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If you are thinking of hurting yourself, or if you are concerned that someone else may be suicidal, call the National Suicide Prevention Lifeline at 1-800-273-TALK (8255).
A local business referred John to the Employee Assistance Program where Laurel worked. The human resources staff at this organization believed that John had a substance abuse problem. Laurel noticed some signs of depression in the intake assessment and referral notes, including John's consistent lateness, his isolation from other employees, and his inability to focus or concentrate on his work. In their first session, it became obvious that John suffered from both an alcohol abuse problem and severe clinical depression. He was upset with himself for drinking, but he could not stop. He was aware that his inability to concentrate on work was becoming worse. He was despondent over his deteriorating relationship with his family and friends. He was also convinced that he was going to lose his job.

Laurel recognized that John was in bad shape. She had just broached the idea of a referral for treatment when he blurted out "I don't need a referral. I'm not going to be around much longer." Laurel was stunned. She had seen other patients who were self-destructive. But she had never heard anyone express such thoughts with this much certainty. She did not know what to do next.

The Role of Alcohol and Other Drug Abuse (AOD) Counselors in Preventing Suicide

It has long been known that alcohol abuse is a risk factor for suicide (Murphy, 2000). Recent research indicates that such a relationship also exists between suicidal behavior and the abuse of other drugs. Consider the following facts:
  • The literature indicates that alcohol abusers have higher rates of both attempted and completed suicide than non-abusers (Lester, 2000).
  • Twenty to 50 percent of the people who die by suicide had alcohol or drug abuse problems. Depression is the only psychiatric problem with a more pronounced association with suicide (Murphy, 2000).
  • Youth who used alcohol or illicit drugs during the past year were more likely to be at risk of suicide than other youth. Youth who used any illicit drug other than marijuana were almost three times more likely to be at risk of suicide (Substance Abuse and Mental Health Services Administration, 2003).
  • Fifteen percent of all alcohol-dependent people die by suicide. This is a loss of 7,000 to 13,000 people every year (Sadock & Sadock, 2002).
A number of factors contribute to the relationship between suicide risk and the abuse of alcohol and other drugs.

Alcohol and other drug abuse is often related to emotional trauma, psychological stress, and other mental health problems (Merikangas et al., 1998). Some people use alcohol or other drugs to "self-medicate"-that is, to relieve their emotional pain. This is especially common among runaway and homeless youth who may be living on the street. Unfortunately, the abuse of alcohol and other drugs is more likely to increase (or initiate) emotional problems than to provide an escape from them.

Alcohol use impairs judgment and leads to impulsive behavior. A person at risk of suicide who might not have made an attempt while sober may do so while intoxicated. Research indicates that alcohol is associated with impulsive suicides, especially those involving firearms (Goldsmith, Pellmar, Kleinman, & Bunney, 2002). This may also be true of other drugs that impair judgment. However, it is difficult to draw the line between an intentional suicide attempt that takes place when a person is intoxicated and an "unintentional" death or injury resulting from self-destructive high-risk behaviors, such as driving while intoxicated or overdosing on an illicitly used drug.

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Recognizing the Warning Signs

Suicide warning signs and risk factors are similar for people who abuse alcohol or other drugs and people who do not (Lester 2000). One such risk factor is a previous suicide attempt. Approximately 40 percent of alcohol-dependent people who died by suicide made a previous attempt (Sadock & Sadock, 2002).

Age can also be a risk factor. People in middle or late adolescence and the elderly are especially at risk of suicide. Alcohol-involved youth who exhibit signs of impulsiveness or irritability are at higher risk of suicide than other youth (Connor, Meldrum, Wieczorek, Duberstein, & Welte, 2004).

Other risk factors indicating that an alcohol- or drug-involved individual may be at high risk of suicide include the following (Weiss and Hufford, 1999):
  • Current or recent interpersonal loss, including a recent separation from a spouse, interpersonal conflict, loss of employment, threatened loss of employment, physical illness, weakening of social supports (real or imagined), and financial loss
  • Depression (especially feelings of hopelessness)
  • Other psychiatric problems (or history of psychiatric problems), including anxiety disorders, bipolar disorders, schizophrenia, impulse control disorder, and other co-morbid DSM Axis I and II disorders
  • A family history of suicide, mood disorder, and/or alcohol abuse
  • A recent return to, or escalation of, alcohol and drug abuse
  • Availability of lethal means, especially firearms
  • Poor self-care
People who are considering harming themselves may try to reach out to you-sometimes directly, sometimes indirectly. AOD counselors should be especially alert for imminent warning signs, for example:
  • Talking about suicide or death
  • Giving direct verbal cues, such as "I wish I were dead" and "I'm going to end it all"
  • Giving less direct verbal cues, such as "What's the point of living?", "Soon you won't have to worry about me," and "Who cares if I'm dead, anyway?"
  • Isolating him- or herself from friends and family
  • Expressing the belief that life is meaningless or hopeless
  • Giving away cherished possessions
  • Exhibiting a sudden and unexplained improvement in mood after being depressed or withdrawn
  • Neglecting his or her appearance and hygiene
A combination of risk factors and warning signs in a person currently involved with drugs or alcohol should be regarded as a problem that needs to be addressed.

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Responding to the Warning Signs

It is beyond the scope of this publication to provide guidance on the clinical management of people who are involved with alcohol and other drugs and are exhibiting warning signs of suicide. In the long term, helping the individual achieve and maintain sobriety, treating co-occurring psychiatric disorders (such as depression), and reconnecting the individual with a social support network are all essential to lowering the risk of suicide (Weiss & Hufford, 1999).

However, it is important for AOD counselors to know how to respond to clients who may be in imminent danger of harming themselves. Your response to warning signs should be targeted at keeping the client safe, providing empathy and support, and ensuring that the client receives the mental health and/or social services necessary to reduce the client's risk.

Science has not yet provided us with fail-safe methods of assessing the risk of suicide. However, you can ask the sometimes difficult questions that will provide you with more evidence about the patient's state of mind and intentions, for example:
  • Do you ever wish you could go to sleep and never wake up?
  • Sometimes when people feel sad, they have thoughts of harming or killing themselves. Have you had such thoughts?
  • Are you thinking about killing yourself?
You should act immediately if you think there is any risk that the patient poses an imminent danger to him- or herself. Immediate action should also be taken when the patient's warning signs are combined with any of the following:
  • Past incidents of suicidal behavior or self-harm
  • A family history of suicide
  • A history of psychiatric disorders
  • Evidence of a psychiatric disorder
You should seek immediate assistance if you have any reason to believe that a client is in imminent danger. In an inpatient or other clinical setting, emergency mental health resources may be available on-site. In other cases, you may have to call a mental health clinic or emergency hotline to obtain assistance. Every health care facility should have a procedure for responding to persons at risk of suicide and should know whom to call for assistance.

If you are alone with a client, a call to the local mental health crisis line, emergency department, or (800) 273-TALK (8255) can be helpful. Make sure that you always have these numbers readily available. Also:
  • Tell the client why the call is important and have the client talk with the crisis worker.
  • Stay with the client until assistance arrives.
  • Call 911 if it looks like the client is in an immediate crisis requiring hospitalization or medical intervention and he or she has no safe way to get to a hospital or emergency room or refuses to go voluntarily. Clients should never be permitted to drive themselves to the hospital.
  • Involve the client's family members and significant others (when possible) in supporting any decision for hospitalization.
  • Err on the side of caution.
If you have any suspicions that a client is seriously considering harming him- or herself, let your client know that you care, that he or she is not alone, and that you are there to help. You may have to work with your client's family to ensure that he or she will be adequately supported until a mental health professional can provide an assessment. In some cases, you may have to accompany your client to the emergency room at an area hospital or crisis center. If your client is uncooperative, combative, or otherwise unwilling to seek help, and you sense that he or she is in acute danger, call 911 or (800) 273-TALK. Tell the dispatcher that you are concerned that the person with you "is a danger to him- or herself" or "cannot take care of him- or herself." These key phrases will alert the dispatcher to locate immediate care for this person with the help of police. Do not hesitate to make such a call if you suspect that someone may be a danger to him- or herself. It could save that person's life.

As an AOD counselor, you work with people who have behaved in ways that are, by definition, self-destructive and who are at elevated risk of suicide. The relationship that you build with your clients may encourage them to ask for help from you-sometimes directly, sometimes indirectly. Whether you are prepared to offer this help can be a matter of life or death.

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References

Conner, K. R., Meldrum, S., Wieczorek, W. F., Duberstein, P. R., & Welte, J. W. (2004). The association of irritability and impulsivity with suicidal ideation among 15- to 20-year-old males. Suicide and Life-Threatening Behavior, 34(4), 363-373.

Goldsmith, S. K., Pellmar, T. C., Kleinman, A. M., & Bunney, W. E. (Eds.). (2002). Reducing suicide: A national imperative. Washington, DC: The National Academies Press. Retrieved March 14, 2005, from http://books.nap.edu/openbook.php?isbn=0309083214

Lester, D. (2000). Alcoholism, substance abuse, and suicide. In R.W. Maris, A. Berman, and M.M. Silverman (Eds.), Comprehensive textbook of suicidology (pp. 357- 375). New York: Guilford Press.

Merikangas, K. R., Mehta, R. L. Molnar, B. E., Walters, E. E., Swendsen, J. D., Aguilar- Gaziola, S., et al. (1998). Comorbidity of substance use disorders with mood and anxiety disorders: Results of the international consortium in psychiatric epidemiology. Addictive Behaviors, 23(6), 893-907.

Murphy, G. (2000). Psychiatric aspects of suicidal behavior: Substance abuse. In K. Hawton and K. Van Heeringen (Eds.), International handbook of suicide and attempted suicide (pp. 135-146). Chichester, UK: John Wiley and Sons.

Sadock, B. J., & Sadock, V. A. (Eds.). (2002). Kaplan & Sadock's synopsis of psychiatry (9th ed.). Philadelphia, PA: Lippincott, Williams, and Wilkins.

Substance Abuse and Mental Health Services Administration. (2003). The NHSDA report: Substance use and the risk of suicide among youths. Retrieved March 14, 2005, from http://oas.samhsa.gov/2k2/suicide/suicide.htm

Weiss, R., & Hufford, M. (1999). Substance abuse and suicide. In D. Jacobs (Ed.), Harvard Medical School guide to suicide assessment and intervention (pp. 300-310). San Francisco: Jossey-Bass.

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Resources

Resources for AOD Counselors

Center for Substance Abuse Prevention. (2002). Suicide, depression, and youth drinking. Prevention Alert, 5(17). Retrieved March 14, 2005, from http://ncadi.samhsa.gov

Conner, K. R., & Duberstein, P. R. (2004). Predisposing and precipitating factors for suicide among alcoholics: Empirical review and conceptual integration. Alcoholism Clinical Experimentation and Research, 28(Suppl. 7), 6S-17S.

Hawton, K., & Wan Heeringen, K. (Eds.). (2000). International handbook of suicide and attempted suicide. Chichester, UK: John Wiley and Sons.

Jacobs, D. (Ed.). (1999). The Harvard Medical School guide to suicide assessment and intervention. San Francisco: Jossey-Bass.

Maris, R., Berman, A., & Silverman, M. M. (Eds.). (2000). Comprehensive textbook of suicidology. New York: Guilford Press.

Murphy, G. E. (1992). Suicide in alcoholism. New York: Oxford University Press.

Preuss, U. W., Schuckit, M. A., Smith, T. L., Danko, G. P., Bucholz, K. K., Hesselbrock, M. N., et al. (2003). Predictors and correlates of suicide attempts over 5 years in 1,237 alcohol-dependent men and women. American Journal of Psychiatry, 160(1), 56-63.

Shea, S. C. (1999). The practical art of suicide assessment: A guide for mental health professionals and substance abuse counselors. New York: John Wiley.

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General Resources on Suicide and Suicide Prevention

Suicide Prevention Resource Center ( http://www.sprc.org/). The Suicide Prevention Resource Center (SPRC) provides prevention support, training, and materials to strengthen suicide prevention efforts. Among the resources found on its website is the SPRC Library Catalog (http://library.sprc.org/), a searchable database a wealth of information on suicide and suicide prevention, including publications, peer-reviewed research studies, curricula, and web-based resources. Many of these items are available online.

American Association of Suicidology ( http://www.suicidology.org/). The American Association of Suicidology is a nonprofit organization dedicated to the understanding and prevention of suicide. It promotes research, public awareness programs, public education, and training for professionals and volunteers and serves as a national clearinghouse for information on suicide.

American Foundation for Suicide Prevention (http://www.afsp.org). The American Foundation for Suicide Prevention (AFSP) is dedicated to advancing our knowledge of suicide and our ability to prevent it. AFSP's activities include supporting research projects; providing information and education about depression and suicide; promoting professional education for the recognition and treatment of depressed and suicidal individuals; publicizing the magnitude of the problems of depression and suicide and the need for research, prevention, and treatment; and supporting programs for suicide survivor treatment, research, and education.

National Center for Injury Prevention and Control (http://www.cdc.gov/ncipc/). The National Center for Injury Prevention and Control (NCIPC), located at the Centers for Disease Control and Prevention, is a valuable source of information and statistics about suicide, suicide risk, and suicide prevention. To locate information on suicide and suicide prevention, scroll down the left-hand navigation bar on the NCIPC website and click on "Suicide" under the "Violence" heading.

National Suicide Prevention Lifeline (http://www.suicidepreventionlifeline.org/). The National Suicide Prevention Lifeline provides immediate assistance to individuals in suicidal crisis by connecting them to the nearest available suicide prevention and mental health service provider through a toll-free telephone number: (800) 273-TALK. Technical assistance, training, and other resources are available to the crisis centers and mental health service providers that participate in the network of services linked to the National Suicide Prevention Lifeline.

Suicide Prevention Action Network USA (http://www.spanusa.org). Suicide Prevention Action Network USA (SPAN USA) is the nation's only suicide prevention organization dedicated to leveraging grassroots support among suicide survivors (those who have lost a loved one to suicide) and others to advance public policies that help prevent suicide.

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This effort has been funded in part with Federal funds from the National Institute of Mental Health, National Institutes of Health, under Contract No. N44MH22044.

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