Contemp School Psychol DOI 10.1007/s40688-017-0147-9
School Psychologists’ Experiences with and Training in Suicide Assessment: Challenges in a Rural State Jacqueline A. Brown 1 & Anisa N. Goforth 1 & Greg Machek 1
# California Association of School Psychologists 2017
Abstract Past research has shown that suicide rates for males and females are higher in rural than in urban areas. Because of the high incidence of suicide attempts and completion of youth in rural areas, it is critical that they receive mental health support within schools. Consequently, the current mixedmethods study surveyed school psychologists in Montana to obtain information about their involvement and training in suicide assessment and the related challenges they have encountered. Thirty-seven school psychologists participated in the study, with 47% serving schools in rural areas. Participants were recruited through the membership listserv of the Montana Association of School Psychologists (response rate of 27%) and through direct e-mail contact (response rate of 16%). Results indicated that only 17% of the participants take the lead in suicide risk assessments and 47% are involved in them less than five times a year, 93% of participants did not have a graduate class exclusively devoted to suicide assessment, and 58% received 10 or more hours of training in suicide assessment post-degree. Furthermore, qualitative thematic analyses, using NVivo software, yielded nine major categories of challenges in suicide assessment identified by school psychologists. Study limitations, future areas for research, and implications for school psychologists are also discussed.
* Jacqueline A. Brown
[email protected] Anisa N. Goforth
[email protected] Greg Machek
[email protected] 1
Department of Psychology, University of Montana, Missoula, MT 59812, USA
Keywords Suicide assessment . Suicide training . Rural . Challenges . School psychologist
Suicide is the third leading cause of death among 10- to 14year-olds and the second leading cause among 15- to 19-yearolds (CDC 2014, 2015). Furthermore, the prevalence of youth having seriously considered suicide ranges from 13 to 20% (Kann et al. 2016). There are also differences in prevalence rates in urban and rural areas (see Hirsch 2006, for an international review), with suicide rates higher for female youth in rural areas and nearly double among rural males (ages 10 to 24) compared to males residing in urban areas (Fontanella et al. 2015). Consistent with previous research (Singh and Siahpush 2002), Fontanella and colleagues’ data note a widening temporal disparity between rural and nonrural suicide rates, most notably for males. As a rural state, Montana has consistently been ranked as a state with one of the highest suicide rates in the nation (American Foundation for Suicide Prevention 2015). In addition, Native Americans, the largest ethnic group in Montana, often have higher suicide rates than do other ethnic groups. Specifically, suicide rates among Native American youth ages 15 to 34 are 1.5 times higher than the national average (Center for Disease Control [CDC] 2015). Poverty, unemployment, and difficulty accessing mental health services contribute to the high suicide rates among rural youth (e.g., ERS 2015; Yoshikawa et al. 2012). To address and prevent these high rates of suicide, school psychologists and other school professionals have an important role in decreasing suicidal behavior. However, school psychologists often indicate that they do not have time to integrate crisis intervention into their hectic schedule (Nickerson and Zhe 2004). Furthermore, limited research has examined how school psychologists address or prevent
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suicide in rural schools. Considering this dearth of research, the purpose of this study is to further investigate rural school psychologists’ experiences with, and training in, suicide assessment. In addition, the study examines whether school psychologists in rural areas encounter greater challenges with suicide assessment than those in urban areas.
Factors Contributing to Suicide in Rural Communities There are a number of complex factors that contribute to the high incidence of completed and attempted suicides in rural communities. Research has suggested that factors such as unemployment and poverty, historical trauma within Native American communities, and difficulties accessing mental health services increase the likelihood of youth suicide. Unemployment and Poverty Unemployment and poverty significantly affect children and adolescents in rural communities. Based on the federal definition, poverty is defined as children living in households with incomes below the federal poverty line (U.S. Census Bureau 2016). Recent estimates show that approximately one fourth of children in rural areas were poor in 2015, compared to about one fifth of children in urban areas (ERS, 2015). Parents in rural areas are also more likely to be unemployed, putting children at higher risk of poverty (ERS, 2015). A clear association also exists between poverty and children’s mental health. Yoshikawa et al. (2012) provide a conceptual framework highlighting the individual and systemic factors related to children’s mental health, including family poverty, parent stress, low job quality and job instability, poor classroom environments, and lack of resources for health care needs. Given the high numbers of rural children in poverty, these factors may contribute to their high rates of depression, anxiety, and other mental health issues. In a study of rural adolescents, one in four reported experiencing symptoms of depression the previous week and one in five reported needing psychological treatment (Curtis et al. 2011). Suicide in Rural Native American Communities Suicide rates among Native American youth are particularly alarming. According to the Centers for Disease Control and Prevention (2013), suicide rates among Native Americans ages 15 to 34 are 250% higher than the general population. Suicide is the second leading cause of death among Native Americans (CDC 2013). There are numerous factors contributing to these high suicide rates, including a history of intergenerational trauma, mental health problems, poverty, and substance abuse. There has been
a significant and long history of cultural genocide and relocation from ancestral lands that subsequently led to intergenerational trauma within Native American communities. Some scholars have suggested that this disconnect or sense of loss associated with cultural identity may contribute to high mental health problems and suicide, and that there are dramatic reductions in suicide when Native American youth preserve and promote their culture (Chandler et al. 2003). Poverty is another significant factor, with one in four Native Americans living in poverty. Research also suggests that perceived discrimination is associated with suicidal ideation among Native American youth ages 9 to 16 (Yoder et al. 2006). Stigma, Geographic Remoteness, and Access to Services Limited access to care, social, and geographic isolation, as well as mental health stigma are also risk factors contributing to the high suicide rates in rural communities. First, there is significantly less access to mental health treatment in rural communities. Research studies suggest that individuals living in rural communities are less likely to have a current mental health diagnosis or a previous history of mental health treatment (Searles et al. 2014). This may be partly due to the fewer psychologists and other mental health providers who may be less likely to work in rural communities due to the higher likelihood of job dissatisfaction, burnout, and challenges with mental health stigma (Hastings and Cohn 2013). Fontanella et al. (2015) suggest that barriers related to travel and convenient access to services may also result in rural residents delaying treatment until their condition is more severe. The stigma associated with mental health can also influence the potential client’s willingness to seek mental health services. It has been suggested that people in rural areas may delay helpseeking until it is debilitating due to stoicism or emotional control (Judd et al. 2006). In one study, rural respondents were more likely to endorse stigma associated with depression than urban respondents (Jones et al. 2011). Even among families with children with emotional and behavior problems, families are often concerned of Bstigma by association,^ where family members may be perceived as having a mental health problem (Heflinger et al. 2014). Furthermore, geographic and social isolation may impact individuals in rural communities because it is more difficult to access social supports (Zaheer et al. 2011). Finally, in addition to these attitudes toward mental health, having easier access to firearms in rural areas increases risk of suicide completion (Fontanella et al. 2015).
School Psychologists Knowledge, Skills, and Training in Suicide Assessment The idea of school-based suicide prevention and intervention is not new (e.g., Miller and DuPaul 1996), and a growing
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emphasis in recent years is likely due to an increase in population-based approaches (Doll and Cummings 2008), federal acknowledgement and funding (e.g., National Strategy for Suicide Prevention; U.S. Department of Health and Human Services 2001), and the growing amount of resources on suicide and crisis prevention and response in the school psychology literature (e.g., Kalafat 2003; Miller et al. 2009). These factors are reflected in our profession’s organizational leadership. The National Association of School Psychologists (NASP) acknowledged crisis management as a needed part of the school psychologists’ skill set in 2001 (Allen et al. 2002) and more recently revised its graduate training standards to influence incorporation of Bevidencebased strategies for effective crisis prevention, preparation, and response^ (NASP 2010, p. 14). Research into the training of school psychologists to deal with crises, including suicide prevention and intervention efforts, suggests growing capacity, though there is still room for improvement. The relevant research also suggests that practitioners may receive more post-degree training than training in graduate school. For example, Allen et al. (2002) surveyed 276 practicing school psychologists and found that only 37% of participants indicated having some type of graduate program training or experience in crisis intervention. However, there was a trend toward inclusion of crisis content over time: more recent graduates (i.e., those graduating between 1994 and 2000) were more likely to receive exposure to crisis intervention training than those graduating before 1980. There were no differences based on level of education for coursework content, but doctoral and specialist level graduates did have higher levels of exposure in practicum and internship than did masters level students. In contrast, considering professional development after graduate training, Allen and colleagues found that practitioners had opportunities for further training, with many having received local in-service training (around 81%). This was followed by reading of books and journal articles (63.5%), attending state and other regional meetings (51.8%), and content provided by the NASP convention (26.6%). Importantly, when the authors inquired about areas for future training, participants indicated that suicide was their number one topic (35.4%). This study also found that only slightly over half (53%) of school psychologists participated in crisis response teams. A more recent analysis demonstrated slightly more relevant job experience and post-graduate training. Debski et al. (2007) analyzed responses from 162 NASP members and practicing school psychologists. They reported a higher rate of crisis intervention team participation (75%) and found that the vast majority of school psychologists participate in at least some suicide-related activity. Seventy-seven respondents indicated having a potentially suicidal student referred to them in the last 2 years. When working with potentially suicidal students, 68% of participants were involved in referring at-risk students
to community resources, 65% worked directly with potentially suicidal students as part of their school services, and 59% provided suicide training to staff (warning signs, appropriate response, etc.). In terms of training, Debski and colleagues’ data generally concur with Allen et al. (2002) in that the majority of school psychologists (99% in Debski et al. 2007) have received training on assessment of suicide risk, but that relatively few practitioners (40%) received it in their graduate training program. The most common non-school sources of training in this 2007 study were professional development workshops (69%), district in-service trainings (40%), and self-study (65%). Similar data were evident for training on postvention efforts. Also consistent with Allen and colleagues, Debski found that recent degree recipients were more likely to have graduate training content specific to suicide assessment training than those graduating more than 5 years ago. In terms of feeling prepared to assist potentially suicidal students, about half felt they were somewhat prepared, while 43% said they were Bwell prepared.^ It should be noted that significantly more doctoral students endorsed well prepared (60%) than did MA, MA plus certificate, and specialist level graduates. A more recent survey (Liebling-Boccio and Jennings 2013) solicited information from school psychology graduate training program coordinators/directors and found that almost 98% of programs indicate coverage of suicide risk assessment. The most common courses in which this content was covered were practicum and other courses devoted to intervention and therapy. It is difficult to ascertain whether the higher amount of graduate program coverage evidenced in this study, relative to Allen et al. (2002) and Debski et al. (2007), is due to the respondent source (i.e., asking training faculty versus past students), an actual increase in content covered in training program, or a combination of these two variables. Slightly over half of the participants (51.8%) said that at least 5–6 h was devoted to the topic; this did not differ by level of training program. Consistent with Debski and colleagues, program directors/coordinators felt that their students were well prepared in certain areas (identifying risk factors and warning signs, ascertaining level of risk, understanding precipitating events) but less prepared in areas related to hospitalization and school-wide prevention and screening efforts. A number of barriers to providing crisis intervention have been proposed. Nickerson and Zhe (2004) sampled 197 practicing school psychologists regarding their experiences and perceptions related to school crisis preparedness, prevention, and intervention. In this study, Bcrisis^ was broadly defined and not specific to suicide prevention and postvention skills. The most common challenge was lack of time within job role
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and school setting. In terms of barriers specific to providing suicide prevention and postvention services, non-doctoral participants in the Debski et al. 2007) reported the following: 39% reported that their job role was mainly defined in terms of assessment and remediation, consistent with Nickerson and Zhe (2004); 29% of practitioners reported that other school professionals took on the role of suicide prevention and response; 19% reported serving too many schools; and 28% indicated a lack of adequate training. Thus, there seems to be a general consensus that the average school psychologist’s role does not often allow time for suicide prevention and postvention activities, and that, as a possible result, these roles are assumed by other building professionals.
Current Study and Rationale Considering the need for additional research addressing suicide in rural areas, the current study expanded upon previous research by highlighting challenges experienced by rural school psychologists. Furthermore, this study focused on school psychologists in Montana, a state that is consistently ranked as having one of the highest suicide completion rates in the USA. The primary purpose of this study was to examine the responses of school psychologists in Montana to questions regarding their current involvement and past training in suicide assessment. In addition, because of the high prevalence rates of suicide in rural states and the challenges associated with providing mental health services in rural communities, a secondary purpose was to identify key themes that arose regarding challenges associated with suicide assessment services. By understanding these challenges, this study can help inform areas of need within schools and training to increase the provision of effective services for at-risk students.
eligible to participate. Due to obtaining a lower response rate than initially expected, the researchers conducted a follow-up e-mail to recruit participants through direct e-mail contact. An undergraduate research assistant conducted a comprehensive online search of school psychologists currently practicing in both school districts and educational cooperatives in Montana. The information for 50 school psychologists in 12 districts and 22 education cooperatives in Montana was obtained. Eligible participants may have received an invitation to complete the survey through both means (MASP listserv and direct email contact). Due to the confidentiality required of MASP membership, it was not feasible to determine which participants received the invitation twice. Twenty-nine participants responded to the invitation to complete the survey through the MASP membership listserv (response rate of 27%), and eight participants responded to the direct e-mail contact (response rate of 16%). Participants were 86% female and 97% were White/NonHispanic. Among participants, 68% indicated that they obtained their Specialist degree in school psychology and 95% indicated that this was their highest degree. Further, 19% had obtained their Master’s degree and 8% their Doctoral degree. Five percent of the participants had been practicing for less than 1 year, 3% had been practicing for 1–2 years, 14% for 3– 5 years, 32% for 5–10 years, and 46% for 10 or more years. In addition, 67% indicated that the approximate ratio of school psychologists to students within their district was either 1:1000 or 1:1500. Only 11% indicated that the ratio was 1:500 or lower, 14% indicated that it was 1:750, and 8% indicated that it was 1:2000. Furthermore, 33% of participants indicated that they serve five or more schools, 8% serve four schools, 24% serve three schools, 27% serve two schools, and 8% serve one school. Measure
Method Participants Participants were 37 practicing school psychologists in Montana. Participants were either recruited through the Montana Association of School Psychologists (MASP) membership listserv (150 professionals) or directly by e-mail (50 professionals). To participate in the study, the inclusion criteria were that the individual had already completed a terminal degree in school psychology and was practicing as a school psychologist. Those who received the survey through the MASP membership listserv were not all eligible to participate, due to being a student, a non-practicing school psychologist, or practicing in a different but related field. In consultation with the MASP Executive Board, it was anticipated that approximately 107 members who received the survey were
A 22-item survey was developed by the researchers asking participants general demographic information, along with specific questions related to their training in suicide assessment and associated challenges. A survey developed by Allen et al. (2002) was used to inform some of the survey items. Allen and colleagues first piloted their survey to finalize the questions prior to using it in their study. In their survey, school psychologists were asked information related to their work, training, and ratio of school psychologists to students. Researchers with expertise in this area developed and reviewed the items in the current survey based on Allen and colleague’s study. In the current survey, demographic information consisted of questions related to number of years practiced as a school psychologist, degree earned, school demographics and students supported, and driving distance to work. Specific questions were also asked related to training in suicide assessment (e.g., frequency of involvement, graduate
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training, post-degree training). Finally, participants were asked to describe in detail specific challenges in suicide assessment and potential challenges that may be directly related to working in a rural area. Please contact the first author if you would like to obtain the survey. Procedure School psychologists in Montana were asked to respond to a 22-item online survey through Qualtrics, which took approximately 10 to 15 min to complete. An e-mail of initial contact and consent form was sent asking potential participants to complete an online survey through Qualtrics. Two follow-up e-mails were sent out through the membership listserv two and then again 3 weeks after the initial contact. Data Analysis The current study utilized a mixed-methods approach. For questions regarding schools served, mileage, driving distance, size of schools, and training and involvement in suicide assessment, demographic results were analyzed using percentage and frequency data. In addition, participants were asked to list the specific schools they serve, and this information was used to determine whether the schools they served met criteria for Brural.^ There are multiple definitions of what constitutes rural versus Burban,^ with the most common ones focusing on population density (Ratcliffe et al. 2016) or county classification (Office of Management and Budget, OMB 2015). Although both definitions have their merit, the population density definition was used in the present study. It defines rural as population and territory outside of cities and towns with 2500 or more people. On the other hand, urbanized areas are areas with 50,000 or more people, and urban clusters are areas with at least 2500 but fewer than 50,000 people. This definition was chosen as it was a better fit with the goal of the study and challenges experienced by school psychologists in rural areas. Otherwise, if the county classification definition was used, some small towns in Montana with limited access to services would not have been considered rural due to their proximity to a metropolitan/urban area. For the two open-ended questions asking participants about the challenges they have experienced with suicide assessment, a specific type of qualitative analysis (thematic analysis; Braun and Clarke 2006) was used to synthesize and categorize the identified responses using NVivo software. NVivo is a qualitative analysis software program that also allows for mixed-methods research. It enables researchers to input open-ended survey responses, in addition to other written responses, and provides tools to organize and manage these responses, and then integrate them into meaningful themes. The coding team consisted of two members: a researcher with a doctoral degree in school psychology and an undergraduate
assistant who was trained on how to use NVivo. The researcher with the doctoral degree (first author) played a large role in recruiting the participants, whereas the other coder (undergraduate student) was involved only in data analysis. Responses were identified and organized into patterns through NVivo. To ensure that each idea was captured, the single ideas were categorized and labeled as nodes in NVivo and then categorized into themes. A node is a specific category or theme that is labeled by the coder, enabling coders to identify and analyze trends or patterns across the responses (Saldana 2013). A theme is essentially defined as Ban extended phrase or sentence that identifies what a unit of data is about and what it means^ (Saldana 2013). The two coders identified these patterns and then discussed and organized them into reoccurring themes. When there was inconsistency in coding, analyst triangulation was conducted, with the first and second coder discussing the theme to better understand multiple ways of viewing the data. Discussions between the two coders were also helpful in ensuring consistency in theme identification, in addition to increasing interrater reliability of the responses and themes. However, the researchers acknowledge that conducting additional reliability checks and obtaining an inter-rater reliability score would have been optimal.
Results School Demographics Percentage and frequency data were utilized to analyze school demographics. Information was obtained about each participant’s school(s) to determine whether they were in a rural area. Only 34 out of the 37 participants provided this information. It was determined that 47% of the participants (16 out of 34 participants) served rural schools. Participants were also asked about their average weekly mileage for work, the largest driving distance between their schools, and the total enrollment of both the smallest and largest school they serve. Their average weekly mileage was 163 miles (ranging from 0 to 815). Furthermore, the average driving distance between schools was 38 miles (ranging from 0 to 230). Finally, the average total enrollment of the smallest school served was 268 students (ranging from 2 to 2115) and the average total enrollment of the largest school served was 725 (ranging from 230 to 2200). Experience with and Training in Suicide Assessment Similar to the above results, training and experience in suicide assessment data were also analyzed through percentage and frequency data. These results are presented below in Table 1.
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Challenges with Suicide Assessment Qualitative analyses were conducted to examine school psychologists’ perceptions and challenges related to suicide assessment, including specific challenges related to working in a rural area. Participants were specifically asked to answer the following questions: (a) What challenges have you experienced with suicide assessment? and (b) What challenges have you experienced with suicide assessment that are related to working in a rural/nonmetropolitan area? Analyses resulted in the following nine themes: (a) Lack of Available Community Health Support and Follow-up, (b) Numerous Obligations of School Psychologists, (c) Lack of Resources and/or Training, (d) Standard School Procedures are Not Available, (e) Parents or School Professionals Do Not Take Suicide Seriously, (f) Limited Knowledge of and Relationships with Students, (g) Lack of Team Collaboration, (h) Stigma Associated with Mental Health, and (i) High Levels of Suicide Completion and Access to Lethal Means. The first three themes were derived from both of the above questions, while the remaining six themes were specific to only one of these questions. These themes, including both the overall percent of school psychologists and the percent of rural school psychologists endorsing each theme, are described below in further detail.
to complete an assessment and follow-up, and struggling to meet the needs of all students due to their numerous responsibilities. When examining the participants’ responses regarding specific rural challenges, 16% of school psychologists made comments specific to this theme, with 57% of those who identified this theme serving rural schools. Similar to the general challenges related to this theme, participants reported challenges related to being spread too thin across schools, having limited time at each school, and having numerous responsibilities. Theme 3: Lack of Resources and/or Training When addressing general challenges, 16% of the participants included this theme in their responses, with 50% being school psychologists working in rural areas. Comments surrounding this challenge included not having training or access to relevant assessments, training being solely available for a limited number of district employees, and lacking confidence in the ability to handle suicide risk. When examining specific rural challenges, 16% of the participants (33% in rural areas) made similar comments focusing on not having training or access to the assessments, having few professionally trained therapists/counselors, and not having the necessary preventative resources.
Theme 1: Lack of Available Community Health Support and Follow-Up In response to Question 1 (general challenges), 31% of the participants endorsed this theme, with 18% of those who endorsed the theme being school psychologists working in rural areas. For example, school psychologists in both rural and urban/urban cluster areas reported that follow-up is limited and that outside therapists often do not return phone calls. In addition, one rural school psychologist wrote, BThe closest mental health providers to my main school are located 50 to >100 miles away. TeleMed services are not available for new casework at this time.^ With respect to Question 2 (specific rural challenges), 27% of the participants endorsed this theme, with 36% of those participants who endorsed it working in rural areas. Similar to Question 1, comments made by both rural and urban/urban cluster school psychologists addressed difficulties surrounding follow-up care and access to highquality health resources for risk assessment, in addition to school-based professionals not trusting clinicians in the community and there being limited available mental health providers.
Theme 4: Standard School Procedures are Not Available This identified theme is specific to Question 1. Twenty-two percent of the participants made comments related to this theme in their responses, with 50% of these participants being school psychologists working in rural areas. Similar comments were made by both rural and urban/urban cluster school psychologists specific to not having a standardized protocol within and across buildings within a district, limited available policies and procedures or documentation surrounding identifying students at risk for suicidal behaviors, and inconsistency in personnel across schools to support students exhibiting suicidal behaviors.
Theme 2: Numerous Obligations of School Psychologists With respect to general challenges, 24% of school psychologists made comments related to this theme, with 45% of these individuals working in rural areas. Comments made by both rural and urban/urban cluster school psychologists included being spread too thin across schools, not having enough time
Theme 6: Limited Knowledge of and Relationships with Students This identified theme is also specific to Question 1, with 8% of the participants including related comments and 33% of the participants being school psychologists working in rural areas. Participants in rural and urban/urban cluster areas commented on their limited relationship with, and knowledge
Theme 5: Parents or School Professionals do Not Take Suicide Seriously This theme was specific to Question 1 (general challenges), with 16% of the participants including comments related to this theme and 33% of these participants working in rural areas. Comments made by both rural and urban/urban cluster school psychologists focused on a lack of parent/teacher interest to address the problem or take it seriously.
Contemp School Psychol Table 1 Experience with and training in suicide assessment
Experience and training variables
Percentage (N)
School professional taking the lead on suicide assessment School counselor
58% (21)
School psychologist Other (e.g., school social worker, principal, multiple professionals)
17% (6) 25% (9)
Involvement per week in suicide assessment Once per week
3% (1)
A few times a month Once a month
19% (7) 3% (1)
Less than once per month Less than 5 times a year
19% (7) 47% (17)
Graduate courses exclusively devoted to suicide assessment Zero courses One course
91% (33) 3% (1)
Two courses Graduate courses partially devoted to suicide assessment Zero courses One courses Two courses Three courses
6% (2) 19% (7) 28% (10) 19% (7) 22% (8)
Four courses Hours of training in suicide assessment post-graduate degree
11% (4)
Less than 5 h 6 to 10 h
39% (14) 3% (1)
More than 10 h
58% (21)
Location of post-degree training (check all that apply) College/university courses taken outside of degree Conference (e.g., Montana Association of School Psychologists; NASP) Non-conference workshop (e.g., District Training) Other (e.g., online self-study)
of, students. As a result of this limited knowledge, one participant indicated that it is therefore difficult to Bdecipher the level of support or intervention needed.^ Theme 7: Lack of Team Collaboration This theme was specific to Question 2 (rural challenges). Sixteen percent of the participants made comments related to this challenge in their responses, with 33% of these participants being school psychologists working in rural areas. Comments made by both rural and urban/urban cluster school psychologists included not having a team approach to the risk assessment, lack of coordination and communication with school-based and community stakeholders, and parents getting angry at schools for conducting these assessments. Theme 8: Stigma Associated with Mental Health Once again, this theme is specific to rural challenges. Fourteen percent of the participants included related comments, with 20% of participants who endorsed this theme working in rural
6% (2) 61% (20) 76% (25) 33% (11)
areas. For example, one rural school psychologist wrote, BTeachers and parents in rural schools are reluctant to refer a student for outside help. There is definitely a stigma attached to mental health in our rural areas, a palpable mistrust and denial of problems.^ School psychologists in urban/urban cluster areas also made comments about parents not being open to counseling services and Bbelief systems that disregard mental health issues or view them as a personal weakness.^ Theme 9: High Levels of Suicide Completion and Access to Lethal Means This final theme is also specific to rural challenges, with 8% of participants commenting upon this theme and 33% of these participants working in rural areas. Comments made by school psychologists in both rural and urban/urban cluster areas focused upon challenges surrounding easy access to weapons and other means and high numbers of completed suicides. For example, one participant wrote Bthere are times when young people who have suicidal
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thoughts are able to put together a plan quickly, and there are many open areas in which to complete their plan.^
Discussion The current study sought to examine school psychologists’ perspectives regarding their training in, and experiences with, suicide assessment. Although there have been studies that have examined school psychologists’ training as it relates to suicide assessment, this study contributes to the current research by highlighting key challenges that school psychologists face in addressing youth suicide in rural schools, where there are often higher rates of youth suicide. Results of the current study show clear themes regarding some of these challenges, such as lack of community support, unavailability of standard school procedures, limited understanding of the seriousness of suicide, and obstacles related to mental health stigma in rural communities. School Demographics, Suicide Assessment, and Associated Challenges School demographic results indicated that almost half of the participants serve rural schools, and there were more similarities than differences in rural versus urban/urban cluster school psychologists’ experiences. The concept of Brurality^ is nuanced, because it not only suggests the population but also the access to the nearest metropolitan city. That is, the population of the largest urban city in Montana is approximately 109,000, and the smallest urban cluster city has a population of approximately 3000. In addition, Montana has a Bfrontier^ culture that permeates across the region, regardless of population density, and this may be one reason that the themes were similar across population boundaries. In other words, school psychologists working in urban and urban cluster may also experience rural-related challenges. School psychologists in this study also reported large variations in driving distances between schools, average weekly mileage, and number of students served, which may affect their ability to address suicide in their schools. Indeed, previous studies of rural school psychologists showed that they drove more miles per week and served more schools, compared to suburban and urban school psychologists (Goforth et al. 2016). Thus, in the context of addressing student suicide risk, some school psychologists who serve smaller schools may have an advantage in being familiar with more students and consequently be better able to identify those at risk for suicidal behavior. On the other hand, there may be disadvantages such as having limited access to resources or support within their schools, or limited time with each student if they are working in multiple schools that are miles apart. This may be a particular challenge for school psychologists serving both
rural and urban areas, who work in schools with both small and large populations, and who have long driving distances between their schools. Surprisingly, school psychologists in the present study reported that only 17% take the lead in suicide assessment and 47% are involved in it less than five times a year. Given the high rates of suicide in Montana, it is troubling that less than half of the respondents were involved in suicide assessment on a regular basis. These results are both consistent and inconsistent with previous research. Unlike the results of the current study, previous research indicates that over 50% of school psychologists were involved in making community referrals for at-risk students, work directly with potentially suicidal students, and provide suicide training to staff (Debski et al. 2007). However, these results are also consistent with previous research (e.g., Debski et al. 2007; Nickerson and Zhe 2004), which has shown that school psychologists do not always have the time to be involved in suicide prevention and response and that other school-based practitioners often take the lead in this area. Similar to Nickerson and Zhe (2004), participants in this study also noted that their numerous work obligations might pose a challenge to addressing suicide in their schools. For example, they indicated that they were being spread too thin, experienced time restraints, and were not always able to meet the needs of all students. These challenges can be particularly problematic for a school psychologist who works at multiple schools yet who must assess a student who is at high risk for suicidal behaviors. Working in more than one school may impact the school psychologist’s ability to develop a relationship with that student, and in fact, he or she may have limited knowledge of that student, both of which participants in the current study identified as a challenge. School psychologists may thus have to rely on their interdisciplinary team members to address an issue when the school psychologist is not present at the school. Yet, respondents in the current study reported a lack of team collaboration and noted this was a significant obstacle to their ability to address suicide. A team approach and open communication is essential when supporting at-risk students and may mitigate some of the challenges that could arise, such as high levels of stress and burnout. With respect to training received in suicide assessment, the majority of school psychologists indicated that they did not have a class exclusively devoted to suicide assessment in their graduate training, whereas over half of the participants indicated that they had at least one course that was partially devoted to it. Furthermore, over half of the participants indicated that they had received ten or more hours of training in suicide assessment post-degree, with the majority of this training either occurring during a non-conference workshop (e.g., district workshop) or at a state or national conference. These data are consistent with the challenges they reported surrounding resources and training: participants indicated a lack of access
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to training or relevant assessments and also lacked confidence in their ability to handle suicide risk. When comparing these results to previous research, findings suggest that similar to Allen et al. (2002) and Debski et al. (2007), participants in this study report having received the majority of their training in suicide assessment and response during post-degree professional development training. Furthermore, although it may appear that findings from other research (Liebling-Boccio and Jennings 2013) report higher levels of training in suicide assessment than the current study, it is important to examine differences in methodology between the studies. Unlike the current study, Liebling-Boccio and Jennings broadly focused on the percent of programs covering suicide assessment. Although a high percent of programs covered this topic in their study (98%), findings of the current study also indicated that 81% of the participants had at least one course partially devoted to suicide assessment. Furthermore, unlike previous research (e.g., Debski et al. 2007), this study did not specifically examine differences in suicide training based on year of graduation. It is possible that if this were examined, recent graduates would be more likely to endorse having higher levels of training in this area. In addition, feelings of uncertainty that a school psychologist may experience due to not receiving in-depth training or being confident about his/her abilities may be further magnified if a standard school protocol is not available to ensure consistency within a district. Indeed, almost one quarter of the participants in this study indicated that standard procedures are not available, with half of these participants working in rural areas. These results emphasize the importance of ensuring that school psychologists, schools, and districts receive ongoing training and support in suicide assessment and intervention, particularly in rural areas where there may be limited access to community resources and mental health professionals. Other Identified Challenges in Suicide Assessment In addition to the challenges reflected upon above, school psychologists also identified other critical themes relevant to challenges they experience with suicide assessment. One main theme that was identified by both urban/urban cluster and rural school psychologists was the lack of available community health support and follow-up. Rural communities have significantly less access to mental health services and because of this, individuals living in rural communities are less likely to have a history of mental health treatment and more previous suicide attempts (Searles et al. 2014). However, school psychologists in rural as well as urban/urban cluster areas similarly noted difficulty accessing community health support and follow-up, suggesting that those in urban areas experienced similar challenges in addressing students’ mental
health outside of the school setting. As noted earlier, Montana is a large state with a small population, thus accessing community services poses a significant challenge. Mental health stigma and perceptions of suicide also pose challenges for school psychologists. Rural communities are often seen as tight knit, in which members rely on each other for support (Wagenfeld 2003). Stigma associated with mental health is higher in rural areas, and these beliefs influence individuals’ motivation to seek out mental health services (e.g., Fontanella et al. 2015; Judd et al. 2006). For example, in one study, rural school psychologists noted that a significant disadvantage of working in rural schools is that community members do not often want to address mental health or Bair out [their] dirty laundry^ (Goforth et al. 2016, p.64). Furthermore, another related challenge endorsed by some participants in the current study was access to lethal means, which is also highlighted as an explanation for the disparity between rural and urban areas by Fontanella. The results from both the current study and past research highlight the importance of addressing and educating professionals and families about risks related to potential stigma, particularly in rural areas. Interestingly, none of the participants in the study commented upon challenges specific to linguistically and culturally diverse students, such as working with Native American students. Native Americans are the largest ethnic group in the state of Montana, are at high risk for mental health problems (Chandler et al. 2003), and have significantly higher suicide rates than the general population (CDC 2013). It is unclear why participants did not explicitly comment on potential challenges related to serving Native American students; however, it may be that the challenges school psychologists experience in rural schools are similar for Native American students as other students. For example, school psychologists in this study may experience challenges related to stigma associated with mental health with families from diverse cultural backgrounds, which may include Native Americans. It is also possible that participants in the current study did not encounter related challenges either due to having provided limited one-on-one support to Native American students or due to these challenges not being attributed directly to cultural differences. Furthermore, it is possible that since the survey questions did not refer to cultural considerations, participants did not consider related challenges. Limitations and Future Research The current study contributes to the existing literature on suicide assessment and rural practice, yet there are several limitations. The main limitation is the sample size. Although multiple attempts were made to identify participants, recruiting
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school psychologists through e-mail and getting them to complete a survey in addition to their daily work commitments can be challenging. Future research should use a national sample, such as the National Association of School Psychologists, to enable a larger comparison between school psychologists in urban and rural areas. Future research should also consider conducting focus groups on this topic to obtain more indepth information about some of the identified themes and provide school psychologists with the opportunity to feel supported and connected to other colleagues, particularly those in more remote areas. Two related limitations are the low response rate and the fact that there may have been a selection bias in the participants who chose to respond, as they may have a particular interest in training and experience in suicide assessment. Consequently, it is important to note that the sample of participants for the current study does not represent the perspectives of all school psychologists conducting suicide assessment in rural or urban areas. The sample was primarily limited to school psychologists in Montana, and not all school psychologists in Montana responded. Additional information and more clear distinctions between rural and urban/urban cluster areas are likely to be seen in states that have a larger difference in population size between urban and rural areas. However, despite the limited sample, past research has suggested that school psychologists in other areas of the USA, both rural and urban, experience similar responsibilities and challenges to participants in the current study (e.g., Debski et al. 2007; Nickerson and Zhe 2004). Other additional limitations are also important to consider. First, although using an online survey to obtain this information was specifically chosen to be mindful of participant time and availability, it is possible that rich information may have been missed about their perspectives that would have been more easily and thoroughly obtained during in-person interviews or focus groups. Finally, although we took various measures to ensure the reliability of the responses, additional interrater reliability checks would have been beneficial. Another additional area of research would be to examine rural teacher and administrators’ perceptions about suicide assessment and prevention. The current study showed that school psychologists faced obstacles from teachers and administrators, noting that teachers were hesitant about referring students due to mental health stigma. Indeed, research indicates that teachers believe that they should be involved in suicide assessment and prevention, but often have limited training or experience and fear that they will make the situation worse (Hatton et al. 2017). Little research has examined how rural cultural values, the potential ethical issues that may evolve from small communities, or mental health stigma may contribute to or hinder the effectiveness of school-based suicide assessment and/or prevention programs.
Implications for School Psychology Youth suicide rates are alarming, particularly in rural communities where there are challenges to accessing mental health services. School psychologists can play a critical role in preventing and addressing suicide in rural schools. The results of this study highlight challenges that rural school psychologists experience, and we suggest a number of implications for training and practice. Although school psychologists in urban/ urban cluster areas of Montana also experience similar challenges, we believe it is important to highlight implications specific to rural areas, in hopes that these will benefit all rural school psychologists. Training Trainers of school psychologists may want to consider examining their program’s core curriculum to determine whether there is sufficient content that covers suicide assessment and intervention. The current study highlighted that the majority of school psychologists reported that they did not receive graduate training that was exclusively devoted to suicide assessment. Thus, it may be important for trainers to consider ways to include suicide assessment as either a standalone course, or perhaps integrate it into a behavior or mental health assessment course. Furthermore, if there is suicide assessment and prevention content embedded within the curriculum, trainers may want to discuss challenges associated with conducting these assessments and interventions in rural communities. Nearly 24% of school psychologists in the USA work in rural communities (Curtis et al. 2012); thus, it is likely that some of their graduate students will obtain positions in rural communities and experience challenges associated with providing mental health services in rural schools. Trainers may also want to consider ways to teach best practices in culturally responsive prevention programs for ethnic minority students, such as Native Americans. Given that Native Americans are at greater risk for suicide than any other ethnic minority group (CDC 2015), training programs may discuss the systemic factors contributing to this higher risk (e.g., intergenerational trauma, racism, poverty). Prevention programs, as well as interventions, such as cultural adaptations of cognitive-behavioral therapy (e.g., Morsette et al. 2012), have been developed to be cultural responsive to Native American youth. Practice A significant number of school psychologists reported that they lacked resources or training in suicide assessment and prevention, and many highlighted the importance of team collaboration. It may be important for rural school psychologists
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to take leadership and invite stakeholders in their community to be part of a team. Stakeholders could include communitybased therapists, as well as other important members such as a religious leader, the Parent Teacher Association President, and others who are respected within their community. As experts in student mental health and evidence-based practice, school psychologists can play an important role in collaborating with community members to reduce mental health stigma and ensure that prevention programs are put into place to address the high rates of suicide in rural communities. Furthermore, it is critical that school psychologists maintain their training and education in suicide assessment and prevention. Participating in state and national conferences to get additional training is important so that they can keep up with the latest developments in research and practice. Specific programs, such as the PREPaRE Training curriculum, which is published by the National Association of School Psychologists (NASP), are available. It may also be helpful for rural school psychologists to obtain mentorship or peer consultation from other rural school psychologists. The current technology allows for numerous ways to obtain emotional and professional support. For example, using video conferencing tools such as ask Skype or Google Hangouts would allow school psychologists who are significant distances from each other to communicate and obtain consultation about students at risk for suicide. This additional consultation would also help in reducing job burnout. Compliance with Ethical Standards Conflict of Interest The authors declare that they have no conflict of interest. Ethical Approval All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. Informed Consent Informed consent was obtained from all individual participants included in the study.
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Jacqueline Brown PhD, is an Assistant Professor of Psychology at the University of Montana. Her research focuses on school-based crisis prevention and intervention, evidence-based practices to support grieving students, and building resilience in youth. Anisa Goforth PhD, is an Assistant Professor of Psychology and Director of the School Psychology Graduate Training Programs at the University of Montana. Her research focuses on culturally responsive evidence-based practices for culturally and linguistically diverse children and families. Greg Machek is Associate Professor of Psychology at the University of Montana. He has research and training interests in developmental psychopathology of children and adolescents, peer aggression in schools, and behavioral interventions within a multi-tiered system of supports.