Oct 28, 2016 | Article, Volume 6 - Issue 4
Mehmet A. Karaman, Richard J. Ricard
Movements such as the Arab Spring (as described by popular media) and recent regional conflicts have forced people to leave their homes and flee to other countries or regions. Syrian refugees are currently the second largest refugee group worldwide, with half of them resettled in Turkey. Turkish government and non-governmental civil organizations have mobilized efforts to address the immediate survival needs of these refugees such as food, shelter and other provisions. Despite efforts to manage the complexity of mental health and social service needs of forcibly displaced people, counseling services are still lacking. This expository article addresses the mental health needs of Syrian refugees and provides implications for counseling professionals working with displaced people from a crisis intervention approach built on principles and perspectives of humanistic mental health. In addition, programs of support, such as the Mental Health Facilitator program, are discussed.
Keywords: Syrian refugees, mental health, Turkey, displaced people, Arab Spring
The Arab Spring has affected many Arabic countries in the region and resulted in regime changes and general disruption in people’s lives (Khan, Ahmad, & Shah, 2014). The Arab Spring refers to a wave of revolutionary civil unrest, riots, demonstrations and protests in the Arab world that began in December 2010 in Tunisia, and spread throughout the countries of the Arab League and its surroundings (“Arab Spring”, n.d.). The Syrian Republic is embroiled in a civil war in which separatists have been protesting for more democratic rights and the imposition of a civilian government. The region has been further destabilized by the conflict surrounding ethnic origin, and the political and religious activities of the Islamic State of Iraq and Syria (ISIS).
Approximately 6 million people have taken refuge in Turkey, Lebanon, Jordan, Iraq and Egypt since the Syrian conflict began in 2011 (United Nations High Commissioner for Refugees [UNHCR], 2016). According to the UNHCR (2016), the Republic of Turkey (Turkey) has accommodated the largest number of Syrian refugees in the region. The Turkish government quickly took the necessary steps, such as opening the border and providing food and shelter, after the first group of Syrian refugees entered Turkey on April 9, 2011. To date, there are roughly 2.8 million refugees living in camps and urban areas; half of these refugees are children (UNHCR, 2016). The majority of refugees (90%) live outside of camps and are surviving under challenging circumstances compared to the refugees who live in camps. Refugee camps offer health care, education, food, security and social services. However, refugees who live outside of camps have limited access to information and public services such as education and health care.
Syrian refugees are enduring daily challenges to physical and mental survival. In addition to the extreme needs for physical and nutritional interventions, mental health professionals recognize the urgent need for counseling services based on widespread documented reports of refugees’ exile experiences and exposure to multiple sources of trauma (Sirin & Rogers-Sirin, 2015). This crisis has resulted in a population of displaced people suffering from a number of mental health issues (Alpak et al., 2014; Betancourt et al., 2015; Clarke & Borders, 2014; Özer, Şirin, & Oppedal, 2013). For example, Önen, Güneş, Türeme, and Ağaç (2014) conducted a quantitative study on Syrians who resettled in refugee camps. The results indicated that 19% of refugees reported high levels of anxiety and 9% experienced high levels of depression. In a recent study, Alpak et al. (2014) reported that approximately one third (33.5%) of Syrian refugees showed symptoms consistent with a diagnosis of post-traumatic stress disorder (PTSD).
The fact that many of the displaced Syrians are especially vulnerable children living far from their homes, cultures and countries further highlights the magnitude of the crisis (Özer et al., 2013). Recent reports indicate that up to 50% of the Syrian refugees are children suffering from exposure to severe traumatic events at rates higher than their adult counterparts (Sirin & Rogers-Sirin, 2015). Özer et al. (2013) reported that 74% of Syrian children in a refugee camp have experienced the loss of a family member or a loved one, and 60% of children felt their lives were in danger. These self-reports of distress and concern are consistent with another recent study of 8,000 displaced Syrian children who reported constant fears (15.1%) and suicidal thoughts (26%; James, Sovcik, Garoff, & Abbasi, 2014).
Several indicators suggest that the severity of the current Syrian refugee crisis is unprecedented. A recent meta-analysis compared the relative rates of mental health disorders between refugees from different world regions and ultimate country of relocation (Fazel, Wheeler, & Danesh, 2005). Fazel et al. (2005) found that while up to 10% of refugees who relocated in Western countries experienced symptoms of PTSD, major depression and generalized anxiety disorder, the frequency of these diagnoses is significantly greater among the current Syrian refugee population (Alpak et al., 2014; Önen et al., 2014). For example, Syrian refugees who resettled in Turkey had a higher incidence of mental health disorders when compared to refugees from Southeast Asia, former Yugoslavia, and Central America who settled in Western countries (i.e., United States, Australia or Canada) collectively referred to as the Organization for Economic Cooperation and Development.
Recognizing the severity of the crisis, Turkey has initiated legal reform, established programs and practices, and requested humanitarian assistance from the international community to help manage the influx of Syrian refugees (Özden, 2013). Turkish government and non-governmental civil organizations have mobilized efforts to address the immediate survival needs of refugees, such as providing food and shelter. Despite these efforts, the available resources, including the number of counselors and other qualified mental health professionals, are inadequate to deal with the constant flow of Syrian refugees (Sahlool, Sankri-Tarbichi, & Kherallah, 2012). The vestiges of war have resulted in an increase in the prevalence of a number of psychosocial stressors and disorders (e.g., PTSD) as well as total desolation of social networks of family, friends and loved ones (Akinsulure-Smith & O’Hara, 2012). These challenges underscore the complexity of mental health and social service needs of forcibly displaced people in the region (Alpak et al., 2014).
This article highlights the challenges faced by the Turkish government related to a humanitarian response to the Syrian refugee crisis. Suggestions are provided for designing appropriate responsive counseling services for refugees from a diversity of sociocultural and geopolitical contexts. Principles and best practices (grounded in humanistic counseling theory) for addressing the mental health needs of diverse displaced people are discussed. Opportunities for generalization and specific cultural applications and adaptations are presented as well.
The Syrian Culture
Syria is located in Southwestern Asia at the eastern end of the Mediterranean Sea. It has its longest border with Turkey on the north, and is bordered by Israel and Lebanon on the west, Iraq on the east, and Jordan on the south. The majority of Syria’s population consists of Arabs (90.3%) and the remaining 9.7% consists of Kurds, Armenians and others (The World Factbook, n.d.). Religiously, Syria is a mosaic society. The vast majority of the population (87%) consists of Muslims (74% are Sunni and 13% are Alawi, Ismaili and Shia). Christians (Orthodox, Uniate, and Nestorian) are the largest single minority religious group (10%), and 3% of the population consists of Druzes (The World Factbook, n.d.). Before the beginning of the civil conflict (between the Syrian government and groups of citizens), positive intergroup relationships, for example between Christians and Muslims, were readily observed. However, the current situation of intergroup relationships is unknown since the political equilibrium has changed and continues to change rapidly.
Adherence to religious principles and cultural edicts are fundamental to a typical Syrian’s daily life. Islamic creeds and beliefs, such as Iman (faith) and Qadar (destiny), are elemental and strictly proscriptive of Muslim lifestyle (Eltaiba, 2014). Accordingly, traditions and customs associated with family life (relationships, marriages and future plans) are rooted in cultural and religious traditional practices. Family life is the center of Syrian social structure and extended families are the most common family type (Mahdi, 2003). Intermarriages between ethnic groups, religions and social classes are rare. As an authority figure, the father or the eldest man (grandfather) in the household has the power and is the foundation of a patriarchal structure, giving an advantage to males (Mahdi, 2003).
Addressing the Needs of the Syrian Refugees
Turkish officials have utilized a physiological and psychological needs-based approach (Inter-Agency Standing Committee [IASC], 2007) in the planning for a response to the refugee crisis. The approach has largely been adapted from humanitarian organizations (e.g., Red Crescent, UNHCR) that provide relief, crisis interventions and emergency services. Counseling services are usually not the immediate priority of refugees; most refugees will not seek available counseling or even be able to take part in counseling activities if they do not have a roof over their heads or food in their stomachs and are struggling to survive (International Federation of Red Cross and Red Crescent Societies [IFRCRCS], 2009). Consistent with Maslow’s (1943) original theory, crisis intervention efforts need to address the most immediate needs that threaten basic survival (e.g., hunger, safety) first. Once these basic needs have been met, individuals can address other difficulties associated with the experience of trauma (IFRCRCS, 2009). In this respect, the crisis level and needs of refugees determine the priority of counseling and psychosocial support services. National and international mental health crisis intervention organizations (IASC, 2007; IFRCRCS, 2009), such as the Turkish Red Crescent organization, have adopted IASC guidelines (2007) and the recommended four-level approach, which is described below, to assess the urgency of needs for refugees and victims of natural disasters.
Level 1: Basic Needs and Security
Syrian refugees are in need of basic services such as shelter, nutrition, education, medication and health care services. Approximately 1.4 million Syrian refugees are children (Orhan & Gündoğar, 2015; UNHCR, 2016), and the United Nations Children’s Fund (UNICEF; 2014) has reported that these children are at risk of being a “lost generation.” Moreover, security is a source of distress because of recurring aggression towards refugees who live out of the camps. These events continue along the border with Turkey. For example, a car bombing killed 57 refugees and wounded at least 80 Syrians near a border crossing between Turkey and Syria (UNICEF, 2014).
Level 2: Situation of the Community and Family Support
There is a sense of distrust within the Syrian refugee community that is rooted in the ongoing conflict in Syria (Chammay, Kheir, & Alaouie, 2013). Displaced persons from both sides of the conflict are often resettled together, despite differing political affiliations. Refugee families are struggling to survive in the midst of widespread fragmentation. For instance, Özer et al. (2013) reported that 74% of children in the Islahiye refugee camp had experienced the loss of a family member, affecting the well-being of the whole family.
Level 3: Focused, Non-Specialized Counseling Support
According to the Disaster and Emergency Management Presidency (DEMP; 2013), 51% of Syrian refugees report a need for some form of psychological support. In the same report, approximately 26% of refugees indicated dissatisfaction with the mental health care they received. In parallel with this finding, Chammay et al. (2013) stated that Syrian refugees felt disrespected by the mental health professionals.
Level 4: Specialized Counseling Services
In Turkey, counseling services are different than those in the United States and other developed countries. Turkish counseling services have focused exclusively on school settings and most counselors work as school counselors (Korkut, 2007; Stockton & Yerin Güneri, 2011). When compared to the United States, there are no specializations in the counseling education system in Turkey, such as clinical mental health, career counseling and addictions counseling. In Turkey, mental health services are provided within the medical field; thus, the majority of professionals who work in mental health have consisted of psychiatrists and nurses (Yilmaz, 2012). This situation has affected the availability of counseling and mental health services for Syrian refugees seeking assistance. The efforts of DEMP, Red Crescent, UNHCR, and other non-government and non-profit humanitarian organizations (e.g., Humanitarian Relief Foundation, Support to Life) are not enough to meet the counseling and mental health needs of Syrian refugees.
Mental Health Needs
Empirically validated research on the mental health needs of the Syrian refugees in Turkey and other countries (e.g., Lebanon) is limited due to a lack of focus on the assessment procedures and diagnostic reporting (Chammay et al., 2013). As documented by previous reports of forcible displaced peoples, Syrian refugees are at especially high risk for mental health problems as well as social and physical concerns and uncertainty about the future and current situation in Syria. Individual accounts of extensive violence, death and war illustrate the distress of refugee life at the personal level. For example, the following illustrates one refugee’s account of witnessed chaos in Syria:
The soldiers were gathering men in some areas. They interrogated a father, “Which one is your son?” the soldier demanded. The desperate man pointed out his son. The soldier then cut the man’s son’s throat first, then they shot the father. They were killing and burning so many people that the smell of burning bodies spread through the entire city, like a blanket of death smothering any hope of survival. (Korucu, 2013, p. 90)
This story highlights not only the experience of physical pain, but also fears, losses and spiritual wounds associated with protracted exposure to physical and emotional trauma. Although all refugees did not experience traumatic events or witness a massacre, they fled with other refugees who experienced loss, trauma and torture. The stories spread to others in camps and in the media, and as a result many fled to other countries to protect themselves and their loved ones.
Each refugee client has different needs, and “not every refugee who seeks counseling will require individual therapy for psycho-emotional issues. Counselors should not assume simply because of a traumatic background, intense loss, and other aspects of refugee experience that a refugee is necessarily psychologically impaired” (Baker, 2011, p. 122). In addition to basic physical needs, counselors need to be aware of and focus on the wellness and psychological needs of refugees. Research on well-being (Davidson, Murray, & Schweitzer, 2008) has highlighted the fact that health and wellness is indicated by more than a “lack of diagnosis” (Savolaine & Granello, 2002). There are common concerns that affect refugees in general. For instance, distress about the future, housing, employment, and separation from the family and the culture of the host country or community are predominant issues in refugees’ lives. These factors affect their emotions and holistic wellness (Clarke & Borders, 2014; Tempany, 2009). There are specific situations that affect the mental health of Syrian refugees. First, 83% of Syrian refugees have experienced a traumatic event (Chammay et al., 2013). The intensity of the experience and duration of exposure may affect the level of mental health. Stories and experiences of refugees who were exposed to the traumatic events can frighten other refugees who did not experience a traumatic event, triggering anxiety and stress. Second, unmet physiological needs may exacerbate feelings of insecurity and affect healthy psychological responses. Moreover, refugees’ lack of personal awareness of their own mental health needs can affect help-seeking behaviors. Third, there may be acculturative stress stemming from cultural differences and adaptation to the host culture, which can adversely affect mental health factors after immigration. Specifically, high risks exist for children who lost one or both of their parents in the war. Last, hearing about and seeing people continuing to die in the conflict through news and social media can increase or sustain depression and PTSD symptoms (Alpak et al., 2014).
These compounding mental health issues exacerbate the daily struggles faced by Syrian refugees and underscore the need for mental health intervention (Alpak et al., 2014; James et al., 2014; Özer et al., 2013). One of the most important counseling services would be multicultural transition and adaptation to a new (even if only temporary) living situation.
The Availability of Multiculturally Competent Mental Health Counselors
The impact of a counselor’s awareness of personal cultural values and a client’s worldview is foundational to multicultural counseling competence (Arredondo et al., 1996). We believe that mental health professionals in Turkey will be better able to provide culturally sensitive counseling support to refugees when they make efforts to understand and appreciate the customs and traditions of their Syrian clients (Arredondo et al., 1996). Despite the proximity and often shared religious ideology, considerable differences between Turkish and Syrian citizens (e.g., language, beliefs, cultural practices) may influence the quality of social services refugees receive in their host country. Although Turkey is the neighbor of Syria and shares many cultural and historical ties, a healthy process of cultural transition and adaptation is needed for refugees. More counselors, mental health facilitators (MHFs) and interpreters are needed to provide adequate mental health services, guide the refugee community in meeting their physiological needs, and inform the host culture to decrease prejudice.
Barriers, Challenges and Implications for Counseling
Counseling professionals need to be mindful of the diversity of displaced people. The majority of Syrian refugees fleeing to another country for survival bring different political experiences, levels of education, religions, ethnicities and levels of income to the resettled environment (DEMP, 2013). Counselors may face some challenges and barriers to providing services when working with this unique population. These challenges may include, but are not limited to, language, culture and dependence on Western-based counseling interventions. For example, some refugees might not attend group counseling if they are assigned to the same group with refugees who have different religious beliefs or ethnicity (Eltaiba, 2014). In such cases, counselors’ sensitivity and skills for addressing issues of cultural heritage and historical background of culturally different clients can transform disadvantages into advantages (Sue, Arredondo, & McDavis, 1992). There are effective resources and handbooks that provide detailed guidelines for working with refugees and forced migrants (Hinkle, 2014; IFRCRCS, 2009; UNHCR, 2013). A counselor can create his or her own guidelines for specific or general challenges of working with a refugee population. Specifically, when counselors work with Syrian refugees to create treatment plans, they should consider clients’ culture, religion, ethnicity, worldview and language in order to be more effective.
Language Barriers
The majority of Syrian refugees have resettled in Jordan, Lebanon, Iraq, Egypt and Turkey (UNHCR, 2016). While Syria, Jordan, Lebanon, Iraq and Egypt are Arabic countries and have a common culture and language, the majority of people in Turkey have a Turkish heritage and speak Turkish. Furthermore, the availability of Arabic-speaking counselors in Turkey is limited. Government organizations and social service agencies have experienced difficulty finding bilingual personnel as well (e.g., medical doctors, counselors; DEMP, 2013). Providers have responded by employing language interpreters to facilitate counseling contacts with refugees. Language barriers may create trust issues due to the existence of a third person in the session and it may be difficult for the counselor to establish rapport with the refugee client (Akinsulure-Smith & O’Hara, 2012; Baker, 2011). In this respect, several best practice approaches for maximizing the beneficial usefulness of interpreters are warranted. First, counselors may need to meet with the interpreter to explain confidentiality and the goals of the counseling interview; discuss the interpreter’s cultural background and cultural expectations; explain the need for detailed translation in the assessment; and discuss seating positions in the session (Baker, 2011; Paone & Malott, 2008).
When counselors work with interpreters they also need to consider interpreters’ citizenship status. Interpreters who are themselves refugees may be vicariously vulnerable to experiences reported by clients. Therefore, a program of careful screening, ongoing training, supervision and support for interpreters is vital (Miller, Martell, Pazdirek, Caruth, & Lopez, 2005). Programs of support, such as the National Board for Certified Counselors’ (NBCC) Mental Health Facilitator (MHF) program (Hinkle, 2014), would be helpful for Turkish counselors and interpreters. The MHF program covers the global aspects of community-based mental health training. The MHF initiatives are designed to empower local community members with skills for providing basic mental health services to people who are in crisis (Hinkle, 2014). By working with local volunteers, the MHF programs bridge the gap created by limited access to mental health services provided by mental health professionals, such as professional counselors, psychiatrists, social workers and clinical psychologists. The MHF curriculum includes implementation strategies for nonclinical, basic assessment, social support and referral services (Hinkle, 2014). While the current MHF curriculum and materials are available in the Arabic language, recent reports indicate that materials have not yet been translated to Turkish. Access to culturally sensitive training programs like MHF may be a crucial element to increasing the impact of mental health initiatives targeting refugee populations. Turkish governmental authorities and non-profit organizations would be wise to take immediate action with NBCC to adapt this program to Turkish.
Language immersion efforts are one promising approach to minimizing the impact of linguistic barriers. For example, approximately 87% of the Syrian refugees in Turkey reported that they wanted to learn Turkish (DEMP, 2013). The government and non-profit organizations have Turkish courses for refugees in the camps and cities. Counselors may use these classes as one of their referral sources. The classes also give an opportunity for clients to attend an activity, engage in the society, meet with new people from their own cultures and communicate with local residents.
Challenges Due to Refugee-Host Community Relations
A rapid influx of migrants can place considerable stress on the fiscal and emotional resources of the host country (Orhan & Gündoğar, 2015). The current Syrian refugee crisis has shifted from a humanitarian to a political crisis for other countries (e.g., Germany, Sweden, France; Hebebrand et al., 2016). Many refugees who live in Turkey are trying to fly to other European countries. However, politicians of those countries are not willing to accept refugees because of security, resources and possible dissent of their citizens (Hebebrand et al., 2016).
Although Turkey and Syria have longstanding historical ties and similar cultural and religious orientations, refugees will almost certainly experience acculturative stress, oftentimes as a result of negative reception from the host country (Betancourt et al., 2015). For instance, residents of the Gaziantep province, which has the second highest number of Syrian refugees in Turkey, protested against refugees and initiated physical attacks on them. The conflict increased the tension in the city and forced authorities to resettle some refugees in other provinces.
Bektaş (2006) has indicated that attempts at a multicultural curriculum in Turkish counseling education programs are not enough, and there is not a current mechanism or system (e.g., CACREP) to promote multicultural counseling competencies among Turkish counselors. Governmental and non-profit organizations need to consider diversity and ethical considerations when recruiting counselors for counseling and mental health services. The Turkish government’s policies toward the ongoing situation in Syria might polarize the government officials and mental health professionals who work with the Syrian refugees. At this point, counselors should be aware of their own personal views, biases and political ideas. They should be able to focus on their role as counselor rather than as resident or citizen.
With respect to provision of clinical mental health services, tensions between residents and refugee groups may interfere with effective receipt of counseling interventions by refugees. These events might cause mistrust towards counselors since they can be seen as part of the system, members of the host culture or representatives of the authorities (Vanguard, 2014). Holistic and advocacy-based services are more beneficial for refugees to cope with cultural difficulties (Baker, 2011; Clarke & Borders, 2014). These services include psychosocial support, counseling, referral sources, education and programs for the host community. Furthermore, counselors can provide additional services, which are not listed here, based on the needs of refugee clients.
Cultural and Spiritual Challenges
Syria represents an Eastern culture with dominant collectivist characteristics (Samovar, Porter, & McDaniel, 2010). The religion of Islam plays a role not only in individuals’ personal lives, but also in social life and society. Religion and spirituality are a way of life for Muslims across different cultures (Eltaiba, 2014). Religion determines the relationship between men and women, social roles, laws of inheritance, what people can and cannot eat, childcare, marriage and more. In addition to the culture of religion, traditions guide people’s lives as well. As mentioned before, the Syrian culture has a patriarchal structure. In this situation, men have more rights and freedom than women (Mahdi, 2003). For example, this patriarchy can create problems when counselors plan for group counseling. It can be difficult for women to talk about or share their problems in front of men. In this respect, dividing groups based on gender can be more effective.
In such cases, religion and spirituality can be explored in individual counseling sessions. Research has shown that religious coping can be used effectively by refugees (Clarke & Borders, 2014). For example, a Muslim refugee client might think that he or she deserves the current circumstances and whatever happens is Allah’s will. This belief represents the basic idea of Qadar – destiny or fate – and should be addressed carefully by the counselor because Qadar includes the individual’s will and belief that everything comes from Allah/God, and since refugees are under stress they can give up all the responsibility to Allah or God. A holistic approach that focuses on both the individual’s and society’s values and needs should be implemented since culture and religion provide significant means for coping.
Challenges With Counseling Interventions
Many migrants and forced refugees are not familiar with the concepts of counseling, which might seem strange to them (Akinsulure-Smith, 2009; Akinsulure-Smith & O’Hara, 2012). Refugees need to understand the services available in order to benefit maximally from them. The government and humanitarian agencies need to use terms that make sense for Syrians. When organizations prepare brochures, handbooks, reports and name plates, they should explain available mental health and counseling services, define counselor, and explain their services. Most Turkish counselors who work with Syrians were educated in Turkish counseling programs, which were modeled on U.S. programs and included Western-based counseling theories (Mocan-Aydin, 2000). This Western-based education and theories might decrease the effectiveness of counseling and challenge counselors because Syrians come from an Eastern culture. Since they have moved to a new culture, been separated from families, and experienced pressure and persecution, many refugees do not understand their new culture or know where to find help. In this respect, a group of Syrian mental health facilitators trained with the NBCC MHF program can be a valuable resource for working with this population (Hinkle, 2014). The inclusion of trained community volunteers will likely increase refugees’ access to mental health services while simultaneously decreasing the work load of professional counselors.
Conclusion
Over 2.8 million Syrian refugees have resettled in Turkey in the period of 2011 to 2016 (UNHCR, 2016). As the refugee population continues to grow, host nations will need to prepare a systematic response to this continuing humanitarian crisis in ways that support the basic human needs of forcibly displaced people. The Turkish government has responded to the presence of Syrian refugees with interventions that support basic survival needs (i.e., food and shelter). The availability of mental health and social services for refugees is limited and remains a focus of humanitarian assistance. Counselors should be cognizant of the traumatic experiences refugees often endure in the context of displacement and ongoing conflict. Counselor training and facilitation of community-based mental health advocates such as those provided by MHF can increase the impact of available counseling interventions for refugees. In addition, the IASC four levels crisis intervention approach, which is used by the Turkish Red Crescent organization, can be beneficial to address traumatic experiences and the needs of refugees.
Conflict of Interest and Funding Disclosure
The authors reported no conflict of interest
or funding contributions for the development
of this manuscript.
References
Akinsulure-Smith, A. M. (2009). Brief psychoeducational group treatment with re-traumatized refugees and asylum seekers. The Journal for Specialists in Group Work, 34, 137–150. doi:10.1080/01933920902798007
Akinsulure-Smith, A. M., & O’Hara, M. (2012). Working with forced migrants: Therapeutic issues and considerations for mental health counselors. Journal of Mental Health Counseling, 34, 38–55.
doi:10.17744/mehc.34.1.62rv11064465j55p
Alpak, G., Ünal, A., Bülbül, F., Sağaltıcı, E., Bez, Y., Altındağ, A., Dalkilic, A., & Savaş, H. A. (2015). Post-traumatic stress disorder among Syrian refugees in Turkey: A cross-sectional study. International Journal of Psychiatry in Clinical Practice, 19, 45–50. doi:10.3109/13651501.2014.961930
Arab Spring. (n.d.). In Wikipedia. Retrieved June 6, 2016 from https://en.wikipedia.org/w/index.php?title=Arab_Spring&oldid=724060662
Arredondo, P., Toporek, R., Brown, S. P., Jones, J., Locke, D. C., Sanchez, J., & Stadler, H. (1996). Operationali-zation of the Multicultural Counseling Competencies. Journal of Multicultural Counseling and Develop-ment, 24, 42–78. doi:10.1002/j.2161-1912.1996.tb00288.x
Baker, M. (2011). An integral approach to counselling refugees. Asia Pacific Journal of Counselling and Psycho-therapy, 2, 117–125. doi:10.1080/21507686.2011.565932
Bektaş, Y. (2006). Kültüre duyarli psikolojik danişma yeterlikleri ve psikolojik danişman eğitimindeki yeri [Multicultural counseling competencies and the place of multicultural competencies in counseling education]. Ege Eğitim Dergisi [Ege Education Journal], 7, 43–59.
Betancourt, T. S., Abdi, S., Ito, B. S., Lilienthal, G. M., Agalab, N., & Ellis, H. (2015). We left one war and came to another: Resource loss, acculturative stress, and caregiver-child relationships in Somali refugee families. Cultural Diversity & Ethnic Minority Psychology, 21, 114–125. doi:10.1037/a0037538
Chammay, R. E., Kheir, W., & Alaouie, H. (2013). Assessment of mental health and psychosocial support services for Syrian refugees in Lebanon. Beirut, Lebanon: UNHCR. Retrieved from https://data.unhcr.org/syrianrefugees/download.php?id=4575
Clarke, L. K., & Borders, L. D. (2014). “You got to apply seriousness”: A phenomenological inquiry of Liberian refugees’ coping. Journal of Counseling & Development, 92, 294–303. doi:10.1002/j.1556-6676.2014.00157.x
Davidson, G. R., Murray, K. E., & Schweitzer, R. (2008). Review of refugee mental health and wellbeing: Australian perspectives. Australian Psychologist, 43, 160–174. doi:10.1080/00050060802163041
Disaster and Emergency Management Presidency. (2013). Türkiye’deki Suriyeli sığınmacılar: 2013 saha arastirmasi sonuclari [Syrian refugees in Turkey: The results of 2013 field study]. Ankara, TR: AFAD. Retrieved from https://www.afad.gov.tr/upload/Node/3925/xfiles/syrian-refugees-in-turkey-2013_baski_30_12_2013_tr.pdf
Eltaiba, N. (2014). Counseling with Muslim refugees: Building rapport. Journal of Social Work Practice, 28, 397–403. doi:10.1080/02650533.2013.875523
Fazel, M., Wheeler, J., & Danesh, J. (2005). Prevalence of serious mental disorder in 7000 refugees resettled in western countries: A systematic review. The Lancet, 365, 1309–1314. doi:10.1016/S0140-6736(05)61027-6
Hebebrand, J., Anagnostopoulos, D., Eliez, S., Linse, H., Pejovic-Milovancevic, M., & Klasen, H. (2016). A first assessment of the needs of young refugees arriving in Europe: What mental health professionals need to know. European Child & Adolescent Psychiatry, 25, 1–6. doi:10.1007/s00787-015-0807-0
Hinkle, J. S. (2014). Population-based mental health facilitation (MHF): A grassroots strategy that works. The Professional Counselor, 4, 1–18. doi:10.15241/jsh.4.1.1
Inter-Agency Standing Committee. (2007). IASC guidelines on mental health and psychosocial support in emergency settings. Genava: IASC. Retrieved from http://www.who.int/mental_health/emergencies/guidelines_iasc_mental_health_psychosocial_june_2007.pdf
International Federation of Red Cross and Red Crescent Societies. (2009). Psychosocial interventions: A handbook. Retrieved from http://pscentre.org/wp-content/uploads/PSIHandbook_EN_July10.pdf
James, L., Sovcik, A., Garoff, F., & Abbasi, R. (2014). The mental health of Syrian refugee children and adoles-cents. Forced Migration Review, 47, 42–44.
Khan, J., Ahmad, M., & Shah, Z. (2014). The Middle East uprising (the Arab Spring): Prospects and challenges. International Journal of Academic Research in Business and Social Sciences, 4, 114–120.
doi:10.6007/IJARBSS/v4-i9/1134
Korkut, F. (2007). Counselor education, program accreditation and counselor credentialing in Turkey. Inter-national Journal for the Advancement of Counselling, 29, 11–20. doi:10.1007/s10447-006-9021-6
Korucu, S. (2013). After “Syria” went to wreck and ruin. Istanbul, TR: Support to Life. Retrieved from www.hayatadestek.org/media/files/pdf/Suriye_yerl_bir_olduktan_sonra.pdf
Mahdi, A. A. (2003). Teen life in the Middle East. Westport, CT: Greenwood Press.
Maslow, A. H. (1943). A theory of human motivation. Psychological Review, 50, 370–396. doi:10.1037/h0054346
Miller, K. E., Martell, Z. L., Pazdirek, L., Caruth, M., & Lopez, D. (2005). The role of interpreters in psycho-therapy with refugees: An exploratory study. American Journal of Orthopsychiatry, 75, 27–39. doi:10.1037/0002-9432.75.1.27
Mocan-Aydin, G. (2000). Western models of counseling and psychotherapy within Turkey: Crossing cultural boundaries. The Counseling Psychologist, 28, 281–298. doi:10.1177/0011000000282007
Orhan, O., & Gündoğar, S. S. (2015). Suriyeli sığınmacıların Türkiye’ye etkileri [The effects of Syrian refugees on Turkey] (Research Report No. 195). Retrieved from http://tesev.org.tr/wp-content/uploads/2015/11/Suriyeli_Siginmacilarin_Turkiyeye_Etkileri.pdf
Önen, C., Güneş, G., Türeme, A., & Ağaç, P. (2014). Bir mülteci kampinda yaşayan Suriyelilerde depresyon ve anksiyete durumu [Depression and anxiety case in Syrians that live in a refugee camp]. Akademik Sosyal Araştırmalar Dergisi, 2, 223–230.
Özden, S. (2013). Syrian refugees in Turkey. Retrieved from http://www.migrationpolicycentre.eu/docs/MPC-RR-2013-05.pdf
Özer, S., Şirin, S., & Oppedal, B. (2013). Bahçeşehir study of Syrian refugee children in Turkey. Retrieved from https://www.fhi.no/globalassets/migrering/dokumenter/pdf/bahcesehir-study-report3.pdf
Paone, T., & Malott, K. M. (2008). Using interpreters in mental health counseling: A literature review and
recommendations. Journal of Multicultural Counseling and Development, 36, 130–142.
doi:10.1002/j.2161-1912.2008.tb00077.x
Sahlool, Z., Sankri-Tarbichi, A. G., & Kherallah, M. (2012). Evaluation report of health care services at the Syrian refugee camps in Turkey. Avicenna Journal of Medicine, 2, 25–28. doi:10.4103/2231-0770.99148
Samovar, L. A., Porter, R. E., & McDaniel, E. R. (2010). Communication between cultures (7th ed.). Belmont, CA: Thomson Wadsworth.
Savolaine, J., & Granello, P. F. (2002). The function of meaning and purpose for individual wellness. The Journal of Humanistic Counseling, 41, 178–189. doi:10.1002/j.2164-490x.2002.tb00141.x
Sirin, S. R., & Rogers-Sirin, L. (2015). The educational and mental health needs of Syrian refugee children. Washington, DC: Migration Policy Institute.
Stockton, R., & Yerin Güneri, O. (2011). Counseling in Turkey: An evolving field. Journal of Counseling & Devel-opment, 89, 98–104. doi:10.1002/j.1556-6678.2011.tb00065
Sue, D. W., Arredondo, P., & McDavis, R. J. (1992). Multicultural counseling competencies and standards: A call to the profession. Journal of Counseling & Development, 70, 477–486.
doi:10.1002/j.1556-6676.1992.tb01642.x
Tempany, M. (2009). What research tells us about the mental health and psychosocial wellbeing of Sudanese refugees: A literature review. Transcultural Psychiatry, 46, 300–315. doi:10.1177/1363461509105820
The World Factbook. (n.d.). In Central Intelligence Agency Library. Retrieved June 6, 2016 from https://www.cia.gov/library/publications/the-world-factbook/geos/sy.html
United Nations Children’s Fund. (2014). Syria crisis: Monthly humanitarian situation report 20 May – 12 June 2014: Syria, Jordan, Lebanon, Iraq, Turkey and Egypt. Sheikhi: UNICEF. Retrieved from http://reliefweb.int/report/syrian-arab-republic/syria-crisis-monthly-humanitarian-situation-report-20-may-12-june-2014
United Nations High Commissioner for Refugees. (2013). UNHCR’s mental health and psychosocial support for persons of concern. Geneva: UNHCR. Retrieved from http://www.unhcr.org/51bec3359.html
United Nations High Commissioner for Refugees. (2016). Syria regional refugee response. Retrieved from http://data.unhcr.org/syrianrefugees/regional.php
Vanguard. (2014, August 14). Hundreds of Syrian refugees leave Turkish city after clashes [Web log post]. Retrieved from http://www.vanguardngr.com/2014/08/hundreds-syrian-refugees-leave-turkish-city-clashes
Yilmaz, V. (2012). Türkiye’de ruh sağlığı politikaları: Tespitler ve öneriler [Mental health policies in Turkey:
Findings and suggestions]. Istanbul, Turkey: RUSIHAK.
Mehmet A. Karaman is an Assistant Professor at the University of Texas Rio Grande Valley. Richard J. Ricard is a Professor at Texas A&M University-Corpus Christi. Correspondence can be addressed to Mehmet A. Karaman, EDUC 1.642, 1201 West University Dr., Edinburg, TX 78539-2999, Mehmet.Karaman@utrgv.edu
Mar 23, 2016 | Article, Volume 6 - Issue 1
Robert C. Schmidt
Youth suicide is a significant public health concern and efforts to reduce youth suicide remain a national priority (Kung, Hoyert, Xu, & Murphy, 2008; National Action Alliance for Suicide Prevention: Research Prioritization Task Force, 2014). In the United States, there were 40,600 suicides in 2012, averaging 111 suicides per day (Centers for Disease Control and Prevention [CDC], 2014a). Of the total number of suicides, 5,183 were youth suicides, averaging 14 youth suicides daily, or one youth suicide every 1 hour and 42 minutes (Drapeau & McIntosh, 2014). Youth suicide is the third leading cause of death between the ages of 10 and 14 and has become the second leading cause of death between the ages of 15 and 24 (CDC, 2014a). The results from the 2013 Youth Risk Behavior Surveillance (YRBS) reported 29.9% of high school students felt sad or hopeless almost every day for 2 weeks or more; 17% of high school students seriously considered attempting suicide; 13.6% of high school students made a suicide plan about how they would attempt suicide; and 8% of students attempted suicide one or more times (CDC, 2014b).
Efforts to address the increasing rate of youth suicide call for the identification of existing training and preparation gaps currently faced by practitioners (National Action Alliance for Suicide Prevention: Research Prioritization Task Force, 2014). These gaps pose many challenges for practitioners to effectively provide appropriate interventions. Although previous studies have investigated training gaps among specific professional disciplines (Debski, Spadafore, Jacob, Poole, & Hixson, 2007; Dexter-Mazza, & Freeman, 2003; O’Connor, Warby, Raphael, & Vassallo, 2004), the current study investigated a broader representation of disciplines including social workers, school counselors, professional counselors, school psychologists and psychologists. This study examined practitioner self-perceived levels of preparedness, levels of confidence and methods used in the assessment of youth suicide.
Practitioner readiness in suicide assessment. In approximately eight of ten suicides, youth give advance clues or warning signs of their intentions that can be detected by others (McEvoy & McEvoy, 2000; Poland & Lieberman, 2002). In a study spanning four years of youth in a rural school district (N = 5,949) screened for suicidal thoughts, 670 (11%) reported having suicidal thoughts within the past year or past few days (Schmidt, Iachini, George, Koller, & Weist, 2015). Practitioners working within school or community mental health settings have an opportunity to play a critical role in the identification, assessment and prevention of youth suicide (Singer & Slovak, 2011). Within either setting, practitioners will encounter clients having suicidal thoughts or behaviors (Rudd, 2006). The practitioner’s responsibility in the assessment of suicide is to estimate risk based on identifying warning signs and associated behaviors and to respond appropriately (Bryan & Rudd, 2006).
In a national sampling of social workers, 93% of the respondents reported having worked with a suicidal patient (Feldman & Freedenthal, 2006), and 55% of clinical social workers reported having a patient attempt suicide (Sanders, Jacobson, & Ting, 2008). In a study of psychology doctoral interns (N = 238) completed by Dexter-Mazza and Freeman (2003), 99% reported providing services to suicidal patients and 5% reported experiencing a patient death by suicide. Across professional disciplines, 22% to 30% of social workers, counselors and psychologists reported having a patient die by suicide (Jacobson, Ting, Sanders, & Harrington, 2004).
Irrespective of the level of suicide training, comfort level or experience (i.e., even those with limited training and preparedness), the circumstances for which practitioners meet with a suicidal client are not only stressful, but also have legal and ethical ramifications (Cramer, Johnson, McLaughlin, Rausch, & Conroy 2013; Poland & Lieberman, 2002). Research suggests significant gaps exist related to the practitioner’s training and readiness to perform suicide risk assessments, highlighting training deficits in the level of preparedness, level of confidence and methods used to determine suicide risk level (Smith, Silva, Covington, & Joiner, 2014).
Although youth suicide remains a national concern and priority, gaps appear most prominent in translating research into practice in developing and providing appropriate levels of training and supervision for practitioners (Smith et al., 2014). Research to support this concern offers valuable recommendations (Osteen, Frey, & Ko 2014; Schmitz, Allen, Feldman, et al., 2012); however, despite these recommendations, training and preparation continue to lag (Rudd, Cukrowicz, & Bryan, 2008). Practitioner competency skills in suicide assessment continue to be neglected by colleges, universities, licensing bodies, clinical supervisors and training sites that can have the greatest impact in reducing youth and adult suicide (Schmitz et al., 2012).
Practitioner preparedness. In the past several decades, researchers began identifying gaps in suicide risk knowledge, finding that practitioners were inadequately prepared to assess suicide risk. In master’s and doctoral clinical and counseling psychology training programs, 40–50% were found to offer formalized training in suicide assessment and management of suicide risk (Kleespies, Penk, & Forsyth, 1993). Suicide-specific training was only included in 2% of accredited professional counseling programs and 6% of accredited marriage and family therapist training programs (Wozny, 2005).
Training also has been identified as limited among social work graduate programs,
averaging 4 hours or fewer specific to suicide education (Ruth et al., 2009). In a study by Feldman and Freedenthal (2006) randomly surveying social workers through the National Association of Social Workers (N = 598), almost all of the social work participants (92.3%) reported working with a suicidal client; however, only 21.1% received any formal suicide-related training in their master’s program. Of the 21.1% of social workers receiving formal training, 46% specified their suicide-devoted training was less than 2 hours.
This pattern continued as additional studies found psychology doctoral interns did not receive adequate training in suicide assessment and/or managing suicide risk in clients. Neither did they receive the necessary levels of clinical supervision in suicide assessment (Mackelprang, Karle, Reihl, & Cash, 2014). In a study of psychology graduate school programs, 76% of the program directors indicated a need for more suicide-specific training and education within their programs but discovered barriers to implement this training (Jahn et al., 2012). The chief barrier reported by the directors was the absence of guidance and curriculum requirements to provide training and, secondly, the inability of colleges to create space in the existing curriculum schedule for added classes (Jahn et al., 2012).
In a survey that included members of the National Association of School Psychologists (N = 162), less than half (40%) of the respondents reported receiving graduate-level training in suicide risk assessment (Debski et al., 2007). Most school psychologists in this study reported feeling at least somewhat prepared to work with suicidal students while doctoral trained practitioners reported feeling well prepared.
School counselors share similar gaps in their preparation to provide suicide intervention and assessment to youth. Research conducted by Wachter (2006) indicated that 30% of school counselors had no suicide prevention training. In a study conducted by Wozny (2005), findings indicated that just 52.3% of the school counselors, averaging 5.6 years of experience, were able to identify critical suicide risk factors. This study exposed competency gaps in suicide assessment, training and intervention consistent with practitioner disciplines that were identified within this study. This is consistent with previous study findings (National Action Alliance for Suicide Prevention, 2014; Schmitz et al., 2012) that identified insufficient training and preparation of practitioners in the assessment and prevention of youth suicide and suicide in general.
Practitioner confidence. Although most practitioners will encounter youth with suicidal thoughts and behaviors, many lack the self-confidence to effectively work with suicidal youth. The lack of confidence appears related to competency levels and limited training (National Action Alliance for Suicide Prevention, 2014; Oordt, Jobes, Fonseca, & Schmidt, 2009).
In contrast, researchers found that as practitioner risk assessment skills increased through suicide-specific training, noticeable increases were measured in practitioner self-confidence (McNiel et al., 2008). Oordt and colleagues (2009) studied mental health practitioner levels of confidence after receiving empirically-based suicide assessment and treatment training. The results indicated that self-reported levels of practitioner confidence increased by 44% and measured a 54% increase specific to self-confidence levels related to the management of suicidal patients. In addition, studies of school counselors identified correlations between self-efficacy, confidence and the ability to improve clinical judgment in providing suicide interventions and assessment (Al-Damarki, 2004).
Adequate training and experience in suicide prevention and assessment has been found to increase practitioner levels of confidence in conducting risk assessments and management planning (Singer & Slovak, 2011). Research suggests that confidence increases the practitioner’s ability to estimate suicide risk level, make effective treatment decisions and base recommendations when conducting a quality assessment. However, when the assessor is not confident, the assessment is more prone to errors or missed information, decreasing the accuracy of their assessment (Douglas & Ogloff, 2003). Paradoxically, overconfidence produces similar results as practitioners lacking confidence. Tetlock (2005) reported that overconfident practitioners are more prone to making errors during a suicide risk assessment unless their clinical judgment is further supported by objective evidence such as using a formal, validated and reliable method of assessment.
Methods Used in Suicide Assessment
There are several categories of suicide assessment instruments developed for youth (Goldston, 2003; National Action Alliance for Suicide Prevention, 2014). These include detection instruments like structured and semi-structured interviews; survey screenings that include self-report inventories and behavior checklists; and risk assessment instruments that include screenings, self-report questionnaires and multi-tier screening assessments.
Across settings including schools, emergency departments, primary care offices and community mental health offices, studies indicate that inconsistent methods are used to assess suicide risk (Horowitz, Ballard, & Paoa, 2009). In most instances, the use of published and validated suicide screening tools are not being properly used as intended or designed, which impacts their reliability and validity (Boudreaux & Horowitz, 2014). This may represent and reflect the practitioner’s limited training, confidence and experience in these areas.
In addition, the documentation of the suicide assessment also can reflect the level of the practitioner’s training and knowledge of suicide assessment. O’Connor and colleagues (2004) noted that practitioner skill deficiencies in youth suicide assessment are likely to appear in clinic notes as a brief statement, “patient currently denies suicidal thoughts,” based on the practitioner’s impressionistic and subjective perception after completing a brief unstructured interview. This is commonly the only form of documentation obtained by the practitioner (O’Connor et al., 2004). Research consistently provides evidence across disciplines that some practitioners are not prepared to make clinical judgments (Debski et al., 2007; Jahn et al., 2012; Mackelprang, et al., 2014; Ruth et al., 2009; Smith et al., 2014). This study offered an opportunity to contribute to the understanding of practitioners’ self-perceived competencies in the assessment of youth suicide while identifying existing gaps in training.
The Current Study
In previous studies, research has focused on confidence and preparedness levels only in specific disciplines related to the identification and assessment of suicidal youth (Al-Damarki, 2004; Debski et al., 2007; Wozny, 2005). This study encompassed a much broader representative sample of practitioner disciplines including psychologists, social workers, school counselors, professional counselors and school psychologists.
The purpose of this study was to determine relationships among practitioners’ self-perceived levels of preparedness, levels of confidence and methods used to perform suicide risk assessments in youth. These efforts were guided by the following research question: What are the relationships among the self-perceived levels of preparedness, levels of confidence, and methods used in the assessment of suicide risk for practitioners whose responsibilities require suicide risk assessment and management? In order to address this, survey questions were designed to obtain participant responses related to skill development, preparation, confidence and methods used in the process of conducting suicide risk assessments.
Method
Procedures and Instrumentation
Since this study sought to collect data using human subjects, the proposal was reviewed and approved by the Wilmington University Human Subjects Review Committee prior to beginning this study. An exploratory descriptive survey design examined practitioner self-perceived levels of preparedness, levels of confidence and methods used to assess suicide risk in youth. Using a quantitative method to guide this study, the researcher attempted to recruit practitioners positioned and responsible for suicide risk assessment. This included working in cooperation with and posting the survey on the Maryland School Psychologists’ Association Web site and the University of Maryland Center for School Mental Health Web site. The survey was forwarded to school districts in Maryland and Virginia and directed to school counselors, school psychologists, and school-based mental health professionals, including social workers and professional counselors. In addition, the survey was forwarded to multiple outpatient mental health clinics in the mid-Atlantic region of the United States. Practitioners were provided with information about the survey, study purposes and ethical standards, and it was noted that participation was voluntary and confidential. Practitioners submitted their responses online, allowing the researcher to evaluate self-reported levels related to suicide assessment. Participants were provided with an access link to anonymously complete the survey using SurveyGizmo. The completed data were then entered into an Excel spreadsheet database.
The Child and Adolescent Suicide Intervention Preparedness Survey was the instrument developed for this study. This researcher received prior approval from the authors of two previously published surveys (Debski, et al., 2007; Stein-Erichsen, 2010) while adding specific queries for the purposes of this study. The survey by Debski and colleagues (2007) included a 42-item questionnaire with vignettes that measured the training, roles and knowledge of school psychologists. These questions targeted participant confidence and perceived levels of preparedness that also were sought in this current study, but from a broader discipline base.
The survey by Stein-Erichsen (2010) included a 55-item measure designed to identify confidence levels of school psychologists providing suicide intervention and prevention within schools. The survey questionnaires designed by Stein-Erichsen (2010) and Debski and colleagues (2007) offered questions adapted for this study specifically focusing on preparedness levels, confidence, roles, methods used to assess suicide levels, and omitted survey questions not relevant to this study. This resulted in a 23-item survey targeting practitioner levels of training, preparedness, confidence and the identification of additional training needs.
Participants
The study had 339 participants representing school counselors (N = 107/32%); social workers (N = 90/27%); school psychologists (N = 37/11%); professional counselors (N = 35/11%); psychologists (N = 5/1%); other (N = 62/18%); and three participants with unknown professional identification.
The final sampling of participants included 43 males, 292 females and four participants with unknown gender identification. Participants averaged in age ranges 22–29 (N = 33/10%), 30–39 (N = 105/31%), 40–49 (N = 94/28%), 50–59 (N = 61/18%) and ages 60 and above (N = 45/13%). The participants responded to the item querying level of education as having a bachelor’s degree (N = 18/6%), doctoral degree (N = 14/4%), master’s degree (N = 275/81%), and other (N = 28/8%) including associate levels of education, as well as four (1%) participants with unknown educational levels.
The participants represented a broad but targeted sampling from a variety of employers, including school settings (N = 166/49%); outpatient mental health settings (N = 108/32%); mental health agencies (N = 31/9%); and other settings (N = 33/10%); as well as one participant with an unknown employment setting. The participants also identified their employment environment as urban (N = 56/60%), rural (N = 174/52%), and suburban (N = 105/31%).
Participants identified the practitioner responsible to assess suicide risk within their work setting having multiple response options (see Table 1). These included a psychiatrist (N = 85/25%), nurse (N = 57/17%), school counselor (N = 179/53%), social worker (N = 168/50%), teacher (N = 7/2%), school psychologist (N = 154/46%), school mental health professional (N = 125/37%), psychologist (N = 64/19%), professional counselor (N = 101/30%), and other (N = 29/9%) including paraprofessionals, while 19 participants (6%) reported they do not complete suicide risk assessments.
Prior exposure with suicidal students/clients. In the survey, 288 (86%) of the participants reported having a student or client referred to them for being potentially suicidal; 45 (14%) did not receive a similar referral; and six participants did not respond. A majority of participants (N = 287/86%) reported having worked with a student or client initially found to be presenting with active suicidal thoughts and 48 (14%) reported not yet having worked with a suicidal student or client.
Analysis
Using descriptive data, participant responses were further examined to determine frequency and percentages of the total responses. In addition, inferential statistics were used to compute possible relationships among variables using SPSS. Data from the primary survey questions provided guidance toward establishing possible relationships between practitioner preparedness, confidence and the methods used in determining suicide risk level.
Results
Self-perceived preparedness in suicide assessment. The majority of the respondents reported some type of exposure or training in suicide intervention and assessment. The participants had an opportunity to select multiple answers: graduate course work (N = 174/52%), attending professional development workshops (N = 233/69%), in-service trainings at work (N = 213/63%), and having not received any training (N = 21/6%). In addition, participants had multiple answer options that represented self-perceived preparedness levels: not feeling at all prepared (N = 15/4%), feeling somewhat prepared (N = 120/36%), feeling well prepared (N = 202/60%), and requesting that someone more prepared meet or assess a suicidal student/client (N = 32/9%).
Self-reported confidence in suicide assessment. The confidence levels reported by the participants reflect professional skill development to conduct suicide risk assessments. The responses included feeling very confident (N = 49/15%), confident (N = 212/63%), and not very confident (N = 63/19%). A similar survey item asked about confidence levels working with a suicidal student or client. The responses included feeling very confident (N = 42/12%), confident (N = 231/69%), and not very confident (N = 63/19%). An additional survey item sought information regarding participant feelings when assessing for suicidal thoughts. Results indicated feeling not prepared (N = 39/12%), anxious (N = 116/34%), calm (N = 145/43%), and confident (N = 185/55%).
Methods Used to Determine Suicide Risk Level During Assessment. Several survey items queried participant levels of training and methods used to assess a suicidal student or client. A survey item asked participants if they had received formal training to conduct suicide risk assessments. The respondents indicated Yes (N = 201/60%) or No (N = 133/40%). In addition, a survey question asked participants if they felt qualified to complete a suicide risk assessment: Yes (N = 241/73%) or No (N = 91/27%). A follow-up survey item asked participants how they determined if the student or client was at imminent risk, high to moderate risk or low risk. The participant responses indicated they would conduct an informal, non-structured interview (N = 213/64%) or use a formal, valid suicide assessment instrument (N = 90/27%); the remaining respondents indicated other (N = 31/9%).
Participants were asked what would limit their ability to provide a suicide intervention. Using a “check all that apply” format, responses included practitioners not receiving formal training to work with suicidal students or clients (N = 55/17%), the role of suicide interventions and response is the job of others (N = 19/6%), not feeling adequately prepared to provide a suicide intervention or assessment (N = 65/20%), workplace policy does not allow formal suicide assessments (N = 12/4%), and feeling prepared (N = 225/68%). The discipline most frequently reported to encounter and assess a youth presenting with suicidal thoughts or behaviors in this study was the school counselor (53%). This supported previous research by Poland (1989) who identified that “the task of suicide assessment was likely to fall on the school counselor” (p. 74).
To determine whether relationships existed among self-perceived levels of preparedness, levels of confidence, and methods used in youth suicide assessment, the researcher completed a chi-square statistical analysis to measure numerical and categorical differences. In order to compare differences among several groups, variables were collapsed to include confident/not confident and prepared/not prepared. The first group compared practitioners’ responses of reporting confident/not confident to prepared/not prepared in the process of providing an informal versus formal suicide risk assessment in youth. The analysis indicated that there were significant differences in preparedness levels according to the method used. Seventy-three percent of those reporting use of formal assessments versus approximately 50% of those using informal assessments indicated confidence in their preparedness abilities (X2 = 12.79; df = 1. Cramer’s V = .206, p = .000). A further analysis indicated there were similar significant differences in practitioner confidence levels conducting informal, non-structured suicide risk assessments and formal assessments (X2 = 23.54, DF = 1. Cramer’s V=.280, p = .000). The results showed that 95.6% of the practitioners using formal suicide risk assessments reported higher levels of confidence versus 70.1% of the practitioners using informal, non-structured suicide risk assessments.
To identify existing gaps, participants were asked to rank by priority the trainings they needed to increase competency levels. The highest priority was (1) to receive a comprehensive training on warning signs, symptoms and suicidal behaviors, and (2) to attend several suicide assessment workshops.
Discussion
The purpose of this study was to determine if relationships existed among practitioners’ self-perceived levels of preparedness, levels of confidence and methods used when assessing for suicide risk in youth. A survey was designed to query participants representing a broad sampling of disciplines related to their perceptions, experience and involvement in youth suicide risk assessment. The results of the survey were analyzed using chi-square to determine if relationships existed among variables, including participant perceptions of feeling prepared and confident, and if this contributed to the methods used to determine suicide risk in youth.
Results of the survey indicated that a majority of the participants (86%) reported having worked with suicidal youth; however, inconsistencies in participant responses emerged related to the constructs of feeling prepared and confident in the assessment of suicide. The results suggested preparedness and training in suicide assessment is linked to practitioner confidence levels when assessing for suicide risk among youth. This finding is supported by earlier research by Oordt and colleagues (2009), who reported that practitioner confidence in suicide assessment is primarily related to competency and training levels. The interrelationship between preparedness and confidence is often reflected in the practitioner’s ability to accurately estimate risk level. This may potentially increase the likelihood of omitting critical information, which may affect the estimate of suicide risk (Douglas & Ogloff, 2003; Singer & Slovak, 2011). The results represent an important finding and highlight existing gaps in practitioner preparation. These gaps may reflect a struggle for most university and college graduate school degree programs to offer a more diversified curriculum (Allen, Burt, Bryan, Carter, Orsi, & Durkan, 2002) that includes courses specific to identifying, intervening in and assessing for suicide risk in youth (Schmitz et al., 2012).
The inconsistencies in participant responses related to feeling prepared and confident became apparent when participants rated themselves in working with a suicidal youth. Although over half of the respondents reported feeling well prepared and qualified in their ability, a much smaller percentage reported feeling confident in themselves (12%) and their skill preparation (15%) to assess for suicide. This finding may reflect a self-evaluation dilemma in wanting to self-report feeling prepared to work with a suicidal youth, but in actuality not feeling prepared or confident to provide a suicide intervention or complete an assessment.
As this study broadened its review of practitioner responses related to preparedness and confidence, findings indicated additional inconsistencies in participant responses related to self-reported feelings of preparedness and confidence when conducting a suicide intervention or suicide assessment. Despite predominantly higher levels of reported confidence, skill development and preparedness to determine if a student or client was at imminent risk, high to moderate risk, or low risk, few participants (27%/N = 90) reported using a formal suicide assessment instrument. Most respondents (64%/N = 213) reported basing their clinical judgment solely on using an informal, non-structured interview. Although practitioners reported feeling prepared and having a sense of confidence assessing for suicide risk, basing clinical judgment on this method alone raises concerns. O’Connor and colleagues (2004) described that practitioner skill deficiencies in suicide assessment are commonly reflected in clinic notes such as “patient currently denies suicidal thoughts,” based on the practitioner’s impressionistic and subjective perceptions. Consistent with identifying training deficiencies in preparation, 52% (N = 174) of the participants reported receiving limited suicide intervention or assessment training in graduate coursework.
The participants in this study who reported using a formal suicide assessment, however, indicated feeling better prepared to conduct a suicide assessment versus practitioners using an informal, non-structured interview. In addition, practitioners using a formal assessment also had greater confidence levels versus practitioners using an informal, non-structured interview. When participants were asked to rank their own levels of needed training to provide a more thorough suicide intervention, participants identified skill deficiencies and training gaps in identifying warning signs and behaviors and assessing for suicide using a suicide risk assessment. These deficiencies pose great concern and competency challenges for practitioners charged with assessing for suicide risk. The combination of skill attributes, guided interview and diagnostic assessment synthesizes the information and allows practitioners to determine risk level and base clinical judgment on a variety of sources (Rudd, 2006; Sullivan & Bongar, 2009). The skill deficiencies reflected across all disciplines represented significant training gaps. This study suggests the need for increased commitment by colleges and universities to prepare future practitioners to more effectively address the growing national youth suicide crisis.
Implications
Despite suicide being identified as a national public health priority, no significant reduction in suicide has been recorded in the past 50 years (Kung et al., 2008; National Action Alliance for Suicide Prevention, 2014). “With the majority of youth suicide deaths being preventable,” (O’Connor, Platt, & Gordon, 2011, p. 581), continued and more urgent calls for increasing practitioner preparedness, confidence and competency skills continue to be neglected.
Each of the disciplines represented in this study is faced with the challenge to address and estimate suicide risk. This study highlighted the critical role of school counselors as being identified by participants (53%) to be the most likely practitioner to respond and provide a suicide assessment. Representing a variety of disciplines and settings, participant responses suggest training deficiencies in the levels of preparedness, confidence and exposure to formal assessment measures. Previous research has made strong recommendations to increase the provisions and training in suicide assessment. Despite heeding previous calls and recommendations to prepare practitioners, more attention is needed to address previous and current identified training deficiencies among practitioners.
Transitioning research into practice includes revisiting several identified recommendations by Schmitz et al. (2012). This includes providing consistent core standards and competencies across disciplines by educational accrediting institutions. This may call for increased suicide-specific educational and training requirements beyond the baccalaureate degree level and include dissecting vignettes, role-playing, exposing practitioners to several suicide assessment instruments and interpreting the results (Fenwick, Vassilas, Carter, & Haque, 2004). This would include increased emphasis on recognizing the signs and symptoms of depression, suicidal thoughts and behaviors and increasing an understanding of potential next steps once a suicide risk level has been determined. In addition, to sustain these skills, state licensing boards can require continuing education specific to suicide identification, assessment and management. Rudd and colleagues (2008) placed emphasis on practitioners receiving increased suicide assessment strategies through supervision. The prevailing need practitioners identified as a chief priority in this study was to become more familiar with the warning signs, symptoms and behaviors associated with suicide and suicide assessment. The findings included within this study offer future research opportunities to monitor suicide training, preparation and continuing educational requirements of colleges, universities and licensing boards that govern and are responsible for the production of competent practitioners.
Although attention has focused on practitioner training deficits in the identification and assessment of youth suicide, future studies also are warranted in the measurement and impact of existing suicide prevention training programs that may provide opportunities for practitioners to increase skill sets in these areas. Another area meriting future study might include a national sampling of school counselor preparation in the identification, assessment and exposure to assessment tools. In this study, school counselors were identified to be the most likely practitioner called upon to provide an initial suicide intervention or assessment given their access to a large number of youth. This serves as a valuable finding, highlighting the call for increased and expanded counselor education, training and preparation in suicide risk identification and assessment in graduate school.
Limitations
Providing a suicide intervention or assessment involves many complex issues, and addressing the many variables paralleling these efforts could not be entirely assessed in this study. This study was intended to explore current levels of practitioner preparedness, confidence and the methods used to assess youth suicide. There are some notable limitations regarding the current study; therefore, caution is warranted regarding the generalizability of the findings.
Although the Internet provided a greater opportunity for the researcher to create survey access to targeted participants and disciplines, this method did not provide a sample size completion rate. In addition, previous Internet survey research (W. Schmidt, 1997) reported that participants have access to multiple submissions, although ethical practice instructions and consent to complete this survey was provided. In order to access participants from multiple disciplines, the survey used in this study was available online as a self-report method of completion. In this process, self-report instruments, including surveys, inherently contain participant response bias. This may be reflected in responding to questions in a socially desirable or expected manner (Heppner, Wampold, & Kivlighan 2007). In addition, online surveys can be submitted containing omitted and blank responses (Sue & Ritter, 2012).
As previously noted, The Child and Adolescent Suicide Intervention Preparedness Survey used in this study was adapted from two previous research surveys (Debski et al., 2007; Stein-Erichsen, 2010). In this study design, survey questions were created and adapted to measure participant constructs in the assessment of youth suicide. The use of a psychometrically sound survey instrument would be an ideal application to implement and duplicate for future research.
Conclusion
The findings from this study identify significant interrelationships between the practitioner’s self-perceived feelings of preparedness, confidence levels and methods used to assess for suicide risk among youth. The self-reported feelings of being prepared and confident seem to contradict the method used to obtain a suicide risk level. This finding suggests many practitioners are well intended, but lack the necessary skills to conduct a thorough suicide risk assessment. The majority of practitioners participating in this study reported conducting a suicide risk intervention using an informal, non-structured interview to formulate a suicide risk level versus using a formalized suicide risk assessment instrument. Prior experience and exposure to suicide risk assessment instruments and increased emphasis in suicide-specific training curriculum in graduate school can offer the opportunity for a practitioner to feel better prepared, feel more confident and utilize a more effective method to determine a youth’s suicide risk level. Practitioner gaps in training are typically augmented by the practitioner seeking personal training and workshops to fill these gaps. Efforts must be made by colleges and universities to increase the competency skills in this area if we are to ever reduce the growing number of youth suicides. The findings from this study supported limited previous research sounding urgent calls to better prepare practitioners, especially school counselors, in the identification of youth presenting with suicidal thoughts or behaviors.
Conflict of Interest and Funding Disclosure
The authors reported no conflict of interest
or funding contributions for the development
of this manuscript.
References
Al-Damarki, F. R. (2004). Counselor training, anxiety, and counseling self-efficacy: Implications for training psychology students from the United Arab Emirates University. Social Behavior and Personality, 32, 429–439. doi:10.2224/sbp.2004.32.5.429
Allen, M., Burt, K., Bryan, E., Carter, D., Orsi, R., & Durkan, L. (2002). School counselor’s preparation for and participation in crisis intervention. Professional School Counseling, 6, 96–102.
Boudreaux, E. D., & Horowitz, L. M. (2014). Suicide risk screening and assessment: Designing instruments with dissemination in mind. American Journal of Preventative Medicine, 47(32), 163–169.
doi:10.1016/j.amepre.2014.06.005
Bryan, C. J., & Rudd, D. M. (2006). Advances in the assessment of suicide risk. Journal of Clinical Psychology, 62, 185–200.
Centers for Disease Control and Prevention. (2014a). Fatal injury data. Web-based injury statistics query and reporting system (WISQARS). Retrieved from http://www.cdc.gov/injury/wisqars/index.html
Centers for Disease Control and Prevention. (2014b). Youth risk behavior surveillance, United States, 2003. Morbidity and Mortality Weekly Report, 63(SS-4), 1–168.
Cramer, R. J., Johnson, S. M., McLaughlin, J., Rausch, E. M., & Conroy, M. A. (2013). Suicide risk assessment training for psychology doctoral programs. Training and Education in Professional Psychology, 7, 1–11.
Debski, J., Spadafore, C. D., Jacob, S., Poole, D. A., & Hixson, M. D. (2007). Suicide intervention: Training, roles and knowledge of school psychologists. Psychology in the Schools, 44, 157–170. doi:10.1002/pits.20213
Dexter-Mazza, E. T., & Freeman, K. A. (2003). Graduate training and the treatment of suicidal clients: The students’ perspective. Suicide and Life-Threatening Behavior, 33, 211–218.
Douglas, K. S., & Ogloff, J. R. P. (2003). The impact of confidence on the accuracy of structured professional and actuarial violence risk judgments in a sample of forensic psychiatric patients. Law and Human Behavior, 27, 573–587.
Drapeau, C. W., & McIntosh, J. L. (2014). U.S.A suicide 2012: Official final data. Washington, DC: American Association of Suicidology.
Feldman, B. N., & Freedenthal, S. (2006). Social work education in suicide intervention and prevention: An unmet need? Suicide and Life-Threatening Behavior, 36, 467–480.
Fenwick, C. D., Vassilas, C. A., Carter, H., & Haque, M. S. (2004). Training health professionals in the recognition, assessment and management of suicide risk. International Journal of Psychiatry in Clinical Practice, 8, 117–121. doi:10.1080/13651500410005658
Goldston, D. B. (2003). Measuring suicidal behavior and risk in children and adolescents. Washington, DC: American Psychological Association.
Heppner, P. P., Wampold, B. E., & Kivlighan, Jr. D. M. (2007). Research design in counseling: Research, statistics, and program evaluation (3rd ed.). Belmont, CA: Brooks/Cole.
Horowitz, L., Ballard, E., & Paoa, M. (2009). Suicide screening in schools, primary care and emergency departments. Current Opinion in Pediatrics, 21, 620–627.
Jacobson, J. M., Ting, L., Sanders, S., & Harrington, D. (2004). Prevalence of and reactions to fatal and nonfatal client suicidal behavior: A national study of mental health social workers. Omega, 49, 237–248.
Jahn, D. R., Wacha-Montes, A., Dra-Peau, C. W., Grant, B., Nadorff, M. R., Pusateri, M. J., Jr., . . . & Cukrowicz, K. C. (2012). Suicide-specific courses and training: Prevalence, beliefs, and barriers. Part I: Graduate psychology programs and professionals schools of psychology. Manuscript in preparation.
Kleespies, P., Penk, W., & Forsyth, J. (1993). The stress of patient suicidal behavior during clinical training: Incidence, impact, and recovery. Professional Psychology: Research and Practice, 24, 293–303.
Kung, H. S., Hoyert, D. L., Xu, J., & Murphy, S. L. (2008). Deaths: Final data for 2005. National Vital Statistics Reports, 56, 1–66.
Mackelprang, J. L., Karle, J., Reihl, K. M., & Cash, R. E. (2014). Suicide intervention skills: Graduate training and exposure to suicide among psychology trainees. Training and Education in Professional Psychology, 8, 136–142.
McEvoy, M. L., & McEvoy, A. W. (2000). Preventing youth suicide: A handbook for educators and human service professionals. Holmes Beach, FL: Learning Publications.
McNiel, D. E., Fordwood, S. R., Weaver, C. M., Chamberlain, J. R., Hall, S. E., & Binder, R. L. (2008). Effects of training on suicide risk assessment. Psychiatric Services, 59, 1462–1465. doi:10.1176/appi.ps.59.12.1462
National Action Alliance for Suicide Prevention: Research Prioritization Task Force. (2014). A prioritized research agenda for suicide prevention: An action plan to save lives. Rockville, MD: National Institute of Mental Health.
O’Connor, R. C., Platt, S., & Gordon, J. (2011). International Handbook of Suicide Prevention: Research, Policy and Practice. United Kingdom: John Wiley & Sons, Ltd.
O’Connor, N., Warby, M., Raphael, B., & Vassallo, T. (2004). Changeability, confidence, common sense and corroboration: Comprehensive suicide risk assessment. Australasian Psychiatry, 12, 352–360.
Oordt, M. S., Jobes, D. A., Fonseca, V. P., & Schmidt, S. M. (2009). Training mental health professionals to assess and manage suicidal behavior: Can provider confidence and practice behaviors be altered? Suicide and Life-Threatening Behavior, 39, 21–32. doi:10.1521/suli.2009.39.1.21
Osteen, P. J., Frey, J. J., & Ko, J. (2014). Advancing training to identify, intervene, and follow up with individuals at risk for suicide through research. American Journal of Preventative Medicine, 47, 216–221. doi:10.1016/j.amepre.2014.05.033
Poland, S. (1989). Suicide intervention in the schools. New York, NY: The Guilford Press.
Poland, S., & Lieberman, S. (2002). Best practices in suicide intervention. In A. Thomas & J. Grimes (Eds.), Best practices in school psychology IV – Volume II (pp. 1151–1165). Bethesda, MD: National Association of School Psychologists.
Rudd, M. D. (2006). The assessment and management of suicidality. Sarasota, FL: Professional Resource Press.
Rudd, M. D., Cukrowicz, K. C., & Bryan, C. J. (2008). Core competencies in suicide risk assessment and management: Implications for supervision. Training and Education in Professional Psychology, 2, 219–228.
Ruth, B. J., Muroff, J., Gianino, M., Feldman, B. N., McLaughlin, D., Ross, A., & Hill, E. (2009). Suicide prevention education in social work education: What do MSW deans, directors and faculty have to say? Paper session presented at the meeting of the American Public Health Association, Philadelphia, PA.
Sanders, S., Jacobson, J. M., & Ting, L. (2008). Preparing for the inevitable: Training social workers to cope with client suicide. Journal of Teaching in Social Work, 28, 1–18.
Schmidt, W. C. (1997). World-wide web survey research: Benefits, potential problems, and solutions. Behavior Research Methods, Instruments, & Computers, 29, 274–279.
Schmidt, R. C., Iachini, A. L., George, M., Koller, J., & Weist, M. (2015). Integrating a suicide prevention program into a school mental health system: A case example from a rural school district. Children & Schools, 37, 18–27.
Schmitz, W. M., Allen, M. H., Feldman, B. N., Gutin, N, J., Jahn, D. R., Kleespies, P. M., . . . & Simpson, J. D. (2012). Preventing suicide through improved training in suicide risk assessment and care: An American Association of Suicidology task force report addressing serious gaps in U.S. mental health training. Suicide and Life-Threatening Behavior, 42, 292–304. doi:10.1111/j.1943-278X.2012.00090.x
Singer, J. B., & Slovak, K. (2011). School social workers’ experiences with youth suicidal behavior: An exploratory study. Children & Schools, 33, 215–228.
Smith, A. R., Silva, C., Covington, D. W., & Joiner, T. E. (2014). An assessment of suicide related knowledge and skills among health professionals. Health Psychology, 33, 110–119.
Stein-Erichsen, J. L. (2010). School psychologists’ confidence level with suicide intervention and prevention in the schools. Retrieved from: http://digitalcommons.pcom.edu/psychology_dissertations/132.
Sue, V. M., & Ritter, L. A. (2012). Conducting online surveys (2nd ed.). Thousand Oaks, CA: Sage.
Sullivan, G. R., & Bongar, B. (2009). Assessing suicide risk in the adult patient. In P. M. Kleespies (Ed.), Behavioral emergencies: An evidenced –based resource for evaluating and managing risk of suicide, violence, and victimization (pp. 59–78). Washington, DC: American Psychological Association.
Tetlock, P. E. (2005). Expert political judgment: How good is it? How can we know? Princeton, NJ: Princeton University Press.
Wachter, C. A. (2006). Crisis in the schools: Crisis, crisis intervention training and school counselor burnout. ACES Research Grant. Association for Counselor Education and Supervision. Retrieved from http://libres.uncg.edu/ir/uncg/f/umi-uncg-1190.pdf
Wozny, D. A. (2005). Suicide risk assessment: Counselor competency. In J. R. Rodgers (Ed.), Suicide 2006: Proceedings of the 39th Annual Conference of the American Suicidology Association (pp. 224–227). Washington, DC: American Association of Suicidology.
Robert C. Schmidt, NCC, is a Behavioral Specialist at Talbot County Public Schools in Easton, MD. Correspondence can be addressed to Robert C. Schmidt, Talbot County Public Schools, 12 Magnolia Street, Easton, MD 21601, rschmidt@tcps.k12.md.us.
