Did You Know?
•Suicide is a leading cause of death among people who abuse alcohol and drugs (Wilcox, Conner, & Caine, 2004).
•Compared to the general population, individuals treated for alcohol abuse or dependence are at about 10 times greater risk to eventually die by suicide compared with the general population, and people who inject drugs are at about 14 times greater risk for eventual suicide (Wilcox et al., 2004).
•Individuals with substance use disorders are also at elevated risk for suicidal ideation and suicide attempts (Kessler, Borges, & Walters, 1999).
•People with substance use disorders who are in treatment are at especially high risk of suicidal behavior for many reasons, including:
–They enter treatment at a point when their substance abuse is out of control, increasing a variety of risk factors for suicide (Ross, Teesson, Darke, Lynskey, Ali, Ritter, et al., 2005).
–They enter treatment when a number of cooccurring life crises may be occurring (e.g., marital, legal, job) (Ross et al., 2005).
–They enter treatment at peaks in depressive symptoms (Ross et al., 2005).
–Mental health problems (e.g., depression, posttraumatic stress disorder [PTSD], anxiety disorders, some personality disorders) associated with suicidality 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).

Suicide risk is a problem that every frontline substance abuse counselor must be able to address. This chapter is written for you if you are a frontline counselor in a substance abuse treatment program and/or if you work with individuals who have both a substance abuse and mental health disorder and/or if you provide supervision or consultation to frontline counselors. While the information in this TIP is specific to clients with a substance use disorder diagnosis who exhibit suicidal thoughts and behaviors, the content can be generalized for counselors addressing all people with suicidal ideation or behavior.

Research consistently shows a high prevalence of suicidal thoughts and suicide attempts among persons with substance abuse problems who are in treatment (Ilgen, Harris, Moos, & Tiet, 2007) and a significant prevalence of death-by-suicide among those who have at one time been in substance abuse treatment when compared with those who do not have a diagnosis of substance use disorder (Wilcox et al., 2004). As a result, substance abuse treatment providers must be prepared to gather information routinely from, refer, and participate in the treatment of clients at risk for suicidal behavior. Suicidal thoughts and behaviors are also a significant indicator of other co-occurring disorders (such as major depression, bipolar disorder, PTSD, schizophrenia, and some personality disorders) that will need to be explored, diagnosed, and addressed to improve outcomes of substance abuse treatment.

Your clinical training in substance abuse counseling puts you in a solid position to perform the tasks outlined in this TIP. As you will learn, the first step in addressing suicidality is to "gather information," or to perform exactly the same kind of information-gathering tasks you do every day. For example, if a client were having trouble with craving, you would first want to know more about it. Think about the types of questions you would ask. They might include "Tell me about your craving. How often do you have it? How strong is it? What makes it worse?" These questions are precisely the type you would ask about suicidal thoughts: "Tell me about your suicidal thoughts. How often do you have them? How strong are they? What makes them worse?"
In other words, even though some content areas may be less familiar to you, your training and experience in substance abuse counseling provides you with the foundation you need to address suicidal behaviors with your clients.

Consensus Panel Recommendations
You are a trained substance abuse treatment professional or an integrated treatment specialist who works with persons with co-occurring substance use and mental disorders, but most likely, your background does not include detailed training in addressing your clients' suicidal thoughts and behaviors. This TIP is designed to fill that gap and increase your understanding of relevant mental disorders.
In particular, the consensus panel recommends the following:
•Clients in substance abuse treatment should be screened for suicidal thoughts and behaviors routinely at intake and at specific points in the course of treatment (see pp. 15–18 ). Screening for clients with high risk factors should occur regularly throughout treatment.
•Counselors should be prepared to develop and implement a treatment plan to address suicidality and coordinate the plan with other providers.
•If a referral is made, counselors should check that referral appointments are kept and continue to monitor clients after crises have passed, through ongoing coordination with mental health providers and other practitioners, family members, and community resources, as appropriate.
•Counselors should acquire basic knowledge about the role of warning signs, risk factors, and protective factors as they relate to suicide risk.
•Counselors should be empathic and nonjudgmental with people who experience suicidal thoughts and behaviors.
•Counselors should understand the impact of their own attitudes and experiences with suicidality on their counseling work with clients.
•Substance abuse counselors should understand the ethical and legal principles and potential areas of conflict that exist in working with clients who have suicidal thoughts and behaviors.

It is important for you to be comfortable and competent when asking your clients questions about suicidal ideation and behavior. It may be challenging to balance your own comfort level with your need to obtain accurate and clear information in order to best help the client. Suggestions made by the consensus panel to ease the process follow.

Be Direct
Talking with clients about their thoughts of suicide and death is uncomfortable. However, you must overcome this discomfort, as it may lead a counselor to ask a guaranteed conversation-ending question, such as "You don't have thoughts about killing yourself, do you?" Discomfort can also lead counselors to avoid asking directly about suicidality, which may convey uneasiness to the patient, imply that the topic is taboo, or result in confusion or lack of clarity. Instead, counselors can learn to ask, "Are you thinking about killing yourself?" Of course, death and suicide are just two examples of taboo topics for many people. The same observations can be made in addressing issues of sexuality and sexual orientation, money and finances, and relationship fantasies and behaviors. The difference is that asking about suicidal thoughts can actually save a life, as it allows a client to feel safe and understood enough to raise concerns and beliefs with you, the counselor. It is important to note that there is no empirical evidence to suggest that talking to a person about suicide will make them suicidal.

Increase Your Knowledge About Suicidality
One of the best ways to become more comfortable with any topic is to learn more about it. Suicide is no exception. Knowing some of the circumstances in which people become suicidal, how suicidality manifests, what warning signs might indicate possible suicidal behavior, what questions to ask to identify suicidality, and, perhaps most important, what the effective interventions are, can increase your competence, and as a result, your comfort in addressing this issue with clients.