Development of A Suicide Prevention Training Module for Social Work Students in India

Abstract

Introduction:

Social workers constitute a significant task force that serves diverse populations experiencing psychosocial challenges in their daily lives. Lack of suicide prevention content/training in the Master of Social Work program may affect the student’s self-esteem/ability to intervene when they come across a person with suicidality in the field. Developing a suicide prevention training module for social work students would be a suitable measure for upbringing their skills in dealing with individuals with suicidality.

Method:

The purpose of the present study was to develop a suicide prevention training module for social work students at the postgraduate level. The researcher conducted two Focused Group Discussions (FGD) each with social work students (n = 13) and social work educators (n = 15) on an online platform. Notes were taken during the discussion, and the contents were videotaped. The videotaped content was transcribed, and content analysis was used to analyze the data. The content that emerged from the FGD with social work students and educators was discussed in later FGD with mental health experts (two psychiatrists, one psychologist, two psychiatric social workers, and two mental health nurses). The discussion with experts clarified what components to retain for the training program.

Results:

Five major themes and 22 sub-themes emerged from the two FGDs each with students and educators, and one FGD with mental health professionals are described. The five major themes were understanding of suicidality, understanding suicide education in the master of social work curriculum, experience with suicidality, training content suggestion, and suggestions for future implications.

Conclusions:

The present study identified the need for suicide prevention training in postgraduate-level social work students. Furthermore, a lack of suicide prevention training was observed indicating the incorporation of suicide education in the postgraduate curriculum.

Key Messages:

Social workers constitute a significant task force that serves diverse populations experiencing psychosocial challenges. Lack of suicide prevention content/training in the Master of Social Work program may affect the student’s self-esteem/ability to intervene. Suicide prevention training module for social work students to improve their knowledge, attitude, and behavior toward suicide prevention among students.

Across the world, various professionals are being trained to reduce suicide rates/attempts. Suicide prevention training is being implemented for a variety of non-health professionals, such as teachers, school staff, police, journalists, general practitioners, and mental health professionals.^1,2 This is a particularly important activity in low- and middle-income countries with fewer resources for the mental health system. These countries have also lower budgetary allocations for health in general and for mental health in particular. As a result, there are few sustained efforts and activities that focus on suicide prevention on a scale necessary to reduce the number of lives lost to suicide. ³ The demand for mental health care in India is enormous and vastly outstrips the supply of clinical mental health professionals, resulting in substantial unmet needs for mental health care. To address this unmet need, task shifting is required whereby the broader health and social workforce is engaged and upskilled around mental health and suicide prevention.

In India, social workers are key members of the health and social workforce. Social workers are employed in different settings, including industries, hospitals, non-governmental organizations, community-based agencies, family and child welfare, correctional settings, and short-stay and long-stay facilities.^4,5 Social workers are trained in different fields according to the nature of the work based on the specialized course offered. Social work education programs train students to understand psycho-social issues and to intervene at the individual, family, group, and community levels. However, there is a lack of uniform teaching components, and training methods, and insufficient skill orientation toward mental health interventions. ⁶

Social workers are well positioned to play a critical role in suicide, regardless of the specific sub-field that they are working in. They are regularly exposed to people experiencing health and psychosocial challenges, many of which are risk factors for suicide. ⁷ They also undertake holistic psychosocial assessments with individuals and their broader family units, which allow them to capture important information closely related to the risk of suicidal behavior. Lack of suicide prevention content/training in the Master of Social Work (MSW) program may affect the student’s self-esteem/ability to intervene when they come across a person with suicidality in the field.^7–9 Yet, to date, there has been limited research into the role of social workers in suicide prevention in India, nor an assessment of their knowledge and skills in undertaking suicide prevention interventions. ¹⁰ To address this gap, this article discusses the development of a suicide prevention training module for social work students, designed to teach skills for working with people experiencing suicidal thoughts and behaviors.

Methods

The researcher followed a qualitative research design to study the needs of social work students, educators, and mental health professionals to develop the suicide prevention training module for social work students by using a purposive sampling technique from November 28, 2020, to December 16, 2020. The research protocol obtained approval from the Institute Ethics Committee. All the participants were oriented to the aim and objectives of the study. The study participants were educated about their rights during their participation, including their right to withdraw from the study at any point. Written informed consent was obtained from each participant. The researcher informed the participants that if they faced emotional difficulties during the program, they would be assisted by the researcher, and further help would be provided to them. Confidentiality and anonymity were ensured and maintained. The researcher used GoTo meeting online platform to conduct the Focused Group Discussions (FGD) (due to COVID-19 restrictions). The researcher used the paid version to record the online discussion. This version complies with the Health Insurance Portability and Accountability Act, which provides data security for recording FGD data.

Study Participants

The researcher conducted two FGDs each with social work students (n = 13) and social work educators (n = 15). Notes were taken during the discussion, and the contents were videotaped. The videotaped content was transcribed, and content analysis was used to analyze the data. The content that emerged from the FGD with social work students and educators was discussed in later FGD with mental health experts (n = 7) (two psychiatrists, one psychologist, two psychiatrist social workers, and two mental health nurses). The discussion with experts clarified what components to retain for the training program.

Data Collection

The researcher planned to conduct separate FGDs with the social work students and social work educators. The research co-guide, who is an expert in qualitative research, conducted training on FGD for the researcher to gain experience before preparing the FGD guide. After the FGD training, the researcher conducted two trials of FGD with the postgraduate M.Phil. Psychiatric social work trainees (approximately six to eight students in each group). With handheld experience, the researcher prepared FGD guides for social work students and social work educators separately, and it was validated by the research supervisor. Subsequently, the researcher sought permission from the institutes offering social work education to conduct FGD with students and educators.

Unfortunately, COVID-19 restrictions were enforced in March 2020, so the institutes declined permission to conduct FGD in person. Then the researcher decided to conduct online FGD instead of in-person FGD. The researcher prepared online FGD guidelines that were validated by the research supervisor and technical staff of the institute’s telemedicine unit before conducting the online trial FGD. After validating the guidelines, the researcher conducted two online trial FGDs with the postgraduate M.Phil. Psychiatric social work trainees (approximately six to eight students in each group). While organizing and conducting the online trial FGD, the researcher understood that the date and time for the FGD should be scheduled prior, and information about the online platform and the ground rules for participation in online FGD has to be informed to participants. The researcher was confident in conducting online FGD with the experience of online trial FGD, and feedback from the moderator helped to rectify the shortcomings to facilitate the online FGD. Further, the researcher conducted two FGDs with social work students and two FGDs with social work educators using the online platform. Online FGDs offer advantages, such as flexibility and convenience in recruiting participants from far away distances. However, the researcher also faced some limitations such as; not being able to observe the non-verbal cues of participants, technical issues (poor internet connection, management of waiting room access), and data security.

Data Analysis

Qualitative data analysis utilized six steps/phases of thematic analysis were employed in this study phase. ¹¹ The researcher transcribed the focused group interviews to familiarization with the data and prepared an initial code list of major themes. Two coders independently read the transcripts multiple times and additional codes were derived inductively for the emerging subthemes from the data. The two coders discussed differences in their interpretation of results and refined the coding frame accordingly. The researcher subsequently coded all transcripts, using ATLAS.ti 22 software to organize and manage the data.

Results

Finally, five major themes and 22 sub-themes emerged from the two FGDs each with students and educators, and one FGD with mental health professionals are described.

“The first major thematic area was around the participant’s understanding of suicidality. While not being a formal assessment of the knowledge, we tried to gauge participants” general levels of understanding of the basic concept of suicide and the methods of suicide commonly used in India. We also explored the concept of risk factors and people’s understanding of some of the factors contributing to suicide, as well as the sources of knowledge participants had around suicide.

Understanding of Suicidality

Understanding of suicide: Students were able to provide reasonable definitions of suicide. They reported suicide means ending one’s own life due to personal reasons or some difficulties. The students reported that suicide results after trying to overcome, being tired of living, not able to look at solutions, etc.

Students: Students’ participants reported understanding of suicide terms like “Committing suicide is taking one’s own life for their personal reasons, some difficulties in their life and they finally choose to give up and take their life” FGDS1 P2. “Suicide is a process of people killing themselves if they are tired of their life or tired of living or when they can’t take something anymore” FGDS2 P2.

Factors for suicide: Students were able to give various reasons for suicide, like failure in the exam, inability to face people after failure, and expectations from others. Some mentioned that mental health concerns lead to suicide, like depression and hopelessness.

Students: Students’ participants thought of factors for suicide in India “For example, if a student has failed a subject or an entire exam or in a board exam, at that time the student will think how should I face my parents, then they attempt” FGDS1 P3. “It is mainly due to depression and for younger people, it is like expectations from others and if they are not able to meet those expectations, it leads to suicide” FGDS1 P6.

Methods of suicide: When it comes to methods of suicide, students identified hanging, slashing of the wrist, overdosing on pills, self-poisoning, burning themselves, drowning, jumping off from bridges/high places, jumping in front of vehicles (trains), shooting themselves, and drinking not edible (shampoo, toilet cleaners, and mosquito repellents).

Students: Students’ participant description of common methods of suicide in India like “The common methods of killing themselves are hanging, cutting their wrist, overdosing and drinking good night fluid also some people tried” FGDS2 P2. “The common methods will be slashing of the wrist, hanging very common, then overdosing on pills, drinking shampoo, Harpic and all kinds of stuff, drowning and jumping off the bridge” FGDS1 P2.

Source of knowledge: Three students reported that they attended webinars. One student gained knowledge from class in under graduation, and the others said learning through surfing the web after a known person ended his/her life by suicide. Students: Students’ participant description of the source of knowledge was

I came across the topic many times but it affected me when my classmate committed suicide because her boyfriend had fought with her. It affected me a lot, so I googled it to make sure that no one of my friends would suffer. So, I read a lot about it that’s how I learned about the topic. (FGDS2 P2)

“I have attended several webinars on suicide prevention and in classes also have some discussions when I am studying B.sc Psychology” FGDS2 P3.

Myths about suicide: Social work educators reported that “they were scared to enquire about suicidality to a person, whether they putting thought into their mind.”

Educators: Participant description of myths about suicide was “I am scared that if I ask, I am putting thought into their mind.”

Understanding Suicide Education in the MSW Curriculum

Lack in the syllabus: Social work educators reported that suicide education was lacking in the MSW curriculum. However, in some subjects like Indian Social Problems, suicide has been mentioned as a topic, not as a separate chapter.

Students: Students’ participants described “In MSW there is no particular module which includes suicide or suicide prevention” FGDS2 P3.

Educators: For example, social work educators stated “We don’t have any particular area or the syllabus talking about suicide ideation, epidemiology, etc.” FGDE1 P3 and “We find only one topic Suicide as a social problem. It is discussed in one particular paper” FGDE2 P2.

Suicide prevention activities: Social work educators and students report that there are some suicide prevention activities carried out in their respective institutes to commemorate suicide prevention day like campaigns, resource person talks, webinars, suicide prevention training, street play, series of lectures, the tableaus that were conducted in the institute.

Collaboration with agencies for suicide- related work: Participants also reported that they collaborate with other agencies on suicide prevention work, like NGOs working in suicide prevention will conduct training for the students, conducting programs related to suicide in collaboration with district mental health programs, mental health settings, etc.

Educators: Services within the campus: Counselling services are also offered for the students in the institute. One of the social work educator participants reported “The department is given the task of offering counselling to the students, unfortunately, many of the students did not turn up” FGDE2 P3.

Experience with Suicidality

Experiences with suicidality are common: Social work educators reported that they witnessed suicidality in their students within/outside the department. Students said that they witnessed suicidality in their family, neighborhood, friends, classmates, and hostel mates.

Lack of skills: Social work educators reported that they lack skills when they are unable to talk to family members or approach a person with distress.

Educators: Participants voice out like “That guilt feeling is there always, that because of our lack of skills we are were not approachable to that person even though we were together” FGDE1 P3 and “We are lacking a lot of skills to intervene with the family members and survivors of suicide” FGDE1 P3.

Unhelpful and fearful reactions to suicidality: Students reported that they were scared and reacted with a high level of distress when they encountered someone with suicidality, especially when the person tried to harm themselves in front of them and or tell them over the phone that they were going to kill themselves.

Students: one of the participants mentioned her experience

I used to scream at her and tell her what are you doing and why you are trying to scare me and all. I also felt very pressured, because if I was not going to be there with her, she was going to do something worse. So, I was getting very depressed because of her. (FGDS1 P2)

Training Content

Content on the knowledge component: Social work educators expect the training on suicide prevention should include basic knowledge components in the module, like myths and facts about suicide, warning signs, risk factors for suicide, and dos and don’ts when encountering persons with suicidality. Mental health professionals suggest more content like the Importance of help-seeking, how to identify suicidality in vulnerable populations/situations, and information on suicide prevention from a larger public health perspective.

Developing skills: The common expectation from the social work students, educators, and mental health professionals to develop skills was how to identify warning signs, how to initiate talks, basic counseling skills (rapport building, empathic listening, communication, ice-breaking), use of different questioning techniques to ask a person about suicidality, psychological first aid, assessment skills to elicit information about the plan and methods. Additionally, educators expressed liaisoning skills, and mental health experts suggested grading the severity of the suicidality, safety planning, and skills in picking up cues from the normal conversation to identify suicidality that emerged from the FGDs.

Intervention: Participants of FGDs expected the training to be focused on capacity building in terms of conducting universal prevention activities like awareness programs, campaigns, stigma reduction activities, and improving knowledge of the resources available for help. Also, improving their skill set to provide psychological first aid, restricting the lethal means, and telephonic counseling skills in indicative aspects. Participants from social work educators cum partitioners expressed the need for postvention training in the module.

Identifying resource: Social work educators and students expressed the need to develop resource mobilization skills specific to suicide prevention to refer for appropriate support when they encounter a situation in the future.

Self-care: Self-care of the trainees’ themes emerged in FGDs with students, educators, and mental health professionals. In self-care, two sub-themes emerged: The importance of self-care and ways to manage self-care. The researcher intended to understand how students handle stressful situations during MSW training. Students reported taking a break, journaling, doing leisure activities, talking to friends, watching videos, talking to professional and personal contacts, and taking professional help to overcome the challenges.

Students: Students’ description of ways to manage self-care

We should know like professionals, easier to overcome the challenges that occur and we should also understand there are also organizations and support groups that can help us to cope with the situation. I have been taking support from the therapist to just generally deal with life. FGDS2 P1.

Training methods: Under the sub-theme of training methods, the preferred method of training from the students and the feasibility of the methodology from the mental health professionals were identified through the FGDs.

Students: Students’ preferred training methodology was activity-based, like brainstorming discussions, use of case studies, role play, sharing the experience, and use of videos (short films, animated videos, etc.).

Mental health professionals: Mental health professionals recommended using case studies instead of role-play, rehearsal, and spacing out sessions for the training by social work educators and Mental health professionals.

Supervision: Social work educators and mental health professionals emphasized the need for handholding supervision for the trainee post-training.

Educators: “Handholding supervision of the trainee after the training program” FGDE2 P5.

Mental health professionals: “Supervision while working with a suicidal person, and emphasis on confidentiality is very important” FGDMHP P6.

Suggestions for Future Implications

Educators: In this theme, social work educators expressed the need for suicide prevention content to be incorporated into the MSW curriculum. For that, they suggested how to structure the course, how many hours can be feasible for incorporation in the syllabus, other ways to incorporate (certificate course, Add-on Course), the appropriate time to include in MSW Course structure, develop an advanced course for Medical and Psychiatric Social work specialization students and also expressed the need for training social work educator and other Professional course faculty and students (e.g., engineering).

Discussion

Social work student participants in two FGDs demonstrated a proficient understanding of suicidality, including its definition and various contributing factors. The factors identified by the participants, such as academic failure, the difficulty facing others after failure, and expectations from others, were found to be consistent with those reported in prior research ¹² which has shown that social workers possess the requisite skills to identify suicide risk factors. Furthermore, students in the study recognized a variety of methods for suicide, such as hanging, wrist slashing, pill overdose, self-poisoning, burning, drowning, jumping from high places, throwing oneself in front of vehicles (train), shooting, and ingesting non-food items (such as shampoo, toilet cleaners, and mosquito repellents). These findings are in alignment with data from the National Crime Records Bureau. ¹³ Participants in the present study reported obtaining knowledge about suicidality through diverse sources, including webinars, in-class instruction, and online resources. However, Social work educators and students felt that suicide prevention content was lacking in MSW programs, which is consistent with previous research, including studies by.^7,8,14 These studies show that a large proportion of participants (79%, 50%, and 78%, respectively) did not receive formal training in suicide prevention during their MSW programs. ¹⁵ The study advocated for the integration of suicide prevention education into the social work curriculum. The lack of training may be attributed to several factors, including the lack of expertise, crowded syllabi, and competing institutional priorities.^9,16

Social work educators and students reported some suicide prevention activities in their respective institutes, such as commemorating suicide prevention day through campaigns, resource person talks, webinars, suicide prevention training, street plays, series of lectures, and tableaus. Participants also reported collaborating with other agencies on suicide prevention work, such as NGOs working in suicide prevention conducting training for students, and conducting programs related to suicide in collaboration with district mental health programs and mental health settings. However, the information provided through these programs may vary, and the trustworthiness of the content is uncertain. ¹⁶ Students may require supervision when encountering individuals with suicidality.^9,17 The current study’s participants highlighted the lack of suicide education in the MSW curriculum. Structural barriers, such as crowded courses, pressure to cover contemporary issues, a shortage of faculty members with proficiency in suicide prevention, and stigma toward the topic of suicide by individuals and institutions, were identified as barriers to integrating suicide education into MSW programs. ⁹ The present study found that both students and educators have encountered individuals with suicidality. Educators reported encountering such individuals both within and outside of their departments, while students reported encountering suicidality in their family members, neighbors, friends, classmates, or hostel mates. Previous studies have also found that social workers often come across suicidal clients in their practice.^18,19 In the Indian context, a study found that 64% of social workers had encountered at least one client with suicidality. ⁷ Social work educators reported a lack of skills in approaching individuals in distress or communicating with their family members. This is partly due to the lack of formal training in suicide prevention and intervention, which contributes to higher levels of stress and anxiety among social workers. ¹⁵ To address this issue, social work educators’ knowledge and skills in suicide prevention should be enhanced through training programs for faculty members.^9,16

Social work educators and mental health professionals have suggested that suicide prevention training should cover various components such as myths and facts about suicide, warning signs, risk factors for suicide, dos, and don’ts when encountering individuals with suicidality, the importance of help-seeking, identifying suicidality in vulnerable populations/situations, and suicide prevention from a larger public health perspective.^9,17,19–21 In addition, there is an expectation from students, educators, and mental health professionals to develop skills such as identifying warning signs, initiating conversations, basic counseling skills, use of different questioning techniques, psychological first aid, assessment skills, grading the severity of the suicidality, safety planning, liaisoning skills, and skills in picking up cues from normal conversation to identify suicidality. Social workers can play a significant role in suicide prevention through broader health and well-being initiatives and education, implementing intervention strategies, and providing postvention support to those bereaved by suicide.^9,17,19–21

The study has revealed that the self-care of the trainees is an important theme that emerged from the FGDs with students, educators, and mental health professionals. Social workers are at a higher risk for compassion fatigue and burnout, which underscores the need to focus on the self-care needs of social workers. ¹⁹ The preferred training methodology by students was activity-based, including brainstorming discussions, use of case studies, role play, sharing experiences, and use of videos, while mental health professionals recommended using case studies instead of role-play, rehearsal, and spacing out sessions for the training by social work educators and mental health professionals. The current study’s training methodology was in line with the previous study participants’ expectations,^14,17,22 and spaced-out training was also recommended. ⁹ Social work educators and mental health professionals emphasized the need for handholding supervision for trainees post-training. The study reported that supervision improves the trainees’ self-efficacy, particularly when working with suicidal clients. ¹⁷ In summary, suicide prevention training for social workers should cover a range of knowledge components and skills, including self-care, activity-based training methods, and supervision for post-training support.

Social work educators have recommended incorporating suicide prevention into the current curriculum. Additionally, a study on suicide prevention among social workers suggests that a self-sustaining course could be disseminated to MSW schools across the country to address the public health issues related to suicide. ¹⁴ Despite a packed curriculum, suicide prevention should be prioritized due to its high prevalence rate and the crucial role of social workers in various sectors of practice. ⁹

Conclusion

This study’s findings are important in understanding the participant’s suicide knowledge and designing of a training module. Social work educators and students had a basic understanding of suicidality. Whereas, the stigma surrounding suicide was observed showcasing a need for detailed suicide education. Though there was a lack of suicide education in the MSW curriculum, the institutes were found to be constantly involved in carrying out various suicide prevention activities in collaboration with other agencies. The educators and students who encountered individuals with suicidality expressed a lack of skills hampering their engagement with them. It was identified that structured participatory activities involving multiple modalities of learning can boost and enhance the autonomy and self- esteem of the students further helping them carry out suicide prevention activities. Furthermore, this training can be implemented as Trainers of Trainers for social work educators to ensure the sustainability of suicide prevention training. Thus, ensuring that suicide prevention training becomes a major focus as part of the social work curriculum considering the alarming suicidality rates in India.

Strength of the Study

This study is also the first attempt to understand the need for suicide prevention training for social workers, highlighting the importance of this area in social work education. The researcher followed a systematic methodology to conduct the study, ensuring scientific rigor and increasing the reliability of the results. The study was conducted in the Indian context, providing important insights into suicide prevention training needs and effectiveness in this cultural context.

Implications of the Study

The implications of the study suggest that incorporating the suicide prevention training module into the MSW curriculum and building the capacity of social work educators to deliver this training would be beneficial. Furthermore, collaboration with professional bodies to conduct workshops and training for mental health professionals, health and para-health professionals, NGO staff, police, media professionals, and volunteers would strengthen the support system for suicide prevention in India. The findings of this study encourage future research in the same area in the Indian context, as it sheds light on the potential effectiveness of suicide prevention training in social work education.