SUICIDALITY AND SUICIDALITY AND ADDICTIONS TREATMENTADDICTIONS TREATMENT

Education and Training DivisionEducation and Training DivisionCenter of Alcohol StudiesCenter of Alcohol Studies

Rutgers, The State UniversityRutgers, The State University

15 November 200715 November 2007Bruce Carruth, Ph.D., LCSWBruce Carruth, Ph.D., LCSW

An overview of the dayAn overview of the day MorningMorning

Attitudes Attitudes KnowledgesKnowledges Talking with clients about suicideTalking with clients about suicide An overall framework for interventionAn overall framework for intervention Screening for suicidalityScreening for suicidality

AfternoonAfternoon Taking action and follow-upTaking action and follow-up Some advanced assessment and Some advanced assessment and

intervention skillsintervention skills Completed suicidesCompleted suicides

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

Clinicians reactions to people who Clinicians reactions to people who want to kill themselveswant to kill themselves

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

People don’t become suicidal for “no reason”People don’t become suicidal for “no 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, vulnerabilityparticularly crises associated with hopelessness, vulnerability legal eventlegal event crises that replicate a prior trauma experience w/ hopelessnesscrises that replicate a prior trauma experience w/ hopelessness

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

Recognizing suicidalityRecognizing suicidality

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

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

the “Big 4”the “Big 4”

other warning signs (w/ one of the Big 4)other warning signs (w/ one of the Big 4)

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)

Talking with people about their Talking with people about their suicidalitysuicidality

Talking about suicide can be uncomfortableTalking about suicide can be uncomfortableUsing the “D” and “K” words Using the “D” and “K” 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 wouldn’t be thinking about otherwise I either wouldn’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 live” : me 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 aren’t being When you think people aren’t being truthful with youtruthful with you

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

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

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

their suicidalitytheir suicidality

Don’t go it alone & don’t become Don’t go it alone & don’t become the “suicide police”the “suicide police”

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

to get organized and see what else you need to to get organized and see what else you need to gathergather

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 “commitment to treatment” help formulating a “commitment to treatment”

contractcontract

To formulate an intervention planTo formulate an intervention plan

And don’t lose sight of And don’t lose sight of addiction and other treatment addiction and other treatment

needsneeds

Helping people mobilize to get Helping people mobilize to get helphelp

Being 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 as much responsibility for taking action as possible possible

Your responsibility doesn’t end with a Your responsibility doesn’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 Harm” and “Commitment No Harm” and “Commitment to Treatment” contractsto Treatment” 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 doesn’t mean someone won’t suicidesigning an agreement doesn’t mean someone won’t suicide

signing an agreement doesn’t make it a “done deal”signing an agreement doesn’t make it a “done 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 “out” for counselor or agencymay appear to the client as a legal “out” 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 “taking action” jobsOther “taking action” 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 PLISSIT PLISSIT And And alwaysalways documenting documenting

ExtendingExtending the action the action

Follow-up on referralsFollow-up on referrals

Ongoing monitoringOngoing monitoringsuicidality is rarely a “single episode” issuesuicidality is rarely a “single episode” issue

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

Portrait of a FamilyPortrait of a Family

Annie lies in her coffin, turtleneck sweater hiding the noose Annie lies in her coffin, turtleneck sweater hiding the noose burns,burns,

Mother worriedly brushes hair off Annie’s forehead, Mother worriedly brushes hair off Annie’s forehead, pretending it matters,pretending it matters,

Father pacing, needing a drinkFather pacing, needing a drink

Oldest sister socializes, trying to hold up the face of Oldest sister socializes, trying to hold up the face of normalcy,normalcy,

Shy sister hides in the back office of the church, her own Shy sister hides in the back office of the church, her own terror closer,terror closer,

The nine-year-old girl puts her favorite purple stuffed bear The nine-year-old girl puts her favorite purple stuffed bear next to Annie, watching for her to move,next to Annie, watching for her to move,

Scared baby girl hovers near Mama, holding on to her skirt,Scared baby girl hovers near Mama, holding on to her skirt,

This is a family portrait; Annie is already hung.This is a family portrait; Annie is already hung.

Kayla Miriyam WeinerKayla Miriyam Weiner

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@earthlink.netbrucecarruth@earthlink.net