Addressing Suicidal Thoughts and Behaviours in Substance Abuse Treatment

ACCSA Module 20: Addressing Suicidal Thoughts and Behaviors in Substance Abuse Treatment

Addiction Counselor Certifications South Africa Pty (Ltd) - Compiled from SAHMSA TIP.

Contents & Manual Organization

• This resources is divided into three main parts:

  • Part 1: Addressing Suicidal Thoughts and Behaviours in Substance Abuse Treatment (for substance abuse counselors).

  • Part 2: An Implementation Guide for Administrators (for program administrators).

  • Part 3: A Review of the Literature (for clinical supervisors, counselors, and administrators).

• Part 1 - Chapter 1: Information You Need to Know

  • Basic suggestions for addressing suicidal thoughts and behaviors.

  • Background information about suicide and substance use disorders, including risk factors and warning signs.

  • GATE: A four-step process (Gather information, Access supervision, Take responsible action, and Extend the action).

  • A set of competencies for counselors.

• Part 1 - Chapter 2: Clinical Vignettes Demonstrating How to Apply the Information

  • Representative vignettes of counseling sessions with clients.

  • Master clinician notes and comments to understand the client and their issues.

  • Descriptions of specific counseling techniques.

• It is recommended to read chapter 1 before chapter 2.

• Part 2: Implementation Guide for Program Administrators

  • Rationale for the approach in chapter 2 and how administrators can support programs and counselors.

  • Detailed information on high-quality implementation of recommendations from Part 1.

    • Benefits of addressing suicidality.

    • Roles of administrators and mid-level staff.

    • Levels of program involvement.

    • Legal and ethical issues.

• Part 3: Literature Review

  • Analysis of available literature.

  • Annotated bibliography of central literature.

  • Bibliography of other available literature.

  • Available for clinical supervisors, counselors, and administrators.

Chapter 1: Information You Need to Know - Overview

• Illustrates and reinforces the material presented in chapter 1; six realistic scenarios involving suicidal behaviors are provided.

• Highlights the GATE process and responsible actions modeled by a counselor and supervisor.

• Master Clinician Notes are provided to explain the thinking behind these actions.

• How-To Notes provide instructions for specific methods and interventions.

• Introduction

• Getting Ready to Address Suicidality: Basic principles about your role in working with clients who are suicidal

• Background Information: Substance abuse and suicidality

• GATE: A four-step process (Gather information, Access supervision, Take responsible action, Extend the action)

• Competencies for working with clients with suicidal thoughts and behaviors.

Introduction - Key Facts

• Suicide is a leading cause of death among people who abuse alcohol and drugs (Wilcox, Conner, & Caine, 2004).

• Individuals treated for alcohol abuse or dependence are at about 10 times greater risk to eventually die by suicide compared with the general population, and people who inject drugs are at about 14 times greater risk for eventual suicide (Wilcox et al., 2004).

• Individuals with substance use disorders are also at elevated risk for suicidal ideation and suicide attempts (Kessler, Borges, & Walters, 1999).

• People with substance use disorders who are in treatment are at especially high risk of suicidal behaviour, including:

  • Out of control substance abuse.

  • Co-occurring life crises (marital, legal, job).

  • Peaks in depressive symptoms.

  • Co-occurring mental health problems (depression, PTSD, anxiety disorders, personality disorders).

  • Crises during treatment (relapse, treatment transitions).

Why a Manual on Suicide for Substance Abuse Counsellors and Supervisors?

• Research shows high rates of suicidal thoughts and attempts among persons with substance abuse problems in treatment (Ilgen, Harris, Moos, & Tiet, 2007).

• Significant prevalence of death-by-suicide among those who have been in substance abuse treatment compared to those without a substance use disorder (Wilcox et al., 2004).

• Substance abuse treatment providers must be prepared to gather information, refer, and participate in the treatment of clients at risk for suicidal behavior.

• Suicidal thoughts and behaviors are significant indicators of co-occurring disorders (major depression, bipolar disorder, PTSD, schizophrenia, personality disorders).

Training and Experience

• Clinical training in substance abuse counseling puts counselors in a good position to perform tasks involving suicide.

  • Gathering the same kind of information you do every day.

  • Gathering information about craving.

    • e.g., "Tell me about your craving. How often do you have it? How strong is it? What makes it worse?"

  • Gathering information about suicidal thoughts.

    • e.g., "Tell me about your suicidal thoughts. How often do you have them? How strong are they? What makes them worse?"

Key Recommendations

• Clients in substance abuse treatment should be screened for suicidal thoughts and behaviors routinely at intake and at specific points in the course of treatment.

• Counselors should be prepared to develop and implement a treatment plan to address suicidality and coordinate the plan with other providers.

• If a referral is made, counselors should ensure appointments are kept and continue to monitor clients after crises have passed, through coordination with mental health providers, family, and community resources.

• Counselors should acquire basic knowledge about warning signs, risk factors, and protective factors.

• Counselors should be empathic and non-judgmental.

• Substance abuse counselors should understand ethical and legal principles and potential areas of conflict.

Getting Ready to Address Suicidality

• Be comfortable and competent when asking clients questions about suicidal ideation and behavior.

  • Balance comfort level with the need to obtain accurate information.

• Be Direct

  • Overcome discomfort in talking about suicide, which may lead to asking conversation-ending questions or avoiding the topic.

  • Instead, ask directly: “Are you thinking about killing yourself?”

  • There is no empirical evidence suggesting that talking about suicide will make someone suicidal.
    *Increase Your Knowledge about Suicidality

  • Learn about circumstances, manifestations, warning signs, questions to ask, and effective interventions.

• Do What You Already Do Well

  • Be empathic, warm, and supportive.

  • Do not employ counter-therapeutic practices (aggressively questioning, demanding assurance, being autocratic, avoiding sensitive topics).

• Practice, Practice, Practice

  • Practice with another counselor or supervisor to reduce discomfort.

  • Get feedback about your approach.

  • Ask every client about suicidality.

  • Attend workshops or get additional training.

• Get Good Clinical Supervision and Consultation

  • Integrate skill development about suicidality into your Individual Development Plan for clinical supervision.

  • Get feedback about your attitudes and skills.

  • Work with a treatment team.

• Work Collaboratively With Suicidal Clients

  • Involve clients in suicide prevention planning, as you would with recovery planning.

  • Explain your concerns and actions, and elicit their input.

  • Informed consent should be part of collaboration, including steps to reduce suicide risk, referral steps, and confidentiality issues.

  • Even when taking action over a client's objections, seek input and make efforts to work collaboratively.

• Realize Limitations of Confidentiality and Be Open with Your Clients about Such Limits

  • Understand ethical and legal principles, and potential conflicts; safety trumps confidentiality in crisis situations.

  • Explain potential steps to promote safety, including breaking confidentiality and involuntary emergency evaluation.

Ten Points to Keep You on Track

1. Almost all of your clients who are suicidal are ambivalent about living or not living.

   • Wishing both to die and to live is typical, even in serious cases.

   • Reinforce realistic hope and support the side of the client that wants to live.

2. Suicidal crises can be overcome.

   • Acute suicidality is a transient state; most individuals spend more time non-suicidal than suicidal.

   • Help clients survive the acute crisis until they want to live again.

   • Treatments like CBT and DBT have shown positive results.

   • Address major risk factors like substance use, depression, and marital strife.

3. Although suicide cannot be predicted with certainty, suicide risk assessment is a valuable clinical tool.

   • Assessment helps ensure that those requiring more services get the help they need.

4. Suicide prevention actions should extend beyond the immediate crisis.

   • Address long-term risk factors (depression, child sexual abuse history, marital problems, repeated relapse).

   • Monitor individuals with a history of suicidal thoughts or attempts.

5. Suicide contracts are not recommended and are never sufficient.

   • They are not effective in ensuring safety or protecting from litigation.

6. Some clients will be at risk of suicide, even after getting clean and sober.

   • Clients with independent depression, unresolved difficulties, personality disturbance, trauma histories, or major psychiatric illness may continue to show risk.

7. Suicide attempts always must be taken seriously.

   • A prior suicide attempt is a potent risk factor for eventually dying by suicide.

   • Any suicide attempt must be taken seriously, including those with little risk of death.

8. Suicidal individuals generally show warning signs.

   • Warning signs come in many forms (expressions of hopelessness, suicidal communication) and are often repeated.

9. It is best to ask clients about suicide and ask directly.

   • Asking about suicide will not put the idea in someone's mind.

10. The outcome does not tell the whole story.

    • Survival does not equate to proper treatment, and death does not equate to improper treatment.

Maintain Positive Attitudes

• Attitudes toward suicide vary widely, influenced by culture, childhood experiences, and personal/professional experiences.

• Before working with suicidal clients, counsellors should conduct their own suicidal attitude inventory.

  • What is my personal and family history with suicidal thoughts and behaviors?

  • What personal experiences do I have with suicide or suicide attempts, and how do they affect my work with suicidal clients?

  • What is my emotional reaction to clients who are suicidal?

  • How do I feel when talking to clients about their suicidal thoughts and behaviors?

  • What did I learn about suicide in my formative years?

  • How does what I learned then affect how I relate today to people who are suicidal, and how do I feel about clients who are suicidal?

  • What beliefs and attitudes do I hold today that might limit me in working with people who are suicidal?

• Empathic attitude can assist counselors in engaging and understanding people in a suicidal crisis.

Positive Attitudes and Behaviors

1. People in substance abuse treatment settings often need additional services to ensure their safety.

   • A good working relationship is a powerful protective factor.

   • Individuals who are acutely suicidal may need more services (mental health evaluation, short-term hospitalization).

2. All clients should be screened for suicidal thoughts and behaviors as a matter of routine.

   • Screen for suicide and ask follow-up questions.

   • Follow up with a client when risk has been previously documented.

   • Take appropriate action when risk is detected.

   • Document suicide-related screening and interventions.

   • Communicate suicide risk to another professional or agency.

3. All expressions of suicidality indicate significant distress and heightened vulnerability that require further questioning and action.

   • Take reports of suicidal thoughts or plans seriously, even if a client appears manipulative.

4. Warning signs for suicide can be indirect; you need to develop a heightened sensitivity to these cues.

   • Warning signs include expressions of hopelessness, feeling trapped, or having no purpose in life, withdrawal from others, mood changes, or reckless behavior.

   • Be aware of clients’ histories of suicidal thoughts and behaviors and watch for indications of recurrence.

5. Talking about a client's past suicidal behavior can provide information about triggers for suicidal behavior.

   • The circumstances of past suicidal ideation and attempts can provide insights into the scenario(s) that may promote future risk.

6. You should give clients who are at risk of suicide the telephone number of a suicide hotline; it does no harm and could actually save a life.

Summary - Positive Attitudes

• Positive, empathic attitudes form the platform for proactive and effective services.

• Negative attitudes can impede quality care.

• Recognize that clients with suicidal thoughts and behaviors can benefit from intervention and treatment, that expressions of suicidality show unmet needs, and that there is a relationship between suicidality and substance abuse.

The Link Between Substance Abuse and Suicidality

• Suicide is a leading cause of death among people who abuse alcohol and drugs (Wilcox et al., 2004).

• Individuals treated for alcohol abuse/dependence are at about 10 times greater risk for suicide; people who inject drugs are at about 14 times greater risk (Wilcox et al., 2004).

• Individuals with substance use disorders are at increased risk for suicidal ideation and suicide attempts (Kessler et al., 1999).

• Depression is a common co-occurring diagnosis (Conner et al., 2007; Murphy, Wetzel, Robins, & McEvoy, 1992; Roy, 2001, 2002).

• People with substance use disorders often seek treatment when their substance use is at its peak, accompanied by suicidal thoughts and behaviours.

• Alcohol's disinhibition, intense focus, and depressed mood increases suicide risk (Hufford, 2001).

• Acute alcohol intoxication is present in about 30–40 percent of suicide attempts and suicides (Cherpitel, Borges, & Wilcox, 2004).

• Intense, short-lived depression is prevalent among treatment-seeking people who abuse cocaine, methamphetamines, and alcohol (Brown et al., 1995; Cornelius, Salloum, Day, Thase, & Mann, 1996; Husband et al., 1996).

• Overdose suicides often involve multiple drugs like alcohol, benzodiazepines, opioids, and other psychiatric medications (Darke & Ross, 2002). *Transition Points and Increased Risk

  • Care transitions increase suicide risk.

    • Changes in inpatient to outpatient, intensive treatment to continuing care, or discharge.

    • Administrative terminations increases suicide risk.

      • Especially for poor attendance or chronic substance use. It is unethical to discharge a client or refuse care to someone who is suicidal without making appropriate alternative arrangements.

  • Relapse creates suicide risk.

    • Clients imply the worst might happen if they relapse.
      For example: "I can't go through this again," "If I relapse, that's it.