Context

Best practice guidelines indicate the need for suicide prevention training for athletic trainers. However, no resources exist that address suicide prevention programs that are specifically designed for athletic trainers and their roles working with student-athletes and mental health crisis teams.

Objective

To describe an introductory model for implementing suicide prevention training into an athletic training curriculum.

Background

Current Commission on Accreditation of Athletic Training Education standards identify suicidal ideation as one of the behavioral health conditions that need to be addressed within athletic training curricula. Introducing educational models for implementing suicide prevention training and mental health emergency action plans (EAPs) into curricula will assist educators in preparing athletic training students to recognize and assist student-athletes who are in a suicidal crisis.

Description

An introductory educational model for implementing suicide prevention training into an athletic training curriculum that highlights gatekeeper training, appropriate suicide terminology, recognition of suicidal ideation in student-athletes, proper responses to student-athletes in crisis, use of experiential exercises, and development of a mental health—suicide-specific EAP.

Clinical Advantage(s)

Within this educational model, a threefold benefit exists for athletic training students: (1) engagement in meaningful experiential exercises to enhance their readiness to enter clinical practice with the skills and knowledge needed to recognize, assist, and refer student-athletes dealing with suicidal ideation; (2) skill development in the design, development, and implementation of a mental health—suicide-specific EAP; (3) interdisciplinary collaboration with mental health professionals that enhances appreciation for their expertise and promotes the value of each professional's role on the mental health crisis team.

Conclusion(s)

This introductory model for implementing suicide prevention training within an athletic training curriculum offers an instructional strategy that supports the Commission on Accreditation of Athletic Training Education standards, professional readiness for athletic training students, and interdisciplinary collaboration among mental health and athletic training professionals.

KEY POINTS

  • Athletic training educators should consider implementing interdisciplinary suicide prevention training into their curricula to help enhance athletic training students' crisis response skills.

  • Greater improvement in crisis response skills have been found in suicide prevention gatekeeper training programs that include experiential exercises over didactic training alone.

  • The incorporation of experiential suicide prevention gatekeeper training into an athletic training curriculum allows for a safe environment in which athletic training students can experience the emotions that surround a suicide crisis incident; practice their recognition, assistance, and referral skills under interdisciplinary professional guidance; and develop mental health—suicide-specific emergency actions plans for better preparation toward their independent clinical practice and professional readiness.

INTRODUCTION

Suicide has become an increasingly prevalent concern in the field of athletic training. From 2003 to 2012, 477 collegiate student-athlete deaths were reported, of which 35 (7.3%) were due to suicide (rate of 0.93/100 000 per year).1  Additionally, suicide rates were shown to be significantly higher in male (1.35/100 000 per year) than female collegiate student-athletes (0.37/100 000 per year), higher for African American (1.22/100 000 per year) than White student-athletes (0.87/100 000 per year), and significantly higher for football (2.25/100 000) than other student-athletes (1.68 swimming, 1.49 baseball, 1.26 soccer, 1.20 track/cross-country, 0.26 other/100 000), thus making men's football the sport with the highest incidence of student-athlete suicide.1  Based on these statistics, as well as growing concerns around mental health issues in collegiate student-athletes, the possibility of athletic trainers encountering a student-athlete with suicidal ideation is probable.13  Therefore, it is extremely important for athletic trainers to be prepared to manage physical and mental health emergencies.

In response to the growing prevalence of suicide and recognition of other mental health illnesses in collegiate student-athletes, the National Athletic Trainers' Association (NATA) and National Collegiate Athletics Association (NCAA) have published recommendations and best practice guidelines for addressing mental health concerns for student-athletes.2,3  Both of these major organizations are promoting more attention and education toward the issue of suicide and other mental health disorders in the athletic population and among athletic trainers working with student-athletes to address the growing incidences. Therefore, the responsibility is on athletic training education programs to include curricular content to educate and prepare athletic training students in the management of mental health emergencies and response to student-athletes with suicidal ideation.

The Commission on Accreditation of Athletic Training Education (CAATE) standards mandate teaching athletic training students the knowledge and skills needed to assist patients in crisis.4,5  Based upon Standard 77, athletic training programs must 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) Furthermore, per Standard 94, athletic training programs must teach students to be able to “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) Even though these standards help guide an athletic training program's curriculum, evidence-based models to assist in the implementation of suicide prevention training and mental health emergency action plans (EAPs) are lacking.

To comply with the NATA's recommendations and the CAATE standards, it is imperative that we take active steps to educate our athletic training students to be competent gatekeepers in suicide prevention, so they are prepared to recognize, assist, and refer student-athletes who are in a suicidal crisis. The purpose of this paper is to introduce an educational model for implementing suicide prevention training into an athletic training curriculum. The model highlights educational techniques used to prepare athletic training students in the recognition of student-athletes with suicidal ideation, use of appropriate responses to student-athletes in crisis, and development of a mental health EAP to handle suicide emergencies.

INTERDISCIPLINARY COLLABORATION

After studying the NATA's consensus statements on recommendations for recognition and referral of student-athletes with psychological concerns2,6  and the NCAA's best practices for understanding and supporting student-athlete mental wellness7  as foundational guidelines, a senior athletic training student proposed to organize and implement a suicide prevention training to be used in the athletic training curriculum as her capstone Honors Project. She invited the Director of the Athletic Training program and the university counseling center's mental health professionals to collaborate on the project. The Director of the Athletic Training program is the instructor for both the organization and administration and the general medical conditions courses that cover developing comprehensive emergency and mental health plans and behavioral health concerns, including suicide, respectively. The mental health professional serves as a team member for the university's suicide prevention training program for gatekeepers and works in the university counseling center as a licensed clinical staff member.

The focus of the initial discussions revolved around athletic trainers serving as gatekeepers in athletics. Gatekeepers are campus or community members who are in an everyday position to interact with at-risk individuals and are trained to detect, appropriately assist, and refer those individuals needing intervention services,8  in this case, specifically athletic trainers interacting with student-athletes that may be considering suicide. Based on the increasing number of cases of suicidal ideation among student-athletes and the involvement of athletic trainers as gatekeepers on our campus, the need for suicide prevention training was evident. Discussion of the CAATE standards provided further evidence that a structured, content-driven, but interactive, interdisciplinary suicide training should be implemented into the curriculum. Therefore, the senior athletic training student, the Director of Athletic Training, and the mental health professional agreed to work together to address the need for a suicide prevention training program to prepare our athletic training students to effectively recognize, assist, and refer student-athletes with suicidal ideation, as well as establish a mental health—suicide-specific EAP.

FOUNDATIONAL CONCEPTS AND CONTENT

The foundational concepts and content for the suicide prevention training were established using systematic factors commonly used in the development, implementation, and evaluation of gatekeeper training9  and the university's suicide prevention training program for gatekeepers.10,11  Adapted from the 5-step strategic planning model for gatekeeper training in campus suicide prevention of Wallack et al,9 Table 1 provides a general overview of the steps and variables that were considered before the implementation of the suicide prevention training for athletic training students. A mental health EAP and hypothetical skill check scenarios were added to the suicide prevention training to further enhance the interactive components of the training and cultivate meaningful, real-world experiences to better prepare athletic training students for independent clinical practice and professional readiness.

Table 1

Five-Step Strategic Planning Model for Suicide Prevention Gatekeeper Traininga

Five-Step Strategic Planning Model for Suicide Prevention Gatekeeper Traininga
Five-Step Strategic Planning Model for Suicide Prevention Gatekeeper Traininga

The university's suicide prevention training program for gatekeepers is modeled after the well-established Campus Connect gatekeeper program developed by the Syracuse University Counseling Center.1113  The gatekeeper training program is a 3-hour interactive training session that incorporates experiential-based exercises to enhance learning in order for trainees to function effectively with a suicidal student.11,12  The training includes “discussion of the gatekeepers' own fears to prepare the gatekeepers for the anxiety-provoking situation of interacting with a suicidal student.”11 (par1) It also focuses on suicide warning signs, directly asking about suicidal thoughts, and referral sources.11,12  Furthermore, guided roleplay and other participatory activities are incorporated, so gatekeepers experience the realistic emotions encountered when assisting students in crisis and develop the effective listening, communication, and relationship skills needed by gatekeepers to manage a crisis.1113 

ATHLETIC TRAINING SUICIDE PREVENTION TRAINING MODEL

The introductory model (Figure 1) for implementing suicide prevention training into the athletic training curriculum highlights suicide terms, how to recognize a student-athlete with suicidal ideation, the appropriate responses to student-athletes in crisis, roleplaying and other participatory learning exercises, and how to establish a mental health—suicide-specific EAP. Hypothetical skill check scenarios are incorporated into the suicide prevention training to allow participants to test their skills and discuss possible solutions and situations specific to a mental health—suicide-specific EAP.

Figure 1

Athletic training suicide prevention training model. Adapted with permission from Wallack and Pasco.13 

Figure 1

Athletic training suicide prevention training model. Adapted with permission from Wallack and Pasco.13 

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.14 Unacceptable 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 Vignettea

Uniform Terms, Unacceptable Terms, and Sample Vignettea
Uniform Terms, Unacceptable Terms, and Sample Vignettea

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 

Figure 2

Risk factors for suicide. Adapted from Suicide Prevention Resource Center15  and Substance Abuse and Mental Health Services Administration.16 

Figure 2

Risk factors for suicide. Adapted from Suicide Prevention Resource Center15  and Substance Abuse and Mental Health Services Administration.16 

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).10,17,18 Tier 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).10,17,18 Tier 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 Suicidea

Warning Signs for Suicidea
Warning Signs for Suicidea

Takeaway Points

Our mental health professional also emphasizes the importance of understanding the emotions of individuals who contemplate suicide and that emotional or physical pain is rated by college students as the Number 1 factor that impacts their consideration of suicide.10  Under this topic, the major takeaway points stressed to athletic training students are: (1) Suicide is a permanent solution to a temporary problem.10  (2) In general, suicide is attempted when pain exceeds resources for coping.19  (3) Suicide does not limit itself to a certain race, gender, age, ethnicity, personality, sexual orientation, or socioeconomic status. No way to identify a person with suicide ideation by appearance exists, and no one should make assumptions.10,20  (4) All threats should be taken seriously, no matter the situation. It should never be assumed that it is for attention.10,20  (5) Talking about suicide is not going to promote the action of suicide. In fact, it is one way to help the person cope by being open about the subject and offering them help.10,20  (6) Individuals experiencing suicidal ideation are seeking relief to their physical or mental pain.10  Thus, the gatekeeper's role is to provide additional resources (Appendix) and support to assist individuals in coping with their pain, not to provide therapy.10 

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.

Figure 3

Steps to approaching a student-athlete possibly contemplating suicide.

Figure 3

Steps to approaching a student-athlete possibly contemplating suicide.

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 recommendations2,6  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 NATA2,6,21  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.

Mental Health—Suicide-Specific EAP: Step 1. Suicide Information

The students begin the development of their mental health—suicide-specific EAP by using the foundational knowledge they gained from the suicide prevention training to develop introductory paragraphs, charts, and tables to present the basic suicide information recommended by the NATA consensus statements.2,6  The information includes suicide facts or figures, symptoms, warning signs, behaviors to monitor, and confidentiality.2,6 

Mental Health—Suicide-Specific EAP: Step 2. Identifying the Mental Health Crisis Team

The students research and identify the on-campus and community professionals and resources they have available to establish a mental health crisis team. From their findings, students select their interdisciplinary team of athletic trainers, campus counseling or mental health professionals, campus police, community-based licensed practitioners in mental health services, and team physicians that will assist in supporting a student-athlete with suicidal ideation that is in crisis.2,6,7,21 

Mental Health—Suicide-Specific EAP: Step 3. Crisis Team Qualifications and Role Delineation

The students research and outline the qualifications of the mental health crisis team members they selected in Step 1. They must then examine those qualifications and skillsets to determine and provide reasons for the assignment of direct and supportive roles for each team member within the mental health EAP.21  The students then document the role delineation for each team member to execute the EAP for a suicidal referral and catastrophic suicide incident.

Mental Health—Suicide-Specific EAP: Step 4. Referral Resources

The students design a reference sheet (location and phone numbers) of emergency, crisis, and nonurgent referral resources (campus, community, and national) for Tier 1 (direct) and Tier 2 (indirect) suicide warning signs.10,17,18  They also document the order the resource initiation should follow for specific circumstances (ie, during versus after regular business hours, for on-campus versus off-campus emergencies).

Mental Health—Suicide-Specific EAP: Step 5. Action Plan

The students develop their communication plan for the mental health crisis team, identify the emergency care facilities that may be required for a suicide intervention, and write step-by-step suicide referral and incident policies and procedures unique to the venue that each athletic training student is currently assigned to (ie, high school, college or university).2,6,7,21  The students are also required to include documentation (eg, figure, schematic, table) identifying the varying levels for a suicide intervention and referral (emergent, urgent, nonurgent).2,6,10 

Mental Health—Suicide-Specific EAP: Step 6. Required Documents

The students identify the necessary documentation (ie, incident report, institutional personnel training records, referral follow-up report) that is to be used within the EAP.21  They are required to include samples of the documents (already established by or newly developed for their venues). The students must also provide information on when and how the documents are to be used in the EAP, as well as which metal health crisis team members are responsible for completing each form.

Mental Health—Suicide-Specific EAP: Step 7. Risk Management

The students discuss the importance of having the EAP reviewed by the mental health crisis team members, administration, and legal counsel of the institution, posting the EAP in all relevant locations, and practicing the plan with every member involved on an annual basis.2,6,7  They list the locations they will post their mental health EAP for access by coaches, student-athletes, athletic training staff, etc and explain when and how they will conduct annual practice sessions or training with their mental health crisis team.21 

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.

Figure 4

Sample scenarios of student-athlete contemplating suicide.

Figure 4

Sample scenarios of student-athlete contemplating suicide.

DISCUSSION OF EDUCATIONAL RELEVANCE

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 NATA2,6  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 programs12,22  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 programs9,12,2326  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.9,2628  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 studies12,26  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.

CONCLUSIONS

The increasing prevalence of suicide among student-athletes significantly necessitates suicide prevention training among athletic trainers and athletic training students as part of the frontline defense in the recognition and intervention for at-risk student-athletes. Our introductory approach to teaching suicide prevention within an athletic training curriculum allows students to practice recognition, assistance, and referral of student-athletes with suicidal ideation in a safe environment with trained mental health professionals to prepare them for independent clinical practice and professional readiness. It also incorporates the development of a mental health—suicide-specific EAP to further prepare athletic training students for the roles and responsibilities they will be engaged in as health care professionals. Through the integration of a suicide prevention gatekeeper training program with the addition of audience-specific interactive experiential exercises and roleplaying as part of the instructional strategies, evidence supports the model's positive enhancement and retention of athletic training students' crisis response skills over traditional didactic training alone.12,2225  This introductory model is by no means the best or only educational technique to address suicide prevention training and the associated educational standards required of athletic training curricula, but it provides a sample of one that has been designed specifically to meet the unique needs of an athletic training program.

Acknowledgments

We would like to thank Susan D. Pasco, PhD, LCSW-R, from Syracuse University for her assistance with information and resources pertinent to the Campus Connect suicide prevention gatekeeper training program, as well as her recommendations and other feedback on our manuscript.

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Appendix

Suicide Prevention Resources2944 

Suicide Prevention Resources29–44
Suicide Prevention Resources29–44