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Addressing Suicidal Thoughts And Behaviors in Substance Abuse Treatment [Internet]. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 2009. (Treatment Improvement Protocol (TIP) Series, No. 50.)
In this chapter you will meet six people with substance use disorders who are experiencing suicidal thoughts and behaviors to varying degrees. Through their dialog with counselors, supervisors, and family members, you will see how suicidal thoughts and behaviors may manifest. You will also see that these thoughts and behaviors are typically accompanied by co-occurring mental disorders, such as depression, psychological trauma, and other anxiety disorders.
The elements of GATE (Gather Information, Access supervision, Take responsible action, Extend the action—see chapter 1) are portrayed in different settings and situations. You will read about counselors working with clients who are resistant to treatment for their suicidal thoughts and behaviors, about the effects of suicidal thoughts and behaviors on family members and others, and about managing suicidal crises. While the vignettes demonstrate treatment methods and techniques that are within the scope of practice and range of substance abuse counselors, vignettes 5 and 6 also include several advanced techniques that are more appropriate for use by experienced counselors. The consensus panel has made a significant effort to present realistic encounters with clients using counseling approaches that include motivational interviewing (MI), cognitive–behavioral therapy (CBT), supportive psychotherapy, and crisis intervention methods. In all of these therapeutic approaches, basic counseling dynamics (such as relationship building; managing rapport in stressful situations; giving feedback; assessing, understanding and responding to the needs expressed by the client; and seeking consultation and supervision as needed) are demonstrated. Please note that the panel does not intend to imply that the approach used by the counselor in the vignette is the “gold standard,” although the approach shown does represent competent practice that can be performed in real-life settings.
The vignettes begin with an overview, a substance abuse history, a suicide-related history, and a list of the learning objectives for the vignette. Each of the following additional features is also embedded in the counselor and client dialog:
Master clinician notes are comments from an experienced counselor or a supervisor about the strategies used, possible alternative techniques, thoughts of the clinician, and other information counselors should have.
“How-to” notes contain information on how to implement a specific intervention.
Master clinician notes represent the combined experience and wisdom of the contributors to this TIP. The notes provide insights into the cases and suggest possible approaches. Some of the techniques described in the notes may or may not be appropriate for you to use, depending on your training, certifications, and licenses. It is your responsibility to determine what services are legally and ethically appropriate for you to provide within the scope of your practice. If you are unsure, ask a supervisor.
This format was chosen to assist counselors at all levels of mastery, including beginning counselors, those who have some experience but need more diversity and depth, and those with years of experience and training who are true master clinicians. Client scenarios are presented in vignettes in the following pages. Each client is in treatment for a substance use disorder, and is experiencing some suicidal thoughts. By way of introduction:
Vignette 1, Clayton, illustrates how to obtain and secure a firearm safely 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 for a high-risk client from an inpatient unit.
Vignette 3, Leon, depicts how to link a high-risk client safely 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).
This case illustrates the GATE process for working with substance abuse clients with suicidal thoughts and behaviors. The vignette begins with a meeting between Clayton and his counselor (Darren) and illustrates how clinical supervision plays an important role in addressing client suicide risk. It specifically addresses working with a client who is not in an immediate suicidal crisis but has warning signs for suicide. It also examines issues of removing a potential suicide weapon and illustrates the importance of working with family.
Participants: Clayton (client), Darren (counselor), Jill (supervisor), and Barbara (daughter).
Clayton is a 61-year-old Caucasian man who used injection drugs as a young adult and contracted hepatitis C. He quit using injection drugs without treatment and about 10 or 15 years later developed alcohol dependence. He entered treatment 5 years ago and has been sober for 18 months. He has a cirrhotic liver but does not want to consider getting on a transplant list. He attends at least four Alcoholics Anonymous (AA) meetings a week, participates in an ongoing recovery group, and sees a substance abuse counselor individually on an as-needed basis. He lives alone, has two grown children with whom he has occasional contact, and lives on his retirement pension. He retired 3 years ago from a supervisory position at a local small manufacturing plant where he worked for 30 years.
Clayton tried to kill himself in his twenties by overdosing on heroin. He was taken to an emergency room and released about 12 hours later. He did not follow up on treatment recommendations. He began having suicidal thoughts again following his last relapse 18 months ago. While drinking, he decided he might shoot himself but did not actually make a suicide attempt. Since stopping drinking and returning to treatment, he has had occasional thoughts of killing himself, particularly when the pain from his liver disease becomes burdensome and when he feels like he has no future. Clayton maintains that he is not acutely suicidal now but says he might act if the pain becomes worse or if he is unable to take care of himself. The suicidal thoughts arise when he feels hopeless and when he becomes afraid that he might reach a point of being physically unable to take care of himself. He took out his gun and examined it last week, an action that concerned his AA sponsor enough to urge Clayton to call his substance abuse counselor for an appointment.
To illustrate GATE and how this model can be applied in substance abuse treatment settings.
To demonstrate screening for suicide risk.
To highlight the role of clinical supervision in addressing the needs of the client.
To recognize when there are indications of continuing risk even when the client is currently denying suicidal thoughts.
To demonstrate three types of action:
Remove a potential suicide weapon.
Involve family in treatment.
Make a referral to a specialized community resource for further assessment.
To illustrate a followup process to ensure that the client has removed the weapon from his home and has followed through on the referral to a specialized community resource.
To illustrate how case management is important in helping Clayton manage a variety of life problems including substance abuse recovery, pain management, suicidality, mental health care, and physical health care.
[Clayton has requested an appointment with his counselor.]
COUNSELOR: Clayton, you said on the phone you are having some trouble and would like to see me.
CLAYTON: Well I haven't been feeling so good. I've been having a fair amount of pain for the past couple of months or so. I'm not sleeping all that great. I don't feel very well. My sponsor in the program told me to give you a call.
COUNSELOR: We'll I'm glad you did call.
CLAYTON: I've been going to the pain management clinic like you told me to. That helps—the meds and the pain management program, but sometimes the pain still gets pretty bad and I start sinking.
COUNSELOR: How much pain have you been having?
CLAYTON: I'm in pain all the time, but it flares up real bad about every other day. What happens is that the bad pain comes for several hours, sometimes four hours or so, and it makes it really hard for me to do anything. It just beats me down.
COUNSELOR: In the past we've used a scale of 1 to 10 to rate your pain. Where would you put yourself on that scale now?
CLAYTON: When it flares up, I'd say about 8 or 9. Then, after a few hours it goes down some—maybe down to a 3 or 4 or 5. It never goes away all the way. And you know, I can't take narcotic pain pills. The pain clinic gives me some meds—the non-addictive kind, but they don't help all the time.
COUNSELOR: When the pain has gotten up in that 8 to 10 level, those are the times when you feel like you're “sinking” and “feeling down?” Clayton, tell me some more about what those terms mean to you.
CLAYTON: Well, I mean it's the whole thing. You know I'm not going to go through with the liver transplant thing, even if I could get a new one. I don't want to be a burden on anybody, and I don't want to slip again. I tried working a little bit last year just to see if I could. A friend in the program let me work a few hours a day at his store. But I couldn't work all the times he wanted me to because of the pain attacks.
COUNSELOR: Sometimes in the past when those feelings of hopelessness have come up and you've had that kind of pain, I know you've had thoughts about suicide. Have those thoughts come back?
Master Clinician Note: Observe that the counselor does not wait for Clayton to bring up issues of suicide, but rather initiates the conversation in a way that normalizes the discussion and invites Clayton to provide more information. Some specific points to consider when discussing suicide with a client include:
Use clear, direct terms, not euphemisms for suicide (for instance, say “have you thought of killing yourself?” or “Have you thought of taking your life” rather than “have you thought of doing anything foolish?”
Ask direct questions, but do so with care and compassion.
Ask open-ended questions that require more than a “yes” or “no” answer.
Acknowledge that talking about suicidal thoughts and behaviors is difficult but that having the discussion is important.
CLAYTON: Well, I think it's, like I said, not knowing what lies ahead. If I'm ever gonna get beyond this and not bother my family about the whole thing and not feel like I can't do as many things as I was able to do. All those kinds of things add up at once and I'd say those thoughts are there especially when everything collapses, when I'm not sleeping and the pain is worse, I don't know … it all just gets to be too much.
COUNSELOR: Yeah, it sounds pretty overwhelming and seems like you feel help would be hard to find.
CLAYTON: Well you know, I don't want to bother my family, and I really don't want to be a burden on anybody. Sometimes I don't even know if I want to continue the liver treatment.
Master Clinician Note: Clayton avoids addressing the question of suicidal thoughts, except in an indirect way. Instead of grilling Clayton for the information, the counselor files away the issue temporarily and talks about pain for a few minutes, a comfortable topic for Clayton. The counselor then returns to his concerns about Clayton's suicidal thoughts. The expectation is that Clayton will feel more comfortable in talking about them if the counselor slows down a bit and goes at his pace.
COUNSELOR: Does it help to talk to anyone about your pain, like people in your AA program, or in the group here or your family when things get real bad?
CLAYTON: I don't know. I really don't want to cry on other peoples' shoulders. I don't want to tell my kids, there's nothing they can do. It helps that some people—friends in the program—know and give me some support. And I've talked to you about it some.
COUNSELOR: It's not easy to share what you're going through with others, and I really respect how you've shared with some peers, and that you've given me your trust. What gets in the way of talking with your kids about it?
CLAYTON: Well, I see my daughter and her family some. She lives about 10 miles out of town. My son and I talk every now and then, but he lives about five hours from here. We just talk about his kids, and I ask him about his job and that's about it. We really haven't been close since he was a teenager. I was drinking the whole time he was growing up, and we never have got beyond what happened back then, what I did and what he did too.
COUNSELOR: We talked a little bit about that: the family relationship has been difficult for you. You said you've been feeling like a burden.
CLAYTON: Yeah. I haven't really told them about the liver, how bad it is. I don't really want them to get all upset. They've got their own lives now.
How To Screen for Suicide.
COUNSELOR: So you've had a sort of mixture of difficulties over the course of the last couple of weeks including thoughts about feeling hopeless and perhaps even thoughts of taking your own life. I know it's a difficult subject, but do you mind if we talk a little bit more about this?
CLAYTON: That's okay.
COUNSELOR: Thanks. I appreciate your willingness. One concern I have is about your hopeless feelings and where they might lead, for instance, whether they lead to thoughts about killing yourself.
CLAYTON: Yeah. I've thought about it. I've had a gun for a long time.
COUNSELOR: I wonder if you could say a little bit more about the thoughts, and what you've thought of in terms of the gun.
CLAYTON: I don't do much with the gun now. I used to use it for target practice and stuff. My son and I used to take it out years ago.
COUNSELOR: Do you remember the last time you got the gun out?
CLAYTON: Yes, last week. Funny, I guess I haven't had it out of the closet in years, but I took it out the other night and just checked it out.
COUNSELOR: Were you thinking about killing yourself when you took the gun out?
CLAYTON: You know, not really. I don't know why I took it out. But later, I was feeling pretty bad, and I wondered if that was what I was doing. It bothered me enough that I told my sponsor about it, and he told me to give you a call.
COUNSELOR: I'm glad you did.
CLAYTON: Me too.
COUNSELOR: Could I ask how often the thoughts of suicide occur?
CLAYTON: I'd say about every week or so.
Master Clinician Note: Observe that the counselor occasionally asks the client's permission to continue probing, showing respect for the client and providing him with a sense of control. Also notice how the counselor picked up on hopelessness and followed it up with a more specific mention of “thoughts about killing yourself.” Using this direct phrase showed Clayton that this is not a taboo subject, and indeed the counselor can handle this topic, opening the door to a revealing discussion about Clayton's suicidal thoughts and plan to use his gun. As you will see, the counselor continues to gather information, which will be necessary for deciding what actions to take. There are many similarities between obtaining information about suicidality and the information you, as a substance abuse counselor, routinely get about substance use history and current use. The information you want to obtain is the information that is directly relevant to treatment planning. Other information that might be useful in later treatment can be gathered at a later time. As with obtaining information about drug history, it is important to be specific and persistent, without “grilling” the client. The counselor will now obtain more specific information about suicidal thoughts.
COUNSELOR: Clayton, when the thoughts about killing yourself come up, how long do they last? How much time do you spend thinking about it? For example, does it come and go quickly or is it something that you stop and really think about?
CLAYTON: Sometimes it will stick around for a while, a couple of hours. I guess it's gotten a little worse over the past 4 or 5 months and lasting longer.
COUNSELOR: Do you mind sharing with me a little bit about what you are thinking about during that period?
CLAYTON: Just not being around and, like I said, not causing my family more grief than I've already caused them, getting out of the pain and things like that. It's not like I spend the whole time then thinking about how I'm going to shoot myself. It's more like I just think I'd be better off dead, I wouldn't feel all this pain … It just seems pretty reasonable when I'm in that frame of mind.
COUNSELOR: Clayton, have you thought about killing yourself today?
CLAYTON: You mean like this morning? No, it's not like it is right in front of me. It just more hangs around in the background.
COUNSELOR: Thank you for that clarification. I also wonder if you've done anything in preparation for taking your life.
CLAYTON: I don't know what you mean.
COUNSELOR: For example, giving away things, saying goodbyes, arranging affairs, making sure your gun works. Have you found yourself doing anything like this?
CLAYTON: Uh, I've made sure that possessions—things that I own and stuff—would be given out the way they should be in terms of taking care of that kind of thing but not really much beyond that.
COUNSELOR: Anything else?
CLAYTON: Well I just talked to an attorney about where whatever possessions I have will go, and I made a will. But with my physical condition, I need to do that anyway. It's not like I'm getting all the ducks in a row.
COUNSELOR: It kinda sounds like you've redone your will.
CLAYTON: Yeah.
Master Clinician Note: There is a pause in the conversation at this point. The counselor is considering that he might consult with Jill, his supervisor, about how to proceed. He is concerned particularly about letting Clayton leave the office, knowing that he has recurrent suicidal thoughts, has considered shooting himself, and has access to a gun. He decides to address the issue of getting some advice from Jill directly with Clayton.
COUNSELOR: Clayton, at this point I am going to take the opportunity to touch base with my supervisor for a few minutes. The reason I need to do that is because some of the areas we have discussed, including your chronic pain, the hopelessness, the suicidal feelings, and your gun have me concerned about your health and safety. If Jill, my supervisor, is available, would you mind if she joins us?
CLAYTON: I knew I shouldn't have said anything. What are you going to do, lock me up?
COUNSELOR: I can appreciate that you feel nervous, but try not to jump to conclusions. I just want to get some input to make sure we're doing everything possible to help you with your struggle and keep you safe. In this instance I think she can be helpful to both of us. What I want to do is give her a call and see if she can step in.
CLAYTON: Okay, I suppose you're just trying to do the right thing.
COUNSELOR: Yes, I want as much expertise available to us as possible. Thanks for understanding.
Master Clinician Note: Darren raised the issue of involving his supervisor skillfully. First, he consulted with Clayton about it. Second, he validated Clayton's feelings. Third, he gave Clayton a rationale for the supervisor consultation. And, fourth, he kept the focus on Clayton's well-being.
[Darren telephones Jill, his clinical supervisor.]
COUNSELOR: Jill, this is Darren. Clayton, who I think you know, is in my office right now, and we're talking about his pain related to his liver disease and how he is coping with that. He's had thoughts about suicide, and I'm wondering if you could join us for a few minutes as we make some decisions about how to handle this.
SUPERVISOR: Yes, I'm glad you called, I'll be right in
[Jill, Darren's supervisor, was in a meeting with another counselor that she broke away from in order to intervene in this more urgent situation.]
How To Prepare for Suicidal Crises.
[In the interim until Jill enters the office, Clayton and Darren resume their conversation, focusing primarily on Clayton's depressive symptoms.]
[Jill enters room after knocking.]
COUNSELOR: Clayton, have you met Jill?
CLAYTON: Yes. Jill, I remember you from when you were a counselor here and did the evening aftercare group.
COUNSELOR: Yes, Clayton, I remember you from the group, it's good to see you again.
[Clayton, Jill, and Darren spend a few minutes developing rapport. Darren briefly describes Clayton's reports of suicidal thoughts, the weapon in his house, his thoughts about redoing his will, and Darren's concerns that Clayton might be depressed. Jill is unaware of Clayton's suicide attempt many years ago.]
SUPERVISOR: Clayton, one other thing that I would like to ask about. Have you ever tried to kill yourself?
CLAYTON: Not really. Well, maybe, when I was doing hard drugs, in my twenties, years ago. I tried to overdose one time. I used enough heroin that it should've killed me, plus I was drinking, but I just passed out, and that was it.
SUPERVISOR: Can you tell me some more about what happened?
CLAYTON: Well, I shot up. I knew the stuff was good, pure. I tried to end it, and I just went out.
SUPERVISOR: Did someone find you?
CLAYTON: I think someone called an ambulance, and they took me to the hospital. They kept me maybe a day.
SUPERVISOR: Was there any followup?
CLAYTON: Nah.
SUPERVISOR: Okay, and you haven't made any other suicide attempts?
CLAYTON: Nah.
SUPERVISOR: Thanks, Clayton, for sharing that with me. I just needed to check that out. The issues that stand out to me are that your pain comes on pretty reliably every other day now, that you can get pretty down when this happens, and sometimes have thoughts of suicide, that you have a gun that you've thought of using, and, for the first time in a long time, you got the gun out. Would you say that's a fair summary?
CLAYTON: Yeah, that says it, I guess.
COUNSELOR: I agree, that captures the situation pretty well.
SUPERVISOR: The place I'd like to start is the gun. The reason I say that is because it's just like getting sober, it's important to get the booze out of the house, so that when the craving hits, or there is a crisis of some sort, a bottle is not right there tempting you. It's the same thing with having a gun, most of the time it's not a problem, but when the worst of the pain hits, and when the suicidal thoughts come, there is that added chance of taking action, and having the gun right there makes it more likely. What do you think of doing something about the gun, in order to make the situation safer?
Master Clinician Note: Bear in mind that Jill knows Clayton from when she did the aftercare group. She has a background in mental health counseling and has had additional training in addressing suicidality. As a result she is clear about what to do and feels confident making this intervention on the spot, rather than discussing it first with Darren, or obtaining additional input from the program director or a consulting expert.
CLAYTON: Well, I must admit when I got sober that I thought it was a little overkill to remove all the alcohol from the house, even the stuff in the liquor cabinet that I never paid any attention to, but it turned out you were right, it would've been tougher to get through those moments when the craving hit if the alcohol was right there.
SUPERVISOR: Agreed. Having a gun in the house is kind of like having alcohol in the house.
CLAYTON: I've thought about it now and then, but I haven't really had it out in a while, except that one time last week, so I'm not exactly sure, what are you suggesting I do?
SUPERVISOR: Well, what I'd like to do is have you make an agreement with me and Darren to go ahead and get rid of the weapon, not necessarily forever, but right now, given your pain and all, giving it to someone you know and trust would seem a lot safer than having it in your home. Whose help might you get in safeguarding the gun?
CLAYTON: My daughter Barbara maybe? I don't really want to get my sponsor involved in this, he's great, but he gets nervous. Truthfully, I don't really like the idea of bothering Barbara. I also don't want to burden her with my liver disease and being sick and not being able to take care of myself. But I can't think of anyone but Barbara who could take care of the gun, and I know she'd do it in a minute for me.
COUNSELOR: I can see that you're not totally comfortable asking Barbara, but if it has to be done, it sounds as if she is the best choice. Is that correct? Am I hearing you right?
CLAYTON: Yeah, that nails it pretty well.
COUNSELOR: Then Barbara it is. Thanks for working with us on that difficult decision.
SUPERVISOR: Agreed. We appreciate your working with us like this. This is difficult stuff to be sure. One more thing I'd like to ask. How would you feel about it if Darren or I confirmed with Barbara that you gave her the gun?
CLAYTON: If you gave me some time to do it.
SUPERVISOR: How much time do you think that you need?
CLAYTON: I could get it to her in the next couple days or so, and she'll have it. I'll talk to her.
SUPERVISOR: Your suggestion is very reasonable and I appreciate it a great deal. However, I think Darren and I would feel even better about it if we took care of it today. I know you might see this as pushy, but I wonder if you would mind if we gave her a call now?
CLAYTON: This feels like it is really rushing it. I mean, I'm not going to shoot myself tonight. I'm pretty sure of that.
SUPERVISOR: Yes, I thought you might feel like you were being rushed. Please let me slow down and explain. Although there is a parallel between having alcohol in the house in recovery and having a gun in the house in this situation, they are not exactly the same. What I mean by that is, with relapse, there is the opportunity to learn from the mistake and remove the alcohol, but, unfortunately, with a gun it's essential to get it right the first time. There may not come a second chance. For that reason, Darren and I tend to be a little more “pushy” and insistent with your situation than, say, if we were talking about preventing a relapse; the stakes are much higher. From our perspective, then, it makes more sense to take care of it now.
CLAYTON (reluctantly): I understand although it still feels pushy. Well … OK. I'm not sure we can get her, and if we do, I don't want to get her all upset. But we can try her cell phone.
COUNSELOR: Thanks for hanging in there. Before we make the call, I suggest that we make a plan for what we're going to say.
Master Clinician Note: Observe that Darren, the counselor, can clearly see where Jill is going at this point and so he steps back into the conversation and assumes the task of working with Clayton and his daughter around safeguarding the gun. Accordingly, Jill recognizes that it is ideal to empower Darren to manage the situation to the extent possible, and so she steps back and allows Darren to work with Clayton around the gun directly, while continuing to observe the interaction to ensure that the plans to remove it are made and that any other important safety issues are addressed. Darren already has a release to speak with Clayton's daughter and has spoken with her briefly on occasion about his progress.
CLAYTON: Well, I guess, I'm thinking y'all are overreacting a bit to all of this. But I understand where you're coming from.
COUNSELOR: I really appreciate you trying to see our point of view. Let's talk for just a minute before we call your daughter, about what you want to say, how you think she might react, how you want us to be involved.
CLAYTON: Yeah, probably, yeah, she doesn't know much. I mean, she knows I've been doing good in the program, and it's working. And she knows that I haven't been feeling well lately but she really doesn't know much about—she knows my liver's not in great shape; but she doesn't know about the pain being so bad.
COUNSELOR: It's a fairly major thing to kind of drop on her and then to talk with you a little bit about the fact that you need to have her take the gun as well. Do you have a sense for how you're going to bring that up with her? Do we need to talk about that for a minute before we make the phone call? It would seem to make some sense for us to discuss it.
CLAYTON: Um, well, like I said, she knows I've had some liver problems but she doesn't know how bad it is. I could just tell her, you know, I don't have to get into that too much, I don't think right now, do I?
COUNSELOR: Well, I think it's up to you. I would imagine she's going to have some questions about why you're calling. You're going to tell her that you need to give her a gun, and you would like her to take it this afternoon if possible, that you've been having some difficulty. So it's really up to you how much you tell her, but I want to make sure we have thought about any kinds of questions or concerns ahead of time.
CLAYTON: Right.
COUNSELOR: So we can kind of anticipate them before you make the phone call.
CLAYTON: Yeah, I don't see any problem, I mean, as long as she can come over, which I think she can; I mean, she lives maybe 20 minutes from my apartment. I thinks she's visiting her mother this afternoon. I think she would do it.
COUNSELOR: Okay, all right. One thing: does Barbara have any experience handling and safely storing guns?
CLAYTON: Not much experience, but she's got an area in her attic that she keeps locked. I know that's where she'd lock up the gun.
COUNSELOR: That's really good to know. If you're okay with it, I think we're ready to make the call.
CLAYTON: Are you going to be listening in to the call?
COUNSELOR: We'd be willing to, glad to in fact, if that's okay. It might come in handy if Barbara has any questions she wants to ask us. Would it be alright if we put the call on speakerphone?
CLAYTON: Yeah, that's fine, sure. I mean, if you want to. You could explain this stuff better than me, I'm sure.
COUNSELOR: Well, we'd be happy to. There may be different points where Jill or I can offer some support or say something if you're a little bit at a loss for words, and when she has a question, if you could kind of give me the nod, I'll certainly chime in and offer some help if you need it.
SUPERVISOR: Yes, that sounds excellent, I'll be happy to enter into the conversation as well if necessary, although for the most part I'll allow you and Darren to speak with Barbara.
CLAYTON: Okay.
[Clayton dials his daughter Barbara's cell phone number.]
BARBARA: Hello?
CLAYTON: Barbara, hi, it's Dad.
BARBARA: Hi, Dad, how are you?
CLAYTON: I'm, you know, I could be better. I'm sitting here with my counselor and his supervisor and they thought I should give you a call; they are actually on the speakerphone here.
BARBARA: Okay.
CLAYTON: Sorry I bothered you; I hope I'm not catching you at a bad time. I know you are probably visiting with your mom right now.
BARBARA: Oh, no, you don't bother me at all when you call, Dad, I'm glad to hear from you. I just wonder why you're calling with your counselor.
CLAYTON: Well, he thinks I should talk to you about maybe coming over and getting my gun, you know, it's …, he thinks that maybe it would be better if you picked it up, or whatever. What do you think?
BARBARA: I think that's pretty scary.
CLAYTON: I'm not sure we need to do it, but he thinks we need to do it, so, but, you know. Could you just keep it for awhile? And in fact, if you want to talk to him, he's here.
BARBARA: I would like to talk to him.
COUNSELOR: Barbara, this is your father's counselor, Darren. I'm imagining you may have some questions.
BARBARA: Hi, Darren. This is pretty scary. I mean, I'll be happy to come over and pick up Dad's gun, but what's going on?
COUNSELOR: Well, your dad's been doing great with sobriety, but unfortunately he's been having a lot of pain, and he feels hopeless on and off, and sometimes has thoughts of killing himself. So, we've advised your dad to get the weapon out of the house, just to be on the safe side.
BARBARA: And I certainly will be happy to come over and get the gun. Dad, do you really think that you could kill yourself? That would be really awful.
CLAYTON: No, I think I'm gonna be all right, my counselor's just being extra cautious, don't worry about me. We can talk more about it, it's a lot to talk about on the phone, but it's okay if you get the gun. It's what they want me to do, and I'm going to go along with them.
BARBARA: Okay, I'll be right over. Are you going to be home Dad?
CLAYTON: Well, I can be there in maybe a half hour.
COUNSELOR: Barbara, I understand it's a scary thing, but it seems like a really good precaution to take.
BARBARA: And I appreciate that you're doing that. And I'll certainly do anything I can to help, but, Dad, why is this happening? What's going on? I mean you've been sober for—it's just like we're getting to know each other, and now all of a sudden, I find out you're depressed. I didn't know any of this was going on.
CLAYTON: Well, it's a lot, you know, we can talk about maybe—I don't know … we can, well, you know, my liver's not been doing great and—
BARBARA: What do you mean your liver's not good? I knew you had some problems with your drinking, what do you mean your liver hasn't been doing great? What's that mean?
CLAYTON: Well, the doctors say my liver is pretty bad, and I've sometimes had a lot of pain with it.
BARBARA: What? We need to talk, Dad. I need to know what's going on. This is all pretty scary—you're scaring me, Dad. But I—I'll be right over.
COUNSELOR: And, Barbara, I appreciate you doing that. One of the things your dad and I can talk about is maybe it would be helpful for the three of us to sit down. This is a lot to take in, particularly over the phone. Do you think that might be a good idea?
CLAYTON: Sure.
BARBARA: I think that would be really helpful for me. I have a lot of questions, and I think I'll probably have a lot more, but the first thing is, I will be right over to get the gun.
COUNSELOR: Just two more quick things. One, do you have a safe way to store the gun? Second, after you've obtained and secured the gun, I wonder if you can call me to confirm that you've picked it up.
BARBARA: Yes, I have an area in my attic where I lock up things and I'm good about keeping the key hidden.
COUNSELOR: That's great, please confirm with me after you've locked away the gun.
BARBARA: Yes, absolutely I'll give you a call.
[Darren proceeds to give Barbara the office telephone number.]
COUNSELOR: And Barbara, the other thing I would encourage you to do is just to make a list of the questions that you have. I know this is overwhelming to have all of this dropped on you in one afternoon. So if you just make a list of the questions, you can bring those in and the three of us can sit down and go through those, and try to get you the information and the answers that you need and that your dad is comfortable with. It's likely that your dad could benefit from more treatment for his hopelessness and depression than he is getting right now, and so I think that's something we should talk about when we meet.
[Darren makes a mental note to give Barbara the 1-800-273-TALK number when she calls back.]
BARBARA: That sounds like a really good idea. I-I-I am so rattled right now, I can't even think, but I can do that and bring those in, and I think that would be helpful.
COUNSELOR: Clayton, anything else that comes to mind?
CLAYTON: No. Thanks, Barbara.
BARBARA: Okay, Dad, I'll be—
CLAYTON: Don't worry about me.
BARBARA: I can't not worry about you, Dad, but I'll be right over to get the gun.
CLAYTON: All right. Thank you. Bye.
BARBARA: Bye.
How To Work With the Family of a Client Who is Suicidal.
COUNSELOR: Clayton, thanks for making the call. How do you feel about the phone call?
CLAYTON: I think it's, you know, a little too much to do all that, but I'm willing to go along with it.
COUNSELOR: Thanks for being flexible. Let's talk tomorrow by phone just to see where we are and where we need to go from here.
SUPERVISOR: I can see that you both have things under control. Thanks for allowing me to join your meeting. You did some excellent work here just now.
[Jill leaves the meeting.]
Darren received a call from Barbara acknowledging that she had stored the gun in her locked attic. Ideally, firearms should be stored unloaded, but in this case, there was probably a greater risk of unintentional injury to Barbara if she attempted to unload the gun. Therefore, she simply stored it, given that she has a locked space for it and is the only person with the key. If Darren had not heard from Barbara, he would have been sure to contact her to determine if anything went wrong with the plan and, if necessary, to develop an alternative plan. A positive outgrowth of the counselor's intervention was that Barbara expressed an interest in meeting with the counselor and her dad to learn more about how she could be involved in his treatment and recovery. With Clayton's permission, a joint visit was arranged for the following week. Clayton also agreed to a mental health consultation, and one was scheduled for later in the week to evaluate his depression and further assess suicide risk. Plans were also made for him to continue to visit a local pain clinic to help with pain relief. He was given the 1-800-273-TALK hotline number to call in an emergency.
Clayton was cooperative throughout, agreeing to remove the weapon that created high potential for taking a lethal action. If his daughter hadn't been available, Darren and Jill would have had a decision to make about whether or not any other immediate intervention steps were necessary. They may have wanted to get additional input concerning this question. A detailed discussion of removing weapons from the possession of suicidal patients is provided by Simon (2007). Although the article is not written specifically for substance abuse treatment settings, it offers sound guidance. Treatment programs may be willing to have clients bring in substances that they might use to kill themselves, with a procedure for handling such substances (e.g., by flushing them with a witness and documenting that this occurred). However, accepting a weapon from a suicidal client is highly problematic, because bringing a weapon into a facility may create risk to staff and clients (and typically violates agency policies) and because the provider may ultimately be required to return the weapon to the client, an untenable situation. As shown in this vignette, family members are often willing to help in such instances and are open to coaching about the need to store guns securely and separately from ammunition. In addition, family members may decide not to return the weapon or to get rid of it. A worthy option to explore for your program is your local police department, as some police departments have special policies for receiving suicide weapons.
Darren took the time, with Jill's help, to debrief and document his actions with Clayton related to his suicidal thoughts and to gain additional guidance for the followup sessions. Some of the points they considered include:
The information he gathered.
How he accessed consultation with Jill and invited her into the session.
The actions he took to contact Barbara and elicit her support in removing the gun.
His referral of Clayton for an evaluation of his depression and Darren's support for Clayton continuing treatment at the pain clinic.
The followup sessions he scheduled with Clayton and Barbara.
Discussion of the necessity for documentation and the style of documentation are provided in chapter 1. It is important to note in the documentation that Clayton and his daughter were both given the hotline number and were advised to call the number at any time if needed.
Angela is a 44-year-old African-American woman with a history of chronic bipolar disorder and substance dependence. These illnesses have created numerous problems, including relationship conflicts with her family, unstable employment and housing, and poor adherence to healthcare treatment. She is currently in an inpatient psychiatric unit that specializes in the treatment of co-occurring disorders following a relapse to crack cocaine use. She made a suicide attempt by drug overdose just prior to this admission. Since being in the hospital, her psychiatric symptoms appear to be stabilized. Her counselor and the treatment staff are concerned that her stability is tenuous, and that if she relapses again following discharge, she may rapidly become suicidal. In light of her suicide attempt and her chronic history of relapse and serious mental illness, her doctor intends to keep her in the hospital for several more days of observation.
Participants: Angela (client), Lupe (counselor), Walter (brother), and Carla (sister-in-law).
Angela has a long history of cocaine dependence with relatively brief periods of abstinence. She was hospitalized for cocaine dependence twice in the past 4 years. Her drug use is intertwined with bipolar symptoms so it is difficult for her to remain clean when hypomanic or depressive symptoms occur, and at the same time, her drug use exacerbates these symptoms. She has done well since being hospitalized and has cooperated with treatment. The primary challenge now concerns discharge planning. Angela believes that she requires minimal aftercare treatment and intends to move back in with her brother and sister-in-law and their two children.
Angela has made two suicide attempts, the first one as a teenager. Her most recent attempt, which precipitated her admission to the co-occurring disorders unit, was made while coming off cocaine. She had been deeply depressed for several weeks and overdosed on a variety of drugs that had been prescribed for her over the last few years. She was unconscious when discovered and taken to the emergency department. Once stabilized medically, she was admitted to the co-occurring disorders program. Although Angela denies any suicidal thoughts at this time, staff remain concerned about her potential for suicidal behavior upon initiation of cocaine use, a likelihood in light of her chronic substance dependence history. She shows poor insight into the severity of her mental illness, drug abuse, and suicide potential.
To illustrate treatment planning with a client at elevated risk of suicide.
To demonstrate family involvement in treatment planning.
To demonstrate case management skills in suicide prevention efforts.
To offer an understanding of the interaction of substance abuse, mental disorders, and suicidal behaviors.
Angela's counselor, Lupe, asked that part of her weekly clinical supervision session be set aside to discuss her concerns about treatment planning for Angela. Angela's family has just notified her that they are not willing to have her return to their home and be with their children if there is a risk of drug relapse. Lupe and her supervisor discuss the complex interplay of Angela's drug use, her psychiatric illness, and the environmental stressors she faces (lack of employment, social isolation, and poverty). They conclude that this combination of forces indicates a high potential for relapse and resultant crises, and though less certain, a potential return of suicidal thoughts. They decide to recommend ongoing treatment efforts, perhaps a day hospital or a long-term mental health/substance abuse residential care program, once she leaves the intensive co-occurring disorders unit. They also agree that it would be unethical to give a false sense of optimism about her prognosis to the family to persuade them to take her back. Assuming that she cannot return to her brother's home to live in the immediate future, other supportive housing resources need to be identified. They know that Angela will need to accept and participate in any discharge plan or she will only undermine it after discharge. They also realize that they cannot force her to accept long-term residential or day treatment after discharge, no matter how clear it is to them that such treatment is warranted.
The decisions reached in the supervision about the next steps include:
Lupe will contact Angela's brother Walter (after Angela has signed a release for Lupe to do so) and ask him to participate in Angela's discharge planning.
The staff will need to work with Angela and her family to find an alternative and more structured setting where she can be monitored for relapse of her substance abuse and psychiatric symptoms, and for a return of suicidal thoughts and behaviors. Since Walter is apparently emphatic that she cannot return to his home, this presents an opportunity to identify a more intensive treatment alternative, for example, supportive living plus day hospital treatment, options that she would never had agreed to if her brother had not forced the issue.
Lupe's objectives are to help Angela and her family with case management services to reach agreement for these arrangements. Some of the treatment goals she will try to implement include seeking to ease Angela's transition back into the community; help her develop peer support; and continue to monitor her psychiatric and substance abuse treatment needs, warning signs for suicide, and medication compliance.
[When Lupe and Walter meet, they have an initial brief interchange focused on developing rapport. Walter seems defensive, and Lupe would like him to be more a part of the solution than an adversary.]
WALTER: Let me get straight to the point: she's gonna relapse. I mean she's come in places like this and then she uses and she shows up at our door. We take care of her and I loan her money. She takes money if I don't lend her any. We're worn out. My wife is giving me a lot of grief about how I keep taking care of my little sister. I mean she's not 18 anymore. She took pills and passed out when she was supposed to be watching our kids. I found her passed out on our sofa and had to call 911when I couldn't wake her up. I wasn't even sure if she was alive. Just to be straight with you, Angela's not coming back to our house now. I know our kids will miss her. When she's clean, she's better to them than she was to her own kids. But when she's using, she's a real burden on me and my family. We just can't do it anymore. And then when she doesn't take her medication and gets out of treatment she gets crazy. It just keeps going on and on.
COUNSELOR: Thank you for being up front with me about this.
WALTER: Yeah, well, it's the only way we'll get anywhere. Thanks for meeting with me, by the way. It's a welcome change. Last time she was in the hospital, nobody talked to me.
COUNSELOR: Yes, it's good we're communicating. Like you, we want to be sure Angela can be in a supportive environment when she leaves, an environment that will support her abstinence and help her keep her psychiatric illness in check. It sounds like you and your wife have been fantastic in terms of supporting your sister. And I know her children are not involved, so it has fallen on you and your wife.
WALTER: I'm glad you see where I'm coming from. This is not the first time with Angela. We've been through this many times with her.
COUNSELOR: Once I learned that you wouldn't be taking Angela back to your house, I had a chance to discuss alternatives with my supervisor and our treatment team, and also discussed possibilities briefly with Angela, although we didn't come to any firm agreement. The alternative that seems to make the most sense is for Angela to first enter a halfway house program for people with co-occurring substance use and mental disorders and then, later, move toward a supportive residential housing program, which could last up to 120 days or more. Additionally, while she's in the halfway house, she would continue to participate in intensive outpatient services here at the clinic. For starters, that outpatient treatment could be as frequent as 5 days a week, what we call “day hospital,” until she achieves some success in recovery.
Master Clinician Note: It is important for counselors to be aware of ongoing residential treatment and housing options for clients who have a history of homelessness, a history of instability in obtaining and maintaining housing, and those in need of long-term supervised care. Some treatment possibilities in your community may include:
Oxford Houses—a residential housing option found throughout the United States for people recovering from substance use disorders.
Halfway houses for people leaving inpatient care.
Sobriety houses, focusing on long-term supervised residential care.
State and Federally funded long-term treatment programs.
Supervised living.
Group homes or other community resources.
In addition, housing options are numerous: housing funded through the HUD Homeless Assistance grants, such as Single Room Occupancy buildings, Shelter Plus Care, and Supportive Housing Programs, which are available to individuals who are homeless and have disabilities; programs that provide rental subsidies for sober housing and supportive services; modified therapeutic communities; day treatment with abstinence-contingent housing and employment services; and emergency and transitional shelters with onsite substance abuse treatment and relapse prevention programs. For more information about substance abuse treatment and homelessness see the planned TIP Substance Abuse Treatment for People Who Are Homeless (CSAT, in development j).
WALTER: Hold on a second, I'm all for Angela doing something besides living with us, but aren't halfway houses places for people who have been to jail?
COUNSELOR: Well, not everyone in halfway houses is coming from jail. The program we would like to use is specific to the needs of people who have both substance use disorders and a co-occurring mental disorder. And we hope that in a few months Angela could transition to having her own small apartment, in a supervised residential environment where there would be someone to make sure that she takes her meds and continues to participate in treatment here. When she is able, they can also help her with employment. And in the meantime, she would be responsible for helping maintain the residential housing facility, in addition to keeping her own unit maintained. And, of course, we really want to monitor her psychiatric symptoms and her potential for suicidal thoughts and behaviors.
I know that Angela feels very connected to you, your wife, and your kids, and that relationship is very important to her. But I hope she can understand your position that going back to your home just isn't an option right now.
WALTER: If you can find a healthy place for her, my wife would kiss you. Angela's been a drug addict since she was in her teens, and she always has big plans. She gets an apartment or she gets a boyfriend or she goes into a program and she always ends up back on our doorstep. What am I gonna do? She's strung out. She's gonna end up on the street. We take her in, we clean her up, she makes promises and then you know what happens. If you can get her in a place where they'll be nice to her and they'll give her medications and be good to her that's great, but I got enough to take care of.
COUNSELOR: I understand, and that's why we hope this kind of step-by-step collaborative plan, between Angela, your family, and us will work. And we do hope you will remain a big part of her life. Help her to be part of the family—have her be a part of family ceremonies and special occasions because we know that is important for her. But as you say, she also needs to live apart from your family, find her own life, and build her own support system. Help her to be independent.
WALTER: About this suicide thing. You know my sister's a drama queen. Do you really think she's gonna kill herself? I mean, she's been using drugs since she was a teenager. Maybe she just went overboard when I found her.
COUNSELOR: We'll never know what would've happened if you hadn't found her, but based on my discussions with her and the report from the emergency department, we do believe that she tried to kill herself. She has a mental illness, bipolar disorder, and that has a high suicide risk. Also, as you might be aware, she tried to kill herself once as a teenager as well, also with pills. Fortunately, people like Angela who are vulnerable to becoming suicidal aren't that way all the time. I'm just getting to know Angela, and I don't have a crystal ball, but she may be vulnerable again if she relapses, and her relapses tend to happen when her mental illness is poorly controlled, especially when she's depressed. So her addiction and mental illness feed off of one another, creating a vicious cycle. Suicide potential isn't the only issue that Angela's facing, but it is an added concern that we have—one that says to us that we should keep her in the hospital a bit longer, for more observation to be sure she's safe, as well as to do everything that we can to put together a sound discharge plan. The success of that plan will ultimately depend on Angela, but we'd like to do our part to make it as realistic and supportive as possible.
WALTER: Well, to be honest, I see it your way. She always says things that are off the wall, but a few weeks ago she made a couple of remarks that were downright scary, something like “you'll be sorry when I'm gone” and “nobody cares about me so what's the difference what happens to me?” I didn't give it much thought at the time, but now it seems she was telling me something.
COUNSELOR: Yes, those statements are what we call warning signs for suicidal behavior. If she does make statements like that in the future, you should interpret it as an indication of danger for suicide, and we can work together to prevent another suicide attempt. Let's discuss this further when we meet with Angela.
Master Clinician Note: Counselors should be aware of warning signs that indicate suicidal thinking and/or acute risk for suicidal behavior. Warning signs include suicidal communications (“It's not worth it anymore,” “You'd be better off without me,” “Nobody cares anyway,” “I might as well kill myself,” “I'd be better off dead,” “I might as well be dead”), seeking access to methods of suicide (for example, hoarding pills, moving a gun that has been in storage), and any actions that suggest getting prepared for suicide (for example, giving away possessions, making arrangements in case of death). Warning signs also include changes that suggest a turn for the worse, for example indications that an individual is feeling trapped or hopeless, behaving recklessly, becoming withdrawn, or experiencing dramatic swings of mood. See pp. 11–12 for a fuller discussion of warning signs. Acute stressful life events may trigger risk for suicidal behavior, like relapsing, breaking up with a partner, losing a job, or being the victim of trauma. Additionally, as discussed below, it is important to help family members be cognizant of warning signs and help them plan how to take action if they notice warning signs.
WALTER: I can't tell you how relieved I am that she's here right now. I sleep good at night knowing she's in this place. Worries me sick what will happen after she leaves. You were saying, there is someplace she can go?
COUNSELOR: We would like her to get into supportive residential housing, but we think first she might do better in a more structured halfway house environment until she is well stabilized with her abstinence and her mental illness. At the moment it's not a guarantee, although the sooner Angela is referred, the better, in terms of any wait.
WALTER: She's got a bed in this place?
COUNSELOR: Not at the moment, no. Getting that process started immediately is important, and for that we'll need Angela to agree to it. We want to be sure that Angela gets enough care. With too little support, her odds of maintaining the gains she started here drop.
Maybe we can call Angela in now and the three of us can meet.
WALTER: Sounds good to me.
[Angela joins Lupe and Walter.]
COUNSELOR: Hi, Angela. Thanks for giving permission for Walter to talk with me today and to join us now.
ANGELA: Hi, Lupe. Hey, hi Walt!
COUNSELOR: How are you doing?
ANGELA: I'm doing fine.
WALTER: Yeah, well you best get yourself fine. I mean how many times have we done this? You get so-called fine, you get cleaned up and then you use drugs, then you show up at our door. We take care of you, and now this lady is telling me you're suicidal.
ANGELA: This is different. I'm really fine this time. I'm gonna be okay.
WALTER: Angela, you know that Carla and I love you. Our kids love you. We wouldn't have you in our lives if we didn't care about you, and we don't want to see anything happen to you. But this suicide thing is scary. I know you're an addict. You've been an addict forever. But, suicide? Angie, when I found you I thought you were dead. Your breathing was so shallow I thought you stopped breathing altogether, I thought you were gone. I was really scared.
ANGELA: This is different. I'm fine this time. I'm gonna be fine.
WALTER: Yeah. Tell it to Carla.
Master Clinician Note: Lupe recognizes that there is family anger as well as little understanding of Angela and her illnesses. She also recognizes that this may be the first chance Walter has had to express this frustration. Rather than focus on his anger, which would likely just make him more defensive, Lupe decides to focus on his concerns and caring for Angela. She also recognizes, however, that if Walter's anger becomes an impediment to his being involved in treatment, it will need to be addressed. Encouraging family involvement in Angela's treatment may be very beneficial for both Angela and her family and will likely enhance treatment efficacy as well.
COUNSELOR: Walter, suicide is an important risk for Angela—and something we need to stay focused on, along with her abstinence and her mental illness. I know that you love your sister and she loves you. I think Angela has been working on helping herself and she's willing to continue working toward that goal. And I know you have some realistic concerns about her relapsing that need to be addressed.
ANGELA: I'm not gonna relapse.
COUNSELOR: Angela, I don't think anybody plans on relapsing. But it happens when people in early recovery aren't paying attention to the things that help them stay clean and sober. One of your goals here is to develop a personal recovery plan that identifies your triggers and looks at the opportunities and resources you have to address those triggers.
How to Incorporate Suicide Prevention in Relapse Planning.
ANGELA: But I can come home later, right Walter? 'Cause I'm fine.
WALTER: I think we should do what Lupe says. I mean no treatment program has ever talked with us like this. She's taken the time to talk with us, to work with us. It sounds like they went through a lot of trouble to make a plan for you and you have a really bad addiction. I mean you've had problems and been an addict since you were 17. You need more than just coming into this hospital. You gotta go to this program like she's talking about, live there, stay sober. We can talk about you coming home later, but you have to keep going to your program. You gotta start listening to these people.
ANGELA: But I'm fine, I'm fine.
WALTER: Yeah. Okay.
COUNSELOR: I know you believe you're fine right now Angela. Our goal, all three of us, you, me, and Walter, is to help you stay fine.
[Lupe outlines for Angela the housing plan that she and Walter discussed.]
LUPE: I just want to see if there were any questions that either of you might have at this point.
WALTER: I want to say I love Angela. We wouldn't have her in our lives if we didn't care about her, and we don't want to see anything happen to her. She's been an addict forever. I'm used to that, but the suicide thing frightens me.
Master Clinician Note: A concern for providers and families is that suicide risk is high after discharge for clients with a history of a previous suicide attempt and/or other significant risk factors. Families can do a number of things. They should remain watchful for warning signs. Before the patient leaves the hospital, family members should have a specific plan for whom to call and/or what to do in the event of acute warning signs (e.g., call the National Suicide Prevention Lifeline at 1-800-273-TALK, bring the individual to the psychiatric emergency department, call the clinic where the patient is being referred). Family members should not presume that, simply because a family member was just in the hospital, they are protected from suicidal behavior.
Other helpful actions are restricting access to firearms and exercising some control over the supply of medications (e.g., giving a week's supply at a time to the client and holding onto the rest, to prevent overdose). Families are also advised to be involved in inpatient and outpatient treatment of their relatives. Some common responses of family members when someone has thought about or attempted suicide include:
Feeling angry toward the suicidal person.
Feeling guilty.
Wanting to punish the suicidal person.
Hovering over the person to ensure that they don't attempt again.
Frequently interrogating the suicidal person about their thinking.
Emotionally withdrawing from the suicidal person.
All of these reactions can be counterproductive. Family counseling for family members and significant others can be of benefit to both the family and the client.
COUNSELOR: Well, Angela is aware that she has a number of risk factors for suicide, including her bipolar illness. She acknowledges that just a few weeks ago she took a bunch of pills in an effort to kill herself. So, it is definitely something we need to be concerned about. And Walter, let's talk for a minute about what you might notice that could mean Angela is having suicidal thoughts.
WALTER: Well, like I said, I feel bad now that Carla and I didn't pick up on her talk about maybe not being around much longer and us “being sorry when she's gone.”
COUNSELOR: Well, listening for those kinds of messages is important. I think another thing is just being aware that there are times when Angela is more likely to be at high risk than other times. For instance, when she is using or when her mood is not well regulated, when she is not taking her medication, when she is avoiding treatment, and when she is depressed.
WALTER: Well, you're right. When Angie isn't too high or low and when she is clean she is okay to be around. She's good with our kids and takes care of herself.
COUNSELOR: Angela, I'm interested to hear what you have to say about this.
ANGELA: Well, I've said, I ain't gonna use, and I ain't gonna try to kill myself. Those days are over.
WALTER: Yes, yes, that's what you always say Angela.
[Pause while Angela looks away, frustrated.]
Master Clinician Note: It is common for tension to exist between clients and family or significant others over the risk of relapse and recurrence of suicidal thoughts and behaviors. While clients may deny or minimize risk, those close to them often experience distrust and anxiety (especially with a past pattern of relapse and recurrence). The counselor can address and normalize this experience and then reorient both parties back to the need for developing plans to support recovery and safety.
COUNSELOR: It's understandable that there is some tension between you about the future. This commonly occurs where the recovering person—Angela—tries to convince her family that she will be fine. What's important is to have plans in place to support recovery and safety. It is not only helpful to you, Angela, but also helpful to your family. So let's review the plan, Walter.
WALTER: So, we should watch for when we think she's depressed or sad or hopeless or if she says she wants to kill herself. And if it sounds like she's gonna be strung out, withdrawn, or out of touch with treatment. Those kinds of things, Right?
COUNSELOR: Right. And one other thing, Walter. What will you do if you see those signs?
WALTER: Well, I'll call her on it, and I'll telephone you.
COUNSELOR: I'd be happy to hear from you in those circumstances, although my primary job is treating patients like Angela when they are here on the floor and so, after discharge, there will be other counselors working more closely with Angela on an ongoing basis. So it will be important to have their contact information and to get in touch with them.
ANGELA: How long are you expecting me to stay in this residential place?
Resources for Family Members and Friends.
COUNSELOR: Well, Angela, let's focus on getting in before we start planning on getting out. I'd like you to sign this release so I can start the process for you to go to a halfway house when you leave our program. Then, when you've had a chance to continue day treatment here on an outpatient basis and you are doing well, we can work on arranging a transition to a place where you can have your own apartment.
ANGELA: Okay, go ahead. I'll sign one more of those papers you're always having me sign.
COUNSELOR: Great, that sounds like a plan. I'll go get a consent form. One other thing we can do is schedule the next meeting with the three of us. Would that be okay with you Walter?
WALTER: Yes, I'm agreeable. Like I said before, nobody asked me to be part of Angie's treatment before. This is the first time I ever felt like I knew what was going on and had information about what I can do to help.
COUNSELOR: Okay, let's set something up. How would the end of the week be for you?
[The session ends with Angela signing a release and a followup session being scheduled.]
Angela completed the inpatient treatment program and was referred to a local halfway house. After 2 months, she was accepted to a supervised living facility. She attended an additional month of day hospital treatment following her discharge and has remained clean and sober for a longer period than any time in her adult life (7 months counting her month-long hospitalization). While in the halfway house, she continued attending a Double Trouble support group for people with co-occurring substance use and mental disorders. She has continued in weekly outpatient counseling, where the focus remains on strengthening her commitment to abstinence, monitoring her psychiatric symptoms, and strengthening her relationships with others. She and other people in the Double Trouble group often eat at a local restaurant after meetings, and Angela expressed much satisfaction at having girlfriends in her life for the first time since she was a teenager. She had one hypomanic episode lasting about 2 weeks shortly after completing her day hospital program. This coincided with her admission to the supervised residential living facility. Her counselor worked with her residential supervisor and with Walter to continue their observation of her behavior, and her medication was readjusted. The hypomanic episode gave staff and Angela a chance to practice the relapse prevention strategies that had been developed during her inpatient stay. The staff concur with Angela's report that she has not experienced suicidal thoughts or behaviors. Angela, Walter, and her outpatient counselor have met on a monthly basis to be sure that communication has been maintained between Angela and her family, and Angela occasionally visits Walter and his family on weekends and some holidays. She feels accepted in the residential setting and has begun to see that as her home.
Leon, age 24, is an African American veteran of the Iraq War who is currently a college sophomore. He delivers pizza in the evenings. He has exhibited symptoms of posttraumatic stress disorder (PTSD) such as flashbacks, startle reactions, general apprehension, and intrusive images. He also shows symptoms of depression (sadness, sleep disturbance) since he returned from Iraq. He was discharged from the military when his 4 years were up, but the symptoms persisted. About a year ago he went to a Veterans Affairs (VA) clinic and received prescriptions for depression and sleep disturbance along with instructions to follow through with mental health counseling. He was in counseling with a psychologist and took the prescribed medication for about 6 months, at which point he discontinued treatment because he was feeling better.
Leon's drinking rapidly escalated after he started college last year, and his alcohol abuse continues. He drinks a fifth, sometimes two fifths, of vodka a week. Mostly he drinks after he gets off work around 11 p.m. and finds that “a couple” of drinks help him get to sleep around 2 a.m. Then he sleeps until around 7 a.m. When he doesn't sleep he gets restless, irritable, and startles easily.
Last night he had his usual two or three drinks of straight vodka in his dorm room after he got off work. He was found in a stuporous state the next morning around 9 a.m. and was rushed by ambulance to the local hospital. They kept him for several hours at the emergency department (ED), determined that he had not been drinking enough to warrant a detoxification admission, and eventually released him after he provided assurances that he would participate in alcohol counseling at the college alcohol and drug program. The ED staff made an appointment for him at the college alcohol and drug program this afternoon.
Leon denied any suicidal thoughts or behaviors when questioned in the ED. The ED personnel ordered a urine toxicology to assess for any drugs that may have contributed to his stuporous state prior to arrival, but when he quickly became alert and responsive, they released him before obtaining the results of his urine tests. They also mentioned ruling out suicidal ideation in their referral to the college counseling center. The emergency room personnel were not aware that Leon had been treated for depression at a VA facility last year.
To highlight the correlation between high alcohol and other drug consumption and suicidal behavior.
To explore how psychological trauma, depression, and substance abuse create a high-risk psychological environment for suicidal thoughts and behaviors.
To illustrate how an individual might minimize or disguise suicidality in an initial interview.
To illustrate how suicidal thoughts and behaviors can manifest among members of ethnic and racial minorities that historically have been thought to be at low risk for suicide.
To demonstrate how to obtain a consult with a supervisor for a client in the office who has a recent suicide attempt.
To emphasize the role of followup after referral of a client with suicidal thoughts and behaviors
[Leon arrives on time for his appointment at the college counseling center and is met by his counselor, James. Leon presents for the session looking somewhat bedraggled and hung over. He is withdrawn, not very communicative, and does not make much eye contact. The counselor is aware of his referral from the ED and the nature of his treatment in the ED, although he is not clear about the circumstances that led to his evaluation.
With this in mind, James decides to take some time to build a connection with Leon. They talk in rather general terms about what brought Leon to the clinic, and Leon begins, without much prompting, to describe his drinking patterns and life at college. Leon also mentions that he is an Iraq War veteran, having served 4 years in the Army after leaving high school. James does not pursue information about Leon's military experience, but rather lets Leon provide the information he is willing to give voluntarily.
Leon then describes what he remembers of the last 24 hours. Apparently he was blacked out part of the time but remembers being in his room last night and being in the ambulance on the way to the hospital.]
COUNSELOR: Leon, let me see if I can summarize some of what you've been telling me. You think you've been drinking too much recently, mostly vodka, and you've had some blackouts. And these have been a concern to you. From your description, it seems your drinking has increased lately.
LEON: Yeah. In fact, I didn't drink the whole year I was in Iraq, 14 months actually.
COUNSELOR: Anything you can think of that caused this increase in drinking?
LEON: Not really. I feel a lot of pressure, feel bad, worried. Then I drink. Actually, I drink pretty much every night. I sometimes drink more than I really want to. It helps me sleep.
COUNSELOR: And it sounds like you mostly drink alone.
LEON: Yeah.
[Long pause while the counselor waits to see if Leon wants to say more.]
COUNSELOR: Lots of pressure.
LEON: Yeah.
COUNSELOR: Can you tell me some more about the pressure?
LEON: Well, I don't have much time for anything but work and school. Work is #*%!. I drive around in the dark looking for addresses to deliver pizza. It's cold. One #*%! last week gave me a 50 cent tip. That didn't even pay for the gas. Also, I only get to study a little bit at work.
COUNSELOR: Other pressures?
[Long pause.]
LEON: When I'm alone, I get to thinking ….
[Pause, counselor doesn't want to interrupt.]
LEON: About stuff in Iraq. I've had #*%!ing incoming mortar land on the building next to where I was sleeping. Two guys were killed. Then the return fire starts. And you wonder where the next incoming is going to land. Plus some other stuff. Sometimes when I finally get home from work and lay down to go to sleep, I think about that stuff.
[The counselor proceeds to inquire about trauma-related symptoms, and Leon reveals a series of symptoms that suggest PTSD. He also tells the counselor about going to the VA Mental Hygiene clinic, the prescription he was given, and his participation in treatment with Dr. Rogers, a VA psychologist, for about 6 months after entering the VA program. Leon also mentions that he attended Alcoholics Anonymous (AA) on and off while in the VA program and had a sponsor at one time.]
Master Clinician Note: Some of Leon's risk factors for suicide include a history of substance abuse, PTSD-related symptoms, depression, and isolation. These symptoms, together with his ED admission, cause the counselor to wonder about suicidal thoughts or behaviors. Because of the combination of the client's age and race, he is also at increased risk of suicide.
COUNSELOR: Leon, I'm wondering if Iraq and the symptoms you just shared with me have anything to do with the increase in your drinking in the last year.
LEON: I drink to go to sleep and not remember that stuff.
[Another long pause.]
COUNSELOR: Leon, I imagine that sometimes you just wish there were a way to escape all of this stuff … the pressure of school and work, the memories, the drinking. …
LEON: Yeah.
[Another long pause.]
LEON: I think I may have had four or five pills last night too. I don't remember taking them, but the bottle was empty when I went back to my room after leaving the emergency room and before coming over here today.
COUNSELOR: Pills?
LEON: Sleeping pills. I don't know how many were there, but there were only a few left, maybe four or five at the most. I got them from VA when I went there last year. I don't remember taking them last night, but the bottle was empty this afternoon.
[Another long pause.]
LEON: I think I just wanted to go to sleep. I guess. Maybe that's why I couldn't wake up this morning and why they took me to the emergency room. I didn't tell anybody about the pills.
COUNSELOR: Thanks for telling me.
LEON: I don't remember taking them.
COUNSELOR: Your guess is that you were taking them to fall asleep. Are there any other possibilities?
LEON: Like what do you mean?
COUNSELOR: Well, you've been having a rough time, so I guess I was wondering if it is possible that you were trying to hurt yourself or even kill yourself when you took the pills since you emptied the bottle.
LEON: Sorry, but I can't really go there.
[Long pause.]
COUNSELOR: Leon, I may be way off, but I get the sense that you want to confide in me, but you are having trouble making the decision to do that.
[Long pause.]
COUNSELOR: Please take your time. This is important.
[Another pause.]
LEON: Screw it, I told myself I wasn't going to say anything, but screw it, I'll talk about it. I tried to off myself last night. I figured pills were the way to go. If it worked, it would be chalked up as an accident. I just can't live like this anymore, you don't know how I feel everyday. Death would be a relief from this. It would have to be.
COUNSELOR: You're in a lot of pain.
LEON: Tell me about it. Yeah, I know, believe me, I've thought about how to do it. I've thought about pills mostly. I've had too much with guns. Sometimes I've thought about what it would have been like to be shot in Iraq. All the blood and stuff. I don't want that. Sometimes I look out a window and think I could jump. But I might just get crippled up. Same thing with stepping out in front of a bus on College Avenue. But, who knows, these are just random ideas. It's not like I think about it all the time. I don't have any clear ideas about how I'd take myself out, if it ever came to that. Anyway, I don't think I'm ever gonna kill myself, what with the effect on my mom and all.
COUNSELOR: Are you concerned you might act on those thoughts? Be unable to control them?
LEON: I'm not too concerned. I'm not going to kill myself. No offense man, but that's what white people do. Last night I was drunk and just made a mistake, I guess.
Master Clinician Note: High rates of suicide and nonfatal suicidal behavior among Black males, particularly among youth, are cause for grave concern. Depending on the age, the suicide rate among Black males ranges from two to seven times higher than among Black females (who are generally at low risk). Suicide is a form of self-destructive behavior that differs from other risk-taking behaviors (e.g., getting killed through drug use and street violence) that some young Black men, particularly those living in urban areas of concentrated poverty, are prone to. In the latter cases, the individual accepts the possibility that physical harm could result from his actions, rather than intending or expecting such an outcome as with suicide (Joe, 2003). Widespread disbelief that Black Americans would engage in suicidal behavior continues despite research documenting a rise in suicide among young Black males (Centers for Disease Control [CDC] 1998; Joe & Marcus, 2003) such that their rate is closer to the rate in young White males than in previous decades, although White males continue to have a somewhat higher rate (National Center for Injury Prevention and Control, 2007).
COUNSELOR: Unfortunately the reality is that Black people as well as White people die by suicide.
LEON: Well, it's probably better that the pills are gone.
COUNSELOR: I hear you. On that we can both agree.
Master Clinician Note: The counselor is organizing his thinking about assessment and treatment planning for Leon. His perception is that Leon is a relatively isolated student, with few social supports, who has PTSD symptoms and depressive symptoms, abuses alcohol, is having suicidal thoughts, and made a suicide attempt last night. His possible co-occurring disorders indicate that he needs more intensive treatment than can be addressed in an outpatient college substance abuse program. James decides to pause the session for now and have Leon briefly wait in the waiting room with another clinical staff member while he consults with his clinical supervisor. James knows that a potentially acutely suicidal client should never be left alone.
COUNSELOR: Leon, the way we usually work here is that, when I meet somebody for the first time and find out about why they came to the counseling center, I check in with my supervisor. The two of us talk and work out what we think would be the best plan for what the next steps should be. Would you mind sitting in the waiting area for a few minutes? I'll be back after I've had a chance to get some input. Okay with you?
LEON: Yeah, I guess.
[James briefly describes the situation to his supervisor and asks for help specifically with treatment planning and how to ensure Leon's safety. James feels that an integrated treatment plan must address Leon's suicidal thoughts and behaviors, his drinking, his PTSD and depressive symptoms, and his disconnection or isolation from friends and family. He suspects that there is a high probability that Leon will not follow through on outpatient referrals without intensive case management. The counselor is sensitive to Leon's sitting in the waiting room and purposefully keeps the consultation session brief.
Decisions the counselor and supervisor reach are:
Further evaluation for suicidality is important, including consultation with the emergency department where Leon was seen this morning.
Leon's potential for suicide is directly linked to his mental health symptoms and substance abuse, and both issues need to be addressed in treatment.
Intensive substance abuse treatment and case management are important over the next few weeks until Leon has stabilized. This can best be accomplished in the local VA treatment facility.
They need to make some plans to support Leon until he can make contact with VA and begin treatment.
The counselor needs to continue to maintain contact with Leon to ensure that he accepts the referral and continues to participate in treatment.
Efforts should be made to help Leon reconnect with the AA group he attended a few times last year.
James returns to his session with Leon.]
COUNSELOR: Leon, I've talked with my supervisor, and we have some ideas that I hope you will agree to accept. In light of last night with the drinking and the pills, we would like to have you talk to someone. We're worried about the pills, and while I believe you when you say you aren't going to kill yourself, it is also important not to just ignore what happened. It is a signal of how much pain you're feeling and it requires that we take the depth of your struggle seriously and develop a plan that can realistically help you to begin to feel better. We can't help but think that your use of alcohol as well as the experiences that you had in Iraq contributed to your drinking and taking the pills last night, so it's important to get help for your drinking and your wartime experiences.
We think the best place to address all of this would be with Dr. Rogers, whom you saw at the VA hospital. They have programs to confront these issues that are really beyond the scope of our treatment programs here. You've been there before, so you know the place a bit, and it sounds as if you responded pretty well to the treatment. And I'm wondering if you agree with this.
LEON: I think you're overreacting to last night. Anyway, it's true I went to VA last year for 6 months or so and then quit going when I started feeling better. I didn't exactly like taking pills but I stuck with them. It wasn't too bad. I liked Dr. Rogers, he was cool.
COUNSELOR: Tell me more about what happened there.
LEON: Well, I started feeling better, so I stopped.
COUNSELOR: Okay, well, what I would like to see us do today is make a plan that really works for you. And I'm going to follow up with you too, to give you the support we can offer and to make sure you get the treatment you need.
LEON: All right, I'm listening.
COUNSELOR: Thanks, I appreciate that. Could I get your permission to call VA and make an appointment for you now? Then I want us to talk some about what you need to do to take care of yourself between now and when you get to VA.
LEON: Okay.
[The counselor has Leon sign the appropriate release of information form and makes the call to the VA intake worker. They arrange an expedited appointment for tomorrow morning. The counselor agrees to fax pertinent materials to the VA in advance of the appointment.]
COUNSELOR: Leon, lets talk some about what you can do to take care of yourself tonight before your appointment tomorrow.
LEON: Whaddya mean?
COUNSELOR: Well, for openers, is there anyone you know who could be a support to you tonight?
LEON: Is this really necessary? I've got an appointment tomorrow, after all, isn't this overkill?
COUNSELOR: I suppose I could see how this might seem like an overreaction but on the other hand, you were in the ED this morning, and took an overdose last night, and so it seems much better to land on the side of overresponding rather than underresponding. As well, I don't think of it as overresponding so much as simply trying to do the smart thing.
LEON: All right, I can see you are not going to drop it, so let me see who I can come up with. Nobody in school, that's for sure, they all drink like me. When I used to go to AA, there was a cool guy there, he was my sponsor for a little while, he would always say “call my cell anytime,” and I did call a few times and he always answered. He'd take me to meetings. I even called his cell once the day after I was drinking, and he didn't yell at me or judge me, just listened patiently and then got me to a meeting, I was pretty amazed. Anyway, I can give him a call. He's a nice guy, graduated from school here a couple of years ago and lives just off campus still.
COUNSELOR: Now that sounds like a “smart thing.” I really appreciate your coming up with that. Since you bring up AA, that might be a solid way to get a little support tonight, or at least keep you from being isolated. Is there a meeting scheduled tonight?
LEON: Yeah, there's one just off campus, it meets every weeknight at 8:00, pretty popular meeting, always a bunch of people there. I used to walk there once or twice a week, that's where I met my sponsor.
COUNSELOR: That's pretty solid, the meeting will be there for you whether or not your sponsor is around, and from what you've said he'd more than likely be willing to talk with you, or perhaps even meet you at the meeting, assuming you can reach him at that number.
LEON: Yeah, he was always gung ho, I wouldn't be surprised. Anyway, I can hit the meeting. I've got nothing better to do tonight. I'm not up for studying, I'll tell you that much, and don't want to mess with any of those guys in the dorm, they act like kids.
COUNSELOR: That's great Leon. I'd like to stay with this safety planning a bit longer. Okay with you?
LEON: We're cool.
COUNSELOR: You said you took all the sleeping pills. You don't have any more. Is that right?
LEON: Yes, that's right.
COUNSELOR: No tranquilizers, no antidepressants, no sleeping pills, no booze. No other prescription drugs in your dorm room, right?
LEON: Yes, roger that. You must've won the “hero counselor award” or something.
COUNSELOR: No, I've won no such award, and hero definitely doesn't come to mind. I am just trying to be thorough. And so thanks for hanging in there while I try to dot all the i's and cross all the t's. Along those lines, I'd also like to provide you information about who you might call if you have a difficult time tonight, for example if you become depressed or start thinking about suicide again. I want you to have my number, the number of a national suicide hotline, and the number of the emergency services program here at the college.
LEON: That's not gonna happen.
COUNSELOR: I believe you, and I hope you're right. I think your plan to go to a meeting tonight, and to contact your old sponsor is fantastic. This is just one last, added safety measure. Here is my card. On the back of it I'll write the number that you can call if you have an emergency during nonbusiness hours. Also, I'll write the number of the national suicide prevention hotline and the emergency services number. These numbers were set up specifically for people who are going through a lot—people like yourself—so there is no shame if you're in a bad way and need someone to speak with to help you through it.
LEON: Okay, got it. All right, this is helpful. I never knew about these numbers.
COUNSELOR: Do you have transportation to VA tomorrow?
LEON: I have my car.
COUNSELOR: Okay, just to confirm. Tomorrow morning, you'll have your VA appointment at 9:30 a.m. with Dr. Rogers. You are going to call your sponsor and make a meeting tonight. If you find yourself getting overwhelmed, thinking about drinking or thinking about suicide, you'll call our emergency number or the 800 hotline on the card you have.
LEON: Okay.
How to Develop a Campus Suicide Prevention Team.
COUNSELOR: Just to let you know, I'm going to follow up with the VA tomorrow afternoon to make sure you made it there and to see how things went.
LEON: Yeah, I figured. Don't worry, I'll keep the appointment, I can't keep living like this, I hope they can do something for me, some meds again or counseling or something.
COUNSELOR: They have several types of treatments available, and they've tailored their services to returning vets like you. So I think they'll be able to help you out. I certainly think that you deserve to feel better than you have been lately.
Leon left the session feeling understood and supported. He had clear plans for the next steps he needs to take and was mobilized to take these steps. The counselor confirmed that Leon kept his appointment at the VA and had been enrolled in a substance abuse and co-occurring disorders program for returning vets. He was able to arrange his treatment schedule in a way that only required dropping one class and was able to continue his job. He has restarted his antidepressant medication, and treatment staff at the VA are continuing to monitor suicide warning signs and risk factors. The counselor in this vignette was careful to document his screening for substance abuse and suicidality, the consultation with his clinical supervisor regarding referral, the referral that was made, and the followup on the referral to the VA.
This case illustrates gathering information from a client who alludes to suicide. The counselor must discern how to proceed with Rob and also address the impact Rob has had on the counseling group where he made indirect references to suicide. The counselor must sift through what she knows to understand Rob's risk factors, warning signs, and protective factors for suicidal behavior. The vignette also raises issues of treatment transition in early recovery and addressing ambivalence.
Rob is a 39-year-old Caucasian accountant. He is gay and is in a conflicted, long-term relationship. He is nearing completion of an intensive outpatient treatment (IOT) program. During his twenties he used a variety of psychoactive substances, but his drug of choice was marijuana, sometimes laced with PCP. In his thirties, he began to drink heavily and has done so for 6 years now. This is his first treatment effort, and he entered treatment as a result of a crisis in his relationship. Also, he has been missing work as a result of his alcohol use and the volatility of the relationship. He went to his Employee Assistance Program (EAP) at work, and EAP personnel identified Rob's substance abuse and referred him to an IOT.
At the end of group last night, Rob made a reference to suicide: “I might be better off dead.” Until then, no significant warning signs of suicidality had been noted with Rob. The group, however, immediately picked up on his comment and began to question him about suicidal thoughts, which he denied. His counselor, Joyce, believed it was important to follow up with Rob after group. Joyce also recognized the importance of addressing the group's anxiety and concern about Rob. Long-term risk factors for Rob include depression, a troubled partner relationship, work-related problems, and minority sexual orientation. In addition, he is at a treatment transition point that may create vulnerability. Protective factors include a generally solid work history and remaining abstinent through the treatment program thus far.
To illustrate how subtle signs of suicidality can manifest in an intensive treatment environment.
To demonstrate a therapeutic response to subtle signs of suicidality.
To illustrate the significance of understanding risk factors, warning signs, and protective factors during the course of treatment.
To illustrate the effect that a client's statements regarding suicide can have on other clients in the treatment program.
[The vignette begins with Joyce's meeting with Rob for an individual counseling session immediately after the group during which he alluded to suicide.]
COUNSELOR: Rob, the reason I asked to speak with you after group is that you made a comment right at the end that you might be better off dead. I have some concern about that. Can you talk a little more about what was going on with you?
ROB: I'm just #*%!. Nothing is going well. Sometimes I think I'd be better off dead. I think it would be better for my parents, for my boyfriend, maybe it would just be better for you. I don't feel like I belong. I don't feel good at all. I thought recovery was supposed to make me better, supposed to fix things, and now I don't feel fixed.
COUNSELOR: You've worked really hard on your recovery, but I'm hearing you say that the struggle, especially with relationships, is so painful that you might do anything to escape it, even use again. Before we go any further though, Rob, I just want to check something out with you. Are you using at all?
Master Clinician Note: Clients who have relapsed to substance use are particularly susceptible to suicidal thinking and, potentially, to suicidal behavior.
ROB: I'm clean, Joyce. I told you that. I told the group that. I'll pee in the cup if you want.
COUNSELOR: Okay, good. I believe you, just wanted to be sure. Providing a urine sample isn't necessary today. At this point, I'd like to focus on your comment in group. I want to hear more from you about your thoughts of killing yourself.
ROB: I haven't given it much thought, really. I'm just frustrated, and things don't seem to be working out like they are supposed to. I just said that in group.
COUNSELOR: It sounds like you'd like to stop how you're feeling. As we talked about in group a few days ago, early recovery can be a real struggle, two steps forward and one step back. And sometimes things don't get better immediately. In fact, sometimes things feel worse when you begin to make changes.
Master Clinician Note: Early in her interview with Rob, Joyce needs to clarify whether Rob is minimizing his suicidality or if he really just made an impulsive statement in group to express his frustration. She wants to establish whether or not managing active suicidality will be the focus of her meeting, or if the focus will be on the provocative nature of his speech and its impact on the group. Therefore, Joyce first prioritizes gathering information about suicidality, and once she is satisfied that there is little data to indicate current risk, she switches the focus to his impact on the group.
Joyce's counseling style is more direct, perhaps even more confrontational, than other counselors depicted in these vignettes. This style illustrates the spectrum of counseling approaches in real world practice. But note that Joyce is still careful to avoid grilling or accusing Rob, which could make him defensive.
ROB: I'd like to stop feeling bad. Recovery isn't what I'd thought it'd be. I thought I'd feel better about myself. I'm not comfortable.
COUNSELOR: And I hear that. And I also know this is hard to talk about. But I want to ask again if you are thinking about killing yourself.
ROB: I don't need that. I don't need that stress. I'm not going to do anything like that today. I'm just stressed out.
COUNSELOR: Okay, not today. But that leaves tomorrow and the next day and next month open.
ROB: No, I'm not really thinking about killing myself, if that is what you want to hear.
COUNSELOR: Rob, it isn't about what I want to hear. It's about what you are contemplating doing.
ROB: Okay, okay. I'm not thinking about killing myself. I just need some relief from this pressure. And I know it would be the end of my relationship with Sammy if I drink again.
COUNSELOR: So what I'm hearing you say is that you have been feeling upset but you haven't been having thoughts of suicide. Is that an accurate summary, or do I have that wrong in some way?
ROB: That sums it up pretty well.
COUNSELOR: I'm glad I understand where you're coming from. I'd like to ask just a couple of more questions along these lines. One question is whether you've ever attempted suicide?
ROB: No, never. I'm scared of pain; that's not my thing.
COUNSELOR: What plans have you made about killing yourself?
ROB: None, I've never gotten that far, I don't know what I'd do if I ever seriously thought about it.
COUNSELOR: Okay, thank you for providing the answers to my questions about your safety. I wonder if we could shift gears now and discuss the group a bit, their concerns about what you said in group tonight and how you might approach this when you go back tomorrow night.
ROB: After they all jumped on me tonight, I'm not sure I want to go back.
COUNSELOR: Part of treatment is learning how to face this kind of situation: how to handle yourself in difficult circumstances and be sober at the same time. You've done a good job in treatment, Rob, and you are almost finished with your IOT program.
ROB: I feel like you're dumping me. I don't understand. What is this place? You bring us in. You help us. You take care of us. You just have some arbitrary deadline when we're supposed to be better. And then you just throw us to the wolves.
Master Clinician Note: Joyce recognizes that Rob is diverting attention from discussing how he will handle himself in group, but also is expressing his concern about the upcoming treatment transition. She wants to acknowledge his concerns and still keep the focus on how Rob will react in the group tomorrow.
COUNSELOR: If you could write your treatment plan right now, if you could spell out your group experience, what would you say would be most useful for you in bettering your group sessions?
ROB: I don't know. I like the one-on-one. I sorta put up with the group. Meeting with you … I like the one-on-ones.
COUNSELOR: Right now, how about if we look at continuing our individual sessions twice a month for the next few months. However, there's something that definitely needs to be addressed. I'm going to insist that in order to stay in the one-on-ones you're going to need some of the group experience too. Did you notice how the group reacted when you said you might kill yourself?
ROB: Did I notice!
COUNSELOR: Greg said you had a lot to live for. Allison asked “does that mean you're going to kill yourself?” Bill said something about making sure you got home okay tonight. The group members are really concerned about you. And I don't think we can just sweep that under the rug now.
ROB: I'm not sure I even heard. I was in my own head.
COUNSELOR: Listening now to what they said, what do you think of their reaction?
ROB: Are you saying I shouldn't say how I feel?
COUNSELOR: No, not at all. Actually, that is part of what I'd like you to work on, to express how you feel. My sense is that your statements about being “better off dead” and related comments weren't really statements of how you feel; you were using them more like slang expressions to indicate your general frustration and anxiety. As a result, with those provocative comments, you threw the group off track from the real issues, including fear of transitioning out of the group and frustration in your relationship. What I would like to help you do is to express more directly your issues and feelings to the group. In that way they won't be going down the wrong path, focusing on your safety, when they could be helping you sort through these difficulties.
ROB: I didn't mean to make people nervous. I was just upset and said something impulsively. Are you saying I did the wrong thing in group?
COUNSELOR: No, I'm not. People were naturally distressed. Because you are part of the group, it has to be talked about that way. It's not about your doing something bad or wrong. It occurs to me that your statement tonight about being better off dead may indicate that we need to think through your transition plan a bit more carefully. Maybe part of this is that you do need to be in primary treatment a bit longer and that we need to look carefully at how the transition occurs.
ROB: One thing's for sure, I'm not looking forward to going back into the group. Are you going to support me?
COUNSELOR: Sure, I'll support you. If it's all right with you, at some point in the group I'll let them know that you want to talk a little bit about what happened in the last group, and straighten them out about what's really going on. However, I won't do that right away, I want to give you the chance to raise the issue on your own first.
ROB Yeah, I can do that.
COUNSELOR: Well that's our plan. Tomorrow, you'll come into group and give the group an opportunity to discuss some of their issues. Also, let me talk with the team about your transition plan to make sure that we are covering all of the bases and going at the right pace.
ROB: Okay, cool.
Rob returned to the next group meeting and, with Joyce's support, addressed his suicide reference in the earlier session. He was able to hear the concerns of the other group members, and a good discussion among group members ensued with several other members briefly sharing prior experiences with suicidal thoughts.
Joyce met with her supervisor and together they decided to adapt Rob's treatment plan to include an extension of treatment with twice-monthly individual sessions for an additional 2 months. Joyce will continue to monitor Rob for warning signs. She will also work to strengthen protective factors such as maintaining abstinence, treatment attendance, and maintaining his employment. She will discuss the possibility that he attend a support group or get involved with another community resource as a kind of safety net that will always be there for him. In a later discussion with Rob, it was decided that couples' counseling might be useful after he has 3 months of stable sobriety. Joyce ensured that both Rob and his partner had information on contact resources if suicidal ideation should recur in the future.
Joyce documented the session with Rob including the information gathered, the distinction between frustration and suicidal ideation as he expressed it, and the re-evaluation of transition plans.
Vince is a 52-year-old Caucasian mill worker with a history of substance abuse, aggression, and relational difficulties. This is his third effort at substance abuse treatment. He volunteered for intensive outpatient treatment three evenings per week after an altercation with his wife that culminated in his physically assaulting her. During his second week of treatment, while at work at the mill, he was served an order of protection, mandating that he not have contact with his wife and that he not enter their home.
He came to the treatment program this evening agitated, angry, and believing he had been victimized. His counselor, Kara, attempted to help Vince work to resolve the crisis, but he deflected the issue and became more agitated. Vince mentioned that he might as well be dead, so Kara began to question him about suicide risk. Vince defiantly described how he would kill himself with his handgun. Kara was unsure whether Vince was making a plea for attention or was actively suicidal and realized she was not in a position to make that decision. The counselor must explain to Vince the need for a psychiatric evaluation for suicidality in the emergency room of the local hospital.
Break-up by a partner or a threat to a partner relationship is a common precipitant of suicide among vulnerable males with substance use disorders (Duberstein Conwell, & Caine, 1993; Heikkinen et al., 1994; Murphy, Armstrong, Hermele, Fischer, & Clendenin, 1979). Often, this scenario follows a pattern of intimate partner violence (Conner, Duberstein, & Conwell, 2000). Men who abuse alcohol and/or drugs and are confronted with a break-up or threat to their relationship, particularly those showing a pattern of jealousy, domestic violence, legal difficulties, or prior suicidal behavior, may also be prone to committing homicide followed by suicide (Bossarte, Simon, & Barker, 2006; Marzuk, Tardiff, & Hirsch, 1992). Indeed, the risk factors (male, substance dependence, violence history), precipitating event (relationship break-up), and warning signs (suicidal communication, ideation, feeling trapped, hopelessness, anger, recklessness, mood change) observed in Vince's case could set the stage for him to take his own life or, even more tragically, to murder his estranged wife before his suicide. Consequently, his case is doubly concerning.
Vince has a history of substance abuse dating back to his teenage years. His academic performance in school indicates that he may have had an undiagnosed learning disability and relationship difficulties with other students and with authority figures. He joined the U.S. Navy and was medically discharged after 6 months for “emotional problems” and misconduct while drinking. He went to work for a local paper mill and, while occasionally in trouble for attendance problems, has worked there for 26 years. He has worked his way up to a forklift driver. He married Jolene when he was 32. They have no children together, although Jolene has two children from a previous marriage who live on their own. Vince's drinking has been a problem in the relationship since before they married, but, until now, they have not been legally separated. Vince's two other treatment efforts were precipitated by marital crises. As a result of the recent physical abuse, Jolene insisted that Vince get treatment again and move out of the house. He moved into a garage apartment belonging to his brother-in-law.
Vince has never sustained abstinence. After both treatment episodes, he was drinking beer again within a month. He has occasionally attended AA as an extension of treatment, but has shown little interest in continuing attendance when active treatment ends. His typical drinking pattern is to drink three to four beers each weekday after work and two six packs or more a day on the weekends. He rarely appears intoxicated but almost always, except when working, is under the influence of alcohol. He makes sure he doesn't have alcohol in his system while at work because forklift drivers at the plant are randomly screened for alcohol and illegal drugs, and a positive screen is grounds for immediate dismissal. The most significant of his alcohol-related problems come when he “breaks out,” drinking bourbon or vodka until he passes out. During these episodes, he becomes verbally and physically abusive. On several occasions, he has ended up in jail on drunk and disorderly or assault charges. These occasions have extended as long as a week. He takes sick leave from work, and Jolene stays at her brother's house until he gets too sick to continue drinking.
Vince's warning signs were triggered by receipt of the protective order. They include his spontaneous suicide communication “I might as well be dead,” a lethal plan (handgun), anger and agitation, and feeling trapped by and hopeless about his marital situation. Vince's long-standing risk factors include a history of chronic alcoholism from an early age, poor response to past treatments, emotional volatility (particularly anger), social isolation, firearm ownership, and history of aggression and violence toward others. Protective factors are stable employment, current sobriety, good attendance in his current treatment program, and a working connection with his counselor.
To demonstrate gathering information about suicidality with a client in an emotional crisis.
To demonstrate the role of compassion and concern in developing a therapeutic relationship with a client who may elicit anger or disgust from the counselor.
To demonstrate crisis intervention and referral with a client who is not initially cooperative with treatment planning.
To illustrate specific strategies for working with resistant clients.
[The dialog begins with Kara and Vince in an individual counseling session that evening. Because Vince is agitated, Kara arranges the seating so they both have a clear path to the door, with no obstructing furniture, and discreetly alerts colleagues near her office to listen for anything (e.g., shouting, unusual or loud noise) that might suggest that she is at risk.]
COUNSELOR: Well, Vince, I appreciate that you came in and sat down to talk with me. I heard from other treatment staff this evening that you've been upset.
VINCE: Damn it, she told me she wasn't gonna do that. She told me if I get treatment, if I'd go again, you know, she wouldn't leave me. And I'm at the mill today, and damn it, there comes this letter from this judge and this damn lawyer that I'm paying for. I'm payin' for him, and he sends me this letter that says I can't go to my own house. Now, that's just not right. I pay for that house.
COUNSELOR: You got the letter today?
VINCE: Yeah.
COUNSELOR: Yeah. That is upsetting.
VINCE: I can't #*%!ing believe it—that she'd do that. You know, the thing is, I mean, I know I get angry at her. She spends money like you can't believe. And I know I get angry, and I know I shouldn't drink. I know that too. But, you know, without her, without her, there's just nothing for me!
COUNSELOR: Well, you know, that's a big leap from getting this letter from a lawyer to saying that you're going to be without her forever. Can you fill in some of the blanks for me, and help me understand what's been happening over the last couple of weeks? We haven't talked in a lot of detail about this.
VINCE: Well, the deal was, we had that bad little episode.
COUNSELOR: Now, that's the one where you got violent, is that correct?
VINCE: Yeah, I did get physical.
COUNSELOR: You hurt her pretty badly, if I recall correctly.
VINCE: Sometimes I think she exaggerates a little bit too.
[Long pause during which Vince stares at the floor, shaking his head.]
VINCE: But I did hit her, I did hit her. I just get so mad, and I did hit her. But that was, you know, we had this deal: I'd come to treatment, and I like treatment, I like the fellows here. I like you, you know, and I could keep working, and I'm living apart from her. I'm living in my brother-in-law's garage. It's her brother, but we kinda get along and I'm living in his garage apartment, and so I've been coming to treatment. And I've been doin' fine until this happened, and it just, like, it knocked the legs out from under me, and I was—
COUNSELOR: You've been working hard. You've made a commitment, and you've been here for every session, I think.
VINCE: Damn right, I've been working hard.
COUNSELOR: You sound extremely upset today. This protective order hit you pretty hard.
VINCE: I just love that woman; I just love her. And I don't know how I can live without her. I just—[sighs].
COUNSELOR: You know, when I hear you say that, it troubles me: that you don't know how you would live without her. What do you mean when you say that you're not sure that you can live without her?
Master Clinician Note: Kara attempts to focus on Vince's allusion to suicide, but Vince deflects. The counselor decides to let the subject go for now and return to it later. For clients who have difficulty talking about suicide, acknowledging this fact and introducing the topic carefully can make a difference. Some examples of introductory comments are:
“Now I have a few questions to ask you about suicide if that's okay.” Then, after the client nods permission, “Have you been having thoughts of suicide?” Proceed with questions.
“I would like to speak with you about suicidal thoughts and behavior. Is that all right?”
“These seem like difficult questions for you. Is it all right if we proceed?”
“The topic of suicide can be uncomfortable, so I really appreciate your discussing it with me openly.”
“I'd like to ask you some more questions about your suicidal thoughts so that I can understand them. Is that okay with you?”
“I'd like to ask you some more questions about your suicide attempt so I can understand what happened. Is that okay with you?”
It is also important to express empathy before seeking permission to explore more sensitive and private questions, especially at the outset of an interview. You might say, for instance, “You're going through a very painful time in your life right now, so painful it could seem that life is unbearable.” You might continue, “The topic of suicide is uncomfortable, so I really appreciate your discussing it with me openly. May I have your permission to hear more and understand that better?”
VINCE: I just can't imagine living without that woman. I just—there would be nothing left for me. We don't have any kids, never did. And she has some kids by her first marriage, but they don't spend that much time with me. And there's just nobody else in my life, and I might as well be dead, if I don't have her. And damn it, you know, it's the lawyer who did all this. There's just no reason for this. There's just [sighs] … One little event, it just goes to hell in a hand basket; it's just too much. It's just—
COUNSELOR: Do you mind—let's talk a little bit about that letter, because when you get upset and angry, I know that it's difficult to keep focused on what's happening now—what really is the problem. So, let's go back to that letter. Do you mind sharing a little bit about that with me? Just help me understand exactly what it said.
VINCE: The lawyer wrote me a letter and said I can't go to my own house and I can't talk to my own wife, and that doesn't leave me much to do except sit in a damn garage. I really don't want to drink 'cause if I drink, man, I know, you know, I'm just gonna get flat out of control if I drink. I've met the cops in this town a few times, and I know that I don't wanna meet them again when I'm drinking. And I just don't wanna drink.
COUNSELOR: Your decision not to drink is a wise one; I really support you on that. It takes a lot to stay sober after getting this kind of news.
[Pause. Vince's eyes tear up briefly but he fights them back. He is looking down, sullenly.]
COUNSELOR: Vince, I want to explore a couple of things with you if I have your permission.
VINCE: Sure, I guess. I'm not going anywhere.
COUNSELOR: You said a minute ago that you aren't sure you could live without Jolene. Does that mean you are having suicidal thoughts or plans?
VINCE: Well, I mean, this woman is my whole life. She's all I have. We're married, damn it! It's that damned lawyer causing all of this.
[Kara senses Vince's agitation and defensiveness and, while not satisfied that the issue of suicidal intent has been adequately addressed, decides to not push the topic now, but to cycle back to it.]
COUNSELOR: Have you been feeling a pretty strong urge to drink?
VINCE: No, not really; I'm just mad as hell, but I know how I am. I've been through treatment a couple of other times here, and one of the things I learned was that when I get mad is when I'm likely to get drunk. It's what AA calls HALT, hungry, angry, lonely, and tired. I drink a little beer at other times, but it's when I get mad and I get drunk that I get in trouble. And, really, I don't wanna do that, you know? But I'm mad as hell right now, I'll tell you that!
COUNSELOR: I'm getting that.
VINCE: It just feels like the whole #*%!ing world's against me!
COUNSELOR: Well, it can seem that way, sometimes.
VINCE: I'm glad somebody understands that, I mean, she sure doesn't, apparently. I haven't talked to her. I can't talk to her, that's that. I can't talk to her; I can't go home.
Master Clinician Note: Kara sees a chance to again address Vince's allusion to suicide and decides this time to seek Vince's permission to discuss “a painful and difficult topic.” By eliciting his cooperation she hopes to avoid his resistance to discussing suicide.
COUNSELOR: Can we, for just a moment, go back and explore your comment that you can't live without Jolene? I want to make sure I understand what you are saying. Are you agreeable?
VINCE: I guess so; I got no place else to go. And actually, I kind of gotta thank you for talking to me. I do. I know I get kind of upset, and I can't be a lot of fun to talk to when I get this way.
COUNSELOR: Well, I appreciate your willingness to talk with me about this difficult topic. Frankly, I'd rather have you sitting here with me being upset, talking about some options and maybe some things we could do about it, than have you outside being upset and deciding to go out and get in trouble.
VINCE: Yeah, I might go out and get in trouble.
COUNSELOR: Well, how about if we go back to that comment that you made a minute ago. I want to make sure that I understand this. You tell me that you're angry, and I know in the past when you've gotten this angry, and particularly when you've started drinking again, that you lose control. And you made a comment about not wanting to live without Jolene. Can you help me understand, what did you mean by that? Did you mean that you're thinking about killing yourself or killing Jolene?
VINCE: I just can't imagine—I can't imagine living without that woman. You know. Kind of serve them right if I went out and just blew my brains out, you know? Just spattered blood and brains all over the place. Maybe she'd feel better. Yeah, yeah. To tell you the truth, I say I don't wanna go out and drink—I'm really kinda scared to; if I went out and got drunk right now, I really don't wanna mess with her, and ain't nobody else to mess with but me. And if I didn't mess with her, I'd probably mess with me. If the truth is known, that's probably the truth. Yeah.
Master Clinician Note: At this point the counselor has made a decision that Vince needs an emergency room evaluation today, given his warning signs (suicidal ideation, suicidal communication, access to a gun, anger/agitation) triggered by an acute stressful event, risk factors (poor impulse control, aggression and violence, inability to establish abstinence, unstable marriage), and his minimal protective factors (with the exception of stable employment). Solidifying this decision, Vince has a recent history of significant violence towards his wife and is alluding to relapsing and “messing with her,” indicating not only that he is at risk, but that she is as well. From this point forward, the counselor's focus is on eliciting as much cooperation from Vince as possible to obtain emergency evaluation, with the understanding that the need for such an evaluation is non-negotiable. The counselor will also bring her supervisor into this process to confirm her decision and to assist her as needed with Vince.
COUNSELOR: When you talked about that, you sounded like, have you had thoughts of shooting yourself? Is that the idea that's been going through your head?
VINCE: Well, you know, like, I'm sittin' here with you right now, I'm not gonna act on it right now.
COUNSELOR: Okay.
VINCE: But I couldn't say I wouldn't act on it if I left here right now, you know, I mean, there's just no #*%! place to go! 'Cept to a garage with a bed in it.
COUNSELOR: I'm glad we're together right now so you're not alone. Really bad feelings and urges to drink or to hurt yourself or someone else are not something we choose; the feelings are just there sometimes. But we can make good choices or less good choices about how to deal with bad feelings. Could we explore your choices in this situation?
VINCE: I guess so, yeah, I mean, I don't have nothing better to do. I don't wanna, I really, I came in tonight, I don't, I don't wanna go to group tonight. I don't wanna deal with this stuff, talk to people about it, I don't want them—whining about it. Analyzing it. I don't wanna do that. So, I'm okay just sitting here talking to you about it. I don't know where it's gonna take me, but, it beats going out and getting drunk.
COUNSELOR: Well, I agree. It definitely beats going out and getting drunk. Why don't we sit here and talk a little while, and then we can come to some decision about what's going to be best for you. I do know that in the past, group has been an option for you to talk about what is going on.
VINCE: Yeah, I just don't wanna go in there tonight and have all these people saying, oh that's terrible, and, I don't know what they're gonna say, really. But, I just know if I start talking about it, every time I start talking about it, I just start getting upset about it again; I open that letter and look at it, and there I go again.
COUNSELOR: Well, when we look back over time and we think about how you've been in treatment a couple of times. I'm sure you've learned some things that have been helpful for you.
VINCE: Yeah.
COUNSELOR: When you get upset, when you get angry, when it triggers that craving and you feel the need to use and you feel like your anger is escalating, what kinds of things have been helpful for you? What sorts of things have you done that have really helped diffuse some of that anger and helped you move forward?
VINCE: Well, one thing is get away from her because when I'm likely to get out of control, I take it out on her. Now, there's two kinds of drinking I do. One kind is I just drink a little beer. And the other kind is where we get in these arguments, and when we get in these arguments, I just say, the hell with the whole thing. And I wanna get as drunk as I can get. And that's how I feel now. But what I've learned in treatment, the other two times, is not to get into those arguments. And that's what happened 2 weeks ago. I thought everything was fine, and she started picking, picking, picking, you know. And it doesn't seem to matter what I do, it ain't gonna be good enough for her. And then I get #*%!ed off, and I drink, and then I hit her a couple of times.
COUNSELOR: It sounds like it's really important for you to keep your distance right now—not to have contact with Jolene.
VINCE: I don't have any choice, I don't think. I mean, if I don't keep my distance, I'm gonna go to jail, and I don't wanna do that.
COUNSELOR: So, we can work on your keeping your distance, but how can you keep your distance in a healthy way? How do you keep your distance in a productive way without drinking and without escalating this anger and, like you said, going back and sitting in that garage apartment?
VINCE: I don't know where I'm goin' tonight. I mean, that just … I can't go home because I don't have a home anymore. I'm paying for most of it, but I can't go to my own home. I don't wanna call people about this and whine about, “oh, my wife gave me a letter, I can't go home,” you know? I don't wanna do that. So I just know if I leave here, it's gonna be real hard not to drink.
COUNSELOR: Well, I know that in the short time that I've known you and that we've worked together, that when you've felt this way and you've been hurt and wounded in this way in the past, that—
VINCE: Well, that wounded is the right word there, I tell ya.
COUNSELOR: How do you feel like you've been wounded? It sounds like that was an accurate word.
VINCE: Jeez, look at what she did to me, you know, I love that woman.
COUNSELOR: Well, in the past you've described her as the most important person in your life, I think.
VINCE: She is, Kara, she is. I can't imagine living without her.
COUNSELOR: It's painful to think about missing somebody that you love, somebody that you care about.
VINCE: I don't plan on losing her. If I lose her, that's it for me. I don't plan on losing her. I don't know how I'm gonna—I really think the lawyer put her up to this. They'll make a big deal and get a whole lot of my money out of it.
COUNSELOR: You know, Vince, when I hear you say that, and I hear you talk in this way, and you feel this amount of anger, I know in those past incidents when you felt this way how out of control things can get. With how angry and upset and hurt you are right now, and how vulnerable you are to drinking, and how bad your judgment might get if you start to drink, well it all adds up to a really volatile and unsafe situation, for both you and Jolene. I'm way too concerned about you to think about what might happen if you go home tonight. Gosh, I'd be worried to death that I'd be reading about you in tomorrow's papers, and that would be a terrible ending to all of the hard work you've put into your recovery. I mean you've been really trying. Gee, you haven't missed a single group, and you've been sober from the get-go, and you've shot straight with me from day one, and I really appreciate that. Therefore, I feel like I've got to be just as straight with you. Tonight Vince, given where you're at, what we really need to start discussing very seriously is you getting an evaluation at our emergency room, and very likely coming into the hospital for a little while until you can right yourself again.
VINCE: Oh, I ain't gonna sit in no emergency room all night. I don't know where I'll go. I really don't wanna drink. I wanna drink, but I know what would happen if I do drink.
COUNSELOR: Well, I don't want you to drink, and I don't want you to be in a position where you're at risk to hurt yourself or to make a bad decision.
VINCE: I don't want a bunch of shrinks looking at me; I don't want people—I know people from the mill go to the emergency room every day and, damned if I want them to see me in the emergency room, waiting to see a shrink!
Master Clinician Note: Vince clearly does not want to go the emergency room and Kara is a critical strategic juncture. MI provides a framework that can be used to address Vince's reluctance to go to the emergency room (see TIP 35, Enhancing Motivation for Change in Substance Abuse Treatment [CSAT, 1999b]). From an MI perspective, the counselor can attempt to “roll” with Vince's resistance by trying to understand his concerns about going to the emergency room and helping him explore both reasons against and reasons for going to the emergency room. By taking this approach, the counselor avoids creating resistance by treating Vince's potentially legitimate concerns as unreasonable. Instead, the counselor acknowledges Vince's concerns and tries to help him explore some of the pros of the decision. Given the severity of the situation, the counselor believes that an evaluation in the emergency department is needed. Although she will show as much respect for Vince's autonomy as she can, she will explain to him that the evaluation is important because it will prevent him from hurting the people he loves or doing something he will regret.
COUNSELOR: But at the same time, you've said that you want to make sure you're safe: that you take the right steps and that you want to honor this commitment that you made to recovery. You've done a nice job working on that. But tonight you've raised enough concern for me that we really need to go down to the emergency department and look at having you evaluated and determine whether or not it's the best place to be. I mean, you've received some incredibly tough news today, and you're reeling from it, and still trying to make sense of it. You're angry and hurt and really just beside yourself. If alcohol gets added in, well, it could just really all blow up, with terrible consequences for you. I'm frankly worried that you could shoot yourself. I also have to be honest with you Vince. I'm afraid for Jolene's safety if you leave here tonight and go drink. This is one of those times, when things have gotten really tough, that it's important to allow me and other professionals like me to do some of your thinking for you, because your judgment is not the best right now. Believe it or not, you can get through even this time, as impossible as that might seem right now, but you have to allow us to help you.
VINCE: Oh, #&*@; I shouldn't have even told you this stuff in the first place, you know?
COUNSELOR: Does it scare you a little bit to think about it?
VINCE: It scares me that, whoa, I don't know what's worse, getting put in the city jail or getting locked in the hospital, you know?
COUNSELOR: What's the worry that you have about the hospital? Can you help me understand that?
VINCE: Yeah, I don't want people calling me crazy. I mean, I'm a drunk, but I'm not crazy! You know? And I don't want people saying, “oh, did you hear about Vince, gonna kill himself, yuk, yuk, yuk,” you know? I don't need that #*%!. I got enough problems already!
COUNSELOR: Is that what you hear me doing? Do you hear me calling you crazy?
VINCE: No, no, no. I really think you want the best for me, Kara. I really do. I really do, but I don't wanna get locked up with a bunch of nuts. And I don't want people talking behind my back, I want … tell you what, we'll just call this off and I'll promise you I won't kill myself.
COUNSELOR: Well, I'm not sure, Vince. Just a few minutes ago, you told me clearly that you felt out of control.
VINCE: Oh, I am. I am mad.
COUNSELOR: Well, what we're talking about is not having you stay in the hospital and be labeled as crazy but recognizing that when you're at risk and feeling out of control we need to do some things to help you regain control. We need to help you maintain your recovery and do some things that are healthy for you. We're talking about your taking that step.
VINCE: Where are you talking about sending me?
COUNSELOR: We'll just walk downstairs to the emergency department and I'll go with you, and as a part of our policy, we have to have a security guard go with us and sit with us, but—
VINCE: Oh, jeez! That's—
COUNSELOR: It sounds like a lot.
VINCE: Yeah.
Master Clinician Note: Vince feels threatened by the referral to the emergency department. Kara, in keeping with agency policy, makes two decisions. The first is that she will not leave Vince alone. The second is she will involve security to help her escort Vince to the emergency department. While the ideal would be to have a collaborative stance with Vince, helping him make the decision to go to the emergency room voluntarily, Kara recognizes that, one way or another, Vince must be assessed by skilled mental health staff for his potential for suicide and interpersonal violence. The more ownership Vince can take of his decision to seek evaluation and treatment, the better.
COUNSELOR: But that's just a part of the policy; it doesn't mean you're being arrested, or anything. What it means is that I would go with you and sit with you and we'll talk with the staff there and get their opinion about what might be best and what is the best way to help you right now. If they think being in the hospital is the best option, you would be in an environment where we can help you regain some control and maintain all the progress that you've made.
VINCE: Yeah, I think what I want you to do is call Jolene and tell her what she's done to me—that I'm gonna end up on a nut ward because of her and her lawyer.
COUNSELOR: You know, it can certainly feel that way, but from where I'm sitting, I see you taking a step to be responsible for your own recovery. I see it as a willingness on your part to do what's necessary to maintain the progress you've made.
VINCE: The way I see it is I'm between a rock and a hard place. I don't have anyplace else to go, but damn, I don't wanna go to the nut ward but I do want her to know how bad she hurt me, too.
COUNSELOR: It sounds like it's pretty important for you to have her understand that you've been hurt.
VINCE: Can she come see me?
COUNSELOR: Vince, I don't see how it could possibly be in your best interests to have Jolene see you the way you are feeling and thinking right now.
VINCE: That's true enough. If I talked to her I'd just get #*%!ed off again, and that wouldn't help. First of all, how long am I gonna be there? How long are you talking about? I mean, are you talking weeks?
COUNSELOR: I can't predict for you what will happen, Vince. Sometimes when clients go to the emergency department, all that happens is an evaluation. Then people stay a day or two or three with a plan to follow up with me. Then there are times where people are admitted to the hospital for a longer period of time. It is highly unusual for people to be admitted to the hospital for weeks, especially with all of the current insurance restrictions. I suppose that's possible but it's highly unlikely. I don't want to guess what will happen in your case, although it is certainly possible that you will be admitted to the hospital until you are under better control of your thinking and your emotions, and that a hospitalization may last a few days or more. It all depends on whether the doctors judge the situation to be safe enough to allow you to be discharged, or if they think more assessment and treatment are necessary in the ED or on one of the hospital floors in order to make things safe. Jolene's safety is also at stake here, and that's a consideration too. Just like me, the staff in the emergency department won't want anything to happen to her, just like they don't want anything to happen to you.
VINCE: So what's gonna happen in the ED?
COUNSELOR: I've had a lot of experience working with the ED. I can tell you that you'll be there at least a few hours and that you'll be evaluated by a counselor first, most likely a nurse or social worker. Then you'll see a doctor who will talk to you and also rely on the information that the nurse or social worker provides him or her. I'll call them to make sure that they also have my opinion. When I speak to them I'm going to advocate that they admit you to the hospital because I know you pretty well, and I really think that you're not in a good position to go back to the garage where you're living at this time, and that you could benefit tremendously from a cooling off period. They'll talk with you about a plan that could range anywhere from being discharged to being admitted to the hospital until things calm down, which I'd prefer. Although they will want your input, it's possible that they will arrange temporary hospitalization for you even if you object strongly to it for the sake of safety. They may also want to touch base with Jolene to make sure that she's safe.
VINCE: Do I have any choice?
COUNSELOR: I've gotten to know you pretty well, and this is really what needs to happen at this point. It's one of those things in recovery that just needs to be done, I'd appreciate it if you could trust me on that.
VINCE: Yeah, I knew you'd say something like that. I'm not sure why I bothered asking.
COUNSELOR: Yeah, well you've gotten to know me pretty well, too. I need to touch base with my supervisor real quick and let him know what we're doing. I just want to quickly let him know our plan, plus I need to let him know where I'll be in case someone wants to get hold of me in the next little while. I also need to touch base with security so that they can escort you and me down there.
[Pause. Vince shows no sign of leaving his chair.]
[Kara calls her supervisor with Vince present, tells him that there is an emergency situation with Vince that requires that he be escorted to the ED as a precaution to prevent suicide and violence. She had discussed Vince with her supervisor, and they had anticipated that he might become homicidal if Jolene initiated separation and discussed that suicidality was also a possibility. Therefore, her supervisor quickly confirms the acuity of the situation. Convinced that emergency evaluation is needed, he endorses the plan without delay and makes arrangements for security to come to assist in escorting Vince to the ED. As the supervisor calls security, it frees up Kara to continue to speak with Vince to keep him calm. Given Vince's history of violence, the supervisor requested more than one security officer to assist. Two security officers arrive, and they allow the counselor to initiate all of the direct interactions with Vince and, although in his presence throughout, allow Vince enough space that he does not feel threatened or “handled.” They are also prepared to call for more back-up and the local police if Vince runs or becomes aggressive, neither of which occur.
After Vince is checked in, the counselor provides all the relevant information to the ED staff and stresses the potential risk to Jolene that will require contacting her as a precaution. She also emphasizes to the ED staff in clear and unambiguous terms that in her opinion, and that of her supervisor, Vince is an acute danger to himself and his wife and requires hospitalization until his affect stabilizes and his judgment improves. She also makes a concrete plan with the ED staff that they will be in communication about Vince's status the following morning. Although the counselor made the decision early about of the need for emergency evaluation, she took the time to discuss this with Vince in a firm but caring manner, facilitating his cooperation. As she has had previous experience in escorting acutely suicidal patients to the ED, has worked collaboratively with her supervisor in these instances, and has specifically discussed in supervision the possibility that Vince might require an emergency evaluation if Jolene initiated separation, all that was required from the supervisor in this situation was a quick confirmation of Vince's acuity and the appropriateness of the plan. Moreover, he was of great assistance in getting security, allowing the counselor to engage Vince uninterrupted.]
Kara stayed with Vince through the ED evaluation process, suspecting that if she left, he would find a reason to impulsively leave. The ED social worker did a brief evaluation, and the psychiatrist who saw Vince following the evaluation decided to admit him to the psychiatric service for observation. With Vince's permission, Kara notified his employer that he was hospitalized. He was hospitalized for 4 days and released with a followup treatment plan that included returning to substance abuse treatment in the intensive outpatient treatment program and regularly scheduled appointments with the attending psychiatrist, who coordinated continuing re-assessment of Vince's suicidality among all his caregivers in partnership with Kara, who served as case manager. Kara provided case management services to ensure that Vince kept his appointments and continued to participate in substance abuse and mental health treatment. As Vince neared completion of intensive substance abuse treatment, Kara arranged for Vince and Jolene to begin couples therapy to decide whether they would dissolve their marriage or work on it. The order of protection filed by Jolene was amended to allow them to meet together in the counselor's office.
Kara's documentation of the case included Vince's expressions of suicidal thoughts, his allusions to potential risk of violence to others, his risk factors for suicide, the warning signs she observed, and his limited protective factors. She noted his high potential for substance use relapse. She also documented Vince's resistance to voluntarily seeking help for his suicidality, her consultation with her supervisor, and the fact that security personnel accompanied her and Vince to the ED. She also described the information she gave to the emergency department personnel and that she remained in the emergency department until the determination to hospitalize Vince was made. She also noted recommendations that were made for post-hospitalization care.
Rena is a Native-American woman living in a rural area of a state in the Western United States. She has been sober for 6 months and has a history of child sexual abuse. She began having obsessive thoughts of killing herself yesterday, and she cannot stop the thoughts. She called her counselor, Martin, and the dialog below is from the telephone call.
The case demonstrates some of the interplay of shame, trauma, substance abuse, and suicidality, and illustrates specific advanced counseling techniques that can be used to interrupt obsessive thoughts, build strengths, and help a client mobilize to take action.
Rena is a 34-year-old Native-American woman with a history of sexual abuse by an uncle. The sexual abuse began when Rena was 8 years old and continued through her teenage years. She has been in recovery from alcohol dependence for about 6 months. She began drinking as a teenager and came into treatment almost a year ago at the insistence of her husband. A significant issue in her recovery has been managing trauma symptoms, including obsessive thoughts. Since she lives almost 40 miles from her treatment center, her primary aftercare services have been provided by telephone with occasional visits to her counselor when she comes to town. She has limited contact with other people recovering from substance abuse, but maintains ongoing supportive relationships with her family. She has three children, ages 15, 12, and 8.
Rena's suicidality is related to her psychological trauma symptoms. Since the age of 15 she has had thoughts of suicide as an escape from her emotional pain. On two occasions as a teenager she made suicide attempts by cutting her wrists. Neither attempt was medically serious and no treatment or followup was undertaken at the time. During her days of active alcohol abuse she would occasionally, while drinking, be overcome with painful feelings of shame, sadness, and fear and would begin having obsessive suicidal thoughts. Until yesterday, she had not had these thoughts since she quit drinking 6 months ago. The thoughts don't include a specific suicide method but are more about the relief she would feel from being dead.
While rates vary widely among tribes, American Indian and Alaska Native people, as a whole, have significantly higher rates of suicidal behavior than people of other races and ethnicities. Some of the variables that seem to affect this elevated suicide rate include high rates of substance abuse and major psychiatric illness and cultural alienation that can increase risk factors and lower protective factors for suicide. Those who live on geographically isolated reservations may have limited educational and employment opportunities, as well as no easy access to mental health or substance abuse services. Particularly high rates of suicide are found among American Indian males, ages 15–24. A higher percentage of American Indian suicides are alcohol related, compared with the general population (Olson & Wahab, 2008). The effects of culture can be seen in each stage of help-seeking behavior (Goldston et al., 2008). Suicide prevention and intervention efforts need to be tribe specific, emphasizing the cultural beliefs and practices unique to the tribe and recognizing the specific helping resources that are available and acceptable to that particular group. The involvement of the community in suicide prevention efforts is critical.
In recent years, the Indian Health Service (IHS) and SAMHSA have made suicide prevention among Native Americans a high priority and have funded a variety of programs to address their needs. Descriptions of these demonstration programs can be found at the Web site of the IHS Community Suicide Prevention initiative (http://www.ihs.gov/suicideprevention/). Also relevant to suicide prevention is SAMHSA's Gathering of Native Americans curriculum (http://www.samhsa.gov/tribal-ttac), a substance abuse prevention program that emphasizes skill transfer and community empowerment and presents a prevention framework based on values inherent in traditional Native cultures. Additional information can also be obtained from the planned TIP, Substance Abuse Treatment With American Indians and Alaska Natives (CSAT, in development h).
To demonstrate a crisis suicide intervention over the telephone.
To illustrate how a detailed safety plan can be developed and used.
To illustrate a specific technique to intervene with obsessive suicide thoughts (the hope box).
To illustrate how an experienced counselor can build strengths for a client to mobilize to take action in the face of powerful emotions of shame, fear, and sadness.
[Martin, Rena's counselor, receives a telephone call around 2 p.m. one afternoon.]
COUNSELOR: Hello?
RENA: Uh, Martin, this is Rena.
COUNSELOR: Rena, how are you doing?
RENA: Uh, Martin, uh, remember helping me develop a safety plan for when I start having thoughts of hurting myself? I tried the first couple of steps, but they didn't help at all.
COUNSELOR: Sure, Rena. Are you having those thoughts now?
How to Help a Client Develop a Detailed Safety Plan.
The first section is a list of the warning signs that indicate that a crisis may be developing. Warning signs can include thoughts (e.g., “I can't take it anymore”), thinking styles (e.g., racing thoughts), emotions (e.g., intense depression), behaviors (e.g., isolating oneself), and/or physiological sensations (e.g., racing heart).
Clients who recognize that they are heading for a suicidal crisis move on to the second section, which consists of coping strategies that clients can use without the help of another person. Examples of these kinds of coping strategies include diverting activities appropriate for the individual, such as walking the dog or reading the Bible.
The third section consists of friends or family members that the client can call in the event that the individual coping strategies are not successful in resolving the crisis. It is important to list the telephone numbers of these individuals so they can be contacted immediately.
The fourth section includes the telephone numbers of professionals who can be contacted in times of crisis, including the client's substance abuse counselor, the on-call counselor who can be reached outside of business hours, a 24-hour emergency treatment facility, and other local support services that handle emergency calls. When the safety plan has been completed, the counselor works with the client to ensure that it will be used successfully, such as by discussing the precise location where the safety plan will be kept. Over the course of treatment, new coping strategies that are developed can be added to the safety plan.
RENA: I'm scared, Martin, I'm scared. I-I-I can't stop the thoughts that I'm gonna hurt myself.
COUNSELOR: Well, I'm glad you called. And I'm really glad you could put your safety plan to use. You sound pretty frightened.
RENA: I'm scared. I can't, I can't, I can't stop myself from thinking I'm gonna hurt myself.
COUNSELOR: Can you tell me what the thoughts are that you're having? What are the thoughts that are going through your head?
RENA: I wanna die. I wanna die.
COUNSELOR: When did this start?
RENA: I don't know. Last night, maybe. Maybe yesterday sometime.
COUNSELOR: So, this has been going on for a couple of days, going on for a little while?
RENA: It just gets worse. It gets worse and worse. All I think about is how I wanna kill myself. I think about what to take—pills—I've got pills here in the house. And I wanna take 'em and I just wanna go to sleep but I'm afraid I'll take 'em and then get sick and throw 'em up and not die.
COUNSELOR: So, you do have pills there in the house.
RENA: Yeah. Yeah. I don't even know what they are. I don't know. Some of them are for the kids, some of 'em are for Frank; I don't know what they are. I have my pills for depression but I haven't taken them in a long time. They're just a bunch of pills. I don't—I just—I want—I'm scared, I just wanna die.
COUNSELOR: Well, I wonder if we could talk for a little bit and you could help me get a better idea about how you're doing. Would that be all right?
RENA: Yeah, okay.
COUNSELOR: Well, I understand what you're saying more or less. I hear that you're scared. Are you there by yourself?
RENA: Huh, what?
COUNSELOR: Are you by yourself? Are you alone?
RENA: Frank got angry at me and he left. He just—he went somewhere. He'll be back.
COUNSELOR: Is anyone else in the house?
RENA: The kids aren't here. The kids are gone. The kids, I don't know where they are. I—I haven't slept in, I don't know, several days, and so this morning, I just couldn't get out of bed, and they all left, and it's just getting worse and worse, and I can't stop the thoughts.
COUNSELOR: Have you been drinking at all?
RENA: A little.
COUNSELOR: Can you help me understand how much when you say, a little bit?
RENA: I just, I want to stop the thoughts and I had, we didn't have much in the house, Frank took most of the alcohol out of the house. But we had some beer and I drank a couple of beers. And some Kahlua. That stuff tastes awful!
COUNSELOR: Do you have any alcohol left at this point?
RENA: No, and that's part of the problem. I'm so scared and I don't have—I've gotta stop the thoughts. I can't stop the thoughts, and I don't have any way to stop 'em except the pills. And so I called you.
COUNSELOR: Well, I'm glad that you called me and I know that that was our agreement, and so I'm glad to hear from you. I know it's hard for you to tell me that you've been drinking again as well, but it's good that you did.
RENA: I feel so ashamed.
COUNSELOR: Well, I appreciate you taking this step. It really is an incredible step, and this is one of the things we talked about, that when you start feeling this way, and it starts to get at a level where you don't feel like you can manage it or control it, that you and I need to talk in order to move things forward and help you try to get some control. Now, as a part of how we've done this in the past, we had talked about using your hope box. Have you done that? Is that something that you did today?
How To Set Up a Hope Box With Clients.
RENA: No, I haven't thought about it.
COUNSELOR: Okay.
RENA: It's here.
COUNSELOR: Would you mind getting it out, and let's just walk through it. Let's talk a little bit about it.
RENA: Give me a minute. I've got it, but I don't see how that's gonna help me.
COUNSELOR: Well, let's go through it. I know in the past that it has helped, and I know that at different times we've gone through it and it's been effective at helping stop some of the obsessive thinking, particularly when you're thinking about suicide. Do you want to take one of the items out and tell me a little bit about it?
Master Clinician Note: The counselor wants to help Rena anchor herself in the present and maintain contact with the counselor, rather than focusing on past trauma or her perceived hopelessness in the future. Focusing on the hope box is in the here-and-now and helps Rena ground herself.
RENA: The thoughts are terrible right now. They're just terrible.
COUNSELOR: Well, let's focus on the hope box. So let's redirect your attention to that. And why don't you just take one of the items out and tell me a little bit about what it is.
RENA: It's a picture, a picture of me with my children.
COUNSELOR: Can you tell me a little bit about the picture? When was it taken, where was it taken?
RENA: I don't know. Maybe a couple of years ago, Marilyn looks like she's about 13. It looks like we were at a pow-wow.
COUNSELOR: Rena, what's happening in the picture?
RENA: We're all just standing there. I think Frank must have taken it. It's me and my girls.
COUNSELOR: Can you talk a little bit about what was happening then?
RENA: I don't know. All I can think about is who will take care of my girls if I'm gone. I'm so sad and so scared.
COUNSELOR: Can you tell me some more about feeling sad, what that is about?
Master Clinician Note: Trauma, particularly during childhood, is common among people who attempt suicide, particularly those who have made multiple suicide attempts. Traumatic memories can be activated in a number of ways, including both internal and external events. External precipitants include day-to-day stressors. This can include a host of possibilities, but most revolve around interpersonal relationships, particularly if they are abusive in nature. It is more common, though, for internal events to activate the suicidal crisis. These include thoughts, feelings, images, and sensations, some that even the client is not fully aware of at the time. When memories of previous trauma are activated, the net result is often overwhelming shame, subordination, impotence, guilt, helplessness, and feelings of being a burden—all facilitating hopelessness and thoughts of suicide.
RENA: I look at my girls and I think about me when I was their age and I just get sad. That's what I'm feelin' now. I feel like I just wanna kill myself. Just quit.
COUNSELOR: There were some difficult times during that period in your life; there were also some times during that period when you felt better, when things were different. Do you recall any of those times?
RENA: I guess I felt better at school.
COUNSELOR: What was it that you liked about school?
RENA: I could be somebody else. I didn't feel dirty at school. They didn't know.
COUNSELOR: How did you feel at school?
RENA: I don't remember, maybe happy. Maybe okay.
COUNSELOR: Do you recall some of the friends, some of the people you spent time with, that you felt close to?
RENA: Yeah, I had girlfriends.
COUNSELOR: Can you tell me a little bit about them?
RENA: They liked me, and we did things together. And I was a good student. Always obeyed the teachers.
COUNSELOR: What did they like about you? What was it that you recall that they liked about you?
RENA: I can't think of why anybody would like me right now. But back then I guess they liked me because I was a good friend. I was loyal.
COUNSELOR: You know, I remember hearing you describe that in the past that you were loyal, dependable; you were somebody that they could count on and look to for support. Do you remember some of those times?
RENA: Yeah. I took care of my brothers and sisters. And I was loyal to my friends.
COUNSELOR: How do you feel, as you talk about it?
RENA: A little better, I guess.
COUNSELOR: Because your voice sounds sad. You sound a bit tearful.
RENA: I'm more sad than scared right now. I'm so sad. I'm so sad for my children.
COUNSELOR: What is it that you feel sad for, about your children?
RENA: That I might leave them.
COUNSELOR: Do you recall when we talked about the difference between sadness and shame?
RENA: Yeah.
COUNSELOR: What do you remember about those conversations?
RENA: That I've felt so much shame in my life, and that when I feel shame I get really sad.
COUNSELOR: And do you remember some of the differences when we talked about your shame about the abuse? We talked about feeling responsible.
RENA: Yeah, that really helped me.
COUNSELOR: What about that was helpful?
RENA: That when I feel shame, I feel like it's my fault. And when I feel sad, it's just that I feel sad about what happened. That was helpful to me.
COUNSELOR: And do you recall when we talked about feeling responsible for the abuse and blaming yourself? Then we connected this to your feeling that maybe you should die: that killing yourself was attached to feeling responsible for something that I think we both agreed you weren't responsible for.
RENA: Yeah. When I feel shame, I want to hurt myself.
COUNSELOR: Yes, and it sounds to me that this really is sadness. That this is sadness over something that happened many years ago.
RENA: I feel really sad right now. I feel sad that I drank.
COUNSELOR: How sad? Say that again.
RENA: I feel sad that I drink. I feel sad for my children.
COUNSELOR: I think it's important that you've recognized that, that you understand that this sadness is about many different things, and it can feel a little bit overwhelming. Does it feel overwhelming to you?
RENA: The sadness doesn't feel overwhelming; the sadness has been with me so long, it just feels natural, and the scary thoughts feel overwhelming.
COUNSELOR: So, maybe, taking your hope box out and starting this process, kind of disrupts those thoughts a bit and stops those thoughts. Would you agree?
Master Clinician Note: As mentioned above, the hope box provides the client with the opportunity to manage the suicidal crisis both independently and effectively. This is important because it facilitates self-efficacy and empowers the client. For many clients, this is the crux of recovery, moving toward independence and empowerment over their life, to have choices and options and not be limited by past traumatic events. The hope box also provides a tangible process to overcome feelings of shame and helplessness so often associated with suicidality. The personal nature of the hope box is most likely responsible for its potency.
The hope box is one of many more advanced techniques that counselors can use to intervene with clients with suicidal thoughts and behaviors. Another advanced technique described in Rena's vignette is the detailed safety plan. These techniques are somewhat more advanced than the other strategies described in this TIP, and extend somewhat beyond GATE, but are illustrated here for substance abuse counselors with advanced mental health training who wish to incorporate suicide-related treatment into their counseling portfolio. Describing additional intervention techniques is beyond the scope of this TIP. There are many excellent resources for clinicians (see Jobes, 2006; Rudd, 2006; Wenzel, Brown, & Beck, in press).
RENA: Yeah.
COUNSELOR: Rena, could we go back to the hope box and your photograph of you and the girls for just a minute? Can you look at the photograph again and tell me your reaction?
RENA: My girls are so sweet. They look happy.
COUNSELOR: And can you tell me about you right now, what's happening with you?
RENA: I feel calmer. Not so sad. I love my girls. I don't think I could kill myself and leave my girls alone.
Master Clinician Note: In many ways, children are a tangible marker of hope for clients. Children are the client's life legacy. It is important for clients to recognize and understand the impact of suicidal behavior on their children, the vulnerability and risk it can create. Similarly, it is critical to emphasize that in their role as parent, they are protector and nurturer. This is true despite their own history of abuse and neglect. They can stop the cycle of abuse and provide for their children that which they wanted most: safety, protection, and love.
COUNSELOR: Let's talk for a minute, now that those thoughts have calmed down a little bit. Do you feel like you're able to talk about some other things? Because I think maybe we need to take some steps to make sure that you're safe.
RENA: Yeah.
Master Clinician Note: The counselor has worked to establish connection and rapport with Rena and to assess the situation. His perception is that Rena is more grounded now than when she called, but he also is aware that she has been drinking and could rapidly lose her grounding when the telephone connection is ended. He therefore decides it would be best if Rena came to town to the emergency room for an evaluation and possible hospitalization. The counselor now begins to move from gathering information to taking action.
COUNSELOR: I'm a little concerned, and I'll tell you, to be real blunt with you, Rena, I'm very concerned that you're alone, that you feel very sad and depressed, and you've been drinking a bit, and you have your pills available. And you've been having these thoughts about killing yourself, and I'm a little concerned about that, and I think we need to take some steps to make sure that you're okay.
RENA: It scares me to think I might do that.
COUNSELOR: It scares me to think that you might do that, too. What do you think would be the best thing for us to do at this point? Is there anyone around who could help?
RENA: No, Frank's not here. I don't know where the kids are. I think they're just with their friends down the road.
COUNSELOR: I think you told me earlier, and we had identified that your mother, in addition to Frank, was someone that we could count on and talk to in case of emergency, in cases of a crisis. Is that still the case? Do you still feel that your mother is somebody we can count on?
RENA: I haven't talked to her today; I guess she's at home.
COUNSELOR: Now, remind me, how close does your mother live to your house?
RENA: Just over the hill, maybe a quarter of a mile.
COUNSELOR: So, just a short distance away? How would you feel about my talking with your mother and having your mother come down and bring you in so that we can make sure that you're safe?
RENA: I hate her knowing—I don't think that I need to come in. I think I can do this by myself.
COUNSELOR: Can you help me understand your thinking about your ability to do this yourself? What is it that makes you come to the conclusion that you can manage this one on your own?
RENA: I just don't want to upset her.
Master Clinician Note: The counselor doesn't want to pressure Rena unnecessarily; feeling this will just increase her resistance and perhaps invite Rena to become more anxious. Rather, he decides to explore the situation more until he feels Rena may be more open to coming into town.
COUNSELOR: Sounds like a more—
RENA: I've upset her enough. And I've been so proud of not drinkin'. And I don't want to upset her.
COUNSELOR: It sounds like you're worried about you using your mom, somehow, and getting her upset. Do you remember when we looked at this issue about shame and sadness, and we said that when you are feeling shame, you have a tendency not to reach out, not to ask for help. Do you remember those conversations?
Resources on Suicide Among American Indians.
RENA: It's never been easy for me to ask for help.
Master Clinician Note: “Shame-based” people often feel they don't deserve help. Arguing or debating with people about their self-worth and value is most often futile. Rather, the counselor just chooses to address Rena as if she feels worthy, even if she can't experience that within herself.
COUNSELOR: And that's why I'm so pleased that you called me, and that you actually used our plan. A part of that plan was to have your mother available as well, and I think that this is one of those times when we need your mother. Let's not let the shame that's there for many reasons, and isn't accurate, block that and stop us from reaching out when we need to reach out. Because I know in the past, your mother's been willing to help, and I really think that she'll be willing to help now and won't think of it as an inconvenience.
RENA: Would you not tell her why, would you not tell her I've been drinking?
COUNSELOR: Well, I think I'm going to have to tell her that you've been having some trouble. I'm not sure we can get around that. It's going to be apparent to your mom, and I know that in the past when we talked with your mother about having her involved during crises, she was more than happy to help, and wanted to do things that would help you recover.
RENA: I don't think I could drive myself.
COUNSELOR: Well, I don't think you could, either; I think we're in agreement on that, and that's why I think I need to go ahead and give your mother a call. So, let me give her a call and have her drive you in.
RENA: Okay, try not to tell her that I'm drinking or that I'm thinking about killing myself.
Master Clinician Note: The most critical thing to remember about crisis phone calls is to remain calm and patient throughout. A calm, patient, and persistent orientation facilitates hope. You should always be oriented toward productive solutions, with the most frequent solution simply being time. In all likelihood, the longer the call continues, the more effectively the crisis will be diffused. The crisis call is about effective regulation of emotions and problem solving. The call provides the client with an opportunity to vent.
It is important not to argue with the client. If the client has not used the hope box, the crisis call is a chance to walk the client through the hope box. It is also critical to make sure that the client's method for suicide has been removed. If the crisis continues unabated, having the client come in for an emergency session or go to the emergency room is advised. Contacting family members during an acute suicidal crisis is also important if initial efforts fail. In most States, it is permissible to violate confidentiality during a suicidal crisis. It is important to also consider having the patient sign crisis management consent forms early in the treatment process, allowing the clinician to contact specific family members if and when a suicidal crisis emerges. This proactive step is particularly important for those who have made multiple suicide attempts. In order to contact family members during a crisis, you need to have access to the appropriate phone numbers, and know which family members offer healthy, supportive relationships. This requires careful planning early in the treatment process.
COUNSELOR: How about if I agree to tell her only what's necessary to make sure that she knows how important it is to get you in so we can make sure you're safe. Would that be agreeable?
RENA: Tell her something like I'm having bad thoughts and I called you.
COUNSELOR: I think we can manage telling her that you're in a position where we're worried about your safety and that she needs to come with you, accompany you and not leave you alone during this time. She was aware that that was a problem for you before. How does that sound to you?
RENA: Okay.
COUNSELOR: Okay. Well, let me walk through with you what I'm going to do, and make sure this is okay with you. I'd like to call your mother and ask her to bring you in. I'm going to give her a time limit: a deadline by which she needs to have you in town. I also will tell her I want her to give me a call when she gets to your house, before the two of you leave for town. Then, if you're not here within an hour and a half, I'm going to have to go ahead and notify the police to come out and make sure that you're safe.
RENA: Oh, please don't call the police. Frank would kill me.
COUNSELOR: Well, at this point, I think that we just need to make sure that you're okay. I don't have any doubt that your mother's going to go ahead and come on down and bring you in, but I just wanted to let you know that we need to have that happen within a certain time limit, just to make sure that everything's okay and that you're safe.
RENA: I don't mean that Frank would really kill me, just that he would be so angry with me.
COUNSELOR: Well, my guess is, he'd want you to be safe as well. And this is one of those times. Do you think you can agree with that?
RENA: I don't want anybody mad at me.
COUNSELOR: Well, let me tell you very clearly, Rena, not only am I not mad at you, I'm actually proud of you for the step that you've taken. This is one of those critical steps in your recovery about overcoming that feeling of shame and reaching out when you need help in order to maintain your recovery and sobriety. This is a step in that direction, and so that was one of our goals. So I'm really proud that you've reached the goal.
RENA: What's going to happen to me when I get to town with you?
COUNSELOR: Well, we're going to sit down and talk with someone else about where you are right now and maybe what the best response is. That may mean that you'll be spending a little bit of time in the hospital to help you get to a place where you're safer and you can return to outpatient care. Do you have some thoughts or questions about that?
RENA: It scares me that I'm gonna have to go to the hospital.
COUNSELOR: It can be a scary thought. But it also can be a good step for you.
RENA: Okay.
COUNSELOR: So, do we have an agreement?
RENA: Mmm-hmm, yeah.
COUNSELOR: Okay, well, I'm going to put you on hold on the phone for now and call your mother. I'll let you know when I've talked to her and that she is on her way to your house. Are you willing to hold on the phone for now? It will be a few minutes.
RENA: Okay.
Martin had Rena's mother's telephone number in her case record. He called her and she agreed to go immediately to Rena's home to take her to the hospital emergency department. Rena's mother telephoned when she arrived at Rena's house. About an hour later, she telephoned Martin to confirm that they had reached the hospital. In the interim, Martin had called the hospital emergency admissions department to notify them that Rena would be arriving. He talked with the social worker to explain the situation and to arrange for the social worker to coordinate services with him. Had Martin not been able to contact Rena's mother, he was prepared to telephone the county sheriff's office to bring her to the hospital.
Martin was careful to document all of the activity in Rena's case record, including:
Providing suicide intervention by telephone.
Soliciting current risk factors (i.e., emotional pain, pills, drinking, being alone).
Reviewing previous learning and validating that the process is painful but also underscoring Rena's progress.
Using the hope box technique to help Rena get grounded and reconnected to positive aspects of her life.
Eliciting agreement to involve her mother in taking her to the emergency room and providing support.
Following up with Rena's mother and emergency room staff.
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