We tell suicidal people to go to therapy. So why are therapists rarely trained in suicide?

We tell virtually every suicidal person to do it. It’s part of most suicide prevention campaigns. When we don’t have the answers, it’s where we tell our loved ones they’ll find them. 

“See a therapist.”

And yet suicide prevention experts say outside of psychiatrists, the majority of mental health professionals have minimal to no formal training in how to effectively treat suicidal people. 

Suicide-specific training is not commonly offered as part of college curriculums, optional post-graduate training opportunities are limited, costly and time-consuming, and experts say some therapists may not be aware they even need the education.

“Any profession’s ethical standards require that you not treat a problem you don’t know, and yet every day thousands of untrained service providers see thousands of suicidal patients and perform uninformed interventions,” said Paul Quinnett, a clinical psychologist and founder of the QPR Institute, an organization that educates people on how to prevent suicide.

“People think if you send someone, a loved one, to a therapist, that therapist will be skilled in how to address … their risk for suicide. Nothing could be farther from the truth.”

Numbers released in January from the U.S. Centers for Disease Control and Prevention show 48,344 people died by suicide in 2018, a small uptick from the year before, though the rise in deaths over time has been steady. Since 1999, the suicide rate has climbed 35%. 

Suicide is the nation’s 10th leading cause of death, yet experts say training for mental health practitioners who treat suicidal patients — psychologists, social workers, marriage and family therapists, among others — is dangerously inadequate.

Many suicide prevention experts say combating suicide requires a holistic approach that includes communities, families, educators and religious leaders working together. But society, they say, has placed the burden of caring for suicidal people on a mental health workforce woefully underprepared to help them. 

In Depth: Funding for suicide lags behind other top killers

There are no national standards that require mental health professionals be trained in how to treat suicidal people, either during their education or their career. Only nine states mandate training in suicide assessment, treatment and management for health professionals, according to the American Foundation for Suicide Prevention. 

The American Psychological Association and the Council on Social Work Education, which accredit graduate programs in psychology and social work, have standards to prepare graduates to treat patients in crisis but do not require specific competencies regarding suicide.

For its 2014 report on guidelines to improve training among the clinical workforce, the National Action Alliance for Suicide Prevention assessed the state of education by sending surveys to 443 academic institutions. Of those, 69 responded, and 70% said no specific training for suicide was provided. 

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A 2012 paper by the American Association of Suicidology cites decades of studies that underscore the training gap, and experts say not much has changed in the last several years. It found about half of psychology students receive formal classroom training on suicide during their graduate education. Only about 25% of social workers receive any suicide prevention training. Marriage and family therapists had even less. Most psychiatrists receive some instruction, but many experts agree it’s insufficient. 

“When people ask me, ‘Who should I see?’ the only thing I can say is ‘See a psychiatrist if you can,’ because … they’re supposed to cover that topic during the course of their training,” Quinnett said. “You have some assurance that they know something about it. But you can’t say that for any other (mental health) profession, which is astounding to me.”

Suicidal people have a spectrum of experiences with therapy, some harmful, some lifesaving. Many people living with suicidal thoughts say when they found the right clinician, someone who didn’t overreact and who made an earnest effort to understand their pain, they felt less suicidal.

“Having someone on your side that gets what you’re going through, that can advocate for your needs, and that gives you the space to talk through your thoughts is a game-changer,” said Whitcomb Terpening, a licensed clinical social worker and founder of The Semicolon Group, a therapy practice in Houston that works exclusively on suicide.

“They’ll have your best interest in mind, not just to keep you alive, but to help you find a life worth living.”

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When someone who’s feeling suicidal opens up to a therapist, they do so expecting the person sitting across from them wants to understand their suffering. But Stacey Freedenthal, a suicide attempt survivor and associate professor at the University of Denver Graduate School of Social Work, says a common feeling among therapists when they realize they’re sitting across from a suicidal person is panic.

They worry the patient might try to kill themselves, could succeed and they may get sued or lose their license. Their reflex is to send the patient to an emergency room. 

Wayne Armstrong, Denver University

“You’ve got this person who has taken weeks or months or more to work up the nerve to go to a professional and the professional is saying, ‘I can’t help you, you have to go somewhere else.’ And that can be very harmful,” Freedenthal said. 

Research shows emergency room visits and involuntary hospitalizations — triggered when a mental health professional believes someone is at imminent risk of killing themselves — can increase a person’s risk of suicide.

Susan Stefan, a scholar and litigator on behalf of people with psychiatric disabilities, says in many cases, an emergency room can be the worst place for a suicidal person. 

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“It’s loud, it’s hurried, people are in a rush,” she said. “There is no training, generally, for emergency physicians, or staff to deal with suicidal people. In many places, there’s not much sympathy.”

Even if a therapist doesn’t overreact, that doesn’t mean they know how to help. Freedenthal says she once had a therapist who made her “promise” she would never do anything to hurt herself. 

“That’s great in principle, but I kind of wouldn’t have been going for help if it was that easy,” she said.

Some therapists try to avoid the question of suicide altogether. Freedenthal says she always asks her students and even colleagues with decades of experience, “What is your fear about asking someone if they’re thinking of suicide?”

The most common answer: “That they’ll say yes.” 

Some chronically suicidal people say they’ve been dropped by therapists who were unable to tolerate the intensity of their pain. Others say their clinicians were so fixated on predicting how likely they were to kill themselves, they didn’t spend enough time listening to why they were hurt or what they might need. 

“A lot of people who say they’re suicidal are trying to convey the depth of their despair,” Stefan said. “I think we as a society waste a lot of time trying to stop people from killing themselves as opposed to exploring why they want to die in the first place.” 

Back in the 90s, Quinnett was the clinical director at a mental health center in Spokane, Washington. One year, they lost 13 patients to suicide. When Quinnett reviewed the death records, he realized his clinicians didn’t know how to treat suicidal patients.

“They were good people. They were good-hearted. They were crushed when their patients died, but they didn’t even know how to ask the question, let alone how to assess and manage the risk,” he said. 

Afterward, Quinnett said he helped put together a comprehensive, mandatory training program on suicide. Once it was fully up and running, he said clinic deaths plummeted, to one or none a year. Eventually a new CEO took over and Quinnett said he decided to shutter the program over cost concerns. Quinnett said suicides started up again, so he quit.

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Almost all mental health professionals see suicidal patients at some point in their careers, experts say, yet only a small fraction seek out specialized training.

For those who do want it, it can be hard to come by. Some of the best therapies aren’t available for training at scale, and those that are require time and money. 

David Jobes is director of the Catholic University of America’s Suicide Prevention Lab and created CAMS – Collaborative Assessment and Management of Suicidality – widely regarded as one of the most effective approaches to treating suicidal patients. In the absence of training, Jobes said many clinicians spend most of their time trying to treat a patient’s underlying mental illness, rather than asking the person, “What makes you want to kill yourself?” 

CDC data published in 2018 shows 54% of people who died by suicide had no known mental health condition.

CAMS, Jobes said, is a model that endeavors to understand the sources of people’s suffering. But very few people are trained, he said, and those who could benefit from it most have probably never heard of it. 

Andrew Evans, president of CAMS-care, which trains practitioners on the CAMS approach, said last year the company trained about 5,000 mental health professionals in the U.S. 

“That’s a drop in the bucket, because millions of people have suicidal thoughts,” said Jobes, noting CDC data from 2017 that showed 10.6 million American adults seriously thought about suicide.

Terpening, who works with suicidal patients, says as long as training for mental health providers is voluntary, patients won’t get the care they need.

“Everyone’s told, ‘Reach out, there’s always somebody to talk to.’ But there isn’t. Because we’re not trained in graduate schools, we’re not trained in our clinical intern hours, we’re not offered those kinds of opportunities,” she said.

Lack of training, Terpening added, doesn’t just leave practitioners ill-equipped, it leaves them afraid.

“Therapists want to do well, they just don’t know how,” she said. “Fear is born out of the unknown.”

Many therapists are so frightened of treating suicidal people they’ll screen out potential patients who they think may be at risk, Quinnett said. Clinicians also are afraid of liability, though Stefan said the concern is far less real than most mental health professionals think. Even if a grieving family sues, she said, most cases are not successful. Facts, however, are not always persuasive when the undesired outcome feels so catastrophic. 

A survey of mental health providers in Colorado, which has one of the highest suicide rates in the nation, showed many do not think they need more training, but desire it, according to a 2018 article in the Journal of Public Health Policy. It found providers reported being “generally pleased with their existing training and felt prepared to address suicide within their practice,” though 80% supported mandating suicide-related continuing education. 

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When confronted with the intensity of pain a suicidal person is feeling, some therapists find themselves overwhelmed – wanting to help, fearing they’re not capable, with stakes that feel enormously high. 

“It is emotionally painful,” said April Foreman, a clinician and board member of the American Association of Suicidology. “Remember, you’re a therapist because you’re emotionally sensitive, and then we give you training to be even more sensitive. Then we put you in a room with someone who has the kind of pain and despair and behaviors that put them at risk of dying.

“Unless you seek out on your own specialized training, and most people do not get this, it will become exquisitely painful for you and impact your well-being.” 

Foreman says therapists practicing Dialectical Behavior Therapy, another highly effective treatment approach for severe suicide risk, are expected to have a consultation team to help manage stress and burnout.

“I will tell you, having lost patients to suicide, the consultation group is invaluable,” she said.

Terpening says being able to talk with peers is a crucial part of her own self-care. 

“The work can be isolating,” she said, “so to be able to hear from other people is so helpful and so healing in ways that a spin class never could be.”

The issue of inadequate training has been documented for decades. In 2001, the National Strategy for Suicide Prevention said it was critical that “mental health personnel receive appropriate graduate school training on the subject of suicide while preparing for their professions.”

Nearly 20 years later, experts say not enough has changed. Anthony Pisani, associate professor of psychiatry and pediatrics at the Center for the Study and Prevention of Suicide at the University of Rochester, said it is essential the goal be met, and training must extend well beyond school. 

“Addressing suicide risk is not something you can get trained in once and be done,” he said. “This is such a hard problem with such serious consequences that people are going to feel and be unprepared unless they are engaged in an ongoing way.”

The American Association of Suicidology report on gaps in mental health training made several recommendations for improving care. It said accrediting organizations must include suicide-specific education as part of their requirements so graduate programs have the training in their curriculum. State licensing boards, it said, must require clinicians be competent in suicide treatment.

And the report said government has a role to play, too, by requiring that health care systems receiving state or federal funds ensure their mental health professionals are trained in suicide risk detection, assessment, treatment and prevention. 

Maybe, most importantly, experts say clinicians have to overcome their fear of not knowing with certainty who may live or die. 

“I get the fear — our licenses are our livelihood, we need to be able to protect them,” Terpening said. “But we also have to be able to see past the risk to do what’s right for our patients.” 

If you or someone you know may be struggling with suicidal thoughts, you can call the U.S. National Suicide Prevention Lifeline at 800-273-TALK (8255) any time day or night, or chat online.

Crisis Text Line also provides free, 24/7, confidential support via text message to people in crisis when they dial 741741.

The American Foundation for Suicide Prevention has resources to help if you need to find support for yourself or a loved one. 

Alia E. Dastagir is a recipient of a Rosalynn Carter fellowship for mental health journalism. Follow her on Twitter: @alia_e