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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.)
This Treatment Improvement Protocol (TIP) is designed not only to help substance abuse counselors meet the needs of clients with suicidal thoughts and behaviors, but also to provide information and direction to program administrators, clinical supervisors, and other senior staff who are charged with developing and implementing policies and administering programs for substance abuse and co-occurring disorder treatment. This part of the TIP is addressed to you in your role as an administrator. Suicidal thoughts and behaviors are a significant issue for many clients in substance abuse treatment, and, as we will demonstrate in this chapter, affect not only the individual, but also other clients, staff, and program functioning. It is essential that programs provide the structure and resources to address suicidality as it emerges with clients considering treatment or while in treatment.
Suicide is among the leading causes of death for people who abuse alcohol and drugs (Wilcox, Conner, & Caine, 2004). Individuals with substance use disorders are also at increased risk for suicidal ideation and suicide attempts (Kessler, Borges, & Walters, 1999). People with substance use disorders who are in treatment are at especially elevated risk for a number of reasons (Wilcox et al., 2004). They enter treatment at a time when their substance abuse is out of control and when stress from marital, legal, job, health, or interpersonal problems is exceptionally high. Many may have other issues that increase their risk for suicide, including co-occurring mental health problems (e.g., depression, posttraumatic stress disorder, and some personality disorders) and substance-induced effects (e.g., symptoms in the context of drug use, intoxication, or withdrawal), such as substance-induced depression, anxiety, or psychosis.
It is particularly important for you to understand two pivotal areas regarding services for substance abuse clients exhibiting suicidal thoughts and behaviors. First, the role of the substance abuse treatment program is to provide safety for its clients. Recognizing suicidality when it appears, having policies and procedures for addressing suicidal thoughts and behaviors, and ensuring that treatment for the substance use disorder is not lost in the suicidal crisis saves lives and improves treatment continuity for all clients in the treatment setting. As discussed below, few substance abuse treatment programs are capable of meeting all of the treatment needs of clients who are suicidal. Treating suicidal thoughts and behaviors is often beyond the scope of services in substance abuse programs, much as treating substance abuse is beyond the scope of many treatment programs for other life problems. Nevertheless, substance abuse programs have an obligation to recognize suicidal ideation and behaviors, to address those symptoms, and to assist clients in getting the help they need.
Second, it is imperative that counselors have a consistent clinical protocol, supported by strong and effective agency policies and clinical supervision, that allows them to act effectively when clients who are suicidal are identified. To this end, the consensus panel for this TIP developed a protocol with the acronym GATE, which calls for the following steps:
Gather information.
Access supervision or consultation.
Take action to ensure appropriate care and safety for the client.
Extend the action beyond the immediate situation to promote ongoing treatment and safety.
The role of administrators, senior staff, and clinical supervisors in each step of the GATE process is discussed in Part 2, chapter 2.
Part 1 of this TIP addresses the needs of substance abuse counselors working with clients with suicidal thoughts and behaviors. But without the substantial and knowledgeable support of program administrators like you, the application of skills and information presented in Part 1 is likely to be limited. Helpful choices and strategies may be underused and inconsistently applied. Program administrators have to create, implement, and monitor policies and procedures for addressing the needs of suicidal clients and for supporting counselors in order for an agency to be successful in the prevention of and intervention in suicidal thoughts and behaviors.
The consensus panel that convened to address administrative issues for this TIP made specific recommendations for you. It is obvious that administrators, senior staff, and clinical supervisors play a role in the development, implementation, and ongoing support of each of these recommendations, and that without your support, these recommendations would not be implemented.
The administrator should be able to articulate the goals and objectives of the program as they relate to suicidality, client safety, and crisis intervention, and must be actively involved in crisis resolution.
Personnel should be trained to a level of competence within their range of expertise and licensure or certification to manage intervention with clients who are suicidal (see the section on competencies, pp. 25–31).
Substance abuse programs should have a risk management plan that addresses the needs of clients who are suicidal. This includes, but is not limited to, the following:
All clients in substance abuse treatment should be screened for suicidality.
The facility should meet all public health and safety codes.
Personal safety for clients and staff should be addressed in policies and procedures.
Suicidal behaviors that become critical events (i.e., circumstances in which clients or staff are at risk of significant psychological or physical trauma or death) should be investigated by a review panel to identify how the program can be strengthened in the context of these events.
Staff should be debriefed after critical events, as this provides an opportunity for positive changes and improvements in client care throughout the organization.
Substance abuse treatment programs need to have protocols, accessible to all staff, that offer guidelines for addressing the needs of clients who exhibit suicidal thoughts and behaviors. These protocols may include a flowchart highlighting the chain of command in seeking supervision and administrative guidance.
Personnel should be knowledgeable of the social and medical resources available to persons in suicidal crisis and the procedures or protocols to be followed for their use.
Community relationships should be developed and maintained that will support interventions with clients who are suicidal within the program or the referral system.
Substance abuse treatment programs need to have standardized methods of documentation for how suicidal ideation or behavior was identified, supervision or consultation that was sought as a result, actions that were taken, and followup that occurred.
Crisis services, either as a component in the treatment program or through arrangement with other agencies, should be available 24 hours a day. This includes referral, coordination, and followup, as required by law enforcement; hospital emergency rooms; and any other referral source.
Historically, misconceptions within agencies (either explicit or implicit) may have hindered effectively addressing suicidal thoughts and behaviors.
Examples of these misconceptions and myths include:
Talking about suicide will put it in the minds of clients.
Raising the issue of suicidality during early treatment will detract from the business at hand.
Screening for suicidality is not the job of a substance abuse counselor.
Once someone enters treatment, they are significantly less likely to have suicidal thoughts or behavior.
If you don't ask about suicidal thoughts or behaviors, the program and the counselor won't be legally at risk if the patient attempts suicide or dies from suicide.
Mistaken ideas such as these serve to perpetuate ineffective responses to clients with suicidal thoughts and behaviors. Other misconceptions about suicide common among substance abuse treatment providers and the general public are discussed in Part 1, chapter 1 (pp. 6–7). Today, however, it is more widely accepted that proactively addressing suicidality in substance abuse treatment programs is advantageous from a number of perspectives.
First, addressing clients' suicidal thoughts and behaviors in substance abuse treatment does save lives. The early action of clinical staff can prevent suicide attempts and suicide deaths.
Second, addressing suicidal thoughts and behaviors of clients in substance abuse treatment keeps clients from dropping out of treatment. More often than not, unacknowledged and unaddressed suicidal thoughts and behaviors represent a crisis in the client's life. The client's response to this crisis may be to lose focus on gaining sobriety and to return to familiar but unhealthy coping mechanisms, which may include substance use. Addressing suicidal thoughts and behaviors gives a clear message to clients that these types of problems are not overwhelming to the counselor and that immediate assistance is available. This reassures clients that they and the counselor are working together to get the help they need and that most problems they encounter can be resolved with the help of appropriate treatment.
Third, active suicidality on the part of a client disrupts treatment for other clients in the treatment setting. A client's suicidal thoughts and behavior can be deeply upsetting to others in treatment. Many, and perhaps most, substance abuse clients in early recovery can identify with a person with suicidal thoughts. The difficulty with identifying and processing powerful emotions related to suicide and with being able to self-affirm in the face of these emotions, along with the difficulty resulting from overidentification with other clients, all serve to disrupt treatment progress. Finally, for treatment programs, addressing issues of suicidality leads to positive programmatic efforts through:
Increasing the competence of staff to address crises.
Reducing risk management issues related to legal liability.
Improving program consistency and coordination.
Increasing staff retention through reducing counselor burnout, lowering staff stress, and promoting a greater sense of counselor and frontline support from administrators.
As previously stated, clients in substance abuse treatment are at elevated risk for suicidal thoughts, suicide attempts, and deaths by suicide. Additionally, research and the experience of clinicians and administrators among the TIP consensus panelists confirms that the suicidal behavior of a client in treatment for substance abuse disrupts treatment for all clients. It increases the anxiety of others who may also be having suicidal thoughts, and invites clients and staff to focus on an issue not necessarily related to their primary treatment and recovery goals. In this sense, it occupies valuable client and staff time that could be spent on recovery goals.
Substance abuse programs need to have policies and procedures to address treatment issues raised by suicidality, such as responding promptly and consistently to suicidal crises, gathering additional information, seeking advice and support of other clinical staff and supervisors, making referrals, following up, and documenting activities.
Suicidal behavior creates unique stressors for staff in terms of time, emotional reactions, clinical uncertainty, and the need for additional supervisory consultation. Research supports significant clinician distress when a client dies by suicide (Hendin, Haas, Maltsberger, Szanto, & Rabinowicz, 2004; Hendin, Lipschitz, Maltsberger, Haas, & Wynecoop, 2000). As with addressing the other needs of clients, administrators need to establish policies and procedures for guiding staff in addressing and resolving suicidal crises. Clear guidelines for accessing supervision and support need to be established, including offering clinical staff opportunities to “debrief” and learn from the experience of the crisis. Suicidal crises in the agency also offer the opportunity to evaluate how current policies and procedures could be strengthened and adapted to better suit current needs.
Issues around suicidality sometimes push the agency toward a crisis state that can potentially disrupt normal patterns of communication, continuity, and governance. You will need to be actively involved in the organization's crisis response to ensure that the agency is strengthened as a result of the experience and that gaps in effective response are identified and addressed. Issues related to suicide often manifest after regular hours or away from primary treatment sites, necessitating new and innovative approaches to addressing the crisis. For instance, the potential for suicidal thoughts and behaviors of clients in intensive outpatient programs may necessitate an on-call system for senior staff and clinical supervisors. For an inpatient setting, a clinical supervisor trained in suicide interventions might need to be on call in the evenings to respond to a suicidal crisis.
Finally, suicidal behavior of clients in treatment poses unique legal and ethical issues for programs. These issues are discussed in some detail later in this chapter.
This TIP identifies three levels of program involvement in suicide prevention and intervention. This chapter describes the programmatic elements that are considered essential to each level. Each level increases the capability of the program to identify clients at risk for suicidal thoughts and behavior, the resources the program possesses to intervene with the client, the programmatic elements in place to provide safety and treatment to people who are suicidal, and the resources the program possesses to intervene in suicidal crisis events.
The TIP consensus panel recommends that, at a minimum, all programs providing substance abuse treatment to clients should be Level 1. Level 1 programs have the basic capacity to identify clients who are at risk and identify warning signs for suicide as they emerge. Clinical staff have the skills to talk comfortably with clients about their suicidal thoughts and behaviors, are knowledgeable about warning signs and risk factors for suicide among clients in treatment for substance abuse, and, with appropriate supervisory support, can make referrals for formal suicide risk assessment. The program has clear policies and procedures for referral in place, and procedures and protocols for managing suicidal crises in the agency are available to all staff. Some of the characteristics of Level 1 programs include:
All clinical staff recognize that clients in substance abuse treatment are at increased risk for suicidal thoughts and behaviors.
All clinical staff have had basic classroom education in risk factors, warning signs, and protective factors for suicide. The educational effort (as with the following two characteristics) focuses on the knowledge, skills, and attitudes described in the professional competencies in Part 1, chapter 1.
All clinical staff have had basic classroom education in recognizing misconceptions about suicide, have had an opportunity to replace them with accurate and contemporary information, and have explored their own attitudes toward suicide and suicidal behavior.
All clinical staff have had basic classroom education and clinical supervision in recognizing clients' direct and indirect expressions of suicidal thoughts.
All clinical staff have the skills to talk with clients about suicidal thoughts and behaviors and collect basic screening information (see the information on screening in Part 1, chapter 1).
The substance abuse treatment program has basic protocols for responding to clients with suicidal thoughts and behaviors. These protocols reflect established policies and procedures of the agency, including when counselors should obtain consultation from other staff, clinical supervisors, or outside mental health consultants; documentation procedures for recording information in client records; referral procedures; and the steps to be undertaken to ensure appropriate followup of referrals and other actions.
The substance abuse treatment program has formalized referral relationships with programs capable of addressing the needs of clients with suicidal thoughts and behaviors and specific protocols for how a referral is made. These formalized referral relationships are documented in writing, specify the conditions under which a referral is made, identify a contact person, specify potential costs and who is responsible for costs of care, and contain any other information relevant to the referral process. These relationships are updated and confirmed on a quarterly basis.
The program has protocols for managing suicidal crises that are available for all staff. These protocols identify the types of situations that might constitute a crisis, indicate how counselors are to receive clinical supervision or consultation, specify what actions can be taken by the counselor and what actions need to be taken by program administrators, and state what documentation should be made regarding crisis interventions.
The TIP consensus panel recognizes that many substance abuse treatment programs (particularly small, free-standing outpatient clinics; programs in rural and remote locations; and specialized treatment resources) may not possess the resources to provide the more advanced care that a Level 2 program (see below) might offer. At the same time, because the risk factors for suicidal thoughts and behaviors are so high among people in substance abuse treatment, and even higher among specific treatment populations (described in Part 1, chapter 1), the characteristics noted above are essential for high-quality care. All programs should at least meet the above standards. These standards meet the basic criteria of client safety, appropriate documentation, and program responsiveness to issues concerning suicide as they emerge and to suicidal crises.
Some substance abuse treatment programs, particularly those with more staff, more diversified services, and possibly those with administrative links to other programs (for instance, mental health) have the capacity to offer more care for clients with suicidal thoughts and behaviors. Specifically, these programs may be able to maintain continuity of substance abuse treatment on an outpatient or residential basis while concurrently addressing the treatment needs of clients with active warning signs for suicidality. These efforts extend beyond Level 1 services and are termed in this TIP as Level 2 programs.
Some of the attributes that might be found in Level 2 programs, in addition to those services and resources of Level 1 programs, include:
The program has at least one staff member with an advanced mental health degree (for instance, licensed Ph.D. psychologist, or licensed clinical social worker) who is specifically skilled in providing suicide prevention and intervention services and in providing clinical supervision to other program staff working with clients with suicidal thoughts and behaviors.
The program has the capability to continue substance abuse treatment services for clients with suicidal thoughts and behaviors while monitoring those clients for suicidal symptoms and an exacerbation of psychiatric symptoms of depression, anxiety, or other co-occurring disorders.
The program has formalized ongoing relationships (within the agency or in the community) with mental health professionals trained in suicide intervention to address emergency needs.
The program can offer consultation services to Level 1 programs on an as-needed basis.
Some substance abuse treatment programs have the capacity to provide services to acutely suicidal clients that allow the client to continue receiving substance abuse treatment while in the midst of a suicidal crisis. The TIP consensus panel has identified these programs as Level 3. Most often, the programs that can offer these services are administratively linked to hospitals and inpatient psychiatric services.
In addition to the standards for Level 1 and Level 2 programs, Level 3 programs can offer:
Programs linked to a mental health or hospital setting that provides security for people who are actively suicidal and have high risk factors.
Frequent, regular periods of contact with the client (known as suicide watch), or beds (or an area) designated as observation beds (previously known as suicide-watch beds).
Clinical staff can perform comprehensive suicide assessments in-house that determine level of risk, treatment needs, and necessity for legal constraint on the client.
The treatment agency has the appropriate certifications to legally detain clients who are actively dangerous to themselves or others. Such certifications are more commonly held by mental health rather than substance abuse treatment facilities.
Fortunately, the need for Level 3 services is limited and the vast majority of clients with suicidal thoughts and behaviors can be effectively managed and treated for their substance abuse and suicidal thoughts and behaviors in Level 1 and 2 programs. Nevertheless, appropriate resources for people who are acutely suicidal and for whom substance abuse is a closely related disorder are a valuable addition to the treatment continuum of care.
A variety of decisions and implementation strategies must go into preparing your program to be Level 1 or 2. These issues can be divided into four broad categories:
Developing an overall policy regarding the program's approach to addressing suicidality
Implementing and revising policies and procedures to reflect the organization's goal to provide quality services to clients who exhibit suicidal thoughts and/or behaviors
Establishing a system to monitor and evaluate policies and procedures regarding suicidality and to adapt these as needed.
Providing staff development and educational opportunities related to suicide for current and newly hired staff.
The following checklist reflects some of how these issues need to be considered.
Do you have a program policy statement about: Acknowledgment of suicide as a significant risk in your client population?
Risk management for suicide and other high-risk behaviors (see sample policies in Part 2, chapter 2)?
Screening for suicide as part of the program's routine protocol?
Provision for services to be provided to suicidal clients?
Staff development for services to suicidal clients? Does the program have a system in place to orient new employees to the policies and procedures regarding suicidal thoughts and behaviors?
Provision for agency review of critical events? Does the program have a procedure for review of critical events (such as suicidal behavior of clients) to adapt and update policy and procedures? Is a specified individual or position responsible for convening and conducting critical event reviews?
What documentation is necessary?
Are these policies implemented as written, reviewed regularly, and revised as necessary?
Are these policies and procedures monitored and evaluated?
Is there a critical incident review process?
Administrative staff, especially executive directors and program directors, play a particularly important leadership role in creating an environment that fosters rapid identification of and quality services to clients with suicidal thoughts and behaviors. Without the commitment of the program's administrative staff, it is difficult for mid-level staff (clinical supervisors and senior counselors) to implement policy and to support effective clinical practices. Commitment is demonstrated by advocacy of the need for services for suicidal clients, by follow-through on suggestions and plans for programming, and by delivery of a consistent message that fosters support for change and program improvement. Program planning should additionally include input from direct services staff in planning and implementation. Not only does this help mid-level and direct-service staff take ownership of the new initiative; it also prevents a sense that they are being told to add responsibilities to their already heavy workload.
Administrative leadership means communicating a vision of how the program can benefit by providing services to clients who are suicidal. This vision is communicated through explicit goals and a clear statement of how all will benefit from improved services. In this light, it is important that program leaders can communicate in a knowledgeable and articulate manner about suicidality. Treating the issue of suicidality with the importance, priority, and seriousness it deserves communicates your commitment to implementation and ongoing improvement of care.
Finally, leadership needs to inspire others in the organization to become aware of and committed to reducing the incidence of clients' suicidal thoughts and behaviors in the program. Inspiration is communicated through enthusiasm for current and new programmatic elements, optimism about the change process, and an unwillingness to accept anything but success in the effort. This enthusiasm can be demonstrated by emphasis on suicide prevention in staff meetings, active participation in the planning process, attendance at and participation in training events, and recurring reminders to staff at all levels of the importance of suicide prevention. Such inspiration becomes contagious to other staff and is particularly effective when resistance to change is expressed by frontline staff. Inspiration supports the significance of the effort.
Clinical supervisors and senior counselors play a critical role in responding to clients' suicidal thoughts and behaviors in substance abuse treatment settings. They are typically the “go-to” staff when a counselor suspects that a client is suicidal. More often than not, their responsibility is to make the clinical decisions that affect client care and the overall functioning of the clinical services component of a substance abuse treatment agency. You can ensure that mid-level staff are aware of these responsibilities and adequately trained to carry them out.
Clinical supervisors have the primary responsibility for gathering necessary information from counselors when a client acknowledges suicidal thoughts and/or behaviors. They must be able to make decisions about what and how much additional information to gather from the client, determine what consultation with appropriate mental health professionals is warranted, decide how the substance abuse counselor can prepare a client for a potential referral, evaluate what assistance the counselor needs in making appropriate referrals, and ensure that the treatment plan has been effectively implemented and/or updated. Additionally, it is often the clinical supervisor who has to make important decisions related to legal and ethical issues when a client has suicidal thoughts and behaviors.
Having the responsibility to address all of these issues means that clinical supervisors need to be particularly knowledgeable and skilled in all elements of GATE, the framework for addressing suicidality used in this TIP. They must also have the clinical skills necessary to manage crisis situations and the clinical and personal attitudes to foster effective use of these skills.
In this sense, clinical supervisors and other mid-level clinical staff are liaisons between frontline substance abuse counselors and administrators. Clinical supervisors and senior clinical staff have the responsibility of informing administrators of the effectiveness of established policies and procedures and, because of their unique perspectives, need to be involved in shaping and formulating policies and procedures. Because of their ability to integrate their clinical experience with an understanding of the program's mission, goals, and services, they should have a primary role in planning and adapting policies related to suicide. It is primarily their responsibility to implement policies and procedures developed as a result. Finally, it is their responsibility to keep the awareness of issues related to suicide risk in the agency in the forefront for administrators, frontline staff, and support staff.
Obviously, mid-level staff play a critical role in addressing suicidal thoughts and behaviors in substance abuse programs. But they can only be effective if administrators recognize the responsibility they shoulder and respond with appropriate support and guidance. Such support includes hearing the concerns and needs of clinical supervisors in regularly scheduled staff meetings, supporting training related to suicidality, participating in developing interagency relationships for the consultation and referral of clients who are suicidal, encouraging the development of relationships with professionals outside the agency, supporting clinical supervisors in improving their skills through supervision of supervisors, and encouraging active involvement of supervisors in developing and adapting policies and procedures.
Clients with suicidal thoughts and behaviors raise unique ethical and legal issues for substance abuse treatment programs. While it is the responsibility of counselors to address these concerns, as administrators, you have the responsibility of setting policies and procedures to ensure that the agency is in compliance with applicable legal and ethical standards. At the broadest level, legal and ethical practice issues are measured in the context of a program offering a reasonable standard of care to clients to ensure their safety and appropriate treatment. Maris, Berman, and Silverman (2000b) define standard of care as “the degree of care which a reasonably prudent person or professional should exercise in the same or similar circumstances” (p. 487). The authors elaborate by including “the duty to exercise that degree of skill and care ordinarily employed in similar circumstances by the average clinical practitioner” (p. 488) and “the duty to make reasonable and appropriate decisions using sound clinical judgment” (p. 490).
Carrying out this standard of care inevitably involves both legal and ethical considerations. In this TIP, legal issues are defined as those issues that are subject to laws and legal regulations. Generally, these issues are fairly clear-cut, with examples or illustrations defining what is legal and what is illegal.
Ethical concerns relate to professional standards of care and concern the moral issues that arise in the conduct of professional services. Each profession concerned with substance abuse treatment (e.g., substance abuse counselors, social workers, professional counselors, psychologists, physicians) has a different set of professional standards. Additionally, each professional association, such as the Association for Addiction Professionals, the National Association of Social Workers, the American Counseling Association, the American Psychiatric Association, and the American Psychological Association, has a set of ethical standards to which their membership agrees to adhere. Finally, in States where these professional groups are licensed, the State licensing board may have an additional set of ethical standards to which persons licensed by that group must adhere. (A more detailed discussion of ethical issues begins on p. 103.)
The legal issues regarding suicidality for substance abuse programs are primarily related to standards of care, maintaining appropriate confidentiality, and obtaining informed consent. Both the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and the Commission on Accreditation of Rehabilitation Facilities (CARF) provide standards of care for clients at risk of suicide that programs must consider for accreditation (e.g., MacNeil, 2007). Additionally, the American Psychiatric Association (2003) and other professional organizations offer practice guidelines for the clinician that set appropriate and reasonable standards of care. While many of these guidelines are for professional activities beyond the scope of substance abuse counselors, they offer a resource for such issues as confidentiality, informed consent, referral procedures, and treatment planning that have relevance to counselors working in substance abuse treatment agencies.
Maris et al. (2000b) points out three common malpractice “failures” for work with suicidal clients.
Failure in assessment. For substance abuse treatment programs, this means failure to (1) gather information (such as the standard screening questions noted in Part 1, chapter 1), (2) consider that information in treatment planning, (3) recognize warning signs or risk factors as they emerge in treatment, or (4) obtain records from other sources (e.g., previous substance abuse or psychiatric treatment) that would have indicated a significant risk of suicidality.
Failures in treatment. For substance abuse treatment programs, this might mean failure to (1) consider the impact of an intense substance abuse treatment environment on a client's suicidality, (2) prepare a client for treatment transitions, including administrative discharges, (3) make appropriate referrals for clients with suicidal thoughts and behaviors, and (4) follow up on referrals.
Failure to safeguard. Substance abuse treatment programs have an obligation to clients to create a physically and psychologically safe environment. Creating this safe environment means observation procedures for clients in inpatient or residential settings who are potentially suicidal, efforts toward weapon removal for both inpatient and outpatient clients, and an awareness of medication use by clients who are potentially suicidal. Informed consent documentation should include an explanation of the limits of confidentiality (i.e., the duty to warn in specific situations). In addition, you should implement a policy and procedure for obtaining a release from clients who are at significant risk or have warning signs of suicide to contact a family member or significant other if the counselor, with appropriate clinical supervision, feels the client may be at significant risk of attempting suicide. While the client must have an opportunity to revoke the release, it gives the agency some option with a client who is actively suicidal.
In all situations, failure to document actions makes it more difficult to legally defend one's professional behavior. It is essential to properly document warning signs, risk factors, and protective factors; steps taken to address these signs; the consultation or supervision that was obtained; the referrals that were considered and/or made; the client's response to the referral; and the followup that was conducted. Examples of appropriate documentation are presented in Part 1, chapter 1.
Still another variable for consideration of legal issues is liability, both for the agency and for the practitioner. Both may be held responsible when standards of care are not met. Rudd (2006) distinguishes between malpractice liability as a concern of the institution and professional liability (failure to meet the ethics or standards of practice of one's profession), which is a concern of the individual practitioner.
Part of your job is to protect the program and the practitioner from both types of liability. Programs may be held responsible for meeting standards of care (e.g., identifying clients who are at risk for suicide and taking steps to ensure the safety of those clients), but programs can also be responsible for the actions of counselors employed by the program when those counselors or other professional staff do not adhere to professional standards of practice, commit a violation of law (e.g., confidentiality), or when the program does not provide adequate support (e.g., clinical supervision) to counselors or other professional staff.
Foreseeability concerns the expectation that a practitioner (substance abuse counselor or mental health professional) should have been able to foresee the potential suicidal risk that a client might experience. Without conducting basic screening for an individual with suicide risk factors, a counselor might be perceived as not taking appropriate steps to foresee suicidality.
In Part 1, chapter 1, the consensus panel recommends that five basic questions be included in initial client interviews and at appropriate followup points to gather information about a client's suicidal thoughts and behaviors. These questions are taken from “Assessing Suicide Risk: Initial Tips for Counselors,” reproduced on page 17. Any affirmative answers require followup questioning, a consultation with a clinical supervisor or consultant, and possible further evaluation by staff trained in suicide assessment. Administrators can implement an intake protocol that includes these five questions, which are:
Are you thinking about killing yourself?
Have you ever tried to kill yourself before?
Do you think you might try to kill yourself today?
Have you thought of ways you might kill yourself?
Do you have pills or a weapon to kill yourself in your possession or in your home?
It is important to note that most substance abuse counselors do not have the skills to conduct an assessment for suicide risk. Assessments need to be conducted by mental health professionals skilled in suicide assessment because they involve making judgments about risk, treatment options, referral needs, and emergency responses. These judgments are beyond the scope of practice for substance abuse counselors. Most substance abuse counselors are, however, capable of screening for suicidality. Screening involves being sensitive to risk factors and warning signs for suicidality (see the descriptions of risk factors and warning signs in Part 1, chapter 1), and asking appropriate questions (such as those listed in Part 1, chapter 1) in interviews and counseling sessions with clients in treatment for substance abuse. If the screening indicates evidence of suicidal thoughts and/or behaviors, the client can and should be referred for a more structured and detailed suicide risk assessment.
Most substance abuse clients with suicidal thoughts and behaviors need specialized care beyond the scope of practice for most substance abuse counselors. In this context, the primary tasks of the substance abuse counselor are to ensure safety of the clients, gather information about suicidal thoughts and behaviors, obtain supervision or consultation to determine a treatment plan, help clients get to the resources they need for successful treatment of their suicidal thoughts and/or behaviors, and follow up to ensure that proper care has been received and that clients accepted the care. This process is analogous to staff in a social service or health program identifying a client with a substance use disorder, concurrent with other problems that brought them to the social service or health care resource. It is the responsibility of staff in such a program to be aware of warning signs and symptoms of substance abuse, to be able to talk to the client about substance use, to make referrals for appropriate treatment, and to follow up to ensure that treatment was accepted and used. But it is beyond the scope of practice of a social service counselor or nurse in a health clinic, for instance, to actually provide the substance abuse treatment.
You have a role in seeing that this chain of events rolls forward in a timely and uninterrupted manner. First, you can ensure that counselors are well trained in gathering information regarding suicidal thoughts and behaviors. This includes developing sensitivity to risk factors and warning signs, becoming comfortable in discussing suicide with clients, and being aware of how one's own attitudes toward suicide affects his or her relationship with people who are suicidal. Second, you need a means of support for counselors working with clients who are suicidal. If the organization does not have a clinical supervision program or staff members with special training and expertise in suicide, the counselor will need assistance from an external consultant. Third, you need to know about and have relationships with community organizations to which clients who are suicidal could be referred or transferred. Developing relationships with other health care facilities, such as mental health clinics and hospitals (preferably formalized through memoranda of understanding) can give a substance abuse treatment team a variety of options for referring clients with suicidal thoughts and behaviors.
The substance abuse counselor's role is pivotal in ensuring that clients receive proper care. But it is equally important that substance abuse counselors, with oversight from their administrators, practice within the scope of their professional competencies and skills. To transcend the limits of acceptable practice creates malpractice liability for counselors and for their agency.
Maintaining safety for clients with suicidal thoughts and behaviors means making reasonable efforts to promote their immediate and long-term well-being. Historically, suicide contracts (sometimes referred to as “no-suicide” contracts) with clients have been used by some clinicians to ensure safety. No-suicide contracts generally specify that clients will not do something that would put them at risk of harm or self-injury. There is often an accompanying agreement that the client will contact the counselor or other professional if they begin having suicidal thoughts or behaviors. There is, however, no credible evidence that these contracts are effective in preventing suicide attempts and deaths (Rudd, Mandrusiak, & Joiner, 2006), and this TIP specifically recommends that agencies refrain from using them.
A more contemporary approach to client contracting is a Commitment to Treatment agreement (see the sample in Part 2, chapter 2). Such treatment agreements can support and enhance engagement with the client, possibly lowering risk, by conveying a message of collaboration.
Another issue of client safety is weapon removal. Every agency should have a written policy and procedure for handling weapons that might be used to cause bodily harm or death. Generally, this policy should promote the client's giving the weapon to a family member or significant other in lieu of giving it to the counselor or other program staff. Significant legal liability can arise if a staff member accepts a gun or other weapon from a client and then refuses to return it, if the weapon is illegal, or if a weapon is kept on the premises of the program with potential availability to other clients.
Efforts to promote client safety are, in part, dependent on the intensity and restrictiveness of the treatment environment. On one end of this continuum of care is outpatient counseling, generally conducted on a once-a-week basis. At the other end of the continuum is a secure, locked, and staff-monitored psychiatric unit. In between are intensive outpatient care, day (or evening) hospitalization, a half-way house environment, and traditional substance abuse inpatient rehabilitation care.
Administrators can establish policies and procedures to match the level on this continuum with the applicable safety needs and concerns for clients with suicidal thoughts and behaviors. For instance, Bongar (1991) cites the following ways to reduce liability of suicide behaviors in an outpatient treatment setting:
Increase the frequency of visits.
Increase the frequency of contacts (for instance, telephone calls).
Obtain consultation with a professional with expertise in suicide.
Give a maximum of a week's supply of antidepressant medication (or a month's supply of other medication).
Make sure weapons are placed in the hands of a third party.
Involve other resources in support (for instance, family members if they can be supportive).
Give the patient telephone numbers of suicide prevention and crisis centers.
Know the resources that are available for emergencies and outpatient crises.
Be reachable (or have another contact) outside of office hours (evenings, weekends, and vacation time).
In an inpatient rehabilitation setting, a different set of safety steps might be taken, including:
Active visual monitoring of the client.
Consideration for referral to a more secure psychiatric unit.
Consultation with a staff or a consultant mental health professional for a suicide risk assessment.
Monitor dispensing of antidepressant and other potentially fatal medications.
Searches at intake and during treatment as indicated to ensure that the client does not possess weapons, drugs, or other prohibited items.
A physical environment free of opportunity for suicidal behaviors (e.g., no sharp objects or bath and shower fixtures from which rope-like material could be suspended).
Two recurring issues of concern to substance abuse program administrators in working with clients with suicidal thoughts and behaviors are (1) the circumstances under which information pertaining to treatment can be released and (2) confidentiality, particularly in contacting family and significant others when a client acknowledges suicidal thoughts and behaviors. The consensus panel recommends having clients who are deemed to be at risk for suicidal thoughts and behaviors sign an emergency release of information at the beginning of treatment that allows the program to contact family members in case of an emergency. Clients, in most cases, must still have the right to revoke the consent if they so desire.
Program policies and procedures should be clear that simply acknowledging suicidal thoughts or behaviors is not sufficient cause for violating a client's rights to confidentiality by contacting family members, friends, or another treatment agency without first obtaining a consent for release of information. As in other situations, the release of information must be specific to the situation, the nature of the material released, who can have access to the information, and a time-frame in which the release is valid.
The informed consent documentation signed by the client on admission should include an explanation of the limits of confidentiality (e.g., the duty to warn in specific situations). If a client is at imminent risk of harming herself or himself, first responders (such as police), can be contacted, but the circumstances necessitating the contact need to be fully justified and documented. It should generally be program policy that such contact is only made with the approval of a clinical supervisor or administrator. Some examples of imminent risk include a telephone call from a client saying he has just made a suicide attempt and is in danger, or a client who leaves the agency threatening to kill himself, has identified a method, and seems likely to carry out a suicidal threat.
When working with a client with suicidal thoughts or behaviors, it is good program policy to actively encourage family involvement in treatment and to encourage the client to be open with her or his family about suicidal thoughts and behaviors. As when treating substance abuse, the family members need education and information about suicide, warning signs, and particularly, about what to do when suicidal thoughts or behaviors are present in the client.
As in any other treatment situation, no information regarding a client's condition, treatment plan, or other data should be released without the client's written permission. The only exception is if the client is in imminent danger of harming himself or herself or others in a life-threatening manner. If this happens, refer to State and Federal regulations that address this issue. Administrative staff or senior clinical supervisors should make the decision if a client's right to confidentiality is to be compromised.
A related question concerns the duty to warn when a client is at risk for harming another person. Generally, there is no duty to warn family members if a client is suicidal, unless that behavior threatens to harm another person.
A wide variety of ethical issues arises when working with substance abuse clients with suicidal thoughts and behaviors. Additionally, the professional groups that work with this population have differing ethical codes. In fact, even within a profession, counselors working in different States can have different ethical codes depending on where they are licensed or certified. As opposed to legal issues, where there is often a clear guideline for legal versus illegal behavior, ethical issues are often grey areas without defined proscriptions for counselor behavior. Finally, ethical issues often overlap with legal issues. For instance, there are legal concerns about confidentiality of client information and records, but ethical standards also govern counselor behavior in this area. The same is true for responsibility for client safety, how a referral is made and followed up, and in client termination from treatment.
You need to make efforts to ensure agency policy is consistent with the ethical guidelines of professional groups that guide clinical staff practice in the agency. These ethical standards may be promulgated by treatment program associations or organizations for clinical supervisors, counselors, and other treatment personnel. They may be established by regulatory organizations that affect the program. As an example, a program's policy about how counseling services are provided to clients with suicidal thoughts and behaviors needs to be consistent with ethical guidelines about scope of practice for substance abuse counselors who are not specifically trained to treat suicidality. The policy should state that treatment for suicidal clients will be provided by staff with degrees in mental health disciplines who have been trained to treat clients who are suicidal.
Ethical practice has to transcend all levels of organizational behavior. Ethics is often thought of as an issue for frontline staff: counselors, physicians and nurses, psychologists, and social workers. But clinical supervisors also have ethical guidelines (see, e.g., ethical standards of the Michigan Certification Board for Addictions Professionals [http://www.mcbap.com/]), and, at least implicitly, program functioning needs to be guided by ethical practice as well. All these levels need to be consistent in the application of ethical boundaries, for instance, how information about a client who is suicidal is released in a crisis situation, or how decisions are made to transfer a client to another program better able to address acute suicidal thoughts and behaviors.
Malpractice is the intentional or unintentional improper or negligent treatment of a client by a counselor, resulting in injury, damage, or significant loss. It is a growing concern for substance abuse treatment programs. Malpractice is a legal proceeding even though the claim of improper or negligent treatment might have been generated by alleged unethical behavior. (For more detailed information on malpractice, see Falvey, 2002 or Gutheil & Brodsky, 2008.)
A special area of ethical practice with clients with suicidal thoughts and behaviors relates to informed consent for treatment (Rudd, Williamson, & Trotter, in press). Informed consent for substance abuse treatment is an ongoing process in which the client is an active participant in defining what treatment methods and approaches will be undertaken, the expected outcomes of that intervention, the risks and expected efficacy inherent in the care, and alternative treatments that might be used. Clients who evidence suicidal thoughts and behaviors have some special needs for informed consent in addition to those normally given to other clients. You should develop and implement protocols for informed consent applicable specifically to clients who are suicidal. For instance, the client should be clear that if his or her suicidality becomes more overt or debilitating, specialized treatment resources may be required. It is important that the issue of informed consent be raised when treatment is initiated.
Additionally, the program might institute special precautions to protect the safety of the client. It might, in some circumstances, be appropriate to inform the client that the intensity of substance abuse treatment might cause suicidal thoughts to become more frequent or more intense. This might be the case, for example, when counselors are working with clients with co-occurring substance abuse, suicidal thoughts, and psychological trauma. The protocols might specify what actions can be taken if suicidal thoughts increase, at what point special protective care measures must be taken, and at what point special treatment (such as medication) is indicated.
Ethical issues for substance abuse treatment programs working with clients with suicidal thoughts and behaviors arise around their admission, transfer, and administrative termination. Historically, many substance abuse treatment programs have simply had a policy not to accept clients who exhibit suicidal thoughts or behaviors. The effect of this policy has been that clients who were suicidal continued to be admitted to these programs but could not openly discuss their suicidal thoughts, or they were denied treatment for their substance abuse. Likewise, many of the same clients would be denied treatment by mental health service providers who saw the clients' problem as originating in a substance use disorder.
Fortunately, these practices have been largely discontinued. In fact, many people in the field would find it unethical for a program to deny care to someone who is suicidal unless the program can clearly define how the client's condition is inappropriate for care in the specific program. In that case, the program has an ethical responsibility to help clients find the best care for their needs available in the community.
A related issue of treating substance abuse clients with suicidal ideation or behavior is when they need to be transferred to another treatment facility that can offer safer or more intense care, often for co-occurring disorders (such as depression) that accompany the substance use disorder and suicidality. Substance abuse treatment programs need to have clear policies and guidelines stipulating that a referral for more intensive care does not necessarily mean the end of a client's involvement with the program. The client may need to return to the program when less intensive care is warranted. In effect, transfer does not mean discharge.
Likewise, clients cannot be discharged if they are discovered to have suicidal thoughts and behaviors. It is unethical and may be illegal to discharge a client in clear distress without guaranteed and subsequently confirmed followup with an appropriate provider. Programs have an obligation to provide services to that client either directly through the resources of the program or by referral or transfer to another program better able to treat the client. From an ethical standpoint, this should be made an organizational policy.
If clients complete substance abuse treatment and are discharged from their intensive substance abuse treatment program but still have some detectable level of suicidal thoughts and behaviors, specific efforts should be made to ensure that treatment for that client continues, either in a specialized program for clients who are suicidal or in a continuing care extension of the substance abuse program.
An ethical issue for substance abuse programs is in providing training for counselors in suicidality. Counselors should not be expected to address suicidal thoughts and behaviors without additional training. The consensus panel strongly recommends that administrators help counselors get additional training to address the competencies listed in Part 1, chapter 1, including these knowledge, skills, and attitudinal domains:
Gathering information.
Accessing supervision and consultation.
Taking responsible action.
Extending the responsible action with follow-up and documentation.
Basic knowledge about the role of warning signs, risk factors, and protective factors.
Empathy for clients who are suicidal.
Cultural competence issues in recognizing and addressing the needs of clients who are suicidal.
Legal and ethical issues in addressing suicidality in the agency.
It is insufficient to simply train counselors to recognize suicidality or in facts about suicide and substance abuse. The above competencies need to be considered in preparing counselors to work with people who are suicidal in the context of substance abuse treatment. A variety of training materials can be used in addition to the material in this TIP. The Suicide Prevention Resource Center (SPRC) produces a variety of workshops and training materials for counselors (http://www.sprc.org) through its Training Institute. The Addiction Technology Transfer Centers (ATTCs), funded by SAMHSA (http://www.healtheknowledge.org/), offer a variety of training opportunities. Courses in Counseling Suicidal Clients and Crisis Intervention are currently being offered by email correspondence and on the Internet. Finally, a variety of State training programs, including summer institutes on alcohol and drug problems, present workshops for substance abuse counselors working with suicidal clients.
In summary, substance abuse treatment programs face a variety of ethical issues in treating substance abuse clients who evidence suicidal thoughts and/or behaviors. Program administrators need to address these ethical concerns in agency policies and to translate those policies into specific procedures for mid-level supervisory staff, for substance abuse counselors, and for other staff members.
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.
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