_________ Rebecca G. Mirick, PhD, LICSW, Associate Professor, School of Social Work, Salem State University, Salem, MA. Copyright © 2022 Authors, Vol. 22 No. 3 (Fall 2022), 993-1005, DOI: 10.18060/25991 This work is licensed under a Creative Commons Attribution 4.0 International License. Are Social Work Students Being Adequately Prepared to Intervene With Suicide? Results of a National Survey of BSW and MSW Programs Rebecca G. Mirick Abstract: Suicide is a major public health issue in the United States, but it is unknown how many social work programs have courses specializing in this topic. The purpose of this study was to establish baseline knowledge of suicide-focused course offerings in social work programs in the United States. A survey of CSWE-accredited programs (n=151) in the United States was used to collect data on social work programs’ suicide content in their curricula at three levels: baccalaureate, graduate, and continuing education. While only 6% of programs offered a required course on suicide, 13.9% offered an elective focused on suicide, and courses with substantial suicide content were available in 25.2% of programs. Continuing education offerings with a focus on suicide were present at 26.5% of programs. The implications for social work education are discussed, including the need for more courses specializing in suicide, especially within MSW programs, and for future research to better understand the factors which limit the development of such courses. Keywords: Suicide; social work education; suicide prevention; MSW programs; BSW programs Historically, social work students have received limited education about suicide (Osteen et al., 2014; Ruth et al., 2012), creating a situation in which graduating social workers lack an understanding of suicide and do not have the skills to effectively conduct a suicide assessment or intervene with individuals with suicidal thoughts and behaviors (Feldman & Freedenthal, 2006; Sanders et al., 2008; Schmidt, 2016; Schmitz et al., 2012; Singer & Slovek, 2011). In the United States, the rate of suicide deaths has increased 30% since 2000, with 45,979 suicide deaths in 2020 (Garnett et al., 2022) and 1.4 million adult suicide attempts (CDC, 2020). Although the overall suicide rate decreased during the COVID pandemic, the suicide rate continued to increase for some vulnerable groups, such as youth of color and adolescent girls (Bray et al., 2021; Bridge et al., 2018; CDC, 2020;Yard et al., 2021). Suicide affects many individuals in the United States, with almost 6.5 million individuals bereaved by a suicide death each year (Cerel et al., 2018). Suicide education is an urgent issue facing many social workers. Being prepared to engage in suicide prevention, intervention, and postvention work is essential for all mental health professionals (Schmitz et al., 2012). Currently, there are 549 BSW and 311 MSW accredited programs in the United States (CSWE, 2021). These programs graduated 19,474 baccalaureate and 31,750 graduate students in 2020 who entered the workforce as practicing social workers (CSWE, 2021). Practicing social workers frequently encounter individuals with suicidal thoughts and behaviors, and often work with individuals who are at high risk of dying by suicide. Sanders et al. (2008) surveyed MSW-level social workers and found that 55% had had a client make a suicide attempt and 31% had lost a client to suicide. Practicing social workers must be prepared to work with individuals with suicidal thoughts and behaviors (Almeida about:blank about:blank ADVANCES IN SOCIAL WORK, Fall 2022, 22(3) 994 et al., 2017; Schmitz et al., 2012) and schools of social work must provide opportunities for this training. Little is known about the learning opportunities available in schools of social work at the baccalaureate, graduate, and continuing education level, including the availability of required courses on suicide, electives focused on suicide prevention and intervention, or courses with substantial suicide content (Sanders et al., 2008). Literature Review Historically, social work graduate programs have provided minimal instruction on suicide assessment and intervention to their students (Feldman & Freedenthal, 2006; Kourgiantakis et al., 2020; Osteen et al., 2014; Quest et al., 2019; Ruth et al., 2012). The two surveys that examined practicing social workers’ perceived exposure to suicide content in their social work programs are both older studies which focus on experiences of individuals in MSW programs (Feldman & Freedenthal, 2006; Sanders et al., 2008). Feldman and Freedenthal (2006) found that only 59.2% of MSW-level social workers had learned suicide-related content in class, and of this group, 46.3% spent two hours or less on suicide, with over two-thirds (67.4%) saying they were insufficiently prepared to work with clients with suicidal thoughts and behaviors. In a survey of practicing social workers, Sanders et al. (2008) found that less than 50% had been taught in their graduate program to work with clients with suicidal thoughts and behaviors. Minimal time is spent on teaching suicide assessment and intervention to graduate students, with many students reporting estimates of 2-4 hours on suicide content (Feldman & Freedenthal, 2006; Quest et al., 2019; Ruth et al., 2012). In a scoping review of social work education in mental health, substance use disorders, and suicide, Kourgiantakis and colleagues (2020) reported a need for more consistency in terms of suicide content and suicide risk assessment across undergraduate and graduate social work programs. There is some support for the integration of suicide content across the curriculum, with particular attention to its inclusion in practice courses (Ruth et al., 2012). However, this requires a sustained commitment and level of expertise required from faculty – both of which are sometimes unavailable in a social work program (Ruth et al., 2012). As with topics such as substance use and gerontology, many social work students want to advance their knowledge of suicide by enrolling in a semester-length course on the topic (Almeida et al., 2017; Quest et al., 2019; Scott, 2015). Quest et al. (2019) surveyed three cohorts of MSW students about their training on suicide content, finding that more than half believed that the two hours spent on suicide in their advanced practice course was inadequate preparation for practice and in fact, raised additional questions for them about working with individuals experiencing suicidality. Consistently, research on social work education has shown that students are enthusiastic and supportive of suicide-focused electives and identify a need for this content (Almeida et al., 2017; Quest et al., 2019; Scott, 2015), even sometimes supporting a required suicide-focused course (Almeida et al., 2017; Scott, 2015). Suicide content is not included in CSWE’s annual survey of schools of social work (CSWE, 2020), so there have been no national analyses of social work curricula or course offerings that support students’ achievement of suicide-related competencies. Therefore, it Mirick/ARE SWK STUDENTS 995 is unknown how many social work programs offer courses on suicide. A survey of BSW and MSW courses in accredited U.S. social work programs found health and health-related courses in 72% of BSW programs and 92.4% of MSW programs (Ruth et al., 2017). Of these courses, 71% focused on three areas: mental health/behavioral health, abuse and trauma, and substance use/addictions, with only 2% focused on suicide (Ruth et al., 2017). A survey of instructors teaching practice courses in accredited BSW and MSW programs found that of the 289 practice instructors, 2.4% reported their program had a required course on suicide, 10.0% said their program offered a suicide elective, and 14.5% said their program offered an elective on a topic related to suicide (e.g., crisis intervention; Mirick, 2022). Although this was a national sample, it is unknown how many distinct programs are represented. While there is no available data on the frequency and prevalence of suicide-focused courses in social work programs, the social work education literature provides some examples of elective courses on suicide. Most are graduate-level clinical practice courses (Almeida et al., 2017; Quest et al., 2019; Ruth et al., 2017), but there is one example of a macro MSW course (Scott, 2015) and one generalist BSW course (Mirick, 2019). Some practice electives also include macro content. For example, Almeida et al. (2017) describe a practice elective for MSW students that focuses primarily on clinical skills such as screening, assessment, and management of suicidal clients, but also includes postvention and a public health perspective. Nedegaard et al. (2019) developed a course titled Suicide Prevention and Intervention for second-year graduate students. This course included clinical topics such as assessment and evidence-based interventions, but also covered theory, traditionally marginalized and oppressed populations, and postvention. Continuing education courses on suicide are more common in social work education than undergraduate or graduate courses (Ruth et al., 2017). Several continuing education programs have been developed for social work students and/or practicing social workers (Kourgiantakis et al., 2020). These include Question, Persuade, Refer (QPR; Jacobson et al., 2012b; Sharpe et al., 2014), Suicide Assessment and Intervention Training (SAIT; Mirick et al., 2016), Counseling for Access to Lethal Means (CALM; Almeida et al., 2017), Recognizing and Responding to Suicide Risk (Jacobson et al., 2012a), and Assessing and Managing Suicide Risk (Scott, 2015). Some of these courses use clinical suicide competencies (Rudd et al., 2008), while others, such as QPR, are designed for gatekeepers, not mental health professionals. There is no data available on how frequently these trainings are used as one component of a practice course or offered in continuing education programs associated with schools of social work. The most common practice for teaching suicide content has been to integrate it into coursework and field instruction (Quest et al., 2019; Ruth et al., 2012). Ruth et al. (2012) surveyed social work faculty, finding that 83.8% agreed that field and classroom instructors should be responsible for student education on suicide. A survey of 225 BSW and MSW practice instructors found that 54.7% included suicide content in all their practice courses and 37.3% in some of their practice courses, with 87.0% teaching assessment and risk formulation, 52.7% intervention, and 50.2% safety planning (Mirick, 2020). LeCloux (2021) described the inclusion of suicide content in an advanced practice course via an asynchronous online module used across all courses, regardless of instructor. ADVANCES IN SOCIAL WORK, Fall 2022, 22(3) 996 When suicide content is integrated into a practice course instead of being offered as a full course, students wanting to engage more deeply with the content must enroll in a continuing education course or read independently if they would like to expand their knowledge on the topic. Other areas of learning, such as mental health, trauma, or substance use disorders, are more commonly offered as full courses (Ruth et al., 2017), and students who wish to learn more about the topic can register for a semester-long course. Suicide content within practice courses tends to focus on risk and protective factors, assessment, safety planning, and intervention, while topics such as management of emotional responses to suicide, culture, racism and oppression, legal issues, and means of safety are often omitted (Kourgiantakis et al., 2020; Mirick, 2020). Practice courses typically devote only a few hours to suicide content (Quest et al., 2019; Ruth et al., 2012), so instructors are limited in the depth and breadth of content covered. This paper describes a survey designed to provide foundational information on the current state of education about suicide within undergraduate and graduate social work programs. At this point in time, the field of social work education has no information on the number of programs offering a course that specializes in suicide, either at the macro or clinical level, or focusing on individual work with clients with suicidal thoughts and behaviors. This research project is a first step in filling that gap in the social work education literature. Methods Overview The Salem State University Institutional Review Board reviewed this project and determined it to be an exempt project. A list of CSWE-accredited social work programs (BSW & MSW) was created from data available on CSWE’s website of accredited programs including the contact person for each program, typically the program coordinator or chairperson. In April 2021, emails were sent to all accredited BSW (n=531) and MSW (n=296) programs with a link to a brief anonymous survey using Survey Monkey online survey software. A reminder was sent two weeks after the initial email. Measures To increase the rate of survey completion, the survey was purposely kept brief. Participants were asked five dichotomous (yes/no) questions to determine if their program had a required course on suicide, an elective on suicide, or an elective with substantial suicide content. Participants were asked to specify the topic of the elective. In addition, participants were asked if their program offered continuing education courses and if so, did they offer courses specific to suicide or with significant suicide prevention content. In an open-ended question, participants were asked to provide the title of the continuing education course. Finally, an open-ended question asked participants to share any additional relevant information about suicide prevention education in their program. Mirick/ARE SWK STUDENTS 997 Data Analysis Data were uploaded to IBM SPSS version 27 and analyzed using descriptive statistics. Open-ended responses were coded using thematic analysis (Braun & Clarke, 2006). Two members of the research team initially coded all the responses, creating initial codes. These responses were then compared, with a discussion around areas of disagreement, creating a final set of codes. The data was then recoded using this final set of codes. Then, similar codes were collapsed into larger themes to create the final themes. Findings Responses were returned from 88 BSW programs and 63 MSW programs. The overall response rate was 18.1%, with a 16.6% response rate for BSW programs and a 21.3% response rate for MSW programs. Courses About Suicide Few BSW or MSW programs offered a required course on suicide (5.7%, n=5 and 6.4%, n=4, respectively) or an elective on suicide (10.2%, n=9, 20.6%, n=13, respectively). However, 20 BSW programs (22.7%) and 18 MSW programs (28.6%) had an elective with substantial suicide content, although suicide was not the focus of the course. More than half of programs who responded to the survey (61.3%, n=92) offered no courses about suicide or electives with substantial suicide content, including 56.5% of BSW programs (n=35) and 64.8% of MSW programs (n=57). There was no significant difference between program level and required courses (χ2 (1)=0.038, p=0.845), suicide electives (χ2 (1)=3.353, p=0.067), suicide-related electives (χ2 (1)=0.764, p=0.382), or continuing education offerings about suicide (χ2 (2)=1.904, p=0.386). See Table 1. Table 1. Differences Between BSW, Suicide-Focused Courses and MSW Programs in the Availability of Courses About Suicide (n=151) n (%) χ2(df) p BSW (n=88) MSW (n=63) Required course Yes 5 (5.7%) 4 (6.4%) 0.038(1) 0.845 No 83 (94.3%) 58 (93.5%) Elective Yes 9 (10.2%) 13 (21%) 3.353(1) 0.067 No 79 (89.8%) 49 (79%) Related course Yes 20 (22.7%) 18 (28.6%) 0.764(1) 0.382 No 68 (77.3%) 44 (71%) Any course about or related to suicide Yes 31 (35.2%) 27 (43.5%) 1.062(1) 0.303 No 57 (64.8%) 35 (56.5%) Continuing Education Suicide Course Yes 13 (14.8%) 12 (19.4%) 1.904(2) 0.386 No 62 (70.5%) 37 (59.7%) Not Sure 13 (14.8%) 13 (21%) ADVANCES IN SOCIAL WORK, Fall 2022, 22(3) 998 Courses with substantial suicide content in BSW and MSW programs included courses on crisis intervention (12.5%, n=11 and 15.9%, n=10, respectively), trauma (1.1%, n=1 and 3.2%, n=2), and mental health/substance use (2.3%, n=2 and 9.5%, n=6, respectively). Eight programs identified additional courses that contained significant suicide content. See Table 2. Table 2. Suicide Focused or Suicide-Related Electives Suicide Focused or Related Electives n (%) BSW MSW Total Understanding Suicide/Suicide Prevention 2 (2.3%) 3 (4.8%) 5 (3.3%) Suicide Assessment and Intervention 1 (1.1%) 7 (11.1%) 8 (5.3%) Courses with Substantial Suicide Content Crisis Intervention 11 (12.5%) 8 (12.7%) 18 (11.9%) Mental Health & Substance Use Disorders 2 (2.3%) 6 (9.5%) 8 (5.3%) Trauma 1 (1.1%) 2 (3.2%) 3 (2%) Other Related Electives* 2 (2.3%) 6 (9.5%) 8 (4.6%) HBSE 1 (1.1%) 1 (1.6%) 2 (1.3%) *e.g., Older Adults, Grief & Loss, DBT, Military Social Work, End-of-life, Family Violence, Resilience, At-Risk Youth Continuing Education about Suicide Eighty-six programs offered continuing education programming – 46 (52.3%) BSW programs and 40 (64.5%) MSW programs. Twenty-five (16.7%) had programming related to suicide on topics such as suicide assessment and intervention (14.0%, n=12), awareness and understanding of suicide (9.3%, n=8), and crisis intervention (4.7%, n=4). See Table 3. Table 3. Continuing Education on Suicide Continuing Education Courses n (%) No continuing education program 65 (43%) Total offering continuing education 86 (57%) No, no suicide related courses 42 (48.8%) Don’t know if there is a suicide related course 4 (4.7%) Yes, suicide related course 40 (46.5%) Suicide Awareness & Understanding 8 (9.3%) Suicide Assessment & Intervention 12 (14%) Crisis Intervention 4 (4.7%) Related Course (borderline personality disorder) 1 (11.6%) No title given 15 (37.5%) Additional Information About Suicide Prevention Education In response to an open-ended question asking for additional relevant information related to suicide prevention education in the program, several respondents described non- credit options for suicide education and resources that made educational opportunities available to students. Nine (10.2%) BSW programs and 3 (4.8%) MSW programs described Mirick/ARE SWK STUDENTS 999 non-course related training and workshops that are available to their students. These included examples such as “intensive suicide workshop off-campus as part of their course work”, Safe Talk training, QPR training, Mental Health First Aid Certification, and biannual suicide workshops for students. These opportunities were often supported by individuals or programs outside of social work, such as the counseling center on campus, a continuing education program, Institutional Diversity, and the Title IX Center. Some of these trainings were embedded in practice and/or field courses. Some program directors perceived these learning opportunities as relevant information when considering their programs’ suicide prevention educational activities. Several program directors identified resources that support and facilitate suicide prevention education on their campuses. One described funding, saying, “This course is offered through a SAMHSA GLS [Garrett Lee Smith] Campus Suicide Prevention grant, and we hope to continue to offer this course after the duration of the grant.” Two program directors highlighted the role of faculty expertise. For example, one said, “Our school has two suicidologists on faculty… [ one of them] headed the mental health concentration for ten years and built suicide-related content into numerous classes and created a class on suicide assessment and intervention…. our school may be a bit of an outlier.” Some program directors indicated that their campus’ access to resources was important information for understanding suicide prevention education in their program. Discussion These findings provide a description of suicide education within a sample of social work programs in the United States, adding new information to the knowledge base about the prevalence of suicide and suicide-related courses in BSW and MSW programs. While required courses on suicide were uncommon among the responding schools, many programs offer an elective course on suicide or with substantial suicide content. The numbers of required courses and electives focused on suicide suggest an increase over time, at least for MSW programs. A previous survey of deans and directors found that only one (1.9% of the sample) reported their MSW program had a course on suicide (Ruth et al., 2012), compared to the current study’s 6.4%. The current findings suggest that education about working with clients with suicidal thoughts and behaviors is still more likely to be integrated into existing courses instead of being covered in a free-standing suicidology course, with more than half of program directors (56.4% MSW and 64.8% BSW) reporting no course about suicide or with significant suicide content (Ruth et al., 2012). Courses on suicide were more likely to have a clinical focus, teaching how to work individually with clients with suicidal thoughts and behaviors, than a more macro focus, such as prevention, policy, systemic issues, or social determinants of health, reflecting previous research on social work curricula across multiple mental health topics (Ruth et al., 2017). To note, in this study, even the suicide-related electives were primarily clinical in nature, with courses focusing on crisis intervention, trauma, and Dialectical Behavioral Therapy (DBT). Surprisingly, the MSW programs in this study were no more likely than BSW programs to offer courses on suicide, although the suicide education literature has often assumed that suicide is graduate-level content, with more education available on the topic in MSW ADVANCES IN SOCIAL WORK, Fall 2022, 22(3) 1000 programs (Almeida et al., 2017; Jahn et al., 2017; Quest et al., 2019; Ruth et al., 2012; Scott, 2015). The current findings suggest that, at least among the surveyed programs, required courses and suicide-specific electives are just as common in undergraduate social work programs as graduate programs. The reasons behind these findings are unknown. It may be that the programs that responded are different in some way than programs that did not respond. It does appear that clinical courses focused on suicide assessment and intervention may be more common in MSW programs (n=7) than BSW programs (n=1). Although there is only one example of a BSW-level course on suicide in the literature (Mirick, 2019), there are several examples of undergraduate courses on suicide in fields outside of social work (Cramer & Long 2018; Muehlenkamp & Thoen, 2019). Undergraduate courses covering suicidality are infrequently discussed in the literature but may be more common than is suggested by the literature. In this study, the number of programs offering suicide-specific continuing education was lower than expected based on previous research on the topic (Ruth et al., 2017). At the surveyed programs, university-affiliated continuing education on suicide does not seem to be an option for the majority of individuals working, studying, or graduating from social work programs, as only about a quarter (26.5%) of the programs surveyed in this study offered suicide-specific continuing education. Previous research has suggested that “the relationship of social work continuing education to social work higher education is varied and ambivalent, and it is difficult to discern whether schools of social work view continuing education as relevant to their mission” (Gianino et al., 2016, p. 344). CSWE began to include a need for “life-long learning” in their Educational Policy and Accreditation Standards (EPAS) in 2015 (CSWE, 2015). Gianino et al. (2016) have suggested this may lead to increased feelings of relevance and commitment to continuing education from schools of social work, yet our findings suggest this may not be the case, at least not for suicide education. Limitations There are several limitations to this research study that should be noted. The response rate of 18%, while typical and expected for an online survey suggests some limitations with external validity. This is particularly true for BSW programs, with a lower response rate of 16.6%, compared to MSW programs, which had a response rate of 21.3%. As a non- random sample, these findings cannot be generalized to all social work programs. In addition, there may have been a response bias. For example, programs with a strong commitment to suicide education may have been more likely to respond than those without this focus. As a quantitative survey that was intentionally designed to be brief to encourage the completion of the survey by program directors, there is a lack of depth and explanation in the responses. In response to the final question, some program directors provided additional detail that they saw as relevant to suicide education in their programs, such as information about available resources and training for their students. As specific questions about funding, resources, and workshops were not included in the survey, it is unknown how other programs in this sample would respond to these questions. However, these findings do suggest additional considerations to expand our understanding of suicide education and frame future research questions. Despite these limitations, this study adds to the existing knowledge base by providing information about the prevalence of courses on Mirick/ARE SWK STUDENTS 1001 suicide within a sample of social work programs, especially in undergraduate programs which have not been previously studied and suggests additional topics to explore in future research on this topic. Implications Consensus is lacking in social work programs about how best to infuse suicide content across the curriculum. These findings suggest that while many programs include some suicide content in courses (Mirick, 2020), most programs do not have opportunities for students to develop a more comprehensive understanding of the topic through a class focused only on suicide. Within social work education, there need to be more discussions and exploration of this issue to develop a better understanding of the implications for students to learn suicide prevention knowledge and skills through content integrated into their practice courses versus in a course devoted to the topic. Apparently, there is agreement in the field that these are essential skills for social work students to develop and for programs to support (Ruth et al., 2012; Schmitz et al., 2012) and that is a good start. Based on data from 151 social work programs, many social work students at the undergraduate and graduate levels lack access to opportunities to take a course dedicated to enhancing knowledge about suicide and expertise in working with individuals with suicidal thoughts and behaviors. Macro courses on suicide focused on systemic issues seem to be particularly scarce (Ruth et al., 2017), as most examples of courses focused on clinical practice. Macro education on mental health topics, including suicide, is beneficial to social work students, providing them with essential knowledge to intervene at systemic levels, such as addressing social determinants of health (Ruth et al., 2017; Scott, 2015). Schools of social work should consider the development of an elective in suicide if one does not already exist. This meets an identified need in the field (Feldman & Freedenthal, 2006; Schmitz et al., 2012) and is often supported and desired by faculty (Ruth et al., 2012) and students alike (Almeida et al., 2017; Quest et al., 2019; Scott, 2015). Conclusion To support more social work programs’ development of a suicidology course or courses that integrate substantial suicide content into a mental health course, it is necessary to understand the factors that prevent or facilitate the development of such a course. For example, the role of faculty expertise, while assumed to support the development of a suicide-focused course (Ruth et al., 2012) is not well understood. Future research should explore this topic, as there is a lack of knowledge of how prepared faculty are to teach this content or the prevalence of faculty with a specialization in suicidology. Previous research has identified other concerns, including the impact of the content on students (Kodaka et al., 2018) and the issue of a course on suicide conflicting with the values of the university, such as at a faith-based institution (Jahn et al., 2017). Funding may also help support the creation of a course, as in the example provided by Almeida et al. (2017). It is important to better understand these issues to continue to develop more opportunities for social work students to develop expertise in working with individuals with suicidal thoughts and behaviors. ADVANCES IN SOCIAL WORK, Fall 2022, 22(3) 1002 Currently, as suicide education is not required content, social work students’ opportunities to develop skills through an independent course on suicide depends on the university at which they are enrolled. Many social work programs, both BSW and MSW, do not offer a course on suicide or one with substantial suicide content. Therefore, schools of social work must evaluate their curriculum to ensure that suicide content is well- integrated across the curriculum, from assessment and intervention skills in practice courses to suicide prevention policy in policy courses and theories of suicide in human behavior courses. Suicide prevention, intervention, and postvention cannot be optional topics but must be taught to all social work students. References Almeida, J., O’Brien, K. H., Gironda, C. M., & Gross, E. B. (2017). Development, implementation, and evaluation of a comprehensive course on suicide in a Master of Social Work program. 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Children & Schools, 33(4), 215-228. https://doi.org/10.1093/cs/33.4.215 Yard, E., Radhakrishnan, L., Ballesteros, M.F., Sheppard, M., Gates, A., Stein, Z., Hartnett, K., Kite-Powell, A., Rodgers, L., Adjemian, J., Ehlman, D.C., Holland, K., Idaikkadar, N., Ivey-Stephenson, A., Martinez, P., Law, R., & Stone, D. (2021). Emergency department visits for suspected suicide attempts among persons aged 12- 25 years before and during the COVID-19 pandemic-United States, January 2019- May 2021. Morbidity and Mortality Weekly Report, 70(24), 888-894. https://doi.org/10.15585/mmwr.mm7024e1 Author note: Address correspondence to Rebecca G. Mirick, School of Social Work, Salem State University, Salem, MA, 01970. Email: rmirick@salemstate.edu https://doi.org/10.1111/j.1943-278X.2012.00090.x https://doi.org/10.1111/j.1943-278X.2012.00090.x https://doi.org/10.1080/10437797.2015.979095 https://doi.org/10.1080/15332985.2013.848831 https://doi.org/10.1093/cs/33.4.215 https://doi.org/10.15585/mmwr.mm7024e1 mailto:rmirick@salemstate.edu