SUICIDALITY AND SUICIDALITY AND ADDICTIONS TREATMENTADDICTIONS TREATMENT

Institute of Addiction StudiesInstitute of Addiction Studies

12 June 201212 June 2012

Bruce Carruth, Ph.D., LCSWBruce Carruth, Ph.D., LCSWSan Miguel de Allende, GTO, MexicoSan Miguel de Allende, GTO, Mexico

Why do people want to kill Why do people want to kill themselves?themselves?

Suicidality Suicidality alwaysalways interacts with interacts with other life contextsother life contexts

People donPeople don’’t become suicidal for t become suicidal for ““no reasonno reason””

Substance use and abuseSubstance use and abuse in early recovery (assoc. w/ depression)in early recovery (assoc. w/ depression) in relapsein relapse during treatment transitionsduring treatment transitions early onset, long duration, seriously debilitating addictive illnessearly onset, long duration, seriously debilitating addictive illness

PsychopathologyPsychopathology depressiondepression trauma disorderstrauma disorders personality disorderspersonality disorders

Overpowering emotional reactions to trauma or life Overpowering emotional reactions to trauma or life crisescrises

Getting stuck in anger, sadness, shame, hopelessness, Getting stuck in anger, sadness, shame, hopelessness, emptinessemptiness

The contexts of suicidality (continued)The contexts of suicidality (continued)

Life crisesLife crises relationship breakups or relationship lossrelationship breakups or relationship loss blindsiding exposure or crises (assoc. w/ emotional collapse)blindsiding exposure or crises (assoc. w/ emotional collapse) particularly crises associated with hopelessness, particularly crises associated with hopelessness,

vulnerabilityvulnerability legal eventlegal event crises that replicate a prior trauma experience w/ crises that replicate a prior trauma experience w/

hopelessnesshopelessness

Major physical health impairmentsMajor physical health impairmentsMaking a cry for help or recognitionMaking a cry for help or recognition

Special issues:Special issues: adolescentsadolescents of gays and lesbiansof gays and lesbians of returning war veteransof returning war veterans elderlyelderly

Some myths about suicideSome myths about suicide

WARNING SIGNSWARNING SIGNS

RISK FACTORSRISK FACTORS

PROTECTIVE FACTORSPROTECTIVE FACTORS

The “Big Three” warning signsThe “Big Three” warning signs

Suicidal communicationSuicidal communication Threatening suicide (if – then, writings)Threatening suicide (if – then, writings)

Talking of wanting to dieTalking of wanting to die

Seeking a methodSeeking a method Saving pills, buying a gun, researching on Saving pills, buying a gun, researching on

the internet, asking questions about the internet, asking questions about deathdeath

Making preparationsMaking preparations Giving away belongings, writing notes, Giving away belongings, writing notes,

planning about “when I’m gone”planning about “when I’m gone”

The greatest warning sign The greatest warning sign of all:of all:

A previous suicide attemptA previous suicide attempt

IS PATH WARM: IS PATH WARM: indirect signsindirect signs IIdeationdeation SSubstance abuseubstance abuse PPurposelessnessurposelessness AAnxietynxiety TTrappedrapped HHopelessnessopelessness WWithdrawalithdrawal AAngernger RRecklessnessecklessness MMood changesood changes

RISK FACTORSRISK FACTORS

Prior history of suicide attemptsPrior history of suicide attempts Family history of suicide or suicide Family history of suicide or suicide

attemptsattempts Severe addictive illnessSevere addictive illness Co-occurring psychiatric illnessCo-occurring psychiatric illness History of childhood abuseHistory of childhood abuse Stressful life situationsStressful life situations Firearm ownershipFirearm ownership

ProtectiveProtective factors:factors:

being clean and soberbeing clean and soberreligious attendance &/or spiritual religious attendance &/or spiritual teachings teachings against suicide against suicidepresence of child in home presence of child in home intact marriageintact marriagestrong therapeutic relationshipstrong therapeutic relationshipemploymentemploymenttrait optimism (confidence, positive trait optimism (confidence, positive outlook)outlook)

Recognizing suicidalityRecognizing suicidality

Risk factors (predisposing Risk factors (predisposing circumstances)circumstances)

Warning signs (indications of Warning signs (indications of immediate risk)immediate risk)

the the ““Big 3” + a previous attemptBig 3” + a previous attempt

other warning signs (w/ one of the Big other warning signs (w/ one of the Big 3)3)

(IS PATH WARM)(IS PATH WARM)

G.A.T.E. G.A.T.E. a four step process for counselorsa four step process for counselors

GGather informationather information

AAccess supervision and consultationccess supervision and consultation

TTake responsible actionake responsible action

EExtend the actionxtend the action

Talking with people about their Talking with people about their suicidalitysuicidality

Talking about suicide can be uncomfortableTalking about suicide can be uncomfortableUsing the Using the ““DD ”” and and ““KK”” words words (as in (as in diedie and and killkill))

Asking open-ended questionsAsking open-ended questions 1) suicidal thoughts1) suicidal thoughts 2) suicidal communications2) suicidal communications 3) suicidal planning3) suicidal planning 4) previous suicide attempts4) previous suicide attempts … … And then following-up with specificsAnd then following-up with specifics

Talking about method and instruments of Talking about method and instruments of suicidesuicide

Avoiding judgments Avoiding judgments (implicit or explicit)(implicit or explicit) with the clientwith the client in recording and documentingin recording and documenting

Suicidal people are Suicidal people are always always ambivalent about killing ambivalent about killing

themselves:themselves:otherwise I either wouldnotherwise I either wouldn’’t be thinking about t be thinking about

killing myself OR I would be deadkilling myself OR I would be dead ““There is a part of me that wants to die and a part of There is a part of me that wants to die and a part of

me that wants to liveme that wants to live”” : : Living life with one foot in and Living life with one foot in and one foot outone foot out

Understanding and compassion for the part and Understanding and compassion for the part and context that wants to die – not arguing with the logic context that wants to die – not arguing with the logic of itof it

Strengthening the part that wants to liveStrengthening the part that wants to live

Ambivalence to getting help: giving up suicidal intentAmbivalence to getting help: giving up suicidal intent

Other issues about talking with Other issues about talking with people about suicidepeople about suicide

When you think people arenWhen you think people aren’’t being t being truthful with youtruthful with you

The The ““withholding clientwithholding client”” ““I donI don’’t want to talk about itt want to talk about it”” Information gathering with people who are Information gathering with people who are

chronically suicidalchronically suicidal The person who chronically The person who chronically ““manipulatesmanipulates””

with suicidal threatswith suicidal threats Most people are relieved to talk about Most people are relieved to talk about

their suicidalitytheir suicidality

Accessing supervision and consultationAccessing supervision and consultation

DonDon’’t go it alone & dont go it alone & don’’t become t become the the ““suicide policesuicide police””

Talk with a supervisor or consultant about what you Talk with a supervisor or consultant about what you have learned from the clienthave learned from the client

to get organized and see what else you need to gatherto get organized and see what else you need to gather to be sure you stick to facts and not express opinions to be sure you stick to facts and not express opinions To make decisions about immediacy and urgencyTo make decisions about immediacy and urgency issues about suicide weaponsissues about suicide weapons when to observe and monitorwhen to observe and monitor decisions about referrals and follow-updecisions about referrals and follow-up help formulating a help formulating a ““commitment to treatmentcommitment to treatment”” contract contract

To formulate an intervention planTo formulate an intervention plan

taking responsible actionstaking responsible actionsHelping people mobilize to get Helping people mobilize to get

helphelpBeing stuck between a rock and a hard placeBeing stuck between a rock and a hard place

Working the ambivalence to help people get mobilized for Working the ambivalence to help people get mobilized for treatmenttreatment

And the ambivalence will be activated with positive steps too!And the ambivalence will be activated with positive steps too!

Being stuck as a function of being overwhelmedBeing stuck as a function of being overwhelmed

Utilizing a Utilizing a collaborative,collaborative, workingworking relationship with relationship with suicidal peoplesuicidal people1) non-rescuing 2) emphasizes client responsibility1) non-rescuing 2) emphasizes client responsibility

3) not over-controlling 4) based on empathy / understanding3) not over-controlling 4) based on empathy / understanding

Let the support system supportLet the support system support familyfamily 12-step sponsor12-step sponsor

Making referralsMaking referrals

The goal is for the client to take as The goal is for the client to take as much responsibility for taking action much responsibility for taking action as possible as possible

Your responsibility doesnYour responsibility doesn’’t end with a t end with a referralreferral

The case management elements of The case management elements of referral makingreferral making

A hierarchy of referral strategiesA hierarchy of referral strategies

Strategies that emphasize client Strategies that emphasize client responsibilityresponsibility

SuggestionSuggestion

PersuasionPersuasion

Creating intrinsic motivationCreating intrinsic motivation

Strategies that emphasize more Strategies that emphasize more counselor responsibilitycounselor responsibility

Defining expectationsDefining expectations

Forced choicesForced choices

CoercionCoercion

““No HarmNo Harm”” and and ““Commitment to Commitment to TreatmentTreatment”” contracts contracts

Lack of empirical support for no harm contractsLack of empirical support for no harm contracts

No harm contracts may invite complacencyNo harm contracts may invite complacency signing an agreement doesnsigning an agreement doesn ’’t mean someone wont mean someone won ’’t suicidet suicide

signing an agreement doesnsigning an agreement doesn ’’t make it a t make it a ““done dealdone deal””

ContractsContracts may actually invite client resistance may actually invite client resistance a signed contract can exacerbate ambivalencea signed contract can exacerbate ambivalence

may appear to the client as a legal may appear to the client as a legal ““outout”” for counselor or agency for counselor or agency

A commitment to treatment A commitment to treatment agreementagreement

A agreement to commit to treatment as an A agreement to commit to treatment as an alternative to all sorts of destructive alternative to all sorts of destructive behaviors, but with emphasis on suicidalitybehaviors, but with emphasis on suicidality

Emphasizes treatment goalsEmphasizes treatment goals

Specifies responsibilities of client and Specifies responsibilities of client and counselorcounselor

Emphasizes a commitment to openness and Emphasizes a commitment to openness and honest about suicidalityhonest about suicidality

Specifies what to do in emergenciesSpecifies what to do in emergencies

Other Other ““taking actiontaking action”” jobs jobs

Method restriction (monitoring and Method restriction (monitoring and acting)acting)

Case managementCase management Ongoing monitoring and supportOngoing monitoring and support Involving and coordinating with family Involving and coordinating with family

and significant othersand significant others releases of confidential informationreleases of confidential information And And alwaysalways documenting documenting

ExtendingExtending the action the action

Follow-up on referralsFollow-up on referrals

Ongoing monitoringOngoing monitoringsuicidality is rarely a suicidality is rarely a ““single episodesingle episode”” issue issue

overt suicidality may overt suicidality may ““go undergroundgo underground””

closing the door on suicide as an optionclosing the door on suicide as an option

Ongoing case managementOngoing case management

DocumentationDocumentation

Advanced assessment skillsAdvanced assessment skills

Evaluating suicidality in context of other Evaluating suicidality in context of other dangerous behaviorsdangerous behaviors

self-injurious behaviors, manipulative threats, high risk self-injurious behaviors, manipulative threats, high risk behaviors, psychotic events with self-harmbehaviors, psychotic events with self-harm

Evaluating suicidality in context of other Evaluating suicidality in context of other dynamics of the clientdynamics of the client

psychiatric co-morbidity, life crises, cognitive impairmentspsychiatric co-morbidity, life crises, cognitive impairments

Suicide risk assessmentSuicide risk assessment ““how likely is this person to kill themselves?how likely is this person to kill themselves?””

Assessing treatment needs and treatment Assessing treatment needs and treatment modalitiesmodalities

““what is the best course of treatment for this person?what is the best course of treatment for this person?””

Advanced intervention skillsAdvanced intervention skills Crisis intervention in difficult casesCrisis intervention in difficult cases Working with clients after a suicide attemptWorking with clients after a suicide attempt Confronting chronic suicidalityConfronting chronic suicidality Suicidality co-occurring with chronic or Suicidality co-occurring with chronic or

profound Axis 1 psychiatric disordersprofound Axis 1 psychiatric disorders Suicidality co-occurring with significant Axis Suicidality co-occurring with significant Axis

2 (personality) disorders 2 (personality) disorders Changing suicidal belief structuresChanging suicidal belief structures Closing the door on suicide as an option for Closing the door on suicide as an option for

managing lifemanaging life Working with families who have Working with families who have

experienced suicide attempts or experienced suicide attempts or completionscompletions

When people When people dodo complete suicide complete suicide

During treatment – impact on the During treatment – impact on the treatment communitytreatment community

anger at the client who suicidedanger at the client who suicided reactions of other clients reactions of other clients ((but for the grace of God)but for the grace of God)

finding faultfinding fault

fears of legal retributionsfears of legal retributions Post treatment – the legacy of questionsPost treatment – the legacy of questions When family and friends of clients suicideWhen family and friends of clients suicide

The legacy of suicideThe legacy of suicide

For the counselor and treatment For the counselor and treatment teamteam

Weiner, Kayla. Weiner, Kayla. Therapeutic and Legal Issues for Therapeutic and Legal Issues for Therapists Who Have Survived a Client Suicide. Therapists Who Have Survived a Client Suicide. Haworth Press, 2005Haworth Press, 2005

For the familyFor the family

resourcesresources

Learning more about suicide and Learning more about suicide and suicide interventionsuicide intervention

And/or feel free to follow-up with me:And/or feel free to follow-up with me:

Bruce CarruthBruce Carruth 713-589-3250 713-589-3250 brucecarruth@gmail.combrucecarruth@gmail.com