense that it delineated risk factors, protective factors and that stuck with me. And the other part of that… so the practical piece came in when I had to do my first assessment with a client who was a teenager. I was working with a teen at a shelter for kids who expressed wanting to die, wanting to just, they just wanted to die. And before I met with this teenager, I met with my supervisor and she said, you’ve already trained for this. What you need to do is just go through the whole assessment with his child. And we had a psychosocial assessment… And so, when we came to the end of the assessment, and we talked about how he was feeling. Really, he didn’t want to die. It was a statement that he had made about his situation. Like my situation just seems so hopeless, I don’t know if I want to be alive… But he didn’t have a plan. He had never thought about it before, he didn’t have a family member that had died as a result of suicide. There was no concern that he would actually follow through because we had safety protocols in place for him. But that was the part about it, the practical piece of what we do.(Desiree)
3.1.2. Primary Client Factors
So, I look at how the family is structured, who is in the household, who they spend their time with. How’s school been for them? So, I really look at that family dynamic. Did they consider it a support to them? Do they feel like they have any support within the family dynamic? Do they have siblings? How the relationship with their siblings is, and then talking about any abuse, whether sexual, physical, emotional, mental, or neglect, or if they witnessed domestic violence. Also, I look at any substance abuse. And with adolescents now, the chemical dependency has increased so much because parents will get their children diagnosed and then put on medications, and then not realize that these teens then become biologically dependent upon these medications. And so, if they can’t get that specific thing, then they’ll go on and get another thing... If they have high suicidality, if they attempted suicide before. If they just have frequent thoughts, aggression or anger, outburst, and history. If they’ve been violent in the past. Have they made threats towards others?(Jessica)
As far as prevention, a lot of what we do is to screen them with what we call the Patient Health Questionnaire. So, it’s a PHQ-9 screening for depression related symptoms. It asks specific questions about motivation, depressed mood. How are you feeling? How are you sleeping? How are you eating? And then the last question is, “Over the last two weeks, have you thought about being better off dead or harming yourself in some way?” And so that’s a question we really look at closely. Depending on how they score, they will assess further, as far as do you have plan, do you have intent? Do you have the means? And then we go through a process depending on that.(Zoey)
3.2. Professional Practice: Applying Practitioner Knowledge
3.2.1. Suicide-Specific Treatments
Means reduction is probably the number one like most important thing, especially if somebody is high risk. So, having a spouse or family member lock up all medications in the house in a safe, having somebody remove the gun from the house, or at least put a trigger lock on the gun and then they give the key to somebody who doesn’t live in the house. If it’s somebody who lives alone, they’ll call law enforcement to come in and safely store a weapon. All the local law enforcement agencies will do that for you. You just gotta ask. So, removing access to means for someone who’s at a high risk for suicide is the number one most important thing you can do to prevent them from hurting themself. And then you work on the other stuff like sobriety and counseling and ambivalence and so on, but you can’t do that stuff if they’ve got a loaded gun in the house.(Clara)
And I think a lot of times, even just not necessarily normalizing it, but making it clear that it’s common to have these kinds of thoughts, and it’s not necessarily cause for feeling like you’re going crazy or something. But figuring out why is this happening and what can we do about it?(Juliet)
We contract for safety, you know, making sure that they’re doing good self-care. I’m very much in favor of more homeopathic and holistic methods when possible. And I have a certified homeopath that I do refer to cause I like to explore that before we go the pharmaceutical and psychiatric route. However, if someone has schizophrenia or schizoaffective, something with more of a serious mental illness or family history of, you know, mental illness and depression and previous suicide history, then of course my go-to would be referring them to a psychiatrist that I know. I’m certified in CBT, so we also apply some of those techniques.(Kloe)
I am a play therapist, so I would say that’s my number one. I advocate for that the most, but I see teenagers as well. So, I am trained in sand tray therapy. I do a lot of expressive types of things, even with middle-schoolers; so, like we’ll play a game or something that’s more expressive. I wouldn’t say that I’m just a talk, CBT person though. But I see 17-, 18-year-olds, so I’m not going to necessarily play with them. I feel like the older teenagers will definitely benefit more from CBT and talk (therapy). I would say like 14 or even 13 maybe and under or even middle school age, I’ll do more sand tray.(Sadie)
Family therapy is usually the most effective. Because therapy in the office is maybe maximum once a week or when I do it twice a week, but with good family dynamics there are other people that are working with that person more often, they can be aware of different things, they can understand things.(Quinn)
3.2.2. Treatment Options Process
We very much start by talking about what those thoughts sound like in their head and what’s happening to trigger those thoughts. And I think that the tool that I use most often would be a no harm contract where me and the client really talk about what the plan is and what to do instead. And also, daily check-in. I had a client once that was severely suicidal, but I was also going on vacation the next day. Within our clinic, we’re able to bring in one of our advocates and she was able to sit in on that assessment with me, and he agreed to answer her call by ten o’clock every morning. He would check in the evenings via text. And he knew that if he didn’t do that, we would make a wellness check call.(Cora)
I’m thinking of two different clients. One, highly emotional in the initial setting. In the initial session had been contemplating suicide, basically his whole life. It was more of an underlying thought, but that popped up really big. I’m not wording that very well. But we get bigger in different areas. So, it’s just a constant thought, right? And that is the one we were able to because he was used to dealing with it and he had some of his own techniques for coping with it. He just needed a little assistance and that’s the one we did the check-ins with. Whereas another client who had less experience with having these types of thoughts, this was very new for her. We needed to override it. CBT works. We also included a family member in her work as well. And so is having a family member… And when you’re bringing in a family member, you have to really be prepared to educate them and prepare them for the things that they might hear or see.(Cora)
3.2.3. Cultural and Ethnic Awareness
It’s more something we talk about, whether they’ve brought it up or I’ve noticed something, and we explore that together, or our racial impact on that person or the climate of society right now and how that’s impacting that individual in every which way. So, I think definitely discussing that, but also, I think as clinicians it can be challenging, too. Maybe this is just my perception, but we’re taught what healthy looks like. And I don’t think that healthy looks the same across people within the same racial ethnic group, but let alone across racial, ethnic groups. Taking things culturally into consideration that may be typical for a very Eurocentric society, by which we tend to live in the U.S., but that may not be typical for that person’s culture. And I have some patients who are immigrants, and so especially taking that into consideration of anything that they’re experiencing here or what would have been different where they grew up.(Stella)
3.3. Ongoing Professional Development: Navigating Practitioner Postvention
3.3.1. Proficiency in Support
[In my previous workplace] there were at least two incidences where I was - I just felt like I was in over my head with this client and I needed someone to come help me. And so, in those two instances, my director was available to come in and to help me direct this session in a way that was the most helpful to the client. So, I had a client who was suicidal. She had her plan; she knew what she was going to do. The only thing holding her back was, who was going to take care of her puppy? And so, we couldn’t guarantee that she could go home and stay safe. We had to get this client to the hospital. And that’s where at that point it was still, at that time we were called interns. I was a young intern. And then it was like, I have no idea what to do with this client because I can’t just plan to not want to go to the hospital. And so, between myself and the director, found a place where she could take her puppy and when we found a place for her to get her dog, then she was willing to go to the hospital. So that took probably about an hour and a half to two hours to sort out and to get her the service that she needed. At that time, we had cab services and the cab service took her to the hospital. And the follow-up was that her emergency contact later contacted me to let me know, yes, she made it to the hospital, she’s fine. So, that’s how we ended that. And what was the most helpful in that situation was to have somebody come in and direct the rest of the session because I was stuck. I didn’t know what to do. And then there was a debriefing after that, “Let’s talk about what you did and how you did it and how you felt in the middle of all of it, and what you learned from that, and what can you do or how can you handle a situation like this in the future?” That was huge. And so, I don’t know about the mental health community as a whole, but for our agency, because of my own experience with that, I like to make sure that the people that I supervise know how to get ahold of me, and if anything happens, I’m here and I can come in and help, too.(Desiree)
At another hospital I was working at, a patient, and it was a frequent flyer.2Very severe psychosis and depression. She had been committed several times, like at a state hospital. And because she was a frequent flyer, she was in the PICU, the psychiatric intensive care unit. And they just let her sit in the lobby because she had come in so many times and she was just telling them I need to get back there. I need to get back there. And this was a situation that I’d heard about once I was gone from the hospital, but they just kept telling her like, okay, we got you, you’re going to get back in a minute, but because she was such a frequent flyer, it was we’ll get to her when we get to her because we know… She ended up leaving and committing suicide that night. And again, I hadn’t been working at the hospital at that time I had moved actually to Houston, but from the therapist who told me about the situation. I was a court liaison, so I was the person who would get her paperwork processed. So, I knew her name very well. She had been committed several times. I don’t believe that they offered them anything for that. I don’t think that they offered the PICU therapists any services because I think they just know that EAP3is there for them. EAP is there, but that’s at your request.(Jessica)
3.3.2. Professional Development Recommendations
The mindfulness, mind-body work that I’ve done, like the training has been so impactful for me and helped me so much in my ability to be present with really difficult conversations that I think I would really love to see that more broadly offered, and chances not just to learn it academically, but to learn it like personally, to have your own experience of doing the work that we ask our clients to do. Because I think that’s one of the biggest things that’s helped me is like doing my own work and yeah, I would love more of that to be offered. I’ve had also a lot of training in collaborative work, collaborative practices. And that’s helped also with flexibility, asking better questions.(Justine)
I’m thinking back to you, the question that you asked me about if there was anything required when I was in going through my schooling through my master’s program, I would say just a little bit more emphasis on that, because I think even now, we have interns who come in and they don’t really know much about crisis interventions specifically for youth.(Zoey)
I think we get a lot of training on how to help our patients and all of that, which is very important. I hesitate to say most important because of this caveat of… I think there is this under emphasis of therapists taking care of themselves, especially when we have a high caseload of suicidal patients. A thing like that is really heavy and it can really weigh on any individual whether they were trained or not. I think what struck me is that… I don’t know what to say about whether there’s support after a patient, like support for therapists after a patient has committed suicide. Like, we have all these groups and individual therapies and treatment centers and stuff for our patients, but where are those groups when it comes to us and things that we might need to process and it’s, I think that there’s a significant… I don’t think it’s a denial, but this significant under emphasis on the importance of our own mental health, especially in a challenging time like this, where most of us in our personal lives are already strained because of COVID and because of everything else going on, and then to add the clinical aspect of that and the heaviness of clinical work always, but especially at a time like this. So, I wish that programs would really over emphasize because programs can be like, make sure you take care of yourself. You do self-care, which is yeah, that’s great, but it’s still important to model that, too. Like I had a professor, “I’m taking next week off for a mental health day and I want all of you to do the same.” There’s this showing by doing, not just telling. Not commanding, “Take care of yourself, but I don’t take any days off and I work when I’m sick because I can’t afford not to work.” I wish that programs had more of that, like where the people in power would model what it’s like to be a good user of mental health as someone working in the mental health field.(Stella)
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Conflicts of Interest
Appendix A. Interview Guide
- To begin, tell me how you first became involved with the mental health field.
- What motivated you to become a practicing clinician?
- What concerns, if any, did you have about becoming a clinician?
- Describe what kind of schooling was required for you prior to becoming a licensed practitioner.
- In what ways was your schooling sufficient or insufficient in preparing you for working with suicidal youth?
- How long did it take to complete your schooling (undergraduate, graduate program) and obtain your license?
- Could you describe for me what suicide-specific trainings, certifications, and continuing education in which you were required to participate? Were any related to interactions with youth?
- What did you find most helpful about these training sessions?
- In what ways could they have been improved?
- What are the primary factors (i.e., actively suicidal, age, insurance) you consider prior to taking on a client? How have you seen your considerations change during the pandemic?
- How often do you refer clients to another mental health professional? Could you describe how this has changed since the start of the pandemic?
- Thinking more generally about approaches and therapeutic techniques that you have used, Can you elaborate on the suicide prevention techniques available that you most often recommend with your clients? What types of therapy do you utilize?
- Can you tell me of an experience where that approach or technique worked especially effectively, or did not work as you had expected?
- Which of the available options have you seen be most effective?
- Reflecting on the different therapeutic pathways, how do intervention techniques differ from prevention?
- How often do you utilize prevention, intervention, and postvention techniques?
- How did you acquire these approaches and techniques?
- Could you elaborate on the process of choosing a treatment option for your clients?
- How would you describe the adaptations in therapeutic delivery and interactions you’ve had to make because of COVID-19-related restrictions?
- Could you tell me about a time when you had to adapt your delivery? How about when you needed to adapt or alter your initial treatment option?
- Cultural competency has become prevalent across various health fields. How do you consider ethnic diversity in your treatment delivery?
- In recent years, there has been an expansion of religious and spiritual awareness in therapeutic treatments. How do you consider the religion and spirituality of a client in your treatments?
- How does your own religious or spiritual background affect your treatment modality?
- (If employed by a religious organization or non-profit: How does the ideology of the organization you work with influence your treatment?)
- Most health insurance plans in the U.S. are required to cover mental health disorder services. What are your thoughts on accepting clients who can only afford mental health services through insurance?
- For clients you take on, how do (ethical) concerns change or remain constant while giving therapeutic treatments?
- How have you seen these concerns shift in the face of the pandemic?
- Could you describe how you interact with a potential client who says they are considering suicide or self-harming?
- The prevalence of stigma and fear of repercussions may prevent a client from sharing suicidal ideation or behaviors. Could you describe how you might adapt your interactions with a client who does not convey suicidal tendencies at the beginning of sessions but later relays those struggles?
- What are a few ethical and legal concerns, if any, that you have about treating youth exhibiting suicidal behaviors?
- Earlier you mentioned how method delivery and interactions have changed because of COVID. What are some legal concerns with these options?
- How does your professional training address any legal concerns that you may encounter?
- What are some protocols you are instructed to follow when encountering a suicidal youth client? How do the protocols differ from suicidal adults?
- Could you describe a situation when you have had to push the boundaries of protocol?
- How would you describe the mental health community’s proficiency in offering postvention treatment options for professionals who experience a client suicide?
- What are available postvention options for professionals?
- Can you recall a time when you’ve had to reach out for assistance or offer assistance to a fellow clinician?
- Thinking back on what you’ve shared with me today, what changes would you make, if any, if you could change professional development in your field?
- How do you think the changes that the pandemic influenced will alter the future of mental health treatment and delivery?
One interview was not relied upon heavily due to limited data collected as a result of time constraints.
Frequent flyer is a mental health care term for an individual who has been admitted into psychiatry wards twice a month across approximately six months.
EAP, the Employee Assistance Program, is a voluntary, work-based program that offers free and confidential assessments, short-term counseling, referrals, and follow-up services to employees who have personal or work-related problems (OPM 2021).
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|* Work Week Hours||* Age Group Specialization||* Area(s) of Specialization||* Experience Under Current License(s)||* Licensure Titles||* Children||Marital Status||* Age||Race||Gender||Participant Pseudonym|
|40+||3–99||Youth||9 yrs||LPC; CRC||2||Divorced||42||Hispanic or Latinx||Female||Caroline|
|40||5+||Clinical Mental Health||5 yrs||LPC||3||Divorced||43||Hispanic or Latinx||Male||Jason|
|45–50||17–3||Child/Adolescent Trauma; Grief||1 yr||LPC-A; NCC||0||Never Married||27||Non-Hispanic White||Female||Justine|
|37.5||Adolescents; Adults||Adolescents; Mindfulness; Family||7 yrs||LPC; LMFT||0||N/A||31||Non-Hispanic White||Female||Kaitlin|
|45–50||0–25; Parents||Trauma; Pediatric Transgender Populations; Youth, Families; Child Welfare||(LPC) 5 yrs; (LPA) 9 yrs||LPC; LPA||0||Married||36||Non-Hispanic White||Female||Arlene|
|40||Adolescents; Adults||Family; Couple, Individual||12 yrs||LPC||1||Married||43||Hispanic or Latinx||Female||Desiree|
|40||6+||Depression, Anxiety, Trauma; Individual Counseling||7 mths||LPC-A||0||Never Married||28||Hispanic or Latinx||Female||Zoey|
|20||Late Adolescents; Adults||Couple; Addiction; Trauma||LPC 3 yrs; LCDC 15 yrs||LPC; LCDC||2||Married||40||Non-Hispanic White||Female||Cora|
|40||17–3||N/A||2 yrs||LPC; NCC||0||Married||30||Non-Hispanic White||Female||Kamila|
|5–10 Clinical; 10–15 Supervising; 15–20 Administrative||6+||Anxiety; Depression; Parenting/Behavioral Issues||6 yrs||LPC; NCC||2||Married||43||Non-Hispanic White||Female||Juliet|
|40||5+||Generalist||4 yrs||LCSW||0||Never Married||31||Non-Hispanic White||Female||Sera|
|30||7+; 40+||Pastoral Counseling; Addiction; Relationships||14 yrs||Grace Life Fellowship Pastoral Counselor||2||Married||59||Non-Hispanic White||Male||Roger|
|40+||13+; Families with Children 5+||Relationships; Trauma; Anxiety||12 yrs||LPC||1||Married||56||Non-Hispanic White||Female||Josie|
|55||3–100||Eclectic||10 yrs||LPC||2||Divorced||61||Non-Hispanic White||Female||Kloe|
|Varies; 20||Adults; Some Adolescents||Trauma||5 yrs||Ministry License; Pastoral Medical License; Prior Psychiatry||0||Never Married||61||Non-Hispanic White||Female||Audrey|
|40||18–3||Play Therapy||1 yr||LPC (Registered Play Therapist)||0||Never Married||28||Non-Hispanic White||Female||Sadie|
|40||3–75||Psychiatry||20 yrs||Psychiatrist||2||Married||44||Asian American||Male||Quinn|
|40||All Ages||Adult/Adolescent Mental Health||11 yrs||PMHNP||2||Married||38||Non-Hispanic White||Female||Clara|
|35||3+||Children and Adolescents||2 yrs||Psychologist||0||Never Married||29||Non-Hispanic White||Female||Nora|
|40||Adolescents; Adults||Clinical Psycho||5 yrs||Psychologist||0||Never Married||36||Non-Hispanic White; Hispanic or Latinx||Male||Rafael|
|40||All Ages||Generalist||1 yr||Pre-Licensed Psychologist||0||Married||30||Non-Hispanic White; Hispanic or Latinx||Female||Stella|
|35||14+||Depression, Anxiety, Mood Disorders, and Chemical Dependency||3 yrs||LPC; NCC; LCDC||1||Never Married||28||African American or Black||Female||Jessica|
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© 2022 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https://creativecommons.org/licenses/by/4.0/).
Klee, K.; Bartkowski, J.P. Minding Mental Health: Clinicians’ Engagement with Youth Suicide Prevention. Soc. Sci. 2022, 11, 209. https://doi.org/10.3390/socsci11050209
Klee K, Bartkowski JP. Minding Mental Health: Clinicians’ Engagement with Youth Suicide Prevention. Social Sciences. 2022; 11(5):209. https://doi.org/10.3390/socsci11050209Chicago/Turabian Style
Klee, Katherine, and John P. Bartkowski. 2022. "Minding Mental Health: Clinicians’ Engagement with Youth Suicide Prevention" Social Sciences 11, no. 5: 209. https://doi.org/10.3390/socsci11050209