Implementing Suicide Prevention Training into an Athletic Training Curriculum: An Introductory Model

Step 1: Foundational Knowledge

When educating athletic training students on managing student-athletes with suicidal ideation, the first step includes establishing foundational knowledge. Within this model, defining terms, discussing statistics and facts, presenting risk factors, and identifying warning signs about suicide are presented in a primarily didactic format to provide the students with the needed foundational knowledge.

Terms and Definitions

Our mental health professional begins the suicide prevention training by discussing terms and definitions issued by the Centers for Disease Control and Prevention (CDC)¹⁴ as uniform or unacceptable (Table 2). Uniform terms (ie, suicide, suicidal ideation) are identified as acceptable, consistent terminology with standard definitions that are used to improve communication among clinicians, researchers, and others when discussing suicide.¹⁴Unacceptable terms (ie, committed suicide, failed attempt) are explained as terms or phrases that should not be used when discussing suicide because they evoke negative underlying connotations or perpetuating stigma.^11,14

Table 2 Uniform Terms, Unacceptable Terms, and Sample Vignette^a

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Athletic training students are encouraged to use the uniform terms throughout the training to learn how to discuss suicide with stigma-free language.^10,14

Vignettes are also used to further contextualize the materials, provide self-assessment and comparative assessment on the application of the terms, and generate questions and discussion among athletic training students.¹⁴ The students are asked to read or listen to a vignette about a hypothetical student-athlete in a particular situation and determine what term describes the situation best (Table 2).¹⁴

Suicide Statistics, Myths, and Risk Factors

Next, our mental health professional asks athletic training students to participate in the training by responding to multiple choice or true or false questions regarding incidence and prevalence of suicide in college students. During this section of training, our mental health professional debunks any myths that students may have regarding suicide, as well as answers other questions they may pose. She also educates athletic training students on the risk factors that often lead to suicidal ideation (Figure 2).^15,16

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One of the profound experiential activities that is included in this portion of the training requires athletic training students to look at a group of yearbook photos and tell the mental health professional who they think may have died by suicide, experienced suicidal ideation, or both, as well as why they selected the photo(s).¹³ This activity is effective because the students often pick 1 or 2 photos, when all pictured individuals died by suicide and experienced suicidal ideation. The takeaway point from this activity is for students to become aware of their biases and preconceived ideas because they may result in overidentifying or under identifying certain individuals at risk for suicide.^10,13

Warning Signs

The final topic in Step 1 focuses on the warning signs that may indicate that a person is contemplating suicide (Table 3). Our mental health professional explains that the warning signs can be separated into 2 tiers: direct (Tier 1) and indirect (Tier 2).^10,17,18Tier 1 or direct warning signs (eg, making statements of wanting to kill oneself) indicate that an immediate risk is present and the student urgently needs help (ie, call 911, the National Suicide Prevention Lifeline, a mental health professional).^10,17,18Tier 2 or indirect warning signs (eg, insomnia, excessive sleeping) may also indicate a serious risk if associated with a painful event or loss.^10,17,18 Our mental health professional further discusses that the warning signs do not directly predict whether a student will attempt suicide. However, the greater the number of warning signs, the greater the likelihood that a student is contemplating suicide.¹⁰

Table 3 Warning Signs for Suicide^a

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Step 2: Experiential Learning

Step 2 of the model focuses on guided roleplaying that exposes athletic training students to talking with student-athletes contemplating suicide. The mental health professional begins this section of training by teaching athletic training students ways to talk to student-athletes with suicidal ideation and appropriate responses to address student-athletes in crisis. Figure 3 provides an easy way for athletic training students to remember the steps to approaching a student-athlete with the key words suspect, reflect, be direct, and connect.¹⁰ The key takeaway concept in this step is that the only way to truly know if someone is suicidal is to ask the direct question: “Are you thinking about killing yourself?” instead of: “Are you thinking about hurting yourself?”¹⁰ Asking this question seems simple, but approaching an athlete is one of the most difficult tasks, which makes roleplaying a critical component in preparing athletic training students to properly assist a student-athlete with suicidal ideation. Within the roleplaying exercise, the mental health professional simulates a student-athlete in crisis. Having the mental health professional serve as the simulated student-athlete in crisis really brings the scenario to life for athletic training students because of her extensive experience in dealing with these specific situations. The mental health professional's ability to realistically simulate a student-athlete in crisis allows athletic training students to experience raw emotions and the uncomfortable scenario they must work through. The roleplaying and other associated experiential exercises give athletic training students the ability to become professionally ready to handle a student-athlete with suicidal ideation before entering their future practice settings. The roleplaying activity ends with a debriefing session by the mental health professional, so athletic training students can process their personal reactions and discuss the interactions that were effective and positive.

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Step 3: Mental Health EAP

Before an athletic trainer can even approach a student-athlete with suicidal ideation, a plan needs to be in place on how to handle a mental health emergency. A mental health EAP will not only improve student-athlete safety and wellbeing, but it will also help avoid any negligence charges that could take place in the event of an emergency by informing athletic training students and staff on proper procedures for recognizing and handling a student-athlete with suicidal ideation.^16,21 The mental health EAP should be established before the start of the season or academic year and should be reviewed annually, allowing for optimal time to practice various scenarios and assess communication skills.^2,6,7,16,21 During each review, all athletic training students, staff, and other members of the crisis team need to run through each step of the EAP and inform all, especially new team members, of their roles and responsibilities during a mental health crisis.⁷

Since athletic trainers are commonly the first responders for student-athletes in an emergency situation, mental or physical, teaching students how to create their own mental health EAP is an imperative part of the suicide prevention efforts.⁷ Athletic training students need to be taught how to develop, what to include in, and how to implement a mental health EAP.

Within Step 3 of our suicide prevention training model, the Director of the Athletic Training program reinforces lessons taught by the mental health professional by discussing stressors and statistics or facts specific to student-athletes.^1,2,6,7 She also emphasizes confidentiality issues and that providing psychological care or therapy to a student-athlete is beyond the scope of practice for an athletic trainer or athletic training student; but it is critical for athletic trainers or athletic training students to recognize the warning signs of suicidal ideation and other mental health behaviors, so they can effectively assist and refer a student-athlete that is in crisis (Appendix).^2,6,10 As a precursor to developing a mental health—suicide-specific EAP, the students compare the institution's plan to recognize and refer student-athletes with psychological concerns to the NATA's recommendations^2,6 to reiterate the necessary elements of a comprehensive mental health EAP and the importance of using professional consensus or position statements. Then discussing and using the guidelines established by the NATA^2,6,21 and the NCAA,⁷ the instructor guides athletic training students through a 7-step approach to establishing a mental health EAP that focuses on a suicide incident.

Step 4: Evaluation of Students' Mental Health—Suicide-Specific EAPs via Mock Skill Check Scenarios

The final imperative step in implementing the suicide prevention training program is to include hypothetical skill check scenarios (Figure 4) that allow athletic training students to test their skills and discuss possible solutions and situations specific to their mental health—suicide-specific EAPs. Evaluating the skills that were introduced in Steps 1 and 2 of our suicide prevention training model assists in professional competency by allowing athletic training students to be assessed on their steps in approaching an athlete in distress and proficiency in asking the critical question: “Are you thinking about killing yourself?” Under the guidance of our mental health professional and the course instructor, athletic training students roleplay a mental health crisis team addressing a student-athlete (simulated by the mental health professional) that is potentially contemplating suicide. In the role as the head or lead athletic trainer, athletic training students must use the assigned scenario to suspect, reflect, be direct, and connect.¹⁰ Then as warranted by the scenario, the head or lead athletic training students activate and engage in the steps of their mental health—suicide-specific EAP with the assistance of their mental health crisis team. The scenarios are used for EAP rehearsal to assist athletic training students in evaluating the effectiveness and quality of their student-developed mental health—suicide-specific EAPs, as well as gain experience in best practices of annually practicing the plan with every mental health crisis team member involved.

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Professional Directives

In recognition of the growing prevalence of the types, severities, and percentages of mental health issues, including suicidal ideation, among student-athletes, the NATA^2,6 and the NCAA⁷ have issued consensus statements on best practices and recommendations for developing a plan to recognize, understand, support, and refer student-athletes with psychological or mental health concerns.^2,6,7 The consensus statements recommend establishing interdisciplinary teams of health care providers (eg, athletic trainers, counselors, psychologists, psychiatrists, team physicians, sport psychologists) and others that will support student-athletes' mental health and wellbeing.^2,6,7 These consensus statements also recommend including educational training on the prevalence of mental health concerns, stressors, and behaviors unique to student-athletes, as well as approaches to questioning and referring student-athletes with mental health issues.^2,6,7 Furthermore, an EAP must be established and should address suicide specifically by including the incidence and prevalence, risks and protective factors, specific signs and symptoms, and the actions to take if a student-athlete is suicidal.^2,6 Lastly, it is recommended that an EAP, including a catastrophic incident guideline and crisis counseling plan, be developed to guide the actions of dealing with the aftermath of a suicide. ^2,6

These consensus statements and their associated recommendations are designed for athletic trainers that are currently practicing in the field as part of an athletic health care team.^2,6,7 By implementing this introductory educational model for suicide prevention training into the athletic training curriculum, athletic training students are better prepared to develop and write mental health—suicide-specific EAPs when they begin practicing within the field as certified athletic trainers. Athletic training students gain the knowledge and skills needed to build an EAP for the recognition and referral of student-athletes dealing with suicidal ideation. They can use the key recommendations from the consensus statements to draft a plan that is built off of consistent and good-quality patient-oriented evidence and best practice guidelines. Through the guided learning activity of writing a mental health—suicide-specific EAP for a high school or college venue, athletic training students gain applied experience in creating the plan and documentation needed for a practical mental health—suicide-specific EAP that they can use as a template in their future administrative duties.

This introductory educational model also assists in meeting the CAATE standards 77 and 94, in that it provides instructors, preceptors, or both with an instructional strategy to teach students to be able to “identify, refer, and give support to patients with behavioral health conditions. Work with other health care professionals to monitor these patients' treatment, compliance, progress, and readiness to participate”^4(p5),5(p44) and “develop and implement specific policies and procedures for the purposes of identifying patients with behavioral health problems and referring patients in crisis to qualified providers.”^4(p7),5(p50) After participating in this suicide prevention training, athletic training students are able to enter clinical practice with the foundational skills and knowledge needed to recognize, assist, and refer student-athletes with suicidal-ideation. They also understand how to establish a mental health EAP. The model's interdisciplinary teaching collaboration between athletic trainers and mental health professionals enhances the learning experiences offered to athletic training students, promotes appreciation for the expertise of these disciplines, and demonstrates the strong communication and working relationship that is needed among the members of the mental health crisis team.

Evidence-Based Training

Suicide prevention gatekeeper training programs are an example of evidence-based programs^12,22 for campus and community members (eg, health care providers, teachers, first responders, university or college students, student leaders) that have frequent interactions with individuals who may have suicidal ideation.^8,22 Many different gatekeeper training programs (ie, Applied Suicide Intervention Skills Training; Campus Connect; Kognito; Question, Persuade, Refer) are available to teach suicide ideation recognition, crisis intervention, and referral.²² Positive outcomes from the evaluation of these gatekeeper training programs^9,12,23–26 support the implementation in an athletic training curriculum.

Campus Connect, a suicide prevention training for gatekeepers, is a nationally recognized experiential (learning through reflection on doing) based training program specific to college student suicide.^9,26–28 Through interactions with qualified Campus Connect trainers, gatekeepers engage in didactic learning (eg, suicide stats, risks) and experiential exercises (eg, asking about suicide, roleplay) to develop empathetic listening and communication skills.²⁷ The Campus Connect trainers are instrumental in engaging the gatekeepers in the emotional responses that arise when confronting college students with suicidal ideation, but more importantly, they coach the gatekeepers in asking a student in crisis if he or she is thinking about suicide.²⁷

Authors of studies^12,26 examining the impact of the Campus Connect suicide prevention gatekeeper training program reported that participation resulted in significant increases in the gatekeepers' knowledge, self-efficacy, confidence, and response skills when confronted with a college student in crisis. Participation in the experiential exercises and roleplay also elicited significant increases in gatekeepers' crisis response skills and self-efficacy when compared to didactic training alone.¹² These positive gains were found from pretraining to posttraining and to 3-month follow up.²⁶

We designed and developed our introductory athletic training suicide prevention training model after the Campus Connect program. Due to the current grassroots level for the implementation of our suicide prevention training model into our athletic training curriculum, the outcomes have yet to be evaluated to determine if the model supports the standards for evidence-based prevention. Once a large enough sample size can be obtained, the effectiveness of our suicide prevention training will be assessed for results at pretraining to posttraining and over time (eg, 3 months, 6 months, 1 year postgatekeeper training).

Meeting the Unique Needs of Athletic Training Programs

Our model is similar to Campus Connect in that it uses didactic and highly interactive experiential exercises (including roleplaying) and the same overall objectives: (1) increase knowledge of suicide warning signs and referral points for students at risk for suicide, (2) increase skills to respond to students at risk for suicide, and (3) increase self-efficacy regarding ability to respond to a student at risk for suicide.²⁷ It differs from Campus Connect in that it uses the homogenous group of athletic training students with a focus on professional interactions with student-athletes and interdisciplinary interactions with mental health professionals across campus. It specifically includes roleplaying and practice scenarios adapted to address the unique situations that athletic trainers or athletic training students may face when working with student-athletes, as well as experiential learning activities with clinical implications.

This aspect of our introductory suicide prevention training model is more consistent with Cimini et al,²³ who reported positive clinical implications for professionals in college or university health care settings that use audience-specific gatekeeper suicide training. Like the Campus Connect results,^12,26 Cimini et al²³ reported significant increases in knowledge and comfort in asking about suicide and in intervening with students at risk for suicide. More importantly, Cimini et al²³ identified that participation in this type of training improved interprofessional relationships among the participants and other gatekeepers who respond to students in crisis.

Once again, due to the current grassroots level for the implementation of our suicide prevention training model, the outcomes have yet to be determined. Once a large enough sample size can be obtained, the outcomes will be evaluated regarding changes in posttraining knowledge, comfort in asking about suicidal ideation or suicide, and competence in suicide intervention and referral. We will also assess what effect our homogenous small-group experiential gatekeeper suicide training program elicits compared with other similar studies and determine if the training truly warrants evidence-based practice for athletic trainers or athletic training students.

Additional Advantages

Our introductory suicide prevention training model demonstrates additional advantages for an athletic training program that include but are not limited to the use of our university's resources without the need for additional spending for commercially available gatekeeper training, the enhancement of our athletic training program's autonomy while addressing the CAATE standards in multiple domains, and the engagement in interdisciplinary teaching collaboration. Most importantly, our model has the functionality and flexibility to continually tailor the suicide prevention training to include experiential exercises, roleplaying, and behavioral rehearsal to meet the needs of athletic trainers or athletic training students.

Limitations

At this preliminary time, we have identified 2 limitations to our model. One limitation is the amount of time needed to conduct and complete the entire training program effectively. Although extremely important, the experiential activities or exercises and roleplaying scenarios, as well as the mental health—suicide-specific EAP writing takes several class periods.

The model's suicide prevention training program for gatekeepers component (Step 1: foundational knowledge and Step 2: experiential learning) takes approximately 2.5 hours to complete. Depending on the course scheduling for the semester, we have completed this component in 3 different styles of course offerings. The offerings have included 1 class session during a night course that meets 1 time per week for 2.5 hours per week, 2 class sessions of a traditional 15-week course that meets Tuesday and Thursday for 75 minutes per class meeting, or 3 class sessions of a traditional 15-week course that meets Monday, Wednesday, and Friday for 50 minutes per class meeting. We recommend the 3 class sessions (50 minutes each session) for better student engagement, participation, and content retention. Although it is feasible, we do not recommend the 1-night, 2.5-hour session. We found that it makes for a very long day for all individuals that are involved in the training, and the students seem to retain less when asked to transfer the information they learned to the Step 3: mental health EAP—suicide information and referral resources components.

The model's 7-step approach to establishing a mental health—suicide-specific EAP within Step 3 takes approximately 6 hours to complete. The content itself takes about 3 hours to teach, and then the additional 3 hours consists of focused question-and-answer and in-class work periods to assist students in their development of the EAP. Depending on the course scheduling for the semester, it takes 2 to 6 class sessions equating to 2 weeks of the course.

Step 4: evaluation of students' mental health—suicide-specific EAPs via mock skill check scenarios is planned for a minimum of 15 minutes per student enrolled in the course. Depending on the class size, additional time outside of the regularly scheduled class periods may be required. Completion of this component is allotted 1 to 2 weeks.

The model's timeframe is also dependent upon the mental health professionals', Campus Connect trainers', or course instructor's schedules; students' preparation from session to session; and students' engagement in suicide prevention or mental health EAP activities. An all-day weekend workshop with multiple breaks offered throughout the day has been considered to extend the time to offer more directed learning and content retention activities, as well as multiple individualized experiential activities and writing workshops to help supplement the model. However, personal and professional obligations as well as clinical education rotations often interfere with finding dates and times that work for all parties involved.

The second limitation may be the ability to transfer the model into another athletic training program's curriculum. We used the resources we had available on campus to develop our introductory training model. Our athletic training program is fortunate enough to have Campus Connect-trained trainers on our campus that are well versed and prepared to provide suicide prevention gatekeeper training sessions. Depending on the suicide prevention program that a campus uses, one may have to engage in additional training to learn the objectives and constructs of the program, as well as get permission from the authors to use an altered version of the program. We are also privileged in that our mental health professional that participates the most in our interprofessional teaching collaborations is married to a certified athletic trainer. She understands the roles and responsibilities we have on campus and the different relationships that student-athletes and athletic trainers have that may influence suicidal interventions from either side. If this is not the case at an institution, one may have to spend additional time educating mental health professionals about the profession of athletic training and what roles and responsibilities athletic trainers or athletic training students have regarding working with student-athletes that may be at risk for suicide.

Future Recommendations

As the model continues to be adjusted and enhanced, we propose the following recommendations to further strengthen our suicide prevention training model: (1) incorporate the use of individuals who have had suicidal ideation, well-trained simulated patients beyond that of our mental health professional, or both to further capitalize on the benefits of the experiential activities and roleplay; (2) solicit athletic trainers that have experienced working with student-athletes with suicidal ideation or have had a student-athlete die by suicide for open interviews with athletic training students to provide additional in-depth conversation about handling a suicide crisis in professional clinical practice; (3) add more technology (eg, game-based classroom response systems played by the whole class on their phone, tablet, or computer in real time, electronic surveys) to enhance the didactic and evaluation portions of the training, as well as collect assessment data; (4) include our on-campus sport psychology, counselor education, social work, and other relevant programs to further promote interdisciplinary and collaborative teaching or learning experiences; (5) develop and implement online modules or tutorials to assist students with the development of their mental health EAP once they leave the classroom; (6) invite more on-campus and community mental health crisis team members to partake in the mental health—suicide-specific EAP portion of the training and mock skill check scenarios to help students understand and value each professional's role and skillset, as well as build interprofessional relationships; (7) include the importance of the critical incident stress management training within an athletic training curriculum and the resources available to athletic trainers or athletic training students at the national and state levels.