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Understand the signs of suicidality

March 15, 2011
by Nicholas A. Roes, PhD
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While those of us in the addiction treatment field address life-or-death issues on a daily basis, many of us remain uncomfortable discussing the possibility of suicide. Since the population we serve is far more likely than the general population to complete suicide, each of us must recognize risk factors and build protective factors.

This 10-item true/false exercise has been designed to highlight some important information on the topic, and to serve as a springboard for discussion. (The information used to design the true/false questions and the explanations of the answers was presented by Paul A. LeBuffe at a workshop co-sponsored by the Suicide Prevention Center of New York State and the New York State Office of Mental Health on Aug. 18, 2010 in Albany.)

  1. Adolescents have higher rates of suicide than any other age group.

  2. Women and minorities complete suicide at a higher rate than white males.

  3. There are more homicides than suicides in the U.S.

  4. The rate of suicide is higher in Washington, DC than in Wyoming.

  5. Firearms are the means for more than half of completed suicides.

  6. Most people who attempt suicide don't die.

  7. 90 percent or more of those who complete suicide communicate their intent to die.

  8. Most suicidal people don't want to die.

  9. 90 percent or more of those who complete suicide have an Axis I disorder.

  10. Most people who die by suicide do it on the first attempt.

#1 is FALSE. The highest rate of suicide is with the 65-and-over demographic. For men the rate increases as they age; for women it declines. Suicide is the third leading cause of death among adolescents (after accidents and homicides).

#2 is FALSE. The suicide rate is 12.9 percent for whites and 4.9 percent for African-Americans. About 70 percent of all completed suicides are white males; 20 percent are white females.

#3 is FALSE. Homicides rank 15th as a cause of death, with about 20,000 a year. Suicide ranks 11th, with about 35,000 annually.

#4 is FALSE. Rates of suicide in the Mountain states are almost double those in the Northeast. Theories to explain this include social isolation, greater access to guns, higher rates of alcoholism, and longer response time in sparsely populated areas.

#5 is TRUE. Firearms are used in more suicides than all other means combined.

#6 is TRUE. The completion rate for attempted suicide is greatest among the elderly-4 attempts per completion. The lowest completion rate is among youths.

#7 is TRUE. The great majority of those who complete or attempt suicide are ambivalent about dying, and communicate their intent in some way. That's why awareness of the warning signs and ways of communicating is so important.

#8 is TRUE. One in 10 high school students attempts suicide.

#9 is TRUE. Axis I disorders include substance-related disorders, mood disorders and anxiety.

#10 is TRUE. This is the reason why we must recognize and reach out to those who are at risk.

Assessing the strategies

There is no evidence that “no suicide contracts” prevent suicide. Worse yet, they might give counselors a false sense of reassurance.

Asking about suicidal thoughts is essential. This won't increase these thoughts or make suicide more likely, but it will get you information that will ensure that you can deliver an appropriate clinical response.

Never try to manage suicide risk alone. It is a collective responsibility, not yours alone, to determine the seriousness of the risk and the actions to be taken.

After the immediate danger is dealt with, be sure to follow up. Make sure your client keeps appointments. Coordinate with mental health providers and case managers on a regular basis. Observe the client when he/she is at your facility, and check with family members for their input. Monitor and update your treatment plan regarding suicide risk.

Useful resource

One of the best free resources for addiction counselors is the Center for Substance Abuse Treatment's (CSAT's) Addressing Suicidal Thoughts and Behaviors in Substance Abuse Treatment. This is publication 50 in CSAT's Treatment Improvement Protocol (TIP) series; it is HHS Publication No. (SMA) 09-4381.

The CSAT 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: Gather information, Access supervision, Take responsible action, Extend the action.

The elements in GATE reflect behaviors that are within the scope of competence of substance abuse counselors. We are familiar with gathering information from clients, and this skill will transfer to gathering information about suicidal thoughts and behaviors. Gathering information is different from making a formal assessment, which stands outside the scope of a substance abuse credential.

Supervision should constitute a regular part of your agency's program and accessing supervision is a necessity with a client who is suicidal. The CSAT TIP covers when to get supervision immediately and when to use your regular supervision session for guidance.

Substance abuse counselors already know how to take action and plan for the treatment of a client with a substance use disorder, and this skill will transfer to planning for a client to address suicidal thoughts and behaviors.