When my oldest son was 16 he developed Hashimoto’s disease and required a delicate thyroid operation. The boy was terrified. “They’re going to cut my throat, right?” he asked, as he lay waiting to be rolled into surgery.

The surgeon stopped by, “Well, Jeff, do you have any last questions for me?”

“Yes,” said Jeff, “What kind of grades did you get in surgery?”

The surgeon smiled. “Straight As.”

In my experience, patients about to enter treatment for suicidal thoughts, feelings, and nonfatal suicide attempts never ask such questions. But if they did, how would we mental health types respond?

“No worries, they covered this in a lecture as I recall.”

“Ah… let me think …”

“I’m pretty sure I had a seminar on that topic…”

Only a handful of mental health professionals ever actually take a course with the word “suicide” in the title, so it is something of a stretch for most of us to reassure suicidal people we can fix what’s wrong with them. While several good treatments for suicidal behaviors actually exist, on exams I’ve given (and I’ve given thousands), less than half of licensed clinicians can name them.

Imagine how much better a suicidal patient would feel if in response to the competency question, the answer was, “Yes, it was a tough course, but I passed the final at 100 percent.”

Would that not be an injection of 2ccs of hope?

With suicide prevention on the move, new training programs are emerging. Some are evidence-based, peer-reviewed, well-evaluated, and specifically designed to improve attitudes, knowledge, and skills in suicide care. To meet emergent demand others are being made up on the fly.

This is where the hard-ass comes in.

I’ve been a part-time college professor and clinical training director forever. According to some of my students I’m a hard-ass. I like my students the same as my martinis – shaken, not stirred. I don’t want my students relaxed. I don’t want them mellow. I don’t want them for friends. I don’t care if they like me and almost prefer they didn’t. Rather, I want them to learn. While I made learning fun, my students were not in class to be entertained, but rather to be trained.

If a student in my class slouched casually in the back of the room while playing with a cell phone, guess who I crushed with a question Einstein couldn’t answer? When a student arrived late to class, my standard line was, “Thank God you’re here! We thought you were killed in a crash!” No one came to class late twice, and some never returned at all. Oh well.

Being a hard-ass means I failed students. When I saw incompetence in clinical care, I fired people. And not just a few. Because her attitude toward suicidal patients was, “If they really want to kill themselves, we can’t stop them,” I fired one of my senior psychiatrists.


Because in good faith I could not safely place a suicidal patient in her care or count on to her to inspire hope in our clinical teams.  If a patient thinks he’s going to die, you don’t want the clinician treating him to agree. The last thing suicidal patients need are therapists more hopeless about their future than they are.

For the firings? No apologies.

Which brings me back to the question my son asked.  Only a well-trained health care professional can exude the kind of competence and confidence that gives hopeless suicidal patients hope, which is why I believe our training programs in assessment, treatment, and management should be rigorous.

Currently, we do have what are called registered best practice training programs in how to conduct a suicide risk assessment and then manage the assessed risk. These have been peer reviewed and have passed minimum standards as educational training programs in this area of clinical practice.  Right now, and as near as we can tell, they are best we have.

To see training recommendations made by an expert panel go to: http://www.sprc.org/bpr/section-II/preventing-suicide-through-improved-training-suicide-risk-assessment-and-care. To see a listing of the training programs go to: http://www.sprc.org/bpr/section-iii-adherence-standards. Not all of the programs listed cover suicide risk assessment, but you can find them by reading the descriptions, one of which is offered by the QPR Institute.

Like others in the field, I’m pushing for high training standards. I want clinicians to not only know something, but show something.

As part of my internship in clinical psychology, I was trained in a hospital-based psychiatry residency program. The director – another hard-ass – didn’t care about how you talked about therapy or assessment, you had to show him.

When your turn came, you went to the ward, brought your patient to an exam room in which six or seven of your peers and other doctors were seated with pens poised over notepads. Your work was about to be carefully examined, as every word you and the patient spoke were written down, together with notes on your body language. Some of your peers grinned at what would be a 45-minute roast; others simply drooled at the prospect.

After you introduced your patient to the group, you conducted your interview. Live. Everyone took furious notes.

At the end of 30 minutes you thanked your patient and escorted him or her back to the ward. Then you returned to the exam room to face – how shall I say this – a pack of ravenous wolves dressed just like doctors.

The critiques were tough. Some were brutal. Residents were known to throw up. Anxiety attacks left pools of sweat on the floor. But you learned. In the end, and if you survived, you felt oddly strong, not unlike graduating from Army boot camp. Even more important was the internal sense of confidence and competence you felt and radiated – just the medicine our suicidal patients need to restore hope.

This medical school rigor was not drive-by training. This was not slouch-and-listen training. This was blood-on-the-floor training. If you didn’t have a four alarm panic attack, the training director felt he’d failed.

And yet it was the best clinical training I ever got. Thank you, Dr. Spiro!

So as we roll out new clinical training programs to help suicidal patients, my vote is for rigorous training. Demanding training. Don’t tell me you do a great job assessing risk in suicidal folks; pass a knowledge exam, demonstrate the National Suicide Prevention Lifeline core skill competencies in a 360-degree peer review role-play, and have your risk stratification decisions supported by experts. Then put your written work in the medical record so your supervisor can review it to external standards.

Did I say lives are literally at stake?

As these programs emerge, and as cell phones populate the classroom, here’s how I rate classroom-only clinical training:
– Attendance only = D
– Attendance and 70% correct on post-training knowledge exam = C
– Attendance and 100% on post-training knowledge exam = B
– Attendance, 100% on the exam, and scored skill demonstration = A

What do I think of video content streamed into your computer?

Did I say D-?

Finally, I have aided and abetted suicide malpractice lawyers on how to disembowel clinical psychologists like me when they are on the witness stand trying to defend their training after losing a patient to suicide.

I have said to them, “Here are five questions that I guarantee will cause little beads of sweat to pop out on their foreheads. Nausea guaranteed. And all will look negligent to the jury.”

I’d tell you what those five questions are, but then I’d have to turn in my hard-ass badge. So, ready or not, here come the training programs. The public thinks we educators know what we’re doing.

Let’s not disappoint them.

Dr. Paul

8 thoughts on “Hard-Ass”

  1. Looks to me as though grade inflation has made it to the realm of hard-ass. In my universe, and particularly as it applies to training people who have the lives of others in their hands, there are only two grades…A and F.

    1. Thanks, Paul! I really appreciate your time. I will definitely check out the video for veterans. I’m currently researching veterans and suicide. I record videos on suicide prevention for continuing education for health professionals. It is also a side income, which is really cool!
      I’m a member of the South Plains Suicide Prevention Coalition and we are trying to take QPR to the community. I think the cultural information you can provide is is just what we need.
      Also, if you aren’t aware of this, there is a series of videos on veterans being offered by the Massachusetts General Hospital, here is a link: http://mghcme.org/page/from_the_war_zone_to_the_home_front
      Thank you for whatever you can send that will help us!
      My email address is: vcox@southplainscollege.edu.

      Valerie Cox

  2. I’m a QPR instructor and I’ve been researching further into suicide and prevention. As counselors, we work to be geared up and ready for the battle against suicide. I’ve learned about assessment, safety plans, etc. Something that is becoming clear to me is that even though the epidemic of suicide cuts across cultures, we don’t do a good job of getting our suicide prevention efforts to many people that will never show up in our offices. That leads me to cultural differences, and when I looked up the research, minorities are less likely to receive mental health care and when they do, they end up misdiagnosed because the self reporting by various cultures can be very different. Not only does the message need to be taken out into the community, but mental health professionals need to be culturally aware of how warning signs and risks may be displayed differently by various cultures during the assessment process. Thoughts?

    Valerie Cox, LCSW

    1. Thanks, Valerie. Most people who die by suicide never receive a single counseling visit with someone who could have helped them. I think the WHO says that only 15% of suicide victims worldwide get any professional help at all before they die. Culture plays a huge role in this area of health disparities. We have adapted QPR to many cultures now and have a SAMHSA-approved process for doing so. Can send it to you if you like. Just email me. We have new translations of QPR to take to 10 EU countries and are working with a Chinese University to translate the program for possible distribution there. A Native American colleague and I wrote a brief paper on QPR for any coulture, which I can also share. As to warning signs by culture — lots to do there, and look for a future blog on this. Reading the QPR Theory paper on the home page may be interesting.

      In the meantime, to see who we need to train to “get to” those who do not self-refer or seek help, see my VOPP QPR for Vets 44 minute presentation on our home page. Best, Paul

  3. Very interesting post, Paul. Yes, you may end up on the Pope’s blacklist, but hopefully not.

    Though not Catholic, I am Christian, and I do think this Pope has made it clear it is no longer business as usual in the Catholic Church and we know as from experience with any bureaucracy (government or otherwise) dramatic change doesn’t happen as quickly as we would like.

    I was unable to Google the specific Bible quotations referenced by Clemons in “What Does the Bible Say About Suicide?” but for informational purposes only, the following are Bible verses I’ve cited in talks about my oldest son’s suicide that have been specific to Christian audiences:

    John 11:25: Jesus said, “He who believes in Me, though he die, yet shall he live.”

    John 6:40: Jesus said, “For my Father’s will is that everyone who looks to the Son and believes in Him shall have eternal life, and I will raise him up at the last day.”

    Also 1st Peter 2:6, in reference to Jesus: “See, I lay a stone in Zion, a chosen and precious cornerstone, and the one who trusts in Him will never be put to shame.”

    I make it clear that death by suicide, the ultimate self-harm, is not a recommended finish to life on this earth.

    What it is clear that St. Augustine and others with the good intentions of halting suicides influenced the church to create a doctrine intended to scare people into believing suicide is a mortal sin from which there is no recovery from condemnation. It was a carefully calculated church scare tactic that reduced incidences of suicide at the time because of shame but causes angst and confusion to this day for those not familiar with the Bible. In summary, there was indeed a (Catholic) church doctrine about suicide, but more important, it never was and still isn’t Biblical.

    Those who suffer from the impression that suicide is the ultimate, unforgivable sin should realize that the Bible doesn’t teach that.

    Dan Casseday, MPA, North Tampa, FL

    1. Thanks for this, Dan. Very helpful for many, I am sure. Do you have a source that this church “scare tactic” reduced suicide rates? Not sure where such data might be found. The reference to Jim Clemons book is about his analysis of the suicides in the Bible and, from his scholarly perspective, he found none of them were condemned in this life or the next.

      As to change not coming quickly enough, I have become increasingly impatient in my dotage. With social media now capable of things like the Arab Spring, I’m gladdened by the awesome power of the smart phone – which is but another reason I started this blog. Paul

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