Remote supervision and training in suicide prevention during Covid-19

Article in review: Hausman, C., Vescera, K., Bacigalupi, R., Giangrasso, V. & Bongar, B. (2021). Remote Supervision and Training in Suicide Prevention During the Time of the Coronavirus Pandemic: Recommendations for Training Programs and Supervisors. Training and Education in Professional Psychology. https://psycnet.apa.org/fulltext/2021-50267-001.html

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Summary
There has been a rise in suicide and mental health problems since the COVID-19 pandemic began. During the pandemic, there has been an increasing shift towards remote service delivery, and an anticipated increase in the need for online psychological services. There are unique considerations around the delivery of psychological services in an online setting, and a need for improvement in training related to this change. Considerations of the impact of this shift must be made for supervisees/ trainees and post-doctoral students who will work with people who are suicidal or self-harming. This article calls for an interdisciplinary public health approach to improve training in this particular area; with applications for “advocacy, program evaluation, community collaboration and policy”.

Considerations for learning telehealth skills
Suicide risk assessment has already been identified as an area where better training is needed. There is a lack of standardised training about the process of assessment of suicide risk, and a 2016 study found that there was insufficient suicide prevention training for psychiatry students based on the likelihood they would encounter a suicidal person during their training period.

Providing improved support and education to supervisees/trainees about the delivery or telehealth services related to suicide risk and assessment is described as a fundamental ethical and legal issue. Problems can arise due to the lack of experimental learning opportunities for students who are working and learning remotely. Students can miss observing supervisors in the practice of clinical skills related to:
• Self-repot assessment measures
• Clinical interview questions
• Safety planning
• Lethal means assessment and counselling
• Higher standards of care

Use and increased demand for and challenges of telehealth services
Before COVID-19, practitioners had primarily used telehealth services to support those living in remote communities. During the pandemic, telehealth services have been expanded. It is likely the demand for telehealth services will only continue to increase, and students entering the professions of psychology or mental health practice will need to be prepared for and demonstrate competency in working in these ways. Health service and psychology training programs will play a critical role in equipping students and trainees in these fields. There are challenges around:

• Knowledge gaps posing a barrier to ensuring the new remote practices do not compromise the high standards of in-clinic protocols
• Technical issues, related to network availability and connectivity require a professional to ensure they have adequate access to patient location, emergency contacts and local emergency rescuers should there be immediate concerns for a person’s health or safety
• Building rapport, with many practitioners stating they find it harder to build rapport in sessions that do not face to face
• Legal and ethical parameters around the practice, with the potential for outdated laws and licensing board regulations related to standards of care in telehealth practice

Tools and technologies already available
Some existing suicide prevention strategies may be adapted to suit use in the virtual environment. There are also several examples of tools and programs that operate remotely. These include:
• Health Buddy – an app that can be used to assess a patient’s symptoms at home and sends responses to questions directly to medical staff
• Brief intervention and contact (BIC) program through which outreach services are provided to suicidal people by telephone
• Caring Contacts – where the professional sends routine caring letters to suicidal patients post-discharge
• DBT- an evidence-based intervention used to treat suicidality through phone coaching
• Services such as Alcoholics Anonymous and Narcotics Anonymous which offered video and phone meetings during the pandemic and smartphone applications such as MY3

Recommendations for training programs
Training programs that are adapted to cover or are specifically written to provide education around using electronic mediums such as video and telephone can provide a great deal of direction for trainees. Suicide risk assessment resources and modules can be adapted to include information about technologies and what to do should technical difficulties arise. One example of this cited is what to do in the situation of a video session terminating abruptly at a critical point in the call. Clear protocols here will give trainees more confidence in handling high-risk situations. Modified training programs can also reduce the risk of stress and burnout for trainees, given that there is less opportunity for peer-to-peer contact and support during remote work. They should cover making time for consultation with colleagues, and how to plan ahead for strategies to be implemented remotely should there be a death by suicide. Personal well-being resources should be available for trainees as part of training packages.

Recommendations for supervisors
Supervisors can support supervisees/trainees to better understand the context of suicide risk assessment and management in an online environment. They should recognise that providing supervision and support in an online environment is different to those sessions provided in person. Providing a range of experiential learning opportunities such as screen sharing and multiple-way video calls can help make up for the lost opportunity for in-person sessions.

Trainees may be experiencing their own levels of pandemic-related uncertainty and are more likely to experience burnout or fatigue. Supervisors should be attentive to the supervisee’s needs and provide strategies for reducing stress and establishing healthy work boundaries. Incidental opportunities for observations of peer-to-peer support and issue resolution may be lost when there is a reduction in time spent together in person. Supervisors also have a responsibility to stay informed about the constantly evolving best practice for technology-based work.

Major changes to training programs were required as a result of the sudden shift towards remote work during the pandemic. These shifts occurred in the absence of consistent or established guidelines equivalent to those in place for work in face-to-face sessions and care. This article advocates for developing standards of practice for virtual training in suicide risk assessment and management.