Transcript Addressing Suicidal Thoughts and Behaviors in Clients In

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 CONFERENCE
STATE 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 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.
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 One
Counselors’ 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
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 Two
administrators guide
Clear strategies and tools for implementation of evidencebased 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 ContinuedSAFETY 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