Addressing Suicidal Thoughts and Behaviors with Clients in Treatment for

Substance Use Disorders (TIP 50)

Kenneth R. Conner, Psy.D., MPH University of Rochester Medical Center

Chair, TIP 50 Panel

PENNSYLVANIA THIRD ANNUAL SUICIDE PREVENTION CONFERENCESTATE COLLEGE, PENNSYLVANIA

SEPTEMBER 16, 2009

TIP 50 is provided by the Substance Abuse and Mental Health Services Administration (SAMHSA),

Center for Substance Abuse Treatment (CSAT)

Recommended citation for TIP 50:

Center for Substance Abuse Treatment.Addressing Suicidal Thoughts and Behaviors in Substance

Abuse Treatment. Treatment Improvement Protocol (TIP) Series 50.

DHHS Publication No. (SMA) 09-4381.Rockville, MD: Substance Abuse and Mental Health

Services Administration, 2009.

TIP 50 Panel

Panel Chair, Kenneth R. Conner, Psy.D., MPH

Part 1 Consensus Panel MembersBruce Carruth, Ph.D.Sean Joe, Ph.D., M.S.W.M. David Rudd, Ph.D., ABPPBarbara M. Teal, M.A., M.B.A., ICADC, CET IIJames D. Wines, Jr., M.D., M.P.H.

Part 2 Consensus Panel MembersBruce Carruth, Ph.D.Lisa Laitman, M.S.Ed., LCADCEdna Meziere, M.S., M.L.S., R.N.

TIP Layout

• Part One: Skills and Knowledge for Substance Abuse Counselors and Supervisors

• Part Two: Administrators’ guide

• Part Three: Web based bibliography

Goals of TIP 50

Increase motivation, self-efficacy, and ability of counselors and their supervisors to effectively manage suicide risk in substance abuse treatment settings.

Increase motivation, self-efficacy, and ability of administrators to implement effective suicide prevention programming.

TIP Content – Part OneCounselors’ Guide

Review risk factors, warning signs, protective factors

Points to Keep You on Track

Teach Core Strategy (GATE)G = Gather Information A = Access Supervision T = Take Appropriate ActionE = Extend the Action

Part One Continued, Vignettes

Vignette 1, Clayton, illustrates how to safely obtain and secure a firearm from a high-risk client by enlisting the help of a family member.

Vignette 2, Angela, shows how to work collaboratively with family in discharge planning of a high-risk client from an inpatient unit.

Vignette 3, Leon, depicts how to safely link a high-risk client with an outpatient mental health program that is better able to meet his needs.

Vignette 4, Rob, shows a therapeutic response to a client who provocatively and inaccurately alludes to suicide in group, causing distress in the group and distracting from his true concerns.

Vignette 5, Vince, illustrates a rapid referral to the emergency department for a client at acute risk for homicide-suicide.

Vignette 6, Rena, depicts a crisis response for a client who calls her counselor when drinking and acutely suicidal, and introduces two advanced techniques (detailed safety plan, hope box).

Vignettes continued

Detailed dialogue and case description

“How-To” Boxes provide step-by-step specific techniques and procedures

Master Clinician Notes provide supervisory observations and comments inviting the

counselor to consider choices and options

Part Two: Chapter Twoadministrators guide

Clear strategies and tools for implementation of evidence-based and best and promising practices illustrated in Chapter One

Different levels of capability depending on program size, staffing, and resources

Part Three The literature review and bibliography

A review of the literature on the relationship of substance abuse and suicide and clinical interventions for suicidal people with substance use disorders

An annotated bibliography of approximately 100 of the most pertinent articles in the literature

A comprehensive bibliography of the literature on the subject.

Updated every 6 months for 5 years.

Web-based

Definitions

Suicidal ideation, also referred to as “suicidal thoughts,” is the idea to carry out an act of suicide.

Suicide attempt is a deliberate, self-injurious behavior with at least some intent to die that is non-fatal.

Suicide is a deliberate, self-injurious behavior with at least some intent to die that is fatal.

Non-suicidal self-injury is a deliberate, self-injurious behavior with no intent to die (not a focus of the current presentation)

Risk Factors

• Prior history of suicide attempts (most potent risk factor)

• Family history of suicide

• Severe substance use (e.g., dependence on multiple substances, early onset of dependence)

• Co-occurring mental disorder– Especially Major Depressive Episodes (including substance-induced

depression)

• Personality traits– Proneness to negative affect (sadness, anxiety, anger)– Aggression and/or impulsive traits

• Personality disorder – best evidence for borderline p.d.

Risk Factors Continued

• History of child abuse (especially sexual abuse)

• Stressful life circumstances

– Interpersonal disruption (divorce/separation/break-up)

– Interpersonal isolation (living alone, low social support)

– Unemployment and low level of education, job

– Legal difficulties

– Major and sudden financial losses

• Firearm ownership or access to a firearm

Warning Signs (Direct)

Suicidal communication: Someone threatening to hurt or kill him- or herself or talking of wanting to hurt or kill him- or herself.

Seeking access to method: Someone looking for ways to kill him- or herself by seeking access to firearms, available pills, or other means.

Making preparations: Someone talking or writing about death, dying, or suicide, when these actions are out of the ordinary for the person.

Warning Signs (Indirect)

I = Ideation

S = Substance Abuse

P = Purposelessness

A = Anxiety

T = Trapped

H = Hopelessness

W = Withdrawal

A = Anger

R = Recklessness

M = Mood Changes

Protective Factors

The following are known and likely protective factors:• Reasons for living• Being clean and sober• Attendance at 12-Step support groups• Religious attendance and/or internalized spiritual teachings against suicide• Presence of a child in the home and/or childrearing responsibilities• Intact marriage• Trusting relationship with a counselor, physician, or other service provider• Employment• Trait optimism (a tendency to look at the positive side of life)

A caution about protective factors: If acute suicide warning signs and/or multiple risk factors are in evidence, the presence of protective factors does not change the bottom-line assessment that preventive actions are necessary, and should not give you a false sense of security.

Points to Keep You on Track

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

Point 2: Suicidal crises can be overcome.

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

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

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

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

Points to Keep You on Track Cont.

Point 7: Suicide attempts always must be taken seriously.

Point 8: Suicidal individuals generally show warning signs.

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

Point 10: The outcome does not tell the whole story.

Additional Point: Be collaborative, warm, and concerned, as you would in any therapeutic situation (in other words, don’t become the “suicide police.”)

Additional Point: Realize limits of confidentiality, and be open with your clients about such limits.

GATE

4-step process for managing suicide risk in substance abuse treatment settings

G = Gather Information

A = Access Supervision or Consultation

T = Take Appropriate Action

E = Extend the Action

G – Gather Information

There are 2 steps: screening, follow-up questions

1) Screening consists of asking very brief uniform questions at intake to determine if further questions about suicide risk are necessary. Spotting warning signs consists of identifying telltale signs of potential risk.

2) Follow-up questions are asked to have as much information as possible to bring to a supervisor, consultant, or multidisciplinary team in order to formulate a sound plan of action.

A - Access Supervision or Consultation

Accessing supervision/consultation can provide invaluable input to: -promote the client’s safety-give needed support-reduce personal liability

Immediate supervision: Acute/emergent situations require obtaining immediate supervision/consultation.

Regular supervision: Non-acute situations call for the use of routine supervision or bringing the case to the regular treatment team.

T - Take Appropriate Action

Key principle is that actions should match the severity and immediacy of risk (in other words, the level of response should make good sense in terms of the need)

Potential Actions

• Gather additional information from the client to assist in a more accurate clinical picture and treatment plan

• Gather additional information from other sources (e.g., spouse, other providers)

• Arrange a referral: – To a clinician for further assessment of suicide risk– To a provider for mental health counseling– To a provider for medication management– To an emergency provider (e.g., hospital emergency department) for

acute risk assessment– To a mental health mobile crisis team that can provide outreach to a

physically inaccessible client at his or her home (or shelter) and make a timely assessment

– To a more intensive substance abuse treatment setting

Potential Actions Continued

• Restrict access to means of suicide (means matter)

• Temporarily increase the frequency of care, including more frequent telephone check-ins

• Involve a case manager (e.g., to coordinate care, to check on the client occasionally)

• Involve the primary care provider

• Encourage the client to attend (or increase attendance) at 12-Step meetings such as Alcoholics Anonymous, Al-Anon, Narcotics Anonymous, or Cocaine Anonymous.

• Enlist family members or significant others (selectively, depending on their health, closeness to the client, and motivation) in observing indications of a return of suicide risk

• Observe the client for signs of a return of risk

Potential Actions Continued- SAFETY CARD

With all clients with suicidal risk, consider developing with the client a written safety card that includes at a minimum:

• A 24-hour crisis number (e.g., 1-800-TALK)

• The phone number and address of the nearest hospital emergency department

• The counselor’s contact information

• Contact information for additional supportive individuals that the client may turn to when needed (e.g., sponsor, supportive family member)

• To maximize the likelihood that the client will make use of the card, it should be personalized and created with the client (not merely handed to him or her).

E - Extend the Action

Key principle is that suicide prevention efforts are not one-time actions.

Potential Extended Actions

• Confirm that a client has kept the referral appointment with a mental health provider (or other professional)

• Follow up with the hospital emergency department when a client has been referred for acute assessment

• Coordinate with a mental health provider (or other professional) on an ongoing basis

• Coordinate with a case manager on an ongoing basis

Extended Actions Continued

• Check in with the client about any recurrence of or change in suicidal thoughts or attempts

• Check in with family members (with the client’s knowledge) about any recurrence of or change in suicidal thoughts or attempts

• Reach out to family members to keep them engaged in the treatment process after a suicide crisis passes

• Observe the client for signs of a return of risk

• Confirm that the client still has a safety plan in the event of a return of suicidality

Extended Actions Continued

• Confirm that the client and, where appropriate, the family, still have an emergency phone number to call in the event of a return of suicidality

• Confirm that the client still does not have access to a major method of suicide (e.g., gun, stash of pills)

• Follow up with the client about suicidal thoughts or behaviors if a relapse (or other stressful life event) occurs

• Monitor and update the treatment plan as it concerns suicide

• Document all relevant information about the client’s condition and your responses, including referrals made and the outcomes of the referrals

Select Case Examples (from TIP 50)

For each patient scenario, answer the following questions:

G: Gather information:1) What additional questions would you ask the client?

A: Access supervision/consultation:2) Would you access immediate supervision or regular?

T: Take action: 3) What specific actions would you take in this situation?

E: Extend the action:4) What extended actions would you take after addressing

the immediate situation?

Obtaining TIP 50

TIP 50 is free.

Today you were presented a Powerpoint summary of TIP 50, not the actual TIP 50 manual which is much more detailed and comprehensive.

Instructions to order TIP 50:

Downloading: This publication may be downloaded or ordered at http://www.samhsa.gov/shin

At the website, click on “substance abuse publications” (right side near top)

In the search box type TIP 50

Ordering by phone: Print versions or a PDF version may also be ordered by calling SAMHSA’s Health Information Network at 1-877-SAMHSA-7 (1-877-726-4727) (English and Español).

Questions / Further Discussion