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

1
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 CenterChair, TIP
50 Panel

• PENNSYLVANIA THIRD ANNUAL SUICIDE PREVENTION
  CONFERENCE
• STATE COLLEGE, PENNSYLVANIA
• SEPTEMBER 16, 2009

2
TIP 50 is provided by the Substance Abuse and
Mental Health Services Administration (SAMHSA),
Center for Substance Abuse Treatment
(CSAT)Recommended citation for TIP 50Center
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.
3
TIP 50 Panel

• Panel Chair, Kenneth R. Conner, Psy.D., MPH
• Part 1 Consensus Panel Members
• Bruce Carruth, Ph.D.
• Sean Joe, Ph.D., M.S.W.
• M. David Rudd, Ph.D., ABPP
• Barbara M. Teal, M.A., M.B.A., ICADC, CET II
• James D. Wines, Jr., M.D., M.P.H.
• Part 2 Consensus Panel Members
• Bruce Carruth, Ph.D.
• Lisa Laitman, M.S.Ed., LCADC
• Edna Meziere, M.S., M.L.S., R.N.

4
TIP Layout

• Part One Skills and Knowledge for Substance
  Abuse Counselors and Supervisors
• Part Two Administrators guide
• Part Three Web based bibliography

5
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.

6
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 Action
• E Extend the Action

7
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).

8
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

9
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

10
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

11
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)

12
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.

13
Risk Factors Continued

• History of child abuse (especially sexual abuse)
• Stressful life circumstances
• Interpersonal disruption (divorce/separation/b
  reak-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

14
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.

15
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

16
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.

17
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.

18
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, dont become the
  suicide police.)
• Additional Point Realize limits of
  confidentiality, and be open with your clients
  about such limits.

19
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

20
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.

21
A - Access Supervision or Consultation

• Accessing supervision/consultation can provide
  invaluable input to
• -promote the clients safety
• -give needed support
• -reduce personal liability
• Immediate supervision Acute/emergent situations
  require obtaining immediate supervision/consultati
  on.
• Regular supervision Non-acute situations call
  for the use of routine supervision or bringing
  the case to the regular treatment team.

22
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)

23
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

24
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

25
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 counselors 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).

26
E - Extend the Action

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

27
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

28
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 clients
  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

29
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
  clients condition and your responses, including
  referrals made and the outcomes of the referrals

30
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?

31
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 SAMHSAs Health Information
  Network at 1-877-SAMHSA-7 (1-877-726-4727)
  (English and Español).

32

• Questions / Further Discussion