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STEPHANIE F. CHARLES LPC, NCC, CCDP-D, ACS, CPCS So You’re Not Going to Kill Yourself Are You? Suicidal client in Addiction tx.

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Presentation on theme: "STEPHANIE F. CHARLES LPC, NCC, CCDP-D, ACS, CPCS So You’re Not Going to Kill Yourself Are You? Suicidal client in Addiction tx."— Presentation transcript:

1 STEPHANIE F. CHARLES LPC, NCC, CCDP-D, ACS, CPCS So You’re Not Going to Kill Yourself Are You? Suicidal client in Addiction tx

2 SO YOU’RE NOT GOING TO KILL YOURSELF ARE YOU? SUICIDAL CLIENT IN ADDICTION TX  Suicide is not a diagnosable MH Disorder  Suicide is a high risk behavior!  People who usually kill themselves usually have a diagnosable MH Disorder or SUD or both  Recognition & tx most promising for preventing suicide & suicidal behavior

3 SO YOU’RE NOT GOING TO KILL YOURSELF ARE YOU? SUICIDAL CLIENT IN ADDICTION TX OBJECTIVES Establish basic framework for understanding the relationship between addiction & suicide Offer suggestions to address suicidal thoughts & behaviors Supply the frontline clinician with information for working with the client who has an addiction & co-occurring suicidal thoughts and behaviors

4 SO YOU’RE NOT GOING TO KILL YOURSELF ARE YOU? SUICIDAL CLIENT IN ADDICTION TX Co-Occurring (COD)— Someone who has both, SUD & MH Disorder Each disorder can be independently diagnosed Co-Occurring (COD) is not a cluster of symptoms 2002, Natl Survey on Drug Use & Health (NSDUH) 4 million adults met criteria for mental illness & SUD

5 SO YOU’RE NOT GOING TO KILL YOURSELF ARE YOU? SUICIDAL CLIENT IN ADDICTION TX Suicide main cause of death in SA SUDs incr risk for suicidal ideation & attempts 2010 approx 30,000 deaths by suicide At time of death 90% suffered MH DO Depression main MH DO seen in suicide

6 SO YOU’RE NOT GOING TO KILL YOURSELF ARE YOU? SUICIDAL CLIENT IN ADDICTION TX One DO Encourage other DO Initial use may have pos effect to min & mod mood Cont’d use aggravate & degrade mood Subseq use may lead to dependence AOD use may lead to incr in sumptom severity AOD use may unmask other mood symptoms AOD helps neg. mood coping

7 SO YOU’RE NOT GOING TO KILL YOURSELF ARE YOU? SUICIDAL CLIENT IN ADDICTION TX “ Kindling” (Neurobiological) a) Over sensitization of brain cells via “repeated disruptions” like what happens in seizures. Disruptions bet AOD use intensifies neuron sensitivity. In turn, use can progress “from occasional to increasingly frequent” AOD use. b) Mood DO may follow “kindling” process c) Alcohol & Cocaine referenced A. Genetics a. Risk factors for SUD & Mood DO b. Brain dev that fosters SUD & Mood DO “neuronal sensitization & kindling” c. Shapes brain so initial AOD exposure makes for changes that over time may lead to Mood DO Quello, S. B., Brady, K. T., & Sonne, S. C. (2005). Mood disorders and substance use disorder: A complex comorbidity. Addiction Science & Clinical Practice 3(1),

8 So You’re Not Going to Kill Yourself Are You? Suicidal client in Addiction tx  Mood DO most common comorbidity in SUDs  Prognosis not as good  More severe clinical course  Mood DOs  Depressive or Bipolar  Mood DO or SUD  Staged screening  Dist symptoms of subst use from mood DO  Simultaneously address both– Mood DO & SUD  Addressing either Mood DO or SUD may impr recovery in the other  Collaboration & communication bet SU provider & MH clinician

9 SO YOU’RE NOT GOING TO KILL YOURSELF ARE YOU? SUICIDAL CLIENT IN ADDICTION TX

10 Suicidal Beh & Tx Risk May Incr: 1. At any point during tx-inpt, outpt, intensive, discharge, continuing care 2. If suicidal, unethical to disch w/out arranging tx to addr suicide risk 3. Hx of suicide attempts or thoughts 4. During stressful life events Acute alcohol intoxification present in 30%-40% suicides & attempts Alcohol: 1. Less inhibiting behavior 2. May incr suicidal behaviors 3. Intensifies focus 4. Lessens appreciation of consequences 5. Encourages depressed mood Depression: Short-lived & intense in tx for 1. Cocaine abuse 2. Amphetamines 3. Alcohol

11 SO YOU’RE NOT GOING TO KILL YOURSELF ARE YOU? SUICIDAL CLIENT IN ADDICTION TX Suicidal Intention: High, acute risk- drafting note, actions against discovery Other Conepts & Behaviors Suicide Preparation: High, acute risk-note, diary entry, will, acquiring method Non-Suicidal Self-Injury (NSSI): Deliberate self- harm or gesture- soothing-no wish or expectation to die Self-Destructive Behaviors: Repeated behaviors that may lead to death

12 SO YOU’RE NOT GOING TO KILL YOURSELF ARE YOU? SUICIDAL CLIENT IN ADDICTION TX Suicide: Death caused by self- directed behavior with any intent to die as a result of that behavior. Taking one’s own life Suicide Attempt: Non-fatal self- directed potentially injurious behavior with any intent to die as a result of the behavior— does not always result in death Unintentional Injury: Injury that was unplanned; not intended to happen. Referred to as accidents-term discouraged- implies injury was not preventable e Postvention: Actions following a suicide-mainly to help those affected by the loss. Word Choice When Communicating

13 SO YOU’RE NOT GOING TO KILL YOURSELF ARE YOU? SUICIDAL CLIENT IN ADDICTION TX Committed Suicide Completed Suicide Successful Suicide Death by SuicideDeath by Suicide Died by SuicideDied by Suicide Death by SuicideDeath by Suicide Died by SuicideDied by Suicide Death by suicideDeath by suicide Died by SuicideDied by Suicide

14 RISK FACTORS, PROTECTIVE FACTORS, & WARNING SIGNS SO YOU’RE NOT GOING TO KILL YOURSELF ARE YOU? SUICIDAL CLIENT IN ADDICTION TX RISK FACTORS, PROTECTIVE FACTORS, & WARNING SIGNS Representative of long- term/ongoing risk Suicidal & SUD Risk Factors Warning signs indicative of immediate risk Suicidal & SUD Warning Signs Buffers that lowers longer- term risks (fewer in number than Risk Factors) Protective Factors

15 SO YOU’RE NOT GOING TO KILL YOURSELF ARE YOU? SUICIDAL CLIENT IN ADDICTION TX  Risk Factors  Family hx of suicide  Trauma-abuse, combat  Hx of mental disorders  Impulsiveness/aggressive tendencies  Hopelessness  Isolation  MH tx barriers  Loss  Access to lethal methods  Previous hx suicide  Cultural beliefs  Stigma assoc w/MH & SUDs  Cultural  Religious  Protective Factors (Buffers)  Tx access (MH, physical, SUDs)  Support (community, family)  Connectedness  Clinical interventions access & support  Continuous MH & medical tx  Interpersonal skill acquisition  Problem solving  Conflict resolution  Cultural  Religious

16 So You’re Not Going to Kill Yourself Are You? Suicidal client in Addiction tx Suicide Warning Signs Threatening to hurt or kill oneself or talking about wanting to hurt or kill oneself Looking for ways to kill oneself by seeking access to firearms, available pills, or other means Talking or writing about death, dying, or suicide when these actions are out of the ordinary for the person Feeling hopeless Feeling rage or uncontrolled anger or seeking revenge Acting recklessly or engaging in risky activities seemingly without thinking Feeling trapped, like there is no way out Increasing alcohol or drug use Withdrawing from friends, family, and society Feeling anxious, agitated, or unable to sleep, or sleeping all the time Experiencing dramatic mood changes Seeing no reason for living or having no sense of purpose in life SAMHSA News - November/December 2007, Volume 15, Number 6 Suicide Warning Signs Threatening to hurt or kill oneself or talking about wanting to hurt or kill oneself Looking for ways to kill oneself by seeking access to firearms, available pills, or other means Talking or writing about death, dying, or suicide when these actions are out of the ordinary for the person Feeling hopeless Feeling rage or uncontrolled anger or seeking revenge Acting recklessly or engaging in risky activities seemingly without thinking Feeling trapped, like there is no way out Increasing alcohol or drug use Withdrawing from friends, family, and society Feeling anxious, agitated, or unable to sleep, or sleeping all the time Experiencing dramatic mood changes Seeing no reason for living or having no sense of purpose in life SAMHSA News - November/December 2007, Volume 15, Number 6 Suicide Warning Signs

17 SO YOU’RE NOT GOING TO KILL YOURSELF ARE YOU? SUICIDAL CLIENT IN ADDICTION TX WARNING SIGNS Direct Indirect  Indicates acute risk  Always requires follow-up questioning  Direct Warning Signs  Suicidal communication  Seeks access to method  Making preparations  Indicates acute risk  Always requires follow-up questioning  Direct Warning Signs  Suicidal communication  Seeks access to method  Making preparations  May be in response to stressful life events  Legal  Financial  Job/Employment  Family Conflict  Relapse  Trauma  Intoxification  May be in response to stressful life events  Legal  Financial  Job/Employment  Family Conflict  Relapse  Trauma  Intoxification

18 SO YOU’RE NOT GOING TO KILL YOURSELF ARE YOU? SUICIDAL CLIENT IN ADDICTION TX WARNING SIGNS Indirect  May be visible in non- suicidal clients  Follow-up critical to determine degree of risk  May require explanation, e.g. trapped, hopelessness, mood changes  May be visible in non- suicidal clients  Follow-up critical to determine degree of risk  May require explanation, e.g. trapped, hopelessness, mood changes I—Ideation S—Substance Abuse P—Purposelessness A—Anxiety T—Trapped H—Hopelessness W—Withdrawal A—Anger R—Recklessness M—Mood Changes I—Ideation S—Substance Abuse P—Purposelessness A—Anxiety T—Trapped H—Hopelessness W—Withdrawal A—Anger R—Recklessness M—Mood Changes

19 S O YOU’RE NOT GOING TO KILL YOURSELF ARE YOU? SUICIDAL CLIENT IN ADDICTION TX THE RESEARCH SHOWS  Suicide more likely in older persons  Higher intent  Deadlier methods  Primarily firearms  Fragility of the body  Alone & less likely to be rescued  Young & adolescents make non-fatal attempts  Hanging  Jumping  Suicide more likely in older persons  Higher intent  Deadlier methods  Primarily firearms  Fragility of the body  Alone & less likely to be rescued  Young & adolescents make non-fatal attempts  Hanging  Jumping  Gender  Women attempt more than men  75% all non-fatal attempts  Medications  Poisons  Men more likely to die  Higher intent  More deadlier methods  Age

20 S O YOU’RE NOT GOING TO KILL YOURSELF ARE YOU? SUICIDAL CLIENT IN ADDICTION TX THE RESEARCH SHOWS Race & EthnicityDiagnosable Psychiatric Condition  Males 75%-80% greatest risk of all racial groups  4x more likely to die by suicide  Whites & Native Amers rate higher than African Americans  White males over 70 yo highest rate of all  Late adol & young adult highest for Native Americans & African American males  African American females lowest rate of suicide deaths  Rates for Hispanics similar to White, non-Hispanics  20% bipolar  15% Schizophrenia  5% Antisocial Personality DO  5%-10% Borderline Personality DO  6% Major Depression  7% Substance Induced Depression

21 S O YOU’RE NOT GOING TO KILL YOURSELF ARE YOU? SUICIDAL CLIENT IN ADDICTION TX THE RESEARCH SHOWS Suicide Suicidality  More survive attempts than die  Highest in Spring months  Peaks around April  Below average in Winter months  Lowest in December  20x greater in SUDs  High-risk behavior associated with Co-Occurring DO (COD)

22 S O YOU’RE NOT GOING TO KILL YOURSELF ARE YOU? SUICIDAL CLIENT IN ADDICTION TX WHY SUICIDE?  Emotional escape  Intoxication lessens limbs  Hopelessness  Stress-impulsive reaction  Burden to others  Stressful life events  Paranoia or psychosis  Sadness  Attention  Hurt inflicted upon another  Health  Feelings of failure or self-hate  Feeling trapped

23 S O YOU’RE NOT GOING TO KILL YOURSELF ARE YOU? SUICIDAL CLIENT IN ADDICTION TX WHAT CAN YOU DO…? FOR YOU  Direct  Find your comfort level  Ask open-ended questions  Ask follow-up questions  Suicide Awareness  Interventions  Warning Signs & Risk Factors  Overall competence  Basic Counseling Skills  Maintain therapeutic stance  Empathetic  Supportive  Stay grounded  Avoid count-therapeutic behaviors  Skill Building & Practice  Collaborative Alliance  Awareness  Confidentiality & Limitations  Ethical implications  Legal principles  Check yourself  Suicide self-evaluation  Spiritual  Moral  Cultural  Personal & family hx  Personal experience  Emotional reations  Beliefs & Attitudes  Seek supervision & consultation

24 S O YOU’RE NOT GOING TO KILL YOURSELF ARE YOU? SUICIDAL CLIENT IN ADDICTION TX WHAT CAN YOU DO…? FOR THE CLIENT  All SUD clients should receive basic suicide screening  Work out your own issues before emergency occurs  Get clear answers from your agency on crisis/stabilization & working with suicidal clients: How to  Work with them  Maintain them in your agency  Address later emerging suicide during tx  Address suicide during relapse  Know immediate available resources  Is there a standardized agency protocol for staff & suicide training?  All SUD clients should receive basic suicide screening  Work out your own issues before emergency occurs  Get clear answers from your agency on crisis/stabilization & working with suicidal clients: How to  Work with them  Maintain them in your agency  Address later emerging suicide during tx  Address suicide during relapse  Know immediate available resources  Is there a standardized agency protocol for staff & suicide training?

25 So You’re Not Going to Kill Yourself Are You? Suicidal client in Addiction tx  Generally show warning signs  Diff to recognize for what they are  Best Practice: Be Direct-Ask  Will not place or remove idea  Won’t know unless you ask  The whole story  Not told by outcome  Death by suicide no indicator of improper tx

26 SO YOU’RE NOT GOING TO KILL YOURSELF ARE YOU? SUICIDAL CLIENT IN ADDICTION TX CLINICIANS PLEASE UNDERSTAND…  Ambivalent about living  Typical across spectrum  Core of crisis  Crisis can be overcome  Transient state across risk levels  Majority relieved after receiving care  Cannot be Predicted  Risk Assessment valuable  Ensures those  Prevention should extend beyond crisis  Regardless of risk address SU clients  Risk beyond clean & sober  Abstinence cl goal w/SUD & suicide  May exist beyond abstinence  Take all suicide attempts seriously  Intent & lethality mismatch common  Consider thoughts, hx, current presentation

27 SO YOU’RE NOT GOING TO KILL YOURSELF ARE YOU? SUICIDAL CLIENT IN ADDICTION TX CLINICIANS PLEASE UNDERSTAND… (CONT’D)  Generally show warning signs  Diff to recognize for what they are  Best Practice: Be Direct-Ask  Will not place or remove idea  Won’t know unless you ask  The whole story  Not told by outcome  Death by suicide no indicator of improper tx

28 SO YOU’RE NOT GOING TO KILL YOURSELF ARE YOU? SUICIDAL CLIENT IN ADDICTION TX CLINICIANS PLEASE UNDERSTAND… (CONT’D)  Cl agrees to not kill self, rather go for emergency tx  Ill-effective as sole intervention  Good-makes therapist & cl feel better  Lessens anxiety for therapist & cl  Good contracts focus on keeping cl safe  Suicide Contracts  “Not Recommended & Never Sufficient”  Does not ensure safety  No evidence of support against litigation  False sense of security  Misguides decision-making if contract hinge on “can,” “can’t,” “will,” or “won’t,”

29 SO YOU’RE NOT GOING TO KILL YOURSELF ARE YOU? SUICIDAL CLIENT IN ADDICTION TX

30 SO YOU’RE NOT GOING TO KILL YOURSELF ARE YOU? SUICIDAL CLIENT IN ADDICTION TX BEFORE THE GATE  Do not automatically assume Mood DO  Cl may exhibit symptoms for Mood DO & SUD  Methodically approach sitution  Carefully screen for additional follow-up before definitive dx assessment  Reasonable abstinence period  Vary periods of abstinence by type of drugs used  Consider subsiding of symps  Inpatient observation may be req’d (symptom withdrawal, psychiatric, suicidal  Severe symptoms of depression or hypomania reqs immed tx vs waiting for symptoms to subside  Co-Occurring Mood DO & SUD pose higher suicide risk

31 SO YOU’RE NOT GOING TO KILL YOURSELF ARE YOU? SUICIDAL CLIENT IN ADDICTION TX  Suicide Screening & Assessment  Provide brief screening for all SU clients  Ask questions, e.g.  Suicidal in the past  Attempted suicide  Having those feelings now  Standardized assessment valid and/or reliable against suicide  Assessments provide clinicial info to help with determining level of suicide risk-mild, moderate, or high  Document! Document! Document!

32 SO YOU’RE NOT GOING TO KILL YOURSELF ARE YOU? SUICIDAL CLIENT IN ADDICTION TX GOOD CONTRACTS FOCUS ON SAFETY—SAFETY PLAN Suggested Safety Plan Sections 1. Warning signs (thoughts, images, mood, behaviors) that a crisis may be dev 2. Internal coping strategies: Things I can do to take my mind off my problems w/out contacting another person (relaxation techs, physical activities) 3. People & social settings that provide direction 4. People I can ask for help 5. Profs or agencies I can contact during a crisis 1. Clinician-name, phone, emerg contact 2. Clinician-name, phone, emerg contact # 3. Local Urgent Care Svcs Urgent Care Svcs (type) Urgent Care Svcs addr Urgent Care Svcs phone # 4. Suicide Prev Lifeline: TALK (8255) 6. Making the envir same: 2-3 actions cl may take One thing most important to me & worth living for

33 SO YOU’RE NOT GOING TO KILL YOURSELF ARE YOU? SUICIDAL CLIENT IN ADDICTION TX

34 DEATH BY SUICIDE & ADDICTION

35 SO YOU’RE NOT GOING TO KILL YOURSELF ARE YOU? SUICIDAL CLIENT IN ADDICTION TX THE END Thank You! Stephanie F. Charles LPC, NCC, CCDP-D, ACS, CPCS Spectrum Health Systems, Inc Direct


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