Addressing Suicidal Thoughts
 

And Behaviors in Substance
 

Abuse Treatment
 

A Treatment 

Improvement 

Protocol
 

TIP
 50
 
Addressing Suicidal Thoughts 

and Behaviors in Substance 

Abuse Treatment 

Treatment Improvement Protocol (TIP) Series 

50 

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES 

Substance Abuse and Mental Health Services Administration 

Center for Substance Abuse Treatment 

1 Choke Cherry Road 

Rockville, MD 20857 
Acknowledgments

This publication was produced under the Knowledge Application Program (KAP) contract number 270­04­

7049 with the Substance Abuse and Mental Health Services Administration (SAMHSA), U.S. Department of

Health and Human Services (HHS). Christina Currier served as the Government Project Officer.

Disclaimer

The views, opinions, and content expressed herein are those of the consensus panel and do not necessarily

reflect the views, opinions, or policies of SAMHSA or HHS. No official support of or endorsement by SAMHSA

or HHS for these opinions or for particular instruments, software, or resources is intended or should be

inferred.

Public Domain Notice

All material appearing in this report is in the public domain and may be reproduced or copied without permission from SAMHSA. Citation of the source is appreciated. However, this publication may not be reproduced or distributed for a fee without the specific, written authorization of the Office of Communications,

SAMHSA, HHS.

Electronic Access and Copies of Publication

This publication may be ordered or downloaded from SAMHSA’s Publications Ordering Web page at

http://store.samhsa.gov. Or, please call SAMHSA at 1­877­SAMHSA­7 (1­877­726­4727) (English and

Español).

Recommended Citation

Center for Substance Abuse Treatment. Addressing Suicidal Thoughts and Behaviors in Substance Abuse

Treatment. Treatment Improvement Protocol (TIP) Series, No. 50. HHS Publication No. (SMA) 15­4381.

Rockville, MD: Substance Abuse and Mental Health Services Administration, 2009.

Originating Office

Quality Improvement and Workforce Development Branch, Division of Services Improvement, Center for

Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration, 1 Choke Cherry

Road, Rockville, MD 20857. 

HHS Publication No. (SMA) 15­4381

Printed 2009

Reprinted 2009 and 2011

Revised 2015

ii
Contents
 

Consensus Panel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v
 

What Is a TIP? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii
 

Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix
 

How This TIP Is Organized . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi
 

Part 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
 

Overview of Part 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
 

Chapter 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
 

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
 

Getting Ready to Address Suicidality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
 

Background Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
 

GATE: Procedures for Substance Abuse Counselors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
 

Competencies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
 

Next Steps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
 

Chapter 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
 

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
 

Vignette 1—Clayton . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
 

Vignette 2—Angela . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
 

Vignette 3—Leon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
 

Vignette 4—Rob . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
 

Vignette 5—Vince . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
 

Vignette 6—Rena . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
 

Part 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89
 

Chapter 1: The Administrative Response to Suicidality in Substance Abuse 


Treatment Settings. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91
 

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91
 

The Benefits of Addressing Suicidality in Substance Abuse 


The Role of Administrators in Implementing and Supporting Programming for 


The Role of Mid-Level Staff in Implementing and Supporting 


Consensus Panel Recommendations for Administrators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92
 

Treatment Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92
 

Why Should Administrators Be Involved in a Clinical Issue? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
 

Levels of Program Involvement and Core Program Components. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94
 

Clients With Suicidal Thoughts and Behaviors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97
 

Programming for Clients With Suicidal Thoughts and Behaviors. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98
 

Legal and Ethical Issues in Addressing Suicidality in Substance Abuse Programs. . . . . . . . . . . . . . . . . . . 98
 

Addressing Suicidal Thoughts and Behaviors in Substance Abuse Treatment iii 
Chapter 2: Building a Suicide Prevention- and Intervention-Capable Agency . . . . . . . . . . . . . . . . . 107
 

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107
 

Organizational Assessment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108
 

Organizational Planning for Becoming a Level 2 Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110
 

Program Implementation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111
 

Helping Your Program Develop and Improve Capabilities in Working With 


Clients Who Are Suicidal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113
 

Helping Your Agency Develop and Improve Its Response to Suicidal Crises . . . . . . . . . . . . . . . . . . . . . . 115
 

Building Administrative Support for All Levels of GATE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117
 

Appendix A—Bibliography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123
 

Appendix B—Advisory Meeting Panel. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133
 

Appendix C—Stakeholders Meeting Participants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135
 

Appendix D—Field Reviewers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139
 

Appendix E—Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141
 

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143
 

iv 
Consensus Panel
 

Note: The information given indicates each participant's affiliation during the time the panel was convened and

may no longer reflect the individual's current affiliation.

Chair, Part 1 and Part 2

Consensus Panels

Kenneth R. Conner, Psy.D., M.P.H.

Associate Professor of Psychiatry 

University of Rochester Medical Center

Rochester, New York 

Part 1 Consensus Panel Members

Bruce Carruth, Ph.D.

KAP Expert Content Director

The CDM Group, Inc.

Bethesda, Maryland

Sean Joe, Ph.D., M.S.W.

School of Social Work

University of Michigan

Ann Arbor, Michigan 

M. David Rudd, Ph.D., ABPP

Texas Tech University

Department of Psychology 

Lubbock, Texas 

Barbara M. Teal, M.A., M.B.A., ICADC, CET II

Consultant

Rehoboth, Delaware 

James D. Wines, Jr., M.D., M.P.H.

McLean Hospital/Harvard Medical School

Alcohol and Drug Abuse Research Center (ADARC)

Belmont, Massachusetts 

Part 2 Consensus Panel Members

Bruce Carruth, Ph.D.

KAP Expert Content Director

The CDM Group, Inc.

Bethesda, Maryland

Lisa Laitman, M.S.Ed., LCADC

Rutgers, The State University of New Jersey

Rutgers University Health Services

Alcohol and Other Drug Assistance Program for

Students

New Brunswick, New Jersey 

Edna Meziere, M.S., M.L.S., R.N.

Consultant

Tulsa, Oklahoma

Addressing Suicidal Thoughts and Behaviors in Substance Abuse Treatment v

What Is a TIP?
 

Treatment Improvement Protocols (TIPs) are developed by the Center for Substance Abuse Treatment (CSAT),

part of the Substance Abuse and Mental Health Services Administration (SAMHSA) within the U.S.

Department of Health and Human Services (HHS). Each TIP involves the development of topic­specific bestpractice guidelines for the prevention and treatment of substance use and mental disorders. TIPs draw on the

experience and knowledge of clinical, research, and administrative experts of various forms of treatment and

prevention. TIPs are distributed to facilities and individuals across the country. Published TIPs can be accessed

via the Internet at http://store.samhsa.gov.

Although each consensus­based TIP strives to include an evidence base for the practices it recommends, SAMHSA recognizes that behavioral health is continually evolving, and research frequently lags behind the innovations pioneered in the field. A major goal of each TIP is to convey "front­line" information quickly but responsibly. If research supports a particular approach, citations are provided. When no citation is provided, the information is based on the collective clinical knowledge and experience of the consensus panel. 

Addressing Suicidal Thoughts and Behaviors in Substance Abuse Treatment vii

Foreword
 

The Substance Abuse and Mental Health Services Administration (SAMHSA) is the agency within the U.S.

Department of Health and Human Services that leads public health efforts to advance the behavioral health of

the nation.  SAMHSA’s mission is to reduce the impact of substance abuse and mental illness on America’s

communities.

The Treatment Improvement Protocol (TIP) series fulfills SAMHSA’s mission to reduce the impact of substance

abuse and mental illness on America's communities by providing evidence­based and best practice guidance to

clinicians, program administrators, and payers. TIPs are the result of careful consideration of all relevant clinical and health services research findings, demonstration experience, and implementation requirements.  A

panel of non­Federal clinical researchers, clinicians, program administrators, and patient advocates debates

and discusses their particular area of expertise until they reach a consensus on best practices.  Field reviewers

then review and critique this panel’s work.

The talent, dedication, and hard work that TIPs panelists and reviewers bring to this highly participatory

process have helped bridge the gap between the promise of research and the needs of practicing clinicians and

administrators to serve, in the most scientifically sound and effective ways, people in need of behavioral health

services. We are grateful to all who have joined with us to contribute to advances in the behavioral health field.

Pamela S. Hyde, J.D.

Administrator

Substance Abuse and Mental Health Services Administration

Daryl W. Kade

Acting Director

Center for Substance Abuse Treatment 

Substance Abuse and Mental Health Services Administration

Addressing Suicidal Thoughts and Behaviors in Substance Abuse Treatment ix

How This TIP Is Organized
 

This TIP is divided into three parts: 

•	 Addressing Suicidal Thoughts and Behaviors in Substance Abuse Treatment, Part 1. 

•	 Addressing Suicidal Thoughts and Behaviors: An Implementation Guide for Administrators, Part 2. 

•	 Addressing Suicidal Thoughts and Behaviors: A Review of the Literature, Part 3. 

Parts 1 and 2 are presented in this publication; Part 3 is available only online at http://www.kap.samhsa.gov. 

Each part is described below. 

Part 1 of the TIP is for substance abuse counselors and consists of two chapters. Chapter 1 presents the “what” 

and “why” of working with clients with substance use disorders who have suicidal thoughts and/or behaviors. It 

covers: 

•	 Basic suggestions for addressing suicidal thoughts and behaviors, along with points to keep you on track and 

positive attitudes and behaviors that will help you provide services to clients who are suicidal. 

•	 Background information about suicide and substance use disorders, including risk factors and warning signs 

for suicide. 

•	 A four-step process for addressing suicidal thoughts and behaviors in substance abuse treatment, summarized by the acronym GATE (Gather information, Access supervision, Take responsible action, and Extend 

the action). 

•	 A set of competencies counselors should incorporate to work effectively with clients who are suicidal. 

Chapter 2 presents the “how to” of working with clients with suicidal thoughts and/or behaviors. Chapter 2 contains: 

•	 Representative vignettes of counseling sessions with clients who have suicidal thoughts and behaviors. 

•	 Master clinician notes and comments that help you understand the client, his or her issues related to suicide, and approaches you can take in your counseling work with clients with suicidal thoughts and 

behaviors. 

•	 “How-to” descriptions of specific counseling techniques. 

It is strongly recommended that you read Chapter 1 before reading Chapter 2. 

Part 2 is an implementation guide for program administrators and consists of two chapters. Chapter 1 lays out 

the rationale for the approach taken in Chapter 2 and will help you understand how administrators can provide 

support for programs and counselors as they address clients’ suicidal thoughts and behaviors. It is hoped that 

this knowledge will enable treatment programs to become suicide capable: that is, to treat substance abuse 

while concurrently addressing the specific needs of those who have warning signs for suicide. Chapter 2 provides detailed information on how to achieve high-quality implementation of the recommendations in 

Addressing Suicidal Thoughts and Behaviors in Substance Abuse Treatment, Part 1. 

The following topics are addressed in Part 2: 

•	 The benefits of addressing suicidality in substance abuse treatment programs. 

•	 The role of administrators and mid-level staff in providing care for clients with suicidal thoughts and 

behaviors. 

•	 Different levels of program involvement in addressing the needs of substance abuse clients with suicidal 

thoughts and behaviors. 

•	 Legal and ethical issues for consideration in managing and providing treatment to clients with suicidal 

thoughts and behaviors. 

Addressing Suicidal Thoughts and Behaviors in Substance Abuse Treatment xi 
Part 3 of this TIP is a literature review on the topic of depressive symptoms and is available for use by clinical 

supervisors, interested counselors, and administrators. Part 3 consists of three sections: an analysis of the 

available literature, an annotated bibliography of the literature most central to the topic, and a bibliography of 

other available literature. It includes literature that addresses both clinical and administrative concerns. To 

facilitate ongoing updates (which will be performed every 6 months for up to 5 years from first publication), the 

literature review will be available only online at http://www.kap.samhsa.gov. 

xii 
Part 1
 

Addressing Suicidal Thoughts
 

and Behaviors in Substance
 

Abuse Treatment
 

Overview of Part 1 

Chapter 1: Information You Need to Know 

Introduction (pp. 3–4) 

Getting Ready To Address Suicidality provides basic principles about your role in working with clients who 

are suicidal (pp. 4–9) 

Background Information concerning substance abuse and suicidality (pp. 9–14) 

GATE, a four-step process (Gather information, Access supervision, Take responsible action, Extend the 

action) for addressing suicidal thoughts and behaviors in substance abuse treatment (pp. 14–25) 

Competencies for working with clients with suicidal thoughts and behaviors (pp. 25–31) 

Chapter 2: Clinical Vignettes Demonstrating How to Apply the 

Information 

To illustrate and reinforce the material presented in chapter 1, six realistic scenarios involving suicidal behaviors that might arise during the course of substance abuse treatment are provided. The vignettes emphasize the 

GATE process and the responsible actions modeled by a counselor and his or her supervisor. Master Clinician 

Notes are provided to explain the thinking behind these actions. How-To Notes provide instructions for specific 

methods and interventions. 

Addressing Suicidal Thoughts and Behaviors in Substance Abuse Treatment 

Chapter 1
 

Introduction 

Did You Know? 

•	 Suicide is a leading cause of death among people 

who abuse alcohol and drugs (Wilcox, Conner, & 

Caine, 2004). 

• Compared to the general population, individuals 

treated for alcohol abuse or dependence are at 

about 10 times greater risk to eventually die by 

suicide compared with the general population, and 

people who inject drugs are at about 14 times 

greater risk for eventual suicide (Wilcox et al., 

2004). 

•	 Individuals with substance use disorders are also 

at elevated risk for suicidal ideation and suicide 

attempts (Kessler, Borges, & Walters, 1999). 

•	 People with substance use disorders who are in 

treatment are at especially high risk of suicidal 

behavior for many reasons, including: 

–	 They enter treatment at a point when their 

substance abuse is out of control, increasing a 

variety of risk factors for suicide (Ross, 

Teesson, Darke, Lynskey, Ali, Ritter, et al., 

2005). 

–	 They enter treatment when a number of cooccurring life crises may be occurring (e.g., 

marital, legal, job) (Ross et al., 2005). 

–	 They enter treatment at peaks in depressive 

symptoms (Ross et al., 2005). 

–	 Mental health problems (e.g., depression, posttraumatic stress disorder [PTSD], anxiety disorders, some personality disorders) associated 

with suicidality often co-occur among people 

who have been treated for substance use 

disorders. 

–	 Crises that are known to increase suicide risk 

sometimes occur during treatment (e.g., relapse 

and treatment transitions). 

Who Should Read This Chapter? 

Suicide risk is a problem that every frontline substance abuse counselor must be able to address. This 

chapter is written for you if you are a frontline counselor in a substance abuse treatment program and/or 

if you work with individuals who have both a substance abuse and mental health disorder and/or if you 

provide supervision or consultation to frontline counselors. While the information in this TIP is specific to 

clients with a substance use disorder diagnosis who 

exhibit suicidal thoughts and behaviors, the content 

can be generalized for counselors addressing all people with suicidal ideation or behavior. 

Why a TIP on Suicide for Substance 

Abuse Counselors and Supervisors? 

Research consistently shows a high prevalence of suicidal thoughts and suicide attempts among persons 

with substance abuse problems who are in treatment 

(Ilgen, Harris, Moos, & Tiet, 2007) and a significant 

prevalence of death-by-suicide among those who have 

at one time been in substance abuse treatment when 

compared with those who do not have a diagnosis of 

substance use disorder (Wilcox et al., 2004). As a 

result, substance abuse treatment providers must be 

prepared to gather information routinely from, refer, 

and participate in the treatment of clients at risk for 

suicidal behavior. Suicidal thoughts and behaviors 

are also a significant indicator of other co-occurring 

disorders (such as major depression, bipolar disorder, 

PTSD, schizophrenia, and some personality disorders) 

that will need to be explored, diagnosed, and 

addressed to improve outcomes of substance abuse 

treatment. 

You Can Do This! 

Your clinical training in substance abuse counseling 

puts you in a solid position to perform the tasks outlined in this TIP. As you will learn, the first step in 

addressing suicidality is to “gather information,” or 

to perform exactly the same kind of informationgathering tasks you do every day. For example, if a 

client were having trouble with craving, you would 

first want to know more about it. Think about the 

types of questions you would ask. They might include 

“Tell me about your craving. How often do you have 

it? How strong is it? What makes it worse?” These 

questions are precisely the type you would ask about 

suicidal thoughts: “Tell me about your suicidal 

thoughts. How often do you have them? How strong 

are they? What makes them worse?” In other words, 

Addressing Suicidal Thoughts and Behaviors in Substance Abuse Treatment 3 
even though some content areas may be less familiar 

to you, your training and experience in substance 

abuse counseling provides you with the foundation 

you need to address suicidal behaviors with your 

clients. 

Consensus Panel 

Recommendations 

You are a trained substance abuse treatment professional or an integrated treatment specialist who 

works with persons with co-occurring substance use 

and mental disorders, but most likely, your background does not include detailed training in addressing your clients’ suicidal thoughts and behaviors. This 

TIP is designed to fill that gap and increase your 

understanding of relevant mental disorders. 

In particular, the consensus panel recommends the 

following: 

•	 Clients in substance abuse treatment should be 

screened for suicidal thoughts and behaviors routinely at intake and at specific points in the course 

of treatment (see pp. 15–18 ). Screening for clients 

with high risk factors should occur regularly 

throughout treatment. 

•	 Counselors should be prepared to develop and 

implement a treatment plan to address suicidality 

and coordinate the plan with other providers. 

•	 If a referral is made, counselors should check that 

referral appointments are kept and continue to 

monitor clients after crises have passed, through 

ongoing coordination with mental health providers 

and other practitioners, family members, and community resources, as appropriate. 

•	 Counselors should acquire basic knowledge about 

the role of warning signs, risk factors, and protective factors as they relate to suicide risk. 

•	 Counselors should be empathic and nonjudgmental with people who experience suicidal thoughts 

and behaviors. 

•	 Counselors should understand the impact of their 

own attitudes and experiences with suicidality on 

their counseling work with clients. 

•	 Substance abuse counselors should understand the 

ethical and legal principles and potential areas of 

conflict that exist in working with clients who 

have suicidal thoughts and behaviors. 

Getting Ready To Address 

Suicidality 

It is important for you to be comfortable and competent when asking your clients questions about suicidal ideation and behavior. It may be challenging to 

balance your own comfort level with your need to 

obtain accurate and clear information in order to best 

help the client. Suggestions made by the consensus 

panel to ease the process follow. 

Be Direct 

Talking with clients about their thoughts of suicide 

and death is uncomfortable. However, you must overcome this discomfort, as it may lead a counselor to 

ask a guaranteed conversation-ending question, such 

as “You don’t have thoughts about killing yourself, do 

you?” Discomfort can also lead counselors to avoid 

asking directly about suicidality, which may convey 

uneasiness to the patient, imply that the topic is 

taboo, or result in confusion or lack of clarity. 

Instead, counselors can learn to ask, “Are you thinking about killing yourself?” Of course, death and suicide are just two examples of taboo topics for many 

people. The same observations can be made in 

addressing issues of sexuality and sexual orientation, 

money and finances, and relationship fantasies and 

behaviors. The difference is that asking about suicidal thoughts can actually save a life, as it allows a 

client to feel safe and understood enough to raise concerns and beliefs with you, the counselor. It is important to note that there is no empirical evidence to 

suggest that talking to a person about suicide will 

make them suicidal. 

Increase Your Knowledge About 

Suicidality 

One of the best ways to become more comfortable 

with any topic is to learn more about it. Suicide is no 

exception. Knowing some of the circumstances in 

which people become suicidal, how suicidality manifests, what warning signs might indicate possible suicidal behavior, what questions to ask to identify suicidality, and, perhaps most important, what the effective interventions are, can increase your competence, 

and as a result, your comfort in addressing this issue 

with clients. 

4 Part 1, Chapter 1 
Do What You Already Do Well 

Good counselors are empathic, warm, and supportive, 

and trust their experience and intuition. However, on 

encountering suicidal thoughts and behaviors, counselors sometimes unwittingly employ countertherapeutic practices, such as aggressively questioning the 

client about his or her thoughts and feelings, 

demanding assurance of safety when a client cannot 

provide such assurance, becoming autocratic and failing to collaborate with the client, and/or avoiding sensitive topics so as not to engender sadness. These 

countertherapeutic practices can be the consequence 

of anxiety and unfamiliarity with the issue, along 

with fear of litigation if the client does make a suicidal act. Given these fears and issues, it is easy to see 

how otherwise highly skilled counselors can fall into 

the trap of becoming “the suicide interrogator.” Your 

option? Deliberately choose another path. Stay 

grounded and make use of your therapeutic skills 

when dealing with suicidal behaviors, as that is the 

most important time to fall back on (and not veer 

away from) your therapeutic abilities, experience, and 

training. Collect objective data, just as you would collect objective data about a client’s substance use, but 

don’t lose your empathy or concern in the process. 

Practice, Practice, Practice 

Remember the first substance abuse client you interviewed? Do you remember your internal reaction to 

that interview? Now, you’re a lot more comfortable 

talking with clients about their drug history, their 

current symptoms, and their plans for recovery. 

Nothing reduces anxiety more than practice. The 

same holds true about talking with your clients about 

suicidal thoughts and behaviors. If you need to reduce 

your initial discomfort on the topic, practice with 

another counselor or your clinical supervisor. Get 

feedback about how you are coming across. Start asking every one of your clients about suicidality. The 

more experience you have, the more comfortable you 

will become. You may also consider attending a workshop or getting additional training specific to the 

topic of suicidality. 

Get Good Clinical Supervision and 

Consultation 

Getting clinical supervision is a great way to learn 

and practice new skills. Contract with your clinical 

supervisor to integrate skill development about suicidality into your Individual Development Plan for clinical supervision. Get feedback from your supervisor 

about your attitudes toward clients who are suicidal 

and your skills in interviewing clients. Working with 

a treatment team almost always increases the quality 

of information gathering, decisionmaking, and taking 

action. 

Work Collaboratively With Suicidal 

Clients 

Just as you involve clients in developing a treatment 

plan for recovery, so too should you involve them in 

suicide prevention planning. You will be most effective if you ask them about suicide with concern (but 

not alarm), just as you would with any other area of 

concern. Explain the reason(s) for your concern and 

any action(s) that you take, elicit their input as to 

what may help them be safe, and (with your supervisor), consider their input as much as possible in 

determining the actions that you take. Most often, 

the client will be willing to work collaboratively with 

you, particularly if you take the time to listen and to 

explain your actions. Informed consent should be part 

of collaboration with your client. Inform the client 

about the steps that might be taken to reduce suicide 

risk, steps for referral if needed, and confidentiality 

issues that might arise. Of course, there may be times 

when you and your supervisor will need to take an 

action over a client’s objections (e.g., arrange for an 

immediate evaluation at a hospital), but even in these 

relatively rare circumstances, you can still seek your 

client’s input, and make efforts to work collaboratively. 

Realize Limitations of 

Confidentiality and Be Open With 

Your Clients About Such Limits 

You should understand existing ethical and legal 

principles and potential areas of conflict (including 

the possible limits of confidentiality) because safety 

and protection of the client trumps confidentiality in 

certain crisis situations. When you first meet clients 

and as appropriate during the course of treatment, 

explain that, in the event of suicide risk, you may 

take steps to promote the client’s safety (including 

the potential for breaking confidentiality, arranging 

for an emergency evaluation over the client’s objecAddressing Suicidal Thoughts and Behaviors in Substance Abuse Treatment 5 
tions, and involving emergency personnel). Clients 

should not be given the false impression that everything is confidential or that all types of treatment are 

always voluntary. 

Ten Points To Keep You on Track 

Point 1: Almost all of your clients who are suicidal 

are ambivalent about living or not living. 

Explanation: Wishing both to die and to live is typical 

of most individuals who are suicidal, even those who 

are seriously suicidal (see, e.g., Brown, Steer, 

Henniques, & Beck, 2005). For example, hesitation 

wounds are commonly seen on individuals who have 

died by suicide (e.g., hesitation scratches before a 

lethal cut, bruises on a temple indicating that a gun 

had been placed there several times before pulling 

the trigger). It has even been argued that the struggle between wanting to die and wanting to live is at 

the core of a suicidal crisis (Shneidman, 1985). Take 

suicidal thinking seriously and think about ways to 

reinforce realistic hope. Do everything you can to support the side of the client that wants to live, but do 

not trivialize or ignore signs of wanting to die. 

Point 2: Suicidal crises can be overcome. 

Explanation: Fortunately, acute suicidality is a transient state (Shneidman, 1985). Even individuals at 

high, long-term risk spend more time being nonsuicidal than being suicidal. Moreover, the majority of 

individuals who have made serious suicide attempts 

are relieved that they did not die after receiving acute 

medical and/or psychiatric care. The challenge is to 

help clients survive the acute, suicidal crisis period 

until such time as they want to live again. Moreover, 

treatments for suicidal clients, many with substance 

use disorders, including cognitive–behavioral treatment (CBT; Brown, et al., 2005) and dialectical 

behavioral therapy (DBT; Linehan, Schmidt, Dimeff, 

Craft, Kanter, & Comtois, 1999) have shown positive 

results in reducing repeated suicide attempts. 

Interventions that successfully address major risk 

factors such as severe substance use, depression, and 

marital strife also have the potential to reduce suicidal behavior. Although data are limited, other specific 

interventions have been shown to prevent suicide 

deaths (Mann, Apter, Bertolote, Beautrais, Currier, 

Haas, et al., 2005). 

Point 3: Although suicide cannot be predicted with 

certainty, suicide risk assessment is a valuable clinical tool. 

Explanation: Substance abuse counselors work with 

many high-risk clients. Determining with accuracy 

who will die by suicide using tests or clinical judgment is extremely difficult, if not impossible 

(Pokorny, 1983). Although precisely who may die by 

suicide cannot be known, suicide risk assessment is a 

valuable clinical tool because it can ensure that those 

requiring more services get the help that they need. 

In other words, it is not necessary to have a crystal 

ball if the assessment information shows that a client 

fits the profile of an individual at significant risk. In 

such instances, appropriate actions should be taken. 

Point 4: Suicide prevention actions should extend 

beyond the immediate crisis. 

Explanation: Clients in substance abuse treatment 

who have long-term risk factors for suicide (e.g., 

depression, child sexual abuse history, marital problems, repeated substance abuse relapse) require 

treatment of these issues, whether or not they show 

any indication of current risk for suicide. Individuals 

with a history of serious suicidal thoughts or suicide 

attempts, but with no recent suicidal thoughts or 

behaviors, may be monitored to identify any recurrence of suicidality. 

Point 5: Suicide contracts are not recommended and 

are never sufficient. 

Explanation: Contracts for safety are often used as a 

stand-alone intervention, but they are never sufficient to ensure the client’s safety. Contracts for safety 

are widely used to reduce legal liability, but the consensus panel is aware of no significant evidence that 

such contracts offer any protection from litigation. 

They may, in fact, make litigation more likely if suicide prevention efforts appear to be hinged on the 

contract or if they provide the counselor with a false 

sense of security. It is misguided to predicate decisions on whether the client “can” or “can’t” or “will” or 

“won’t” contract for safety. Use this TIP and choose 

from among the many other strategies to promote 

safety. Use contracts sparingly, if at all. 

Point 6: Some clients will be at risk of suicide, even 

after getting clean and sober. 

Explanation: Abstinence should be a primary goal of 

any client with a substance use disorder and suicidal 

thoughts and/or behaviors (Weiss & Hufford, 1999). 

Indeed, risk will diminish for most clients when they 

achieve abstinence. Nonetheless, some individuals 

remain at risk even after achieving abstinence 

6 Part 1, Chapter 1 
(Conner, Duberstein, Conwell, Herrmann, Jr., Cox, 

Barrington, et al., 2000). For example, clients with an 

independent depression (one that does not resolve 

with abstinence or is not substance induced), those 

who have unresolved difficulties that promote suicidal thoughts (e.g., a deteriorating partner relationship, ongoing domestic violence, victimization, 

impending legal sentencing), those who have a 

marked personality disturbance (e.g., borderline personality disorder), those with trauma histories (e.g., 

sexual abuse history), and/or individuals with a major 

psychiatric illness may continue to show signs of risk. 

Point 7: Suicide attempts always must be taken seriously. 

Explanation: There is often a mismatch between the 

intent of the suicidal act and the lethality of the 

method chosen (Brown, Henriques, Sosdjan, & Beck, 

2004). Therefore, clients who genuinely want to die 

(and expect to die) may nonetheless survive because 

their method was not foolproof and/or because they 

were interrupted or rescued. Indeed, a prior suicide 

attempt is a highly potent risk factor for eventually 

dying by suicide (Kapur, Cooper, King-Hele, Webb, 

Lawlor, Rodway, et al., 2006). Any suicide attempt 

must be taken seriously, including those that involve 

little risk of death, and any suicidal thoughts must be 

carefully considered in relation to the client’s history 

and current presentation. 

Point 8: Suicidal individuals generally show warning 

signs. 

Explanation: Fortunately, suicidal individuals usually 

give warning signs. Such warning signs come in 

many forms (e.g., expressions of hopelessness, suicidal communication) and are often repeated. The difficulty is in recognizing them for what they are. See 

the section on warning signs (pp. 11–12). 

Point 9: It is best to ask clients about suicide, and 

ask directly. 

Explanation: Available data do not support the idea 

that asking about suicide will put this idea in an individual’s mind (Gould et al., 2005). A counselor’s 

power is limited and does not include the ability to 

place the idea of suicide in a client’s head or to magically remove such an idea. You may never know 

about a client’s suicidality unless you ask. You are 

encouraged to ask directly about suicide (see the 

Gathering Information section, pp. 14–18). 

Point 10: The outcome does not tell the whole story. 

Explanation: Suicide deaths have a much lower base 

rate than many other deleterious outcomes that counselors encounter (e.g., relapse, treatment dropout). A 

client at significant risk may survive despite never 

being screened, assessed, or offered intervention for 

suicide simply because of the relatively low base rate 

of suicide. Therefore, a good outcome (survival) does 

not, by itself, equate to proper treatment of suicidal 

thoughts and behaviors. On the other hand, a clinical 

team may do a solid job of screening, assessing, and 

intervening with a high-risk client. Despite these 

efforts, a high-risk client may eventually die by suicide. Therefore, a tragic outcome (death) does not, by 

itself, equate to improper treatment of suicidality. 

Maintain Positive Attitudes 

Attitudes toward suicide vary widely. Some people 

hold religious or spiritual views that have strong 

sanctions against suicidal behavior. Others see suicide as a viable option for ending unmanageable pain 

or suffering or as an acceptable option in other circumstances. Some hold the view that it is all right to 

think about suicide but not to act on those thoughts. 

Our attitudes are influenced by our culture, childhood 

experiences, and especially, by our professional and 

personal experiences with suicidal thinking and 

behavior. 

Before working with clients who are suicidal, counselors are advised to conduct their own suicidal attitude inventory. The goal of the inventory is not to 

change your views but rather to help you understand 

what your views are and how those views can positively or negatively affect your interactions with 

clients. Some of the items you might consider in an 

inventory include: 

•	 What is my personal and family history with suicidal thoughts and behaviors? 

•	 What personal experiences do I have with suicide 

or suicide attempts, and how do they affect my 

work with suicidal clients? 

•	 What is my emotional reaction to clients who are 

suicidal? 

•	 How do I feel when talking to clients about their 

suicidal thoughts and behaviors? 

•	 What did I learn about suicide in my formative 

years? 

Addressing Suicidal Thoughts and Behaviors in Substance Abuse Treatment 7 
•	 How does what I learned then affect how I relate 

today to people who are suicidal, and how do I feel 

about clients who are suicidal? 

•	 What beliefs and attitudes do I hold today that 

might limit me in working with people who are 

suicidal? 

These views may also need to be further clarified by 

consultation with your clinical supervisor or with 

your peers. 

As noted, your attitudes about suicide are strongly 

influenced by your life experiences with suicide and 

similar events. Needless to say, your responses to suicide and to people who are suicidal are highly susceptible to attitudinal influence, and these attitudes play 

a critical role in work with people who are suicidal. 

An empathic attitude can assist you in engaging and 

understanding people in a suicidal crisis. A negative 

attitude can cause you to miss opportunities to offer 

hope and help or to overreact to people in a suicidal 

crisis. Below are some attitudinal issues to consider 

in working with people who are suicidal. 

Positive Attitude and Behavior 1: People in substance abuse treatment settings often need additional 

services to ensure their safety. 

Explanation: Merely receiving substance abuse treatment may lessen the risk of suicide. A good working 

relationship with a substance abuse treatment professional is, in fact, a powerful protective factor against 

suicide. However, individuals who are acutely suicidal may need more services (e.g., mental health evaluation, short-term emergency hospitalization) to 

ensure their safety. In addition, certain clients, 

including those who are poorly connected to other 

clients and to treatment providers, clients who are 

making little progress in treatment, and clients at 

major transition points in care (e.g., moving from 

inpatient to outpatient care or being administratively 

discharged) may be at increased risk. An empathic 

attitude can help you recognize these challenging circumstances and proactively assess and intervene. 

Positive Attitude and Behavior 2: All clients 

should be screened for suicidal thoughts and behaviors as a matter of routine. 

Explanation: “Don’t ask, don’t tell” is not an effective 

agency suicide policy. Take the following actions to 

prevent clients from being exposed to life-threatening 

situations and to prevent exposing yourself and your 

agency to legal risk of malpractice: 

•	 Screen for suicide and ask followup questions. 

•	 Follow up with a client when risk has been previously documented. 

•	 Take appropriate action when risk is detected. 

•	 Document suicide-related screening and interventions. 

•	 Communicate suicide risk to another professional 

or agency. 

Positive Attitude and Behavior 3: All expressions 

of suicidality indicate significant distress and heightened vulnerability that require further questioning 

and action. 

Explanation: Even in rare circumstances where 

clients appear to be purposefully using reports of suicidal thoughts or plans to manipulate their treatment 

regimen, expressions of suicidality must be taken 

seriously. Thus, when clients appear to “use” suicidality, it should be recognized as a very limited approach 

to coping. Indeed, there is often more than one reason 

for an act of suicide (e.g., one may simultaneously 

want to die and elicit attention). You must address 

clients “where they are” and not impose your own 

agenda. If suicidal thoughts or behaviors occur, 

addressing suicidality must be a priority. Even if a 

client really does not want to die, if his or her reports 

of suicidal ideation are not taken seriously, the client 

may act on them to “save face.” 

Positive Attitude and Behavior 4: Warning signs 

for suicide can be indirect; you need to develop a 

heightened sensitivity to these cues. 

Explanation: Fortunately, clients often give warning 

signs before making a suicide attempt, and often 

these warning signs include expressions of suicidal 

thoughts or plans. More indirect signals include 

expressions of hopelessness, feeling trapped, or having no purpose in life, and observable signs such as 

withdrawal from others, mood changes, or reckless 

behavior. Such signs require followup. Beyond screening for current risk, counselors should be aware of 

clients’ histories of suicidal thoughts and behaviors 

and should be on watch for indications of recurrence 

of suicidal thoughts or behavior and/or the emergence 

of warning signs, particularly when acute stressful 

life events (such as relapse, relationship breakup, or 

psychological trauma) occur. 

Positive Attitude and Behavior 5: Talking about a 

client’s past suicidal behavior can provide information 

about triggers for suicidal behavior. 

8 Part 1, Chapter 1 
Explanation: Discussing past suicidal thoughts or 

behaviors is an important part of gathering information for suicide screening. The circumstances of past 

suicidal ideation and attempts can provide important 

insights into the scenario(s) that may promote future 

risk. Some clients may also wish to discuss past suicidal behavior in more depth for a variety of reasons 

(e.g., they never talked about it before, it represented 

their “hitting bottom,” the spiritual implications) that 

should be honored. 

Positive Attitude and Behavior 6: You should give 

clients who are at risk of suicide the telephone number of a suicide hotline; it does no harm and could 

actually save a life. 

Explanation: It is true that some clients will never 

use a hotline number. However, others will use a hotline resource. It is best to give all clients who may be 

at risk of suicide a hotline number because you cannot predict which clients will take advantage of it. In 

addition, always give “at risk” clients other options, 

including how to contact emergency resources after 

hours, mental health emergency services in the community, and instructions to go to the nearest hospital 

emergency room. The national suicide hotline, 1-800­

273-TALK, and 911 can be accessed from anywhere 

in the United States. How to use a safety card with 

emergency contact information is discussed later in 

this chapter. 

Summary 

Positive, empathic attitudes toward clients experiencing suicidal thoughts and behaviors do not, by themselves, mean that clients will initiate or receive 

appropriate services. However, they do form the platform on which proactive, effective services can be 

built. It is important to remember that the thoughts, 

emotions, and behaviors accompanying negative attitudes toward suicidality can be a major impediment 

to quality care. Understanding that clients with suicidal thoughts and behaviors can benefit from intervention and treatment, that people who make verbal 

expressions of suicidality have needs that aren’t 

being addressed, and that there is a relationship 

between a client’s suicidality and his or her substance 

abuse can make a huge difference in a client’s overcoming a suicidal crisis and staying in recovery. 

Background Information 

The Link Between Substance Abuse 

and Suicidality 

There is a strong link between substance use 

disorders and risk for suicidal behavior. 

•	 Suicide is a leading cause of death among people 

who abuse alcohol and drugs (Wilcox et al., 2004). 

•	 Compared with the general population, individuals 

treated for alcohol abuse or dependence are at 

about 10 times greater risk for suicide; people who 

inject drugs are at about 14 times greater risk for 

suicide (Wilcox, et al., 2004). 

•	 Individuals with substance use disorders are also 

at increased risk for suicidal ideation and suicide 

attempts (Kessler et al., 1999). 

•	 Depression is a common co-occurring diagnosis 

among people who abuse substances that confers 

risk for suicidal behavior (Conner et al., 2007; 

Murphy, Wetzel, Robins, & McEvoy, 1992; Roy, 

2001, 2002). Other mental disorders are also 

implicated. 

•	 People with substance use disorders often seek 

treatment at times when their substance use difficulties are at their peak—a vulnerable period that 

may be accompanied by suicidal thoughts and 

behaviors. 

There is a strong link between acute substance 

use and risk for suicidal behavior. 

•	 Alcohol’s acute effects include disinhibition, 

intense focus on the current situation with little 

appreciation for consequences, and promoting 

depressed mood, all of which may increase risk for 

suicidal behavior (Hufford, 2001). Other central 

nervous system depressants may act similarly. 

•	 Acute alcohol intoxication is present in about 

30–40 percent of suicide attempts and suicides 

(Cherpitel, Borges, & Wilcox, 2004). 

•	 Intense, short-lived depression is prevalent among 

treatment-seeking people who abuse cocaine, 

methamphetamines, and alcohol, among other 

groups (Brown et al., 1995; Cornelius, Salloum, 

Day, Thase, & Mann, 1996; Husband et al., 1996). 

Even transient depression is a potent risk factor 

for suicidal behavior among people with substance 

use disorders. 

Addressing Suicidal Thoughts and Behaviors in Substance Abuse Treatment 9 
Overdose suicides often involve multiple drugs like 

alcohol, benzodiazepines, opioids, and other psychiatric medications (Darke & Ross, 2002). 

The risk for suicidal behavior may increase at 

any point in treatment. 

•	 Suicide risk may increase at transition points in 

care (inpatient to outpatient, intensive treatment 

to continuing care, discharge), especially when a 

planned transition breaks down. Anticipating risk 

at such transition points should be regarded as an 

issue in treatment planning. 

•	 Suicide risk may increase when a client is terminated administratively (e.g., because of poor attendance, chronic substance use) or is refused care. It 

is unethical to discharge a client and/or refuse 

care to someone who is suicidal without making 

appropriate alternative arrangements for treatment to address suicide risk. 

•	 Suicide risk may increase in clients with a history 

of suicidal thoughts or attempts who relapse. 

Treatment plans for such clients should provide 

for this possibility. 

•	 Suicide risk may increase in clients with a history 

of suicidal thoughts or attempts who imply that 

the worst might happen if they relapse (e.g., “I 

can’t go through this again,” “if I relapse, that’s 

it”)—especially for those who make a direct threat 

(e.g., “This is my last chance; if I relapse, I’m 

going to kill myself”). Treatment plans for such 

clients should provide for this possibility. 

•	 Suicide risk may increase in clients with a history 

of suicidal thoughts or attempts when they are 

experiencing acute stressful life events. Treatment 

plans for such clients should provide for this possibility, for example, by adding more intensive treatment, closer observation, or additional services to 

manage the life crises. 

Types of Suicidal Thoughts and 

Behaviors 

Precise definitions of four types of suicide-related concepts will help clarify important nuances in the subject matter of this TIP. 

Suicidal thoughts 

Suicidal ideation: Suicidal ideation is much more 

common than suicidal behavior (Conner et al., 2007; 

Kessler et al., 1999). Suicidal ideation lies on a continuum of severity from fleeting and vague thoughts 

of death to those that are persistent and highly specific. Serious suicidal ideation is frequent, intense, 

and perceived as uncontrollable. 

Suicide plans: Suicide plans are important because 

they signal more serious risk to carry out suicidal 

behavior than suicidal ideation that does not involve 

planning (Conner et al., 2007; Kessler et al., 1999). 

Suicide planning lies on a continuum from vague and 

unrealistic plans to those that are highly specific and 

feasible. Serious suicide planning may also involve 

rehearsal or preparation for a suicide attempt. 

Suicidal behaviors 

Suicide attempt: A suicide attempt is a deliberate act 

of self-harm that does not result in death and that 

has at least some intent to die (Silverman, Berman, 

Sanddal, O’Carroll, & Joiner, 2007). Attempts have 

two major elements: (a) the subjective level of intent 

to die (from the client’s subjective perspective, how 

intensely did he or she want to die and to what extent 

did he or she expect to die?); and (b) the objective 

lethality of the act (from a medical perspective, how 

likely was it that the behavior would have led to 

death?) (Beck, Schuyler, & Herman, 1974; Harriss, 

Hawton, & Zahl, 2005). Although all suicide attempts 

are serious, those with high intent (client clearly 

wanted to die and expected to die) and high lethality 

(behavior could have easily led to death) are the most 

serious. 

Suicide: Suicide is an acute, deliberate act of selfharm with at least some intention to die resulting in 

death (Silverman et al., 2007). 

Other suicide-related concepts 

Suicidal intention: Suicidal intention (also called 

“intent”) signals high, acute risk for suicidal behavior. 

Having suicidal intent is always serious because it 

signals that the client “intends” to make a suicide 

attempt. Some indicators of “high intent” include 

drafting a suicide note or taking precautions against 

discovery at the time of an attempt. 

Suicide preparation: Behaviors that suggest preparation signal high, acute risk for suicidal behavior. 

Preparation may come in many forms, such as writing a suicide note or diary entry, giving away possessions, writing a will, acquiring a method of suicide 

(e.g., hoarding pills, buying a weapon), making a 

10 Part 1, Chapter 1 
method more available (e.g., moving a gun from the 

attic to beside the bed), visiting a site where suicide 

may be carried out (e.g., driving to a bridge), rehearsing suicide (e.g., loading and unloading a weapon), 

and saying goodbye to loved ones directly or symbolically. 

Other harmful behaviors 

Non-suicidal self-injury (NSSI): NSSI is also commonly referred to in the literature as “deliberate selfharm” and “suicidal gesture.” NSSI (for example, selfmutilation or self-injury by cutting for the purpose of 

self-soothing with no wish to die and no expectation 

of dying) is distinguished from a suicide attempt or 

suicide because NSSI does not include suicidal intent. 

This TIP does not focus on NSSI. Suicidal behaviors 

and NSSI can co-exist in the same person and both 

can lead to serious bodily injury. 

Self-destructive behaviors: Behaviors that are repeated and may eventually lead to death (e.g., drug 

abuse, smoking, anorexia, pattern of reckless driving, 

getting into fights) are distinguished from suicidal 

behavior because an act of suicide is an acute action 

intended to bring on death in the short term. This 

TIP does not focus on self-destructive behaviors. 

Warning Signs for Suicide 

Warning signs are defined as acute indications of elevated risk. In other words, they signal potential risk 

for suicidal behavior in the near future. Warning 

signs may be evident at intake or may arise during 

the course of treatment. Warning signs always 

require asking followup questions (discussed in the 

Gathering Information section, pp. 14–18). As identified by a panel of experts on suicidal behavior (Rudd 

et al., 2006), warning signs can be direct or indirect. 

Direct indications of acute suicidality are given the 

highest priority. They are: 

•	 Suicidal communication: Someone threatening 

to hurt or kill him- or herself or talking of wanting 

to hurt or kill him- or herself. 

•	 Seeking access to a method: Someone looking 

for ways to kill him- or herself by seeking access to 

firearms, available pills, or other means. 

•	 Making preparations: Someone talking or writing about death, dying, or suicide, when these 

actions are out of the ordinary for the person. 

You may also observe indirect warning signs in substance abuse clients who are not suicidal. Nonetheless, these warning signs are critical to follow up on 

to determine the extent to which they may signal 

acute risk for suicidal behavior. You can remember 

them by the mnemonic IS PATH WARM: 

•	 I = Ideation 

•	 S = Substance Abuse 

•	 P = Purposelessness 

•	 A = Anxiety 

•	 T = Trapped 

•	 H = Hopelessness 

•	 W = Withdrawal 

•	 A = Anger 

•	 R = Recklessness 

•	 M = Mood Changes 

Some of the IS PATH WARM warning signs are selfevident (e.g., substance abuse); others require brief 

explanation. “Purposelessness” refers to a lack of a 

sense of purpose in life or reason for living. “Trapped” 

refers to perceiving a terrible situation from which 

there is no escape. “Withdrawal” refers to increasing 

social isolation. “Anger” refers to rage, uncontrolled 

anger, or revenge-seeking. “Anxiety” is a broad term 

that refers to severe anxiety, agitation, and/or sleep 

disturbance. “Mood changes” refers to dramatic shifts 

in emotions. 

Warning signs are often in evidence following acute 

stressful life events. Among people who abuse substances, break-up of a partner relationship is most 

common. It is also important to look for warning 

signs in your clients when relapse occurs and during 

acute intoxication. 

Stressful life events include: 

•	 Break-up of a partner relationship. 

•	 Experience of trauma. 

•	 Legal event. 

•	 Job loss or other major employment setback. 

•	 Financial crisis. 

•	 Family conflict or disruption. 

•	 Relapse. 

•	 Intoxication. 

Each of the direct warning signs indicates potential 

for suicidal behavior in its own right, and, if present, 

requires rigorous followup. The indirect warning 

signs may or may not signal risk for acute suicidal 

behavior (for example, “substance abuse” is the norm 

Addressing Suicidal Thoughts and Behaviors in Substance Abuse Treatment 11 
among your clients). In all cases, they require further 

followup questions to determine if they may indeed 

indicate acute suicidality. 

Risk Factors 

Risk factors are defined as indicators of long-term (or 

ongoing) risk. They are different from warning signs, 

which signal immediate risk. Risk factors for suicidal 

thoughts and behaviors among individuals with substance use disorders have been well researched 

(Conner, Beautrais, & Conwell, 2003; Conner et al., 

2007; Darke & Ross, 2002; Ilgen et al., 2007; Murphy 

et al., 1992; Preuss et al., 2002; Roy, 2001; Schneider 

et al., 2006). The list below, although not exhaustive, 

is informed by these studies. 

Risk factors for suicidal thoughts 

and behaviors 

These risk factors include: 

•	 Prior history of suicide attempts (most potent risk 

factor, although it should be remembered that 

about half of all deaths by suicide are first-time 

attempts). 

•	 Family history of suicide. 

•	 Severe substance use (e.g., dependence on multiple 

substances, early onset of dependence). 

•	 Co-occurring mental disorder: 

–	 Depression (including substance-induced
 

depression).
 

–	 Anxiety disorders (especially PTSD). 

–	 Severe mental illness (schizophrenia, bipolar 

disorder). 

–	 Personality disorder (best researched are borderline and antisocial personality disorders). 

–	 Anorexia nervosa. 

•	 History of childhood abuse (especially sexual 

abuse). 

•	 Stressful life circumstances: 

– Unemployment and low level of education, job 

loss, especially when nearing retirement. 

–	 Divorce or separation. 

–	 Legal difficulties. 

–	 Major and sudden financial losses. 

–	 Social isolation, low social support. 

–	 Conflicted relationships. 

•	 Personality traits: 

–	 Proneness to negative affect (sadness, anxiety, 

anger). 

–	 Aggression and/or impulsive traits. 

•	 Firearm ownership or access to a firearm. 

•	 Probable risk factors (although greater certainty 

requires more research in people with substance 

use disorders): 

–	 Inflexible/rigid personality characteristics. 

–	 Sexual orientation (lesbian, gay, or bisexual). 

–	 Chronic pain. 

Protective Factors 

Protective factors are defined as buffers that lower 

long-term risk. Unlike risk factors, factors that are 

protective against suicidal behavior are not well 

researched (Goldsmith, Pellmar, Kleinman, & 

Bunney, 2002). Fewer protective factors than risk factors have been identified among people who abuse 

substances and other populations. Reasons for living 

are perhaps the best researched protective factors in 

the literature (Linehan Goodstein, Nielsen, & Chiles, 

1983; Oquendo Dragasti et al., 2005). 

The following are known and likely protective factors: 

•	 Reasons for living. 

•	 Being clean and sober. 

•	 Attendance at 12-Step support groups. 

•	 Religious attendance and/or internalized spiritual 

teachings against suicide. 

•	 Presence of a child in the home and/or childrearing responsibilities. 

•	 Intact marriage. 

•	 Trusting relationship with a counselor, physician, 

or other service provider. 

•	 Employment. 

•	 Trait optimism (a tendency to look at the positive 

side of life). 

A caution about protective factors: If acute suicide warning signs and/or multiple risk factors are in 

evidence, the presence of protective factors does not 

change the bottom-line assessment that preventive 

actions are necessary, and should not give you a false 

sense of security. Although protective factors may 

sustain someone showing ongoing signs of risk (e.g., 

due to chronic depression), they do not immunize 

clients from suicidal behavior and may afford no protection in acute crises. 

Protective factors vary with cultural values. For 

example, in cultures where extended families are 

closely knit, family support can act as a protective 

factor. Others include a strong affiliation with a clan, 

tribe, or ethnic community; faith in and reliance on 

traditional healing methods; strong spiritual values 

12 Part 1, Chapter 1 
shared among community members; and absence of 

cultural trauma such as that of families of Holocaust 

survivors and American Indians who were sent 

unwillingly to boarding schools to be acculturated. 

Suicide Versus Suicide Attempt 

Prevalence: Suicide attempts are much more common 

than suicides. In the United States, there are approximately 32,000 suicides annually (National Center for 

Injury Prevention and Control [NCIPC], 2007). More 

than 10 times that number of self-inflicted injuries 

were reported in 2006, although the proportion of 

these injuries in which there was intent to die is 

unknown (NCIPC, 2007). 

Suicide Methods: The most common method of 

attempted suicide is an attempt to overdose. Cutting 

(for instance, wrists) with a knife is also common. 

Lethality: Use of a firearm and hanging are the most 

lethal methods of suicide. The most common method 

of death by suicide is firearms, followed by hanging 

(NCIPC, 2007). Attempts by overdose and self-cutting 

are much more likely to be survived (Shenassa, 

Catlin, & Buka, 2003). 

Risk of Suicide and Suicide 

Attempts: Age, Gender, and Race 

or Ethnicity 

Age 

Adolescents and young adults are more likely to 

make nonfatal suicide attempts than older individuals (NCIPC, 2007). However, older individuals are 

more likely to die by suicide. Older adults’ elevated 

risk for suicide deaths is attributable to their tendency to show high suicide intent, to use more deadly 

methods, and to their bodies’ greater fragility to the 

effects of acts of self-harm (Conwell, Duberstein, & 

Caine, 2002). Because many older adults live alone, 

they are less likely to be rescued (Szanto et al., 2002). 

The extent to which these general population patterns pertain to people treated for substance use disorders is not clear. 

Gender 

Women are more likely to attempt suicide than men, 

although the difference in prevalence of suicide 

attempts between men and women is not as high as 

once believed (Nock & Kessler, 2006). Men are more 

likely to die by suicide than women (NCIPC, 2007). 

Overall, men carry out fewer suicidal acts, but they 

tend to show higher intent to die (Nock & Kessler, 

2006), and use more deadly methods (Goldsmith et 

al., 2002). The extent to which these general population patterns pertain to people treated for substance 

use disorders is not clear. 

Race and ethnicity 

According to national statistics on suicide (NCIPC, 

2007), Whites and Native Americans have higher 

rates of suicide than African Americans; males are at 

highest risk in all of these racial groups. The highest 

rate of suicide among White males is during older 

adulthood (age 70 and older), while the highest rates 

of suicide among Native American and African 

American males occur much younger—during late 

adolescence and young adulthood. It should be noted 

that suicide rates among Native Americans vary significantly depending on tribe and region of the country. Some data also suggest that risk factors differ 

across racial groups. For example, the presence of an 

anxiety disorder may be an especially important risk 

factor for suicide attempts among Blacks (Joe, Baser, 

Breeden, Neighbors, & Jackson, 2006). The extent to 

which these general population patterns pertain to 

people treated for substance use disorders is not 

clear. There is a particularly low prevalence of deaths 

by suicide among African American females, although 

it is unknown if this data holds true for African 

American females with a substance use disorder 

(NCIPC, 2007). 

Hispanics/Latinos have fairly similar rates of suicidal 

thoughts and behavior compared with White, nonHispanic individuals (NCIPC, 2007). Among youth 

and young adults, the prevalence of suicidal thoughts 

and behavior increases among Hispanics/Latinos who 

are more acculturated to mainstream American culture, particularly among females (Zayas, Lester, 

Cabassa, & Fortuna, 2007). The extent to which these 

general population patterns pertain to people treated 

for substance use disorders is not clear. Additional 

information on race and ethnicity and substance 

abuse treatment can be obtained in the planned TIP, 

Improving Cultural Competence in Substance Abuse 

Treatment (CSAT, in development d) 

Addressing Suicidal Thoughts and Behaviors in Substance Abuse Treatment 13 
Reasons for Suicidal Behavior 

There is often more than one reason for a suicide 

attempt. For example, a client may want to get back 

at his or her estranged partner (induce guilt), demonstrate distress (cry for help), and want to die. 

Therefore, it is important not to trivialize suicide 

attempts that may involve motivations other than to 

die. In other words, if at least some wish to die was 

present at the time of the attempt, regardless of 

whether there were other reasons for the act, then 

the behavior should be considered a suicide attempt. 

Some, but not all, potential reasons for a suicide 

attempt include: 

•	 Desire to die. 

•	 Hopelessness. 

•	 Extreme or prolonged sadness. 

•	 Perceived failure or self-hate following relapse. 

•	 Loneliness. 

•	 Feeling like a burden to others. 

•	 Disinhibition while intoxicated. 

•	 Escape from a painful emotional state. 

•	 Escape from an entrapping situation. 

•	 Get attention. 

•	 Impulsive reaction to an acute stressful life event 

(e.g., break-up). 

•	 Hurt another individual (e.g., make another individual feel guilty). 

•	 Paranoia or other psychosis (e.g., command hallucination to take one’s life). 

•	 Escape a progressively deteriorating health situation (e.g., terminal disease). 

GATE: Procedures for 

Substance Abuse 

Counselors 

Gather information
 

Access supervision
 

Take responsible action
 

Extend the action
 

The Consensus Panel agreed on a formulation of the 

role of substance abuse treatment counselors in 

addressing suicidal thoughts and behaviors identified 

by the acronym GATE. The elements in GATE reflect 

behaviors that are within your scope of competence as 

a substance abuse counselor regarding helping clients 

who are at risk for suicide. You are familiar with 

gathering information from clients with substance 

use disorders; this skill can be translated into gathering information about suicidal thoughts and behaviors. Supervision may be a regular part of your 

agency’s program; with a client who is suicidal, it is a 

necessity. You know how to plan for the treatment of 

a client with a substance use disorder; this skill can 

be applied to planning for a client to address his or 

her suicidal thoughts and behaviors. You typically follow up with clients to coordinate care, check on referral appointments, monitor progress, and enlist support from family and community resources. These 

counselor activities are essential when working with 

clients who are suicidal. 

If you have advanced training in a mental health discipline (such as social work, psychology, or professional counseling) along with specialized training in suicidality, you might also be prepared to take on other 

treatment tasks with clients with suicidal thoughts 

and behaviors, such as assessment, specialized suicide interventions, or treatment of co-occurring mental disorders such as depression and psychological 

trauma. These advanced skills, while very important, 

are not a primary focus of this TIP, although some 

advanced skills are illustrated in the clinical 

vignettes of Vince and Rena in chapter 2. 

The quick overview below is supplemented by a flow 

chart (see p. 16) and the more detailed sections that 

follow. 

Quick Overview of GATE 

G: Gather information 

There are two steps to gathering information: (1) 

screening and spotting warning signs, and (2) asking 

followup questions. Screening consists of asking very 

brief, uniform questions at intake to determine if further questions about suicide risk are necessary. 

Spotting warning signs consists of identifying telltale 

signs of potential risk. Ask followup questions when 

clients respond “yes” to one or more screening questions or any time you notice a warning sign(s). The 

purpose of asking followup questions is to have as 

much information as possible so that you and your 

supervisor and/or treatment team can develop a good 

plan of action. You will want to provide as much 

information as possible to another provider should 

14 Part 1, Chapter 1 
you make a referral. Examples of screening questions, 

warning signs, and followup questions are provided 

below. 

A: Access supervision and/or 

consultation 

You should never attempt to manage suicide risk 

alone even if you have substantial specialized training and education. With suicidal clients, two or three 

heads are almost always better than one. Therefore, 

speak with a supervisor, an experienced consultant 

who has been vetted by your agency, and/or your multidisciplinary treatment team when working with a 

client who you suspect may be dealing with suicidal 

concerns. It is a collective responsibility, not yours 

alone, to formulate a preliminary impression of the 

seriousness of risk and to determine the action(s) that 

will be taken. Accessing supervision or consultation 

can provide invaluable input to promote the client’s 

safety, give you needed support, and reduce your personal liability. Some guidelines for making effective 

use of supervision and consultation are provided 

below. 

T: Take responsible action(s) 

The guiding principle here is that your action(s) 

should make good sense in light of the seriousness of 

suicide risk. The phrase “make good sense” indicates 

that your action(s) is “responsible,” given the seriousness of risk. The next section expands on this principle and provides a list of potential actions covering a 

wide range of intensity and immediacy that you and 

your supervisor or team may take. 

E: Extend the action(s) 

Too often, suicide risk is dealt with acutely, on a onetime basis, and then forgotten. As with substance 

abuse, vulnerable clients may relapse into suicidal 

thoughts or behaviors. This means that you will need 

to continue to observe and check in with the client to 

identify a possible return of risk. Another common 

problem is referring a suicidal client but failing to 

coordinate or even follow up with the provider. 

Suicide risk management requires a team approach, 

and as your client’s addiction counselor, you are an 

essential part of this team. A range of extended 

actions is provided below. 

Documenting all the actions you have taken is important because it creates a medical and legal account of 

the client’s care: what information you obtained, 

when and what actions were taken, and how you followed up on the client’s substance abuse treatment 

and suicidal thoughts and behaviors. This record can 

be useful for your supervision or consultation, to your 

team, and to other providers. 

On the next page is a graphic depiction of the elements of GATE (Figure 1.1). It is designed to help 

you see how the completion of one element leads to 

decisions and specific actions in the next. 

Detailed Explanation of GATE 

G: Gather information 

This stage proceeds in two steps: (1) screening and/or 

spotting warning sign(s) and (2) asking followup 

questions. Substance abuse counselors should be 

expected to gather information about suicidal 

thoughts and behaviors. Gathering information is different from formal assessment because an assessment is a process by which a professional synthesizes 

and interprets information. Substantial training, 

supervision, and experience is required to have sufficient clinical judgment to make the fine distinctions 

necessary for assessment. 

As much as possible, you should avoid “stacking” 

questions (peppering clients with one closed-end 

question after the other), which will tend to generate 

defensiveness and/or false reassurances of safety. If 

you are unclear about the answer from the client or if 

you sense a degree of defensiveness, you might consider asking the same question in a different way 

somewhat later in the interview. Ambiguous or vague 

answers are always important to pursue further 

because they may be a sign of discomfort with the 

topic, anxiety about disclosure, evasiveness, and/or 

uncertainty (e.g., “I don’t know”, “I’m not sure”), with 

the understanding that clients will not always be able 

or willing to provide greater clarity. 

Screening 

Sample screening questions: If your agency does 

not provide you with standard screening question(s) 

on suicidal thoughts and behaviors, use the questions 

provided below. They introduce the topic of suicide 

and screen for suicidal thoughts and attempts. The 

timing of the questions is important; they should be 

asked in the context of a larger discussion of, for 

Addressing Suicidal Thoughts and Behaviors in Substance Abuse Treatment 15 
Figure 1.1
 

Decision Tree
 

How to Address Suicidal Thoughts and Behaviors
 

in Substance Abuse Treatment
 

instance, mood or quality of life. Ask the same screening questions verbatim for every new client. 

Introducing the topic (use either statement): 

1. Now I am going to ask you a few questions about 

suicide. 

2.	 I have a few questions to ask you about suicidal 

thoughts and behaviors. 

Screening for suicidal thoughts (ask either question): 

3. Have you thought about killing yourself? 

4. Have you thought about carrying out suicide? 

Screening for suicide attempts (ask either question): 

5. Have you ever tried to take your own life? 

6. Have you ever attempted suicide? 

Note that the introductory items are brief and 

straightforward. With slight word changes, items 3 

and 5 are taken from a research interview for the 

study of alcoholism (Bucholz et al., 1994) that have 

been used in research on suicidal thoughts and 

behavior (Conner et al., 2007), and items 4 and 6 are 

taken from a national survey that has provided information on suicidal thoughts and behavior in the general population (Kessler et al., 1999). 

16 Part 1, Chapter 1 
           

             

             

             

         

             

           

               

         

               

           

                 

               

       

The National Suicide Prevention Lifeline has produced a wallet­sized card for counselors entitled:

“Assessing Suicide Risk: Initial Tips for

Counselors” that lists five questions counselors

can ask abut suicide. The card additionally provides the warning signs contained in “IS PATH

WARM” (described on p. 11 of this TIP) and offers

brief advice on actions to take with people who

are at risk. The card is available online at

http://stepupprogram.org/docs/handouts/

suicide_warning_signs.pdf. Bulk copies (item

SVP06­0153) can be ordered at http://nmhicstore.samhsa.gov/publications/ordering.aspx.

Additional options for screening 

Multi­item measures that contain an item about

suicidal thoughts and behaviors may also be

used for screening. Items that screen for suicidal

thoughts can be found on several other wellvalidated depression measures including the

original and revised versions of the Beck Depression

Inventory (BDI or BDI­II; Beck, Ward, Mendelsohn,

Mock, & Erbaugh, 1961; Beck, Steer, & Brown, 1996)

and Hamilton Depression Rating Scale (Hamilton,

1960) as well as on instruments that are administered

verbally, including versions of the Addiction Severity

Index (ASI; McLellan et al., 1992). The BDI­II may be

purchased, whereas the ASI may be downloaded at no

cost from the Internet (http://www.tresearch.org/

tools/download­asi­instruments­manuals/)

If a client endorses any level of suicidality on

the relevant items from these measures, you

will want to ask followup questions. TIP 42:

Substance Abuse Treatment for Persons With

Co­Occurring Disorders (CSAT, 2005d), also

contains useful suicide screening options for

persons with co­occurring disorders.

Asking followup questions

It is important to ask followup questions when

a client answers “yes” to a screening question at

intake, when you note a warning sign(s), or at

any time during the course of treatment when

you suspect the client is suicidal, even if you

can’t pinpoint why. Followup questions and

their answers enable you to have as much information as possible when you discuss the situation with your supervisor or team and allow you

to convey solid information if you make a referral to another provider. 

Sample followup questions about suicidal

thoughts:

1. Can you tell me about the suicidal thoughts? 

2. If the client requires more direction:

For example, What brings them on? 

How strong are they? 

How long do they last? 

3. If you do not already know:

Addressing Suicidal Thoughts and Behaviors in Substance Abuse Treatment 17
Have you made a plan? (If yes) What is your plan? 

Do you have access to a method of suicide? A gun? 

An overdose? 

Do you intend to attempt suicide? 

Always ask an open-ended question first (see sample 

question 1). Clients may tell you spontaneously all of 

the information you need to know. Open-ended questions can help you avoid “grilling” the client. 

Information not provided by clients may be elicited 

with followup questions to determine characteristics 

such as the precipitants, strength, and duration of 

the suicidal thoughts (see sample question 2). Finally, 

if information related to planning, method, and 

intent does not come to light spontaneously, always 

gather these critical pieces of information (see sample 

question 3). A client’s inability or unwillingness to 

provide the necessary information may be an indicator of increased risk and that should be noted in discussion with your treatment team or your supervisor. 

Gathering additional information about suicide 

attempts is straightforward. You will want to ask the 

client to explain the attempt through an open-ended 

question such as “Please tell me about the attempt” 

and ask followup questions to find out more about it. 

If there was more than one suicide attempt, ask these 

questions about the most recent attempt and the most 

severe attempt (if it differs from the most recent act). 

The answers to these questions will be very helpful in 

characterizing the seriousness of suicidal behavior. 

Sample followup questions about suicide attempts: 

1. Please tell me about the attempt. 

2. If the client requires more direction: 

For example, What brought it on? Where were you? 

Were you drinking or high? 

3. If you do not already know: 

To gather information about lethality: 

What method did you use to try to kill yourself? 

Did you receive emergency medical treatment? 

To gather information about intent: 

Did you want to die? How much? 

Afterward, were you relieved you survived, or would 

you rather have died? 

The lessons that apply to asking about suicidal 

thoughts also apply here: ask an open-ended question 

first, ask followup questions to determine the circumstances of the attempt such as the precipitating 

event, setting, and the role of acute alcohol or drug 

use, and finally, if information related to lethality 

and intent does not come to light spontaneously, 

always continue to gather these critical pieces of 

information (see sample question 3). 

Summary of G: Gather information 

The gathering information task consists of collecting 

relevant facts. Screening questions should be asked of 

all new clients when you note warning sign(s) and 

any time you have a concern about suicide, whether 

or not you can pinpoint the reason. Inquiries about 

suicidal thoughts and attempts always start with an 

open-ended question that invites the client to provide 

more information. Followup questions are then asked 

to gather additional, critical information. Routine 

monitoring of suicide risk throughout treatment 

should be a basic standard in all substance abuse 

treatment programs. 

A: Access supervision or 

consultation 

You should not make a judgment about the seriousness of suicide risk or try to manage suicide risk on 

your own unless you have an advanced mental health 

degree and specialized training in suicide risk management and it is understood by your agency that you 

are qualified to manage such risk independently. For 

this step, obtaining consultation does not refer to 

merely getting input from a peer. Although such 

input may be helpful, consultation is a more formal 

process whereby information and advice are obtained 

from (a) a professional with clear supervisory responsibilities, (b) a multidisciplinary team that includes 

such person(s), and/or (c) a consultant experienced in 

managing suicidal clients who has been vetted by 

your agency for this purpose. When obtaining supervision or consultation, assemble all the information 

you have gathered on your client’s suicidal thoughts 

and/or suicide attempts through the screening and 

followup questions, as well as data from other sources 

of information (e.g., other providers, family members, 

treatment records). 

In some circumstances, you will need to obtain immediate consultation (see the vignettes in chapter 2 on 

18 Part 1, Chapter 1 
Clayton and Leon). In other circumstances, obtaining 

consultation at regularly scheduled supervision or 

team meetings may be sufficient (regular consultation). The examples listed below are for illustrative 

purposes only; other circumstances requiring immediate consultation may exist. 

Circumstances at intake requiring access to immediate supervision or consultation include: 

•	 Direct warning signs are evident (suicidal communication, seeking access to method, making preparations). 

•	 Followup questions to suicide screening questions 

suggest that there is current risk. 

•	 Followup questions to indirect warning signs suggest that there is current risk. 

•	 Additional information (e.g., from the referral 

source, family member, medical record) suggests 

that there is current risk. 

Circumstances during treatment that require access 

to immediate supervision or consultation include: 

•	 Emergence (or re-emergence) of direct warning 

signs. 

•	 Emergence (or re-emergence) of indirect warning 

signs that, on followup questioning, suggest current risk. 

•	 Your client’s answers to suicide screening questions asked during the course of treatment suggest 

current risk. 

•	 Additional information (e.g., from another provider 

or family member) suggests current risk. 

Circumstances at intake requiring access to regularly 

scheduled supervision or consultation include: 

•	 One or more indirect warning signs are present, 

but followup questions indicate that there is no 

reason to suspect current risk for suicidal behavior 

per se (e.g., a client is socially isolated and abusing substances, but otherwise shows no indications 

of suicidality). 

•	 One or more risk factors are present, but there are 

no accompanying warning signs or other indications to suspect current risk for suicidal behavior. 

•	 During screening, your client discloses a history 

of suicidal thoughts or suicide attempt(s), but 

there are no accompanying warning signs or other 

indications to suspect current risk for suicidal 

behavior. 

•	 Additional information (e.g., from the referral 

source or family member) suggests your client has 

a history of suicidal thoughts or attempts, but 

there are no accompanying warning signs or other 

indications to suspect current risk for suicidal 

behavior. 

Circumstances during treatment that require access 

to regularly scheduled supervision or consultation 

include: 

•	 Your client reports (or alludes to) a history of suicidal thoughts that you had not previously been 

aware of, but there are no accompanying warning 

signs or other indications to suspect current risk 

for suicidal behavior. 

•	 Your client reports (or alludes to) prior suicide 

attempt(s) that you had not previously been aware 

of, but there are no accompanying warning signs 

or other indications to suspect current risk for suicidal behavior. 

•	 Additional information (e.g., from another provider 

or family member) suggests a history of suicidal 

thoughts or attempts that you had not previously 

been aware of, but there are no accompanying 

warning signs or other indications to suspect current risk for suicidal behavior. 

•	 Client with a history of suicidal thoughts or 

behavior experiences an acute stressful life event 

or a setback in treatment (e.g., substance abuse 

relapse), but there are no accompanying warning 

signs or other indications to suspect current risk 

for suicidal behavior. 

You will find it useful to know who your consultant 

(supervisor, team, outside consultant) is for issues of 

sucidality in your program, what your agency policy 

is regarding acutely suicidal clients, and where such 

patients could be referred. Having this information in 

advance can free you to focus on the immediate situation when a crisis arises. If you suspect that information on acute suicidality might arise in a session, it is 

wise to alert your supervisor in advance that you 

might contact him or her for information, support or 

consultation while the client is still in your office. 

Summary of A: Access supervision or 

consultation 

Risk for suicidal behavior may be evident at intake or 

at any time during the course of treatment. 

Supervision or consultation to address risk may be 

obtained immediately or at a regularly scheduled 

time, depending on the urgency of the situation. 

Addressing Suicidal Thoughts and Behaviors in Substance Abuse Treatment 19 
Having a plan in place ahead of time for obtaining 

immediate supervision or consultation will help 

ensure a therapeutic response and will avoid unnecessary distress and scrambling. 

Immediate supervision or consultation should be 

obtained when clients exhibit direct suicide warning 

signs (see p. 11 for direct warning signs) or when 

they report at intake having made a recent suicide 

attempt. Substance abuse relapse during treatment is 

also an indication for supervisory involvement for 

clients who have a history of suicidal behavior or 

attempts. 

T: Take responsible action 

A useful guiding principle in taking responsible 

action is that your actions should make good sense in 

light of the seriousness of suicide risk. This section 

explains this principle, applies it to taking responsible action(s), and provides a list of potential actions. 

In the legal system, the standard used to assess 

responsibility and liability is to compare a given practitioner’s judgment and behavior with what another 

equally trained and experienced treatment practitioner would have done in the same circumstances. 

The key factor—although not the only factor—in considering the action(s) to take is a judgment about the 

seriousness of risk. Seriousness is defined as the likelihood that a suicide attempt will occur and the 

potential consequences of an attempt. Briefly, if a 

client is judged to be likely to carry out a suicide 

attempt (for example, has persistent suicidal 

thoughts and a clear plan) and if the client expects 

the suicide attempt to be lethal (for example, a plan 

to use a gun that the client keeps at home), there is 

high seriousness. In contrast, if a client is judged to 

be unlikely to carry out an attempt (for example, has 

fleeting ideation, no clear plan, and no intention to 

act) and any attempt may be expected to be nonlethal 

(for example, thoughts of swallowing some aspirin if 

there is any in the medicine cabinet), there is lower 

seriousness. In chapter 2, you will meet counselors 

who address issues of seriousness of a threat or 

attempt to make judgments about how to proceed 

with the session. Judgments about the degree of 

seriousness of risk should be made in consultation with a supervisor and/or a treatment team, 

not by a counselor acting alone. 

The actions taken should be sensible in light of the 

information that has been gathered about suicidal 

thoughts and/or previous suicide attempts. Although 

the potential actions are many, they can generally be 

described along a continuum of intensiveness. In 

instances of greater seriousness, you will generally 

take more intensive actions. For less serious circumstances, you will be more likely to take less intensive 

actions. Note that “less intensive” does not equate to 

inaction; it merely indicates that there may be more 

time to formulate a response, the actions may be of 

lower intensity, and/or fewer individuals and 

resources may be involved. 

In some instances, an immediate response is required 

(see the vignettes in chapter 2 about Clayton, Vince, 

and Rena). In general, responses that require immediate action may be considered more intensive. 

Examples of immediate actions include arranging 

transportation to a hospital emergency department 

for evaluation, contacting a spouse to have him or her 

arrange for removal of a gun from the home and 

arrange safe storage, and arranging on the spot to 

have a mental health specialist in your program further evaluate a client. Examples of non-immediate, 

but important, actions include making a referral for a 

client to an outpatient mental health facility for evaluation, scheduling the client to see a psychiatrist for 

possible medication management, and ordering past 

mental health records from another provider. 

Some interventions can be considered more intensive 

than others. These include interventions that reduce 

freedom of movement (e.g., arranging an ambulance 

to transport a client to a hospital emergency department), are expensive (e.g., inpatient hospitalization), 

compromise privacy (e.g., contacting the police to 

check on a high-risk client), and/or restrict autonomy 

(e.g., asking a spouse to arrange for safe storage of a 

weapon). Other interventions in managing suicide 

risk, although less intensive, may also go beyond the 

usual care of a substance abuse client and may be 

experienced by a client as unnecessary or intrusive. 

Arranging further assessment with an outpatient 

mental health provider or through a home visit by a 

mental health mobile crisis team, for instance, may 

be seen as burdensome to the client. Less intensive 

interventions do not reduce freedom of movement, do 

not sacrifice privacy, are comparatively inexpensive, 

and/or do not restrict autonomy. 

Another aspect of intensiveness concerns the number 

of individuals involved (e.g., client, case manager, 

counselor, mental health professional, concerned 

spouse) and the number of actions taken (e.g., psychi20 Part 1, Chapter 1 
atric medications, substance abuse counseling, family 

sessions, case management coordination). In other 

words, in general, the greater the number of interventions, and the more individuals involved, the more 

intensive the action(s). 

What actions can you take? 

The list of actions below is not exhaustive but 

includes the most common actions. At times, one 

action will suffice, whereas at other times, more than 

one (and perhaps many) will be required. You and 

your supervisor or team will strive to do things that 

make good sense in terms of their intensity. Your 

actions should match the seriousness of risk. Often 

your response will involve arranging a referral (if the 

necessary resources are not available within your 

agency). The list below is in no particular order. 

•	 Gather additional information from the client to 

assist in a more accurate clinical picture and 

treatment plan. 

•	 Gather additional information from other sources 

(e.g., spouse, other providers). 

•	 Arrange a referral: 

–	 To a clinician for further assessment of suicide 

risk. 

–	 To a provider for mental health counseling. 

–	 To a provider for medication management. 

–	 To an emergency provider (e.g., hospital emergency department) for acute risk assessment 

(see the vignette on Vince for a discussion of 

relevant issues). 

–	 To a mental health mobile crisis team that can 

provide outreach to a physically inaccessible 

client at his or her home (or shelter) and make 

a timely assessment. 

–	 To a more intensive substance abuse treatment 

setting. 

•	 Restrict access to means of suicide. 

•	 Temporarily increase the frequency of care, including more frequent telephone check-ins. 

•	 Temporarily increase the level of care (e.g., refer 

to day treatment). 

•	 Involve a case manager (e.g., to coordinate care, to 

check on the client occasionally). 

•	 Involve the primary care provider. 

•	 Encourage the client to attend (or increase attendance) at 12-Step meetings such as Alcoholics 

Anonymous, Narcotics Anonymous, or Cocaine 

Anonymous. 

•	 Enlist family members or significant others (selectively, depending on their health, closeness to the 

client, and motivation) in observing indications of 

a return of suicide risk. 

•	 Observe the client for signs of a return of risk 

•	 Create a safety card (see below) with the client in 

the event of a return of acute suicidality. 

Safety Cards and Safety Plans 

With all clients with suicidal risk, consider developing with the client a written safety card that includes at a minimum: 

•	 A 24-hour crisis number (e.g., 1-800-273-TALK). 

•	 The phone number and address of the nearest hospital emergency department. 

•	 The counselor’s contact information. 

•	 Contact information for additional supportive individuals that the client may turn to when needed (e.g., sponsor, supportive family member). 

To maximize the likelihood that the client will make use of the card, it should be personalized and created with 

the client (not merely handed to him or her). Discuss with the client the type(s) of signs and situations that would 

warrant using one or more of the resources on the card. It is ideal to create a wallet-size card with this information so clients can easily keep it with them. Have backup copies of the card available in the event that the client 

loses the card (which frequently happens) so that it can be quickly replaced. Consistent with this TIP’s emphasis on Extending the action, you should check in with the client from time to time to confirm that he or she still 

has the card (ask the client to show it to you) and remains willing to use it if the need arises. 

Counselors with advanced mental health training and experience in work with clients who are suicidal may be in 

a position to formulate a more detailed safety plan. Such a safety plan and an example of its use with a client 

are described in chapter 2 in the vignette with Rena. 

Addressing Suicidal Thoughts and Behaviors in Substance Abuse Treatment 21 
•	 Create a detailed safety plan (see below) with the 

client in the event of relapse to alcohol or drugs. 

•	 Give the client an emergency hotline number, for 

instance, the national hotline 1-800-273-TALK. 

•	 Invite the client to contact you (or an emergency 

hotline) in the event of acute suicidality. 

As mentioned earlier, there is little or no empirical 

evidence to support “suicide contracts” (an agreement 

from a client to contact the counselor or someone else 

before making a suicide attempt) as a “stand alone” 

intervention. However, the consensus panel strongly 

recommends that counselors help clients at risk of 

suicidal thoughts and behaviors develop a safety card, 

sometimes referred to as an emergency card. Such a 

plan ideally identifies who a client in crisis can turn 

to for immediate help, where they can go for help, 

other proactive behaviors the client can take (such as 

maintaining sobriety), and what kind of information 

they should give to providers so that the crisis is recognized and addressed. A related technique is a 

Commitment to Treatment agreement, which focuses 

the client’s attention on the specific behaviors (such 

as attending treatment sessions, setting recovery 

goals, completing homework assignments, and taking 

medications as prescribed) that support recovery and 

potentially reduce suicidal thoughts and behaviors. 

The difference in the two techniques is that safety 

cards and plans focus on preventing or intervening in 

crises, while the Commitment to Treatment agreement focuses on behaviors that positively support 

treatment outcome. 

For counselors with more experience and training in 

work with clients who are suicidal, an advanced skills 

safety plan can be used. An example of an advanced 

skills plan is described in the vignette with Rena. An 

advanced plan might emphasize helping the client 

recognize when direct and indirect warning signs are 

becoming more apparent, develop coping responses, 

and focus on the client’s emotional regulation. 

Referring a client who Is ambivalent about 

treatment or is resisting treatment: It is common 

to make a referral either for further evaluation, treatment of suicide risk, treatment of a mental health 

condition (for example, depression), or for a combination of services. Sometimes, however, there will be 

times when you make a referral that a client does not 

agree is necessary or simply does not wish to accept. 

By taking the time to discuss the reasons for your 

actions and by listening and acknowledging their concerns, clients who are suicidal will usually soften 

their stance and become more willing. Eliciting a 

client’s input as to what he or she believes would be 

most helpful and using these suggestions, as appropriate, can also go a long way to eliciting cooperation. 

Anything appropriate that you can do to give a client 

a sense of choice or control will be helpful. 

Although a referral for emergency evaluation is usually not necessary and less intensive action(s) will 

typically suffice, there will be times when such an 

action is needed. In these instances, a resistant client 

may become more willing if provided some sense of 

control, for example, through a question such as 

“Would you prefer to call your family before you go to 

the emergency department or would you rather I call 

them after you get there?” 

In the end, if a client refuses to cooperate in additional evaluation, you (in close coordination with your 

supervisor or team) will need to take the necessary 

steps to arrange for the evaluation (e.g., by arranging 

an ambulance or police escort) as described in your 

agency policy. The client should not be left unaccompanied while such arrangements are being made. 

Supervisors can facilitate their counselors’ current 

knowledge of the company’s policy on emergency 

referrals by reviewing it with them on a regular 

basis, as appropriate. 

A note on inpatient treatment for suicidality: It 

is important that counselors, clients, and their family 

members know what to expect from inpatient psychiatric hospitalization. Generally, the treatments are 

short term (5–7 days), and if the clinical team concludes that suicidality is substance-induced, the stay 

may be shorter (Ries, Yuodelis-Flores, Comtois, RoyByrne, & Russo, 2008). During hospitalization, the 

focus is typically on medication management and disposition planning, with a minimal focus on addressing ongoing stressors therapeutically. As a result, 

most or all of the psychosocial difficulties that 

prompted admission will still need to be addressed 

when the client returns to treatment. A study of psychiatric inpatient admissions to one large, universitybased hospital showed that “substance-induced suicidality,” as rated by clinicians, represented 40 percent 

of all admissions, indicating the extent to which substance-related problems promote such admissions 

(Ries et al., 2008). 

Summary of T: Take responsible action 

The intensiveness of the actions that you take in coordination with your supervisor or team should make 

good sense in light of the information that you have 

22 Part 1, Chapter 1 
gathered, with more serious risk requiring more 

intensive action(s). The action(s) may include referring the client for a formal assessment or for additional treatment. Taking the time to prepare clients 

for a referral and providing them some sense of control will be helpful in eliciting their cooperation. 

E: Extend the action 

A common misconception is that suicide risk is an 

acute problem that, once dealt with, ends. 

Unfortunately, individuals who are suicidal commonly experience a return of suicide risk following any 

number of setbacks, including relapse to substance 

use, a distressing life event (e.g., break-up with a 

partner), increased depression, or any number of 

other situations. Sometimes suicidal behavior even 

occurs in the context of substantial improvement in 

mood and energy. Therefore, monitoring for signs of a 

return of suicidal thoughts or behavior is essential. 

There is also a tendency to refer a client experiencing 

suicidal thoughts and behaviors to another provider 

and then assume that the issue has been taken care 

of. This is a mistake. It is essential to follow up with 

the provider to determine that the client kept the 

appointment. It is also critical to coordinate care on 

an ongoing basis, for example, to alert a provider that 

a client has relapsed and may be vulnerable to suicidal thoughts. Extending the action emphasizes the 

importance of watching for a return of suicidal 

thoughts and behaviors, following up with referrals, 

and coordinating on an ongoing basis with providers 

who are addressing the client’s suicidal thoughts and 

behaviors. 

What extended actions can you take? 

The list below mentions many common extended 

actions but is not exhaustive. It is in no particular 

order. 

•	 Confirm that a client has kept the referral 

appointment with a mental health provider (or 

other professional). 

•	 Follow up with the hospital emergency department when a client has been referred for acute 

assessment. 

•	 Coordinate with a mental health provider (or other 

professional) on an ongoing basis. 

•	 Coordinate with a case manager on an ongoing 

basis. 

•	 Check in with the client about any recurrence of or 

change in suicidal thoughts or attempts. 

•	 Check in with family members (with the client’s 

knowledge) about any recurrence of or change in 

suicidal thoughts or attempts. 

•	 Reach out to family members to keep them 

engaged in the treatment process after a suicide 

crisis passes. 

•	 Observe the client for signs of a return of risk. 

•	 Confirm that the client still has a safety plan in 

the event of a return of suicidality. 

•	 Confirm that the client and, where appropriate, 

the family, still have an emergency phone number 

to call in the event of a return of suicidality. 

•	 Confirm that the client still does not have access 

to a major method of suicide (e.g., gun, stash of 

pills). 

•	 Follow up with the client about suicidal thoughts 

or behaviors if a relapse (or other stressful life 

event) occurs. 

•	 Monitor and update the treatment plan as it concerns suicide. 

•	 Document all relevant information about the 

client’s condition and your responses, including 

referrals made and the outcomes of the referrals. 

•	 Complete a formal treatment termination summary when and under whatever circumstances this 

stage of care is reached. 

Summary of E: Extend the action 

Suicide prevention efforts are not one-time actions. 

They should be ongoing because suicidal clients are 

vulnerable to a recurrence of risk. A team approach is 

also essential, as it requires you to follow up on referrals and coordinate with other providers in an ongoing manner. The actions listed above represent many, 

but not all, of the extended actions you may use to 

promote safety throughout treatment. Work closely 

with your supervisor or team in developing a plan of 

extended actions. Finally, document the client’s eventual progress and status at the point of your treatment termination. 

Documenting GATE 

Documentation of suicidality is critical to promoting 

client safety, coordinating care among treatment professionals, and establishing a solid medical and legal 

record. Documentation entails providing a written 

summary of any steps taken pertaining to GATE, 

along with a statement of conclusions that shows the 

rationale for the resultant plan. The plan should 

make good sense in light of the seriousness of risk. 

Addressing Suicidal Thoughts and Behaviors in Substance Abuse Treatment 23 
Examples of Roberta, Mark, and Fernando, below, 

illustrate documentation across a continuum of seriousness of suicidality. Counselors, supervisors, or 

consultants may provide such documentation. Many 

programs or State regulatory bodies recommend or 

mandate a particular format in which this documentation can occur. Generally, such formats can accommodate all of the information contained in our GATE 

protocol. 

In the notes below, the italicized text is the actual 

note. These examples are “ideals.” Notes in routine 

clinical practice may fall short of this level of detail 

and organization. Nonetheless, the notes serve as 

models for documentation. Agencies may implement 

checklists as well (e.g., warning signs, risk factors, 

protective factors) to assist you with documentation. 

Even with the use of a checklist, a conclusion statement and the articulation of the plan are always 

needed. 

Documentation example 1 

The following is from an intake evaluation of Roberta, 

a 40-year-old African-American woman seeking treatment for cocaine dependence. The situation was not 

acute, so regular supervision was used and no immediate actions were taken. 

Gather information: The client made a suicide 

attempt at age 31 by overdosing on over-the-counter 

sleeping pills following a sexual assault for which she 

received overnight treatment in a hospital emergency 

department. She was ambivalent about the suicide 

attempt and immediately afterward was relieved that 

she survived. Since that time, she has not reattempted; 

she reported no current or recent ideation, plan, or 

intent. She reported that she no longer uses sleeping 

pills and has none in her possession. She stated that 

her strong faith in God prevents her from making 

another attempt. No warning signs for suicidal behavior were evident. 

Conclusion: There is a history of suicidal behavior but 

no indication of a need for action. 

Access supervision: Her suicide-related history will be 

discussed at the next team meeting on January 14. 

Documentation example 2 

The following is from an intake evaluation of Mark, a 

29-year-old White male who is separated from his 

wife and entering treatment for alcohol dependence. 

The situation required immediate supervision and an 

intervention of intermediate intensity. 

Gather information: Mark reports that he has 

thoughts of suicide when intoxicated (about once a 

week), during which he becomes preoccupied with the 

separation from his wife. The thoughts last a few 

hours, until he falls asleep. They occur while he is 

home alone. He has not acted on them, reports no plan 

or intent to attempt suicide, and reports that he does 

not own a firearm. He reports no history of suicide 

attempts. 

Access supervision: This writer took a break in the 

intake to review this information with supervisor, 

John Davidson, LCSW. 

Conclusion: It was concluded that emergency intervention is not required because Mark has not acted on his 

suicidal thoughts and has no plan or intent. However, 

further assessment is indicated given suicidal 

ideation, marital estrangement, and active alcohol 

dependence. 

Take action: I reviewed these considerations with 

Mark and he agreed to a referral for an outpatient 

mental health evaluation. Mark has an appointment 

scheduled for June 18 at 1:00 p.m. with Martha 

Jones, MSW, of the Mental Health Clinic. 

Extend the action: On Tuesday, June 17, this writer 

called Mark to remind him of his appointment. He 

said he remembered his appointment and planned to 

attend. I called the Mental Health Clinic late in the 

afternoon on June 18. Mark had kept his appointment 

and scheduled a second appointment for the following 

week. 

Documentation example 3 

The following is from a progress note for Fernando, a 

22-year-old Hispanic male. He is an Iraq war veteran 

who had been doing well in treatment for dependence 

on alcohol and opiates, but had missed group therapy 

sessions and not returned phone calls for the past 10 

days. This situation occurred in a substance abuse 

clinic within a hospital and required accessing immediate supervision and interventions of high intensity. 

Gather information: Fernando came in, unannounced, 

at 10:30 a.m. today and reported that he relapsed on 

alcohol and opiates 10 days ago and has been using 

daily and heavily since. Breathalyzer was .08, and he 

reported using two bags of heroin earlier this morn24 Part 1, Chapter 1 
ing. He reported that he held his loaded rifle in his 

lap last night while high and drunk, contemplating 

suicide. 

Access supervision: This writer’s supervisor, Janice 

Davis, CDC, was called to join the session. 

Conclusion: It was determined that emergency intervention is necessary because of intense substance use, 

suicidal thoughts with a lethal plan, and access to a 

weapon. 

Take action: At 11:00 a.m., a hospital security guard 

and this writer escorted Fernando to the emergency 

department where he was checked in. He was cooperative throughout the process. 

Extend the action: Dr. McIntyre, the Emergency 

Department physician, determined that Fernando 

requires hospitalization. He is currently awaiting 

admission. This writer will follow up with the hospital unit after he is admitted and will raise the issue of 

his access to a gun. 

Competencies 

You now have some basic information about suicide 

and the effects of suicidal thoughts and behaviors on 

substance abuse treatment. Through the steps summarized as GATE in this TIP, you are becoming 

familiar with your role in addressing suicidal 

thoughts and behaviors. These capabilities result in a 

short list of the knowledge, skills, and attitudes you 

need to be able to effectively work with people in substance abuse treatment who are suicidal or have a 

history of suicidal thoughts and behaviors. 

The consensus panel agreed on eight competencies for 

working with clients who are suicidal in substance 

abuse treatment settings. These competencies are 

derived from a variety of resources, including Practice 

Guideline and Resources for the Assessment and 

Treatment of Patients with Suicidal Behaviors 

(American Psychiatric Association, 2003), Assessing 

and Managing Suicidal Risk: Core Competencies for 

Mental Health Professionals (American Association of 

Suicidology, Suicide Prevention Resource Center, and 

Education Development Center, 2006), and The 

Assessment and Management of Suicidality (Rudd, 

2006). They reflect the core knowledge, skills, and 

attitudes that you as a substance abuse counselor 

should incorporate to work effectively with clients 

who evidence suicidal thoughts and behaviors and 

form the basis for the skills presented in the 

vignettes in chapter 2 of this TIP. Few counselors 

will be proficient in all of these competencies. 

However, it will be helpful to evaluate your strengths 

and weaknesses in light of these competencies, so 

you can increase your skills in working with these 

individuals. 

Addressing Suicidal Thoughts and Behaviors in Substance Abuse Treatment 25 
COMPETENCIES FOR ADDRESSING SUICIDAL THOUGHTS AND BEHAVIORS WITH 

CLIENTS IN SUBSTANCE ABUSE TREATMENT1 

Core Competencies Knowledge Skills Attitudes 

1. GATE: Gather information by consistently asking 

uniform screening questions of all new clients, recognizing warning signs, 

and asking followup questions about suicidal 

thoughts, behaviors and 

warning signs. 

• 

• 

• 

• 

• 

The importance of routinely addressing suicide 

because it is a leading 

cause of death among 

people with substance 

use disorders 

The importance of routine screening and what 

to do if a screen is positive 

The warning signs that 

indicate the need to ask 

questions 

Followup questions to 

ask in order to characterize suicidal thoughts 

Followup questions to 

ask in order to characterize suicide attempts 

• 

• 

• 

• 

• 

• 

• 

Consistently ask screening questions 

Consistently spot warning signs 

Consistently ask followup questions when 

screening questions or 

warning signs indicate 

the need 

Ask questions about suicide in a nonjudgmental 

and nonconfrontational 

manner 

Supportively gather 

information on suicidal 

thoughts including frequency, intensity, and 

factors that make the 

thoughts more painful or 

less painful 

Supportively gather 

information on suicide 

attempts including the 

degree of desire to die, 

the method used, and 

any treatment received 

Gather information in 

a culturally sensitive 

manner 

• 

• 

• 

• 

• 

View suicide screening, 

watching for warning 

signs, and asking followup questions as a 

routine part of the job of 

substance abuse counselor, in light of the elevated risk for suicidal 

behavior among substance abuse clients 

Desire to understand 

suicidal thoughts and 

behaviors as well as 

possible, without assuming a formal role as 

expert or making independent judgments 

about risk 

Do not dismiss clients’ 

reasons for being suicidal or trivialize their suicidal thoughts or behaviors 

Desire to understand the 

client’s distress and 

point of view 

Manage the anxiety 

that arises when 

empathically listening to 

clients 

1. Based on American Psychiatric Association, 2003; Rudd, 2006; and American Association of Suicidology, Suicide Prevention 

Resource Center, & Education Development Center, Inc. (2006). 

26 Part 1, Chapter 1 
Core Competencies Knowledge Skills Attitudes 

2. GATE: Access supervi­ • The need to obtain such • Present the information • Be willing to seek input 

sion and/or consultation input for treatment to supervisors or con­ and/or assistance when 

to ensure quality care and planning sultants in an efficient, suicide-related informaplanning next steps for • How to organize materi­ organized fashion tion indicates the need 

client services and referral al on suicidal thoughts • Present all of the poten­ • Err on the side of getting 

to additional resources. and behaviors, including tially relevant information input when there is 

There is a need to obtain information presented by (avoid presenting data doubt about whether 

input from supervisors clients and other selectively, for example, such input is required 

and/or consultants in inter- sources, to make best to make one course of • Maintain a positive attipreting information gath­ use of supervision and action more likely than tude toward eliciting 

ered about suicidal consultation another) supervision and consulthoughts and behaviors. • Your agency’s crisis 

response plan in an 

emergency 

• 

• 

Integrate information 

from a variety of sources 

(supervision and consultation) into an action 

plan 

Prepare an action plan 

based on information 

gained in clinical supervision and/or consultation 

tation and a willingness 

to make use of such 

input 

3. GATE: Take responsi­ • The need to make refer­ • Respond to positive sui­ • Maintain objectivity in 

ble action by developing rals for assessment and cide screens and to talking to clients about 

and implementing a treat- treatment of suicidal warning signs (at intake, suicidal thoughts 

ment plan to address suici­ thoughts or behaviors or during treatment, at tran­ • Maintain a therapeutic 

dality and coordinating the related mental health 

conditions • 

sitions in care) 

Participate in the develstance with clients who are resistant to a crisis plan with other providers. • 

• 

• 

• 

The roles of a variety of 

community agencies and 

resources to address 

suicide and other mental 

health-related needs 

How to make referrals to 

such agencies and 

resources in a timely 

manner (e.g., numbers 

to call, where to send 

the client, what he or 

she should expect) 

Elements of collaborative treatment planning 

steps 

The principle that the 

level of the response to 

suicidality by providers 

should match the level 

of acuity of risk (i.e., the 

plan should make sense 

in light of the assessed 

need) 

• 

• 

• 

• 

opment and implementation of a written assessment and treatment plan 

that addresses the 

client’s risk for suicide 

along with the client’s 

substance abuse problems 

Collaborate with supervisor and/or treatment 

team to develop an 

emergency plan for 

high-risk clients to 

ensure safety 

Make referrals to appropriate resources, including helping resistant 

clients accept and follow 

through on referrals 

Apply principles of crisis 

management with 

actively suicidal clients 

Restrict suicide methods 

for clients who are suicidal (e.g. remove 

weapons, restrict medication availability) 

• 

• 

• 

• 

response plan or commitment-to-treatment 

agreement 

Maintain objectivity in 

weighing the value of 

hospitalization for individual clients in close 

coordination and cooperation with other treatment team members 

and professionals 

Respond therapeutically 

to clients who express 

strong emotions of 

hopelessness, sadness, 

anxiety, or anger in 

treatment 

Maintain a positive, nonpunitive attitude toward 

clients who are noncompliant with treatment 

plans 

Be aware of attitudes of 

self and others toward 

inappropriately using 

coercive measures with 

suicidal clients 

Addressing Suicidal Thoughts and Behaviors in Substance Abuse Treatment 

27 
Core Competencies Knowledge Skills Attitudes 

4. GATE: Extend the • Warning signs and • Monitor and respond to • Maintain an objective, 

responsible action(s) by changes in such signs re-emergence of warn- nonjudgmental attitude 

ensuring that referral that may indicate deteri­ ing signs toward a variety of helpappointments have been oration or emergent risk • Work collaboratively with ing organizations and 

kept, sharing information, • Strategies to collaborate other treatment their staff 

and continuing to monitor with other disciplines providers including men­ • Advocate for suicidal 

clients after crises have and agencies in a man­ tal health providers clients to receive treatpassed (through ongoing ner that meets the • Follow up and track ment and use communicoordinating with mental needs of the client and clients to monitor quality ty and family resources, 

health providers, and is mutually beneficial of care while not assuming 

enlisting the support of • Strategies to collaborate • Help clients accept and responsibility for their 

family and community with family and other follow through on com- behavior 

resources as appropriate). community supports in a 

manner that meets the 

needs of the client and 

is mutually beneficial 

• 

• 

• 

munity referrals 

Work collaboratively with 

family members to 

improve treatment compliance and safety 

Explore family attitudes 

and values that could 

facilitate or impede 

treatment 

Maintain ongoing documentation of client 

services 

• 

• 

Foster a sense that a 

variety of community 

resources working 

together may be more 

helpful than one person 

or agency working alone 

Acknowledge the value 

of family and other support systems 

28 Part 1, Chapter 1 
Core Competencies Knowledge Skills Attitudes 

5. Basic knowledge about 

the role of warning signs, 

risk factors, and protective factors in suicide 

risk among people with 

substance use disorders. 

Warning Signs: 

• Direct: 

Suicidal communication 

Seeking access to 

method 

Making preparations 

• Indirect: 

I Ideation 

S Substance Abuse 

P Purposelessness 

A Anxiety 

T Trapped 

H Hopelessness 

W Withdrawal 

A Anger 

R Recklessness 

M Mood Changes 

Risk Factors: 

• History of prior suicide 

attempt 

• Family history of suicide 

• Severe substance abuse 

• Co-occurring mental 

disorder 

• Personality disorder or 

maladaptive traits 

• Child abuse (especially 

sexual) 

• Stressful life circumstances 

• Firearm ownership or 

access 

Protective Factors: 

• Clean and sober 

• Religious attendance/ 

holds faith beliefs 

against suicide 

• Childrearing responsibilities 

• Intact marriage 

• Trusting relationship with 

a helping provider 

• 

• 

• 

Understand difference in 

perspective/goals (e.g., 

counselor’s goal to prevent suicide and client’s 

goal to eliminate psychological pain) and the 

need for the counselor 

and client to collaborate 

to articulate common 

goals 

Make a realistic judgment of one’s competence, training, and time 

to evaluate and care for 

a suicidal client with a 

substance use disorder 

Note warning signs, risk 

factors, and protective 

factors but does not 

independently conduct a 

formal risk assessment 

(without specialized 

training and education) 

• 

• 

• 

Manage one’s own reactions to suicidal behavior 

Maintain a collaborative, 

nonadversarial therapeutic stance 

Be empathic and nonjudgmental with people 

who experience suicidal 

thoughts and behaviors 

Addressing Suicidal Thoughts and Behaviors in Substance Abuse Treatment 29 
Core Competencies Knowledge Skills Attitudes 

6. Empathy for suicidal 

clients. Have empathy for 

individuals who are suicidal, particularly those who 

are chronically suicidal, by 

appreciating the complex 

reasons for suicidal behavior and distinguishing 

myths from facts about 

suicide. 

• 

• 

• 

• 

There is usually more 

than one reason for a 

suicidal act 

Ambivalence about suicide is the norm and 

showing hesitancy (or 

ambivalence) about an 

act of suicide in no way 

guarantees future safety 

Clients who are chronically suicidal (e.g., those 

with past acts of selfinjury that were for 

manipulation or to get 

attention) are not protected from suicide 

Clients with borderline 

personality disorder 

have high rates of suicidal behaviors 

• 

• 

• 

• 

Understand and appreciate the client’s perspective 

Provide support to 

potentially suicidal 

clients at setbacks and 

transition points in treatment and at the time of 

stressful life events 

Refer the client to speak 

with his or her mental 

health provider about 

issues related to chronic 

suicidal thoughts and 

behaviors 

Collaborate closely with 

such providers to reduce 

the potential for risk 

• 

• 

• 

Recognize that clients’ 

perceptions of the reasons for suicidal behavior, although not necessarily logical to others, 

are congruent with the 

client's own perceptions 

Identify one’s own attitudes that are counterproductive in managing 

suicide risk 

Approach client suicidality from the perspective 

of a complex problem 

with many options for 

response 

7. Cultural competence. 

Honor and respect the 

beliefs, language, interpersonal styles, and behaviors 

of the cultures of individuals and families receiving 

services. 

• 

• 

• 

The culture’s beliefs, 

norms, and values influence ideas about the 

nature of relationships, 

the way people live, and 

the way people organize 

their world 

No culture is fully protected against suicide 

Suicide may be regarded differently in different 

cultures 

• 

• 

• 

• 

Work effectively in 

cross-cultural situations 

Identify and adapt to cultural norms of clients 

Ask questions in a culturally sensitive manner 

Make referrals in a culturally sensitive manner 

• 

• 

• 

Value the differences 

among cultural groups 

Recognize that clients 

need to present their 

dilemma in the context 

of their cultural norms 

Appreciate that different 

cultures use and represent suicide differently 

30 Part 1, Chapter 1 
Core Competencies Knowledge Skills Attitudes 

8. Legal and ethical 

issues. Understand legal 

and ethical issues (for the 

counselor) related to suicide risk assessment, management, and documentation. 

• 

• 

• 

• 

• 

• 

• 

Steps necessary to 

obtain informed consent 

Elements related to risk 

screening and treatment 

planning 

How and when to obtain 

clinical supervision or 

consult with a senior colleague concerning a 

client who is suicidal 

State laws pertaining to 

suicide 

Regulatory statutes 

and agency riskmanagement policy 

Legal issues related to 

clients who are suicidal 

Exceptions to 

confidentiality 

• 

• 

• 

• 

Document informed consent, screening information, warning signs, risk 

considerations, treatment plan, care management, interaction 

with colleagues, 

progress, and outcomes 

Protect client records 

and rights to privacy and 

confidentiality following 

Health Insurance 

Portability and 

Accountability Act 

(HIPAA) 

Implement, with clinical 

supervision, usual and 

customary care for these 

clients 

Protect clients’ rights in 

the event of suicidal 

behavior or a client’s 

death from suicide 

• 

• 

• 

• 

• 

• 

Understand that a “don’t 

ask, don’t tell” policy 

toward suicide generally 

increases (not decreases) vulnerability to a 

lawsuit 

Understand that documenting suicide risk promotes client safety and 

communication among 

providers and is important for the sake of the 

medical/legal record 

Understand that refusing 

care to individuals who 

are suicidal and referring 

them out, but failing to 

see that such individuals 

follow through with a 

referral, generally increases (not decreases) 

vulnerability to a lawsuit 

Determine objectively 

whether consultation 

with another professional would be helpful in an 

individual case 

Understand the need to 

respond to the legal and 

regulatory issues related 

to work with clients who 

are suicidal 

Do not allow fear of 

blame or lawsuits to 

interrupt quality client 

care 

Next Steps 

You have probably started thinking about how you 

might assist a suicidal client in your own substance 

abuse treatment program. Now you have basic information, fundamental clinical principles and positive 

attitudes, basic facts about suicide and its relationship to substance use disorders, a set of competencies 

that will help you address suicidality, and guidelines 

about what your role as a substance abuse counselor 

can be in working with clients who are suicidal. 

In the next chapter, you will meet a number of clients 

who are experiencing or have experienced suicidal 

thoughts and behaviors of varying degrees of intensity. The dialog among clients, counselors, and supervisors illustrates a number of ways substance abuse 

treatment and suicidality intervention can interact, 

and how GATE can be implemented in several treatment settings, and with different types of complicating factors. 

Addressing Suicidal Thoughts and Behaviors in Substance Abuse Treatment 31 

Chapter 2
 

Introduction
 

In this chapter you will meet six people with substance use disorders who are experiencing suicidal thoughts 

and behaviors to varying degrees. Through their dialog with counselors, supervisors, and family members, you 

will see how suicidal thoughts and behaviors may manifest. You will also see that these thoughts and behaviors 

are typically accompanied by co-occurring mental disorders, such as depression, psychological trauma, and 

other anxiety disorders. 

The elements of GATE (Gather Information, Access supervision, Take responsible action, Extend the action— 

see chapter 1) are portrayed in different settings and situations. You will read about counselors working with 

clients who are resistant to treatment for their suicidal thoughts and behaviors, about the effects of suicidal 

thoughts and behaviors on family members and others, and about managing suicidal crises. While the vignettes 

demonstrate treatment methods and techniques that are within the scope of practice and range of substance 

abuse counselors, vignettes 5 and 6 also include several advanced techniques that are more appropriate for use 

by experienced counselors. The consensus panel has made a significant effort to present realistic encounters 

with clients using counseling approaches that include motivational interviewing (MI), cognitive–behavioral 

therapy (CBT), supportive psychotherapy, and crisis intervention methods. In all of these therapeutic approaches, basic counseling dynamics (such as relationship building; managing rapport in stressful situations; giving 

feedback; assessing, understanding and responding to the needs expressed by the client; and seeking consultation and supervision as needed) are demonstrated. Please note that the panel does not intend to imply that the 

approach used by the counselor in the vignette is the “gold standard,” although the approach shown does represent competent practice that can be performed in real-life settings. 

The vignettes begin with an overview, a substance abuse history, a suicide-related history, and a list of the 

learning objectives for the vignette. Each of the following additional features is also embedded in the counselor 

and client dialog: 

•	 Master clinician notes are comments from an experienced counselor or a supervisor about the strategies 

used, possible alternative techniques, thoughts of the clinician, and other information counselors should 

have. 

•	 “How-to” notes contain information on how to implement a specific intervention. 

Master clinician notes represent the combined experience and wisdom of the contributors to this TIP. The notes 

provide insights into the cases and suggest possible approaches. Some of the techniques described in the notes 

may or may not be appropriate for you to use, depending on your training, certifications, and licenses. It is your 

responsibility to determine what services are legally and ethically appropriate for you to provide within the 

scope of your practice. If you are unsure, ask a supervisor. 

This format was chosen to assist counselors at all levels of mastery, including beginning counselors, those who 

have some experience but need more diversity and depth, and those with years of experience and training who 

are true master clinicians. Client scenarios are presented in vignettes in the following pages. Each client is in 

treatment for a substance use disorder, and is experiencing some suicidal thoughts. By way of introduction: 

Vignette 1, Clayton, illustrates how to obtain and secure a firearm safely from a high-risk client by enlisting 

the help of a family member. 

Vignette 2, Angela, shows how to work collaboratively with family in discharge planning for a high-risk client 

from an inpatient unit. 

Addressing Suicidal Thoughts and Behaviors in Substance Abuse Treatment 33 
Vignette 3, Leon, depicts how to link a high-risk client safely with an outpatient mental health program that 

is better able to meet his needs. 

Vignette 4, Rob, shows a therapeutic response to a client who provocatively and inaccurately alludes to suicide 

in group, causing distress in the group and distracting from his true concerns. 

Vignette 5, Vince, illustrates a rapid referral to the emergency department for a client at acute risk for homicide-suicide. 

Vignette 6, Rena, depicts a crisis response for a client who calls her counselor when drinking and acutely suicidal, and introduces two advanced techniques (detailed safety plan, hope box). 

Vignette 1—Clayton 

Overview 

This case illustrates the GATE process for working with substance abuse clients with suicidal thoughts and 

behaviors. The vignette begins with a meeting between Clayton and his counselor (Darren) and illustrates how 

clinical supervision plays an important role in addressing client suicide risk. It specifically addresses working 

with a client who is not in an immediate suicidal crisis but has warning signs for suicide. It also examines 

issues of removing a potential suicide weapon and illustrates the importance of working with family. 

Participants: Clayton (client), Darren (counselor), Jill (supervisor), and Barbara (daughter). 

Substance Abuse History 

Clayton is a 61-year-old Caucasian man who used injection drugs as a young adult and contracted hepatitis C. 

He quit using injection drugs without treatment and about 10 or 15 years later developed alcohol dependence. 

He entered treatment 5 years ago and has been sober for 18 months. He has a cirrhotic liver but does not want 

to consider getting on a transplant list. He attends at least four Alcoholics Anonymous (AA) meetings a week, 

participates in an ongoing recovery group, and sees a substance abuse counselor individually on an as-needed 

basis. He lives alone, has two grown children with whom he has occasional contact, and lives on his retirement 

pension. He retired 3 years ago from a supervisory position at a local small manufacturing plant where he 

worked for 30 years. 

Suicide-Related History 

Clayton tried to kill himself in his twenties by overdosing on heroin. He was taken to an emergency room and 

released about 12 hours later. He did not follow up on treatment recommendations. He began having suicidal 

thoughts again following his last relapse 18 months ago. While drinking, he decided he might shoot himself but 

did not actually make a suicide attempt. Since stopping drinking and returning to treatment, he has had occasional thoughts of killing himself, particularly when the pain from his liver disease becomes burdensome and 

when he feels like he has no future. Clayton maintains that he is not acutely suicidal now but says he might act 

if the pain becomes worse or if he is unable to take care of himself. The suicidal thoughts arise when he feels 

hopeless and when he becomes afraid that he might reach a point of being physically unable to take care of 

himself. He took out his gun and examined it last week, an action that concerned his AA sponsor enough to 

urge Clayton to call his substance abuse counselor for an appointment. 

Learning Objectives 

1. To illustrate GATE and how this model can be applied in substance abuse treatment settings. 

2. To demonstrate screening for suicide risk. 

3. To highlight the role of clinical supervision in addressing the needs of the client. 

34 Part 1, Chapter 2 
4. To recognize when there are indications of continuing risk even when the client is currently denying suicidal 

thoughts. 

5. To demonstrate three types of action: 

• Remove a potential suicide weapon. 

• Involve family in treatment. 

• Make a referral to a specialized community resource for further assessment. 

6. To illustrate a followup process to ensure that the client has removed the weapon from his home and has followed through on the referral to a specialized community resource. 

7. To illustrate how case management is important in helping Clayton manage a variety of life problems 

including substance abuse recovery, pain management, suicidality, mental health care, and physical health 

care. 

[Clayton has requested an appointment with his counselor.] 

COUNSELOR: Clayton, you said on the phone you are having some trouble and would like to see me. 

CLAYTON: Well I haven’t been feeling so good. I’ve been having a fair amount of pain for the past couple of 

months or so. I’m not sleeping all that great. I don’t feel very well. My sponsor in the program told me to give 

you a call. 

COUNSELOR: We’ll I’m glad you did call. 

CLAYTON: I’ve been going to the pain management clinic like you told me to. That helps—the meds and the 

pain management program, but sometimes the pain still gets pretty bad and I start sinking. 

COUNSELOR: How much pain have you been having? 

CLAYTON: I’m in pain all the time, but it flares up real bad about every other day. What happens is that the 

bad pain comes for several hours, sometimes four hours or so, and it makes it really hard for me to do anything. 

It just beats me down. 

COUNSELOR: In the past we’ve used a scale of 1 to 10 to rate your pain. Where would you put yourself on that 

scale now? 

CLAYTON: When it flares up, I’d say about 8 or 9. Then, after a few hours it goes down some—maybe down to 

a 3 or 4 or 5. It never goes away all the way. And you know, I can’t take narcotic pain pills. The pain clinic 

gives me some meds—the non-addictive kind, but they don’t help all the time. 

COUNSELOR: When the pain has gotten up in that 8 to 10 level, those are the times when you feel like you’re 

“sinking” and “feeling down?” Clayton, tell me some more about what those terms mean to you. 

CLAYTON: Well, I mean it’s the whole thing. You know I’m not going to go through with the liver transplant 

thing, even if I could get a new one. I don’t want to be a burden on anybody, and I don’t want to slip again. I 

tried working a little bit last year just to see if I could. A friend in the program let me work a few hours a day 

at his store. But I couldn’t work all the times he wanted me to because of the pain attacks. 

COUNSELOR: Sometimes in the past when those feelings of hopelessness have come up and you’ve had that 

kind of pain, I know you’ve had thoughts about suicide. Have those thoughts come back? 

Addressing Suicidal Thoughts and Behaviors in Substance Abuse Treatment 35 
Master Clinician Note: Observe that the counselor does not wait for Clayton to 

bring up issues of suicide, but rather initiates the conversation in a way that 

normalizes the discussion and invites Clayton to provide more information. 

Some specific points to consider when discussing suicide with a client include: 

•	 Use clear, direct terms, not euphemisms for suicide (for instance, say “have 

you thought of killing yourself?” or “Have you thought of taking your life”“ 

rather than “have you thought of doing anything foolish?” 

•	 Ask direct questions, but do so with care and compassion. 

•	 Ask open-ended questions that require more than a “yes” or “no” answer. 

•	 Acknowledge that talking about suicidal thoughts and behaviors is difficult 

but that having the discussion is important. 

CLAYTON: Well, I think it’s, like I said, not knowing what lies ahead. If I’m ever gonna get beyond this and 

not bother my family about the whole thing and not feel like I can’t do as many things as I was able to do. All 

those kinds of things add up at once and I’d say those thoughts are there especially when everything collapses, 

when I’m not sleeping and the pain is worse, I don’t know . . . it all just gets to be too much. 

COUNSELOR: Yeah, it sounds pretty overwhelming and seems like you feel help would be hard to find. 

CLAYTON: Well you know, I don’t want to bother my family, and I really don’t want to be a burden on anybody. Sometimes I don’t even know if I want to continue the liver treatment. 

Master Clinician Note: Clayton avoids addressing the question of suicidal 

thoughts, except in an indirect way. Instead of grilling Clayton for the information, the counselor files away the issue temporarily and talks about pain for a 

few minutes, a comfortable topic for Clayton. The counselor then returns to his 

concerns about Clayton’s suicidal thoughts. The expectation is that Clayton will 

feel more comfortable in talking about them if the counselor slows down a bit 

and goes at his pace. 

COUNSELOR: Does it help to talk to anyone about your pain, like people in your AA program, or in the group 

here or your family when things get real bad? 

CLAYTON: I don’t know. I really don’t want to cry on other peoples’ shoulders. I don’t want to tell my kids, 

there’s nothing they can do. It helps that some people—friends in the program—know and give me some support. And I’ve talked to you about it some. 

COUNSELOR: It’s not easy to share what you’re going through with others, and I really respect how you’ve 

shared with some peers, and that you’ve given me your trust. What gets in the way of talking with your kids 

about it? 

CLAYTON: Well, I see my daughter and her family some. She lives about 10 miles out of town. My son and I 

talk every now and then, but he lives about five hours from here. We just talk about his kids, and I ask him 

about his job and that’s about it. We really haven’t been close since he was a teenager. I was drinking the whole 

time he was growing up, and we never have got beyond what happened back then, what I did and what he did 

too. 

COUNSELOR: We talked a little bit about that: the family relationship has been difficult for you. You said 

you’ve been feeling like a burden. 

36 Part 1, Chapter 2 
CLAYTON: Yeah. I haven’t really told them about the liver, how bad it is. I don’t really want them to get all 

upset. They’ve got their own lives now. 

How To Screen for Suicide 

Just a few questions about suicidal thoughts and behaviors can provide substance abuse counselors with the information they need to decide if further 

exploration of suicide is necessary. The five questions used in this vignette are 

drawn from the longer discussion of gathering information in chapter 1. The five 

questions used in this vignette are: 

1.	 Are you thinking about killing yourself? 

2.	 Have you ever tried to kill yourself before? 

3.	 Do you think you might try to hurt yourself today? 

4.	 Have you thought of ways you might kill yourself? or Do you have a plan for 

how you might kill yourself? 

5.	 Do you have pills or weapons to kill yourself in your possession or in your 

home? or Do you have ready access to pills or a weapon that you might use 

to kill yourself? 

When a reply indicates the presence of suicidal thoughts or behaviors, the counselor should follow up with open-ended questions that seek to obtain additional 

information. For instance, if a client acknowledges a prior suicide attempt, the 

counselor would want to know more about when the attempt occurred, what 

method was used, what else was happening in the person’s life when the attempt 

occurred, and why the attempt was unsuccessful. (See the detailed discussion on 

this important topic in Part 1, chapter 1.) 

COUNSELOR: So you’ve had a sort of mixture of difficulties over the course of the last couple of weeks including thoughts about feeling hopeless and perhaps even thoughts of taking your own life. I know it’s a difficult
 

subject, but do you mind if we talk a little bit more about this?
 

CLAYTON: That’s okay.
 

COUNSELOR: Thanks. I appreciate your willingness. One concern I have is about your hopeless feelings and
 

where they might lead, for instance, whether they lead to thoughts about killing yourself.
 

CLAYTON: Yeah. I’ve thought about it. I’ve had a gun for a long time.
 

COUNSELOR: I wonder if you could say a little bit more about the thoughts, and what you’ve thought of in
 

terms of the gun.
 

CLAYTON: I don’t do much with the gun now. I used to use it for target practice and stuff. My son and I used
 

to take it out years ago.
 

COUNSELOR: Do you remember the last time you got the gun out?
 

CLAYTON: Yes, last week. Funny, I guess I haven’t had it out of the closet in years, but I took it out the other
 

night and just checked it out.
 

COUNSELOR: Were you thinking about killing yourself when you took the gun out?
 

CLAYTON: You know, not really. I don’t know why I took it out. But later, I was
 

feeling pretty bad, and I wondered if that was what I was doing. It bothered me
 

enough that I told my sponsor about it, and he told me to give you a call.
 

Addressing Suicidal Thoughts and Behaviors in Substance Abuse Treatment 37 
COUNSELOR: I’m glad you did.
 

CLAYTON: Me too.
 

COUNSELOR: Could I ask how often the thoughts of suicide occur?
 

CLAYTON: I’d say about every week or so.
 

Master Clinician Note: Observe that the counselor occasionally asks the 

client’s permission to continue probing, showing respect for the client and providing him with a sense of control. Also notice how the counselor picked up on 

hopelessness and followed it up with a more specific mention of “thoughts about 

killing yourself.” Using this direct phrase showed Clayton that this is not a taboo 

subject, and indeed the counselor can handle this topic, opening the door to a 

revealing discussion about Clayton’s suicidal thoughts and plan to use his gun. 

As you will see, the counselor continues to gather information, which will be necessary for deciding what actions to take. There are many similarities between 

obtaining information about suicidality and the information you, as a substance 

abuse counselor, routinely get about substance use history and current use. The 

information you want to obtain is the information that is directly relevant to 

treatment planning. Other information that might be useful in later treatment 

can be gathered at a later time. As with obtaining information about drug history, it is important to be specific and persistent, without “grilling” the client. The 

counselor will now obtain more specific information about suicidal thoughts. 

COUNSELOR: Clayton, when the thoughts about killing yourself come up, how long do they last? How much 

time do you spend thinking about it? For example, does it come and go quickly or is it something that you stop 

and really think about? 

CLAYTON: Sometimes it will stick around for a while, a couple of hours. I guess it’s gotten a little worse over 

the past 4 or 5 months and lasting longer. 

COUNSELOR: Do you mind sharing with me a little bit about what you are thinking about during that period? 

CLAYTON: Just not being around and, like I said, not causing my family more grief than I’ve already caused 

them, getting out of the pain and things like that. It’s not like I spend the whole time then thinking about how 

I’m going to shoot myself. It’s more like I just think I’d be better off dead, I wouldn’t feel all this pain. . . It just 

seems pretty reasonable when I’m in that frame of mind. 

COUNSELOR: Clayton, have you thought about killing yourself today? 

CLAYTON: You mean like this morning? No, it’s not like it is right in front of me. It just more hangs around in 

the background. 

COUNSELOR: Thank you for that clarification. I also wonder if you’ve done anything in preparation for taking 

your life. 

CLAYTON: I don’t know what you mean. 

COUNSELOR: For example, giving away things, saying goodbyes, arranging affairs, making sure your gun 

works. Have you found yourself doing anything like this? 

CLAYTON: Uh, I’ve made sure that possessions—things that I own and stuff—would be given out the way they 

should be in terms of taking care of that kind of thing but not really much beyond that. 

COUNSELOR: Anything else? 

38 Part 1, Chapter 2 
CLAYTON: Well I just talked to an attorney about where whatever possessions I have will go, and I made a
 

will. But with my physical condition, I need to do that anyway. It’s not like I’m getting all the ducks in a row.
 

COUNSELOR: It kinda sounds like you’ve redone your will.
 

CLAYTON: Yeah.
 

Master Clinician Note: There is a pause in the conversation at this point. The 

counselor is considering that he might consult with Jill, his supervisor, about 

how to proceed. He is concerned particularly about letting Clayton leave the 

office, knowing that he has recurrent suicidal thoughts, has considered shooting 

himself, and has access to a gun. He decides to address the issue of getting some 

advice from Jill directly with Clayton. 

COUNSELOR: Clayton, at this point I am going to take the opportunity to touch base with my supervisor for a 

few minutes. The reason I need to do that is because some of the areas we have discussed, including your 

chronic pain, the hopelessness, the suicidal feelings, and your gun have me concerned about your health and 

safety. If Jill, my supervisor, is available, would you mind if she joins us? 

CLAYTON: I knew I shouldn’t have said anything. What are you going to do, lock me up? 

COUNSELOR: I can appreciate that you feel nervous, but try not to jump to conclusions. I just want to get 

some input to make sure we’re doing everything possible to help you with your struggle and keep you safe. In 

this instance I think she can be helpful to both of us. What I want to do is give her a call and see if she can step 

in. 

CLAYTON: Okay, I suppose you’re just trying to do the right thing. 

COUNSELOR: Yes, I want as much expertise available to us as possible. Thanks for understanding. 

Master Clinician Note: Darren raised the issue of involving his supervisor 

skillfully. First, he consulted with Clayton about it. Second, he validated 

Clayton’s feelings. Third, he gave Clayton a rationale for the supervisor consultation. And, fourth, he kept the focus on Clayton’s well-being. 

[Darren telephones Jill, his clinical supervisor.] 

COUNSELOR: Jill, this is Darren. Clayton, who I think you know, is in my office right now, and we’re talking 

about his pain related to his liver disease and how he is coping with that. He’s had thoughts about suicide, and 

I’m wondering if you could join us for a few minutes as we make some decisions about how to handle this. 

SUPERVISOR: Yes, I’m glad you called, I’ll be right in 

[Jill, Darren’s supervisor, was in a meeting with another counselor that she broke away from in order to intervene in this more urgent situation.] 

Addressing Suicidal Thoughts and Behaviors in Substance Abuse Treatment 39 
How To Prepare for Suicidal Crises 

Agencies should have a policy for addressing immediate crises that arise during 

counseling sessions. The policy should specifically state that if a counselor feels 

he or she needs direction in a life-threatening crisis, a supervisor or other senior 

staff member should be contacted for input. More information is included in Part 

2 of this TIP. 

[In the interim until Jill enters the office, Clayton and Darren resume their conversation, focusing primarily on
 

Clayton’s depressive symptoms.]
 

[Jill enters room after knocking.]
 

COUNSELOR: Clayton, have you met Jill?
 

CLAYTON: Yes. Jill, I remember you from when you were a counselor here and did the evening aftercare
 

group.
 

COUNSELOR: Yes, Clayton, I remember you from the group, it’s good to see you again.
 

[Clayton, Jill, and Darren spend a few minutes developing rapport. Darren briefly describes Clayton’s reports of 

suicidal thoughts, the weapon in his house, his thoughts about redoing his will, and Darren’s concerns that 

Clayton might be depressed. Jill is unaware of Clayton’s suicide attempt many years ago.] 

SUPERVISOR: Clayton, one other thing that I would like to ask about. Have you ever tried to kill yourself?
 

CLAYTON: Not really. Well, maybe, when I was doing hard drugs, in my twenties, years ago. I tried to overdose one time. I used enough heroin that it should’ve killed me, plus I was drinking, but I just passed out, and
 

that was it.
 

SUPERVISOR: Can you tell me some more about what happened?
 

CLAYTON: Well, I shot up. I knew the stuff was good, pure. I tried to end it, and I just went out.
 

SUPERVISOR: Did someone find you?
 

CLAYTON: I think someone called an ambulance, and they took me to the hospital. They kept me maybe a day.
 

SUPERVISOR: Was there any followup?
 

CLAYTON: Nah.
 

SUPERVISOR: Okay, and you haven’t made any other suicide attempts?
 

CLAYTON: Nah.
 

SUPERVISOR: Thanks, Clayton, for sharing that with me. I just needed to check that out. The issues that
 

stand out to me are that your pain comes on pretty reliably every other day now, that you can get pretty down 

when this happens, and sometimes have thoughts of suicide, that you have a gun that you’ve thought of using, 

and, for the first time in a long time, you got the gun out. Would you say that’s a fair summary? 

CLAYTON: Yeah, that says it, I guess.
 

COUNSELOR: I agree, that captures the situation pretty well.
 

SUPERVISOR: The place I’d like to start is the gun. The reason I say that is because it’s just like getting sober,
 

it’s important to get the booze out of the house, so that when the craving hits, or there is a crisis of some sort, a 

bottle is not right there tempting you. It’s the same thing with having a gun, most of the time it’s not a prob40 Part 1, Chapter 2 
lem, but when the worst of the pain hits, and when the suicidal thoughts come, there is that added chance of 

taking action, and having the gun right there makes it more likely. What do you think of doing something 

about the gun, in order to make the situation safer? 

Master Clinician Note: Bear in mind that Jill knows Clayton from when she 

did the aftercare group. She has a background in mental health counseling and 

has had additional training in addressing suicidality. As a result she is clear 

about what to do and feels confident making this intervention on the spot, rather 

than discussing it first with Darren, or obtaining additional input from the program director or a consulting expert. 

CLAYTON: Well, I must admit when I got sober that I thought it was a little overkill to remove all the alcohol 

from the house, even the stuff in the liquor cabinet that I never paid any attention to, but it turned out you 

were right, it would’ve been tougher to get through those moments when the craving hit if the alcohol was right 

there. 

SUPERVISOR: Agreed. Having a gun in the house is kind of like having alcohol in the house. 

CLAYTON: I’ve thought about it now and then, but I haven’t really had it out in a while, except that one time 

last week, so I’m not exactly sure, what are you suggesting I do? 

SUPERVISOR: Well, what I’d like to do is have you make an agreement with me and Darren to go ahead and 

get rid of the weapon, not necessarily forever, but right now, given your pain and all, giving it to someone you 

know and trust would seem a lot safer than having it in your home. Whose help might you get in safeguarding 

the gun? 

CLAYTON: My daughter Barbara maybe? I don’t really want to get my sponsor involved in this, he’s great, but 

he gets nervous. Truthfully, I don’t really like the idea of bothering Barbara. I also don’t want to burden her 

with my liver disease and being sick and not being able to take care of myself. But I can’t think of anyone but 

Barbara who could take care of the gun, and I know she’d do it in a minute for me. 

COUNSELOR: I can see that you’re not totally comfortable asking Barbara, but if it has to be done, it sounds 

as if she is the best choice. Is that correct? Am I hearing you right? 

CLAYTON: Yeah, that nails it pretty well. 

COUNSELOR: Then Barbara it is. Thanks for working with us on that difficult decision. 

SUPERVISOR: Agreed. We appreciate your working with us like this. This is difficult stuff to be sure. One 

more thing I’d like to ask. How would you feel about it if Darren or I confirmed with Barbara that you gave her 

the gun? 

CLAYTON: If you gave me some time to do it. 

SUPERVISOR: How much time do you think that you need? 

CLAYTON: I could get it to her in the next couple days or so, and she’ll have it. I’ll talk to her. 

SUPERVISOR: Your suggestion is very reasonable and I appreciate it a great deal. However, I think Darren 

and I would feel even better about it if we took care of it today. I know you might see this as pushy, but I wonder if you would mind if we gave her a call now? 

CLAYTON: This feels like it is really rushing it. I mean, I’m not going to shoot myself tonight. I’m pretty sure 

of that. 

SUPERVISOR: Yes, I thought you might feel like you were being rushed. Please let me slow down and explain. 

Although there is a parallel between having alcohol in the house in recovery and having a gun in the house in 

Addressing Suicidal Thoughts and Behaviors in Substance Abuse Treatment 41 
this situation, they are not exactly the same. What I mean by that is, with relapse, there is the opportunity to 

learn from the mistake and remove the alcohol, but, unfortunately, with a gun it’s essential to get it right the 

first time. There may not come a second chance. For that reason, Darren and I tend to be a little more “pushy” 

and insistent with your situation than, say, if we were talking about preventing a relapse; the stakes are much 

higher. From our perspective, then, it makes more sense to take care of it now. 

CLAYTON (reluctantly): I understand although it still feels pushy. Well . . . OK. I’m not sure we can get her, 

and if we do, I don’t want to get her all upset. But we can try her cell phone. 

COUNSELOR: Thanks for hanging in there. Before we make the call, I suggest that we make a plan for what 

we’re going to say. 

Master Clinician Note: Observe that Darren, the counselor, can clearly see 

where Jill is going at this point and so he steps back into the conversation and 

assumes the task of working with Clayton and his daughter around safeguarding the gun. Accordingly, Jill recognizes that it is ideal to empower Darren to 

manage the situation to the extent possible, and so she steps back and allows 

Darren to work with Clayton around the gun directly, while continuing to 

observe the interaction to ensure that the plans to remove it are made and that 

any other important safety issues are addressed. Darren already has a release to 

speak with Clayton’s daughter and has spoken with her briefly on occasion about 

his progress. 

CLAYTON: Well, I guess, I’m thinking y’all are overreacting a bit to all of this. But I understand where you’re 

coming from. 

COUNSELOR: I really appreciate you trying to see our point of view. Let’s talk for just a minute before we call 

your daughter, about what you want to say, how you think she might react, how you want us to be involved. 

CLAYTON: Yeah, probably, yeah, she doesn’t know much. I mean, she knows I’ve been doing good in the program, and it’s working. And she knows that I haven’t been feeling well lately but she really doesn’t know much 

about—she knows my liver’s not in great shape; but she doesn’t know about the pain being so bad. 

COUNSELOR: It’s a fairly major thing to kind of drop on her and then to talk with you a little bit about the 

fact that you need to have her take the gun as well. Do you have a sense for how you’re going to bring that up 

with her? Do we need to talk about that for a minute before we make the phone call? It would seem to make 

some sense for us to discuss it. 

CLAYTON: Um, well, like I said, she knows I’ve had some liver problems but she doesn’t know how bad it is. I 

could just tell her, you know, I don’t have to get into that too much, I don’t think right now, do I? 

COUNSELOR: Well, I think it’s up to you. I would imagine she’s going to have some questions about why 

you’re calling. You’re going to tell her that you need to give her a gun, and you would like her to take it this 

afternoon if possible, that you’ve been having some difficulty. So it’s really up to you how much you tell her, but 

I want to make sure we have thought about any kinds of questions or concerns ahead of time. 

CLAYTON: Right. 

COUNSELOR: So we can kind of anticipate them before you make the phone call. 

CLAYTON: Yeah, I don’t see any problem, I mean, as long as she can come over, which I think she can; I mean, 

she lives maybe 20 minutes from my apartment. I thinks she’s visiting her mother this afternoon. I think she 

would do it. 

COUNSELOR: Okay, all right. One thing: does Barbara have any experience handling and safely storing guns? 

42 Part 1, Chapter 2 
CLAYTON: Not much experience, but she’s got an area in her attic that she keeps locked. I know that’s where
 

she’d lock up the gun.
 

COUNSELOR: That’s really good to know. If you’re okay with it, I think we’re ready to make the call.
 

CLAYTON: Are you going to be listening in to the call?
 

COUNSELOR: We’d be willing to, glad to in fact, if that’s okay. It might come in handy if Barbara has any
 

questions she wants to ask us. Would it be alright if we put the call on speakerphone?
 

CLAYTON: Yeah, that’s fine, sure. I mean, if you want to. You could explain this stuff better than me, I’m sure.
 

COUNSELOR: Well, we’d be happy to. There may be different points where Jill or I can offer some support or
 

say something if you’re a little bit at a loss for words, and when she has a question, if you could kind of give me
 

the nod, I’ll certainly chime in and offer some help if you need it.
 

SUPERVISOR: Yes, that sounds excellent, I’ll be happy to enter into the conversation as well if necessary,
 

although for the most part I’ll allow you and Darren to speak with Barbara.
 

CLAYTON: Okay.
 

[Clayton dials his daughter Barbara’s cell phone number.] 

BARBARA: Hello?
 

CLAYTON: Barbara, hi, it’s Dad.
 

BARBARA: Hi, Dad, how are you?
 

CLAYTON: I’m, you know, I could be better. I’m sitting here with my counselor and his supervisor and they
 

thought I should give you a call; they are actually on the speakerphone here.
 

BARBARA: Okay.
 

CLAYTON: Sorry I bothered you; I hope I’m not catching you at a bad time. I know you are probably visiting
 

with your mom right now.
 

BARBARA: Oh, no, you don’t bother me at all when you call, Dad, I’m glad to hear from you. I just wonder why
 

you’re calling with your counselor.
 

CLAYTON: Well, he thinks I should talk to you about maybe coming over and getting my gun, you know, 


it’s . . . , he thinks that maybe it would be better if you picked it up, or whatever. What do you think?
 

BARBARA: I think that’s pretty scary.
 

CLAYTON: I’m not sure we need to do it, but he thinks we need to do it, so, but, you know. Could you just keep
 

it for awhile? And in fact, if you want to talk to him, he’s here.
 

BARBARA: I would like to talk to him.
 

COUNSELOR: Barbara, this is your father’s counselor, Darren. I’m imagining you may have some questions.
 

BARBARA: Hi, Darren. This is pretty scary. I mean, I’ll be happy to come over and pick up Dad’s gun, but
 

what’s going on?
 

COUNSELOR: Well, your dad’s been doing great with sobriety, but unfortunately he’s been having a lot of pain,
 

and he feels hopeless on and off, and sometimes has thoughts of killing himself. So, we’ve advised your dad to
 

get the weapon out of the house, just to be on the safe side.
 

Addressing Suicidal Thoughts and Behaviors in Substance Abuse Treatment 43 
BARBARA: And I certainly will be happy to come over and get the gun. Dad, do you really think that you could
 

kill yourself? That would be really awful.
 

CLAYTON: No, I think I’m gonna be all right, my counselor’s just being extra cautious, don’t worry about me.
 

We can talk more about it, it’s a lot to talk about on the phone, but it’s okay if you get the gun. It’s what they
 

want me to do, and I’m going to go along with them.
 

BARBARA: Okay, I’ll be right over. Are you going to be home Dad?
 

CLAYTON: Well, I can be there in maybe a half hour.
 

COUNSELOR: Barbara, I understand it’s a scary thing, but it seems like a really good precaution to take.
 

BARBARA: And I appreciate that you’re doing that. And I’ll certainly do anything I can to help, but, Dad, why
 

is this happening? What’s going on? I mean you’ve been sober for—it’s just like we’re getting to know each
 

other, and now all of a sudden, I find out you’re depressed. I didn’t know any of this was going on.
 

CLAYTON: Well, it’s a lot, you know, we can talk about maybe—I don’t know . . . we can, well, you know, my
 

liver’s not been doing great and—
 

BARBARA: What do you mean your liver’s not good? I knew you had some problems with your drinking, what
 

do you mean your liver hasn’t been doing great? What’s that mean?
 

CLAYTON: Well, the doctors say my liver is pretty bad, and I’ve sometimes had a lot of pain with it.
 

BARBARA: What? We need to talk, Dad. I need to know what’s going on. This is all pretty scary—you’re scaring me, Dad. But I—I’ll be right over.
 

COUNSELOR: And, Barbara, I appreciate you doing that. One of the things your dad and I can talk about is
 

maybe it would be helpful for the three of us to sit down. This is a lot to take in, particularly over the phone. Do
 

you think that might be a good idea?
 

CLAYTON: Sure.
 

BARBARA: I think that would be really helpful for me. I have a lot of questions, and I think I’ll probably have
 

a lot more, but the first thing is, I will be right over to get the gun.
 

COUNSELOR: Just two more quick things. One, do you have a safe way to store the gun? Second, after you’ve
 

obtained and secured the gun, I wonder if you can call me to confirm that you’ve picked it up.
 

BARBARA: Yes, I have an area in my attic where I lock up things and I’m good about keeping the key hidden.
 

COUNSELOR: That’s great, please confirm with me after you’ve locked away the gun.
 

BARBARA: Yes, absolutely I’ll give you a call.
 

[Darren proceeds to give Barbara the office telephone number.] 

COUNSELOR: And Barbara, the other thing I would encourage you to do is just to make a list of the questions 

that you have. I know this is overwhelming to have all of this dropped on you in one afternoon. So if you just 

make a list of the questions, you can bring those in and the three of us can sit down and go through those, and 

try to get you the information and the answers that you need and that your dad is comfortable with. It’s likely 

that your dad could benefit from more treatment for his hopelessness and depression than he is getting right 

now, and so I think that’s something we should talk about when we meet. 

[Darren makes a mental note to give Barbara the 1-800-273-TALK number when she calls back.] 

BARBARA: That sounds like a really good idea. I-I-I am so rattled right now, I can’t even think, but I can do 

that and bring those in, and I think that would be helpful. 

COUNSELOR: Clayton, anything else that comes to mind? 

44 Part 1, Chapter 2 
CLAYTON: No. Thanks, Barbara.
 

BARBARA: Okay, Dad, I’ll be—
 

CLAYTON: Don’t worry about me.
 

BARBARA: I can’t not worry about you, Dad, but I’ll be right over to get the gun.
 

CLAYTON: All right. Thank you. Bye.
 

BARBARA: Bye.
 

How To Work With the Family of a Client Who is Suicidal 

As in treatment of substance abuse illnesses, family and significant others can 

be an important recovery resource. Some of the steps you, as a counselor, can 

take with family members include: 

1.	 Providing information about suicide, particularly dispelling misconceptions 

and providing accurate information. 

2.	 Increasing awareness of signs and symptoms that a loved one might be experiencing suicidal thoughts and/or behaviors, especially recognizing warning 

signs or a significant change in risk factors. 

3.	 Making suggestions about how to talk to a loved one who is experiencing suicidal thoughts: what to say, and equally important, what not to say. 

4.	 Making suggestions for how to recognize the need for and provide emotional 

support to a person who might be feeling overwhelmed and hopeless. 

5.	 Providing emergency resources (such as 1-800-273-TALK or local suicide hotlines and crisis centers in a suicidal crises). 

6.	 Planning for how to access and possibly remove suicide methods, such as 

guns or pills, to reduce the likelihood of high-risk behaviors. 

In working with family members, be sure to honor ethical and legal constraints 

on confidentiality and obtain appropriate consents for release of information 

from your client. 

Sometimes family members are not a positive force for suicide prevention and 

intervention, so care must be taken to assess how responsive the family members are to helping the client and if they possess the capacity to be a positive 

force in the client’s life at this time. 

COUNSELOR: Clayton, thanks for making the call. How do you feel about the phone call?
 

CLAYTON: I think it’s, you know, a little too much to do all that, but I’m willing to go along with it.
 

COUNSELOR: Thanks for being flexible. Let’s talk tomorrow by phone just to see where we are and where we
 

need to go from here.
 

SUPERVISOR: I can see that you both have things under control. Thanks for allowing me to join your meeting.
 

You did some excellent work here just now.
 

[Jill leaves the meeting.] 

Addressing Suicidal Thoughts and Behaviors in Substance Abuse Treatment 45 
Followup 

Darren received a call from Barbara acknowledging that she had stored the gun in her locked attic. Ideally, 

firearms should be stored unloaded, but in this case, there was probably a greater risk of unintentional injury 

to Barbara if she attempted to unload the gun. Therefore, she simply stored it, given that she has a locked 

space for it and is the only person with the key. If Darren had not heard from Barbara, he would have been 

sure to contact her to determine if anything went wrong with the plan and, if necessary, to develop an alternative plan. A positive outgrowth of the counselor’s intervention was that Barbara expressed an interest in meeting with the counselor and her dad to learn more about how she could be involved in his treatment and recovery. With Clayton’s permission, a joint visit was arranged for the following week. Clayton also agreed to a mental health consultation, and one was scheduled for later in the week to evaluate his depression and further 

assess suicide risk. Plans were also made for him to continue to visit a local pain clinic to help with pain relief. 

He was given the 1-800-273-TALK hotline number to call in an emergency. 

Clayton was cooperative throughout, agreeing to remove the weapon that created high potential for taking a 

lethal action. If his daughter hadn’t been available, Darren and Jill would have had a decision to make about 

whether or not any other immediate intervention steps were necessary. They may have wanted to get additional input concerning this question. A detailed discussion of removing weapons from the possession of suicidal 

patients is provided by Simon (2007). Although the article is not written specifically for substance abuse treatment settings, it offers sound guidance. Treatment programs may be willing to have clients bring in substances 

that they might use to kill themselves, with a procedure for handling such substances (e.g., by flushing them 

with a witness and documenting that this occurred). However, accepting a weapon from a suicidal client is 

highly problematic, because bringing a weapon into a facility may create risk to staff and clients (and typically 

violates agency policies) and because the provider may ultimately be required to return the weapon to the 

client, an untenable situation. As shown in this vignette, family members are often willing to help in such 

instances and are open to coaching about the need to store guns securely and separately from ammunition. In 

addition, family members may decide not to return the weapon or to get rid of it. A worthy option to explore for 

your program is your local police department, as some police departments have special policies for receiving suicide weapons. 

Darren took the time, with Jill’s help, to debrief and document his actions with Clayton related to his suicidal 

thoughts and to gain additional guidance for the followup sessions. Some of the points they considered include: 

•	 The information he gathered. 

•	 How he accessed consultation with Jill and invited her into the session. 

•	 The actions he took to contact Barbara and elicit her support in removing the gun. 

•	 His referral of Clayton for an evaluation of his depression and Darren’s support for Clayton continuing treatment at the pain clinic. 

•	 The followup sessions he scheduled with Clayton and Barbara. 

Discussion of the necessity for documentation and the style of documentation are provided in chapter 1. It is 

important to note in the documentation that Clayton and his daughter were both given the hotline number and 

were advised to call the number at any time if needed. 

Vignette 2—Angela 

Overview 

Angela is a 44-year-old African-American woman with a history of chronic bipolar disorder and substance 

dependence. These illnesses have created numerous problems, including relationship conflicts with her family, 

unstable employment and housing, and poor adherence to healthcare treatment. She is currently in an inpatient psychiatric unit that specializes in the treatment of co-occurring disorders following a relapse to crack 

46 Part 1, Chapter 2 
cocaine use. She made a suicide attempt by drug overdose just prior to this admission. Since being in the hospital, her psychiatric symptoms appear to be stabilized. Her counselor and the treatment staff are concerned that 

her stability is tenuous, and that if she relapses again following discharge, she may rapidly become suicidal. In 

light of her suicide attempt and her chronic history of relapse and serious mental illness, her doctor intends to 

keep her in the hospital for several more days of observation. 

Participants: Angela (client), Lupe (counselor), Walter (brother), and Carla (sister-in-law). 

Substance Abuse History 

Angela has a long history of cocaine dependence with relatively brief periods of abstinence. She was hospitalized for cocaine dependence twice in the past 4 years. Her drug use is intertwined with bipolar symptoms so it 

is difficult for her to remain clean when hypomanic or depressive symptoms occur, and at the same time, her 

drug use exacerbates these symptoms. She has done well since being hospitalized and has cooperated with 

treatment. The primary challenge now concerns discharge planning. Angela believes that she requires minimal 

aftercare treatment and intends to move back in with her brother and sister-in-law and their two children. 

Suicide-Related History 

Angela has made two suicide attempts, the first one as a teenager. Her most recent attempt, which precipitated 

her admission to the co-occurring disorders unit, was made while coming off cocaine. She had been deeply 

depressed for several weeks and overdosed on a variety of drugs that had been prescribed for her over the last 

few years. She was unconscious when discovered and taken to the emergency department. Once stabilized medically, she was admitted to the co-occurring disorders program. Although Angela denies any suicidal thoughts 

at this time, staff remain concerned about her potential for suicidal behavior upon initiation of cocaine use, a 

likelihood in light of her chronic substance dependence history. She shows poor insight into the severity of her 

mental illness, drug abuse, and suicide potential. 

Learning Objectives 

1. To illustrate treatment planning with a client at elevated risk of suicide. 

2. To demonstrate family involvement in treatment planning. 

3. To demonstrate case management skills in suicide prevention efforts. 

4. To offer an understanding of the interaction of substance abuse, mental disorders, and suicidal behaviors. 

Meeting Between Angela’s Counselor and Her Clinical Supervisor 

Angela’s counselor, Lupe, asked that part of her weekly clinical supervision session be set aside to discuss her 

concerns about treatment planning for Angela. Angela’s family has just notified her that they are not willing to 

have her return to their home and be with their children if there is a risk of drug relapse. Lupe and her supervisor discuss the complex interplay of Angela’s drug use, her psychiatric illness, and the environmental stressors she faces (lack of employment, social isolation, and poverty). They conclude that this combination of forces 

indicates a high potential for relapse and resultant crises, and though less certain, a potential return of suicidal 

thoughts. They decide to recommend ongoing treatment efforts, perhaps a day hospital or a long-term mental 

health/substance abuse residential care program, once she leaves the intensive co-occurring disorders unit. 

They also agree that it would be unethical to give a false sense of optimism about her prognosis to the family to 

persuade them to take her back. Assuming that she cannot return to her brother’s home to live in the immediate future, other supportive housing resources need to be identified. They know that Angela will need to accept 

and participate in any discharge plan or she will only undermine it after discharge. They also realize that they 

cannot force her to accept long-term residential or day treatment after discharge, no matter how clear it is to 

them that such treatment is warranted. 

Addressing Suicidal Thoughts and Behaviors in Substance Abuse Treatment 47 
The decisions reached in the supervision about the next steps include: 

Lupe will contact Angela’s brother Walter (after Angela has signed a release for Lupe to do so) and ask him to 

participate in Angela’s discharge planning. 

The staff will need to work with Angela and her family to find an alternative and more structured setting 

where she can be monitored for relapse of her substance abuse and psychiatric symptoms, and for a return of 

suicidal thoughts and behaviors. Since Walter is apparently emphatic that she cannot return to his home, this 

presents an opportunity to identify a more intensive treatment alternative, for example, supportive living plus 

day hospital treatment, options that she would never had agreed to if her brother had not forced the issue. 

Lupe’s objectives are to help Angela and her family with case management services to reach agreement for 

these arrangements. Some of the treatment goals she will try to implement include seeking to ease Angela’s 

transition back into the community; help her develop peer support; and continue to monitor her psychiatric and 

substance abuse treatment needs, warning signs for suicide, and medication compliance. 

Counselor and Angela’s Brother 

[When Lupe and Walter meet, they have an initial brief interchange focused on developing rapport. Walter seems 

defensive, and Lupe would like him to be more a part of the solution than an adversary.] 

WALTER: Let me get straight to the point: she’s gonna relapse. I mean she’s come in places like this and then 

she uses and she shows up at our door. We take care of her and I loan her money. She takes money if I don’t 

lend her any. We’re worn out. My wife is giving me a lot of grief about how I keep taking care of my little sister. 

I mean she’s not 18 anymore. She took pills and passed out when she was supposed to be watching our kids. I 

found her passed out on our sofa and had to call 911when I couldn’t wake her up. I wasn’t even sure if she was 

alive. Just to be straight with you, Angela’s not coming back to our house now. I know our kids will miss her. 

When she’s clean, she’s better to them than she was to her own kids. But when she’s using, she’s a real burden 

on me and my family. We just can’t do it anymore. And then when she doesn’t take her medication and gets out 

of treatment she gets crazy. It just keeps going on and on. 

COUNSELOR: Thank you for being up front with me about this. 

WALTER: Yeah, well, it’s the only way we’ll get anywhere. Thanks for meeting with me, by the way. It’s a welcome change. Last time she was in the hospital, nobody talked to me. 

COUNSELOR: Yes, it’s good we’re communicating. Like you, we want to be sure Angela can be in a supportive 

environment when she leaves, an environment that will support her abstinence and help her keep her psychiatric illness in check. It sounds like you and your wife have been fantastic in terms of supporting your sister. 

And I know her children are not involved, so it has fallen on you and your wife. 

WALTER: I’m glad you see where I’m coming from. This is not the first time with Angela. We’ve been through 

this many times with her. 

COUNSELOR: Once I learned that you wouldn’t be taking Angela back to your house, I had a chance to discuss 

alternatives with my supervisor and our treatment team, and also discussed possibilities briefly with Angela, 

although we didn’t come to any firm agreement. The alternative that seems to make the most sense is for 

Angela to first enter a halfway house program for people with co-occurring substance use and mental disorders 

and then, later, move toward a supportive residential housing program, which could last up to 120 days or 

more. Additionally, while she’s in the halfway house, she would continue to participate in intensive outpatient 

services here at the clinic. For starters, that outpatient treatment could be as frequent as 5 days a week, what 

we call “day hospital,” until she achieves some success in recovery. 

48 Part 1, Chapter 2 
Master Clinician Note: It is important for counselors to be aware of ongoing 

residential treatment and housing options for clients who have a history of 

homelessness, a history of instability in obtaining and maintaining housing, and 

those in need of long-term supervised care. Some treatment possibilities in your 

community may include: 

•	 Oxford Houses—a residential housing option found throughout the United 

States for people recovering from substance use disorders. 

•	 Halfway houses for people leaving inpatient care. 

•	 Sobriety houses, focusing on long-term supervised residential care. 

•	 State and Federally funded long-term treatment programs. 

•	 Supervised living. 

•	 Group homes or other community resources. 

In addition, housing options are numerous: housing funded through the HUD 

Homeless Assistance grants, such as Single Room Occupancy buildings, Shelter 

Plus Care, and Supportive Housing Programs, which are available to individuals 

who are homeless and have disabilities; programs that provide rental subsidies 

for sober housing and supportive services; modified therapeutic communities; 

day treatment with abstinence-contingent housing and employment services; 

and emergency and transitional shelters with onsite substance abuse treatment 

and relapse prevention programs. For more information about substance abuse 

treatment and homelessness see the planned TIP Substance Abuse Treatment for 

People Who Are Homeless (CSAT, in development j). 

WALTER: Hold on a second, I’m all for Angela doing something besides living with us, but aren’t halfway houses places for people who have been to jail? 

COUNSELOR: Well, not everyone in halfway houses is coming from jail. The program we would like to use is 

specific to the needs of people who have both substance use disorders and a co-occurring mental disorder. And 

we hope that in a few months Angela could transition to having her own small apartment, in a supervised residential environment where there would be someone to make sure that she takes her meds and continues to participate in treatment here. When she is able, they can also help her with employment. And in the meantime, 

she would be responsible for helping maintain the residential housing facility, in addition to keeping her own 

unit maintained. And, of course, we really want to monitor her psychiatric symptoms and her potential for suicidal thoughts and behaviors. 

I know that Angela feels very connected to you, your wife, and your kids, and that relationship is very important to her. But I hope she can understand your position that going back to your home just isn’t an option right 

now. 

WALTER: If you can find a healthy place for her, my wife would kiss you. Angela’s been a drug addict since she 

was in her teens, and she always has big plans. She gets an apartment or she gets a boyfriend or she goes into 

a program and she always ends up back on our doorstep. What am I gonna do? She’s strung out. She’s gonna 

end up on the street. We take her in, we clean her up, she makes promises and then you know what happens. If 

you can get her in a place where they’ll be nice to her and they’ll give her medications and be good to her that’s 

great, but I got enough to take care of. 

COUNSELOR: I understand, and that’s why we hope this kind of step-by-step collaborative plan, between 

Angela, your family, and us will work. And we do hope you will remain a big part of her life. Help her to be part 

of the family—have her be a part of family ceremonies and special occasions because we know that is important 

Addressing Suicidal Thoughts and Behaviors in Substance Abuse Treatment 49 
for her. But as you say, she also needs to live apart from your family, find her own life, and build her own support system. Help her to be independent. 

WALTER: About this suicide thing. You know my sister’s a drama queen. Do you really think she’s gonna kill 

herself? I mean, she’s been using drugs since she was a teenager. Maybe she just went overboard when I found 

her. 

COUNSELOR: We’ll never know what would’ve happened if you hadn’t found her, but based on my discussions 

with her and the report from the emergency department, we do believe that she tried to kill herself. She has a 

mental illness, bipolar disorder, and that has a high suicide risk. Also, as you might be aware, she tried to kill 

herself once as a teenager as well, also with pills. Fortunately, people like Angela who are vulnerable to becoming suicidal aren’t that way all the time. I’m just getting to know Angela, and I don’t have a crystal ball, but 

she may be vulnerable again if she relapses, and her relapses tend to happen when her mental illness is poorly 

controlled, especially when she’s depressed. So her addiction and mental illness feed off of one another, creating 

a vicious cycle. Suicide potential isn’t the only issue that Angela’s facing, but it is an added concern that we 

have—one that says to us that we should keep her in the hospital a bit longer, for more observation to be sure 

she’s safe, as well as to do everything that we can to put together a sound discharge plan. The success of that 

plan will ultimately depend on Angela, but we’d like to do our part to make it as realistic and supportive as 

possible. 

WALTER: Well, to be honest, I see it your way. She always says things that are off the wall, but a few weeks 

ago she made a couple of remarks that were downright scary, something like “you’ll be sorry when I’m gone” 

and “nobody cares about me so what’s the difference what happens to me?” I didn’t give it much thought at the 

time, but now it seems she was telling me something. 

COUNSELOR: Yes, those statements are what we call warning signs for suicidal behavior. If she does make 

statements like that in the future, you should interpret it as an indication of danger for suicide, and we can 

work together to prevent another suicide attempt. Let’s discuss this further when we meet with Angela. 

Master Clinician Note: Counselors should be aware of warning signs that indicate suicidal thinking and/or acute risk for suicidal behavior. Warning signs 

include suicidal communications (“It’s not worth it anymore,” “You’d be better off 

without me,” “Nobody cares anyway,” “I might as well kill myself,” “I’d be better 

off dead,” “I might as well be dead”), seeking access to methods of suicide (for 

example, hoarding pills, moving a gun that has been in storage), and any actions 

that suggest getting prepared for suicide (for example, giving away possessions, 

making arrangements in case of death). Warning signs also include changes that 

suggest a turn for the worse, for example indications that an individual is feeling 

trapped or hopeless, behaving recklessly, becoming withdrawn, or experiencing 

dramatic swings of mood. See pp. 11–12 for a fuller discussion of warning signs. 

Acute stressful life events may trigger risk for suicidal behavior, like relapsing, 

breaking up with a partner, losing a job, or being the victim of trauma. 

Additionally, as discussed below, it is important to help family members be cognizant of warning signs and help them plan how to take action if they notice 

warning signs. 

WALTER: I can’t tell you how relieved I am that she’s here right now. I sleep good at night knowing she’s in 

this place. Worries me sick what will happen after she leaves. You were saying, there is someplace she can go? 

COUNSELOR: We would like her to get into supportive residential housing, but we think first she might do 

better in a more structured halfway house environment until she is well stabilized with her abstinence and her 

50 Part 1, Chapter 2 
mental illness. At the moment it’s not a guarantee, although the sooner Angela is referred, the better, in terms
 

of any wait.
 

WALTER: She’s got a bed in this place?
 

COUNSELOR: Not at the moment, no. Getting that process started immediately is important, and for that we’ll
 

need Angela to agree to it. We want to be sure that Angela gets enough care. With too little support, her odds of
 

maintaining the gains she started here drop.
 

Maybe we can call Angela in now and the three of us can meet.
 

WALTER: Sounds good to me.
 

[Angela joins Lupe and Walter.]
 

COUNSELOR: Hi, Angela. Thanks for giving permission for Walter to talk with me today and to join us now.
 

ANGELA: Hi, Lupe. Hey, hi Walt!
 

COUNSELOR: How are you doing?
 

ANGELA: I’m doing fine.
 

WALTER: Yeah, well you best get yourself fine. I mean how many times have we done this? You get so-called
 

fine, you get cleaned up and then you use drugs, then you show up at our door. We take care of you, and now
 

this lady is telling me you’re suicidal.
 

ANGELA: This is different. I’m really fine this time. I’m gonna be okay.
 

WALTER: Angela, you know that Carla and I love you. Our kids love you. We wouldn’t have you in our lives if
 

we didn’t care about you, and we don’t want to see anything happen to you. But this suicide thing is scary. I
 

know you’re an addict. You’ve been an addict forever. But, suicide? Angie, when I found you I thought you were
 

dead. Your breathing was so shallow I thought you stopped breathing altogether, I thought you were gone. I
 

was really scared.
 

ANGELA: This is different. I’m fine this time. I’m gonna be fine.
 

WALTER: Yeah. Tell it to Carla.
 

Master Clinician Note: Lupe recognizes that there is family anger as well as 

little understanding of Angela and her illnesses. She also recognizes that this 

may be the first chance Walter has had to express this frustration. Rather than 

focus on his anger, which would likely just make him more defensive, Lupe 

decides to focus on his concerns and caring for Angela. She also recognizes, however, that if Walter’s anger becomes an impediment to his being involved in 

treatment, it will need to be addressed. Encouraging family involvement in 

Angela’s treatment may be very beneficial for both Angela and her family and 

will likely enhance treatment efficacy as well. 

COUNSELOR: Walter, suicide is an important risk for Angela—and something we need to stay focused on, 

along with her abstinence and her mental illness. I know that you love your sister and she loves you. I think 

Angela has been working on helping herself and she’s willing to continue working toward that goal. And I know 

you have some realistic concerns about her relapsing that need to be addressed. 

ANGELA: I’m not gonna relapse. 

Addressing Suicidal Thoughts and Behaviors in Substance Abuse Treatment 51 
COUNSELOR: Angela, I don’t think anybody plans on relapsing. But it happens when people in early recovery 

aren’t paying attention to the things that help them stay clean and sober. One of your goals here is to develop a 

personal recovery plan that identifies your triggers and looks at the opportunities and resources you have to 

address those triggers. 

How to Incorporate Suicide Prevention in Relapse Planning 

Clients who relapse with alcohol or drugs and active mental illness are at significant risk for suicidal thoughts and behaviors. As a result, planning for coping 

with suicidal thoughts and behaviors needs to be part of a relapse plan (see the 

planned TIP, Relapse Prevention and Recovery Promotion [CSAT, in development f]). Some possible elements of the plan are: 

1.	 Develop a plan for safety in the event of relapse in individuals who you have 

reason to believe will be at risk for suicide upon relapse (e.g., call your counselor, come to the clinic to see your counselor, call the National Suicide 

Prevention Lifeline at 1-800-273-TALK, go to the emergency department of 

your nearest hospital). 

2.	 Be aware of and address client speech that projects a suicidal result from 

relapse (e.g., challenge statements such as “if I use, I’ll kill myself,” “if I 

relapse, I’ll use ’til I die,” or “if I relapse, that will be the end for me”). 

3.	 Use mental health interventions to aid in relapse prevention (e.g., psychopharmacology, individual psychotherapy). 

4.	 Encourge the client to be actively involved (including a sponsor) in a 12-Step 

or other supportive program. 

ANGELA: But I can come home later, right Walter? ’Cause I’m fine. 

WALTER: I think we should do what Lupe says. I mean no treatment program has ever talked with us like 

this. She’s taken the time to talk with us, to work with us. It sounds like they went through a lot of trouble to 

make a plan for you and you have a really bad addiction. I mean you’ve had problems and been an addict since 

you were 17. You need more than just coming into this hospital. You gotta go to this program like she’s talking 

about, live there, stay sober. We can talk about you coming home later, but you have to keep going to your program. You gotta start listening to these people. 

ANGELA: But I’m fine, I’m fine. 

WALTER: Yeah. Okay. 

COUNSELOR: I know you believe you’re fine right now Angela. Our goal, all three of us, you, me, and Walter, 

is to help you stay fine. 

[Lupe outlines for Angela the housing plan that she and Walter discussed.] 

LUPE: I just want to see if there were any questions that either of you might have at this point. 

WALTER: I want to say I love Angela. We wouldn’t have her in our lives if we didn’t care about her, and we 

don’t want to see anything happen to her. She’s been an addict forever. I’m used to that, but the suicide thing 

frightens me. 

52 Part 1, Chapter 2 
Master Clinician Note: A concern for providers and families is that suicide 

risk is high after discharge for clients with a history of a previous suicide 

attempt and/or other significant risk factors. Families can do a number of things. 

They should remain watchful for warning signs. Before the patient leaves the 

hospital, family members should have a specific plan for whom to call and/or 

what to do in the event of acute warning signs (e.g., call the National Suicide 

Prevention Lifeline at 1-800-273-TALK, bring the individual to the psychiatric 

emergency department, call the clinic where the patient is being referred). 

Family members should not presume that, simply because a family member was 

just in the hospital, they are protected from suicidal behavior. 

Other helpful actions are restricting access to firearms and exercising some control over the supply of medications (e.g., giving a week’s supply at a time to the 

client and holding onto the rest, to prevent overdose). Families are also advised 

to be involved in inpatient and outpatient treatment of their relatives. Some 

common responses of family members when someone has thought about or 

attempted suicide include: 

• Feeling angry toward the suicidal person. 

• Feeling guilty. 

• Wanting to punish the suicidal person. 

• Hovering over the person to ensure that they don’t attempt again. 

• Frequently interrogating the suicidal person about their thinking. 

• Emotionally withdrawing from the suicidal person. 

All of these reactions can be counterproductive. Family counseling for family 

members and significant others can be of benefit to both the family and the 

client. 

COUNSELOR: Well, Angela is aware that she has a number of risk factors for suicide, including her bipolar illness. She acknowledges that just a few weeks ago she took a bunch of pills in an effort to kill herself. So, it is 

definitely something we need to be concerned about. And Walter, let’s talk for a minute about what you might 

notice that could mean Angela is having suicidal thoughts. 

WALTER: Well, like I said, I feel bad now that Carla and I didn’t pick up on her talk about maybe not being 

around much longer and us “being sorry when she’s gone.” 

COUNSELOR: Well, listening for those kinds of messages is important. I think another thing is just being 

aware that there are times when Angela is more likely to be at high risk than other times. For instance, when 

she is using or when her mood is not well regulated, when she is not taking her medication, when she is avoiding treatment, and when she is depressed. 

WALTER: Well, you’re right. When Angie isn’t too high or low and when she is clean she is okay to be around. 

She’s good with our kids and takes care of herself. 

COUNSELOR: Angela, I’m interested to hear what you have to say about this. 

ANGELA: Well, I’ve said, I ain’t gonna use, and I ain’t gonna try to kill myself. Those days are over. 

WALTER: Yes, yes, that’s what you always say Angela. 

[Pause while Angela looks away, frustrated.] 

Addressing Suicidal Thoughts and Behaviors in Substance Abuse Treatment 53 
                             

                           

                     

Master Clinician Note: It is common for tension to exist between clients and

family or significant others over the risk of relapse and recurrence of suicidal

thoughts and behaviors. While clients may deny or minimize risk, those close to

them often experience distrust and anxiety (especially with a past pattern of

relapse and recurrence). The counselor can address and normalize this experience and then reorient both parties back to the need for developing plans to support recovery and safety.

COUNSELOR: It’s understandable that there is some tension between you about the future. This commonly

occurs where the recovering person—Angela—tries to convince her family that she will be fine. What’s important is to have plans in place to support recovery and safety. It is not only helpful to you, Angela, but also helpful to your family. So let’s review the plan, Walter.

WALTER: So, we should watch for when we think she’s depressed or sad or hopeless or if she says she wants to

kill herself. And if it sounds like she’s gonna be strung out, withdrawn, or out of touch with treatment. Those

kinds of things, Right?

COUNSELOR: Right. And one other thing, Walter. What will you do if you see those signs?

WALTER: Well, I’ll call her on it, and I’ll telephone you.

COUNSELOR: I’d be happy to hear from you in those circumstances, although my primary job is treating

patients like Angela when they are here on the floor and so, after discharge, there will be other counselors

working more closely with Angela on an ongoing basis. So it will be important to have their contact information

and to get in touch with them.

ANGELA: How long are you expecting me to stay in this residential place?

Resources for Family Members and Friends

The National Suicide Prevention Lifeline has published a booklet, After an Attempt: A Guide for Taking

Care of Your Family Member After Treatment in the Emergency Department, with a Spanish version,

Después de un Intento de Suicidio. These can be downloaded from https://store.samhsa.gov/shin/content/

SMA08­4357/SMA08­4357.pdf and http://store.samhsa.gov/product/Despu­s­de­un­intento­de­suicidioGu­a­para­cuidar­a­su­familiar­despu­s­del­tratamiento­en­la­sala­de­emergencias/SMA08­4358,

respectively. Additionally the American Association of Suicidology publishes a newsletter, Surviving

Suicide, written by survivors for survivors. Click on the Survivors page at http://www.suicidology.org.

Several excellent sources of information are available for those whose family member or friend has died

by suicide:

• Suicide Prevention Resource Center (http://www.sprc.org). In the customized information menu,

select “survivors.”

• The National Organization for People of Color Against Suicide (http://www.nopcas.com/) has valuable

information that can be accessed via it’s website.

• American Foundation for Suicide Prevention (http://www.afsp.org). Click on the menu option

“Surviving Suicide Loss.”

• The American Association of Suicidology (http://www.suicidology.org) has a variety of print resources,

including information about support groups.

54 Part 1, Chapter 2
COUNSELOR: Well, Angela, let’s focus on getting in before we start planning on getting out. I’d like you to sign 

this release so I can start the process for you to go to a halfway house when you leave our program. Then, when 

you’ve had a chance to continue day treatment here on an outpatient basis and you are doing well, we can work 

on arranging a transition to a place where you can have your own apartment. 

ANGELA: Okay, go ahead. I’ll sign one more of those papers you’re always having me sign. 

COUNSELOR: Great, that sounds like a plan. I’ll go get a consent form. One other thing we can do is schedule 

the next meeting with the three of us. Would that be okay with you Walter? 

WALTER: Yes, I’m agreeable. Like I said before, nobody asked me to be part of Angie’s treatment before. This 

is the first time I ever felt like I knew what was going on and had information about what I can do to help. 

COUNSELOR: Okay, let’s set something up. How would the end of the week be for you? 

[The session ends with Angela signing a release and a followup session being scheduled.] 

Followup at 6 Months 

Angela completed the inpatient treatment program and was referred to a local halfway house. After 2 months, 

she was accepted to a supervised living facility. She attended an additional month of day hospital treatment following her discharge and has remained clean and sober for a longer period than any time in her adult life (7 

months counting her month-long hospitalization). While in the halfway house, she continued attending a 

Double Trouble support group for people with co-occurring substance use and mental disorders. She has continued in weekly outpatient counseling, where the focus remains on strengthening her commitment to abstinence, 

monitoring her psychiatric symptoms, and strengthening her relationships with others. She and other people in 

the Double Trouble group often eat at a local restaurant after meetings, and Angela expressed much satisfaction at having girlfriends in her life for the first time since she was a teenager. She had one hypomanic episode 

lasting about 2 weeks shortly after completing her day hospital program. This coincided with her admission to 

the supervised residential living facility. Her counselor worked with her residential supervisor and with Walter 

to continue their observation of her behavior, and her medication was readjusted. The hypomanic episode gave 

staff and Angela a chance to practice the relapse prevention strategies that had been developed during her 

inpatient stay. The staff concur with Angela’s report that she has not experienced suicidal thoughts or behaviors. Angela, Walter, and her outpatient counselor have met on a monthly basis to be sure that communication 

has been maintained between Angela and her family, and Angela occasionally visits Walter and his family on 

weekends and some holidays. She feels accepted in the residential setting and has begun to see that as her 

home. 

Vignette 3—Leon 

Overview 

Leon, age 24, is an African American veteran of the Iraq War who is currently a college sophomore. He delivers 

pizza in the evenings. He has exhibited symptoms of posttraumatic stress disorder (PTSD) such as flashbacks, 

startle reactions, general apprehension, and intrusive images. He also shows symptoms of depression (sadness, 

sleep disturbance) since he returned from Iraq. He was discharged from the military when his 4 years were up, 

but the symptoms persisted. About a year ago he went to a Veterans Affairs (VA) clinic and received prescriptions for depression and sleep disturbance along with instructions to follow through with mental health counseling. He was in counseling with a psychologist and took the prescribed medication for about 6 months, at 

which point he discontinued treatment because he was feeling better. 

Addressing Suicidal Thoughts and Behaviors in Substance Abuse Treatment 55 
Substance Abuse History 

Leon’s drinking rapidly escalated after he started college last year, and his alcohol abuse continues. He drinks 

a fifth, sometimes two fifths, of vodka a week. Mostly he drinks after he gets off work around 11 p.m. and finds 

that “a couple” of drinks help him get to sleep around 2 a.m. Then he sleeps until around 7 a.m. When he 

doesn’t sleep he gets restless, irritable, and startles easily. 

Last night he had his usual two or three drinks of straight vodka in his dorm room after he got off work. He 

was found in a stuporous state the next morning around 9 a.m. and was rushed by ambulance to the local hospital. They kept him for several hours at the emergency department (ED), determined that he had not been 

drinking enough to warrant a detoxification admission, and eventually released him after he provided assurances that he would participate in alcohol counseling at the college alcohol and drug program. The ED staff 

made an appointment for him at the college alcohol and drug program this afternoon. 

Suicide-Related History 

Leon denied any suicidal thoughts or behaviors when questioned in the ED. The ED personnel ordered a urine 

toxicology to assess for any drugs that may have contributed to his stuporous state prior to arrival, but when he 

quickly became alert and responsive, they released him before obtaining the results of his urine tests. They also 

mentioned ruling out suicidal ideation in their referral to the college counseling center. The emergency room 

personnel were not aware that Leon had been treated for depression at a VA facility last year. 

Learning Goals 

1.	 To highlight the correlation between high alcohol and other drug consumption and suicidal behavior. 

2.	 To explore how psychological trauma, depression, and substance abuse create a high-risk psychological 

environment for suicidal thoughts and behaviors. 

3.	 To illustrate how an individual might minimize or disguise suicidality in an initial interview. 

4.	 To illustrate how suicidal thoughts and behaviors can manifest among members of ethnic and racial minorities that historically have been thought to be at low risk for suicide. 

5.	 To demonstrate how to obtain a consult with a supervisor for a client in the office who has a recent suicide 

attempt. 

6.	 To emphasize the role of followup after referral of a client with suicidal thoughts and behaviors 

[Leon arrives on time for his appointment at the college counseling center and is met by his counselor, James. 

Leon presents for the session looking somewhat bedraggled and hung over. He is withdrawn, not very communicative, and does not make much eye contact. The counselor is aware of his referral from the ED and the nature 

of his treatment in the ED, although he is not clear about the circumstances that led to his evaluation. 

With this in mind, James decides to take some time to build a connection with Leon. They talk in rather general 

terms about what brought Leon to the clinic, and Leon begins, without much prompting, to describe his drinking 

patterns and life at college. Leon also mentions that he is an Iraq War veteran, having served 4 years in the 

Army after leaving high school. James does not pursue information about Leon’s military experience, but rather 

lets Leon provide the information he is willing to give voluntarily. 

Leon then describes what he remembers of the last 24 hours. Apparently he was blacked out part of the time but 

remembers being in his room last night and being in the ambulance on the way to the hospital.] 

COUNSELOR: Leon, let me see if I can summarize some of what you’ve been telling me. You think you’ve been 

drinking too much recently, mostly vodka, and you’ve had some blackouts. And these have been a concern to 

you. From your description, it seems your drinking has increased lately. 

LEON: Yeah. In fact, I didn’t drink the whole year I was in Iraq, 14 months actually. 

COUNSELOR: Anything you can think of that caused this increase in drinking? 

56 Part 1, Chapter 2 
LEON: Not really. I feel a lot of pressure, feel bad, worried. Then I drink. Actually, I drink pretty much every
 

night. I sometimes drink more than I really want to. It helps me sleep.
 

COUNSELOR: And it sounds like you mostly drink alone.
 

LEON: Yeah.
 

[Long pause while the counselor waits to see if Leon wants to say more.] 

COUNSELOR: Lots of pressure.
 

LEON: Yeah.
 

COUNSELOR: Can you tell me some more about the pressure?
 

LEON: Well, I don’t have much time for anything but work and school. Work is #*%!. I drive around in the dark
 

looking for addresses to deliver pizza. It’s cold. One #*%! last week gave me a 50 cent tip. That didn’t even pay
 

for the gas. Also, I only get to study a little bit at work.
 

COUNSELOR: Other pressures?
 

[Long pause.] 

LEON: When I’m alone, I get to thinking .... 

[Pause, counselor doesn’t want to interrupt.] 

LEON: About stuff in Iraq. I’ve had #*%!ing incoming mortar land on the building next to where I was sleeping. 

Two guys were killed. Then the return fire starts. And you wonder where the next incoming is going to land. 

Plus some other stuff. Sometimes when I finally get home from work and lay down to go to sleep, I think about 

that stuff. 

[The counselor proceeds to inquire about trauma-related symptoms, and Leon reveals a series of symptoms that 

suggest PTSD. He also tells the counselor about going to the VA Mental Hygiene clinic, the prescription he was 

given, and his participation in treatment with Dr. Rogers, a VA psychologist, for about 6 months after entering 

the VA program. Leon also mentions that he attended Alcoholics Anonymous (AA) on and off while in the VA 

program and had a sponsor at one time.] 

Master Clinician Note: Some of Leon’s risk factors for suicide include a history 

of substance abuse, PTSD-related symptoms, depression, and isolation. These 

symptoms, together with his ED admission, cause the counselor to wonder about 

suicidal thoughts or behaviors. Because of the combination of the client’s age and 

race, he is also at increased risk of suicide. 

COUNSELOR: Leon, I’m wondering if Iraq and the symptoms you just shared with me have anything to do 

with the increase in your drinking in the last year. 

LEON: I drink to go to sleep and not remember that stuff. 

[Another long pause.] 

COUNSELOR: Leon, I imagine that sometimes you just wish there were a way to escape all of this stuff . . . the 

pressure of school and work, the memories, the drinking. . . . 

LEON: Yeah. 

[Another long pause.] 

Addressing Suicidal Thoughts and Behaviors in Substance Abuse Treatment 57 
LEON: I think I may have had four or five pills last night too. I don’t remember taking them, but the bottle was 

empty when I went back to my room after leaving the emergency room and before coming over here today. 

COUNSELOR: Pills? 

LEON: Sleeping pills. I don’t know how many were there, but there were only a few left, maybe four or five at 

the most. I got them from VA when I went there last year. I don’t remember taking them last night, but the 

bottle was empty this afternoon. 

[Another long pause.] 

LEON: I think I just wanted to go to sleep. I guess. Maybe that’s why I couldn’t wake up this morning and why
 

they took me to the emergency room. I didn’t tell anybody about the pills.
 

COUNSELOR: Thanks for telling me.
 

LEON: I don’t remember taking them.
 

COUNSELOR: Your guess is that you were taking them to fall asleep. Are there any other possibilities?
 

LEON: Like what do you mean?
 

COUNSELOR: Well, you’ve been having a rough time, so I guess I was wondering if it is possible that you were
 

trying to hurt yourself or even kill yourself when you took the pills since you emptied the bottle.
 

LEON: Sorry, but I can’t really go there.
 

[Long pause.] 

COUNSELOR: Leon, I may be way off, but I get the sense that you want to confide in me, but you are having 

trouble making the decision to do that. 

[Long pause.] 

COUNSELOR: Please take your time. This is important. 

[Another pause.] 

LEON: Screw it, I told myself I wasn’t going to say anything, but screw it, I’ll talk about it. I tried to off myself 

last night. I figured pills were the way to go. If it worked, it would be chalked up as an accident. I just can’t live 

like this anymore, you don’t know how I feel everyday. Death would be a relief from this. It would have to be. 

COUNSELOR: You’re in a lot of pain. 

LEON: Tell me about it. Yeah, I know, believe me, I’ve thought about how to do it. I’ve thought about pills 

mostly. I’ve had too much with guns. Sometimes I’ve thought about what it would have been like to be shot in 

Iraq. All the blood and stuff. I don’t want that. Sometimes I look out a window and think I could jump. But I 

might just get crippled up. Same thing with stepping out in front of a bus on College Avenue. But, who knows, 

these are just random ideas. It’s not like I think about it all the time. I don’t have any clear ideas about how I’d 

take myself out, if it ever came to that. Anyway, I don’t think I’m ever gonna kill myself, what with the effect 

on my mom and all. 

COUNSELOR: Are you concerned you might act on those thoughts? Be unable to control them? 

LEON: I’m not too concerned. I’m not going to kill myself. No offense man, but that’s what white people do. 

Last night I was drunk and just made a mistake, I guess. 

58 Part 1, Chapter 2 
Master Clinician Note: High rates of suicide and nonfatal suicidal behavior 

among Black males, particularly among youth, are cause for grave concern. 

Depending on the age, the suicide rate among Black males ranges from two to 

seven times higher than among Black females (who are generally at low risk). 

Suicide is a form of self-destructive behavior that differs from other risk-taking 

behaviors (e.g., getting killed through drug use and street violence) that some 

young Black men, particularly those living in urban areas of concentrated poverty, are prone to. In the latter cases, the individual accepts the possibility that 

physical harm could result from his actions, rather than intending or expecting 

such an outcome as with suicide (Joe, 2003). Widespread disbelief that Black 

Americans would engage in suicidal behavior continues despite research documenting a rise in suicide among young Black males (Centers for Disease Control 

[CDC] 1998; Joe & Marcus, 2003) such that their rate is closer to the rate in 

young White males than in previous decades, although White males continue to 

have a somewhat higher rate (National Center for Injury Prevention and 

Control, 2007). 

COUNSELOR: Unfortunately the reality is that Black people as well as White people die by suicide.
 

LEON: Well, it’s probably better that the pills are gone.
 

COUNSELOR: I hear you. On that we can both agree.
 

Master Clinician Note: The counselor is organizing his thinking about assessment and treatment planning for Leon. His perception is that Leon is a relatively isolated student, with few social supports, who has PTSD symptoms and 

depressive symptoms, abuses alcohol, is having suicidal thoughts, and made a 

suicide attempt last night. His possible co-occurring disorders indicate that he 

needs more intensive treatment than can be addressed in an outpatient college 

substance abuse program. James decides to pause the session for now and have 

Leon briefly wait in the waiting room with another clinical staff member while 

he consults with his clinical supervisor. James knows that a potentially acutely 

suicidal client should never be left alone. 

COUNSELOR: Leon, the way we usually work here is that, when I meet somebody for the first time and find 

out about why they came to the counseling center, I check in with my supervisor. The two of us talk and work 

out what we think would be the best plan for what the next steps should be. Would you mind sitting in the 

waiting area for a few minutes? I’ll be back after I’ve had a chance to get some input. Okay with you? 

LEON: Yeah, I guess. 

[James briefly describes the situation to his supervisor and asks for help specifically with treatment planning 

and how to ensure Leon’s safety. James feels that an integrated treatment plan must address Leon’s suicidal 

thoughts and behaviors, his drinking, his PTSD and depressive symptoms, and his disconnection or isolation 

from friends and family. He suspects that there is a high probability that Leon will not follow through on outpatient referrals without intensive case management. The counselor is sensitive to Leon’s sitting in the waiting 

room and purposefully keeps the consultation session brief. 

Addressing Suicidal Thoughts and Behaviors in Substance Abuse Treatment 59 
Decisions the counselor and supervisor reach are: 

1.	 Further evaluation for suicidality is important, including consultation with the emergency department where 

Leon was seen this morning. 

2.	 Leon’s potential for suicide is directly linked to his mental health symptoms and substance abuse, and both 

issues need to be addressed in treatment. 

3.	 Intensive substance abuse treatment and case management are important over the next few weeks until Leon 

has stabilized. This can best be accomplished in the local VA treatment facility. 

4.	 They need to make some plans to support Leon until he can make contact with VA and begin treatment. 

5.	 The counselor needs to continue to maintain contact with Leon to ensure that he accepts the referral and continues to participate in treatment. 

6.	 Efforts should be made to help Leon reconnect with the AA group he attended a few times last year. 

James returns to his session with Leon.] 

COUNSELOR: Leon, I’ve talked with my supervisor, and we have some ideas that I hope you will agree to 

accept. In light of last night with the drinking and the pills, we would like to have you talk to someone. We’re 

worried about the pills, and while I believe you when you say you aren’t going to kill yourself, it is also important not to just ignore what happened. It is a signal of how much pain you’re feeling and it requires that we 

take the depth of your struggle seriously and develop a plan that can realistically help you to begin to feel better. We can’t help but think that your use of alcohol as well as the experiences that you had in Iraq contributed 

to your drinking and taking the pills last night, so it’s important to get help for your drinking and your wartime experiences. 

We think the best place to address all of this would be with Dr. Rogers, whom you saw at the VA hospital. They 

have programs to confront these issues that are really beyond the scope of our treatment programs here. You’ve 

been there before, so you know the place a bit, and it sounds as if you responded pretty well to the treatment. 

And I’m wondering if you agree with this. 

LEON: I think you’re overreacting to last night. Anyway, it’s true I went to VA last year for 6 months or so and 

then quit going when I started feeling better. I didn’t exactly like taking pills but I stuck with them. It wasn’t 

too bad. I liked Dr. Rogers, he was cool. 

COUNSELOR: Tell me more about what happened there. 

LEON: Well, I started feeling better, so I stopped. 

COUNSELOR: Okay, well, what I would like to see us do today is make a plan that really works for you. And 

I’m going to follow up with you too, to give you the support we can offer and to make sure you get the treatment 

you need. 

LEON: All right, I’m listening. 

COUNSELOR: Thanks, I appreciate that. Could I get your permission to call VA and make an appointment for 

you now? Then I want us to talk some about what you need to do to take care of yourself between now and 

when you get to VA. 

LEON: Okay. 

[The counselor has Leon sign the appropriate release of information form and makes the call to the VA intake 

worker. They arrange an expedited appointment for tomorrow morning. The counselor agrees to fax pertinent 

materials to the VA in advance of the appointment.] 

COUNSELOR: Leon, lets talk some about what you can do to take care of yourself tonight before your appointment tomorrow. 

LEON: Whaddya mean? 

60 Part 1, Chapter 2 
COUNSELOR: Well, for openers, is there anyone you know who could be a support to you tonight? 

LEON: Is this really necessary? I’ve got an appointment tomorrow, after all, isn’t this overkill? 

COUNSELOR: I suppose I could see how this might seem like an overreaction but on the other hand, you were 

in the ED this morning, and took an overdose last night, and so it seems much better to land on the side of 

overresponding rather than underresponding. As well, I don’t think of it as overresponding so much as simply 

trying to do the smart thing. 

LEON: All right, I can see you are not going to drop it, so let me see who I can come up with. Nobody in school, 

that’s for sure, they all drink like me. When I used to go to AA, there was a cool guy there, he was my sponsor 

for a little while, he would always say “call my cell anytime,” and I did call a few times and he always 

answered. He’d take me to meetings. I even called his cell once the day after I was drinking, and he didn’t yell 

at me or judge me, just listened patiently and then got me to a meeting, I was pretty amazed. Anyway, I can 

give him a call. He’s a nice guy, graduated from school here a couple of years ago and lives just off campus still. 

COUNSELOR: Now that sounds like a “smart thing.” I really appreciate your coming up with that. Since you 

bring up AA, that might be a solid way to get a little support tonight, or at least keep you from being isolated. 

Is there a meeting scheduled tonight? 

LEON: Yeah, there’s one just off campus, it meets every weeknight at 8:00, pretty popular meeting, always a 

bunch of people there. I used to walk there once or twice a week, that’s where I met my sponsor. 

COUNSELOR: That’s pretty solid, the meeting will be there for you whether or not your sponsor is around, and 

from what you’ve said he’d more than likely be willing to talk with you, or perhaps even meet you at the meeting, assuming you can reach him at that number. 

LEON: Yeah, he was always gung ho, I wouldn’t be surprised. Anyway, I can hit the meeting. I’ve got nothing 

better to do tonight. I’m not up for studying, I’ll tell you that much, and don’t want to mess with any of those 

guys in the dorm, they act like kids. 

COUNSELOR: That’s great Leon. I’d like to stay with this safety planning a bit longer. Okay with you? 

LEON: We’re cool. 

COUNSELOR: You said you took all the sleeping pills. You don’t have any more. Is that right? 

LEON: Yes, that’s right. 

COUNSELOR: No tranquilizers, no antidepressants, no sleeping pills, no booze. No other prescription drugs in 

your dorm room, right? 

LEON: Yes, roger that. You must’ve won the “hero counselor award” or something. 

COUNSELOR: No, I’ve won no such award, and hero definitely doesn’t come to mind. I am just trying to be 

thorough. And so thanks for hanging in there while I try to dot all the i’s and cross all the t’s. Along those lines, 

I’d also like to provide you information about who you might call if you have a difficult time tonight, for example if you become depressed or start thinking about suicide again. I want you to have my number, the number 

of a national suicide hotline, and the number of the emergency services program here at the college. 

LEON: That’s not gonna happen. 

COUNSELOR: I believe you, and I hope you’re right. I think your plan to go to a meeting tonight, and to contact your old sponsor is fantastic. This is just one last, added safety measure. Here is my card. On the back of it 

I’ll write the number that you can call if you have an emergency during nonbusiness hours. Also, I’ll write the 

number of the national suicide prevention hotline and the emergency services number. These numbers were set 

up specifically for people who are going through a lot—people like yourself—so there is no shame if you’re in a 

bad way and need someone to speak with to help you through it. 

Addressing Suicidal Thoughts and Behaviors in Substance Abuse Treatment 61 
LEON: Okay, got it. All right, this is helpful. I never knew about these numbers.
 

COUNSELOR: Do you have transportation to VA tomorrow?
 

LEON: I have my car.
 

COUNSELOR: Okay, just to confirm. Tomorrow morning, you’ll have your VA appointment at 9:30 a.m. with
 

Dr. Rogers. You are going to call your sponsor and make a meeting tonight. If you find yourself getting overwhelmed, thinking about drinking or thinking about suicide, you’ll call our emergency number or the 800 hotline on the card you have. 

LEON: Okay. 

How to Develop a Campus Suicide Prevention Team 

On most campuses, mental health resources are limited, yet after recent highly 

publicized incidents of campus violence, anxiety about students with mental 

health problems is high. Campus suicide prevention teams ultimately can assist 

and support limited mental health professionals. To develop a campus suicide 

prevention team: 

• Identify campus professionals who have responsibility for students at risk. 

Most often they are deans of students; health, counseling and substance 

abuse services; residence life; judicial affairs; police; and emergency medical 

technicians. 

• Identify a variety of situations and what the issues are: confidentiality concerns, legal issues, voluntary and involuntary situations, campus and community resources, evening and weekend professional mental health support, gaps 

in services, and procedures for managing alcohol intoxication and drug overdoses. 

• Develop a smaller group to meet weekly to discuss at-risk students and coordinate mental health, academic, and environmental risks. 

• Create policies and procedures to support both voluntary and involuntary 

medical leave processes for at-risk students. Most often, voluntary procedures 

are used; however, involuntary procedures are sometimes necessary and often 

require legal counsel to develop. 

COUNSELOR: Just to let you know, I’m going to follow up with the VA tomorrow afternoon to make sure you 

made it there and to see how things went. 

LEON: Yeah, I figured. Don’t worry, I’ll keep the appointment, I can’t keep living like this, I hope they can do 

something for me, some meds again or counseling or something. 

COUNSELOR: They have several types of treatments available, and they’ve tailored their services to returning 

vets like you. So I think they’ll be able to help you out. I certainly think that you deserve to feel better than you 

have been lately. 

Followup 

Leon left the session feeling understood and supported. He had clear plans for the next steps he needs to take 

and was mobilized to take these steps. The counselor confirmed that Leon kept his appointment at the VA and 

had been enrolled in a substance abuse and co-occurring disorders program for returning vets. He was able to 

arrange his treatment schedule in a way that only required dropping one class and was able to continue his job. 

He has restarted his antidepressant medication, and treatment staff at the VA are continuing to monitor suicide warning signs and risk factors. The counselor in this vignette was careful to document his screening for 

62 Part 1, Chapter 2 
substance abuse and suicidality, the consultation with his clinical supervisor regarding referral, the referral 

that was made, and the followup on the referral to the VA. 

Vignette 4—Rob 

Overview 

This case illustrates gathering information from a client who alludes to suicide. The counselor must discern 

how to proceed with Rob and also address the impact Rob has had on the counseling group where he made indirect references to suicide. The counselor must sift through what she knows to understand Rob’s risk factors, 

warning signs, and protective factors for suicidal behavior. The vignette also raises issues of treatment transition in early recovery and addressing ambivalence. 

Substance Abuse History 

Rob is a 39-year-old Caucasian accountant. He is gay and is in a conflicted, long-term relationship. He is nearing completion of an intensive outpatient treatment (IOT) program. During his twenties he used a variety of 

psychoactive substances, but his drug of choice was marijuana, sometimes laced with PCP. In his thirties, he 

began to drink heavily and has done so for 6 years now. This is his first treatment effort, and he entered treatment as a result of a crisis in his relationship. Also, he has been missing work as a result of his alcohol use and 

the volatility of the relationship. He went to his Employee Assistance Program (EAP) at work, and EAP personnel identified Rob’s substance abuse and referred him to an IOT. 

Suicide-Related History 

At the end of group last night, Rob made a reference to suicide: “I might be better off dead.” Until then, no significant warning signs of suicidality had been noted with Rob. The group, however, immediately picked up on 

his comment and began to question him about suicidal thoughts, which he denied. His counselor, Joyce, 

believed it was important to follow up with Rob after group. Joyce also recognized the importance of addressing 

the group’s anxiety and concern about Rob. Long-term risk factors for Rob include depression, a troubled partner relationship, work-related problems, and minority sexual orientation. In addition, he is at a treatment transition point that may create vulnerability. Protective factors include a generally solid work history and remaining abstinent through the treatment program thus far. 

Learning Objectives 

1.	 To illustrate how subtle signs of suicidality can manifest in an intensive treatment environment. 

2.	 To demonstrate a therapeutic response to subtle signs of suicidality. 

3.	 To illustrate the significance of understanding risk factors, warning signs, and protective factors during the 

course of treatment. 

4.	 To illustrate the effect that a client’s statements regarding suicide can have on other clients in the treatment program. 

[The vignette begins with Joyce’s meeting with Rob for an individual counseling session immediately after the 

group during which he alluded to suicide.] 

COUNSELOR: Rob, the reason I asked to speak with you after group is that you made a comment right at the 

end that you might be better off dead. I have some concern about that. Can you talk a little more about what 

was going on with you? 

ROB: I’m just #*%!. Nothing is going well. Sometimes I think I’d be better off dead. I think it would be better 

for my parents, for my boyfriend, maybe it would just be better for you. I don’t feel like I belong. I don’t feel 

Addressing Suicidal Thoughts and Behaviors in Substance Abuse Treatment 63 
good at all. I thought recovery was supposed to make me better, supposed to fix things, and now I don’t feel 

fixed. 

COUNSELOR: You’ve worked really hard on your recovery, but I’m hearing you say that the struggle, especially with relationships, is so painful that you might do anything to escape it, even use again. Before we go any 

further though, Rob, I just want to check something out with you. Are you using at all? 

Master Clinician Note: Clients who have relapsed to substance use are particularly susceptible to suicidal thinking and, potentially, to suicidal behavior. 

ROB: I’m clean, Joyce. I told you that. I told the group that. I’ll pee in the cup if you want. 

COUNSELOR: Okay, good. I believe you, just wanted to be sure. Providing a urine sample isn’t necessary 

today. At this point, I’d like to focus on your comment in group. I want to hear more from you about your 

thoughts of killing yourself. 

ROB: I haven’t given it much thought, really. I’m just frustrated, and things don’t seem to be working out like 

they are supposed to. I just said that in group. 

COUNSELOR: It sounds like you’d like to stop how you’re feeling. As we talked about in group a few days ago, 

early recovery can be a real struggle, two steps forward and one step back. And sometimes things don’t get better immediately. In fact, sometimes things feel worse when you begin to make changes. 

Master Clinician Note: Early in her interview with Rob, Joyce needs to clarify 

whether Rob is minimizing his suicidality or if he really just made an impulsive 

statement in group to express his frustration. She wants to establish whether or 

not managing active suicidality will be the focus of her meeting, or if the focus 

will be on the provocative nature of his speech and its impact on the group. 

Therefore, Joyce first prioritizes gathering information about suicidality, and 

once she is satisfied that there is little data to indicate current risk, she switches 

the focus to his impact on the group. 

Joyce’s counseling style is more direct, perhaps even more confrontational, than 

other counselors depicted in these vignettes. This style illustrates the spectrum 

of counseling approaches in real world practice. But note that Joyce is still careful to avoid grilling or accusing Rob, which could make him defensive. 

ROB: I’d like to stop feeling bad. Recovery isn’t what I’d thought it’d be. I thought I’d feel better about myself.
 

I’m not comfortable.
 

COUNSELOR: And I hear that. And I also know this is hard to talk about. But I want to ask again if you are
 

thinking about killing yourself.
 

ROB: I don’t need that. I don’t need that stress. I’m not going to do anything like that today. I’m just stressed
 

out.
 

COUNSELOR: Okay, not today. But that leaves tomorrow and the next day and next month open.
 

ROB: No, I’m not really thinking about killing myself, if that is what you want to hear.
 

COUNSELOR: Rob, it isn’t about what I want to hear. It’s about what you are contemplating doing.
 

64 Part 1, Chapter 2 
ROB: Okay, okay. I’m not thinking about killing myself. I just need some relief from this pressure. And I know
 

it would be the end of my relationship with Sammy if I drink again.
 

COUNSELOR: So what I’m hearing you say is that you have been feeling upset but you haven’t been having
 

thoughts of suicide. Is that an accurate summary, or do I have that wrong in some way?
 

ROB: That sums it up pretty well.
 

COUNSELOR: I’m glad I understand where you’re coming from. I’d like to ask just a couple of more questions
 

along these lines. One question is whether you’ve ever attempted suicide?
 

ROB: No, never. I’m scared of pain; that’s not my thing.
 

COUNSELOR: What plans have you made about killing yourself?
 

ROB: None, I’ve never gotten that far, I don’t know what I’d do if I ever seriously thought about it.
 

COUNSELOR: Okay, thank you for providing the answers to my questions about your safety. I wonder if we
 

could shift gears now and discuss the group a bit, their concerns about what you said in group tonight and how
 

you might approach this when you go back tomorrow night.
 

ROB: After they all jumped on me tonight, I’m not sure I want to go back.
 

COUNSELOR: Part of treatment is learning how to face this kind of situation: how to handle yourself in difficult circumstances and be sober at the same time. You’ve done a good job in treatment, Rob, and you are almost
 

finished with your IOT program.
 

ROB: I feel like you’re dumping me. I don’t understand. What is this place? You bring us in. You help us. You
 

take care of us. You just have some arbitrary deadline when we’re supposed to be better. And then you just
 

throw us to the wolves.
 

Master Clinician Note: Joyce recognizes that Rob is diverting attention from 

discussing how he will handle himself in group, but also is expressing his concern about the upcoming treatment transition. She wants to acknowledge his 

concerns and still keep the focus on how Rob will react in the group tomorrow. 

COUNSELOR: If you could write your treatment plan right now, if you could spell out your group experience, 

what would you say would be most useful for you in bettering your group sessions? 

ROB: I don’t know. I like the one-on-one. I sorta put up with the group. Meeting with you . . . I like the one-onones. 

COUNSELOR: Right now, how about if we look at continuing our individual sessions twice a month for the 

next few months. However, there’s something that definitely needs to be addressed. I’m going to insist that in 

order to stay in the one-on-ones you’re going to need some of the group experience too. Did you notice how the 

group reacted when you said you might kill yourself? 

ROB: Did I notice! 

COUNSELOR: Greg said you had a lot to live for. Allison asked “does that mean you’re going to kill yourself?” 

Bill said something about making sure you got home okay tonight. The group members are really concerned 

about you. And I don’t think we can just sweep that under the rug now. 

ROB: I’m not sure I even heard. I was in my own head. 

COUNSELOR: Listening now to what they said, what do you think of their reaction? 

Addressing Suicidal Thoughts and Behaviors in Substance Abuse Treatment 65 
ROB: Are you saying I shouldn’t say how I feel? 

COUNSELOR: No, not at all. Actually, that is part of what I’d like you to work on, to express how you feel. My 

sense is that your statements about being “better off dead” and related comments weren’t really statements of 

how you feel; you were using them more like slang expressions to indicate your general frustration and anxiety. 

As a result, with those provocative comments, you threw the group off track from the real issues, including fear 

of transitioning out of the group and frustration in your relationship. What I would like to help you do is to 

express more directly your issues and feelings to the group. In that way they won’t be going down the wrong 

path, focusing on your safety, when they could be helping you sort through these difficulties. 

ROB: I didn’t mean to make people nervous. I was just upset and said something impulsively. Are you saying I 

did the wrong thing in group? 

COUNSELOR: No, I’m not. People were naturally distressed. Because you are part of the group, it has to be 

talked about that way. It’s not about your doing something bad or wrong. It occurs to me that your statement 

tonight about being better off dead may indicate that we need to think through your transition plan a bit more 

carefully. Maybe part of this is that you do need to be in primary treatment a bit longer and that we need to 

look carefully at how the transition occurs. 

ROB: One thing’s for sure, I’m not looking forward to going back into the group. Are you going to support me? 

COUNSELOR: Sure, I’ll support you. If it’s all right with you, at some point in the group I’ll let them know that 

you want to talk a little bit about what happened in the last group, and straighten them out about what’s really 

going on. However, I won’t do that right away, I want to give you the chance to raise the issue on your own 

first. 

ROB Yeah, I can do that. 

COUNSELOR: Well that’s our plan. Tomorrow, you’ll come into group and give the group an opportunity to discuss some of their issues. Also, let me talk with the team about your transition plan to make sure that we are 

covering all of the bases and going at the right pace. 

ROB: Okay, cool. 

Followup 

Rob returned to the next group meeting and, with Joyce’s support, addressed his suicide reference in the earlier 

session. He was able to hear the concerns of the other group members, and a good discussion among group 

members ensued with several other members briefly sharing prior experiences with suicidal thoughts. 

Joyce met with her supervisor and together they decided to adapt Rob’s treatment plan to include an extension 

of treatment with twice-monthly individual sessions for an additional 2 months. Joyce will continue to monitor 

Rob for warning signs. She will also work to strengthen protective factors such as maintaining abstinence, 

treatment attendance, and maintaining his employment. She will discuss the possibility that he attend a support group or get involved with another community resource as a kind of safety net that will always be there for 

him. In a later discussion with Rob, it was decided that couples’ counseling might be useful after he has 3 

months of stable sobriety. Joyce ensured that both Rob and his partner had information on contact resources if 

suicidal ideation should recur in the future. 

Joyce documented the session with Rob including the information gathered, the distinction between frustration 

and suicidal ideation as he expressed it, and the re-evaluation of transition plans. 

66 Part 1, Chapter 2 
Vignette 5—Vince 

Overview 

Vince is a 52-year-old Caucasian mill worker with a history of substance abuse, aggression, and relational difficulties. This is his third effort at substance abuse treatment. He volunteered for intensive outpatient treatment 

three evenings per week after an altercation with his wife that culminated in his physically assaulting her. 

During his second week of treatment, while at work at the mill, he was served an order of protection, mandating that he not have contact with his wife and that he not enter their home. 

He came to the treatment program this evening agitated, angry, and believing he had been victimized. His 

counselor, Kara, attempted to help Vince work to resolve the crisis, but he deflected the issue and became more 

agitated. Vince mentioned that he might as well be dead, so Kara began to question him about suicide risk. 

Vince defiantly described how he would kill himself with his handgun. Kara was unsure whether Vince was 

making a plea for attention or was actively suicidal and realized she was not in a position to make that decision. The counselor must explain to Vince the need for a psychiatric evaluation for suicidality in the emergency 

room of the local hospital. 

A Note on Homicide/Suicide 

Break-up by a partner or a threat to a partner relationship is a common precipitant of suicide among vulnerable males with substance use disorders (Duberstein Conwell, & Caine, 1993; Heikkinen et al., 1994; Murphy, 

Armstrong, Hermele, Fischer, & Clendenin, 1979). Often, this scenario follows a pattern of intimate partner 

violence (Conner , Duberstein, & Conwell, 2000). Men who abuse alcohol and/or drugs and are confronted with 

a break-up or threat to their relationship, particularly those showing a pattern of jealousy, domestic violence, 

legal difficulties, or prior suicidal behavior, may also be prone to committing homicide followed by suicide 

(Bossarte, Simon, & Barker, 2006; Marzuk, Tardiff, & Hirsch, 1992). Indeed, the risk factors (male, substance 

dependence, violence history), precipitating event (relationship break-up), and warning signs (suicidal communication, ideation, feeling trapped, hopelessness, anger, recklessness, mood change) observed in Vince’s case 

could set the stage for him to take his own life or, even more tragically, to murder his estranged wife before his 

suicide. Consequently, his case is doubly concerning. 

Substance Abuse History 

Vince has a history of substance abuse dating back to his teenage years. His academic performance in school 

indicates that he may have had an undiagnosed learning disability and relationship difficulties with other students and with authority figures. He joined the U.S. Navy and was medically discharged after 6 months for 

“emotional problems” and misconduct while drinking. He went to work for a local paper mill and, while occasionally in trouble for attendance problems, has worked there for 26 years. He has worked his way up to a 

forklift driver. He married Jolene when he was 32. They have no children together, although Jolene has two 

children from a previous marriage who live on their own. Vince’s drinking has been a problem in the relationship since before they married, but, until now, they have not been legally separated. Vince’s two other treatment efforts were precipitated by marital crises. As a result of the recent physical abuse, Jolene insisted that 

Vince get treatment again and move out of the house. He moved into a garage apartment belonging to his 

brother-in-law. 

Vince has never sustained abstinence. After both treatment episodes, he was drinking beer again within a 

month. He has occasionally attended AA as an extension of treatment, but has shown little interest in continuing attendance when active treatment ends. His typical drinking pattern is to drink three to four beers each 

weekday after work and two six packs or more a day on the weekends. He rarely appears intoxicated but 

almost always, except when working, is under the influence of alcohol. He makes sure he doesn’t have alcohol 

in his system while at work because forklift drivers at the plant are randomly screened for alcohol and illegal 

Addressing Suicidal Thoughts and Behaviors in Substance Abuse Treatment 67 
drugs, and a positive screen is grounds for immediate dismissal. The most significant of his alcohol-related 

problems come when he “breaks out,” drinking bourbon or vodka until he passes out. During these episodes, he 

becomes verbally and physically abusive. On several occasions, he has ended up in jail on drunk and disorderly 

or assault charges. These occasions have extended as long as a week. He takes sick leave from work, and Jolene 

stays at her brother’s house until he gets too sick to continue drinking. 

Suicide-Related History 

Vince’s warning signs were triggered by receipt of the protective order. They include his spontaneous suicide 

communication “I might as well be dead,” a lethal plan (handgun), anger and agitation, and feeling trapped by 

and hopeless about his marital situation. Vince’s long-standing risk factors include a history of chronic alcoholism from an early age, poor response to past treatments, emotional volatility (particularly anger), social isolation, firearm ownership, and history of aggression and violence toward others. Protective factors are stable 

employment, current sobriety, good attendance in his current treatment program, and a working connection 

with his counselor. 

Learning Objectives 

1.	 To demonstrate gathering information about suicidality with a client in an emotional crisis. 

2.	 To demonstrate the role of compassion and concern in developing a therapeutic relationship with a client 

who may elicit anger or disgust from the counselor. 

3.	 To demonstrate crisis intervention and referral with a client who is not initially cooperative with treatment 

planning. 

4.	 To illustrate specific strategies for working with resistant clients. 

[The dialog begins with Kara and Vince in an individual counseling session that evening. Because Vince is agitated, Kara arranges the seating so they both have a clear path to the door, with no obstructing furniture, and 

discreetly alerts colleagues near her office to listen for anything (e.g., shouting, unusual or loud noise) that might 

suggest that she is at risk.] 

COUNSELOR: Well, Vince, I appreciate that you came in and sat down to talk with me. I heard from other 

treatment staff this evening that you’ve been upset. 

VINCE: Damn it, she told me she wasn’t gonna do that. She told me if I get treatment, if I’d go again, you 

know, she wouldn’t leave me. And I’m at the mill today, and damn it, there comes this letter from this judge 

and this damn lawyer that I’m paying for. I’m payin’ for him, and he sends me this letter that says I can’t go to 

my own house. Now, that’s just not right. I pay for that house. 

COUNSELOR: You got the letter today? 

VINCE: Yeah. 

COUNSELOR: Yeah. That is upsetting. 

VINCE: I can’t #*%!ing believe it—that she’d do that. You know, the thing is, I mean, I know I get angry at her. 

She spends money like you can’t believe. And I know I get angry, and I know I shouldn’t drink. I know that too. 

But, you know, without her, without her, there’s just nothing for me! 

COUNSELOR: Well, you know, that’s a big leap from getting this letter from a lawyer to saying that you’re 

going to be without her forever. Can you fill in some of the blanks for me, and help me understand what’s been 

happening over the last couple of weeks? We haven’t talked in a lot of detail about this. 

VINCE: Well, the deal was, we had that bad little episode. 

COUNSELOR: Now, that’s the one where you got violent, is that correct? 

VINCE: Yeah, I did get physical. 

68 Part 1, Chapter 2 
COUNSELOR: You hurt her pretty badly, if I recall correctly. 

VINCE: Sometimes I think she exaggerates a little bit too. 

[Long pause during which Vince stares at the floor, shaking his head.] 

VINCE: But I did hit her, I did hit her. I just get so mad, and I did hit her. But that was, you know, we had 

this deal: I’d come to treatment, and I like treatment, I like the fellows here. I like you, you know, and I could 

keep working, and I’m living apart from her. I’m living in my brother-in-law’s garage. It’s her brother, but we 

kinda get along and I’m living in his garage apartment, and so I’ve been coming to treatment. And I’ve been 

doin’ fine until this happened, and it just, like, it knocked the legs out from under me, and I was— 

COUNSELOR: You’ve been working hard. You’ve made a commitment, and you’ve been here for every session, I 

think. 

VINCE: Damn right, I’ve been working hard. 

COUNSELOR: You sound extremely upset today. This protective order hit you pretty hard. 

VINCE: I just love that woman; I just love her. And I don’t know how I can live without her. I just—[sighs]. 

COUNSELOR: You know, when I hear you say that, it troubles me: that you don’t know how you would live 

without her. What do you mean when you say that you’re not sure that you can live without her? 

Master Clinician Note: Kara attempts to focus on Vince’s allusion to suicide, 

but Vince deflects. The counselor decides to let the subject go for now and return 

to it later. For clients who have difficulty talking about suicide, acknowledging 

this fact and introducing the topic carefully can make a difference. Some examples of introductory comments are: 

•	 “Now I have a few questions to ask you about suicide if that’s okay.” Then, 

after the client nods permission, “Have you been having thoughts of suicide?” 

Proceed with questions. 

•	 “I would like to speak with you about suicidal thoughts and behavior. Is that 

all right?” 

•	 “These seem like difficult questions for you. Is it all right if we proceed?” 

•	 “The topic of suicide can be uncomfortable, so I really appreciate your discussing it with me openly.” 

•	 “I’d like to ask you some more questions about your suicidal thoughts so that 

I can understand them. Is that okay with you?” 

•	 “I’d like to ask you some more questions about your suicide attempt so I can 

understand what happened. Is that okay with you?” 

It is also important to express empathy before seeking permission to explore 

more sensitive and private questions, especially at the outset of an interview. 

You might say, for instance, “You’re going through a very painful time in your 

life right now, so painful it could seem that life is unbearable.” You might continue, “The topic of suicide is uncomfortable, so I really appreciate your discussing 

it with me openly. May I have your permission to hear more and understand 

that better?” 

VINCE: I just can’t imagine living without that woman. I just—there would be nothing left for me. We don’t 

have any kids, never did. And she has some kids by her first marriage, but they don’t spend that much time 

with me. And there’s just nobody else in my life, and I might as well be dead, if I don’t have her. And damn it, 

you know, it’s the lawyer who did all this. There’s just no reason for this. There’s just [sighs] . . . One little 

event, it just goes to hell in a hand basket; it’s just too much. It’s just— 

Addressing Suicidal Thoughts and Behaviors in Substance Abuse Treatment 69 
COUNSELOR: Do you mind—let’s talk a little bit about that letter, because when you get upset and angry, I 

know that it’s difficult to keep focused on what’s happening now—what really is the problem. So, let’s go back 

to that letter. Do you mind sharing a little bit about that with me? Just help me understand exactly what it 

said. 

VINCE: The lawyer wrote me a letter and said I can’t go to my own house and I can’t talk to my own wife, and 

that doesn’t leave me much to do except sit in a damn garage. I really don’t want to drink ‘cause if I drink, 

man, I know, you know, I’m just gonna get flat out of control if I drink. I’ve met the cops in this town a few 

times, and I know that I don’t wanna meet them again when I’m drinking. And I just don’t wanna drink. 

COUNSELOR: Your decision not to drink is a wise one; I really support you on that. It takes a lot to stay sober 

after getting this kind of news. 

[Pause. Vince’s eyes tear up briefly but he fights them back. He is looking down, sullenly.] 

COUNSELOR: Vince, I want to explore a couple of things with you if I have your permission. 

VINCE: Sure, I guess. I’m not going anywhere. 

COUNSELOR: You said a minute ago that you aren’t sure you could live without Jolene. Does that mean you 

are having suicidal thoughts or plans? 

VINCE: Well, I mean, this woman is my whole life. She’s all I have. We’re married, damn it! It’s that damned 

lawyer causing all of this. 

[Kara senses Vince’s agitation and defensiveness and, while not satisfied that the issue of suicidal intent has 

been adequately addressed, decides to not push the topic now, but to cycle back to it.] 

COUNSELOR: Have you been feeling a pretty strong urge to drink? 

VINCE: No, not really; I’m just mad as hell, but I know how I am. I’ve been through treatment a couple of other 

times here, and one of the things I learned was that when I get mad is when I’m likely to get drunk. It’s what 

AA calls HALT, hungry, angry, lonely, and tired. I drink a little beer at other times, but it’s when I get mad 

and I get drunk that I get in trouble. And, really, I don’t wanna do that, you know? But I’m mad as hell right 

now, I’ll tell you that! 

COUNSELOR: I’m getting that. 

VINCE: It just feels like the whole #*%!ing world’s against me! 

COUNSELOR: Well, it can seem that way, sometimes. 

VINCE: I’m glad somebody understands that, I mean, she sure doesn’t, apparently. I haven’t talked to her. I 

can’t talk to her, that’s that. I can’t talk to her; I can’t go home. 

Master Clinician Note: Kara sees a chance to again address Vince’s allusion to 

suicide and decides this time to seek Vince’s permission to discuss “a painful and 

difficult topic.” By eliciting his cooperation she hopes to avoid his resistance to 

discussing suicide. 

COUNSELOR: Can we, for just a moment, go back and explore your comment that you can’t live without 

Jolene? I want to make sure I understand what you are saying. Are you agreeable? 

VINCE: I guess so; I got no place else to go. And actually, I kind of gotta thank you for talking to me. I do. I 

know I get kind of upset, and I can’t be a lot of fun to talk to when I get this way. 

70 Part 1, Chapter 2 
COUNSELOR: Well, I appreciate your willingness to talk with me about this difficult topic. Frankly, I’d rather 

have you sitting here with me being upset, talking about some options and maybe some things we could do 

about it, than have you outside being upset and deciding to go out and get in trouble. 

VINCE: Yeah, I might go out and get in trouble. 

COUNSELOR: Well, how about if we go back to that comment that you made a minute ago. I want to make 

sure that I understand this. You tell me that you’re angry, and I know in the past when you’ve gotten this 

angry, and particularly when you’ve started drinking again, that you lose control. And you made a comment 

about not wanting to live without Jolene. Can you help me understand, what did you mean by that? Did you 

mean that you’re thinking about killing yourself or killing Jolene? 

VINCE: I just can’t imagine—I can’t imagine living without that woman. You know. Kind of serve them right if 

I went out and just blew my brains out, you know? Just spattered blood and brains all over the place. Maybe 

she’d feel better. Yeah, yeah. To tell you the truth, I say I don’t wanna go out and drink—I’m really kinda 

scared to; if I went out and got drunk right now, I really don’t wanna mess with her, and ain’t nobody else to 

mess with but me. And if I didn’t mess with her, I’d probably mess with me. If the truth is known, that’s probably the truth. Yeah. 

Master Clinician Note: At this point the counselor has made a decision that 

Vince needs an emergency room evaluation today, given his warning signs (suicidal ideation, suicidal communication, access to a gun, anger/agitation) triggered 

by an acute stressful event, risk factors (poor impulse control, aggression and 

violence, inability to establish abstinence, unstable marriage), and his minimal 

protective factors (with the exception of stable employment). Solidifying this 

decision, Vince has a recent history of significant violence towards his wife and 

is alluding to relapsing and “messing with her,” indicating not only that he is 

at risk, but that she is as well. From this point forward, the counselor’s focus is 

on eliciting as much cooperation from Vince as possible to obtain emergency 

evaluation, with the understanding that the need for such an evaluation is nonnegotiable. The counselor will also bring her supervisor into this process to confirm her decision and to assist her as needed with Vince. 

COUNSELOR: When you talked about that, you sounded like, have you had thoughts of shooting yourself? Is 

that the idea that’s been going through your head? 

VINCE: Well, you know, like, I’m sittin’ here with you right now, I’m not gonna act on it right now. 

COUNSELOR: Okay. 

VINCE: But I couldn’t say I wouldn’t act on it if I left here right now, you know, I mean, there’s just no #*%! 

place to go! ’Cept to a garage with a bed in it. 

COUNSELOR: I’m glad we’re together right now so you’re not alone. Really bad feelings and urges to drink or 

to hurt yourself or someone else are not something we choose; the feelings are just there sometimes. But we can 

make good choices or less good choices about how to deal with bad feelings. Could we explore your choices in 

this situation? 

VINCE: I guess so, yeah, I mean, I don’t have nothing better to do. I don’t wanna, I really, I came in tonight, I 

don’t, I don’t wanna go to group tonight. I don’t wanna deal with this stuff, talk to people about it, I don’t want 

them—whining about it. Analyzing it. I don’t wanna do that. So, I’m okay just sitting here talking to you about 

it. I don’t know where it’s gonna take me, but, it beats going out and getting drunk. 

Addressing Suicidal Thoughts and Behaviors in Substance Abuse Treatment 71 
COUNSELOR: Well, I agree. It definitely beats going out and getting drunk. Why don’t we sit here and talk a 

little while, and then we can come to some decision about what’s going to be best for you. I do know that in the 

past, group has been an option for you to talk about what is going on. 

VINCE: Yeah, I just don’t wanna go in there tonight and have all these people saying, oh that’s terrible, and, I 

don’t know what they’re gonna say, really. But, I just know if I start talking about it, every time I start talking 

about it, I just start getting upset about it again; I open that letter and look at it, and there I go again. 

COUNSELOR: Well, when we look back over time and we think about how you’ve been in treatment a couple of 

times. I’m sure you’ve learned some things that have been helpful for you. 

VINCE: Yeah. 

COUNSELOR: When you get upset, when you get angry, when it triggers that craving and you feel the need to 

use and you feel like your anger is escalating, what kinds of things have been helpful for you? What sorts of 

things have you done that have really helped diffuse some of that anger and helped you move forward? 

VINCE: Well, one thing is get away from her because when I’m likely to get out of control, I take it out on her. 

Now, there’s two kinds of drinking I do. One kind is I just drink a little beer. And the other kind is where we 

get in these arguments, and when we get in these arguments, I just say, the hell with the whole thing. And I 

wanna get as drunk as I can get. And that’s how I feel now. But what I’ve learned in treatment, the other two 

times, is not to get into those arguments. And that’s what happened 2 weeks ago. I thought everything was 

fine, and she started picking, picking, picking, you know. And it doesn’t seem to matter what I do, it ain’t gonna 

be good enough for her. And then I get #*%!ed off, and I drink, and then I hit her a couple of times. 

COUNSELOR: It sounds like it’s really important for you to keep your distance right now—not to have contact 

with Jolene. 

VINCE: I don’t have any choice, I don’t think. I mean, if I don’t keep my distance, I’m gonna go to jail, and I 

don’t wanna do that. 

COUNSELOR: So, we can work on your keeping your distance, but how can you keep your distance in a 

healthy way? How do you keep your distance in a productive way without drinking and without escalating this 

anger and, like you said, going back and sitting in that garage apartment? 

VINCE: I don’t know where I’m goin’ tonight. I mean, that just . . . I can’t go home because I don’t have a home 

anymore. I’m paying for most of it, but I can’t go to my own home. I don’t wanna call people about this and 

whine about, “oh, my wife gave me a letter, I can’t go home,” you know? I don’t wanna do that. So I just know if 

I leave here, it’s gonna be real hard not to drink. 

COUNSELOR: Well, I know that in the short time that I’ve known you and that we’ve worked together, that 

when you’ve felt this way and you’ve been hurt and wounded in this way in the past, that— 

VINCE: Well, that wounded is the right word there, I tell ya. 

COUNSELOR: How do you feel like you’ve been wounded? It sounds like that was an accurate word. 

VINCE: Jeez, look at what she did to me, you know, I love that woman. 

COUNSELOR: Well, in the past you’ve described her as the most important person in your life, I think. 

VINCE: She is, Kara, she is. I can’t imagine living without her. 

COUNSELOR: It’s painful to think about missing somebody that you love, somebody that you care about. 

VINCE: I don’t plan on losing her. If I lose her, that’s it for me. I don’t plan on losing her. I don’t know how I’m 

gonna—I really think the lawyer put her up to this. They’ll make a big deal and get a whole lot of my money 

out of it. 

72 Part 1, Chapter 2 
COUNSELOR: You know, Vince, when I hear you say that, and I hear you talk in this way, and you feel this 

amount of anger, I know in those past incidents when you felt this way how out of control things can get. With 

how angry and upset and hurt you are right now, and how vulnerable you are to drinking, and how bad your 

judgment might get if you start to drink, well it all adds up to a really volatile and unsafe situation, for both 

you and Jolene. I’m way too concerned about you to think about what might happen if you go home tonight. 

Gosh, I’d be worried to death that I’d be reading about you in tomorrow’s papers, and that would be a terrible 

ending to all of the hard work you’ve put into your recovery. I mean you’ve been really trying. Gee, you haven’t 

missed a single group, and you’ve been sober from the get-go, and you’ve shot straight with me from day one, 

and I really appreciate that. Therefore, I feel like I’ve got to be just as straight with you. Tonight Vince, given 

where you’re at, what we really need to start discussing very seriously is you getting an evaluation at our emergency room, and very likely coming into the hospital for a little while until you can right yourself again. 

VINCE: Oh, I ain’t gonna sit in no emergency room all night. I don’t know where I’ll go. I really don’t wanna 

drink. I wanna drink, but I know what would happen if I do drink. 

COUNSELOR: Well, I don’t want you to drink, and I don’t want you to be in a position where you’re at risk to 

hurt yourself or to make a bad decision. 

VINCE: I don’t want a bunch of shrinks looking at me; I don’t want people—I know people from the mill go to 

the emergency room every day and, damned if I want them to see me in the emergency room, waiting to see a 

shrink! 

Master Clinician Note: Vince clearly does not want to go the emergency room 

and Kara is a critical strategic juncture. MI provides a framework that can be 

used to address Vince’s reluctance to go to the emergency room (see TIP 35, 

Enhancing Motivation for Change in Substance Abuse Treatment [CSAT, 

1999b]). From an MI perspective, the counselor can attempt to “roll” with Vince’s 

resistance by trying to understand his concerns about going to the emergency 

room and helping him explore both reasons against and reasons for going to the 

emergency room. By taking this approach, the counselor avoids creating resistance by treating Vince’s potentially legitimate concerns as unreasonable. 

Instead, the counselor acknowledges Vince’s concerns and tries to help him 

explore some of the pros of the decision. Given the severity of the situation, the 

counselor believes that an evaluation in the emergency department is needed. 

Although she will show as much respect for Vince’s autonomy as she can, she 

will explain to him that the evaluation is important because it will prevent him 

from hurting the people he loves or doing something he will regret. 

COUNSELOR: But at the same time, you’ve said that you want to make sure you’re safe: that you take the 

right steps and that you want to honor this commitment that you made to recovery. You’ve done a nice job 

working on that. But tonight you’ve raised enough concern for me that we really need to go down to the emergency department and look at having you evaluated and determine whether or not it’s the best place to be. I 

mean, you’ve received some incredibly tough news today, and you’re reeling from it, and still trying to make 

sense of it. You’re angry and hurt and really just beside yourself. If alcohol gets added in, well, it could just 

really all blow up, with terrible consequences for you. I’m frankly worried that you could shoot yourself. I also 

have to be honest with you Vince. I’m afraid for Jolene’s safety if you leave here tonight and go drink. This is 

one of those times, when things have gotten really tough, that it’s important to allow me and other professionals like me to do some of your thinking for you, because your judgment is not the best right now. Believe it or 

not, you can get through even this time, as impossible as that might seem right now, but you have to allow us 

to help you. 

VINCE: Oh, #&*@; I shouldn’t have even told you this stuff in the first place, you know? 

Addressing Suicidal Thoughts and Behaviors in Substance Abuse Treatment 73 
COUNSELOR: Does it scare you a little bit to think about it?
 

VINCE: It scares me that, whoa, I don’t know what’s worse, getting put in the city jail or getting locked in the
 

hospital, you know?
 

COUNSELOR: What’s the worry that you have about the hospital? Can you help me understand that?
 

VINCE: Yeah, I don’t want people calling me crazy. I mean, I’m a drunk, but I’m not crazy! You know? And I
 

don’t want people saying, “oh, did you hear about Vince, gonna kill himself, yuk, yuk, yuk,” you know? I don’t
 

need that #*%!. I got enough problems already!
 

COUNSELOR: Is that what you hear me doing? Do you hear me calling you crazy?
 

VINCE: No, no, no. I really think you want the best for me, Kara. I really do. I really do, but I don’t wanna get
 

locked up with a bunch of nuts. And I don’t want people talking behind my back, I want . . . tell you what, we’ll
 

just call this off and I’ll promise you I won’t kill myself.
 

COUNSELOR: Well, I’m not sure, Vince. Just a few minutes ago, you told me clearly that you felt out of control.
 

VINCE: Oh, I am. I am mad.
 

COUNSELOR: Well, what we’re talking about is not having you stay in the hospital and be labeled as crazy but
 

recognizing that when you’re at risk and feeling out of control we need to do some things to help you regain control. We need to help you maintain your recovery and do some things that are healthy for you. We’re talking
 

about your taking that step.
 

VINCE: Where are you talking about sending me?
 

COUNSELOR: We’ll just walk downstairs to the emergency department and I’ll go with you, and as a part of
 

our policy, we have to have a security guard go with us and sit with us, but—
 

VINCE: Oh, jeez! That’s—
 

COUNSELOR: It sounds like a lot.
 

VINCE: Yeah.
 

Master Clinician Note: Vince feels threatened by the referral to the emergency 

department. Kara, in keeping with agency policy, makes two decisions. The first 

is that she will not leave Vince alone. The second is she will involve security to 

help her escort Vince to the emergency department. While the ideal would be to 

have a collaborative stance with Vince, helping him make the decision to go to 

the emergency room voluntarily, Kara recognizes that, one way or another, 

Vince must be assessed by skilled mental health staff for his potential for suicide 

and interpersonal violence. The more ownership Vince can take of his decision to 

seek evaluation and treatment, the better. 

COUNSELOR: But that’s just a part of the policy; it doesn’t mean you’re being arrested, or anything. What it 

means is that I would go with you and sit with you and we’ll talk with the staff there and get their opinion 

about what might be best and what is the best way to help you right now. If they think being in the hospital is 

the best option, you would be in an environment where we can help you regain some control and maintain all 

the progress that you’ve made. 

VINCE: Yeah, I think what I want you to do is call Jolene and tell her what she’s done to me—that I’m gonna 

end up on a nut ward because of her and her lawyer. 

74 Part 1, Chapter 2 
COUNSELOR: You know, it can certainly feel that way, but from where I’m sitting, I see you taking a step to 

be responsible for your own recovery. I see it as a willingness on your part to do what’s necessary to maintain 

the progress you’ve made. 

VINCE: The way I see it is I’m between a rock and a hard place. I don’t have anyplace else to go, but damn, I 

don’t wanna go to the nut ward but I do want her to know how bad she hurt me, too. 

COUNSELOR: It sounds like it’s pretty important for you to have her understand that you’ve been hurt. 

VINCE: Can she come see me? 

COUNSELOR: Vince, I don’t see how it could possibly be in your best interests to have Jolene see you the way 

you are feeling and thinking right now. 

VINCE: That’s true enough. If I talked to her I’d just get #*%!ed off again, and that wouldn’t help. First of all, 

how long am I gonna be there? How long are you talking about? I mean, are you talking weeks? 

COUNSELOR: I can’t predict for you what will happen, Vince. Sometimes when clients go to the emergency 

department, all that happens is an evaluation. Then people stay a day or two or three with a plan to follow up 

with me. Then there are times where people are admitted to the hospital for a longer period of time. It is highly 

unusual for people to be admitted to the hospital for weeks, especially with all of the current insurance restrictions. I suppose that’s possible but it’s highly unlikely. I don’t want to guess what will happen in your case, 

although it is certainly possible that you will be admitted to the hospital until you are under better control of 

your thinking and your emotions, and that a hospitalization may last a few days or more. It all depends on 

whether the doctors judge the situation to be safe enough to allow you to be discharged, or if they think more 

assessment and treatment are necessary in the ED or on one of the hospital floors in order to make things safe. 

Jolene’s safety is also at stake here, and that’s a consideration too. Just like me, the staff in the emergency 

department won’t want anything to happen to her, just like they don’t want anything to happen to you. 

VINCE: So what’s gonna happen in the ED? 

COUNSELOR: I’ve had a lot of experience working with the ED. I can tell you that you’ll be there at least a few 

hours and that you’ll be evaluated by a counselor first, most likely a nurse or social worker. Then you’ll see a 

doctor who will talk to you and also rely on the information that the nurse or social worker provides him or her. 

I’ll call them to make sure that they also have my opinion. When I speak to them I’m going to advocate that 

they admit you to the hospital because I know you pretty well, and I really think that you’re not in a good position to go back to the garage where you’re living at this time, and that you could benefit tremendously from a 

cooling off period. They’ll talk with you about a plan that could range anywhere from being discharged to being 

admitted to the hospital until things calm down, which I’d prefer. Although they will want your input, it’s possible that they will arrange temporary hospitalization for you even if you object strongly to it for the sake of 

safety. They may also want to touch base with Jolene to make sure that she’s safe. 

VINCE: Do I have any choice? 

COUNSELOR: I’ve gotten to know you pretty well, and this is really what needs to happen at this point. It’s 

one of those things in recovery that just needs to be done, I’d appreciate it if you could trust me on that. 

VINCE: Yeah, I knew you’d say something like that. I’m not sure why I bothered asking. 

COUNSELOR: Yeah, well you’ve gotten to know me pretty well, too. I need to touch base with my supervisor 

real quick and let him know what we’re doing. I just want to quickly let him know our plan, plus I need to let 

him know where I’ll be in case someone wants to get hold of me in the next little while. I also need to touch 

base with security so that they can escort you and me down there. 

[Pause. Vince shows no sign of leaving his chair.] 

Addressing Suicidal Thoughts and Behaviors in Substance Abuse Treatment 75 
[Kara calls her supervisor with Vince present, tells him that there is an emergency situation with Vince that 

requires that he be escorted to the ED as a precaution to prevent suicide and violence. She had discussed Vince 

with her supervisor, and they had anticipated that he might become homicidal if Jolene initiated separation and 

discussed that suicidality was also a possibility. Therefore, her supervisor quickly confirms the acuity of the situation. Convinced that emergency evaluation is needed, he endorses the plan without delay and makes arrangements for security to come to assist in escorting Vince to the ED. As the supervisor calls security, it frees up Kara 

to continue to speak with Vince to keep him calm. Given Vince’s history of violence, the supervisor requested more 

than one security officer to assist. Two security officers arrive, and they allow the counselor to initiate all of the 

direct interactions with Vince and, although in his presence throughout, allow Vince enough space that he does 

not feel threatened or “handled.” They are also prepared to call for more back-up and the local police if Vince 

runs or becomes aggressive, neither of which occur. 

After Vince is checked in, the counselor provides all the relevant information to the ED staff and stresses the 

potential risk to Jolene that will require contacting her as a precaution. She also emphasizes to the ED staff in 

clear and unambiguous terms that in her opinion, and that of her supervisor, Vince is an acute danger to himself 

and his wife and requires hospitalization until his affect stabilizes and his judgment improves. She also makes a 

concrete plan with the ED staff that they will be in communication about Vince’s status the following morning. 

Although the counselor made the decision early about of the need for emergency evaluation, she took the time to 

discuss this with Vince in a firm but caring manner, facilitating his cooperation. As she has had previous experience in escorting acutely suicidal patients to the ED, has worked collaboratively with her supervisor in these 

instances, and has specifically discussed in supervision the possibility that Vince might require an emergency 

evaluation if Jolene initiated separation, all that was required from the supervisor in this situation was a quick 

confirmation of Vince’s acuity and the appropriateness of the plan. Moreover, he was of great assistance in getting security, allowing the counselor to engage Vince uninterrupted.] 

Followup 

Kara stayed with Vince through the ED evaluation process, suspecting that if she left, he would find a reason 

to impulsively leave. The ED social worker did a brief evaluation, and the psychiatrist who saw Vince following 

the evaluation decided to admit him to the psychiatric service for observation. With Vince’s permission, Kara 

notified his employer that he was hospitalized. He was hospitalized for 4 days and released with a followup 

treatment plan that included returning to substance abuse treatment in the intensive outpatient treatment 

program and regularly scheduled appointments with the attending psychiatrist, who coordinated continuing reassessment of Vince’s suicidality among all his caregivers in partnership with Kara, who served as case manager. Kara provided case management services to ensure that Vince kept his appointments and continued to participate in substance abuse and mental health treatment. As Vince neared completion of intensive substance 

abuse treatment, Kara arranged for Vince and Jolene to begin couples therapy to decide whether they would 

dissolve their marriage or work on it. The order of protection filed by Jolene was amended to allow them to 

meet together in the counselor’s office. 

Kara’s documentation of the case included Vince’s expressions of suicidal thoughts, his allusions to potential 

risk of violence to others, his risk factors for suicide, the warning signs she observed, and his limited protective 

factors. She noted his high potential for substance use relapse. She also documented Vince’s resistance to voluntarily seeking help for his suicidality, her consultation with her supervisor, and the fact that security personnel accompanied her and Vince to the ED. She also described the information she gave to the emergency 

department personnel and that she remained in the emergency department until the determination to hospitalize Vince was made. She also noted recommendations that were made for post-hospitalization care. 

76 Part 1, Chapter 2 
Vignette 6—Rena 

Overview 

Rena is a Native-American woman living in a rural area of a state in the Western United States. She has been 

sober for 6 months and has a history of child sexual abuse. She began having obsessive thoughts of killing herself yesterday, and she cannot stop the thoughts. She called her counselor, Martin, and the dialog below is from 

the telephone call. 

The case demonstrates some of the interplay of shame, trauma, substance abuse, and suicidality, and illustrates specific advanced counseling techniques that can be used to interrupt obsessive thoughts, build 

strengths, and help a client mobilize to take action. 

Substance Abuse History 

Rena is a 34-year-old Native-American woman with a history of sexual abuse by an uncle. The sexual abuse 

began when Rena was 8 years old and continued through her teenage years. She has been in recovery from 

alcohol dependence for about 6 months. She began drinking as a teenager and came into treatment almost a 

year ago at the insistence of her husband. A significant issue in her recovery has been managing trauma symptoms, including obsessive thoughts. Since she lives almost 40 miles from her treatment center, her primary 

aftercare services have been provided by telephone with occasional visits to her counselor when she comes to 

town. She has limited contact with other people recovering from substance abuse, but maintains ongoing supportive relationships with her family. She has three children, ages 15, 12, and 8. 

Suicide-Related History 

Rena’s suicidality is related to her psychological trauma symptoms. Since the age of 15 she has had thoughts of 

suicide as an escape from her emotional pain. On two occasions as a teenager she made suicide attempts by cutting her wrists. Neither attempt was medically serious and no treatment or followup was undertaken at the 

time. During her days of active alcohol abuse she would occasionally, while drinking, be overcome with painful 

feelings of shame, sadness, and fear and would begin having obsessive suicidal thoughts. Until yesterday, she 

had not had these thoughts since she quit drinking 6 months ago. The thoughts don’t include a specific suicide 

method but are more about the relief she would feel from being dead. 

Suicide and American Indian/Alaska Native Populations 

While rates vary widely among tribes, American Indian and Alaska Native people, as a whole, have significantly higher rates of suicidal behavior than people of other races and ethnicities. Some of the variables that seem 

to affect this elevated suicide rate include high rates of substance abuse and major psychiatric illness and cultural alienation that can increase risk factors and lower protective factors for suicide. Those who live on geographically isolated reservations may have limited educational and employment opportunities, as well as no 

easy access to mental health or substance abuse services. Particularly high rates of suicide are found among 

American Indian males, ages 15–24. A higher percentage of American Indian suicides are alcohol related, compared with the general population (Olson & Wahab, 2008). The effects of culture can be seen in each stage of 

help-seeking behavior (Goldston et al., 2008). Suicide prevention and intervention efforts need to be tribe specific, emphasizing the cultural beliefs and practices unique to the tribe and recognizing the specific helping 

resources that are available and acceptable to that particular group. The involvement of the community in suicide prevention efforts is critical. 

In recent years, the Indian Health Service (IHS) and SAMHSA have made suicide prevention among Native 

Americans a high priority and have funded a variety of programs to address their needs. Descriptions of these 

demonstration programs can be found at the Web site of the IHS Community Suicide Prevention initiative 

Addressing Suicidal Thoughts and Behaviors in Substance Abuse Treatment 77 
                   

           

                     

                           

                 

(http://www.ihs.gov/suicideprevention/). Also relevant to suicide prevention is SAMHSA’s Gathering of Native

Americans curriculum (http://www.samhsa.gov/tribal­ttac), a substance abuse prevention program that

emphasizes skill transfer and community empowerment and presents a prevention framework based on values

inherent in traditional Native cultures. Additional information can also be obtained from the planned TIP,

Substance Abuse Treatment With American Indians and Alaska Natives (CSAT, in development h).

Learning Objectives

1.	 To demonstrate a crisis suicide intervention over the telephone.

2.	 To illustrate how a detailed safety plan can be developed and used.

3.	 To illustrate a specific technique to intervene with obsessive suicide thoughts (the hope box).

4.	 To illustrate how an experienced counselor can build strengths for a client to mobilize to take action in the

face of powerful emotions of shame, fear, and sadness.

[Martin, Rena’s counselor, receives a telephone call around 2 p.m. one afternoon.]

COUNSELOR: Hello?

RENA: Uh, Martin, this is Rena.

COUNSELOR: Rena, how are you doing?

RENA: Uh, Martin, uh, remember helping me develop a safety plan for when I

start having thoughts of hurting myself? I tried the first couple of steps, but they

didn’t help at all.

COUNSELOR: Sure, Rena. Are you having those thoughts now?

How to Help a Client Develop a Detailed Safety Plan

A variety of strategies can be used to help clients anticipate, identify, prepare

for, and intervene in suicidal crises. All clients with suicide risk factors can benefit from a Commitment to Treatment agreement (described in Part 2, chapter

2). All clients at risk for a suicide crisis should have a safety card (described in

Part 1, chapter 1) that lists people and organizations that can be contacted in a

suicidal crisis or when the client anticipates a suicidal crisis. These contacts

include emergency contact information for their counselor, local treatment

resources, local and national suicide hotlines, and contact information for significant others who can assist in a crisis. The safety card should be individualized

for each client.

A more detailed safety plan is a more advanced treatment intervention that consists of a hierarchically arranged description of coping strategies that the client

agrees to use during a suicidal crisis. It is developed collaboratively by the client

and counselor and written down so that both the client and counselor can keep a

copy. The safety plan consists of four main sections, with the understanding that

clients can move to a subsequent section if their crisis is not resolved by following the instructions in an earlier section. (See Berk, Henriques, Warman,

Brown, & Beck, 2004; Henriques, Beck, & Brown, 2003; Wenzel, Brown, & Beck,

in press).

78 Part 1, Chapter 2
The first section is a list of the warning signs that indicate that a crisis may be developing. Warning signs can 

include thoughts (e.g., “I can’t take it anymore”), thinking styles (e.g., racing thoughts), emotions (e.g., intense 

depression), behaviors (e.g., isolating oneself), and/or physiological sensations (e.g., racing heart). 

Clients who recognize that they are heading for a suicidal crisis move on to the second section, which consists of 

coping strategies that clients can use without the help of another person. Examples of these kinds of coping 

strategies include diverting activities appropriate for the individual, such as walking the dog or reading the 

Bible. 

The third section consists of friends or family members that the client can call in the event that the individual 

coping strategies are not successful in resolving the crisis. It is important to list the telephone numbers of these 

individuals so they can be contacted immediately. 

The fourth section includes the telephone numbers of professionals who can be contacted in times of crisis, 

including the client’s substance abuse counselor, the on-call counselor who can be reached outside of business 

hours, a 24-hour emergency treatment facility, and other local support services that handle emergency calls. 

When the safety plan has been completed, the counselor works with the client to ensure that it will be used successfully, such as by discussing the precise location where the safety plan will be kept. Over the course of treatment, new coping strategies that are developed can be added to the safety plan. 

RENA: I’m scared, Martin, I’m scared. I-I-I can’t stop the thoughts that I’m gonna hurt myself. 

COUNSELOR: Well, I’m glad you called. And I’m really glad you could put your safety plan to use. You sound 

pretty frightened. 

RENA: I’m scared. I can’t, I can’t, I can’t stop myself from thinking I’m gonna hurt myself. 

COUNSELOR: Can you tell me what the thoughts are that you’re having? What are the thoughts that are 

going through your head? 

RENA: I wanna die. I wanna die. 

COUNSELOR: When did this start? 

RENA: I don’t know. Last night, maybe. Maybe yesterday sometime. 

COUNSELOR: So, this has been going on for a couple of days, going on for a little while? 

RENA: It just gets worse. It gets worse and worse. All I think about is how I wanna kill myself. I think about 

what to take—pills—I’ve got pills here in the house. And I wanna take ‘em and I just wanna go to sleep but I’m 

afraid I’ll take ‘em and then get sick and throw ‘em up and not die. 

COUNSELOR: So, you do have pills there in the house. 

RENA: Yeah. Yeah. I don’t even know what they are. I don’t know. Some of them are for the kids, some of ‘em 

are for Frank; I don’t know what they are. I have my pills for depression but I haven’t taken them in a long 

time. They’re just a bunch of pills. I don’t—I just—I want—I’m scared, I just wanna die. 

COUNSELOR: Well, I wonder if we could talk for a little bit and you could help me get a better idea about how 

you’re doing. Would that be all right? 

RENA: Yeah, okay. 

COUNSELOR: Well, I understand what you’re saying more or less. I hear that you’re scared. Are you there by 

yourself? 

RENA: Huh, what? 

COUNSELOR: Are you by yourself? Are you alone? 

Addressing Suicidal Thoughts and Behaviors in Substance Abuse Treatment 79 
RENA: Frank got angry at me and he left. He just—he went somewhere. He’ll be back. 

COUNSELOR: Is anyone else in the house? 

RENA: The kids aren’t here. The kids are gone. The kids, I don’t know where they are. I—I haven’t slept in, I 

don’t know, several days, and so this morning, I just couldn’t get out of bed, and they all left, and it’s just getting worse and worse, and I can’t stop the thoughts. 

COUNSELOR: Have you been drinking at all? 

RENA: A little. 

COUNSELOR: Can you help me understand how much when you say, a little bit? 

RENA: I just, I want to stop the thoughts and I had, we didn’t have much in the house, Frank took most of the 

alcohol out of the house. But we had some beer and I drank a couple of beers. And some Kahlua. That stuff 

tastes awful! 

COUNSELOR: Do you have any alcohol left at this point? 

RENA: No, and that’s part of the problem. I’m so scared and I don’t have—I’ve gotta stop the thoughts. I can’t 

stop the thoughts, and I don’t have any way to stop ‘em except the pills. And so I called you. 

COUNSELOR: Well, I’m glad that you called me and I know that that was our agreement, and so I’m glad to 

hear from you. I know it’s hard for you to tell me that you’ve been drinking again as well, but it’s good that you 

did. 

RENA: I feel so ashamed. 

COUNSELOR: Well, I appreciate you taking this step. It really is an incredible step, and this is one of the 

things we talked about, that when you start feeling this way, and it starts to get at a level where you don’t feel 

like you can manage it or control it, that you and I need to talk in order to move things forward and help you 

try to get some control. Now, as a part of how we’ve done this in the past, we had talked about using your hope 

box. Have you done that? Is that something that you did today? 

How To Set Up a Hope Box With Clients 

The hope box is a cognitive–behavioral intervention developed by researchers at 

the University of Pennsylvania (Berk, Henriques, Warman, Brown, & Beck, 

2004; Henriques, Beck, & Brown, 2003; Wenzel, Brown, & Beck, in press). When 

people are having suicidal thoughts and feeling hopeless, they tend to think in 

all-or-nothing terms: their life is truly hopeless. They need to be reminded to 

examine how they are thinking and use the coping skills they have developed to 

manage other times when they have felt hopeless. They need to be challenged to 

think of actions they can take other than suicide. There is no single way to 

establish a hope box (sometimes referred to as a “hope kit”) with a client, but the 

guidelines below may be helpful. 

Get clients thinking about things in the past that have given them hope or that 

have prevented them from attempting suicide: 

• Pick a time when a family member helped you in the past. 

• Go back in your life and recall when a particular friend was helpful. 

•	 Tell me about a time when someone you didn’t know well did something special (a doctor, an employer). 

•	 Pick a situation when you did something that made you feel more hopeful 

(walking in your neighborhood, working in the garden). 

80 Part 1, Chapter 2 
•	 Describe a time in your life when you felt proud of yourself or something you 

did (when you got a good report card, when you got a raise or a compliment). 

•	 If you were to give me a photograph of hope, what would it look like? 

Ask them to put something that reminds them of each person, event, activity, or 

time into a container. 

When they have a new item for the hope box, they should explain to you what it 

is, its significance, and in what way it makes them feel hopeful. 

Elicit a commitment from the client to practice thinking about two items in the 

hope box every day at home. They should describe to themselves how they feel 

when they recall the person, event, or time. 

Encourage the client to add one new item to the hope box each week (or appropriate length of time). 

After the hope box has been established, remind clients that they can go to their 

hope box when they are feeling hopeless or sad, pick an item, and try to regain 

the feelings they have experienced in the past. 

The hope box is a concrete marker of hope and serves multiple purposes. If a 

client has gone through the steps of developing and implementing a hope box, 

they have made a tangible commitment to living: one that, by its very nature, is 

personalized. The hope box helps stop the escalation of obsessive ruminations 

about reasons for dying, along with associated emotional upset and dysphoria. 

The hope box is a practical exercise designed to activate reasons for living and 

disrupt the cycle of despair. It helps reorient the client toward constructive problemsolving and effective regulation of emotions. Most important, though, the 

hope box is an intervention that facilitates self-management; that is, it provides 

an opportunity for the client to learn to manage crises and emotional upset individually, without external intervention. Real and lasting hope is founded in the 

client’s knowing that he or she can effectively and independently manage the 

problems of daily living. 

RENA: No, I haven’t thought about it.
 

COUNSELOR: Okay.
 

RENA: It’s here.
 

COUNSELOR: Would you mind getting it out, and let’s just walk through it. Let’s talk a little bit about it.
 

RENA: Give me a minute. I’ve got it, but I don’t see how that’s gonna help me.
 

COUNSELOR: Well, let’s go through it. I know in the past that it has helped, and I know that at different
 

times we’ve gone through it and it’s been effective at helping stop some of the obsessive thinking, particularly 

when you’re thinking about suicide. Do you want to take one of the items out and tell me a little bit about it? 

Master Clinician Note: The counselor wants to help Rena anchor herself in the 

present and maintain contact with the counselor, rather than focusing on past 

trauma or her perceived hopelessness in the future. Focusing on the hope box is 

in the here-and-now and helps Rena ground herself. 

Addressing Suicidal Thoughts and Behaviors in Substance Abuse Treatment 81 
RENA: The thoughts are terrible right now. They’re just terrible.
 

COUNSELOR: Well, let’s focus on the hope box. So let’s redirect your attention to that. And why don’t you just
 

take one of the items out and tell me a little bit about what it is.
 

RENA: It’s a picture, a picture of me with my children.
 

COUNSELOR: Can you tell me a little bit about the picture? When was it taken, where was it taken?
 

RENA: I don’t know. Maybe a couple of years ago, Marilyn looks like she’s about 13. It looks like we were at a
 

pow-wow.
 

COUNSELOR: Rena, what’s happening in the picture?
 

RENA: We’re all just standing there. I think Frank must have taken it. It’s me and my girls.
 

COUNSELOR: Can you talk a little bit about what was happening then?
 

RENA: I don’t know. All I can think about is who will take care of my girls if I’m gone. I’m so sad and so scared.
 

COUNSELOR: Can you tell me some more about feeling sad, what that is about?
 

Master Clinician Note: Trauma, particularly during childhood, is common 

among people who attempt suicide, particularly those who have made multiple 

suicide attempts. Traumatic memories can be activated in a number of ways, 

including both internal and external events. External precipitants include dayto-day stressors. This can include a host of possibilities, but most revolve around 

interpersonal relationships, particularly if they are abusive in nature. It is more 

common, though, for internal events to activate the suicidal crisis. These include 

thoughts, feelings, images, and sensations, some that even the client is not fully 

aware of at the time. When memories of previous trauma are activated, the net 

result is often overwhelming shame, subordination, impotence, guilt, helplessness, and feelings of being a burden—all facilitating hopelessness and thoughts 

of suicide. 

RENA: I look at my girls and I think about me when I was their age and I just get sad. That’s what I’m feelin’
 

now. I feel like I just wanna kill myself. Just quit.
 

COUNSELOR: There were some difficult times during that period in your life; there were also some times during that period when you felt better, when things were different. Do you recall any of those times?
 

RENA: I guess I felt better at school.
 

COUNSELOR: What was it that you liked about school?
 

RENA: I could be somebody else. I didn’t feel dirty at school. They didn’t know.
 

COUNSELOR: How did you feel at school?
 

RENA: I don’t remember, maybe happy. Maybe okay.
 

COUNSELOR: Do you recall some of the friends, some of the people you spent time with, that you felt close to?
 

RENA: Yeah, I had girlfriends.
 

COUNSELOR: Can you tell me a little bit about them?
 

RENA: They liked me, and we did things together. And I was a good student. Always obeyed the teachers.
 

82 Part 1, Chapter 2 
COUNSELOR: What did they like about you? What was it that you recall that they liked about you?
 

RENA: I can’t think of why anybody would like me right now. But back then I guess they liked me because I
 

was a good friend. I was loyal.
 

COUNSELOR: You know, I remember hearing you describe that in the past that you were loyal, dependable;
 

you were somebody that they could count on and look to for support. Do you remember some of those times?
 

RENA: Yeah. I took care of my brothers and sisters. And I was loyal to my friends.
 

COUNSELOR: How do you feel, as you talk about it?
 

RENA: A little better, I guess.
 

COUNSELOR: Because your voice sounds sad. You sound a bit tearful.
 

RENA: I’m more sad than scared right now. I’m so sad. I’m so sad for my children.
 

COUNSELOR: What is it that you feel sad for, about your children?
 

RENA: That I might leave them.
 

COUNSELOR: Do you recall when we talked about the difference between sadness and shame?
 

RENA: Yeah.
 

COUNSELOR: What do you remember about those conversations?
 

RENA: That I’ve felt so much shame in my life, and that when I feel shame I get really sad.
 

COUNSELOR: And do you remember some of the differences when we talked about your shame about the
 

abuse? We talked about feeling responsible.
 

RENA: Yeah, that really helped me.
 

COUNSELOR: What about that was helpful?
 

RENA: That when I feel shame, I feel like it’s my fault. And when I feel sad, it’s just that I feel sad about what
 

happened. That was helpful to me.
 

COUNSELOR: And do you recall when we talked about feeling responsible for the abuse and blaming yourself?
 

Then we connected this to your feeling that maybe you should die: that killing yourself was attached to feeling
 

responsible for something that I think we both agreed you weren’t responsible for.
 

RENA: Yeah. When I feel shame, I want to hurt myself.
 

COUNSELOR: Yes, and it sounds to me that this really is sadness. That this is sadness over something that
 

happened many years ago.
 

RENA: I feel really sad right now. I feel sad that I drank.
 

COUNSELOR: How sad? Say that again.
 

RENA: I feel sad that I drink. I feel sad for my children.
 

COUNSELOR: I think it’s important that you’ve recognized that, that you understand that this sadness is
 

about many different things, and it can feel a little bit overwhelming. Does it feel overwhelming to you?
 

RENA: The sadness doesn’t feel overwhelming; the sadness has been with me so long, it just feels natural, and
 

the scary thoughts feel overwhelming.
 

COUNSELOR: So, maybe, taking your hope box out and starting this process, kind of disrupts those thoughts a
 

bit and stops those thoughts. Would you agree?
 

Addressing Suicidal Thoughts and Behaviors in Substance Abuse Treatment 83 
Master Clinician Note: As mentioned above, the hope box provides the client 

with the opportunity to manage the suicidal crisis both independently and effectively. This is important because it facilitates self-efficacy and empowers the 

client. For many clients, this is the crux of recovery, moving toward independence and empowerment over their life, to have choices and options and not be 

limited by past traumatic events. The hope box also provides a tangible process 

to overcome feelings of shame and helplessness so often associated with suicidality. The personal nature of the hope box is most likely responsible for its 

potency. 

The hope box is one of many more advanced techniques that counselors can use 

to intervene with clients with suicidal thoughts and behaviors. Another 

advanced technique described in Rena’s vignette is the detailed safety plan. 

These techniques are somewhat more advanced than the other strategies 

described in this TIP, and extend somewhat beyond GATE, but are illustrated 

here for substance abuse counselors with advanced mental health training who 

wish to incorporate suicide-related treatment into their counseling portfolio. 

Describing additional intervention techniques is beyond the scope of this TIP. 

There are many excellent resources for clinicians (see Jobes, 2006; Rudd, 2006; 

Wenzel, Brown, & Beck, in press). 

RENA: Yeah.
 

COUNSELOR: Rena, could we go back to the hope box and your photograph of you and the girls for just a
 

minute? Can you look at the photograph again and tell me your reaction?
 

RENA: My girls are so sweet. They look happy.
 

COUNSELOR: And can you tell me about you right now, what’s happening with you?
 

RENA: I feel calmer. Not so sad. I love my girls. I don’t think I could kill myself and leave my girls alone.
 

Master Clinician Note: In many ways, children are a tangible marker of hope 

for clients. Children are the client’s life legacy. It is important for clients to recognize and understand the impact of suicidal behavior on their children, the vulnerability and risk it can create. Similarly, it is critical to emphasize that in 

their role as parent, they are protector and nurturer. This is true despite their 

own history of abuse and neglect. They can stop the cycle of abuse and provide 

for their children that which they wanted most: safety, protection, and love. 

COUNSELOR: Let’s talk for a minute, now that those thoughts have calmed down a little bit. Do you feel like 

you’re able to talk about some other things? Because I think maybe we need to take some steps to make sure 

that you’re safe. 

RENA: Yeah. 

84 Part 1, Chapter 2 
Master Clinician Note: The counselor has worked to establish connection and 

rapport with Rena and to assess the situation. His perception is that Rena is 

more grounded now than when she called, but he also is aware that she has 

been drinking and could rapidly lose her grounding when the telephone connection is ended. He therefore decides it would be best if Rena came to town to the 

emergency room for an evaluation and possible hospitalization. The counselor 

now begins to move from gathering information to taking action. 

COUNSELOR: I’m a little concerned, and I’ll tell you, to be real blunt with you, Rena, I’m very concerned that 

you’re alone, that you feel very sad and depressed, and you’ve been drinking a bit, and you have your pills 

available. And you’ve been having these thoughts about killing yourself, and I’m a little concerned about that, 

and I think we need to take some steps to make sure that you’re okay. 

RENA: It scares me to think I might do that. 

COUNSELOR: It scares me to think that you might do that, too. What do you think would be the best thing for
 

us to do at this point? Is there anyone around who could help?
 

RENA: No, Frank’s not here. I don’t know where the kids are. I think they’re just with their friends down the
 

road.
 

COUNSELOR: I think you told me earlier, and we had identified that your mother, in addition to Frank, was
 

someone that we could count on and talk to in case of emergency, in cases of a crisis. Is that still the case? Do
 

you still feel that your mother is somebody we can count on?
 

RENA: I haven’t talked to her today; I guess she’s at home.
 

COUNSELOR: Now, remind me, how close does your mother live to your house?
 

RENA: Just over the hill, maybe a quarter of a mile.
 

COUNSELOR: So, just a short distance away? How would you feel about my talking with your mother and having your mother come down and bring you in so that we can make sure that you’re safe?
 

RENA: I hate her knowing—I don’t think that I need to come in. I think I can do this by myself.
 

COUNSELOR: Can you help me understand your thinking about your ability to do this yourself? What is it
 

that makes you come to the conclusion that you can manage this one on your own?
 

RENA: I just don’t want to upset her.
 

Master Clinician Note: The counselor doesn’t want to pressure Rena unnecessarily; feeling this will just increase her resistance and perhaps invite Rena to 

become more anxious. Rather, he decides to explore the situation more until he 

feels Rena may be more open to coming into town. 

COUNSELOR: Sounds like a more— 

RENA: I’ve upset her enough. And I’ve been so proud of not drinkin’. And I don’t want to upset her. 

COUNSELOR: It sounds like you’re worried about you using your mom, somehow, and getting her upset. Do 

you remember when we looked at this issue about shame and sadness, and we said that when you are feeling 

shame, you have a tendency not to reach out, not to ask for help. Do you remember those conversations? 

Addressing Suicidal Thoughts and Behaviors in Substance Abuse Treatment 85 
Resources on Suicide Among American Indians

Several Web sites provide information on suicide specifically for American Indian populations:

• One Sky Center (http://www.oneskycenter.org) has the draft of a 100­page Guide to Suicide Prevention

on its Web site. The Guide includes a Community Assessment Tool and lists additional resources.

• The Suicide and Mental Health Association International (https://www.iasp.info/resources/

Groups_at_Risk/First_Nations/) Web site has readings and facts about suicide.

• Healing of Nations (http://www.healingofnations.org) devotes several pages of its Web site to suicide prevention and crisis intervention.

• The American Indian Health Council (http://www.indianhealth.com/human_services.htm) has a page on

suicide prevention.

• The Indian Health Service Web site has descriptions of programs, curricula, and other resources on suicide of particular relevance to American Indians (http://www.ihs.gov/suicideprevention/).

RENA: It’s never been easy for me to ask for help.

Master Clinician Note: “Shame­based” people often feel they don’t deserve

help. Arguing or debating with people about their self­worth and value is most

often futile. Rather, the counselor just chooses to address Rena as if she feels

worthy, even if she can’t experience that within herself.

COUNSELOR: And that’s why I’m so pleased that you called me, and that you actually used our plan. A part of

that plan was to have your mother available as well, and I think that this is one of those times when we need

your mother. Let’s not let the shame that’s there for many reasons, and isn’t accurate, block that and stop us

from reaching out when we need to reach out. Because I know in the past, your mother’s been willing to help,

and I really think that she’ll be willing to help now and won’t think of it as an inconvenience.

RENA: Would you not tell her why, would you not tell her I’ve been drinking?

COUNSELOR: Well, I think I’m going to have to tell her that you’ve been having some trouble. I’m not sure we

can get around that. It’s going to be apparent to your mom, and I know that in the past when we talked with

your mother about having her involved during crises, she was more than happy to help, and wanted to do

things that would help you recover.

RENA: I don’t think I could drive myself.

COUNSELOR: Well, I don’t think you could, either; I think we’re in agreement on that, and that’s why I think I

need to go ahead and give your mother a call. So, let me give her a call and have her drive you in.

RENA: Okay, try not to tell her that I’m drinking or that I’m thinking about killing myself.

Master Clinician Note: The most critical thing to remember about crisis phone

calls is to remain calm and patient throughout. A calm, patient, and persistent

orientation facilitates hope. You should always be oriented toward productive

solutions, with the most frequent solution simply being time. In all likelihood,

the longer the call continues, the more effectively the crisis will be diffused. The

crisis call is about effective regulation of emotions and problem solving. The call

provides the client with an opportunity to vent.

86 Part 1, Chapter 2
It is important not to argue with the client. If the client has not used the hope 

box, the crisis call is a chance to walk the client through the hope box. It is also 

critical to make sure that the client’s method for suicide has been removed. If 

the crisis continues unabated, having the client come in for an emergency session or go to the emergency room is advised. Contacting family members during 

an acute suicidal crisis is also important if initial efforts fail. In most States, it is 

permissible to violate confidentiality during a suicidal crisis. It is important to 

also consider having the patient sign crisis management consent forms early in 

the treatment process, allowing the clinician to contact specific family members 

if and when a suicidal crisis emerges. This proactive step is particularly important for those who have made multiple suicide attempts. In order to contact family members during a crisis, you need to have access to the appropriate phone 

numbers, and know which family members offer healthy, supportive relationships. This requires careful planning early in the treatment process. 

COUNSELOR: How about if I agree to tell her only what’s necessary to make sure that she knows how important it is to get you in so we can make sure you’re safe. Would that be agreeable? 

RENA: Tell her something like I’m having bad thoughts and I called you. 

COUNSELOR: I think we can manage telling her that you’re in a position where we’re worried about your safety and that she needs to come with you, accompany you and not leave you alone during this time. She was 

aware that that was a problem for you before. How does that sound to you? 

RENA: Okay. 

COUNSELOR: Okay. Well, let me walk through with you what I’m going to do, and make sure this is okay with 

you. I’d like to call your mother and ask her to bring you in. I’m going to give her a time limit: a deadline by 

which she needs to have you in town. I also will tell her I want her to give me a call when she gets to your 

house, before the two of you leave for town. Then, if you’re not here within an hour and a half, I’m going to 

have to go ahead and notify the police to come out and make sure that you’re safe. 

RENA: Oh, please don’t call the police. Frank would kill me. 

COUNSELOR: Well, at this point, I think that we just need to make sure that you’re okay. I don’t have any 

doubt that your mother’s going to go ahead and come on down and bring you in, but I just wanted to let you 

know that we need to have that happen within a certain time limit, just to make sure that everything’s okay 

and that you’re safe. 

RENA: I don’t mean that Frank would really kill me, just that he would be so angry with me. 

COUNSELOR: Well, my guess is, he’d want you to be safe as well. And this is one of those times. Do you think 

you can agree with that? 

RENA: I don’t want anybody mad at me. 

COUNSELOR: Well, let me tell you very clearly, Rena, not only am I not mad at you, I’m actually proud of you 

for the step that you’ve taken. This is one of those critical steps in your recovery about overcoming that feeling 

of shame and reaching out when you need help in order to maintain your recovery and sobriety. This is a step 

in that direction, and so that was one of our goals. So I’m really proud that you’ve reached the goal. 

RENA: What’s going to happen to me when I get to town with you? 

COUNSELOR: Well, we’re going to sit down and talk with someone else about where you are right now and 

maybe what the best response is. That may mean that you’ll be spending a little bit of time in the hospital to 

Addressing Suicidal Thoughts and Behaviors in Substance Abuse Treatment 87 
help you get to a place where you’re safer and you can return to outpatient care. Do you have some thoughts or 

questions about that? 

RENA: It scares me that I’m gonna have to go to the hospital. 

COUNSELOR: It can be a scary thought. But it also can be a good step for you. 

RENA: Okay. 

COUNSELOR: So, do we have an agreement? 

RENA: Mmm-hmm, yeah. 

COUNSELOR: Okay, well, I’m going to put you on hold on the phone for now and call your mother. I’ll let you 

know when I’ve talked to her and that she is on her way to your house. Are you willing to hold on the phone for 

now? It will be a few minutes. 

RENA: Okay. 

Followup 

Martin had Rena’s mother’s telephone number in her case record. He called her and she agreed to go immediately to Rena’s home to take her to the hospital emergency department. Rena’s mother telephoned when she 

arrived at Rena’s house. About an hour later, she telephoned Martin to confirm that they had reached the hospital. In the interim, Martin had called the hospital emergency admissions department to notify them that 

Rena would be arriving. He talked with the social worker to explain the situation and to arrange for the social 

worker to coordinate services with him. Had Martin not been able to contact Rena’s mother, he was prepared to 

telephone the county sheriff’s office to bring her to the hospital. 

Martin was careful to document all of the activity in Rena’s case record, including: 

•	 Providing suicide intervention by telephone. 

•	 Soliciting current risk factors (i.e., emotional pain, pills, drinking, being alone). 

•	 Reviewing previous learning and validating that the process is painful but also underscoring Rena’s 

progress. 

•	 Using the hope box technique to help Rena get grounded and reconnected to positive aspects of her life. 

•	 Eliciting agreement to involve her mother in taking her to the emergency room and providing support. 

•	 Following up with Rena’s mother and emergency room staff. 

88 Part 1, Chapter 2 
Part 2
 

Addressing Suicidal Thoughts 

and Behaviors:
 

An Implementation Guide for
 

Administrators
 

An Overview of Part 2

This guide for administrators has two chapters:

Chapter 1 surveys pertinent issues for administrators regarding how suicidal thoughts and behaviors can and

should be addressed in substance abuse treatment, including:

•	 The role of administrators and mid­level staff in providing care for clients with suicidal thoughts and

behaviors.

•	 Different levels of program involvement in addressing the needs of substance abuse clients with suicidal

thoughts and behaviors.

•	 Legal and ethical issues for consideration in managing and providing treatment to clients with suicidal

thoughts and behaviors.

Chapter 2 presents specific protocols, policies, and procedures useful in:

•	 Helping an agency become capable of handling suicide prevention and intervention.

•	 Helping a program develop and improve staff capabilities in working with clients who are suicidal.

•	 Helping an agency develop and improve its response to suicidal crises.

•	 Building administrative support for all components of GATE.

89

Chapter 1
 

The Administrative Response to
 

Suicidality in Substance Abuse 

Treatment Settings
 

Introduction

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 co­occurring 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 co­occurring mental health

problems (e.g., depression, posttraumatic stress disorder, and some personality disorders) and substanceinduced effects (e.g., symptoms in the context of drug

use, intoxication, or withdrawal), such as substanceinduced 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.

Addressing Suicidal Thoughts and Behaviors in Substance Abuse Treatment 91
PART

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.

Consensus Panel

Recommendations for

Administrators

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.

The Benefits of

Addressing Suicidality in

Substance Abuse

Treatment Programs

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.

92 Part 2, Chapter 1
     

•	 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

self­affirm 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.

Why Should

Administrators Be

Involved in a Clinical

Issue?

Suicide Is an Important

Programmatic Issue

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,

Addressing Suicidal Thoughts and Behaviors in Substance Abuse Treatment 93
   

PART

2

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 on­call 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.

Levels of Program

Involvement and Core

Program Components

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.

Level 1 Programs

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

94 Part 2, Chapter 1
   

   

undertaken to ensure appropriate followup of while concurrently addressing the treatment needs of

referrals and other actions. clients with active warning signs for suicidality.

•	 The substance abuse treatment program has for­ These efforts extend beyond Level 1 services and are

malized referral relationships with programs capa­ termed in this TIP as Level 2 programs.

ble 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,

free­standing 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 high­quality 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.

Level 2 Programs

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

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 co­occurring 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 as­needed basis.

Level 3 Programs

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 suicide­watch beds).

•	 Clinical staff can perform comprehensive suicide

assessments in­house that determine level of risk,

Addressing Suicidal Thoughts and Behaviors in Substance Abuse Treatment 95
           

PART

2

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.

Implementing a Level 1 or Level 2

Program

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:

1. Developing an overall policy regarding the program’s approach to addressing suicidality

2. 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

3. Establishing a system to monitor and evaluate

policies and procedures regarding suicidality and

to adapt these as needed.

4. 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.

1. Do you have a program policy statement about:

Acknowledgment of suicide as a significant risk

in your client population?

If no, establish a committee to write one.
 

If yes, is it fully understood by all staff?
 

Risk management for suicide and other highrisk behaviors (see sample policies in Part 2, 

chapter 2)?

If no, establish a work group to study the issue

and write one.

If yes, is it fully implemented with all staff?

Screening for suicide as part of the program’s routine protocol?

If no, develop or adapt screening questions in

this TIP or other knowledgeable sources, then

arrange training for all staff (support, counseling, substance abuse, and clinical supervisory).

If yes, do you have specific questions to explore

with clients with suicidal thoughts and behaviors? Has training been completed for all staff?

Is the training specific to each staff member’s

role? Is there a provision for clinical supervision or consultation?

Provision for services to be provided to suicidal

clients?

If no, read this TIP carefully, consult with

other community substance abuse and mental

health resources about their services, and

attend training or hire a trainer for your

agency.

If yes and services are provided by referral,

does your agency have formal agreements with

other agencies or individuals?

If yes and services are provided in­house, what

services are available? Who is responsible for

overseeing these services? Who is qualified to

provide them? Who monitors their use and

effectiveness? How do clients access them? Do

the policies include involvement of family members or significant others? Do the policies

include transportation to other care providers?

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?

Are there opportunities for all clinical staff to

have refresher or advanced courses emphasizing skills in working with clients with 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?

96 Part 2, Chapter 1
What documentation is necessary?

2. Are these policies implemented as written,

reviewed regularly, and revised as necessary?

If no, create a workgroup to explore the gaps in

implementation and review. Charge the group

with creating a plan to complete the implementation process and systematically review the

policies with an eye to making revisions as

needed. 

If yes, are the policies regarding the likelihood

of suicidal thoughts and behaviors, screening,

services, followup, and documentation fully

integrated into the program? Are they congruent with current staffing? Do they match the

current client population?

3. Are these policies and procedures monitored and

evaluated?

If no, establish a workgroup (or assign an individual) to devise a method for monitoring and

evaluation. Get buy­in from staff members to

make needed program improvements.

If yes, is there an individual or work group

assigned to monitor and evaluate them?

Monitoring should include the outcomes for all

positive screens for suicidal thoughts and

behaviors. How is the feedback from monitoring

and evaluation communicated to program staff

so that program improvements can be made?

4. Is there a critical incident review process?

If no, design and develop a process to review

events and recommend changes to existing policies and procedures.

If yes, is a critical event committee established

to collect data, evaluate them in light of existing policies and procedures, and recommend

changes to existing policies and procedures as

needed?

The Role of

Administrators in

Implementing and

Supporting Programming

for Clients With Suicidal

Thoughts and Behaviors

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 mid­level 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 follow­through 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

mid­level and direct­service 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

Addressing Suicidal Thoughts and Behaviors in Substance Abuse Treatment 97
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2

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.

The Role of Mid­Level

Staff in Implementing and

Supporting Programming

for Clients With Suicidal

Thoughts and Behaviors

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 “go­to” 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 mid­level 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 mid­level

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, mid­level 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.

Legal and Ethical Issues in

Addressing Suicidality in

Substance Abuse

Programs

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 administra98 Part 2, Chapter 1
tors, 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 clear­cut, 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.)

Legal Issues

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.

1.	 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.

2.	 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.

3.	 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 sig

Addressing Suicidal Thoughts and Behaviors in Substance Abuse Treatment 99
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2

nificant 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

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.

Implementing treatment and

referrals to reduce the potential

for suicide

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

100 Part 2, Chapter 1
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 at

risk of suicide

Maintaining safety for clients with suicidal thoughts

and behaviors means making reasonable efforts to

promote their immediate and long­term well­being.

Historically, suicide contracts (sometimes referred to

as “no­suicide” contracts) with clients have been used

by some clinicians to ensure safety. No­suicide contracts generally specify that clients will not do something that would put them at risk of harm or selfinjury. 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 once­a­week basis. At the other end of the continuum is a secure, locked, and staff­monitored psychiatric unit. In between are intensive outpatient care,

day (or evening) hospitalization, a half­way house

environment, and traditional substance abuse inpatient rehabilitation care.

Administrators can establish policies and procedures

to match the level on this continuum with the appli

Addressing Suicidal Thoughts and Behaviors in Substance Abuse Treatment 101
PART

2

cable 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 rope­like material

could be suspended).

Release of information and 

confidentiality Issues

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 timeframe 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 life­threatening manner. If this happens, refer to State and Federal regulations that

address this issue. Administrative staff or senior clin102 Part 2, Chapter 1
ical 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.

Ethical Issues

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

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.)

Informed consent

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

Addressing Suicidal Thoughts and Behaviors in Substance Abuse Treatment 103
PART

2

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 co­occurring 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.

Admission, transfer, and 

treatment termination

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 cooccurring 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.

104

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.

Additional training

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 follow­up

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

Part 2, Chapter 1
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 midlevel supervisory staff, for substance abuse counselors, and for other staff members.

Addressing Suicidal Thoughts and Behaviors in Substance Abuse Treatment 105

Chapter 2
 

Building a Suicide Prevention­ and
 

Intervention­Capable 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).

Community­based 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 high­risk 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 co­occurring 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 co­occurring mental disorders

who would otherwise have to be referred, thereby

Addressing Suicidal Thoughts and Behaviors in Substance Abuse Treatment 107
         

     

PART

2

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 co­occurring 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.

108

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, data­based, quality improvement­focused 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, self­disclosed 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 high­risk

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

Part 2, Chapter 2
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 day­to­day

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).

Addressing Suicidal Thoughts and Behaviors in Substance Abuse Treatment 109
PART

2

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 data­gathering is not a static, one­time 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 suicide­related 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.

110 Part 2, Chapter 2
       

   

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. Ill­timed

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 cooccurring 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 co­occurring 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 co­occurring 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

Sample Policy 1

Topic: Clinical staff training and competence

Policy Statement: All clinical staff will receive training in suicidality and its impact on substance abuse treatment

and can demonstrate basic competence in screening clients with substance use disorders for suicidal thoughts and

behaviors.

Procedures:

1. All clinical and support staff will participate in a 1­day training session covering suicidality and its impact on substance abuse treatment retention and outcomes, attitudes toward clients with suicidal thoughts and behaviors,

and intervention resources for clients who are suicidal.

2. The clinical supervisor of new employees will provide site­specific information on the procedures for screening

and referring individuals who are experiencing suicidal thoughts and behaviors.

3. Clinical competence checklists completed at hire and annually thereafter will ensure that all clinical staff members have a basic knowledge of the benefits of addressing suicidal symptoms, understanding protocols for

detecting client suicidality, and awareness of appropriate referral procedures.

Addressing Suicidal Thoughts and Behaviors in Substance Abuse Treatment 111
PART

2

Sample Policy 2

Topic: Screening and referral of clients with substance use disorders and suicidal thoughts and behaviors

Policy Statement: All clients will be screened for suicidality and will be monitored and/or referred as needed.

Procedures:

1. During the intake process, all clients will be screened for suicidal thoughts and behaviors using a standard protocol in which all counselors are trained.

2. Individuals demonstrating suicidal thoughts and behaviors will, after appropriate clinical supervision or consultation, be referred for assessment by a qualified mental health professional (QMHP) as needed.

3. All screening results, consultation sessions with the clinical supervisor, and referrals (and ongoing communications) to a QMHP will be documented in the client’s record.

4. The counselor providing services to clients with suicidal thoughts and behaviors will provide the client with an

emergency contact list that includes agency personnel, emergency mental health providers, and a suicide hotline. The client can refer to this list if his or her symptoms worsen outside business hours or when substance

abuse counselors are not available.

Sample Policy 3

Topic: Individual client observation in a residential facility

Policy Statement: Special procedures will be instituted for clients in crisis who require hourly monitoring.

Provisions will be made for observation and/or a treatment area for clients who are displaying a level of emotional

or psychological crisis and may need to be separated from their treatment unit for a period of time up to 48 hours.

Each transfer or observation must result in a psychological or psychiatric consult. An observation checklist will be

completed every hour during a client’s stay in observation. This is not designed to assess for suicidality, but to

identify symptoms that may require additional professional re­assessment.

Intent:

This policy is not designed to replace the policy for suicidal patients. This facility is not dually licensed as a psychiatric or mental health facility; therefore patients who have been assessed as being capable of carrying out suicidal

or homicidal ideation or intent will be transferred to an acute stabilization unit.

It is the intent of this policy to address the needs of crisis stabilization that do not meet the criteria for hospitalization or involuntary admission to an acute care hospital. Clients will receive the appropriate level of ongoing observation and treatment for their individual needs, such as the patient who is evaluated as not being a threat to himself or others yet manifests a level of emotional or psychological crisis. This process will allow clients to have a

quiet space to focus on their immediate stabilization and ensure that the treatment unit is not harmed by these 

crisis situations.

Procedure:

1. The client’s counselor, unit Clinical Coordinator, and/or the Executive Director are responsible for the initial

assessment and ongoing decision for observation of all clients, whether this occurs on the treatment unit or in

the Medical Unit.

2. During client crisis, a psychologist, psychiatrist, Masters­level counselor or a nurse will perform assessment and

re­assessment.

3. The Medical Unit, staffed with nurses and support staff is the first choice for crisis stabilization up to 48 hours.

Clients in the Medical Unit or observation area will remain on the census of their treatment unit.

• The Coordinator or Director of the treatment unit will call the charge nurse of the Medical Unit to make the

initial request for observation.

• The charge nurse will make every attempt to accommodate the request to observe the patient if there is a

bed available and the acuity of the rest of the clients allows staff to observe. (Other staff members may be

used if staffing is an issue.) The admissions schedule for the unit will be evaluated to assess bed availability.

112 Part 2, Chapter 2
•	 On approval, the client treatment unit staff will transport the client to the Medical Unit and provide a staff

member to remain on the unit for the duration of the observation and assist either the Medical Unit staff or

observe the client, depending on the needs of the Medical Unit and the client. The staff member may be

requested by the nurse to be present on the Medical Unit a number of hours or for the entire shift.

•	 It is preferred that the staff member accompanying the client has rapport with the client or clinical credentials

to assist the client in stabilization.

4. If the Medical Unit is unable to accept the client for observation, the following options exist. The Director or oncall coordinator will make the determination as to the next best option based on the individual case.

•	 The coordinator may use other units or programs in the agency. It is recommended that the client be moved

from his or her treatment unit to a safe and available dormitory area. The door alarms on either side of the

area should be set in order to monitor the client’s whereabouts during observation.

•	 Other available areas should be safe, with priorities for units with lower census, first floor rooms, genderseparate areas, quiet and comfortable, and those that do not interfere with the programs.

•	 To best use available staff in monitoring the client on an individual basis, staff should preferably be of the

same sex and have some existing rapport with the patient.

•	 Staff should be equipped with a communication device and have surrounding staff aware of the location of

the observation as well as the need to relieve or assist the observer if needed. Hourly communication is

required.

•	 Staff observing the patient are to be trained in both de­escalation of clients as well as the purpose and

process of observing. This training includes the use of an hourly checklist and protocol for contacting professional staff if needed.

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 cooccurring 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.

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 in­house,

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

Well­written 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.

Addressing Suicidal Thoughts and Behaviors in Substance Abuse Treatment 113
Checklist: Characteristics and Competencies of Clinical Supervisors

Attitudes

____ Clinical supervisors have the basic characteristics needed to provide services to treat clients with suicidal

thoughts and behaviors and to supervise others to manage such clients

____ Clinical supervision extends beyond talking about treatment to directly observing and coaching counselors

____ Awareness of compassion fatigue or vicarious trauma in counselors and when to facilitate help for counselors

experiencing these symptoms

Knowledge

Clinical supervisors need to have all of the training of frontline counselors. In addition, they need the following

knowledge specific to supervision:

____ The role of clinical supervision in substance abuse treatment

____ How to train frontline substance abuse counselors in screening of suicidal clients

____ When a client with suicidal thoughts and behaviors needs additional services beyond the qualifications of

substance abuse counselors

____ The role of transference and countertransference in the counseling and supervisory relationship

____ How to recognize resistance to change among clinical staff and strategies to address it

____ Change processes, process steps, and strategies for supporting them

Supervisory Skills

____ Articulates his or her approach and philosophy to clinical supervision as it relates to approaches described in

the literature

____ Identifies and responds to variations in learning styles among counselors

____ Is comfortable with and able to resolve conflict among team members

____ Models advanced counseling skills, including development of therapeutic alliance, termination, and managing

client resistance

____ Uses direct observation or taping to conduct supervisory sessions

____ Can teach and model skills in a variety of approaches to counseling that are applicable to substance abuse

clients with suicidal thoughts and behaviors

____ Can determine when referral to a QMHP for a suicide assessment is required

____ Facilitates referrals to QMHPs both within and outside the treating agency

____ Provides incentives through encouragement and support for counselors to enhance skills in treating clients

who are suicidal

____ Can assess counselor competence and develop professional learning plans and supervisory interventions

PART

2

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.

114

Rather than a one­time 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 full­day 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

Part 2, Chapter 2
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 high­risk

clients in the discussion.

•	 Have a brown­bag lunch with a senior staff member as trainer.

•	 Designate one senior counselor or clinical supervisor in a treatment unit to be the “go­to 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 1­hour 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 matter­of­fact, 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, re­experiences 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 non­crisis 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.

Addressing Suicidal Thoughts and Behaviors in Substance Abuse Treatment 115
PART

2

•	 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

Figure 1. Sample Commitment to Treatment Statement

I, __________________________, agree to make a commitment to the treatment process. I understand that this

means that I have agreed to be actively involved in all aspects of treatment, including:

1. Attending sessions (or letting my counselor know when I can’t make it).

2. Setting goals.

3. Voicing my opinions, thoughts, and feelings honestly and openly with my counselor (whether they are negative

or positive, but most importantly my negative feelings).

4. Being actively involved during sessions.

5. Completing homework assignments.

6. Taking my medications as prescribed.

7. Experimenting with new behaviors and new ways of doing things.

8. Implementing my crisis response plan when needed.

I also understand and acknowledge that, to a large degree, a successful treatment outcome depends on the

amount of energy and effort I make. If I feel that treatment is not working, I agree to discuss it with my counselor

and attempt to come to a common understanding as to what the problems are and identify potential solutions. In

short, I agree to make a commitment to living. This agreement will apply for the next 3 months, at which time it will

be reviewed and modified.

Signed _______________________________________________ Date _________________________________

Witness _____________________________________

Adapted from Rudd, 2006.

116 Part 2, Chapter 2
the statement helps promote engagement in treatment.

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 self­injury 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 co­occurring 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

Addressing Suicidal Thoughts and Behaviors in Substance Abuse Treatment 117
Figure 2. Gathering Information Regarding Suicidality

Check all that apply

Warning Signs Risk Factors Protective Factors

Direct warnings:

___ Suicidal communication

___ Seeking a method of suicide

___ Making preparations for suicide

Indirect warnings:

___ I= Ideation

___ S= Substance Abuse

___ P= Purposelessness

___ A= Anxiety

___ T= Trapped

___ H= Hopelessness

___ W= Withdrawal

___ A= Anger

___ R= Recklessness

___ M= Mood Changes

___ History of attempt

___ Family history of suicide

___ Mood disorder

___ Substance use disorder

___ Anxiety disorder

___ Psychotic disorder

___ Select personality disorder

___ Child abuse

___ Stressful life circumstances

___ Aggressive or impulsive

___ Avoidant or isolated

___ Rigid or inflexible

___ Firearm ownership or access

___ Minority sexual orientation

___ Chronic pain

___ Religious attendance

___ Internalized teachings against

suicide

___ Child in the home

___ Childrearing responsibilities

___ Intact marriage

___ Trusting relationship with a

provider

___ Treatment adherent

___ Employed

___ Trait optimism

___ Abstinent from substances

Summary: __________________________________________________________________________________

___________________________________________________________________________________________

____________________________________________________________________________________________

Plan: _______________________________________________________________________________________

___________________________________________________________________________________________

____________________________________________________________________________________________

Counselor signature:___________________________________Date:____________________________________

Counselor signature:___________________________________Date:____________________________________

PART

2

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, follow­up

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.

Clinical supervisors should make sure that all clinical

staff are aware of the policy and that the policy proce118

dures 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

Part 2, Chapter 2
counselors working with clients who are suicidal need Some of the common points might be:

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.

•	 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 24­Hour 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.

Addressing Suicidal Thoughts and Behaviors in Substance Abuse Treatment 119
  

  

  

PART

2

Figure 3. 24­Hour Suicide Assessment Tool

Assessment

Category No Monitoring Suicide Alert—Watch(Minimum 15 min.)

Level II—Observation

(Minimum 15 min.)

Level I—Precaution

(Constant

Observation—1:1)

• Suicidal ideation • Verbalizes no current • Verbalizes current • Verbalizes current • Verbalizes current

• Thoughts ideation suicidal ideation suicidal ideation suicidal ideation

• Plans • None to occasional • Frequent suicidal • Frequent suicidal • Frequent suicidal

• Method suicidal thoughts with

no plan

ideation

• Has no plan or vague

plan

• Method unavailable

or nonlethal

ideation

• Has specific plan

• Method unavailable

or available and nonlethal

ideation

• Specific plan and

available method

• Attempt within last 24

hours

Behavior cues • Adequate impulse • Inconsistent impulse • Unpredictable at • Impulsive and unpre­

• Impulse control control control times or inconsistent dictable behavior

• Behavioral • Consistent in behav­ • Some changes in impulse control • Sudden or abrupt

activity ior patterns usual behavior pat­ • Distinct changes in change in behavior

• Preparation for terns behavior patterns • Marked increase or

death (suicide decrease in

note, giving away behavior

belongings) • Death preparation

Mood or affect • Signs of mild • Signs of moderate • Signs of moderate • Severe depression

• Predominant depression depression depression • Indicators of helpmood or affect • Indicators of • Indicators of • Indicators of lessness and hope­

• Mood stability hopefulness helplessness helplessness and lessness

• Tolerance of • Mood stable • Some mood hopelessness • Calm resolution

feelings • Feelings tolerable fluctuations

• Some anxiety,

agitation•Feelings

periodically

distressing

• Labile mood

• Moderate anxiety

• Increased affective

distress

• Severe anxiety

• Unbearable psychological pain

Cognition/ • Problem solving • Limited problem • Poor problem solving • Unable to problem

Perception intact

• Accurate perception

of reality

solving

• Inconsistent or narrowed perception

• Impaired reality

testing

solve

• Psychotic with command hallucinations

• Sees no alternative

to suicide

1. The nurse will complete the Suicide Assessment Tool (SAT) when the client is admitted.

2. Results of the SAT will be communicated to the physician within 4 hours on determination of the level of suicide precaution

warranted.

3. The nurse will complete a new SAT at least every 24 hours for all suicide alerts.

• Suicide Alert—Watch: The nurse will document in progress notes once per shift the condition of the client. Designated

staff will do safety checks a minimum of every 15 minutes.

• Level II—Observation: The nurse will document in progress notes the condition of the client a minimum of every 4

hours. Designated staff will do safety checks a minimum of every 15 minutes.

• Level I—Precaution (constant observation, 1:1): The nurse will document in progress notes the client’s condition a minimum of every 2 hours. Designated staff assigned for constant observation.

4. The attending physician will review the results of the SAT level of monitoring determined every 24 hours.

5. The physician will order to continue or discontinue the monitoring precaution either in writing or

verbally.

_______________________________________  __________________________________

Nurse Signature Date

_______________________________________  __________________________________

Physician Signature Review Date

_______________________________________  __________________________________

Client Name Unit

120 Part 2, Chapter 2
     

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 re­emerge 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 senior­level staff member should

review the documentation for oversight and quality

assurance purposes.

Addressing Suicidal Thoughts and Behaviors in Substance Abuse Treatment 121
PART

2

Sample Policy 4

Topic: Criteria for and transfer to psychiatric facility

Policy Statement: Clients meeting the criteria for transfer to a psychiatric facility will be transferred either voluntarily or involuntarily.

Criteria for Transfer

Occasionally, clients of our treatment program have co­occurring psychiatric symptoms or conditions in addition to

their substance use disorder. There are occasions when clients who experience significant psychiatric symptoms

may require transfer to a psychiatric facility for evaluation or treatment.

Criteria for transfer include:

1. A clear and present danger to themselves or to others in the form of suicidality, homicidality, or the intent to

harm another

2. Significant psychotic behavior

3. Overt aggressive behavior endangering self or others

Process for Hospital Admission

Voluntary Admission

1. The patient is willing to sign voluntarily for admission to psychiatric facility.

2. The unit and/or on­call clinical supervisor, along with counseling staff, will determine the appropriate facility and

arrange for discharge from the agency and transportation to the facility.

Involuntary Commitment

Counseling staff working with a client who is suicidal or otherwise dangerous to him­ or herself or others will

review the client’s condition with the clinical coordinator or the Executive Director and then contact the on­call clinical supervisor who will initiate the following process. Medical staff will consult with the medical director or on­call

physician prior to initiating this process.

1. Contact the County Crisis Intervention Unit at [phone number] and inform them that we would like to admit the

patient as an involuntary hospital admission. A delegate will be assigned to assist with the involuntary process,

to interview the client, and to authorize the warrant for transportation.

2. The staff member who witnessed the suicidal behavior or heard the suicidal statements should be present to

offer that information to the delegate when they arrive.

3. After the delegate arrives and it is determined that the patient will need admission to a psychiatric facility, the

delegate will contact an ambulance for transportation of the patient and when appropriate, will assist them in

making those arrangements.

4. If the patient is physically unmanageable or dangerous, the police will be contacted to ensure the safety of the

client and to assist in the process.

Before all admissions to a psychiatric facility, the following must be completed:

1. Have available client demographics, including insurance information, and clinical information.

2. Notify parents of an adolescent or the emergency contact for an adult that a transfer to a psychiatric facility is

occurring.

122 Part 2, Chapter 2
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Appendix B:
 

Advisory Meeting Panel
 

Note: The information given indicates each participant's affiliation during the time the panel was convened and may no longer reflect the

individual's current affiliation.

H. Westley Clark, M.D., J.D., M.P.H., CAS, FASAM

Director

Center for Substance Abuse Treatment

Substance Abuse and Mental Health Services Administration

Rockville, Maryland

Mady Chalk, Ph.D.

Director

Division of Services Improvement

Center for Substance Abuse Treatment

Substance Abuse and Mental Health Services Administration

Rockville, Maryland

Christina Currier

Public Health Analyst 

Practice Improvement Branch 

Division of Services Improvement 

Center for Substance Abuse Treatment

Substance Abuse and Mental Health Services Administration

Rockville, Maryland

Michael T. Flaherty, Ph.D.

Northeast Addiction Technology Transfer Center

Institute for Research, Education and Training in Addictions

Pittsburgh, Pennsylvania

Kevin Hennessy, Ph.D.

Science to Service Coordinator

Substance Abuse and Mental Health Services Administration/OPPB

Rockville, Maryland

Constance M. Pechura, Ph.D.

Senior Program Officer

Robert Wood Johnson Foundation

Princeton, New Jersey

133
Richard A. Rawson, Ph.D. 

Pacific Southwest Addiction Technology 

Transfer Center 

Los Angeles, California 

Jack B. Stein, Ph.D. 

Acting Deputy Director 

Division of Epidemiology, Services, and 

Prevention Research 

National Institute on Drug Abuse 

National Institutes of Health 

Bethesda, Maryland 

Richard T. Suchinsky, M.D. 

Associate Chief for Addictive Disorders 

Mental Health and Behavioral Sciences 

Service 

U.S. Department of Veteran Affairs 

Washington, D.C. 

Karl D. White, Ed.D. 

Public Health Analyst 

Practice Improvement Branch 

Division of Services Improvement 

Center for Substance Abuse Treatment 

Substance Abuse and Mental Health 

Services Administration 

Rockville, Maryland 

Mark Willenbring, M.D. 

Director 

Division of Treatment and Recovery 

Research 

National Institute on Alcohol Abuse 

and Alcoholism 

National Institutes of Health 

Bethesda, Maryland 

134 Advisory Meeting Panel 
Appendix C—

Stakeholders Meeting

Participants

Note: The information given indicates each participant's affiliation during the time the meeting was convened and may no longer reflect the

individual's current affiliation.

Brenda Bruun

Special Assistant to the Director

Division of Prevention, Traumatic Stress and Special Programs

Center for Mental Health Services

Substance Abuse and Mental Health Services Administration 

Rockville, Maryland

Page Chiapella, Ph.D.

Division of Biometry and Epidemiology

National Institute on Alcohol Abuse and Alcoholism

Rockville, Maryland

H. Westley Clark, M.D., J.D., M.P.H., CAS, FASAM

Director

Center for Substance Abuse Treatment

Substance Abuse and Mental Health Services Administration

Rockville, Maryland

Kenneth R. Conner, Psy.D., M.P.H. (TIP Chair)

Associate Professor of Psychiatry 

University of Rochester Medical Center

Rochester, New York

Christina Currier

Government Project Officer

Knowledge Application Program

Center for Substance Abuse Treatment

Substance Abuse and Mental Health Services Administration 

Rockville, Maryland

135
Anne M. Herron, M.S.W. 

Director 

Division of State and Community Assistance 

Center for Substance Abuse Treatment 

Substance Abuse and Mental Health Services 

Administration 

Rockville, Maryland 

Larke Huang, Ph.D. 

Special Expert 

Office of the Administrator 

Substance Abuse and Mental Health Services 

Administration 

Rockville, Maryland 

Richard Kopanda, M.A.

Deputy Director

Center for Substance Abuse Treatment 

Substance Abuse and Mental Health Services 

Administration 

Rockville, Maryland 

Andrea Kopstein, Ph.D. 

Practice Improvement Branch Chief 

Division of Services Improvement 

Center for Substance Abuse Treatment 

Substance Abuse and Mental Health Services 

Administration 

Rockville, Maryland 

Charlene LeFauve, Ph.D. 

Co-Occurring and Homeless Activities Branch 

Chief 

Division of State and Community Assistance 

Center for Substance Abuse Treatment 

Substance Abuse and Mental Health Services 

Administration 

Rockville, Maryland 

Richard McKeon, Ph.D., M.P.H. 

Special Advisor Suicide Prevention 

Division of Prevention, Traumatic Stress and 

Special Programs 

Center for Mental Health Services 

Substance Abuse and Mental Health Services 

Administration 

Rockville, Maryland 

Cathy Nugent 

Public Health Advisor 

Division of Services Improvement 

Center for Substance Abuse Treatment 

Substance Abuse and Mental Health Services 

Administration 

Rockville, Maryland 

Lisa Onken, Ph.D. 

Associate Director 

Chief, Behavioral and Integrative Treatment 

Branch 

Division of Clinical Neuroscience and 

Behavioral Research 

National Institution on Drug Abuse 

Bethesda, Maryland 

Lisa Park, M.S.W. 

Public Health Analyst 

Office of the Administrator 

Office of Policy, Planning and Budget 

Substance Abuse and Mental Health Services 

Administration 

Rockville, Maryland 

Jane Pearson, Ph.D. 

Health Scientist Administrator 

National Institute of Mental Health 

Rockville, Maryland 

Jerry Reed, M.S.W. 

Executive Director 

Suicide Prevention Action Network USA 

(SPAN-USA) 

Washington, DC 

Beatrice Rouse, Ph.D. 

Team Leader 

Office of Applied Studies 

Substance Abuse and Mental Health Services 

Administration 

Rockville, Maryland 

Leslie J. Scallet, J.D. 

Principal 

Suicide Prevention Action Network 

Washington, DC 

136 Stakeholders Meeting Particpants 
Joel Sherrill, Ph.D. 

Chief, Psychosocial Treatment Research 

Program 

National Institute of Mental Health 

Rockville, Maryland 

Jack Stein, M.S.W., Ph.D. 

Director 

Division of Services Improvement 

Center for Substance Abuse Treatment 

Substance Abuse and Mental Health Services 

Administration 

Rockville, Maryland 

Shannon Taitt, MPA 

Public Health Analyst 

Center for Substance Abuse Treatment 

Substance Abuse and Mental Health Services 

Administration 

Rockville, Maryland 

Douglas Tipperman, M.S.W., LCSW-C 

Public Health Advisor 

Center for Substance Abuse Prevention 

Substance Abuse and Mental Health Services 

Administration 

Rockville, Maryland 

Ivette A. Torres, M.Ed. M.S. 

Associate Director of Consumer Affairs 

Center for Substance Abuse Treatment 

Substance Abuse and Mental Health Services 

Administration 

Rockville, Maryland 

Mark Weber 

Director 

Office of Communications 

Substance Abuse and Mental Health Services 

Administration 

Rockville, Maryland 

Stakeholders Meeting Particpants 137 

Appendix D:

Field Reviewers 

Note: The information given indicates each participant's affiliation during the time the review was conducted and may no longer reflect the

individual's current affiliation.

Lanny Berman, Ph.D.

Executive Director

American Association of Suicidology

Washington, D.C.

Yolanda Bogan, Ph.D.

Associate Professor

Florida A & M University

Tallahassee, Florida

Gary Forrest, Ph.D.

Private Practice

Colorado Springs, Colorado

Joyce Fowler, Ph.D.

Licensed Psychologist

Fowler Institute

Little Rock, Arkansas

Scarlett Harris, LCSW

Private Practice Social Worker

Adjunct Faculty, University of Arkansas at Little Rock

Little Rock, Arkansas

David C. Hill, Ph.D.

Professor and Licensed Psychologist

Millersville University of Pennsylvania

Millersville, Pennsylvania

139
Denise A. Horton, Ph.D., LPC, CEAP

Alcohol/Drug Control Officer/Employee

Assistance

Professional Army Substance Abuse Program

Fort Dix, New Jersey

Thomas Joiner, Ph.D.

Distinguished Research Professor of

Psychology

Florida State University

Tallahassee, Florida

Charlene Le Fauve

Branch Chief, Co­Occurring and Homeless

Activities Branch

Center for Substance Abuse Treatment

Substance Abuse and Mental Health Services

Administration

Rockville, Maryland

Pamela Mattel, LCSW­R, CASAC

Deputy Executive Director

Basics, Inc.

New York, New York

Mary Ellen McAlevey, M.A., LPC, ATRBC

Art Therapist

Temada Associates

Toms River, New Jersey

Richard McKeon, Ph.D., M.P.H.

Special Advisor Suicide Prevention

Center for Mental Health Services

Substance Abuse and Mental Health Services

Administration

Rockville, Maryland

Hunter L. McQuistion, M.D.

Director, Division of Integrated Psychiatric

Services, Department of Psychiatry

The St. Luke’s–Roosevelt Hospitals

New York, New York

Sherry Davis Molock, Ph.D.

Associate Professor

George Washington University

Washington, D.C.

Richard K. Ries, M.D.

Professor of Psychiatry

University of Washington School of Medicine

Seattle, Washington

Stephen Roggenbaum, M.A.

Assistant in Research

Louis de la Parte Florida Mental Health

Institute

University of South Florida

Tampa, Florida

Bette Ann Weinstein, Ph.D., LCSW

Private Practice

Delray Beach, Florida

Amy Wenzel, Ph.D.

Research Assistant Professor

University of Pennsylvania

Philadelphia, Pennsylvania

Michael Wolf­Branigin, M.S.W., Ph.D.

Associate Professor

George Mason University

Arlington, Virginia

Harry Zerler, M.A., LCADC, MAC

Psychotherapist 

Emergency Services, Hunterdon Medical

Center

Hackettstown, New Jersey

140 Field Reviewers
Appendix E—Acknowledgments 


Numerous people contributed to the development of this TIP, including the TIP Consensus 

Panel (see page v), the Knowledge Application Program (KAP) Advisory Meeting Panel (see 

Appendix B), the Stakeholders Meeting Participants (see Appendix C), and TIP Field Reviewers 

(see Appendix D). 

This publication was produced under KAP, a Joint Venture of The CDM Group, Inc. (CDM), 

and JBS International, Inc. (JBS), for the Substance Abuse and Mental Health Services 

Administration, Center for Substance Abuse Treatment. 

CDM KAP personnel included Rose M. Urban, M.S.W., J.D., LCSW, LCAS, KAP Executive 

Deputy Project Director; Susan Kimner, KAP Managing Project Co-Director; Jessica Culotta, 

M.A., Managing Editor; Bruce Carruth, Ph.D., Expert Content Director; Janet Humphrey, M.A., 

former Editor; Sheldon R. Weinberg, Ph.D., Senior Researcher/Applied Psychologist; Jonathan 

Gilbert, Ph.D., Writer/Editor; Virgie D. Paul, M.L.S., Librarian; Maggie Nelson, KAP Project 

Coordinator; Marion Munford, KAP Project Assistant; Lee Ann Knapp, Quality Assurance 

Editor. 

Special thanks go to Caron Treatment Centers for their contributions to this TIP. 

141 

Index
 

A

Accessing supervision and/or consultation element of 

GATE
 

administrative support for, 118–119
 

Clayton vignette, 39, 41
 

consultation process, 18
 

description, 15
 

immediate consultation, 18–19
 

Leon vignette, 59
 

overview, 15
 

regularly scheduled consultation, 19
 

Rob vignette, 66
 

summary, 19–20
 

Vince vignette, 71, 76
 

Addiction Severity Index, 17
 

Addiction Technology Transfer Centers training
 

materials, 105
 

Administrative response to suicidality adapting existing policies and programs, 111
 

administrative leadership attributes, 97
 

benefits of addressing suicidality, 92–93
 

building a suicide prevention- and intervention-


capable agency, 107–122 

competencies for working with clients, 25–31, 

104–105
 

Consensus Panel recommendations, 92
 

criteria for and transfer to psychiatric facility
 

sample policy, 122
 

developing and improving program capabilities,
 

113–115
 

developing and improving the agency’s response
 

to suicidal crises, 115–117
 

effects of suicidality on the program, 108–110
 

ethical issues, 98–99, 103–105
 

GATE procedure role, 101
 

impact of suicidal clients on program staffing,
 

109
 

implementing and integrating new programmatic
 

elements, 111–113
 

importance of suicide as a programmatic issue,
 

93–94
 

leadership role in implementing and supporting
 

programming for suicidal clients, 97–98
 

legal issues, 98–103
 

level 1 programs, 94–95, 96–97, 108
 

level 2 programs, 95, 96–97, 107–108, 110–111
 

level 3 programs, 95–96
 

mid-level staff role, 98
 

on-call system for senior staff, 94
 

organizational assessment, 108–111
 

organizational culture and, 109
 

organizational planning for becoming a level 2
 

program, 110–111
 

organizational response to clients with suicidal
 

thoughts and behaviors, 109
 

other programs as sources of information,
 

109–110 

program implementation, 111–113 

reasons for administrators to be involved in a 

clinical issue, 93–94
 

sample policies, 111–113, 122
 

targets for clients with suicidal thoughts and
 

behaviors, 110–111
 

variety of treatment programs and client needs
 

and levels of risk and, 107
 

written policies and implementation plans, 113
 

Adolescents and young people
 

suicide risk, 13
 

African Americans
 

suicide risk, 13, 56, 57, 59
 

After an Attempt: A Guide for Taking Care of Your
 

Family Member After Treatment in the Emergency
 

Department, 54
 

Age factors
 

suicide risk, 13, 57
 

Alaska Natives. See Native Americans/Alaska
 

Natives
 

Alcohol use and abuse
 

suicide and, 9
 

American Association of Suicidology
 

resources for families, 54
 

American Counseling Association
 

ethical standards, 99
 

American Foundation for Suicide Prevention
 

resources for families, 54
 

American Indian Health Council
 

suicide prevention Web site, 86
 

American Indians. See Native Americans/Alaska
 

Natives
 

American Psychiatric Association
 

ethical standards, 99
 

American Psychological Association
 

ethical standards, 99
 

Addressing Suicidal Thoughts and Behaviors in Substance Abuse Treatment 143
Angela vignette
 

co-occurring mental health problems, 46–47
 

counselor and Angela’s brother, 48–55
 

counselor/client dialogue, 47–55
 

followup, 55
 

learning objectives, 47
 

meeting between Angela’s counselor and her clinical supervisor, 47–48
 

overview, 33, 46–47
 

substance abuse history, 47
 

suicide-related history, 47
 

Assessing and Managing Suicidal Risk: Core
 

Competencies for mental Health Professionals, 25
 

“Assessing Suicide Risk: Initial Tips for Counselors”
 

card, 17, 100
 

The Assessment and Management of Suicidality, 25
 

Association for Addiction Professionals
 

ethical standards, 99
 

ATTCs. See Addiction Technology Transfer Centers
 

B

Background information
 

age factors, 13
 

gender factors, 13
 

link between substance abuse and suicidality,
 

9–10
 

protective factors, 12–13
 

race and ethnicity and, 13
 

reasons for suicidal behavior, 14
 

risk factors, 12
 

suicide compared with suicide attempt, 13
 

transition points in care and risk of suicide, 10
 

types of suicidal thoughts and behaviors, 10–11
 

Beck Depression Inventory, 17
 

C

Campus suicide prevention teams
 

developing, 62
 

CARF. See Commission on Accreditation of
 

Rehabilitation Facilities
 

Case management
 

Clayton vignette and, 35
 

Clayton vignette
 

avoidance of grilling the client and, 36, 38
 

consultation with a supervisor, 39, 41
 

counselor/client dialogue, 35–46
 

direct questions about suicidality, 36, 38
 

followup, 46
 

learning objectives, 34–35
 

overview, 33, 34
 

substance abuse history, 34
 

suicidal crisis example, 115
 

suicide-related history, 34
 

Commission on Accreditation of Rehabilitation
 

Facilities
 

standards of care for clients at risk of suicide, 99
 

Commitment to Treatment agreements
 

description, 22, 101
 

having both the client and the counselor sign,
 

116–117 

sample agreement, 116
 

Community treatment options, 49
 

Competencies for working with clients. See also
 

Training issues
 

checklist, 114
 

Consensus Panel recommendations, 25–31
 

ethical issues, 25–31, 104–105
 

Confidentiality
 

informing clients about, 5
 

legal issues, 102–103
 

limitations of, 5–6, 45, 87, 102–103
 

Consensus Panel recommendations for administrators, 92
 

asking directly about suicidality, 4, 7, 36, 38
 

competencies for working with clients, 25–31
 

confidentiality issues, 5–6, 45
 

emergency release of information documents, 102
 

GATE procedures, 14–18, 91, 117–122
 

general recommendations, 4
 

getting good clinical supervision and consultation, 5, 39, 41, 47–48, 59, 66, 71, 76
 

increasing your knowledge about suicidality, 4
 

level 1 programs, 95
 

level 3 programs, 95
 

practicing with another counselor or clinical
 

supervisor, 5
 

using your therapeutic skills, 5
 

working collaboratively with suicidal clients, 5
 

“Crisis Management: A Guide for Substance Abuse
 

Counselors,” 115
 

Cultural effects
 

help-seeking behavior, 77
 

as a protective factor, 12–13
 

D

Depression
 

co-occurrence with suicidality, 7, 9
 

screening measures, 17
 

Documentation
 

administrative support for, 121
 

Clayton vignette, 46
 

elements of, 23–24
 

144 Index 
examples, 24–25
 

importance of, 23, 121
 

legal issues, 100
 

Leon vignette, 62–63
 

Rena vignette, 88
 

Rob vignette, 66
 

Vince vignette, 76
 

E

Emergency evaluation referrals, 22, 71, 74, 76
 

Enhancing Motivation for Change in Substance Abuse
 

Treatment, 73
 

Ethical issues 

administrators and, 98–99, 103–105 

admission, transfer, and treatment termination, 

104
 

compared with legal issues, 103
 

competencies for working with clients, 25–31,
 

104–105
 

description, 99
 

informed consent, 103–104
 

malpractice, 103
 

professional groups and, 103
 

training for counselors in suicidality, 104–105
 

Ethnic factors. See Racial and ethnic factors 

Extend the action(s) element of GATE
 

administrative support for, 121
 

list of possible actions, 23
 

monitoring clients, 15
 

overview, 15
 

summary, 23
 

F

Families 

common responses to a family member’s suicidal 

thoughts or attempts, 53, 54
 

counseling for, 53
 

family anger and understanding of clients’ illness, 51
 

helpful actions, 53
 

knowledge of the warning signs of suicide, 50
 

resources for family members and friends, 54
 

working with the family of a client who is suicidal, 45
 

Followup
 

administrative support for, 121
 

Angela vignette, 55
 

Clayton vignette, 46
 

followup questions, 17–18, 100
 

Leon vignette, 62–63
 

Rena vignette, 88
 

Rob vignette, 66
 

Vince vignette, 76
 

G

GATE procedures. See also specific elements
 

administrators’ role, 101, 117–122
 

Angela vignette, 46–55
 

Clayton vignette, 34–46
 

decision tree (figure), 16
 

detailed explanation, 15–18
 

documenting all actions, 15, 23–25
 

Leon vignette, 55–63
 

overview, 14–15, 91
 

Rena vignette, 77–88
 

Rob vignette, 63–66
 

suicide assessment component, 117
 

treatment of suicidal state component, 117
 

Vince vignette, 67–76
 

Gather information element of GATE
 

administrative support for, 117–118
 

checklist for, 118
 

followup questions, 17–18, 100
 

open-ended questions, 18, 35
 

overview, 14–15
 

screening measures, 17
 

screening questions, 15–17, 37, 100
 

“stacking” questions and, 15
 

summary, 18
 

Gathering of Native Americans curriculum, 78
 

Gender factors
 

suicide risk, 13, 57, 59
 

H

Hamilton Depression Rating Scale, 17
 

Healing of Nations
 

suicide prevention Web site, 86
 

Hispanics/Latinos
 

suicide risk, 13
 

Homelessness
 

housing options, 49
 

Homicide
 

risk factors, 67
 

Hope boxes
 

setting up a hope box, 80–81
 

uses for, 84
 

Hotlines
 

national suicide hotline, 9, 22, 52, 53
 

Housing options, 49
 

Addressing Suicidal Thoughts and Behaviors in Substance Abuse Treatment 145
I

IHS. See Indian Health Service 

Improving Cultural Competence in Substance Abuse 

Treatment, 13 

Indian Health Service 

Community Suicide Prevention initiative, 77–78 

suicide prevention Web site, 86 

Informed consent 

description, 5 

ethical issues, 103–104 

legal issues, 102 

Internet 

training materials and courses, 105 

J

JCAHO. See Joint Commission on Accreditation of 

Healthcare Organizations 

Joint Commission on Accreditation of Healthcare 

Organizations 

standards of care for clients at risk of suicide, 99 

L

Legal issues 

administrators and, 98–103 

compared with ethical issues, 103 

confidentiality issues, 102–103 

description, 99 

documentation, 100 

duty to warn when a client is at risk of harming 

another person, 103 

foreseeability, 100 

implementing treatment and referrals to reduce 

the potential for suicide, 100–101 

informed consent, 102 

levels of treatment and, 101–102 

liability, 100 

maintaining safety for clients, 101–102 

malpractice “failures” for work with suicidal 

clients, 99–100 

professional liability, 100 

reasonable standard of care, 99 

reducing liability in inpatient settings, 102 

reducing liability in outpatient settings, 102 

release of information, 102–103 

Leon vignette 

consultation with a supervisor, 59 

counselor/client dialogue, 56–62 

followup, 62–63 

learning goals, 56 

minimization of suicidality by client, 56 

overview, 34, 55 

substance abuse history, 56
 

suicide-related history, 56
 

Lethality of method 

description, 13 

Level 1 programs 

characteristics of, 94–95, 108 

implementation strategies, 96–97 

Level 2 programs 

benefits of, 107–108 

characteristics of, 95 

implementation strategies, 96–97 

organizational planning for becoming, 110–111 

Level 3 programs 

characteristics of, 95–96 

limited need for, 96 

M

Managing Depressive Symptoms in Substance Abuse 

Clients During Early Recovery, 110 

Men. See Gender factors 

Mental health issues 

co-occurrence with suicidality, 3, 7, 9, 12, 46–63, 

91 

MI. See Motivational interviewing 

Mid-level staff. See also Administrative response to 

suicidality; Substance abuse counselors role in 

implementing and supporting programming, 98 

Motivational interviewing 

skills training, 114–115 

Vince vignette and, 73 

N

National Association of Social Workers 

ethical standards, 99 

National Organization for People of Color Against 

Suicide 

resources for families, 54 

National Suicide Prevention Lifeline 

After an Attempt: A Guide for Taking Care of 

Your Family Member After Treatment in the 

Emergency Department, 54 

“Assessing Suicide Risk: Initial Tips for 

Counselors” card, 17, 100 

suicide hotline, 9, 22, 52, 53 

Native Americans/Alaska Natives 

Rena vignette, 77–88 

resources on suicide among, 86 

suicide risk, 13, 77–78 

Non-suicidal self-injury 

description, 11 

NSSI. See Non-suicidal self-injury 

146 Index 
O

Older persons
 

suicide risk, 13
 

One Sky Center
 

suicide prevention Web site, 86
 

P

Positive attitudes towards clients
 

addressing suicidality as a priority issue, 8
 

giving clients a suicide hotline number, 9
 

indirect warning signs, 8
 

need for additional services for clients, 8
 

routine screening for suicidal thoughts and
 

behaviors, 8
 

talking about a client’s past suicidal behavior,
 

8–9
 

Posttraumatic stress disorder
 

Leon vignette, 55–63
 

Practice Guidelines and Resources for the Assessment
 

and Treatment of Patients with Suicidal
 

Behaviors, 25
 

Protective factors
 

cautions about, 12
 

cultural values and, 12–13
 

description, 12, 68
 

list of, 12
 

PTSD. See Posttraumatic stress disorder 

R

Racial and ethnic factors
 

suicide risk, 13, 56, 57, 59
 

Referrals
 

clients who are ambivalent or resistant to treatment and, 22, 68, 70
 

for emergency evaluation, 22, 71, 74, 76
 

sample policy, 112
 

Relapse planning
 

incorporating suicide prevention in, 52
 

Rena vignette
 

advanced skills of counselors and, 113
 

counselor/client dialogue, 78–88
 

followup, 88
 

hope box and, 81, 84
 

overview, 34, 77
 

substance abuse history, 77
 

suicidal crisis example, 115
 

suicide and American Indian/Alaska Native populations, 77–78
 

suicide-related history, 77
 

Resources
 

for family members and friends, 54
 

on suicide among Native Americans/Alaska
 

Natives, 86
 

Risk factors. See also Warning signs of suicide; specific factors
 

administrators’ responsibilities, 101
 

discharge from treatment programs and, 53
 

homicide/suicide, 67
 

list of, 12
 

Rob vignette
 

counselor/client dialogue, 63–66
 

counselor’s consultation with a supervisor, 66
 

counselor’s style, 63
 

followup, 66
 

learning objectives, 63
 

overview, 34, 63
 

substance abuse history, 63
 

suicide-related history, 63
 

S

Safety cards and safety plans
 

coping strategies section, 79
 

description, 21, 117
 

elements of a safety plan, 78–79
 

helping a client develop a detailed safety plan,
 

78–79
 

Rena vignette, 84
 

telephone numbers of friends and family, 79
 

telephone numbers of professionals, 79
 

warning signs list, 79
 

Safety plans. See Safety cards and safety plans
 

Screening
 

sample policy, 112
 

Screening questions
 

list, 15–17, 37, 100
 

Self-destructive behaviors
 

description, 11
 

SPRC. See Suicide Prevention Resource Center
 

States
 

ethical standards, 99
 

release of information and, 102
 

Substance abuse counselors. See also Administrative 

response to suicidality; Mid-level staff; specific 

vignettes 

appropriateness of training for suicide prevention, 3–4
 

“Assessing Suicide Risk: Initial Tips for
 

Counselors” card, 17, 100
 

awareness of community treatment and housing
 

options, 49
 

Addressing Suicidal Thoughts and Behaviors in Substance Abuse Treatment 147
introductory comments examples, 69 

maintaining positive attitudes towards clients 

experiencing suicidal thoughts and behaviors, 

7–9 

policy for handling suicidal crises, 40
 

primary responsibilities, 100–101
 

supervisors’ liaisons with, 98
 

working with the family of a client who is suicidal, 45
 

Substance Abuse Treatment for People Who Are
 

Homeless, 49
 

Substance Abuse Treatment for Persons With Co-


Occurring Disorders, 17
 

Substance Abuse Treatment With American Indians
 

and Alaska Natives, 78
 

Suicidal ideation
 

description, 10
 

Suicidal intention
 

description, 10
 

Suicidal thoughts and behaviors
 

non-suicidal self-injury, 11
 

self-destructive behaviors, 11
 

suicidal behaviors, 10
 

suicidal intention, 10
 

suicidal preparation, 10–11
 

suicidal thoughts, 10
 

warning signs for suicide, 7, 8, 11–12
 

Suicidality
 

achieving abstinence and, 6–7
 

administrative response to, 91–105
 

ambivalence about, 6
 

asking directly about, 4, 7, 36, 38
 

benefits of proactively addressing, 93
 

effects on children of clients, 84
 

inpatient treatment, 22
 

long-term monitoring and, 6
 

myths and misconceptions about, 92–93
 

outcomes and, 7
 

reasons for, 14
 

risk assessment and, 6
 

suicide contracts and, 6
 

taking attempts seriously, 7
 

transient nature of, 6
 

warning signs, 7, 50
 

Suicide 

as cause of death for people who abuse alcohol or 

drugs, 3, 9, 91
 

description, 10
 

elevated risk for persons in substance abuse
 

treatment, 3
 

mental health problems and, 3
 

Suicide and Mental Health Association International
 

suicide prevention Web site, 86
 

Suicide attempts
 

compared with completed suicide, 13
 

description, 10
 

Suicide contracts
 

legal liability and, 6, 101
 

usefulness of, 6, 22, 101
 

Suicide crises 

Commitment to Treatment agreements, 116–117 

developing and improving the agency’s response 

to, 115–117
 

policy components, 115–116
 

postvention for staff, 117
 

safety cards and, 117
 

vignette examples, 115
 

Suicide plans
 

description, 10
 

Suicide preparation
 

description, 10–11
 

Suicide Prevention Resource Center
 

guidelines for programs, 110
 

resources for families, 54
 

training materials, 105
 

Supervisors. See also Access supervision and/or consultation element of GATE
 

liaisons with substance abuse counselors, 98
 

responsibilities, 98
 

role in responding to clients’ suicidal thoughts
 

and behaviors, 98
 

tasks in extending care, 121
 

T

Take responsible action(s) element of GATE
 

actions that “make good sense,” 15, 20
 

administrative support for, 119, 121
 

advanced skills safety plans, 22, 78–79, 113
 

Commitment to Treatment agreements, 22, 101,
 

116
 

continuum of intensiveness, 20–23
 

immediate actions, 20
 

inpatient treatment for suicidality, 22
 

levels of care, 119
 

list of possible actions, 21
 

non-immediate actions, 20
 

number of individuals involved and, 20–21
 

overview, 15
 

referrals for emergency evaluation, 22, 71, 74, 76
 

referring clients who are ambivalent about treatment or resistant to treatment, 22, 68, 70
 

safety cards and safety plans (exhibit), 21
 

148 Index 
“seriousness” definition, 20
 

suicide contracts, 22
 

summary, 22–23
 

24-Hour Suicide Assessment Tool, 119
 

Telephone interviews 

crisis telephone calls, 86–87 

Rena vignette, 77–88 

Telephone numbers
 

national suicide hotline, 9, 22, 52, 53
 

safety plans and, 79
 

Training issues. See also Competencies for working 

with clients
 

ethical issues, 104–105
 

sample policy, 111
 

substance abuse counselors, 3–4
 

Trauma symptoms 

Leon vignette, 55–63 

Rena vignette, 77–88 

24-Hour Suicide Assessment Tool, 119, 120
 

V
 

Vignettes 

Angela, 33, 46–55 

Clayton, 33, 34–46 

Leon, 34, 55–63 

Rena, 34, 77–88 

Rob, 34, 63–66 

Vince, 34, 67–76 

Vince vignette
 

advanced skills of counselors and, 113
 

counselor/client dialogue, 68–76
 

counselor’s consultation with a supervisor, 71, 76
 

followup, 76
 

homicide/suicide and, 67
 

introductory comments examples, 69
 

learning objectives, 68
 

overview, 34, 67
 

substance abuse history, 67–68
 

suicidal crisis example, 115
 

suicide-related history, 68
 

W

Warning signs of suicide. See also Risk factors
 

administrators’ responsibilities, 101
 

direct signs, 11
 

family members and, 50
 

forms of, 7, 50
 

indirect, 8, 11–12
 

IS PATH WARM mnemonic, 11, 17
 

stressful life events and, 11, 12, 50
 

Weapons 

Clayton vignette and, 34, 35, 42
 

legal responsibility for removal of, 101
 

Vince vignette and, 67
 

Web sites
 

suicide prevention, 86
 

Whites
 

suicide risk, 13
 

Women. See Gender factors
 

Addressing Suicidal Thoughts and Behaviors in Substance Abuse Treatment 149

                               

                               

                             

                           

             

             

             

SAMHSA TIPs and Publications Based on TIPs

What Is a TIP?

Treatment Improvement Protocols (TIPs) are the products of a systematic and innovative process that brings together clinicians, researchers,

program managers, policymakers, and other Federal and non­Federal experts to reach consensus on state­of­the­art treatment practices. TIPs

are developed under the Substance Abuse and Mental Health Services Administration’s (SAMHSA’s) Knowledge Application Program (KAP)

to improve the treatment capabilities of the Nation’s alcohol and drug abuse treatment service system.

What Is a Quick Guide?

A Quick Guide clearly and concisely presents the primary information from a TIP in a pocket­sized booklet. Each Quick Guide is

divided into sections to help readers quickly locate relevant material. Some contain glossaries of terms or lists of resources. Page

numbers from the original TIP are referenced so providers can refer back to the source document for more information.

What Are KAP Keys?

Also based on TIPs, KAP Keys are handy, durable tools. Keys may include assessment or screening in­struments, checklists, and

summaries of treatment phases. Printed on coated paper, each KAP Keys set is fastened together with a key ring and can be kept

within a treatment provider’s reach and consulted fre­quently. The Keys allow you, the busy clinician or program administrator, to

locate information easily and to use this information to enhance treatment services.

Ordering Information

Publications may be ordered or downloaded for free at http://store.samhsa.gov. To order over the phone, please call 

1­877­SAMHSA­7 (1­877­726­4727) (English and Español).

TIP 1    State Methadone Treatment Guidelines—Replaced by TIP 13  Role and Current Status of Patient Placement

TIP 43 Criteria in the Treatment of Substance Use

Disorders

TIP 2    Pregnant, Substance­Using Women—Replaced by Quick Guide for Clinicians  TIP 51

                Quick Guide for Administrators 

TIP 3    Screening and Assessment of Alcohol­ and Other                 KAP Keys for Clinicians

Drug­Abusing Adolescents—Replaced by TIP 31

TIP 14  Developing State Outcomes Monitoring Systems for

TIP 4    Guidelines for the Treatment of Alcohol­ and Other Alcohol and Other Drug Abuse Treatment

Drug­Abusing Adolescents—Replaced by TIP 32

TIP 15  Treatment for HIV­Infected Alcohol and Other Drug

TIP 5    Improving Treatment for Drug­Exposed Infants Abusers—Replaced by TIP 37

TIP 6    Screening for Infectious Diseases Among Substance TIP 16  Alcohol and Other Drug Screening of Hospitalized

Abusers—Archived Trauma Patients 

Quick Guide for Clinicians  TIP 7    Screening and Assessment for Alcohol and Other                 KAP Keys for Clinicians  Drug Abuse Among Adults in the Criminal Justice
 

System—Replaced by TIP 44
 TIP 17  Planning for Alcohol and Other Drug Abuse

Treatment for Adults in the Criminal Justice TIP 8    Intensive Outpatient Treatment for Alcohol and System—Replaced by TIP 44 Other Drug Abuse—Replaced by TIPs 46 and 47

TIP 18  The Tuberculosis Epidemic: Legal and Ethical Issues

TIP 9    Assessment and Treatment of Patients With for Alcohol and Other Drug Abuse Treatment

Coexisting Mental Illness and Alcohol and Other Providers—Archived

Drug Abuse—Replaced by TIP 42

TIP 19  Detoxification From Alcohol and Other Drugs—

TIP 10  Assessment and Treatment of Cocaine­ Abusing Replaced by TIP 45

Methadone­Maintained Patients—Replaced by TIP 43

TIP 20  Matching Treatment to Patient Needs in Opioid

TIP 11  Simple Screening Instruments for Outreach for Substitution Therapy—Replaced by TIP 43

Alcohol and Other Drug Abuse and Infectious

Diseases—Replaced by TIP 53	 TIP 21  Combining Alcohol and Other Drug Abuse

Treatment With Diversion for Juveniles in the

TIP 12  Combining Substance Abuse Treatment With Justice System 

Intermediate Sanctions for Adults in the Criminal Quick Guide for Clinicians and Administrators  Justice System—Replaced by TIP 44

151
             

             

             

             

             

             

             

             

             

             

             

             

             

             

             

             

             

             

TIP 22  LAAM in the Treatment of Opiate Addiction—

Replaced by TIP 43

TIP 23  Treatment Drug Courts: Integrating Substance Abuse

Treatment With Legal Case Processing 

Quick Guide for Administrators 

TIP 24  A Guide to Substance Abuse Services for Primary

Care Clinicians 

Concise Desk Reference Guide 

                Quick Guide for Clinicians 

                KAP Keys for Clinicians 

TIP 25  Substance Abuse Treatment and Domestic Violence 

Linking Substance Abuse Treatment and Domestic

Violence Services: A Guide for Treatment Providers 

                Linking Substance Abuse Treatment and Domestic

Violence Services: A Guide for Administrators 

                Quick Guide for Clinicians 

                KAP Keys for Clinicians 

TIP 26  Substance Abuse Among Older Adults 

Substance Abuse Among Older Adults: A Guide for

Treatment Providers 

                Substance Abuse Among Older Adults: A Guide for

Social Service Providers 

                Substance Abuse Among Older Adults: Physician’s

Guide 

                Quick Guide for Clinicians 

                KAP Keys for Clinicians

TIP 27  Comprehensive Case Management for Substance

Abuse Treatment

Case Management for Substance Abuse Treatment: A

Guide for Treatment Providers 

                Case Management for Substance Abuse Treatment: A

Guide for Administrators 

Quick Guide for Clinicians 

                Quick Guide for Administrators
 

TIP 28  Naltrexone and Alcoholism Treatment—Replaced by

TIP 49

TIP 29  Substance Use Disorder Treatment for People With

Physical and Cognitive Disabilities

Quick Guide for Clinicians

                Quick Guide for Administrators 

                KAP Keys for Clinicians 

TIP 30  Continuity of Offender Treatment for Substance Use

Disorders From Institution to Community 

Quick Guide for Clinicians

                KAP Keys for Clinicians
 

TIP 31  Screening and Assessing Adolescents for Substance

Use Disorders

See companion products for TIP 32.

TIP 32  Treatment of Adolescents With Substance Use

Disorders 

Quick Guide for Clinicians 

                KAP Keys for Clinicians 

TIP 33  Treatment for Stimulant Use Disorders

Quick Guide for Clinicians

                KAP Keys for Clinicians
 

TIP 34  Brief Interventions and Brief Therapies for Substance

Abuse 

Quick Guide for Clinicians 

                KAP Keys for Clinicians 

TIP 35  Enhancing Motivation for Change in Substance Abuse

Treatment

Quick Guide for Clinicians 

                KAP Keys for Clinicians 

TIP 36  Substance Abuse Treatment for Persons With Child

Abuse and Neglect Issues

Quick Guide for Clinicians 

                KAP Keys for Clinicians

                Helping Yourself Heal: A Recovering Woman’s Guide to

Coping With Childhood Abuse Issues 

                Also available in Spanish

                Helping Yourself Heal: A Recovering Man’s Guide to

Coping With the Effects of Childhood Abuse 

Also available in Spanish

TIP 37  Substance Abuse Treatment for Persons With

HIV/AIDS

Quick Guide for Clinicians

                KAP Keys for Clinicians 

                Drugs, Alcohol, and HIV/AIDS: A Consumer Guide 

                Also available in Spanish

                Drugs, Alcohol, and HIV/AIDS: A Consumer Guide for

African Americans

TIP 38  Integrating Substance Abuse Treatment and

Vocational Services

Quick Guide for Clinicians 

                Quick Guide for Administrators 

                KAP Keys for Clinicians 

TIP 39  Substance Abuse Treatment and Family Therapy

Quick Guide for Clinicians

                Quick Guide for Administrators

                Family Therapy Can Help: For People in Recovery

From Mental Illness or Addiction

152
             

             

             

             

             

             

             

             

             

             

             

             

             

             

             

             

             

             

TIP 40  Clinical Guidelines for the Use of Buprenorphine in

the Treatment of Opioid Addiction

Quick Guide for Physicians 

                KAP Keys for Physicians 

TIP 41  Substance Abuse Treatment: Group Therapy

Quick Guide for Clinicians 

TIP 42  Substance Abuse Treatment for Persons With CoOccurring Disorders

Quick Guide for Clinicians 

Quick Guide for Administrators 

                KAP Keys for Clinicians 

TIP 43  Medication­Assisted Treatment for Opioid Addiction

in Opioid Treatment Programs

Quick Guide for Clinicians 

                KAP Keys for Clinicians 

TIP 44  Substance Abuse Treatment for Adults in the

Criminal Justice System

Quick Guide for Clinicians

                KAP Keys for Clinicians 

TIP 45  Detoxification and Substance Abuse Treatment

Quick Guide for Clinicians

                Quick Guide for Administrators

                KAP Keys for Clinicians 

TIP 46  Substance Abuse: Administrative Issues in

Outpatient Treatment

Quick Guide for Administrators

TIP 47  Substance Abuse: Clinical Issues in Outpatient

Treatment

Quick Guide for Clinicians 

                KAP Keys for Clinicians
 

TIP 48  Managing Depressive Symptoms in Substance Abuse

Clients During Early Recovery

TIP 49  Incorporating Alcohol Pharmacotherapies Into

Medical Practice

Quick Guide for Counselors 

                Quick Guide for Physicians 

KAP Keys for Clinicians 

TIP 50  Addressing Suicidal Thoughts and Behaviors in

Substance Abuse Treatment

Quick Guide for Clinicians 

                Quick Guide for Administrators
 

TIP 51  Substance Abuse Treatment: Addressing the Specific

Needs of Women

KAP Keys for Clinicians
 

Quick Guide for Clinicians

                Quick Guide for Administrators
 

TIP 52  Clinical Supervision and Professional Development

of the Substance Abuse Counselor

Quick Guide for Clinical Supervisors

                Quick Guide for Administrators

TIP 53  Addressing Viral Hepatitis in People With Substance

Use Disorders

Quick Guide for Clinicians and Administrators

                KAP Keys for Clinicians 

TIP 54  Managing Chronic Pain in Adults With or in

Recovery From Substance Use Disorders

Quick Guide for Clinicians 

                KAP Keys for Clinicians

                You Can Manage Your Chronic Pain To Live a Good

Life: A Guide for People in Recovery From Mental

Illness or Addiction

TIP 55  Behavioral Health Services for People Who Are

Homeless

TIP 56  Addressing the Specific Behavioral Health Needs of

Men 

Quick Guide for Clinicians

                KAP Keys for Clinicians
 

TIP 57  Trauma­Informed Care in Behavioral Health

Services 

                Quick Guide for Clinicians

                KAP Keys for Clinicians
 

TIP 58  Addressing Fetal Alcohol Spectrum Disorders

(FASD)

TIP 59  Improving Cultural Competence

153

Addressing Suicidal Thoughts and Behaviors
 

in Substance Abuse Treatment

This TIP is divided into three parts that are bound and produced separately.

Addressing Suicidal Thoughts and Behaviors in Substance Abuse Treatment, Part 1, is for substance abuse counselors. It provides the “what” and “why” and “how” of working with clients in

substance abuse treatment with suicidal thoughts and behaviors. It covers background information about suicide and substance use disorders, including risk factors and warning signs for suicide and a four­step process for addressing suicidal thoughts and behaviors in substance abuse

treatment, summarized by the acronym GATE (Gather information, Access supervision, Take

responsible action, and Extend the action). It also includes a set of competencies counselors

should incorporate to work effectively with clients who are suicidal. Chapter 2 of Part 1 represents the heart of the “how­to” for counselors. It consists of representative vignettes of counseling

sessions with clients who have suicidal thoughts and behaviors. Master clinician notes help you

understand the client and his or her issues related to suicide, and present approaches you can

take in your counseling work with clients with suicidal thoughts and behaviors. “How­to” notes

describe specific counseling techniques.

Addressing Suicidal Thoughts and Behaviors: An Implementation Guide for Administrators, Part

2, clarifies why program administrators should be concerned about this clinical issue. It will help

you understand how administrators can provide support for programs and counselors as they use

GATE to address clients’ suicidal thoughts and behaviors. It is hoped that this knowledge will

enable treatment programs to treat substance abuse while concurrently addressing the specific

needs of those who have warning signs for suicide.

Addressing Suicidal Thoughts and Behaviors: A Review of the Literature, Part 3, is for clinical

supervisors, interested counselors, and administrators. It consists of three sections: an analysis

of the available literature on suicidal thoughts and behaviors in clients with substance use disorders, an annotated bibliography of the literature most central to the topic, and a bibliography of

other available literature. Part 3 is available only online at http://www.kap.samhsa.gov.

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Substance Abuse and Mental Health Services Administration

HHS Publication No. (SMA) 15­4381

Printed 2009

Reprinted 2009 and 2011

Revised 2015