SUICIDALITY in ADDICTION and RECOVERY

Addressing Suicidal Thoughts and

Behaviors in Substance Abuse Treatment -
SAMHSA

Jasmin Rogg, MA, LMFT

I would like to introduce myself. I have been a

therapist for decades, working with addicts and co-
occurring disorders, but before that I was a heroin
addict and an alcoholic, also for decades. I did get
clean and sober in the last millennium, but I know this
disease inside and out from a personal and a
professional perspective.

This also means that I am familiar with the topic of

suicidality as it goes with addictive behavior and it
can also become a problem when the drugs are taken
from an addict as it happens in treatment. Most

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addicts can tell you that they self-medicate suffering,
that alcohol, heroin, and meth is not so much their
problem as it is their solution. Most addicts are
survivors of trauma, violent, emotional, sexual, or
neglect, bullying and so forth. Many will tell you that
drugs feel like the only loyal friend that has never
abandoned them, that drugs help to numb out and not
care.

Let's first clarify the term suicidality. It refers to dark

thoughts about life and death, perhaps a lack of
commitment to life. The patient may be passive,
secretly wishing to be dead, indifferent about his own
survival, "a hope-to-die drug addict" using more and
harder drugs under increasingly dangerous or life-
threatening circumstances, moving from snorting
drugs to shooting up, neglecting safety or hygiene. Or
the patient may be verbal and active with it, stating
habitual suicidal ideation, past suicide attempts, or
current intent. The Pt may brag about 25 OD's with
Fentanyl, ER visits, and having to be resuscitated

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several times. The patient may state with bravado
how many Minutes they have been dead and that
they took more drugs later that same day. This could
also indicate possible brain damage, as well as a
tendency to continue with such behaviors. It can be
hard to tell. It's ultimately left to the clinician's
judgment. We ask, observe, and listen. We inquire
about actual intent, plan, and availability of means, we
discuss this with the tx team, we pass on the
information and concern to the psychiatrist, but it
remains a difficult aspect of our profession. It can be
uncomfortable and scary to deal with this aspect of
addiction in recovery.

Suicide used to be considered a crime, a sin, and a

source of shame. There was no compassion for the
survivor and it would be silenced. In18th century
England attempted suicide was punishable by death.
In Massachusetts the body of a suicide victim would
be burned at a crossroads.

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The clinician may have the best intentions, but how to
keep a patient safe against their secret wishes? And
do we ever really know their secret wishes? The
patient may be coming along beautifully, fall in love
with another Pt, feel rejected, hurt, and thrown into
trauma mode. They may feel unlovable and
worthless, thinking their life means nothing to anyone,
that everybody would be better off without them. The
patient may experience mood swings, reacting to
chronic stressors or lacking the coping skills for a
sudden and unforeseen event. We can only observe,
ask questions, and listen to verbal communication. It's
associated with intense emotions that feel
overwhelming, a despairing defeatist outlook, a
flooding with anger, the end result of innumerable
experiences and thoughts where the person feels
disgusted, lonely, and utterly disappointed with
everything. There is no single, readily identifiable
cause for suicide, but we can safely assume that
people have reasons for what they do even though
we may not know what they are. We know that the

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majority of people who kill themselves are depressed.
Underlying reasons for depression is grief, illness, low
self-esteem, loneliness, job loss disappointment,
especially when associated with childhood trauma
and exacerbated with drugs and alcohol.

Psychosocial stressors can include financial stress,

unemployment, or lack of social support, which often
happens after years of alcohol abuse. Environmental
factors include availability of means, such as drugs
and firearms. Childhood trauma (physical, sexual,
emotional) increases suicide risk by x12. A huge
contributing factor is a psychiatric diagnosis, such as
a psychotic disorder, or a personality disorder, such
as Borderline, narcissistic, or antisocial; the risk
increases if there was a previous suicide attempt, or if
there are two or more co-occurring disorders, which
can become overwhelming, such as depression or
bipolar disorder along with substance use disorder,
chronic pain, and "the lethality of loneliness."

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On the other hand, there are statistics that confirm
that many suicide attempt survivors are glad they
were rescued and experience a renewed joy of life.
Remember, suicide is not necessarily about ending
one's life, but rather, ending one's suffering. In AA the
saying goes, "Don't kill yourself in your first year of
sobriety! You might kill the wrong person." The
understanding being that recovery is about psychic
transformation and the newly sober person is reborn
and gets another chance at life.

So you see this is a complex topic. It's not

straightforward, there is a big gray area. We are
taught not to use a so-called no-suicide or no-harm
contract by some sources that say it's no protection
and it's actually as absurd as it sounds. We are taught
not to call for a 5150 hold unnecessarily, just because
the Pt trusts their therapist and shares about self-
hatred and despair while in residential treatment. That
needs to be carefully evaluated, with sensitivity,
considering Pt's lack of insight, judgment, and impulse
control at that time.

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In treatment we make an assessment, and we must
consider clinical, as well as legal aspects to ensure Pt
safety and self-endangerment behavior. While
treatment and therapy is a gradual process, the
patient is raw and experiencing fear and depression,
regret and remorse, confusion and ambivalence and
other difficult emotional states. Early recovery is a
challenging time. In tx the patient receives detox
meds, which usually help, but not enough, never
enough. If the patient doesn't suffer in detox they are
usually over-medicated and the detox process is
protracted, which is not how it's supposed to go.

Withdrawal, as well as PAWS (Post-Acute Withdrawal

Symptoms) is difficult as it takes time until the body
gets used to functioning again without addictive
substances. Meanwhile, withdrawal symptoms can be
highly uncomfortable, painful, disturbing, confusing,
agitating, and the patient needs monitoring and
support while they are struggling to change habitual

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thought and behavior patterns, possibly tempted to
self-sabotage anything good that comes their way.

Also, the patient may experience intense symptoms of

co-occurring disorders, meaning that anxiety,
depression, agitation, and disturbing thoughts may
come up, exacerbating withdrawal discomfort. The
process is challenging, and the Pt must be seen and
assessed. In rehab the Pt is typically seen by a
psychiatrist for diagnosis and medication, also a
nurse for ongoing monitoring, care, and medication
management.

I want to pass on to you some information that will

help to clarify proper approach and will help you feel
more confident around this topic.

Suicide and Danger to Self

 Since 2021 MFT's are required to complete 6
hours of continuing education in suicide risk
assessment and intervention.

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 A therapist has no legal duty to prevent
suicide.
 However, therapists incur legal liability if they fall
below the standard of care.
 This means failing to take "appropriate
preventative measures" to avert harm to
suicidal clients.
 The law permits therapists to break confidentiality
when clients are in danger to themselves in order
to prevent the danger.
 A therapist referring a suicidal client has a duty to
inform the new therapist of the potential suicide
risk. This arguably extends to violent clients, as
well.
 Preventive measures that do not break
confidentiality: Self-care, no self-harm, no-
suicide contract; increased contact (extra
sessions, phone check-ins); involve client support
systems (release to speak to family or friends);

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 referral to physician or psychiatrist for
medication; voluntary hospitalization.
 Preventive measures that break
confidentiality:
Clinical consultation with client's other health
care
providers; 24-hour watch (family, friends)
arranged
without the patient's permission; involuntary
hospitalization W.I.C. 5150 (Welfare and
Institutions
Code).
 Record keeping with suicidal clients should
include:
Documentation of any concerns and/or
discussions of
issues regarding potential suicide.
Assessment should include the following:
History of suicide attempts,
Family history of suicide,
Medical history and psychiatric hospitalizations,

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 substance abuse, impulse control;
Conclusions drawn from the client's appearance,
demeanor, behavior, and current mental or
emotional
state, e.g. is there suicidal ideation;
Interventions to try to prevent self-harm and the
client's
responses;
Records should detail the therapist's actions and
the
reasoning behind these decisions;
Records should reflect any consultation a
therapist took
in managing a suicidal client, including the
consultant's
experience in working with suicidal clients.

Involuntary Confinement 5150 Hold - LPS Act

(Lanterman, Petris, Short Act)

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A 5150 hold is a 72-hour hold for treatment and
evaluation for a person who due to a mental
disorder, is gravely disabled or a danger to self or
others.
Mental health disorder is defined by a DSM-5
diagnosis or by a description of the client's current
state of mind, intoxication level, suicidality etc
A 5150 can be initiated by a mental health worker, but
can be invoked only by a peace officer, a designated
member of a country mobile crisis team, or another
professional person designated by the country (or by
a mental health profession with special training by
their county Department of Mental Health).
Initiating means calling a law enforcement or local
PET team, in which the mental health professional
may assess the client's mental state.
Invoking means locating, transporting, and applying
for placement in a hospital, in which a certified LPS
provider would apply for involuntary hospitalization.
In the involuntary certification review hearing process,
LMFT's and LPCC's are authorized personnel who

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can sign a notice of certification that is required to be
signed by 2 people.

TIP 50 refers to Treatment Improvement Protocols

(TIPs)
developed by SAMHSA (Substance Abuse and
Mental Health Services Administration) and
provides recommendations for optimal clinical
approaches (http://www.samhsa.gov).

Steps to address suicidality in treatment are

outlined with the acronym GATE:
G - Gather information - necessary to develop a
plan of action; ask direct and clear questions, ask to
explain, e.g. Tell me about your suicidal thoughts.
What happened? What brings it on?
How can you make it better? The therapist ought to
be empathetic, use body language; not let anxiety
prevent the therapist from gathering information
(avoid the issue) or on the other extreme become a

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suicide interrogator; rather stay calm and ask open-
ended questions to explore the Pt's thoughts and
experience.

Also ask about warning signs (signs of acute risk):

Direct warning signs -
 Suicidal communication, i.e. Pt expresses wish or
intent to die
 Pt has or seeks access to a method e.g. has
lethal amount of substances at their disposal or
can get a gun
 Making preparations e.g. talks or writes about
death
 Says good-bye to loved ones, family members

Indirect warning signs - IS PATH WARM?

I - Ideation (threatened or communicated)
S - Substance Abuse (excessive or increased)
P - Purposelessness (no reason for living)
A - Anxiety (agitation, insomnia, obsessing)
T - Trapped (feeling there is no way out)
H - Hopelessness

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W - Withdrawal (from friends, family, society)
A - Anger, resentments, rage, aggression, seeking
revenge
R - Recklessness (risky acts, unthinking)
M - Mood Changes (dramatic shifts in emotions)

Warning signs are often following acute stressful life

events:
 Break-up of relationship
 Experience of trauma
 Legal event (scary, possibly unexpected)
 Job loss or other major employment setback
 Financial crisis
 Family conflict or disruption
 Relapse (experienced as discouraging)
 Intoxication (lack of impulse control)

Risk factors - long-term risk, helpful to identify risk

 Personal history and family history of suicidality
 Severe substance abuse disorder (implications)
 Co-occurring mental disorders e.g. Pt becoming
more depressed, psychotic episode

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  History of childhood sexual abuse
 Stressful life events
 Access to fire arms
 Anger, aggression, agitation
 Impulsivity (lack of impulse control)
 Anxiety (exhausting, discouraging)
 Depression (mood)
 Chronic medical problems (dejection)
 Chronic pain (opioid addiction, side effects)
 Perception of not belonging anywhere
 Perception of being a burden, being unloved

Protective factors - stabilizing aspects, lower the risk

of acting out on suicidal impulse
 Having reasons for living
 Staying clean and sober (recovery network,
support)
 Religious attendance or spiritual beliefs against
suicide
 Presence of a child in the home
 Intact marriage (feeling loved and supported)

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  Trusting therapeutic relationship (feel seen,
heard, and understood)
 Social support (friends and family)
 Employment (stable income)
 Generally hopeful outlook (tendency for
optimism)
Not safe - Consider the warning signs and risk
factors, too - the whole picture!

A - Access supervision
 Immediate supervision
 Direct warning signs
 Indirect warning signs that, on follow-up, suggest
current risk
 Suspicion of current risk
 Additional information (from another provider or
family member) suggests current risk

T - Take action
 Access key information
 Identify high risk - Pt requires intensive
immediate action

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  Differentiate lower risk - less intensive actions
necessary
 Avoid over-response, which might undermine the
therapeutic relationship (Pt might feel betrayed)

Potential Actions:
 Gather more information from the client
 Gather more information from other sources, e.g.
records, family
 Arrange emergency evaluation
 Increase frequency of contact (in person, phone)
 Involve suicide prevention coordinator
 Involve a primary care provider
 Arrange outpatient mental health evaluation
 Restrict access to means
 Enlist family members to observe the client
 Encourage client to attend 12 step meetings (AA,
NA etc)
 Observe client for signs of return of risk
 Complete a formal safety plan, i.e. VA mental
health eval

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E - Extend the Action - develop a plan together with
the client
 ask first, what the client would like to implement
for safety,
 be direct, clear, and also collaborative with the
client re working out a safety plan
 get more clarity and reduce uncertainty, e.g.
consider co-occurring disorder
 Address access to means, e.g. firearm; include a
family member for safety; put the gun in a safe
place (just like alcohol and drugs to avoid
temptation in emotional moments)
 See also Addressing Suicidal Thoughts and
Behaviors in Substance Abuse Treatment,
youtube video - Take Action, Part 2 - Min 51:21 -
1:00:35
 Involve family members, if possible, parents,
siblings, partner, decide with the patient, who
feels most comfortable

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  Continue to check in with a supervisor
 Confirm the patient has kept referral
appointments
 Coordinate with other providers, e.g. psychiatrist
 Monitor suicidal thoughts and behavior
 Confirm that the client has a safety plan
 Assess any changes in access to methods of
suicide
 Following up in case of relapse
 Prepare the client for difficult situations that may
arise, e.g. relationship problem, relapse
 Monitor and update the treatment plan
Document everything, i.e. 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.

Safety Cards and Safety Plans

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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.
 The phone number and address of the nearest
hospital emergency department.
 The therapist’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
mentioned). 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 save the safety plan on the
phone so that it can be accessed easily.
Therapists could also create a more detailed

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 safety plan together with the patient, as shown
in the vignette.

INVENTORIES
PHQ-9 Depression Inventory
BDI Beck's Depression Inventory
BAI Beck's Anxiety Inventory
Beck's Suicide Risk Assessment Form
C-SSRS Columbia Suicide Severity Rating Scale

EXTRA:
PTSD and SGB (Stellate Ganglion Block)
PTSD is associated with higher rates of depression,
substance abuse, and suicide.
The brain can become "stuck" in high gear after
experiencing trauma.
This can cause a change in the brain, resulting in
chronic symptoms of PTSD like hypervigilance,

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insomnia, irritability, startle response, difficulties
concentrating.
Stellate Ganglion Block (SGB) is a procedure
designed to relieve symptoms of PTSD and reset the
brain's over-activity to its pre-trauma states.

healthquality.va.gov
Also check out:
 VA Suicide Prevention Pocket Guide and
 Military Veterans Safety Plan Worksheet
Provider and Patient complete Safety Plan together
and patient keeps it with them
Step 1 Warning Signs
Step 2 Internal Coping Strategies
Step 3 Healthy Distraction (people, places, social
settings)
Step 4 People to contact for help
Step 5 Professionals to ask for help
Step 6 Making my environment safe
Step 7 My reasons for living

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Resources:
SAMHSA
American Association of Suicidology
American Journal of Psychiatry
ACE study, Felitti

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