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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.)

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Addressing Suicidal Thoughts And Behaviors in Substance Abuse Treatment [Internet].

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Chapter 2 Building a Suicide Prevention- and Intervention-Capable Agency

Introduction

The previous chapter presented an orientation for administrators about how suicide affects a substance abuse treatment program. It focused on several conceptual issues, including why a program administrator should be concerned with suicide, levels of agency preparedness to address suicide, and the legal and ethical considerations of working with clients in substance abuse treatment who have suicidal thoughts and behaviors.

This chapter presents four programming and implementation issues of primary concern to administrators and provides the tools you will need to:

Help an agency become suicide prevention and intervention capable.

Help a program develop and improve staff capabilities in working with suicidal clients.

Help an agency develop and enhance its response system to suicide crises.

Build administrative support for all components of GATE (Gathering information, Accessing supervision, Taking action, and Extending the action).

Community-based substance abuse treatment programs come in a wide variety of sizes and orientations, with major differences in staff and other features. Given their size, staffing, orientation, and other features, not all substance abuse treatment programs will be able to provide all of the necessary services to all clients with suicidal thoughts and behaviors. In addition, some high-risk clients may be inappropriate for a given agency.

To further complicate matters, clients come into substance abuse treatment with a variety of needs and levels of risk. In the past, many agencies simply declined to treat anyone who might be a suicidal risk. However, such an option no longer exists, and such a general declaration now seems irresponsible and possibly programmatically unethical. With this in mind, substance abuse treatment programs now have to decide:

Which clients who are suicidal they can adequately serve.

Which clients will need to be linked with an agency that can better meet their needs.

Substance abuse treatment programs also need to strive to improve their services to a point where clients with elevated risk may be accommodated and treated (Level 2). Such an orientation is within the realm of most programs today. Such a shift does, however, require your knowledgeable commitment along with a plan for design, implementation, and evaluation of services and training of clinical supervisors, substance abuse counselors, and other treatment staff.

As noted before, the accrued benefits of becoming a Level 2 substance abuse treatment program are:

Clients can remain in substance abuse treatment even though co-occurring problems like suicidality are present. Staying in treatment for substance use disorders may be critical for the client's recovery and rehabilitation.

The Level 2 substance abuse program can be responsive to a variety of crisis states related to suicide that might otherwise disrupt functioning for the client who is suicidal, other clients, and program staff.

The responsiveness of the program to issues of suicidality may increase the capacity of the program to respond to other client crises that present in the treatment program.

Being a Level 2 substance abuse treatment program means staff have additional skills and diversity that can benefit the overall treatment program.

Being Level 2 allows the program to treat clients who have specific co-occurring mental disorders who would otherwise have to be referred, thereby potentially increasing program effectiveness and building financial benefits to the program.

Most important, being a Level 2 program helps identify clients with suicidal thoughts and behaviors who would otherwise be undetected. Being a Level 2 program, in fact, has the potential to save lives.

This TIP recognizes that not all programs can treat clients with elevated risk of suicide. A Level 2 program has specially trained staff, being able to address and monitor suicidality onsite for many clients rather than through referral, and being prepared to coordinate treatment for a variety of co-occurring disorders often implicated in suicide risk (e.g., depression, borderline personality disorder, PTSD, anxiety disorders). Some programs are too small to have this capacity, others too specialized (such as many halfway houses). For these programs, being Level 1, and having working relationships with other agencies in the community for consultation, supervision, and referral may be sufficient.

Being a Level 2 program begins with your recognition of the need and value of addressing suicidal thoughts and behaviors in the program in a comprehensive way. This process requires three basic steps.

1.

Organizational assessment

2.

Organizational planning

Organizing a team or workgroup to address planning

Deciding on specific targets for change

Determining how and when to begin implementation

3.

Program implementation

Adapting existing policies and programs

Implementing and integrating new programmatic elements

A valuable resource for administrators working in substance abuse treatment settings is The Change Book (Addiction Technology Transfer Center, 2004), which describes the organizational change process used in this TIP. In addition, you may want to review Implementation Research: A Synthesis of the Literature (Fixsen, Naoom, Friedman, Blase, & Wallace, 2005) for more information on the scientific basis for various implementation practices.

Organizational Assessment

Historically, organizational change in substance abuse treatment settings has tended to occur as a result of pressure from the outside: mandates from funding resources, rules and regulations from State agencies, or standards from accrediting bodies. But more and more, as programs and management become increasingly skilled and sophisticated, the perception of organizational assessment and change as an ongoing, internal, data-based, quality improvement-focused process has evolved. Research (e.g., Ogbonna & Harris, 1998; Schneider, 2002) supports that successful interventions and positive evolution of organizations depend not only on the quality of the intervention, but also on the organizational culture.

Gathering Data on the Effects of Suicidality on the Program

To get a snapshot of your organization's current ability to address suicidal thoughts and behaviors, you will need to consider your responses to the questions below.

Clients with suicidal thoughts and behaviors:

How are clients with suicidal thoughts and behaviors currently identified in the treatment population? Does the program only identify clients who are in an obvious, self-disclosed suicidal crisis? Are screening questions for suicide routinely asked in clinical interviews? If not, a study of current clients might be considered in which the five screening questions recommended in this TIP (see Part 1, chapter 1, p. 17) are asked of all clients.

What might you do to identify those clients whose suicidality is “under the program radar”? Are counselors aware of risk factors and warning signs of suicidality that might encourage them to explore suicidality in more detail with high-risk clients?

How do suicidal thoughts and behaviors among clients in your program affect treatment in your program? Do clients with suicidal thoughts and behaviors have their treatment interrupted by referral to other programs? Do staff routinely dismiss suicidality as merely representing a defense against doing the work of recovery? Do clients experience their suicidality as a disruption to their substance abuse treatment? Do clients experience their disclosure of suicidal thoughts and behaviors and subsequent referral to another program for treatment as “punishment” for their disclosure?

What is the impact of client suicidality on the performance of treatment staff? Do staff feel prepared to screen and respond to clients with suicidal thoughts and behaviors? Are staff prepared to manage individuals who are suicidal not only for the clients' own safety, but also in ways that minimize any impact on other clients? Do staff feel prepared to address this issue in their day-to-day practice?

The current organizational response to clients with suicidal thoughts and behaviors:

What is the current organizational response to clients who are suicidal? Are there clear policy and procedure statements for managing clients with identified suicidal thoughts and behaviors?

Do staff consistently document current and past suicidal thoughts and behaviors of clients?

Do treatment records indicate that most clients with suicidal thoughts and behaviors are referred for specialized consultations when needed for services or treatment planning?

Are the client's suicidal thoughts and behaviors and the organization's response (including consultations) integrated as a clinical issue into the treatment plan?

What is the typical treatment response to clients who are experiencing a suicidal crisis? Are they able to maintain their substance abuse treatment while their suicidality needs are addressed?

How would clinical staff (including clinical supervisors) define the optimal response to the variety of treatment issues raised by clients who are suicidal?

The impact of suicidal clients on program staffing:

If the program is to become Level 2, how will that change affect staffing patterns, clinical practices, and staff morale?

Are staff fearful of working with clients who are suicidal because of legal and malpractice consequences?

Do staff believe that they have sufficient skills and knowledge to screen for suicidality and talk comfortably about suicidality with clients? Do they know about treatment resources for suicidality?

Can training and clinical support in the form of supervision and consultation be developed and/or enhanced to help clinical staff feel more positive about the change?

Is there a mechanism within the program to offer debriefing and professional support to counselors after serious adverse events (e.g., suicide attempt at the facility, suicide attempt by a client that led to significant injury regardless of where the attempt occurred, suicide death)?

Is the staff resistant to this organizational change? If so, will it be helpful to have this information up front so that staff needs can be addressed and accommodated?

The organizational culture, including attitudes about suicide:

Is suicide treated as a serious problem in the agency?

Do staff at any level of the organization have negative attitudes toward suicide? If so, can administrators expect resistance to the effort to become a Level 2 program?

Will attitudes such as “people who are suicidal do not belong in substance abuse treatment” or “working with people who are suicidal is dangerous and a real source of legal liability” or “clients who are suicidal will disrupt treatment for everyone else in the program” be barriers to effective change? Does the organizational change process need to be prepared to confront these attitudes?

Does the organization have good relationships with mental health agencies, hospitals, and other places where clients with suicidal thoughts and behaviors can be referred?

Is it feasible to include staff from all levels of the organization in the change process to promote ownership of the changes by all staff?

A good source of information on addressing suicidal thoughts and behaviors is to consider what other programs in your area are already doing and the efforts they made to arrive at their current level of competence in meeting the needs of clients who are suicidal. The goal of organizational change is not to duplicate services or to create overlapping, competitive environments. At the same time, each program should be able to offer services to its client population without automatically referring clients out who present with complicating difficulties (passing the buck).

Additionally, the experience of other programs in your area in organizational change regarding suicidality may provide valuable information in planning your own change process.

Other good resources for strengthening the capacity of a substance abuse treatment program to be Level 2 include Shea (2002) and Jobes (2006). The Suicide Prevention Resource Center (http://www.sprc.org) can provide helpful guidelines to assist substance abuse programs in becoming Level 2.

As these kinds of data are being gathered, the information has to be organized, placed in the context of the organizational goals to address suicidality, and integrated into steps in the planning process. Generally, data will come in various forms: some solid numbers, some impressions, some as summaries of the reactions of a variety of staff. It must be noted that data-gathering is not a static, one-time process but an evolving effort that needs to be part of the total, ongoing change effort. A method for documenting the implementation of policies toward becoming Level 2 and of assessing adherence to policies should be implemented.

Organizational Planning for Becoming a Level 2 Program

Once data have been collected and the problem has been defined and described, the next step is to organize a team or work group to address the issue of planning the change. TIP 48, Managing Depressive Symptoms in Substance Abuse Clients During Early Recovery (CSAT, 2008), describes the process of team development that can be applied to organizational planning for addressing suicidality:

1.

Identify one person to lead the effort. This person must have the backing of senior administration and the respect of clinical staff.

2.

Obtain the commitment of the chief executive officer of the agency to articulate the vision for implementation throughout the agency, with all stakeholders, and to the public.

3.

Convene an implementation work group consisting of key leaders from different stakeholder groups: consumer leaders, family leaders, team leaders, clinical leaders, and program and administrative leaders. Some stakeholders will serve as ongoing members of the work group while information from others may be solicited through focus groups.

4.

Identify the program oversight committee to which the work group will report. For example, if your agency has a quality improvement committee, the work group may report its findings, recommendations, strategic plans, and modifications to that committee. This is one way to initiate and sustain implementation of program changes.

Some issues specific to suicide should be included in the planning process. For instance, depending on your program's current level of competence in suicidality, local mental health providers who have specialized knowledge and skills in addressing suicidal thoughts and behaviors should be invited into the planning process. Their knowledge of the needs of individuals with suicidal thoughts and behaviors and their awareness of community resources might prove helpful. If you anticipate that the management of clients' suicidal thoughts and behaviors will involve referral to other agencies, those agencies might need to be involved in the program planning stages.

The organizational work group should be able to arrive at specific targets for change. Some examples of targets for clients with suicidal thoughts and behaviors might include:

Screening all new clients for suicidal thoughts and behaviors.

Increasing the number of clients who are able to stay active in substance abuse treatment while their suicidal thoughts and/or behaviors are monitored and addressed entirely within the program or conjointly by another agency that is taking the lead in addressing suicidality.

Increasing the skills of frontline substance abuse counselors in working with GATE: their comfort and skill levels in screening for suicidality and talking with clients about their suicidal thoughts and behaviors, their willingness to seek supervision or consultation on suicide-related issues, their ability to effectively make appropriate referrals to other resources for suicidal clients and to follow up with clients who have been referred.

Increasing the capacity of clinical supervisors in the program to address the supervision needs of frontline counselors regarding suicide.

Improving the connection between policies and procedures in the program and the actual needs of frontline counselors and clients.

The third step in organizational planning is deciding how and when to start the implementation process. Most programs find it more productive to make organizational changes in incremental steps, observing and evaluating the changes as they occur, rather than in one large leap. Larger changes tend to be more difficult to integrate into the existing system, and it is harder to correct the missteps that inevitably occur in the process. The timing of implementation is also important. Basically, should initiate change when the organizational system is most likely to be able to integrate the changes without distracting from the program's mission. Making too many changes too quickly can disrupt normal functioning and hinder the integration of new efforts. Ill-timed change can create more resistance than would have otherwise occurred. The implementation should have a system to monitor milestones so as to ensure sustainability.

Program Implementation

Adapting Existing Policies and Programs

It is quite possible that your program already has a variety of policy statements and programmatic elements that relate to client suicidality. For instance, your program probably has a policy about how to handle weapons that are brought onsite, what actions are to be taken when weapons are discovered, and who is to be notified. You also probably have policy statements that indicate what actions are to be taken when a client acknowledges active suicidal thoughts, intent, or behavior. You have policies concerning who can be contacted in client emergencies and when police or other first responders can be notified.

You already have program policy and programmatic elements that, while not being specific to suicidal clients, may be directly translatable to suicidal crises and to care for clients who acknowledge suicidal thoughts and behaviors. For instance, you probably have policies related to the care of clients with co-occurring disorders, such as a “no wrong door” policy, or programmatic elements such as one or more clinicians who are specially trained in working with clients with co-occurring disorders.

Implementing new policies and programmatic elements, therefore, is more often a case of adapting existing policies and procedures to meet the needs of clients with suicidal thoughts and behaviors. The organizational planning group mentioned earlier could review current program policies and procedures to see how they need to be adapted and revised. The work group might also be charged with examining how issues of client suicidality can be integrated into current policies for co-occurring disorders, crisis management in the program, contact with family and significant others in emergencies, and making referrals to other, specialized resources.

Implementing and Integrating New Programmatic Elements

It may be the case, however, that new policies and programmatic elements need to be incorporated into the treatment program. New policies may need to be specific to suicide or may address larger issues in the program, such as clinical supervision, how emergencies are handled, or screening for a variety of co-occurring disorders. Every substance abuse treatment program should, at the least, have a policy statement that acknowledges that suicide is a significant issue for clients in substance abuse treatment and that the program has a role in identifying suicidality among its clients by screening all clients for suicidality and a responsibility to help those clients get the services they need, either through program staff or referral. The policy should then elaborate on procedures for addressing those issues.

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Sample Policy 1.

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Sample Policy 2.

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Sample Policy 3.

New programmatic elements that might need to be instituted include training for all clinical supervisors regarding when services for clients with suicidal thoughts and behaviors can be provided in-house, how referrals are made, and managing suicidal crises in the agency.

Helping Your Program Develop and Improve Capabilities in Working With Clients Who Are Suicidal

Well-written policies and implementation plans to address suicidal thoughts and behaviors will be ineffective without clinical and support staff who have the training, skills, and motivation to carry them out. It is your responsibility to ensure that staff are prepared to address these needs.

Part 1, chapter 1 lists eight core competencies for substance abuse counselors working with clients who are suicidal. These competencies offer a good baseline for defining the knowledge, skills, and attitudes required of frontline counselors. In addition, senior counseling staff and clinical supervisors should be skilled in recognizing and managing suicidal crises, using consultations with external experts, and working with clients who are suicidal and resistant to counseling interventions. (See vignettes 5 and 6 in Part 1, chapter 2. Vince and Rena are clients who require more advanced skills.) The checklist below reflects some of the skills applicable to senior clinical staff and clinical supervisors that extend beyond the eight competencies mentioned above.

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Checklist: Characteristics and Competencies of Clinical Supervisors.

It is important that training reflect the skills needed by substance abuse counselors. This TIP emphasizes that the role of the substance abuse counselor in working with clients with suicidal thoughts and behaviors is to screen, obtain supervision or consultation, take appropriate action (including potentially making a referral), monitor (under clinical supervision), and follow up with clients who are suicidal. Treating suicidality is beyond the scope of practice for most substance abuse counselors, as it requires advanced training in mental health disciplines and, preferably, advanced training in assessment, treatment, and intervention. Trainers should understand the needs and limits of practice of substance abuse counselors and not offer skills that most counselors are not prepared to use.

Rather than a one-time training, the training plan for developing skills in working with clients who are suicidal in substance abuse treatment needs to be ongoing. Shorter training sessions extending over several weeks are preferable to a single full-day session. Regardless of the format for initial training, followup refresher programs lasting 2 hours and emphasizing actual experiences of the participants in working with clients who are suicidal are essential. Training should emphasize building on existing skills and applying existing skills (for instance, in making referrals) to clients who are suicidal, rather than introducing new skills sets. For instance, if counselors in Program A have already received extensive training in motivational interviewing (MI), then the skills training for addressing suicidal thoughts and behaviors should emphasize MI methods (e.g., Gathering information from clients who may be at risk in a manner that does not create defensiveness).

In addition to didactic training sessions, other ways to stimulate dialog and the development of clinical skills for use with clients who are suicidal are:

Have the topic be a regular agenda item in treatment team meetings and include all high-risk clients in the discussion.

Have a brown-bag lunch with a senior staff member as trainer.

Designate one senior counselor or clinical supervisor in a treatment unit to be the “go-to person” on suicide and give that person time (on the job) to take an online or continuing education course.

Peer review accompanying group supervision.

Make it a topic of the month for clinical supervision for all counselors.

Have a training session on treatment planning for suicidal clients.

Have pairs of counselors role play various parts of GATE.

Keep GATE active as a clinical tool by having annual 1-hour refreshers on suicide and the use of GATE.

Helping Your Agency Develop and Improve Its Response to Suicidal Crises

Suicide risk management too often is reactionary and reserved for clients in acute, suicidal crisis. However, most clients experiencing suicidal thoughts and behaviors are not in an acute crisis and do not warrant crisis management. Indeed, most situations can be managed adequately in a matter-of-fact, methodical manner that is not crisis driven. This TIP encourages programs to screen, educate, and intervene early when clients experience suicidal thoughts and/or behaviors, and to take action across the continuum of risk. By doing so, you are likely to prevent many situations from erupting into full blown crises, and be more effective in managing suicide risk within your agency.

That said, there will inevitably be situations that arise suddenly and unpredictably where a crisis response is required. Programs should have specific policies that address those crisis situations. Three examples of suicidal crises are the vignettes of Clayton, Vince, and Rena in Part 1, chapter 2. Clayton reveals suicide ideation and acknowledges that he as taken a gun in his house out of safekeeping and examined it while thinking of suicide. Vince receives news that his wife has filed an order of protection against him, and he rapidly spirals into a preoccupation with suicide. He also alludes to potential violence towards his wife and her lawyer. Rena begins drinking, re-experiences childhood trauma, finds herself losing her psychological supports, and begins to have intense thoughts of suicide. These are just a few of the myriad circumstances that can occur even in the face of the best treatment and organizational planning and for which specific agency policies and procedures need to be in place.

Policy and procedure for suicidal crises are often best considered in the context of larger issues of crisis management in the agency. CSAT is developing a tool entitled “Crisis Management: A Guide for Substance Abuse Counselors” that addresses this issue. The kinds of crises that can occur in a program include active suicidality on the part of a client, aggressiveness, violence, threats of violence toward others, death of a client, severe injuries or health crises with clients, and special protective issues for children and adolescents at risk for endangerment or abuse. In addition to providing a rationale for crisis management, the tool offers specific advice on what steps counselors should plan for, the varieties of contact information front line staff should have available in crisis situations, and the importance of documentation.

Some of the components of effective policy and procedures for suicidal crises that need to be considered include:

Defining a situation requiring a crisis response (compared with a non-crisis event).

Specific actions that the counselor or treatment provider should take to ensure the client's safety (e.g., taking action to reduce availability of methods of suicide).

Who should be notified and how quickly that notification should take place.

What kinds of consultation or clinical supervision should occur and how it should be requested.

The situations under which significant others or first responders should be notified and how pertinent confidentiality regulations can be upheld.

How a client's possession of a weapon or other suicide method (such as medication) should be addressed by the counselor and/or the clinical supervisor or other senior staff.

How clients should be monitored during the crisis (e.g., the policy might specifically state that clients should not be left alone in an office, the waiting room, or other unsecured areas without supervision). A policy of physical restraint needs to be clearly stated.

How staff who greet clients and receive incoming telephone calls are to respond to crisis calls or events in the agency.

How a counselor can access immediate help by telephone or other emergency notification process

How emergency referrals should be made, who should actually make the referral, and what kind of information should be released to the referral program or institution.

How to address a client's resistance to receiving care for suicidality or resistance to accepting referral for consultation or treatment.

How clients should be transported to other programs or resources.

What followup contact should be made with other programs or resources after the referral.

What kinds of documentation should occur throughout this process.

Program policies should specifically state that it is not the counselor's role to make a final determination of whether the client is at acute or imminent risk for suicide. This judgment needs to be left to providers with the necessary training and education. It is the counselor's role to help the client get to the appropriate resources where those kinds of evaluations can be made.

Specific agency policies should spell out how clinical supervisors should address suicidal crises. Such policies might indicate when the supervisor should step in and become actively involved in the client's care (as opposed to being a resource for the counselor); when program senior administration should be notified; when first responders (such as police and emergency medical services) should be contacted; and the types of incident documentation the supervisor needs to prepare and file.

As mentioned earlier, the Commitment to Treatment Statement (see figure 1 below) is one procedure that can be adopted when suicidal thoughts and behaviors are noted. Having both the client and counselor sign the statement helps promote engagement in treatment.

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Figure 1.

Sample Commitment to Treatment Statement.

A related technique is a safety card, which gives clients resources to use in a crisis (see p. 21 in Part 1, chapter 1). Counselors might want to use both techniques.

The goal of agency policy for managing clients who are acutely suicidal is to give enough direction to clinicians and clinical supervisors to guide them in crisis situations, while at the same time not attempting to anticipate every kind of crisis situation related to suicidal thoughts and behaviors. Counselors and supervisors need to be able to use their clinical training, experience, and judgment to address specific situations. Policy needs to guide how the counselor's and supervisor's clinical skills are used.

Finally, every serious adverse event (e.g., suicide attempt at the facility, suicide attempt by a client that leads to significant injury regardless of where the attempt occurred, suicide death) should result in a debriefing and postvention that considers how the event unfolded, how the specific action steps facilitated or hindered resolution of the crisis, how policy worked (or didn't work) to address the crisis, and how policy and procedure can be improved to further enhance the capability of the agency in responding to crises.

Postvention refers to dealing with the aftermath of suicide with survivors who may be family, friends, fellow students, teachers, coworkers, supervisors, fellow patients, counselors, physicians, or any other people who knew the individual and may be affected by the suicide. Additionally, the postvention needs to address how the emotional and psychological responses of the staff involved in the situation were considered. Staff should emerge from the postvention feeling supported and capable and guided by agency policy, senior administration, and clinical supervisors. They should feel their emotional responses to the event were addressed and that they had an opportunity to resolve unfinished business that may have arisen during the crisis. Counselors who provided direct services to clients who died by suicide may also benefit from counseling to help them work through the situation, ideally by a provider experienced in postvention. Counselors who have experienced a suicide in their personal life may especially benefit. Time is often an ally in the healing process.

Building Administrative Support for All Levels of GATE

This TIP has advocated a protocol, GATE, that recognizes the skills of substance abuse counselors and how those skills can be applied in substance abuse treatment settings with clients who are experiencing suicidal thoughts and behaviors. The protocol emphasizes screening for suicidality, obtaining supervision or consultation, taking appropriate actions, and following up on the actions taken.

GATE recognizes that two components frequently addressed in training for suicide prevention and intervention are beyond the skill level of many substance abuse counselors and should be left to persons in mental health disciplines with advanced training and skills in suicidology. These two components are:

1.

Suicide assessment, in which the extent of suicidal thinking and behavior is determined, an assessment of risk for self-injury or death may be undertaken, and clinical diagnoses (such as depression and trauma syndromes) may need to be made.

2.

Treatment of suicidal states, which may include addressing co-occurring disorders, prescribing medication, decisions about hospitalization, challenging suicidal beliefs, and other treatment methods beyond the scope of most substance abuse counselors.

It is imperative that administrators, senior organizational policymakers, and clinical supervisors recognize the strengths and limitations of practice of substance abuse counselors and not ask staff to practice in areas beyond the scope of their skills and knowledge. That said, it is also important that substance abuse counselors be supported by administration in their efforts to address the needs of suicidal clients.

Gathering Information

Because of the elevated risk of suicidality among clients in substance abuse treatment, it is important for programs to have a clear policy statement affirming that all clients entering substance abuse treatment are screened for suicidal thoughts and behaviors. There should also be procedures for screening for suicidality when client risk factors increase, such as after a substance use relapse, after an emotional crisis, or during a treatment transition.

The procedure should spell out a specific screening mechanism or protocol and should specify actions to be taken if suicidality is detected. If there are positive answers to any of the screening questions, follow-up questions should be asked to gather further information (see the section on Gathering Information in Part 1, chapter 1, pp. 15–18).

An example of a checklist for gathering information regarding suicidality is presented in figure 2. Note that the information obtained is the basis for making a plan for addressing suicidal thoughts and behaviors.

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Figure 2.

Gathering Information Regarding Suicidality.

Clinical supervisors should make sure that all clinical staff are aware of the policy and that the policy procedures are followed. Clinical supervisors should conduct a periodic review of all staff to ensure that all clinical staff are current on suicide policy in the agency. Procedures for documentation of screening and actions taken as a result of screening should be standardized to ensure that appropriate documentation occurs. Clinical supervisors should be responsible for ensuring that documentation efforts are carried out by counselors.

Accessing Supervision and/or Consultation

Clinical supervision or consultation from persons knowledgeable and skilled in addressing suicidal behavior is essential for quality care of clients with suicidal thoughts and behaviors. Substance abuse counselors working with clients who are suicidal need to have a clear understanding, guided by agency policy and procedure, of when and how to access supervision and consultation. They need to know when to seek immediate supervision versus supervision at some later time, what kinds of information need to be brought to the supervisor's attention, and how to access supervision or consultation in crisis situations. Even counselors with substantial experience and training in addressing suicidal thoughts and behavior need to have an opportunity to access consultation for treatment planning, and program policy should reflect this. In some settings, the treatment group may serve as an adjunct or alternative to more formal clinical supervision. Where work groups are used as a primary support system for counselors, policy should define how the group is used and how consultation is documented.

Administrators have an essential responsibility to ensure that supervision or consultation (either in the program or from outside consultants) is available and accessible and that program policy defines the role of the supervisor or consultant. The policy should be clear about the circumstances in which a counselor should obtain consultation and make provisions to ensure that consultation is immediately available in crisis situations. It should also differentiate the roles that supervisors might play in intervening with suicidal clients (in addition to roles as a consultant or teacher) and specify which actions (such as contacting first responders outside the program) can only be taken by or with approval of a senior staff person or clinical supervisor.

Supervisors can only undertake such roles with adequate training and knowledge (of suicidality, treatment, and community resources) and with a sense of competence to respond to crises and to the concerns of the counselor. In addition, clinical supervisors have to be able to respond sensitively and professionally to the emotional needs of counselors who may find their work with clients with suicidal thoughts and behaviors to be emotionally provocative and stressful.

Taking Action

All counselor actions with clients who are suicidal should be guided by and in concert with established program policies and procedures. These policies, while unique to each program, will, for the most part, have consistent points across a variety of agencies.

Some of the common points might be:

That clients with suicidal thoughts and behaviors will not automatically be excluded from treatment for acknowledging their suicidal thoughts or behaviors.

That all efforts will be made to help these clients stay in substance abuse treatment as long as their safety can be maintained.

That all clients entering the program will be screened for suicidality.

That potential warning signs that emerge during the course of treatment will be followed up.

That all counselors will be trained in identifying and responding to suicidal thoughts and behaviors of clients in the program.

That the program will strive to ensure that clients receive the best care available for their suicidal thoughts and behaviors, whether that care is provided in the program or by referral.

There should be a “check off” procedure so counselors are not left on their own to make care decisions for clients at acute risk. Some of the levels of care that might be considered include:

Observation.

Contact with the client's family and/or significant others.

Arrangements for disposal of suicide weapons in the possession of the client.

Referral for assessment or for more intense care

Referral for hospitalization as required for safety.

The 24-Hour Suicide Assessment Tool (see figure 3) is an example of a tool for rating a client's current suicidal thoughts and behaviors. It rates the areas of suicidal ideation, behavior, general mood, and cognition/perception. Although this tool is more appropriate for an inpatient psychiatric setting, it can be adapted to a variety of substance abuse treatment settings—especially therapeutic communities, detoxification centers, and residential rehabilitation environments. Such a tool can be used to help guide staff to seek more intensive levels of mental health care. It should be noted that this instrument was developed by a community agency for residential treatment settings. The tool has not undergone extensive field testing.

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Figure 3.

24-Hour Suicide Assessment Tool.

Treatment programs should have a policy on referrals for clients who are suicidal or those needing other specialized services. An example is provided in sample policy 4 (p. 122). The specifics of such a policy will depend on State laws and regulations.

Documenting the clinical actions taken with clients who are suicidal is critical, so counselors need to be given the time to complete this important task. Forms for use in these situations should be developed to ensure that all necessary information is obtained (additional information on documentation can be found in Part 1, chapter 1).

Counselors should also be able to look to you for guidance and support with clients who are suicidal but resist treatment. Senior clinical staff, clinical supervisors, and administrators should be prepared to work with the counselor (and the client if necessary) to resolve some of the resistance and help the client accept appropriate treatment. Several of the vignettes in Part 1, chapter 2 illustrate counselors working with resistant clients. The collaboration of senior clinical staff and clinical supervisors with counselors in these client situations enables counselors to develop their clinical skills with clients who are showing resistance and improve services to clients with a variety of needs.

As the program becomes more experienced in working with clients with suicidal thoughts and behaviors, it can be expected that a more consistent repertoire of responses to suicidality will evolve. This does not mean that responses to clients will become stereotyped, but rather that experience will create more options and greater versatility in care.

Extending the Action and Following Up

It is important for counselors and program administrators to understand that program responsibilities do not end with a client's referral to another agency. Both the counselor and administrators continue to have a responsibility to ensure that the client follows through on the referral, that the referring agency accepts the client for treatment, and that treatment is actually implemented. You also have an ethical responsibility to ensure that the client's substance abuse treatment needs do not get lost in the process of referral. Such monitoring requires oversight by the substance abuse program with specific staff (perhaps clinical supervisors) to ensure this continuum of treatment.

Administrators can assign clinical supervisors the job of making sure that the tasks involved in extending care beyond the immediate actions are carried out. These tasks include:

Following up on referrals.

Case management as required, monitoring that clients are following a treatment plan established by the counselor and the clinical supervisor or by the treatment team.

Checking in with the client and significant others (if warranted) to ensure that care is progressing.

Continued observation and monitoring for suicidal thoughts and behaviors that may re-emerge after the initial crisis has passed.

An organized system of followup by the supervisor, such as a checklist of clients with suicidal ideation or behavior may be required. Clinical supervision training may need to emphasize the need for such followup.

Finally, the program needs to have a standardized system of documenting followup. Often, programs are not as consistent with documentation of followup actions as they are with documentation of clinical interventions undertaken by the counseling staff. Most charting in client records is oriented to responses to specific client behaviors or problems rather than to follow up on those behaviors or problems. As a result, program policy needs to describe how the followup documentation should occur and who in the program is responsible for the documentation. Furthermore, a senior-level staff member should review the documentation for oversight and quality assurance purposes.

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Sample Policy 4.

Copyright Notice

This is an open-access report distributed under the terms of the Creative Commons Public Domain License. You can copy, modify, distribute and perform the work, even for commercial purposes, all without asking permission.

Bookshelf ID: NBK572977

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