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Crisis Intervention in Substance Abuse Treatment
Based in part on SAMHSA TIP 50 Addressing Suicidal Thoughts and Behaviors in Substance Abuse Treatment
Dr. Dawn-Elise Snipes PhD, LPC-MHSP
AllCEUs Counselor Continuing Education

CEUs Available at:

• Explore crisis/ disaster counseling
• Articulate helpful tips for dealing with client suicidality.
• List 6 Positive Attitudes and Behaviors towards clients dealing with suicidal thoughts.
• Identify warning signs for suicidality using the acronym IS PATH WARM.
• Know statistics related to suicide in order to better identify potentially suicidal clients.
• Become familiar with the GATE Procedures for substance abuse counselors.
• Suicidality issues at different levels of care

Statistics Related To Suicide
– Suicide danger zones: Between age 10 and 24 years and after age 70
– More than 90% of persons who die from suicide satisfy the criteria for one or more psychiatric disorders (including adjustment disorder)
– Anxiety disorders are associated with a six- to 10-fold increase in suicide risk
– Alcohol abuse or dependence is present in 25%–50% of those who died by suicide
– When trauma and substance abuse are combined, the risk for suicide jumps to 42%
– Impending interpersonal losses and comorbid psychiatric disorders, have been specifically linked to suicide in alcoholic individuals.
Characteristics of Crisis
– Complicated
– Generally does not have one simple cause
– Beliefs may be operating when an emotion or reaction seems out of proportion to what you’re thinking in the heat of the moment
– Precipitating events may impact many different areas of life
– No Panaceas or Quick Fixes
– May provide temporary, immediate relief
– Ensure they do not make problem worse
– Necessity of Choice
– Making a choice requires action
– Choosing not to act is a still a choice
Types of Crisis & Risk Factors
– Physical (Illness, addiction)/Developmental (Life stages)
– Affective (anxiety, depression, bipolar)
– Cognitive (Alzheimer’s, Dementia, Psychotic (schizophrenia, Parkinson’s)
– Environmental/Financial
– Job Loss
– Homelessness
– Cabin Fever
– Changes in levels of care
– Relational (breakups, death, abuse history, isolation)
– Spiritual (loss of meaning)
Addiction and Suicidality
• People with substance use disorders who are in treatment are at especially high risk of suicidal behavior for many reasons, including:
• Entering treatment when their substance abuse is out of control and a number of co-occurring life crises may be occurring (e.g., marital, legal, job)
• They enter treatment at peaks in depressive symptoms
• Mental health problems 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).

Mitigating Factors
– Physical
– Sleep
– Nutrition
– Sunlight/Circadian Rhythms
– Affective: Emotional regulation and psychological flexibility
– Cognitive: Hope, commitment, control/empowerment, challenge (Hardiness, Kobasa 1977)
– Environmental: Safety and Positive Triggers
– Relational: Social support, effective interpersonal skills (boundaries, communication)
6 Positive Attitudes and Behaviors
– Provide an array of biopsychosocial services
– Screen and communicate status and interventions
– All expressions of suicidality indicate significant distress and increased vulnerability
– Be aware of indirect signs including those warning signs unique to the client (agitation, giving away things, no future plans)
– Explore past suicide attempts and ideation to identify exacerbating and mitigating factors
– Make sure all clients have the number of a suicide hotline and/or a procedure for addressing suicidal or self-injurious thoughts.
Warning Signs: IS PATH WARM
– Ideation
– Substance Abuse

– Purposelessness
– Anger
– Trapped
– Hopeless/Helpless

– Withdrawing
– Anxiety
– Recklessness
– Mood Change
GATE Procedures
– Gather information
– Early identification of warning signs, and asking follow-up questions
– Focus on the nature, frequency, intensity, duration and triggers of suicidal thoughts and context in which they are occurring.
– If the patient does not report a plan, ask whether there are certain conditions under which the patient would consider suicide
– Access supervision
– Take responsible action
– Extend the action
– Vulnerable clients may relapse into suicidal thoughts or behaviors. Continue to observe and check in

Inpatient settings
– There are not specific risk factors unique to the inpatient setting
– Fewer than half of the patients who die by suicide in the hospital were admitted with suicidal ideation
– Extreme agitation or anxiety or a rapidly fluctuating course is common before suicide.
– Many people report a state of extreme calm immediately preceding the attempt
– Each suicidal crisis must be treated as new with each admission and assessed accordingly.
Outpatient settings
– Initial evaluation should be comprehensive and include a suicide assessment including strengths, vulnerabilities, stressors and development of a safety plan
– Be aware that suicidality may wax and wane in the course of treatment.
– Sudden changes in clinical status, which may include worsening or unexpected improvements in reported symptoms, require that suicidality be reconsidered
– Risk may also be increased by
– The lack of a reliable therapeutic alliance
– The patient's unwillingness to engage in psychotherapy or adhere to medication treatment
– Inadequate family or social supports
Long-term care facilities
– Indirect self-destructive acts are found among both men and women are a common manifestation of suicide in institutional settings
– Physical illness, functional impairment, and pain are associated with increased risk for suicide
– Hopelessness and personality styles that impede adaptation to a dependent role also play a role
Jail and correctional facilities
– Suicide is one of the leading causes of death in correctional settings.
– Persons who die by suicide in jails tend to be young, white, single, intoxicated substance abusers
– Suicide in correctional facilities generally occurs by hanging
– Isolation may increase suicide
– Suicidal behaviors increase
– Immediately on entry into the facility
– After new legal complications with the inmate's case (e.g., denial of parole)
– After inmates receive bad news about loved ones
– After sexual assault or other trauma
Helpful Tips
– People who are suicidal are often ambivalent
– Crisis is an opportunity and a risk
– Suicide risk assessment and regular screening is vital
– Prevention must be ongoing
– Suicide contracts are NOT recommended
– Many clients will be at risk of suicide even after getting clean

– Suicidality is not uncommon
– It is important to regularly screen all clients for suicidality (e.g. check in sheets, monitoring logs)
– Suicidality is an opportunity for change
– A variety of different issues can contribute to suicidality.
– Early recovery is a period of extreme vulnerability for many people and treatment plans should always contain a suicide prevention plan (does not substitute for active monitoring)