Addressing Suicidal Thoughts and Behaviors in Substance Abuse Treatment

Addressing Suicidal Thoughts and Behaviors in Substance Abuse Treatment


– HELLO AND WELCOME TO THIS
TRAINING VIDEO ON PREVENTING AND TREATING SUICIDAL BEHAVIOR
AMONG CLIENTS WITH SUBSTANCE USE DISORDERS. MY NAME IS KIRK PENBERTHY,
AND I’LL BE MODERATING TODAY’S DISCUSSION. JOINING ME TODAY ARE OUR
3 DISTINGUISHED PANELISTS. DR. MARY SCHOHN, WHO’S
DIRECTOR OF THE VA VISN 2 BEHAVIORAL HEALTH CARE LINE;
MS. TAMEKIA SLAUGHTER, WHO’S A SOCIAL WORKER AT THE BUFFALO
VA MEDICAL CENTER AND GOES BY NIKKI; DR. MATTHEW BARRY,
WHO’S A PSYCHIATRIST AT THE CANANDAIGUA VA MEDICAL
CENTER, WHOSE EXPERIENCE INCLUDES TREATING FRONTLINE
TROOPS IN AFGHANISTAN. MARY, CAN SUBSTANCE ABUSE
TREATMENT PROVIDERS PLAY AN IMPORTANT ROLE IN SUICIDE
PREVENTION IN THE VA? – YES,
THEY CERTAINLY CAN. CLIENTS WITH SUBSTANCE ABUSE
DISORDERS ARE AT ELEVATED RISK FOR SUICIDE,
PARTICULARLY THOSE WITH CO-OCCURRING CONDITIONS. THEREFORE, IT IS ESSENTIAL
THAT SUBSTANCE ABUSE TREATMENT PROVIDERS BE PREPARED TO
RECOGNIZE AND RESPOND TO SUICIDAL THOUGHTS
AND BEHAVIORS. IT IS ALSO ESSENTIAL THAT
PROGRAM ADMINISTRATORS PROVIDE THE NEEDED SUPPORT AND
GUIDANCE IN THIS EFFORT. – MARY, WHAT ARE YOU
RECOMMENDING THAT VA SUBSTANCE ABUSE TREATMENT PROVIDERS
DO TO MANAGE SUICIDE RISK? – THE PROCEDURE WE’RE
RECOMMENDING IS SPELLED OUT IN THE TREATMENT IMPROVEMENT
PROTOCOL, OR TIP, PROVIDED BY THE CENTER FOR SUBSTANCE
ABUSE TREATMENT AT SAMHSA. THIS TIP, NUMBER 50, IS CALLED
“ADDRESSING SUICIDAL THOUGHTS AND BEHAVIORS IN
SUBSTANCE ABUSE TREATMENT.” – I SEE. WHAT’S IN THE TIP? – TIP 50 EXPLAINS TO SUBSTANCE
ABUSE TREATMENT PROVIDERS AND THEIR SUPERVISORS HOW TO
DEAL WITH SUICIDAL CLIENTS. NEXT, IT SHOWS THEM WHAT TO DO
THROUGH DETAILED CASE EXAMPLES CALLED VIGNETTES. FINALLY, IT PROVIDES
INFORMATION ABOUT HOW A PROGRAM ADMINISTRATOR COULD
IMPLEMENT TIP 50 IN A GIVEN TREATMENT PROGRAM. – MARY,
WHAT ARE THE STEPS IN MANAGING SUICIDE RISK? – THESE STEPS ARE SPELLED
OUT IN TIP 50 USING THE ACRONYM GATE: G-A-T-E. GATHER INFORMATION, ACCESS
SUPERVISION, TAKE ACTION, EXTEND THE ACTION. THE FIRST STEP, GATHER
INFORMATION, REFERS TO OBTAINING THE INFORMATION
THAT WILL BE NEEDED TO DEVELOP A PLAN OF ACTION. – NIKKI,
I IMAGINE IT CAN BE TRICKY TO GATHER INFORMATION
FROM A SUICIDAL VETERAN WITH A SUBSTANCE
ABUSE PROBLEM. HOW DO YOU GO ABOUT THAT? – TIP RECOMMENDS THAT
COUNSELORS BE DIRECT AND CLEAR, REMAIN EMPATHETIC AND SUPPORTIVE, AND USE OPEN BODY LANGUAGE. ALSO, ALTHOUGH A COUNSELOR MAY FEEL ANXIOUS ABOUT THE TOPIC OF SUICIDE, IT IS IMPORTANT NOT TO ALLOW ANXIETY TO PREVENT ONE FROM GATHERING INFORMATION OR LEAD ONE INTO THE TRAP OF BECOMING A “SUICIDE INTERROGATOR.” – WHAT DO YOU MEAN BY NOT LETTING A COUNSELOR’S ANXIETY PREVENT THEM FROM
GATHERING INFORMATION? – ANXIETY ABOUT SUICIDE CAN
CAUSE A COUNSELOR TO AVOID THE ISSUE ALTOGETHER OR SEEK FALSE
REASSURANCES FROM A CLIENT. SUCH AVOIDANCE CAN
TAKE MANY FORMS. FOR EXAMPLE, A QUESTION SUCH
AS, “YOU’RE NOT SUICIDAL, ARE YOU?” IS WORDED IN A WAY
THAT CONVEYS TO THE CLIENT THAT SUICIDE IS NOT A TOPIC
THAT THE COUNSELOR WANTS TO DISCUSS. – WHAT DO YOU MEAN,
“AVOID BEING THE SUICIDE INTERROGATOR”? – ANXIETY ABOUT SUICIDE
CAN ALSO CAUSE A COUNSELOR TO GRILL A CLIENT
ABOUT SUICIDALITY BY ASKING RAPID-FIRE CLOSE-ENDED
QUESTIONS, A PATTERN THAT IS REFERRED TO IN THE
TIP AS BECOMING THE SUICIDE INTERROGATOR. SUBSTANCE ABUSE COUNSELORS ARE
ENCOURAGED TO RELAX AS MUCH AS POSSIBLE, TO TAKE THEIR TIME,
TO ASK OPEN-ENDED QUESTIONS, AND TO ALLOW THE CLIENT THE
SPACE TO EXPLAIN THEIR STORY IN THEIR OWN WORDS. IN GENERAL, COUNSELORS SHOULD
APPLY THEIR BEST THERAPEUTIC SKILLS WITH SUICIDAL CLIENTS
JUST AS THEY WOULD ANY SENSITIVE TOPIC. – MATT,
WHAT QUESTIONS SHOULD YOU ASK A CLIENT WHEN YOU’RE
GATHERING INFORMATION? – THAT’S A GOOD
QUESTION, KIRK. THE MOST CRITICAL THING TO
ASK ABOUT IS SUICIDALITY ITSELF–THAT IS,
TO ASK ABOUT SUICIDAL THOUGHTS AND SUICIDAL BEHAVIOR
AND TO DO SO DIRECTLY. SOMETIMES THE TOPIC COMES UP
SPONTANEOUSLY, BUT MORE OFTEN THE COUNSELOR NEEDS TO
INTRODUCE THE TOPIC, AND DON’T BE AFRAID TO DO SO. BY AND LARGE, CLIENTS WILL
EXPECT AND/OR BE RELIEVED IF THE SUBJECT IS BROUGHT UP. AND WE’D RECOMMEND THAT THE COUNSELORS OPEN THE TOPIC WITH A BRIEF STATEMENT SUCH AS “NOW I’M GOING TO ASK YOU SOME QUESTIONS ABOUT SUICIDE” OR “I “HAVE SOME QUESTIONS TO ASK YOU “ABOUT SUICIDAL THOUGHTS AND BEHAVIOR.” THEN YOU SHOULD ASK SCREENING
QUESTIONS ABOUT SUICIDAL THOUGHTS AND SUICIDE
ATTEMPTS TO SEE IF IT’S AN ACTIVE ISSUE. SOME EXAMPLES OF SUCH
QUESTIONS CAN BE FOUND ON PAGES 15 TO 17 OF
THE TIP 50 MANUAL. – ONCE YOU’VE DETERMINED
THAT SUICIDE IS AN ISSUE, WHAT THEN? – YOU WANT TO LEARN MORE
ABOUT IT IN THE WAY YOU ASK ABOUT ANY THERAPEUTIC ISSUE. SO TAKING, FOR EXAMPLE,
ALCOHOL CRAVING. IN THAT CASE, A COUNSELOR
MIGHT INVITE A CLIENT TO EXPLAIN THEIR CRAVINGS WITH
AN OPENING STATEMENT SUCH AS, “TELL ME ABOUT YOUR CRAVINGS.” AND THIS COULD BE FOLLOWED UP
AS NEEDED WITH MORE SPECIFIC QUESTIONS SUCH AS, WHAT
BRINGS THE CRAVINGS ON? HOW BAD DO THEY GET? WHAT MAKES THEM BETTER? AND HOW MUCH CONTROL DO YOU
FEEL YOU HAVE WHEN YOU’RE EXPERIENCING THEM? SO THE SKILL SET
IS ALREADY THERE. IT’S JUST APPLYING THE SAME
APPROACH TO A DIFFERENT TOPIC, AND THAT TOPIC
BEING SUICIDALITY. SO FOR EXAMPLE, ONE CAN START
WITH AN INVITATION TO EXPLAIN, SUCH AS “TELL ME ABOUT YOUR
SUICIDAL THOUGHTS,” AND THAT CAN BE FOLLOWED UP BY MORE
SPECIFIC QUESTIONS AS NEEDED, SUCH AS, WHAT BRINGS THE
SUICIDAL THOUGHTS ON? HOW BAD CAN THEY GET? WHAT MAKES THEM BETTER? AND HOW MUCH CONTROL DO
YOU FEEL YOU HAVE WHEN YOU EXPERIENCE THEM? – AND CAN EXAMPLES LIKE THIS
ALSO BE FOUND IN TIP 50? – YEAH, THEY SURE CAN. QUESTIONS LIKE THESE ARE
LISTED ON PAGES 17 TO 18 OF THE TIP 50 MANUAL. – YOU’VE COVERED ASKING
ABOUT SUICIDAL THOUGHTS. HOW ABOUT SUICIDAL BEHAVIOR? WHAT TYPES OF FOLLOW-UP
QUESTIONS WOULD YOU ASK? – WELL, THE TIP 50 HAS
NUMEROUS FOLLOW-UP QUESTIONS FOR SUICIDE ATTEMPTS,
AND THESE CAN BE FOUND ON PAGE 18 OF THE TIP 50 MANUAL. YOU’D WANT TO ASK
OPEN-ENDED QUESTIONS ABOUT AN ATTEMPT SUCH AS,
“PLEASE TELL ME WHAT HAPPENED” AND THEN AS NEEDED, YOU
CAN FOLLOW IT UP WITH MORE SPECIFIC QUESTIONS, SUCH AS
WHAT METHOD DID YOU USE TO ATTEMPT SUICIDE? ANOTHER GOOD QUESTION IS, WHAT HAPPENED AS A RESULT? SO FOR EXAMPLE, DID YOU RECEIVE ANY TREATMENT OR HAVE TO GO TO THE HOSPITAL? YOU WOULD ALSO WANT TO LEARN IF THERE WAS ANY OTHER ATTEMPTS OR IF THERE HAVE BEEN OTHERS IN THE PAST. – MARY,
IS THAT IT, THEN? TO GATHER INFORMATION
ABOUT SUICIDAL THOUGHTS AND BEHAVIOR? – IT IS ALSO IMPORTANT
TO GATHER INFORMATION ABOUT WARNING SIGNS,
RISK FACTORS, AND PROTECTIVE FACTORS. – WHAT’S A WARNING SIGN? – WARNING SIGNS ARE
INDICATIONS OF ACUTE RISK. TIP 50 PROVIDES A LIST OF
WARNING SIGNS THAT WERE IDENTIFIED BY A
PANEL OF EXPERTS. WARNING SIGNS MAY BE
DIRECT OR INDIRECT. DIRECT WARNING SIGNS ARE
GIVEN THE HIGHEST PRIORITY BECAUSE THEY ARE THE
CLEAREST SIGNALS OF DANGER. THESE CONSIST OF SUICIDAL COMMUNICATION, WHERE A CLIENT EXPRESSES OR ALLUDES TO THOUGHTS OR PLANS FOR SUICIDE; SEEKING ACCESS TO A METHOD– FOR EXAMPLE, ACQUIRING A STASH OF PILLS OR SEEKING OUT A GUN OR A MEANS FOR HANGING; AND MAKING PREPARATIONS FOR SUICIDE–FOR EXAMPLE, REHEARSING A SUICIDAL ACT, SAYING GOOD-BYE TO LOVED ONES,
OR GETTING AFFAIRS IN ORDER. – WHAT ABOUT
INDIRECT WARNING SIGNS? – A PANEL OF EXPERTS ALSO CAME
UP WITH A LIST OF 10 INDIRECT WARNING SIGNS THAT SPELL
OUT THE ACRONYM ISPATHWARM. ALTHOUGH INDIRECT WARNING SIGNS MAY INDICATE ACUTE SUICIDE RISK, THIS IS NOT ALWAYS THE CASE. FOR EXAMPLE. MANY SUBSTANCE ABUSE CLIENTS SHOW ANGER, RECKLESSNESS, OR ANXIETY, BUT THIS DOES NOT NECESSARILY MEAN THAT THEY ARE SUICIDAL. THEREFORE IT IS IMPORTANT TO CONSIDER THESE INDIRECT WARNING SIGNS IN THE CONTEXT OF OTHER INDICATORS OF RISK. – WHEN DO WARNING SIGNS TEND TO OCCUR? – THEY OFTEN OCCUR FOLLOWING
ACUTE STRESSFUL EVENTS–FOR EXAMPLE, FOLLOWING A
RELAPSE OR THE BREAKUP OF A PARTNER RELATIONSHIP. THEY’RE ALSO MORE LIKELY
TO OCCUR WHEN A CLIENT IS INTOXICATED OR HIGH. A RULE OF THUMB IS THAT
FOLLOWING A STRESSFUL LIFE EVENT, A COUNSELOR WANTS
TO LOOK FOR WARNING SIGNS. – ALONG WITH WARNING SIGNS,
YOU ALSO MENTIONED THAT RISK FACTORS ARE IMPORTANT
TO CONSIDER. WHAT DO YOU MEAN BY RISK
FACTOR, AND HOW ARE THEY DIFFERENT FROM WARNING SIGNS? – WARNING SIGNS INDICATE ACUTE
RISK, WHEREAS RISK FACTORS ARE INDICATORS OF MORE
LONG-TERM RISK. RISK FACTORS ARE HELPFUL FOR
IDENTIFYING WHICH CLIENTS ARE VULNERABLE TO BECOME SUICIDAL
DURING THE COURSE OF TREATMENT AND WHICH CLIENTS MAY REQUIRE
ADDITIONAL TREATMENT SERVICES IN ORDER TO LOWER
THEIR OVERALL RISK. RISK FACTORS MAY ALSO CHANGE
OVER THE COURSE OF TIME. FOR EXAMPLE, CLIENTS MAY
BECOME MORE DEPRESSED, AND SUCH CHANGES ARE ALSO VERY
IMPORTANT TO PAY ATTENTION TO. HERE IS A LIST OF RISK FACTORS: PERSONAL OR FAMILY HISTORY; SEVERE SUBSTANCE ABUSE; CO-OCCURRING MENTAL DISORDER; CHILDHOOD SEXUAL ABUSE; STRESS; ACCESS TO FIREARM; AGGRESSION, IMPULSIVITY, ANGER, OR ANXIETY; CHRONIC MEDICAL PROBLEMS; PERCEPTION OF NOT BELONGING; AND PERCEPTION OF BEING A BURDEN. SUICIDAL CLIENTS
TYPICALLY SHOW MORE THAN ONE RISK FACTOR. – HOW ABOUT PROTECTIVE
FACTORS? – PROTECTIVE FACTORS SERVE
TO LOWER RISK FOR SUICIDAL BEHAVIOR. UNFORTUNATELY, THERE HAS
NOT BEEN MUCH RESEARCH OF PROTECTIVE FACTORS,
BUT HERE IS A LIST OF FACTORS THAT APPEAR TO LOWER
RISK FOR SUICIDE. PROTECTIVE FACTORS INCLUDE HAVING REASONS FOR LIVING, STAYING CLEAN AND SOBER, RELIGIOUS ATTENDANCE OR SPIRITUAL BELIEFS AGAINST SUICIDE, PRESENCE OF A CHILD IN THE HOME OR CHILD-REARING RESPONSIBILITIES, AN INTACT MARRIAGE, A TRUSTING THERAPEUTIC RELATIONSHIP, SOCIAL SUPPORT, EMPLOYMENT, AND A GENERALLY HOPEFUL OUTLOOK. – SO IF A CLIENT HAS PROTECTIVE FACTORS, THEN ARE THEY SAFE? – NO. IT ISN’T THAT SIMPLE. ALTHOUGH PROTECTIVE FACTORS
CAN HELP, THEY ARE NOT 100% PROTECTIVE, AND THEY CAN BE
OVERWHELMED BY WARNING SIGNS AND RISK FACTORS. IT IS A MISTAKE TO PUT TOO
MUCH STOCK IN A PROTECTIVE FACTOR WHEN THERE ARE
CLEAR SIGNS OF DANGER. OVERALL, IT IS ESSENTIAL
TO CONSIDER ALL OF THE INFORMATION PERTAINING
TO WARNING SIGNS, RISK FACTORS, AND PROTECTIVE
FACTORS RATHER THAN TO GRAB ON TO ANY ONE PIECE
OF INFORMATION. ONE NEEDS TO CONSIDER
THE WHOLE PICTURE. – THANK YOU FOR WALKING US
THROUGH “GATHER INFORMATION.” MATT, I UNDERSTAND THAT YOU
HAVE A CLIP TO SHOW US THAT DEMONSTRATES THIS STEP. – THAT’S RIGHT, KIRK. THIS IS A VIGNETTE ABOUT
ANTONIO RODRIGUEZ, WHO IS A 25-YEAR-OLD OIF VETERAN,
AND HE COMPLETED HIS MILITARY SERVICE ABOUT TWO YEARS PRIOR,
AND SINCE THAT TIME, HE’S HAD A DIFFICULT ADJUSTMENT. HE’S CURRENTLY IN AN
OUTPATIENT SUBSTANCE ABUSE TREATMENT AT A VA CLINIC FOR
THE TREATMENT OF ALCOHOLISM AND CANNABIS DEPENDENCE. PRECIPITATING HIS TREATMENT WAS
AN ARREST FOR DRIVING WHILE INTOXICATED AND MARIJUANA
POSSESSION, AND THAT LED TO MISDEMEANOR CHARGES
AND ULTIMATELY TO A COURT DIVERSION PROGRAM. CONDITIONS OF THE COURT
DIVERSION PROGRAM INCLUDED THAT HE WORK WITH A COURT CASE
MANAGER AND COMPLETE A COURSE OF SUBSTANCE ABUSE TREATMENT. SO HE’D BEEN DOING WELL IN
HIS TREATMENT, WITH GOOD ATTENDANCE AND CONTINUOUS
SOBRIETY, BUT HE’D BEEN ABSENT FOR ABOUT A WEEK AND DID
NOT RETURN HIS COUNSELOR’S PHONE CALLS. HE DID SHOW UP TO HIS
REGULARLY SCHEDULED GROUP THERAPY APPOINTMENT, AND THE
COUNSELOR, WHOSE NAME IS JILL, ASKED TO SPEAK WITH
HIM AFTER GROUP. – ANTONIO, IT WAS GOOD TO
SEE YOU IN GROUP AGAIN TODAY. YOU KNOW, I’VE BEEN CONCERNED
BECAUSE YOU’VE BEEN ABSENT LATELY AND I HAVEN’T
HEARD FROM YOU. – I’VE BEEN BUSY. – YEAH? WHAT’S BEEN GOING ON? – JUST CRAZY BUSY. – WOULD YOU LIKE TO FILL ME
IN A LITTLE MORE ON THAT? – IF YOU MUST KNOW… MY GIRLFRIEND KICKED ME OUT. – YOU MEAN LOUISA? – YEAH. – OH,
I’M SORRY TO HEAR THAT. WHERE ARE YOU STAYING NOW? – AT EVA’S–MY SISTER’S. LOUISA WON’T RETURN MY CALLS. I THINK SHE’S DONE
WITH ME THIS TIME. – THAT MUST BE
REALLY HARD FOR YOU. YOU’VE OFTEN TALKED ABOUT
HOW IMPORTANT SHE IS TO YOU. – SHE’S EVERYTHING. – WOULD YOU MIND TELLING
ME WHAT BROUGHT THIS ON? – STUFF HAPPENED, YOU KNOW? – ANTONIO, I CAN TELL THAT
THIS IS A SENSITIVE SUBJECT, BUT PERHAPS IT MIGHT HELP
IN SOME SMALL WAY TO TALK ABOUT IT. – LOUISA KICKED ME OUT BECAUSE
I GOT DRUNK AND STAYED OUT ALL NIGHT. – I SEE. SO YOU’RE NOT ONLY
DEALING WITH THE STRESS WITH LOUISA BUT ALSO THE
STRESS OF A RELAPSE. – YEAH. IT WAS STUPID. I, UH… I RAN INTO THIS GUY THAT
I USED TO HANG WITH, AND THE NEXT THING I KNOW,
WE’RE AT THIS BAR, AND WE’RE THROWING THEM DOWN, AND
I WAS OUT ALL NIGHT. I DON’T EVEN REMEMBER
HOW I GOT HOME. – WERE YOU ABLE TO STOP
DRINKING AFTER THAT? – I WISH. – YOU JUST TAKE
YOUR TIME, OK? – WHEN I GOT HOME, LOUISA
WAS SCREAMING AT ME. I REMEMBER THAT. SHE THREATENED TO CALL THE
COPS IF I DIDN’T LEAVE. SHE BARELY GAVE ME SOME
TIME TO GRAB MY STUFF. I WENT TO MY SISTER’S, AND
SHE WASN’T THRILLED TO SEE ME. SHE WASN’T THRILLED TO SEE
THAT I HAD BEEN DRINKING ALL NIGHT, SO SHE LEANED
INTO ME PRETTY HARD. WELL, I WAS IN NO MOOD TO SIT
AROUND FOR THAT, SO I GRABBED A BOTTLE OF LIQUOR FROM HER
LIQUOR CABINET AND WENT TO THE PARK AND GOT DRUNK
ALL OVER AGAIN. UH… AS I WAS SITTING THERE… AS I WAS SITTING THERE,
I WAS RUNNING THE ARGUMENT WITH LOUISA OVER IN MY MIND. SHE LOVES ME, YOU KNOW? GOD, I LET HER DOWN. I LET HER DOWN AGAIN, AND I
JUST COULDN’T STOP THINKING ABOUT WHAT I HAD DONE TO
HER–LOUISA, EVEN WHAT I DID TO EVA. AND AT THAT MOMENT, IT JUST… SEEMED LIKE THE BEST WAY TO
FIX EVERYTHING WAS TO GET RID OF THE PERSON CAUSING
THE PROBLEMS, GET RID OF EVERYONE’S
PAIN AND ANGER… GET RID OF ME. – YOU WERE IN A LOT OF
EMOTIONAL PAIN SITTING THERE AT THAT PARK. JUST TAKE YOUR TIME, ANTONIO. I CAN SEE THAT THIS IS
VERY DIFFICULT FOR YOU TO TALK ABOUT. – YEAH. MY GUN WAS AT MY
SISTER’S, BUT… IF I’D HAD IT WITH ME, I’D
BE SOMEWHERE ELSE RIGHT NOW. I HAD SOME EVIL THOUGHTS JUST
SITTING THERE, AND NO MATTER HOW MUCH BOOZE I DRANK, I
JUST COULDN’T STOP THINKING ABOUT WHAT I HAD DONE. AND FINALLY A COP CAME BY AND
TOLD ME THE PARK WAS CLOSED AND TO GO HOME. – WOW. THAT WAS A PRETTY
INTENSE COUPLE OF DAYS. HEY, LOOK, I’M GLAD TO SEE
YOU’VE MADE IT THROUGH IN ONE PIECE. HOW YOU BEEN DOING SINCE THEN? – [SIGH] WELL, NO DRINKING,
IF THAT’S WHAT YOU MEAN. UH, UNTIL COMING TO GROUP
TODAY, I HAVEN’T EVEN LEFT MY SISTER’S. I DIDN’T TRUST MYSELF TO
GO ANYWHERE, AND I HAD NOWHERE TO GO. IT FELT GOOD TO BE BACK IN
GROUP TODAY, ALTHOUGH I DIDN’T SAY NOTHING. – WELL,
I WAS GLAD YOU’RE BACK, AND FROM THE LOOKS ON
THE OTHER MEMBER’S FACES, IT WAS PRETTY CLEAR THAT
THEY WERE HAPPY TO SEE YOU, TOO. ANTONIO, YOU HAD SOME BOUTS OF
SUICIDE WHILE YOU WERE SITTING AT THE PARK. I WAS WONDERING IF I COULD
ASK YOU A FEW MORE QUESTIONS ABOUT THAT. – ARE YOU GONNA LOCK ME UP? – WHILE IT IS TRUE THAT SOME
CLIENTS HAVE TO GO TO THE HOSPITAL FOR AN EMERGENCY
EVALUATION, THERE ARE OFTEN OTHER SAFE ALTERNATIVES. – YEAH? LIKE WHAT? – WELL,
FOR EXAMPLE, ANY PLAN WE MAKE TODAY, WE’LL MAKE TOGETHER. I WANT TO LET YOU KNOW THAT
I’M GONNA TOUCH BASE WITH MY SUPERVISOR BEFORE WE BREAK
TODAY, JUST TO MAKE SURE I’M NOT MISSING ANYTHING
IMPORTANT. BUT BEFORE WE MAKE ANY PLANS,
IT WOULD BE HELPFUL TO LEARN A BIT MORE ABOUT HOW YOU’VE
BEEN DOING SINCE THAT DAY AT THE PARK. – YOUR SUPERVISOR,
TOO? THAT’S GREAT. UH…I HAVEN’T THOUGHT ABOUT
SUICIDE SINCE THAT DAY. I HAVEN’T DRANK. I MIGHT HAVE DONE
SOMETHING CRAZY THAT DAY, BUT I’M OK NOW. – WELL,
I’M GLAD THAT YOU’VE BEEN ABLE TO STAY SOBER SINCE THAT DAY,
AND I’M GLAD THAT YOU’RE FEELING BETTER. LOOKING BACK ON WHAT HAPPENED,
HOW DO YOU FEEL ABOUT IT NOW? – WELL,
KILLING MYSELF WOULD BE LIKE KILLING MY MOM. I’M HER ONLY SON. MY FATHER’S DEAD, AND SHE’D
NEVER GET OVER IT, AND I’D BRING SHAME
ON HER, TOO. TO HER,
SUICIDE IS A SIN, AND I JUST– I COULDN’T DO THAT TO HER. MY SISTER WOULD ALSO GO
CRAZY IF I KILLED MYSELF. – YOU REALLY CARE FOR YOUR
MOM AND YOUR SISTER, AND YOU REALIZE HOW MUCH SUICIDE WOULD
HURT THEM, AND THAT HELPS YOU TO FOCUS HOW TO GO ON
LIVING DESPITE THE PROBLEMS WITH LOUISA? – YEAH. EXACTLY. – I’D LIKE TO ASK YOU A FEW
MORE QUESTIONS ABOUT THIS. WOULD THAT BE OK? – YOU’RE GONNA DO IT ANYWAY,
SO GET ON WITH IT. – THANKS FOR BEARING
WITH ME, ANTONIO. I REALLY APPRECIATE IT. I REALIZE THAT THESE ARE
VERY DIFFICULT QUESTIONS. AT THIS POINT, DO YOU HAVE
A PLAN FOR SUICIDE? – NO,
NOTHING LIKE THAT. I HAVEN’T THOUGHT ABOUT IT
SINCE THAT DAY IN THE PARK. – HOW DO YOU ACCOUNT FOR
FEELING DIFFERENTLY NOW THAN YOU DID THAT DAY? – I’M ONLY 25, AND I HOPE TO
HAVE A LOT OF YEARS OF LIFE LEFT, AND I JUST–I COULDN’T–
I COULDN’T DO THAT TO MY MOM. LIKE I SAID, I DON’T WANT
TO GO OUT THAT WAY. – YEAH. SEE? NOW, YOU’VE GOT A LOT OF
GOOD REASONS TO GO ON LIVING. AT THE PARK, YOU HAD
SOME SUICIDAL THOUGHTS, BUT FORTUNATELY, IT
NEVER WENT ANY FURTHER. HAVE YOU EVER HAD
THOUGHTS LIKE THAT BEFORE? – ONCE IN A WHILE, WHEN I WAS
HAMMERED, I HAD SOME THOUGHTS, BUT NOTHING LIKE THAT
DAY IN THE PARK. THAT WAS THE WORST BY FAR. – HAVE YOU EVER ACTUALLY
TRIED TO COMMIT SUICIDE? – NO, NEVER HAVE. WHEN I WAS IN IRAQ, THIS GUY
IN OUR UNIT KILLED HIMSELF. JUST WALKED OFF ONE DAY AND
PUT A BULLET IN HIS HEAD. THERE WERE A BUNCH OF RUMORS
ABOUT WHY HE DID IT, BUT NO ONE KNOWS WHAT THE TRUTH IS. I BARELY KNEW HIM. ANYWAYS, NO, I’VE NEVER
TRIED TO KILL MYSELF. – I’M SORRY TO HEAR ABOUT
THE GUY IN YOUR UNIT. HAS ANYONE ELSE YOU KNOW
EVER TRIED TO COMMIT SUICIDE? – NO,
JUST THAT GUY. – OK. NOW, YOU
MENTIONED A GUN. – YEAH. IT’S A GLOCK. IT’S IN MY BAG AT MY SISTER’S. SO WHAT? – WELL,
I MENTION IT BECAUSE I’M CONCERNED FOR YOUR SAFETY AND
YOU THOUGHT OF USING IT WHILE YOU WERE DRUNK AT THE PARK. – I’M NOT THINKING
ABOUT IT NOW, AM I? – UNDERSTOOD. IT’S GOOD TO
KNOW THOSE THOUGHTS HAVE NOT COME BACK. IS THAT YOUR ONLY GUN? – YES. YEAH. – OK. SO, WHAT ARE
YOUR PLANS NOW? – [SIGH] JUST TAKING IT ONE
DAY AT A TIME. I HOPE TO GET MY SOBRIETY
BACK, MAYBE ONE DAY CONVINCE LOUISA TO TAKE ME BACK. RIGHT NOW SHE’D PROBABLY
CALL THE COPS IF I SHOWED UP. BUT SHE STUCK WITH ME THROUGH
MY LAST TWO DEPLOYMENTS. AND WE WERE PLANNING ON
GETTING MARRIED AND HAVING KIDS, AND MY MOM
AND SISTER LOVE HER. RIGHT NOW I’M JUST GONNA STAY
AT MY SISTER’S AND TRY TO GET MYSELF TOGETHER. – HOW IS THE SITUATION
AT YOUR SISTER’S? FOR EXAMPLE, IS IT
JUST THE TWO OF YOU? – NO. SHE’S THERE WITH HER
HUSBAND AND DAUGHTER, MY NIECE. AND MY BROTHER-IN-LAW IS COOL. HE’S EX-MILITARY, SO
WE GET ALONG GOOD. – DO YOU FEEL IT’S A SAFE
PLACE TO STAY CLEAN AND SOBER? – WELL,
THERE’S NO ALCOHOL IN THE HOUSE. MY SISTER SAW TO THAT. SINCE I TOOK THAT BOTTLE,
SHE GOT RID OF ALL OF IT. AND MY BROTHER-IN-LAW NEVER
HAD A PROBLEM HANDLING IT LIKE I DID,
SO AS LONG AS I’M THERE, SHE’D KILL HIM IF HE
BROUGHT LIQUOR TO THE HOUSE. THEY DON’T DO DRUGS,
DON’T EVEN SMOKE. ACTUALLY, THAT’S ONE THING I
HAVEN’T DONE SINCE SEEING YOU IS SMOKE MARIJUANA, SO AT
LEAST THAT’S SOMETHING, RIGHT? – AGREED. THAT IS A POSITIVE. IT SEEMS AS THOUGH YOU HAVE A
PRETTY GOOD SITUATION AT YOUR SISTER’S FOR NOW. – YEAH. – HAVE YOU EVER HAD TREATMENT
FOR A MENTAL DISORDER–FOR EXAMPLE, DEPRESSION OR PTSD? – NO. I SAW SOMEONE AT VA FOR
AN EVALUATION, BUT HE SAID I DON’T NEED ANY MEDICATIONS
OR ANYTHING LIKE THAT. I JUST NEED TO STOP DRINKING
AND SMOKING MARIJUANA. – WELL, THANK YOU
FOR ANSWERING MY QUESTIONS, ANTONIO. AT THIS POINT, I’M GONNA
TAKE A FEW MINUTES AND SPEAK WITH MY SUPERVISOR ABOUT YOUR
SITUATION, AND THEN I’LL COME BACK AND WE’LL MAKE A PLAN. IT’LL JUST BE A FEW MINUTES,
SO PLEASE BE PATIENT, OK? – WHO’S THIS SUPERVISOR
YOU’RE TALKING TO? – HER NAME IS GLORIA JOHNSON. I BELIEVE YOU MET HER. SHE COVERED MY GROUP A
COUPLE OF TIMES WHEN I WAS ON VACATION. – YEAH. I REMEMBER HER. – GOOD TO KNOW THE TWO
OF YOU HAVE MET. OK, I’LL BE BACK TO TALK
WITH YOU IN A FEW MINUTES. I APPRECIATE YOUR PATIENCE. I’M GONNA HAVE YOU WAIT IN THE
PRIVATE WAITING ROOM WHILE I SPEAK WITH MS.
JOHNSON, OK? – MATT, THAT’S A
VERY MOVING SCENE. ANTONIO IS OBVIOUSLY HAVING
A DIFFICULT TIME. – THAT’S RIGHT, KIRK.
I THINK WE CAN ALL FEEL FOR HIM. ANTONIO IS CLEARLY IN A
LOT OF EMOTIONAL PAIN. HE BECAME TEARFUL IN
THE SESSION AND SHOWED GENUINE SADNESS. FROM MY EXPERIENCE, IT IS ALSO
IMPORTANT TO NOTE THAT MANY VETERANS IN ANTONIO’S
SITUATION WOULD NOT NECESSARILY SHOW TEARS
OR BE OVERTLY SAD. INSTEAD, A VETERAN MAY PRESENT
AS ANGRY OR EVEN APPEAR STOIC BUT STILL COULD BE EVERY BIT
AS MUCH A RISK AS ANTONIO IS. OVERALL, SUICIDAL CLIENTS
HAVE MANY DIFFERENT WAYS OF EXPRESSING THEIR
EMOTIONAL DIFFICULTIES. – I SUPPOSE THAT THE CENTRAL
LESSON IS THAT SUICIDAL VETERANS ARE A DIVERSE GROUP
AND THEY CAN PRESENT IN MANY DIFFERENT WAYS. – THAT’S WELL-SAID, KIRK. I THINK THAT’S EXACTLY RIGHT. – THE THERAPIST SEEMED TO
GATHER A LOT OF IMPORTANT INFORMATION THERE. – AGREED. I LIKE THE
WAY SHE WENT ABOUT IT. ANTONIO WAS OBVIOUSLY
UNCOMFORTABLE AT FIRST AND HESITANT TO TO DISCUSS
HIS SUICIDAL THOUGHTS, BUT THE THERAPIST MADE AN
EFFORT TO MAKE HIM MORE COMFORTABLE BY ASKING OPEN-
ENDED QUESTIONS AS MUCH AS POSSIBLE. SHE WAS ALSO GOOD AT
LISTENING AND MAINTAINING AN OPEN POSTURE. I ALSO REALLY LIKED THAT SHE
INVITED HIM TO TAKE HIS TIME AND THAT SHE ASKED PERMISSION
AT TIMES BEFORE PROCEEDING ON TO THE NEXT QUESTION,
AND I THINK THAT GIVING CLIENTS A SENSE OF CONTROL
LIKE THAT CAN PAY HANDSOME DIVIDENDS IN TERMS OF RAPPORT
AND INVESTMENT IN THE PROCESS. – ALONG WITH HAVING A
GOOD THERAPEUTIC STYLE, THE COUNSELOR ALSO SEEMED
TO COVER A LOT OF GROUND. – YES. I LIKED THE
QUESTIONS THAT SHE ASKED. SHE GATHERED IMPORTANT
INFORMATION ABOUT SUICIDAL THOUGHTS, HOW THEY CAME ABOUT,
HOW SERIOUS THEY WERE, AND OTHER FACTORS RELATED TO
RISK, INCLUDING THE BREAKUP WITH HIS GIRLFRIEND,
AND HIS FIREARM. SHE ALSO ASKED ABOUT MENTAL
HEALTH TREATMENT HISTORY, PRIOR SUICIDAL BEHAVIOR,
AND ANY SUICIDAL THOUGHTS OR PLANS SINCE THAT DAY IN THE
PARK, ALL OF WHICH ARE VERY IMPORTANT TO CONSIDER. SHE ALSO CLARIFIED THAT THE
SUICIDAL THOUGHTS OCCURRED WHILE HE WAS INTOXICATED AND
THAT THEY HAVE NOT RETURNED SINCE, ALTHOUGH THERE IS
ALWAYS A POSSIBILITY THAT ANTONIO IS MINIMIZING
THE SITUATION. THE COUNSELOR ACCOMPLISHED ALL
THIS EFFICIENTLY, AND INDEED, THE CLIP WE JUST SAW WAS ONLY
ABOUT 14 MINUTES, YET SHE WAS ABLE TO GATHER
ESSENTIAL INFORMATION IN THAT SPACE OF TIME. – OK. NIKKI, NOW THAT THE
COUNSELOR HAS GATHERED INFORMATION, WHAT’S NEXT? – THE NEXT STEP IS
ACCESS SUPERVISION. TIP 50 DESCRIBES TWO
BROAD TYPES OF SUPERVISION A CLINICIAN COULD ACCESS. ONE IS IMMEDIATE SUPERVISION,
AND TWO IS REGULAR SUPERVISION. – WHAT DO YOU MEAN BY
IMMEDIATE SUPERVISION? – IMMEDIATE SUPERVISION IS
REQUIRED WHEN THE COUNSELOR HAS INFORMATION TO SUGGEST
THAT THERE IS CURRENT RISK OF SUICIDAL BEHAVIOR. EARLIER, MARY REVIEWED DIRECT
WARNING SIGNS THAT INCLUDE SUICIDAL COMMUNICATION,
SEEKING A METHOD, AND MAKING PREPARATIONS FOR SUICIDE. THE PRESENCE OF ANY OF THESE DIRECT WARNING SIGNS INDICATES THE NEED TO OBTAIN IMMEDIATE SUPERVISION. IMMEDIATE SUPERVISION SHOULD ALSO BE OBTAINED IN ANY INSTANCE WHERE THE COUNSELOR SUSPECTS THAT THERE IS CURRENT RISK, WHETHER OR NOT THERE IS A DIRECT RISK FACTOR SUCH AS YOU SEE ON YOUR SCREEN. FOR EXAMPLE, IN ANTONIO’S CASE, IMMEDIATE SUPERVISION IS REQUIRED BECAUSE SUICIDAL THOUGHTS OCCURRED RECENTLY. THESE THOUGHTS INCLUDED
SHOOTING HIMSELF–A DEADLY METHOD OF SUICIDE. HE HAS ACCESS
TO A GUN, AND HE HAS RELAPSED RECENTLY. THEREFORE, EVEN THOUGH ANTONIO
IS SEEKING TO REASSURE HIS COUNSELOR THAT THE CRISIS
HAS PASSED, NONETHELESS THE COUNSELOR RECOGNIZES THAT
SHE SHOULD SPEAK WITH HER SUPERVISOR IMMEDIATELY. – I IMAGINE THAT REGULAR
SUPERVISION INVOLVES MORE ROUTINE SITUATIONS. – THAT’S RIGHT. REGULAR
SUPERVISION REFERS TO BRINGING UP AN ISSUE DURING YOUR WEEKLY
MEETINGS WITH YOUR SUPERVISOR OR DURING YOUR REGULARLY
SCHEDULED TEAM MEETINGS. SOME SITUATIONS WHEN REGULAR
SUPERVISION WOULD MAKE THE MOST SENSE WOULD BE WHEN INDIRECT WARNING SIGNS ARE PRESENT BUT FOLLOW-UP QUESTIONS SUGGEST NO CURRENT RISK, RISK FACTORS ARE PRESENT BUT FOLLOW-UP QUESTIONS SUGGEST NO CURRENT RISK, AND WHEN THERE’S A HISTORY OF SUICIDAL THOUGHTS OR SUICIDE ATTEMPTS BUT FOLLOW-UP QUESTIONS SUGGEST NO CURRENT RISK. OF COURSE, AS WE’RE LEARNING, THE TIP 50 MANUAL IS COMPREHENSIVE, AND THIS
INFORMATION CAN BE FOUND ON PAGE 19 OF THE MANUAL. – WELL,
LET’S SHOW THE TAPE OF THE COUNSELOR ACCESSING
IMMEDIATE SUPERVISION. [KNOCK ON DOOR] – GLORIA, I SEE THAT
YOU’RE ON THE PHONE. I’M SORRY TO BOTHER YOU,
BUT THERE IS A SITUATION THAT I NEED TO SPEAK
WITH YOU ABOUT. – OK. I’LL HAVE
TO CALL YOU BACK. SOMETHING HAS JUST COME UP. – THANKS FOR TALKING. I DID GROUP TODAY, AND ANTONIO
RODRIGUEZ RETURNED AFTER BEING ABSENT FOR A WEEK. DO YOU REMEMBER
ANTONIO FROM GROUP? – SURE, I REMEMBER HIM. – OK, WELL, I
TOUCHED BASE WITH HIM AFTER GROUP, AND TO MAKE A
LONG STORY SHORT, A WEEK AGO, HE MET AN OLD FRIEND, AND THEY
WENT OUT AND THEY GOT DRUNK. HE CAME HOME. HIS
GIRLFRIEND WAS FURIOUS. SHE KICKED HIM OUT OF THE
HOUSE, AND HE SAT AT A PARK DRINKING AND THOUGHT
ABOUT SUICIDE. NOW, THAT WAS A WEEK AGO,
AND SINCE THEN HE HAS NO THOUGHTS OF SUICIDE, HE’S
BEEN CLEAN AND SOBER, AND IS STAYING AT HIS SISTER’S HOUSE. – SO WHERE IS HE NOW? – HE’S IN THE
PRIVATE WAITING AREA. I TOLD THE RECEPTIONIST I
WOULD COME IN HERE AND TALK TO YOU AND TO CALL IMMEDIATELY
IF HE STARTS TO GET UPSET OR GOES TO LEAVE. – OK,
GOOD. YOU KNOW, I’M GLAD THAT YOU CAME TO ME. TELL ME MORE ABOUT
WHAT’S GOING ON. – HE SAT AT THE PARK DRINKING
AND HE HAD THE THOUGHT TO SHOOT HIMSELF
WITH HIS HANDGUN. HE TOLD ME THAT IF HE HAD HIS
HANDGUN WITH HIM, HE WOULD HAVE GONE THROUGH WITH IT. HE THOUGHT DRINKING MIGHT
MAKE HIM FEEL BETTER, BUT IT PROVIDED NO RELIEF. HE SEEMED SAD AND
WAS TEARFUL AT TIMES. HE ALSO DESCRIBED LOUISA–
THAT’S HIS GIRLFRIEND–AS EVERYTHING TO HIM, AND HE’S
AFRAID HE’S BLOWN IT WITH HER. – THAT’S PRETTY SERIOUS. HOW IS HE DOING SINCE
THAT DAY AT THE PARK? – AS FAR AS I CAN TELL,
A LOT BETTER. THERE HAVE BEEN NO
THOUGHTS OF SUICIDE. HE HAS NO PLAN OR
INTENT FOR SUICIDE. HE’S GLAD TO BE BACK IN
RECOVERY AND HOPES THAT LOUISA MIGHT TAKE HIM
BACK EVENTUALLY. – NOW,
DID YOU BELIEVE HIM, OR DID YOU THINK THAT HE WAS JUST
SAYING THOSE THINGS TO REASSURE YOU? – WELL,
HE WAS HESITANT TO TALK AT FIRST. FOR EXAMPLE, HE SAID THAT HE
WAS AFRAID WE’D LOCK HIM UP IF MENTIONED SUICIDE. YOU KNOW, BUT EVENTUALLY HE
OPENED UP, AND I BELIEVE HE WAS BEING HONEST WITH ME. – DID HE VOLUNTEER ANY REASONS
NOT TO KILL HIMSELF–FOR EXAMPLE, BECAUSE IT’S AGAINST
HIS SPIRITUAL OR RELIGIOUS BELIEFS OR BECAUSE OF
FAMILY RELATIONSHIPS? – HE SAID THAT HE REALIZES
NOW THAT KILLING HIMSELF WOULD DEVASTATE HIS MOTHER AND
HIS SISTER, PARTICULARLY HIS MOTHER. HE ALSO SAID THAT HE’S YOUNG
AND HE HOPES TO HAVE MANY MORE YEARS TO LIVE AND HE DOESN’T
WANT TO GO OUT THAT WAY. – HAS HE BEEN SUICIDAL BEFORE? – HE SAYS HE HAS HAD THOUGHTS
BEFORE BUT NOTHING AS INTENSE AS HIS THOUGHTS AT THE PARK. – HAS HE EVER TRIED
TO KILL HIMSELF? – NO. HE’S NEVER
MADE AN ATTEMPT. WHEN I ASKED HIM THAT
QUESTION, HE MENTIONED THAT A MEMBER IN HIS UNIT HAD SHOT
HIMSELF, ALTHOUGH HE BARELY KNEW THE MAN, AND HE SAID
THAT’S THE ONLY PERSON HE’S KNOWN WHO’S COMMITTED SUICIDE. – SO,
WHAT’S HIS MENTAL HEALTH SITUATION? – HE DID HAVE AN EVAL WHEN HE
CAME IN FOR TREATMENT, AND AS I RECALL, THE DOCTOR SAID
THAT HIS PROBLEMS WERE MOSTLY SUBSTANCE-RELATED AND
HE DIDN’T NEED MENTAL HEALTH TREATMENT. – DID HE SEE ANY COMBAT
IN IRAQ, ANY TRAUMA? – I ACTUALLY DON’T
KNOW ABOUT THAT. HE DOESN’T REALLY TALK
ABOUT HIS DEPLOYMENTS. HE MOSTLY TALKS ABOUT HIS
RELATIONSHIP, HIS LEGAL SITUATION, PLUS THE FACT
THAT HE’S LOOKING FOR A JOB. – SO HOW DO YOU FEEL ABOUT
HIS LIVING SITUATION WITH HIS SISTER? – I FEEL GOOD
ABOUT IT, YOU KNOW. IT’S A SOBER AND SUPPORTIVE
ARRANGEMENT, AS BEST AS I CAN TELL. – NOW,
YOU MENTIONED HIS GUN. WHERE DOES HE KEEP IT? – IT’S IN HIS BAG
AT HIS SISTER’S. – SO DO YOU KNOW IF
IT’S LOADED OR IF HE HAS AMMUNITION WITH IT? – YOU KNOW, I’M SORRY. I DIDN’T ASK THAT QUESTION,
ALTHOUGH I GET THE SENSE THAT IT IS LOADED OR HE HAS
AMMUNITION BASED ON WHAT HE SAID COULD HAVE HAPPENED
HAD HE HAD THE GUN WITH HIM AT THE PARK. PLUS HE SAID
THAT’S HIS ONLY GUN. – ANY OTHER STRESSORS? – WELL,
HE IS COURT-MANDATED FOR TREATMENT,
AND I’M IN TOUCH WITH HIS CASE MANAGER. HE’S ALSO OUT OF WORK
AND LOOKING FOR A JOB. – ANYTHING ELSE THAT’S
IMPORTANT TO CONSIDER? – I HAVE A GOOD WORKING
RELATIONSHIP WITH HIM, AND HE’S VERY POPULAR
WITH THE GROUP. THEY WERE HAPPY TO
SEE HIM COME BACK. – OK,
LET’S QUICKLY MAKE A PLAN SO THAT YOU CAN
GO BACK AND TALK TO HIM. HE MAY START TO FEEL
ANXIOUS IF YOU’RE AWAY TOO MUCH LONGER. – MARY,
THE THERAPIST DIDN’T HESITATE TO COME INTO HER SUPERVISOR’S
OFFICE AND ASK TO TALK TO HER. – YES. THIS WAS REALLY NO TIME
TO BE TENTATIVELY KNOCKING ON THE DOOR OR PATIENTLY
WAITING FOR THE SUPERVISOR TO FINISH HER CALL. SHE REALLY NEEDED TO SPEAK
WITH THE SUPERVISOR THEN AND THERE AND MADE THIS
CLEAR IN AN ASSERTIVE THOUGH RESPECTFUL WAY. – THE THERAPIST SEEMED
WELL-PREPARED TO DESCRIBE THE SITUATION AND ANSWER THE
SUPERVISOR’S QUESTIONS. – SHE CERTAINLY DID. SHE SPELLED OUT THE
INFORMATION EFFICIENTLY AND HIT ALL OF THE MAJOR
POINTS, INCLUDING THAT ANTONIO RELAPSED RECENTLY,
THE INTENSITY OF HIS SUICIDAL THOUGHTS AT THE PARK,
THE RECENT BREAKUP WITH HIS GIRLFRIEND AND HOW MUCH SHE
MEANS TO HIM, HIS ACCESS TO A FIREARM, AND HIS
TEARFULNESS IN THE SESSION AND OVERALL SADNESS. SHE ALSO MENTIONED PROTECTIVE
FACTORS, INCLUDING HIS CLOSE RELATIONSHIP WITH HIS MOTHER
AND SISTER AND THAT THE COUNSELOR AND ANTONIO HAVE A
GOOD THERAPEUTIC RELATIONSHIP. – THE SUPERVISOR SEEMED
WELL-ORGANIZED WITH HER QUESTIONS AS WELL. – ABSOLUTELY. SHE IS OBVIOUSLY
EXPERIENCED WITH THIS ISSUE AND GUIDED THE COUNSELOR
THROUGH THE KEY POINTS IN AN EFFICIENT MANNER. I NOTICED THAT SHE ALSO ASKED
WHERE ANTONIO WAS TO CONFIRM THAT HE IS IN A PRIVATE
WAITING AREA AND THAT THE RECEPTIONIST WILL CALL IN
IMMEDIATELY IF HE STARTS TO GET ANXIOUS OR
BEGINS TO LEAVE. – MARY,
THE THERAPIST HAS GATHERED KEY INFORMATION AND
ACCESSED SUPERVISION. NOW WHAT? – THE NEXT STEP, AS SPELLED
OUT IN TIP 50, IS TAKE ACTION. THERE ARE MANY DIFFERENT
ACTIONS THAT CAN BE TAKEN TO LOWER THE RISK FOR SUICIDE. THE GENERAL PRINCIPLE IS THAT
THE ACTION SHOULD MAKE GOOD SENSE GIVEN THE LEVEL OF
RISK IN A SITUATION. FOR EXAMPLE, CLIENTS AT HIGH
ACUTE SUICIDAL RISK REQUIRE INTENSIVE, IMMEDIATE ACTION,
WHEREAS CLIENTS AT LOWER RISK WOULD REQUIRE LESS
INTENSIVE ACTIONS THAT ARE LESS IMMEDIATE. IT IS WHEN THERE IS A MISMATCH
BETWEEN THE SEVERITY OF RISK AND THE LEVEL OF ACTION
THAT THERE IS A PROBLEM. FOR EXAMPLE, IN ANTONIO’S
CASE, IT WOULD NOT BE SUFFICIENT TO SIMPLY WELCOME
HIM BACK TO GROUP WITHOUT TAKING ANY ADDITIONAL
STEPS TO LOWER RISK. MISMATCHES CAN ALSO
WORK THE OTHER WAY. FOR EXAMPLE, SENDING A CLIENT
TO THE EMERGENCY DEPARTMENT FOR AN EVALUATION SIMPLY
BECAUSE OF A PRIOR HISTORY OF SUICIDE ATTEMPT IS A
MISMATCH BECAUSE IT IS AN OVER-RESPONSE TO THAT
SITUATION THAT WASTES RESOURCES AND CAN UNDERMINE
THE TREATMENT RELATIONSHIP. – NIKKI, SO, WHAT ARE THE
ACTIONS THAT COULD BE TAKEN WITH A SUICIDAL CLIENT? – HERE’S A LIST OF ACTIONS
THAT ARE LISTED IN TIP 50. THEY INCLUDE GATHERING
MORE INFORMATION, ARRANGING EMERGENCY OR OUTPATIENT
EVALUATION, INCREASING FREQUENCY OF CONTACT,
INVOLVING THE SUICIDE PREVENTION COORDINATOR,
INVOLVING A CARE PROVIDER OR CASE MANAGER, AS WELL AS
RESTRICTING ACCESS TO MEANS OF SUICIDE, INVOLVING FAMILY
MEMBERS, PROMOTING ATTENDANCE AT SELF-HELP MEETINGS,
OBSERVING FOR SIGNS OF RETURN TO RISK, AND CONDUCTING
A FORMAL SAFETY PLAN. A COMPLETE LIST OF THESE
POTENTIAL ACTIONS CAN BE FOUND ON PAGES 21 AND 22 OF TIP 50. – NIKKI, THAT’S A
LOT OF OPTIONS. HOW DOES THE COUNSELOR
KNOW WHERE TO START? – YES, IT CAN FEEL
OVERWHELMING TO A COUNSELOR, BUT THAT’S WHERE GETTING
SUPERVISION CAN BE REALLY CRITICAL TO HELP THE
COUNSELOR SORT THROUGH THE VARIOUS OPTIONS. THIS NEXT CLIP WILL SHOW YOU
HOW THE COUNSELOR AND SUPERVISOR DEVELOPED A PLAN
OF ACTION TOGETHER. – AS FAR AS WE CAN TELL,
ANTONIO HAS NOT BEEN SUICIDAL SINCE THE INCIDENT IN THE PARK. HE’S FUTURE-ORIENTED, AND HIS
TEMPORARY LIVING SITUATION IS SOBER AND SUPPORTIVE. HE’S ALSO CONNECTED
TO YOU AND THE GROUP. I MEAN, OVERALL,
HE APPEARS TO POSE NO ACUTE DANGER TO HIMSELF. I BELIEVE THAT
AN OUTPATIENT-BASED PLAN IS APPROPRIATE AT THIS TIME. – THAT’S HOW I SEE IT, TOO. OUTPATIENT IS SUFFICIENT
RIGHT NOW. – YOU KNOW, WE ALWAYS
HAVE THE OPTION OF HAVING HIM GO
FOR AN EMERGENCY EVAL IF THE SITUATION WORSENS. YOU’LL DEFINITELY NEED
TO DO THE STANDARD VA SAFETY PLAN WITH HIM. YOU KNOW HIM BETTER THAN I. WHAT ELSE COMES TO MIND
THAT MIGHT BE HELPFUL? – WELL, I’D FEEL A LOT BETTER
ABOUT THE SITUATION IF HE GOT ANOTHER
MENTAL HEALTH EVAL. – WELL, SOUNDS GOOD. DO YOU THINK HE’LL
GO FOR ANOTHER EVAL? – WELL, HE’LL PROBABLY GIVE ME
A BIT OF A HARD TIME AT FIRST, BUT I THINK HE’LL EVENTUALLY
AGREE AND FOLLOW THROUGH. HE’S FAIRLY COMPLIANT
WITH TREATMENT. – GREAT. IT WILL ALSO BE VERY
IMPORTANT TO ADDRESS THE GUN. – AGREED. ALTHOUGH DEALING
WITH THAT MAKES ME THE MOST NERVOUS. – IT’S A REALLY TOUGH ISSUE. YOU KNOW, MAKING
THE ENVIRONMENT SAFE IS THE LAST THING THAT COMES UP
IN THE SAFETY PLAN, AND BY THAT TIME,
PERHAPS, HE’LL BE FEELING PRETTY COMFORTABLE WITH THE PLAN AND THEN BE MORE WILLING
TO ADDRESS THE GUN. – SO WHAT DO YOU SUGGEST I DO? – COULD HE BE PERSUADED
TO HAVE A FAMILY MEMBER TAKE THE GUN AND STORE IT
IN A SAFE AND SECURE PLACE FOR THE TIME BEING? – WELL, HE MENTIONED HIS
SISTER’S HUSBAND IS EX-MILITARY AND THEY HAVE A FAIRLY
GOOD RELATIONSHIP, AND I ASSUME HE’S EXPERIENCED
DEALING WITH WEAPONS AND HE MIGHT BE WILLING TO
HELP US OUT WITH THIS SITUATION. – BEST CASE SCENARIO IS
TO GIVE HIS SISTER A CALL BEFORE HE LEAVES TODAY. THAT WAY THERE’S NO RISK
THAT HE’LL CHANGE HIS MIND BEFORE HE GETS HOME. NOW, IN THE CALL, YOU COULD
EXPLAIN THE SITUATION AND THEN HAVE
HER AND HER HUSBAND TAKE CARE OF THE GUN. – YES, I SPOKE WITH
HIS SISTER BEFORE AND ALREADY OBTAINED
A SIGNED RELEASE. WHAT IF HE’S NOT
WILLING TO DO THAT? – WELL, HE MAY SURPRISE YOU AND ALLOW A CALL
WITH HIS SISTER. I MEAN, IT’S CERTAINLY
WORTH A TRY. IF HE WON’T GO FOR THAT,
THERE ARE OTHER POSSIBILITIES, INCLUDING GETTING HIS COMMITMENT TO GIVE HIS WEAPON
TO HIS BROTHER-IN-LAW WHEN HE GETS HOME. IF HE INSISTS ON
HOLDING ON TO THE GUN, WE ALSO HAVE A FREE GUN LOCK
THAT WE CAN PROVIDE HIM, ALTHOUGH IT WOULD BE MUCH BETTER IF HE’D BE WILLING
TO PART WITH THE GUN FOR NOW. – I’LL TRY MY BEST.
SO IN A NUTSHELL, THE PLAN IS TO REFER HIM
FOR ANOTHER MENTAL HEALTH EVAL, DO THE SAFETY PLAN WITH HIM, AND END THE SESSION
BY ADDRESSING THE GUN. – I THINK YOU’VE GOT IT. WOULD YOU LIKE FOR ME TO COME IN AND, YOU KNOW, WORK OUT
THIS PLAN WITH YOU? – I THINK HE MIGHT BE
A LITTLE MORE COMFORTABLE IF I WORK WITH HIM ONE ON ONE, SO LET ME SEE IF I CAN
DO THIS ON MY OWN. – OK. THAT’S FINE.
I’LL BE RIGHT HERE
AND AVAILABLE TO HELP IF YOU GET STUCK. NOW, YOU WANT TO BE
DIRECT AND CLEAR WITH HIM. IT’S ALSO VERY IMPORTANT
TO BE COLLABORATIVE. IF HE DOESN’T FEEL LIKE
HE HAS A SAY IN THE PLAN, HE’S GOING TO BE LESS LIKELY
TO FOLLOW THROUGH. SO ALONG THESE LINES,
YOU MIGHT START OUT THE SESSION BY ASKING WHAT HE WOULD THINK
WOULD BE HELPFUL BEFORE SPELLING OUT
YOUR RECOMMENDATIONS. – WILL DO.
I’LL CALL YOU IF I GET STUCK.
THANKS. – MATT, WHAT ARE YOUR THOUGHTS ABOUT THE PLAN THAT
THEY CAME UP WITH? – IT’S A REAL SOLID PLAN, KIRK. THEY BASICALLY INTEND
TO TAKE 3 ACTIONS. NUMBER ONE IS TO ARRANGE
A MENTAL HEALTH EVALUATION. NUMBER W, DEVELOP A STANDARD
VA SAFETY PLAN WITH ANTONIO. AND NUMBER 3, ADDRESS HIS ACCESS
TO A FIREARM. SO FAR HIS TREATMENT IS FOCUSED
ON THE SUBSTANCE ABUSE, BUT THE POSSIBILITY OF
A MENTAL HEALTH PROBLEM SHOULD BE REVISITED. ASSUMING HE’S WILLING,
JILL WILL SET ANTONIO UP FOR AN APPOINTMENT WITH
A BEHAVIORAL HEALTH PROFESSIONAL TO DETERMINE IF
A MENTAL HEALTH CONDITION, SUCH AS DEPRESSION OR PTSD, REQUIRES TREATMENT WITH
MEDICATIONS OR THERAPY. ANOTHER ACTION IS TO DO
THE STANDARD VA SAFETY PLAN THAT WE’LL DISCUSS IN MORE
DETAIL A LITTLE LATER. THEY ALSO WANT
TO ADDRESS THE FACT
THAT ANTONIO HAS A PISTOL, BECAUSE FIREARMS ARE THE MOST
LETHAL METHOD OF SUICIDE. – THEY CONCLUDED
THAT HE DOESN’T NEED AN EMERGENCY EVALUATION
AT THE HOSPITAL. WHAT DO YOU THINK OF THAT? – THEIR DECISION IS SOUND,
BECAUSE AS FAR AS WE KNOW, NO SUICIDAL THOUGHTS
HAVE OCCURRED SINCE HE WAS
INTOXICATED IN THE PARK. HE’S EXPRESSING RELIEF
THAT HE DID NOT KILL HIMSELF AND CAN PROVIDE
REASONS FOR LIVING. HE AND THE THERAPIST HAVE A
SOLID THERAPEUTIC RELATIONSHIP, AND UP UNTIL RECENTLY,
HE HAD DONE WELL IN TREATMENT. AND HE IS STAYING
WITH HIS SISTER, WHO IS A GOOD, SOBER SUPPORT, THEREFORE, THERE ARE
ENOUGH POSITIVE SIGNS TO INDICATE THAT AN OUTPATIENT
PLAN WOULD BE SUFFICIENT. – I NOTICED AT THE END
OF THE CLIP THE SUPERVISOR ENCOURAGED JILL
TO BE COLLABORATIVE. – THAT’S EXACTLY RIGHT,
AND ALTHOUGH IT’S EASY
FOR CLINICIANS TO FALL INTO THE TRAP
OF DICTATING A PLAN, CLIENTS ARE MUCH MORE LIKELY
TO FOLLOW THROUGH IF THEY HAVE A REAL SAY IN
DEVELOPING THEIR SPECIFIC PLAN. AS WELL, CLIENTS
CAN COME UP WITH REALLY GOOD IDEAS
TO KEEP THEM SAFE, AND THESE MIGHT BE IDEAS
THAT APPEAL TO THEM
ON A PERSONAL LEVEL OR ONES THAT THE COUNSELOR
MIGHT NOT EVEN THINK OF. ALONG THESE LINES,
THE SUPERVISOR ENCOURAGED JILL TO START OFF THE MEETING
BY GETTING ANTONIO’S IDEAS, WHICH WILL HELP SENT THE TONE
FOR COLLABORATION. ANOTHER THING THAT WILL HELP IS
THAT THE STANDARD VA SAFETY PLAN IS DONE COLLABORATIVELY
WITH THE CLIENT, AND THAT COLLABORATION
CANNOT BE OVEREMPHASIZED. – HERE’S THE NEXT CLIP
THAT SHOWS THE COUNSELOR GOING BACK TO MEET WITH ANTONIO. LET’S SEE HOW IT PLAYS OUT. – THANKS FOR WAITING, ANTONIO. – WHAT’D YOU GUYS COME UP WITH?
AM I GONNA GET LOCKED UP? – MS. JOHNSON AND I DO NOT THINK AN EMERGENCY EVALUATION
AT THE HOSPITAL IS NEEDED TODAY. – YOU GUYS WOULD HAVE
HAD TO DRAG ME THERE. – I THINK WE’RE GONNA
HAVE TO HANDLE THIS
THE OLD-FASHIONED WAY– BY TALKING IT THROUGH. ALTHOUGH WE DON’T THINK
AN EMERGENCY EVAL IS NECESSARY, YOU AND I HAVE TO HAVE
A DISCUSSION TO COME UP WITH A PLAN TO DEAL
WITH THE SUICIDAL THOUGHTS. – WHAT PLAN? – ANY PLAN WE’LL MAKE TOGETHER. – I DON’T THINK I NEED A PLAN. – ANTONIO, I HAVE TO ADMIT
THAT I SEE IT DIFFERENTLY. YOU’VE BEEN THROUGH AN AWFUL LOT
IN THE PAST WEEK, AND YOU’VE BEEN THROUGH
A LOT OF PRESSURE– THE STRESS WITH LOUISA
AND THE RELAPSE. PLUS, THOSE THOUGHTS
THAT YOU HAD AT THE PARK
ARE REALLY SCARY. IT’S VERY REASSURING THAT THOSE
THOUGHTS HAVE NOT COME BACK. AND YOU TOOK A BIG STEP
IN COMING HERE TODAY. I REALLY ADMIRE YOU FOR BEING
SO HONEST WITH ME. ALL OF THAT SAYS A LOT ABOUT
YOUR COMMITMENT TO RECOVERY. AND ALL OF THAT
MAKES ME REALLY OPTIMISTIC THAT WE CAN MAKE A GOOD PLAN. I FEEL STRONGLY THAT
WE SHOULD MAKE A PLAN. IT’S NOT GONNA BE GOOD
FOR YOU TO JUST PRETEND THAT THIS DIDN’T HAPPEN. – YEAH. WHATEVER. – ANTONIO…I FEEL
REALLY STRONGLY ABOUT THIS. – OK. OK.
WHAT DO YOU WANT ME TO DO? – MS. JOHNSON AND I
CAME UP WITH A FEW IDEAS, BUT I’D LIKE TO KNOW
IF YOU HAVE ANYTHING THAT YOU THINK MIGHT BE HELPFUL. – I GOT NOTHING. – YOU SEEM TO HAVE A THOUGHT.
MAYBE HAVE AN IDEA THERE? – WELL, I…I DON’T LIKE
TALKING IN GROUP. THOSE GUYS ARE OK,
BUT I DON’T WANT TO TALK ABOUT MY PERSONAL STUFF WITH THEM. I LIKE–I LIKE TALKING
TO YOU MORE. – YEAH. WE HAVE SOME
REALLY GOOD, HONEST, ONE-ON-ONE CONVERSATIONS. YOU REALLY USE THESE INDIVIDUAL
THERAPY SESSIONS VERY WELL. – YEAH, IT’S JUST
EASIER TALKING TO YOU. – OK, SO, WHY DON’T WE
UP OUR SESSIONS TO ONCE A WEEK? WOULD THAT WORK FOR YOU? – I SUPPOSE. – OK. SO I’LL SEE YOU ONCE A
WEEK FOR OUR INDIVIDUAL SESSIONS FOR THE NEXT MONTH, AND THEN WE’LL SEE
WHERE YOU’RE AT. – WHAT ELSE DO I HAVE TO DO? – WELL, ONE THING I WOULD LIKE IS TO SET YOU UP FOR ANOTHER
MENTAL HEALTH EVAL. – I TOLD YOU I WAS NOT CRAZY.
I JUST GOT DRUNK ONE DAY AND I’M OK NOW. – WOULD YOU BE WILLING
TO HEAR ME OUT AND I’LL EXPLAIN
THE RECOMMENDATION TO YOU? – YEAH, YEAH, WHATEVER.
GO FOR IT. – THANKS FOR
HEARING ME OUT, ANTONIO. LOOK, YOU’VE BEEN THROUGH
AN AWFUL LOT LATELY… AND I BELIEVE YOU. I REALLY DO BELIEVE YOU
WHEN YOU TELL ME THAT YOU HAD SUICIDAL THOUGHTS
AT THE PARK AND ONLY AT THE PARK, AND YOU HAVEN’T
HAD THEM SINCE THEN. I ALSO DO NOT
THINK YOU’RE CRAZY. BUT YOU’VE BEEN THROUGH
AN AWFUL LOT. AND WHEN YOU GO THROUGH
SOMETHING LIKE THAT, SEEING A MENTAL HEALTH
PROFESSIONAL MIGHT BE HELPFUL FOR YOU,
YOU KNOW? SEEING A DOCTOR OR A THERAPIST. MIGHT BE WORTH
GETTING THEIR OPINION. AT THIS POINT, IT’S JUST
GONNA BE AN EVALUATION. WE DON’T KNOW WHAT
THE DOCTOR’S GONNA SAY. MAYBE HE’LL RECOMMEND TREATMENT.
MAYBE NOT. MAYBE HE’LL
RECOMMEND MEDICATIONS.
MAYBE NOT. YOU KNOW?
WHO KNOWS? IT’S JUST AFTER WHAT
YOU’VE BEEN THROUGH, IT’S A REALLY GOOD IDEA
TO GET CHECKED OUT. MAYBE TALKING TO SOMEBODY ELSE WILL PROVE
TO HELP YOU EVEN MORE. – WHAT CHOICE DO I HAVE?
THE COURT SAYS I HAVE TO DO WHAT YOU SAY. – WELL, THE COURT DOES KEEP
AN EYE ON THINGS, DOESN’T IT? BUT TO BE PERFECTLY
HONEST WITH YOU, MS. JOHNSON AND I
WERE NOT THINKING ABOUT THAT. WE’RE THINKING ABOUT
WHAT WOULD BEST SUIT SOMEBODY IN A SITUATION
LIKE YOU, YOU KNOW? WHAT’S BEST TO HELP YOU, REGARDLESS OF
THE LEGAL SITUATION. YOU WERE IN A LOT OF PAIN THAT
DAY, A LOT OF EMOTIONAL PAIN, AND WE DON’T EVER
WANT TO SEE YOU BACK AT THE PARK LIKE THAT. NOBODY SHOULD EVER HAVE
TO SUFFER THE WAY YOU DID. – I SUPPOSE YOU’LL TELL
THE DOCTOR WHAT HAPPENED. – I’LL GIVE HIM A BRIEF SUMMARY BUT I’LL LEAVE IT FOR YOU
TO FILL IN THE DETAILS. OK? – IS THAT IT, THEN? – WELL, THERE ARE A FEW OTHER
THINGS I’D LIKE TO COVER. FOR ONE THING,
I WOULD LIKE TO GO THROUGH A STEP-BY-STEP SAFETY PLAN
WITH YOU FIRST. WOULD THAT BE ALL RIGHT? – WHATEVER. – MARY, WHAT STANDS OUT TO YOU
AS YOU WATCH THE TAPE? – SHE DID A NICE JOB. SHE OPENED THE SESSION
BY ASKING FOR ANTONIO’S INPUT AND PICKED UP ON HIS COMFORT
WITH THE INDIVIDUAL SESSIONS BY OFFERING TO INCREASE
THE FREQUENCY OF THESE MEETINGS. THAT GOT THE MEETING
OFF ON THE RIGHT FOOT. SHE WAS CLEAR AND FIRM
THAT SHE IS RECOMMENDING A MENTAL HEALTH EVALUATION, AND BEING CLEAR AND FIRM
WITH SUCH A KEY RECOMMENDATION IS IMPORTANT. BUT AT THE SAME TIME,
SHE ALSO TOOK THE TIME TO EXPLAIN THE REASON FOR IT, AND TRIED HER BEST
TO NORMALIZE IT, WHICH IS REALLY IMPORTANT,
GIVEN ANTONIO’S FEAR OF BEING CONSIDERED CRAZY. AS WELL, THEY TOUCHED ON
THE MAJOR ISSUES THAT ARE WEIGHING ON HIS MIND, INCLUDING THE BREAKUP
WITH THE GIRLFRIEND AND HIS LEGAL SITUATION. – THE COUNSELOR ALSO MENTIONED
DOING A SAFETY PLAN. – THAT’S RIGHT, KIRK.
THE VA HAS A STANDARD
SAFETY PLAN THAT HAS TO BE DONE
WITH SUICIDAL CLIENTS. HERE’S THE TEMPLATE FOR THE PLAN THAT GOES RIGHT
IN THE TREATMENT RECORD. WE WILL NOT ELABORATE
ON THE PLAN HERE, AND WE DID NOT
SHOW THE COUNSELOR DOING THE SAFETY PLAN
WITH ANTONIO, BECAUSE AN EXCELLENT
TRAINING TAPE THAT SHOWS
THE VA SAFETY PLAN IS ALREADY AVAILABLE. VIEWERS INTERESTED IN LEARNING
MORE ABOUT THE SAFETY PLAN SHOULD WATCH THE SAFETY PLAN
TRAINING VIDEO. – AS I RECALL,
THERE’S ALSO THE ISSUE OF ANTONIO’S FIREARM. – THAT’S CORRECT. HERE’S THE CLIP OF THE THERAPIST
ADDRESSING THIS ISSUE. – ANTONIO, THE LAST PART
OF THE SAFETY PLAN THAT I WOULD LIKE
TO DISCUSS WITH YOU IS KEEPING
YOUR ENVIRONMENT SAFE. YOU’VE BEEN REALLY FORTUNATE
TO LIVE WITH EVA AND HER FAMILY, AND I MET EVA WHEN WE FIRST
STARTED DOING RECOVERY TOGETHER, AND I WAS REALLY IMPRESSED
WITH HOW MUCH SHE KNEW ABOUT RECOVERY AND ADDICTION AND HOW
SUPPORTIVE SHE IS OF YOU. – YEAH. WE’RE A CLOSE FAMILY. THE ONLY THING I’M
REALLY CONCERNED ABOUT
IN YOUR ENVIRONMENT IS YOUR GUN. – WHAT ABOUT MY GUN? – LOOK, IT’S CERTAINLY
YOUR RIGHT TO HAVE A GUN. NOBODY’S ARGUING THAT. HOWEVER, GIVEN WHAT HAPPENED
IN THE PARK AND THAT YOU’RE
ONLY JUST BEGINNING TO REESTABLISH YOUR SOBRIETY, I WONDER IF WE COULD
WORK OUT A WAY TO LESSEN ANY RISK
ASSOCIATED WITH THE GUN. – WHAT ARE YOU SAYING? – WELL, I’D LIKE TO WORK
ON AN ARRANGEMENT WITH YOU SO THAT FOR THE TIME BEING,
SOMEONE ELSE TAKES THE GUN AND STORES IT SAFELY. – THAT’S NOT NECESSARY. – LET ME TRY TO EXPLAIN
WHERE I’M COMING FROM. WOULD YOU AT LEAST BE
WILLING TO HEAR ME OUT? – GO FOR IT. – OK. THANKS FOR BEING WILLING. DO YOU REMEMBER WHEN YOU FIRST
STARTED YOUR PROGRAM AND WE WORKED OUT A PLAN
WHERE YOU WOULD GET RID OF ALL THE LIQUOR AND MARIJUANA
IN YOUR PLACE? – YEAH.
– IT’S BASICALLY THE SAME
PRINCIPLE HERE. IN EARLY RECOVERY,
PEOPLE TEND TO HAVE MOMENTS WHEN THEY’RE CRAVING, OR THEIR JUDGMENT
ISN’T VERY GOOD, AND IN THOSE MOMENTS,
HAVING A SUBSTANCE NEARBY
WITHIN EASY REACH COULD BE THE DIFFERENCE
BETWEEN RELAPSING AND MAKING IT THROUGH
CLEAN AND SOBER. YOU KNOW, THIS ALSO
APPLIES TO SUICIDE. FOR EXAMPLE, IF YOU
WERE TO HAVE A DAY WHEN YOU GOT DOWN
AND GOT BAD NEWS FROM LOUISA OR YOU RELAPSED, WELL, THEN HAVING A GUN NEARBY
COULD POSE A RISK. YOU WOULDN’T NEED
TO GIVE UP THE GUN FOREVER, BUT FOR NOW, IT WOULD BE
A GOOD PRECAUTION. – OK. IF IT’LL MAKE YOU HAPPY,
I’LL GIVE IT TO A FRIEND
TO HOLD ON TO. – ACTUALLY, I WAS THINKING
OF YOUR BROTHER-IN-LAW. – YEAH. SURE.
HE’S EX-MILITARY. HE KNOWS HOW TO HANDLE WEAPONS. – GOOD. WOULD IT BE OK WITH YOU
IF WE GAVE YOUR SISTER A CALL AND ARRANGED FOR
YOUR BROTHER-IN-LAW TO GET YOUR GUN TODAY? – NO. THAT’S NOT OK. I TOLD YOU I WILL–
I WILL GIVE MY GUN TO MY BROTHER-IN-LAW
WHEN I GET HOME. THERE’S NO REASON TO CALL EVA. – ANTONIO, IF YOU INSIST
THAT I NOT CALL YOUR SISTER AND YOU MAKE THE COMMITMENT
TO GIVE YOUR GUN TO YOUR BROTHER-IN-LAW
TO HOLD ON TO WHEN YOU GET HOME, YOU KNOW, I WOULD CERTAINLY
GO ALONG WITH THAT. IN FACT, THAT WOULD BE
A REALLY IMPORTANT STEP AND MAKE THE SITUATION
MUCH SAFER THAN IT IS NOW. HOWEVER, FIRST I’D LIKE
TO BRIEFLY EXPLORE WITH YOU WHY YOU DON’T WANT TO MAKE
THE CALL TO YOUR SISTER. WOULD YOU BE WILLING TO AT LEAST
TALK ABOUT THAT SOME MORE? – TALK AS MUCH AS YOU WANT.
WE’RE NOT CALLING HER. – WELL, THANKS FOR BEING WILLING
TO HEAR ME OUT, ANTONIO. YOU KNOW, THIS IS JUST A GUESS,
BUT I’LL ASK ANYWAY. IS THE REASON YOU DON’T
WANT TO CALL YOUR SISTER BECAUSE YOU DON’T
WANT TO SCARE HER? – YEAH. EXACTLY. – YOU KNOW, I KNOW HOW MUCH
EVA CARES ABOUT YOU AND HOW INVESTED SHE IS
IN YOUR RECOVERY. I’M REALLY GUESSING
THAT SHE WOULD MUCH PREFER TO KNOW WHAT’S GOING ON RATHER THAN BE LEFT IN THE DARK. YOU KNOW, EVEN IF IT DID
CAUSE HER TO WORRY A LITTLE BIT. WE COULD DO OUR BEST
TO TALK ABOUT IT IN A WAY THAT DOESN’T ALARM HER, BUT RATHER PRESENTS IT AS
SOMETHING MORE OF A PRECAUTION. YOU KNOW, I COULD EXPLAIN TO HER
THAT THE THOUGHTS OF SUICIDE ENTERED YOUR MIND
WHEN YOU WERE DRINKING AFTER THE BREAKUP WITH LOUISA,
BUT THEY’RE GONE NOW. AND THAT TEMPORARILY
MOVING THE GUN IS JUST A PRECAUTION,
JUST IN CASE ANOTHER CRISIS HITS. YOU KNOW, NO DOUBT SHE’S GONNA
HAVE SOME WORRIES, BUT I CAN ALSO LET HER KNOW
OF THE POSITIVE THINGS
YOU ARE DOING AND JUST REASSURE HER ONCE AGAIN
THAT THIS IS JUST A PRECAUTION. – LIKE I SAID, I WILL GIVE MY
GLOCK TO MY BROTHER-IN-LAW. YOU WIN. – I APPRECIATE YOUR WILLINGNESS. YOU KNOW, THAT’S A REALLY
IMPORTANT COMMITMENT. NOW, HOW ABOUT MY SUGGESTION
TO MAKE THE CALL TO YOUR SISTER? IS THAT SOMETHING YOU’LL DO? I REALIZE I’M PUSHING
THE IDEA A BIT, BUT IT’S ONLY BECAUSE
I THINK IT WOULD BE HELPFUL. THE GOOD THING ABOUT A CALL IS THAT IT WOULD BE
OVER AND DONE WITH AND THERE’D BE NO WORRIES
ABOUT CHANGING YOUR MIND
ON THE WAY HOME OR A CRISIS COMING UP
BEFORE YOU HAVE A CHANCE TO GIVE IT TO
YOUR BROTHER-IN-LAW. THERE’S REALLY NOTHING LIKE
TAKING CARE OF SOMETHING
RIGHT AWAY AND GETTING IT OVER WITH. – ALL RIGHT.
YOU CAN–YOU CAN CALL HER. – YOU KNOW, ACTUALLY…
I WAS THINKING WE COULD CALL HER
ON THE SPEAKERPHONE. THAT WAY YOU COULD PARTICIPATE
IN THE CONVERSATION. HMM? GOOD.
WHAT’S HER NUMBER? – HER CELL IS 703-462-8559. [BUTTONS ON TELEPHONE BEEPING] [TELEPHONE RINGING] [RINGING] – HELLO?
– HELLO, EVA? – YES?
– THIS IS JILL CARLTON– ANTONIO’S SUBSTANCE ABUSE
COUNSELOR. – YEAH. HI.
– HI. DO YOU HAVE JUST A COUPLE
MINUTES TO TALK? – SURE. SURE.
WHAT’S THIS ABOUT? – SIS, UH, MY COUNSELOR
IS WORRIED ABOUT MY GUN AND WANTS VICTOR TO TAKE IT
SO I DON’T SHOOT MYSELF. – WHAT? WHAT’S GOING ON?
HOW DID THIS COME UP? – SEE? I TOLD YOU
SHE’D GO CRAZY. – HI, EVA.
I CAN SEE HOW
YOU’D BE WORRIED. LET ME TAKE A MINUTE TO EXPLAIN
THE SITUATION TO YOU. AS YOU KNOW, ANTONIO RELAPSED
AND LOUISA BROKE UP WITH HIM, AND IN REACTION TO THAT CRISIS,
HE CONFIDED IN ME HE WAS THINKING OF SUICIDE. NOW, THE GOOD NEWS IS THAT
THE SUICIDAL THOUGHTS ONLY HAPPENED ON ONE DAY
WHEN HE WAS DRINKING AND THERE HAVE BEEN
NO THOUGHTS SINCE THEN. ALSO, IN TERMS OF THE GOOD NEWS, ANTONIO CAME BACK
TO TREATMENT TODAY AND WE HAD A GOOD SESSION, AND WE MADE SOME SOLID PLANS
TO GET HIM BACK ON TRACK. OVERALL, I FEEL GOOD
ABOUT OUR PLAN. HOWEVER, DEALING WITH
ANTONIO’S GUN COULD MAKE THE SITUATION SAFER IN CASE THERE IS A RELAPSE
OR ANOTHER CRISIS WITH LOUISA. SO THEREFORE, I’M RECOMMENDING
THAT AS A PRECAUTION, SOMEONE TAKE THE GUN
AND STORE IT
OUT OF HIS WHEREABOUTS FOR THE TIME BEING. I THOUGHT THAT YOUR HUSBAND MIGHT BE ABLE
TO HELP OUT WITH THIS BECAUSE HE HAS EXPERIENCE
HANDLING GUNS. – THERE–THERE ARE
A MILLION THINGS RUNNING THROUGH MY HEAD
RIGHT NOW. I’M–I’M A LITTLE SCARED.
UM…YES, YES. OF COURSE.
VICTOR–VICTOR WILL
TAKE CARE OF THE GUN. ANTONIO, WHERE IS IT? – UH, IT’S IN MY BAG
IN ONE OF THE SIDE COMPARTMENTS. IT’S NOT LOADED BUT THERE’S
SOME AMMO IN THERE, TOO. – OK. OK.
UH, VICTOR WILL BE HOME SOON AND I’LL HAVE HIM TAKE CARE
OF IT WHEN HE GETS HOME. – THANKS, EVA.
THAT WOULD BE VERY HELPFUL. UM, COULD YOU PLEASE MAKE SURE
HE STORES IT IN A SAFE PLACE? – OK. OK.
HE’S GOT A SAFE WHERE
HE KEEPS HIS GUNS AND I’M SURE HE’LL PUT THIS ONE
IN THERE WITH THEM. – EVA, YOU SEEM
A LITTLE SHOOK UP, AND THAT IS VERY UNDERSTANDABLE. YOU KNOW, I’M SORRY
TO SCARE YOU LIKE THIS. I DON’T HAVE A CRYSTAL BALL,
AND I CERTAINLY DON’T KNOW IF ANTONIO WOULD EVER
USE THE GUN. BUT HE’S FEELING MUCH BETTER
AND HE REALLY WANTS TO GET BACK ON TRACK
WITH HIS RECOVERY. AND THIS IS A POSITIVE SIGN. THIS STEP IS JUST
A SAFETY PRECAUTION, ALTHOUGH IT’S ONE
THAT MAKES GOOD SENSE. – OK. OK.
UM, THAT’S–THAT’S GOOD TO HEAR. UM, I KNOW WE TALKED ONCE WHEN
ANTONIO STARTED HIS TREATMENT, BUT WOULD IT BE POSSIBLE FOR ME
TO COME TALK TO YOU IN PERSON? – WELL, WHAT DO YOU
THINK, ANTONIO? CAN EVA COME
TO OUR NEXT SESSION? – SURE, SIS, YOU CAN COME
AND YOU CAN MEET
MY COUNSELOR HERE. I TOLD HER IT WAS NOT NECESSARY,
BUT SHE PRETTY MUCH INSISTED. – ANTONIO, I’M GLAD SHE TOLD ME.
I WANT TO KNOW WHAT’S GOING ON. I MEAN, CAN YOU IMAGINE
WHAT THIS WOULD DO TO MAMA
IF YOU KILLED YOURSELF? NOT TO MENTION
HOW IT WOULD AFFECT ME. JUST–JUST DO WHAT
YOUR COUNSELOR TELLS YOU TO DO. UM…ALL RIGHT.
SO WHEN IS THIS MEETING? – ANTONIO, COULD YOU
BOTH MAKE IT THURSDAY AT 2:00 FOR A MEETING? – I’M NOT WORKING,
SO I DON’T EXACTLY HAVE A LOT OF OTHER PLANS. – HOW IS THAT WITH YOU, EVA? – YEAH. YEAH, THAT WORKS GREAT. – GOOD. NOW, JUST IN CASE
THERE’S EVER A PROBLEM, LET ME GIVE YOU
A COUPLE OF PHONE NUMBERS. DO YOU HAVE A PEN? – UH, YEAH.
GOT ONE.
GO AHEAD. – OK. MY NUMBER
HERE AT THE OFFICE IS 462-3516. AND ALSO, THE NATIONAL
SUICIDE PREVENTION HOTLINE IS 1-800-273-8255. YOU KNOW, THEY TAKE CALLS
FROM CONCERNED FAMILY MEMBERS AS WELL AS PEOPLE IN A CRISIS
ANYTIME, 7 DAYS A WEEK, 24 HOURS A DAY. – OK. ALL RIGHT.
I GOT IT. ANTONIO, ARE YOU
ON YOUR WAY HOME NOW? – YEAH. I’LL BE THERE
IN A FEW MINUTES. – OK. GOOD.
ANY QUESTIONS
ON OUR PLANS, EVA, OR ARE YOU ALL SET? – UM, NO, I THINK
I UNDERSTAND EVERYTHING. UM, VICTOR IS
GOING TO STORE THE GUN AND I’LL SEE YOU NEXT THURSDAY
WITH ANTONIO FOR THE MEETING, AND IF I HAVE ANY OTHER
QUESTIONS, I HAVE YOUR NUMBER. – THAT SOUNDS GREAT.
LOOKING FORWARD TO SEE YOU THURSDAY AT 2. – OK.
THANKS. BYE. – BYE. – MATT, ANTONIO WAS
HESITANT ABOUT THE ISSUE, BUT ULTIMATELY
WENT ALONG WITH A PLAN TO REMOVE THE FIREARM. DID THE COUNSELOR DO ANYTHING
TO MAKE IT TURN OUT SO WELL? – SHE SURE DID.
JILL DID A GREAT JOB AND HAD SHE JUMPED IN
ON THE FIREARM ISSUE EARLIER, IT MAY HAVE GONE
MUCH DIFFERENTLY. BUT BY THE TIME SHE RAISED IT, SHE HAD OFFERED TO INCREASE
THEIR INDIVIDUAL
COUNSELING SESSIONS, PICKING UP ON ANTONIO’S
COMFORTS WITH THESE MEETINGS. SHE ALSO TOOK THE TIME
TO LISTEN TO ANTONIO AND DID HER BEST
TO ALIGN WITH HIM, AND THEY WORKED OUT
A SAFETY PLAN COLLABORATIVELY. AS A RESULT, SHE WAS IN A GOOD
PLACE TO INTRODUCE THE TOPIC. I ADMIRE THE FACT THAT
SHE DID NOT GIVE UP AT THE FIRST SIGN OF RESISTANCE OR EVEN THE SECOND
SIGN OF RESISTANCE BUT REALLY HUNG IN THERE
AND EXPLAINED WHERE SHE WAS COMING FROM
IN A SUPPORTIVE YET
PLAIN-SPOKEN MANNER. DRAWING A PARALLEL
BETWEEN REDUCING ACCESS
TO THE FIREARM NOW AND REDUCING ACCESS
TO ALCOHOL AND DRUGS
WHEN HE FIRST GOT SOBER SEEMED TO HELP. THIS PARALLEL PROBABLY
HELPED ANTONIO TO FRAME THIS IN A POSITIVE WAY
AS PART OF HIS RECOVERY, RATHER THAN MORE NEGATIVELY
AS A TYPE OF SURRENDER OR A LOSS OF FREEDOM. IF TAKING A PRECAUTION
WITH A FIREARM CAN BE REFRAMED, IT OFTEN GOES A LONG WAY IN
ENLISTING A CLIENT’S AGREEMENT. – IT WAS FORTUNATE THAT ANTONIO
HAD THE OPTION OF TURNING TO HIS SISTER
AND HER HUSBAND TO HELP IN THIS SITUATION. – YES, KIRK, IT WAS
EXTREMELY HELPFUL. IN SITUATIONS LIKE THESE,
IT IS OFTEN THE BEST OPTION TO HAVE A TRUSTWORTHY PERSON
REMOVE AND SECURE THE WEAPON IF AT ALL POSSIBLE. IN THIS CASE, ANTONIO’S
BROTHER-IN-LAW’S EXPERIENCED HANDLING AND STORING FIREARMS, AND WAS A GOOD CHOICE. AN ADDED BENEFIT
OF THE CALL TO HIS SISTER IS THAT IT MOBILIZED
HER INVOLVEMENT IN TREATMENT
AS WELL. – WHAT IF ANTONIO REFUSED
TO MAKE THE CALL TO HIS SISTER? – THE COUNSELOR WAS PREPARED
TO USE AN ALTERNATIVE STRATEGY, INCLUDING HAVING ANTONIO COMMIT TO GIVE THE WEAPON
TO HIS BROTHER-IN-LAW FOR SAFE STORAGE
WHEN HE GOT HOME. IF HE HAD REFUSED TO DO THAT, ANOTHER ALTERNATIVE
WOULD HAVE BEEN TO PROVIDE ANTONIO
A GUN SAFETY LOCK ALONG WITH GIVING INSTRUCTION
ON HOW TO USE IT. ANOTHER OPTION,
WAS NOT MENTIONED, COULD BE TO GET
ANTONIO’S COMMITMENT TO TAKE THE FIREARM
TO THE NEAREST POLICE STATION AFTER CONFIRMING THAT THE POLICE
WOULD BE WILLING TO STORE AND SECURE THE WEAPON. IT’S ALSO IMPORTANT TO MENTION
THAT FIREARM LAWS DIFFER AMONG STATES
AND LOCALITIES. THEREFORE, IT’S INCUMBENT
UPON THE PROGRAM ADMINISTRATORS TO HAVE A FIREARM
POLICY IN PLACE THAT MAXIMIZES CLIENTS’ SAFETY, THAT BEARS IN MIND
STATE AND LOCAL LAWS. – NIKKI, WHAT’S THE NEXT STEP? – THE NEXT STEP IS
TO EXTEND THE ACTION. THIS IS THE STEP THAT IS
MOST LIKELY TO BE MISSED, BUT IT IS EVERY BIT AS IMPORTANT
AS THE OTHER STEPS. “EXTEND THE ACTION” REFERS
TO THE FOLLOW-UP ACTIONS THAT ARE DONE TO ENSURE
A CLIENT SAFETY PLAN ON AN ONGOING BASIS. – WHAT TYPES OF EXTENDED ACTIONS
DO YOU RECOMMEND? – HERE’S A LIST OF WAYS
OF EXTENDING THE ACTION. CONTINUING TO CHECK IN
WITH YOUR SUPERVISOR; CONFIRMING THE PATIENT HAS KEPT
REFERRAL APPOINTMENTS; FOLLOWING UP WITH ANY
EMERGENCY PROVIDERS; COORDINATING WITH
OTHER PROVIDERS; COMMUNICATING WITH SUICIDE
PREVENTION COORDINATOR; MONITORING SUICIDAL THOUGHTS
AND BEHAVIOR; INVOLVING FAMILY;
CONFIRMING THE CLIENT
HAS A SAFETY PLAN; ASSESSING CHANGES IN ACCESS
TO METHODS OF SUICIDE; FOLLOWING UP IN CASE OF RELAPSE; PREPARING THE CLIENT FOR ANY
DIFFICULT SITUATIONS; MONITORING AND UPDATING
A TREATMENT PLAN; AND DOCUMENTING EVERYTHING. A LONGER LIST OF POTENTIAL
EXTENDED ACTIONS CAN BE FOUND ON PAGE 23
OF THE TIP 50 MANUAL. – NOW LET’S TAKE A LOOK AT
A CLIP OF ANTONIO’S COUNSELOR EXTENDING THE ACTION IN THEIR
NEXT COUNSELING SESSION. – IT’S GOOD TO SEE YOU
TODAY, ANTONIO, AND IT’S NICE TO MEET YOU
IN PERSON, EVA. – NICE TO MEET YOU, TOO. – GREETINGS, SUPER COUNSELOR. – IF ONLY THAT WERE TRUE. HA.
SO, HOW’S IT GOING? – SO FAR, SO GOOD.
ANTONIO’S BEEN GOING TO HIS TREATMENT APPOINTMENTS
AND HAS BEEN STAYING SOBER. AT LEAST AS BEST I CAN TELL. – I’M ON THE STRAIGHT
AND NARROW NOW. YOU CAN PISS TEST ME
IF YOU LIKE. YOU’LL FIND NO ALCOHOL.
NO MARIJUANA. – THAT’S GREAT TO HEAR. ALTHOUGH WE’RE NOT GONNA GIVE
YOU A URINALYSIS TEST TODAY. WE DO THEM RANDOMLY OVER TIME,
AS PER NORMAL PROCEDURE. – YEAH. OK. – SO, HOW YOU DOING? – NOT TOO BAD.
HAVEN’T REALLY HAD
ANY CRAVINGS. I STICK PRETTY CLOSE
TO MY SISTER’S PLACE EXCEPT WHEN I MAKE
MY APPOINTMENTS. IT KEEPS ME OUT OF TROUBLE. – IT’S GOOD TO HEAR YOU HAVEN’T
HAD ANY CRAVINGS. IF YOU DO, AND IT WILL HAPPEN,
DON’T HESITATE TO LET ME KNOW, BECAUSE IT’S A NORMAL PART
OF RECOVERY AND IT’S REALLY GOOD
TO TALK ABOUT IT. EVA, YOU MENTIONED
THAT HE’S DOING VERY WELL WITH HIS APPOINTMENTS
AND HIS SOBRIETY. DO YOU HAVE ANY OTHER
OBSERVATIONS OR COMMENTS YOU’D LIKE TO ADD ABOUT THAT? – SOMETIMES ANTONIO MOPES. I ASSUME HE’S
THINKING ABOUT LOUISA. AND HE HAS A LOT OF TIME ON HIS
HANDS RIGHT NOW, NOT WORKING. HE MOSTLY STAYS HOME,
AND HE PLAYS WITH MY DAUGHTER, AND SHE REALLY LOVES HIM. MY HUSBAND VICTOR AND HE
WENT TO A BASEBALL GAME AND VICTOR TREATED,
AND ANTONIO SEEMED
TO REALLY APPRECIATE THAT. AND I WARNED VICTOR,
“NO BEER AT THE GAME,” AND I’M CONFIDENT
HE WENT ALONG WITH THAT. – ANTONIO, WHAT DO YOU THINK? – I GUESS I DO MOPE SOMETIMES, BUT I DON’T REALLY LET MYSELF
SINK INTO IT. I USUALLY DISTRACT MYSELF
WITH WATCHING TV OR PLAYING A VIDEO GAME. PLAYING WITH MY NIECE
OR WHATEVER. – HAVE ANY OF THE SUICIDAL
THOUGHTS RETURNED? – NO. NOTHING. – DO YOU HAVE ANY COMMENTS
ALONG THESE LINES? – WELL, I CERTAINLY
CAN’T READ HIS MIND. I REALLY DON’T KNOW.
BUT HE HASN’T SAID ANYTHING THAT WOULD MAKE ME THINK
HE’S THINKING ABOUT SUICIDE. – THAT’S GOOD TO HEAR. OFTEN WHEN PEOPLE
ARE HAVING SUICIDAL THOUGHTS, THEY MAKE COMMENTS THAT SUGGEST
THEY’RE THINKING OF SUICIDE, WHICH IS LIKE A WARNING SIGN FOR
FAMILY MEMBERS TO PICK UP ON. IT CAN BE SOMETHING OBVIOUS
OR NOT SO OBVIOUS, FROM HOPELESSNESS TO
“LIFE IS NOT WORTH LIVING,” YOU KNOW, ANYTHING
ALONG THOSE LINES. – WELL, I’LL–I’LL
CERTAINLY LISTEN FOR THINGS LIKE THAT, BUT I HAVEN’T HEARD
ANYTHING LIKE THAT. – JILL, THE EDUCATION ON SUICIDE
IS REALLY IMPRESSIVE, BUT IT’S REALLY NOT NECESSARY. – WELL, FROM YOUR STANDPOINT,
IT MAY NOT SEEM NECESSARY, BUT IT IS HELPFUL TO ME. IT IS.
I REALLY APPRECIATE IT. – I CAN SEE HOW ANTONIO THINKS
I’M BLOWING THIS
OUT OF PROPORTION, BUT FROM MY STANDPOINT, IT’S
BETTER TO ERR ON THE SAFE SIDE. MAY I ASK ABOUT THE GUN? – VICTOR TOOK CARE OF IT
AND LOCKED IT IN HIS SAFE. UM, ANTONIO DOESN’T
KNOW THE COMBINATION AND I NEVER REMEMBER IT
MYSELF, SO, ANYWAY, IT’S–ITS LOCKED AWAY. – OK. ANTONIO, HOW DO YOU
FEEL ABOUT THAT? – I’M OK.
I’M NOT WORRIED ABOUT THE GUN. I’VE GOT PLENTY OF OTHER THINGS
TO WORRY ABOUT. – MAY I ASK ABOUT
YOUR MENTAL HEALTH EVAL? – YEAH. IT WENT FINE. SAW HIM YESTERDAY.
ANSWERED SOME QUESTIONS. FILLED OUT SOME QUESTIONNAIRES. DO YOU HEAR THINGS?
DO YOU FREAK OUT WHEN
YOU HEAR LOUD NOISES? YOU KNOW, JUST STUFF LIKE THAT. HE SAID HE WANTED TO SEE YOU. – OK. GREAT.
I’LL LOOK FORWARD
TO SPEAKING WITH HIM. – DO YOU THINK THAT ANTONIO
NEEDS MENTAL HEALTH TREATMENT? – I HONESTLY DON’T KNOW, BUT I AM LOOKING FORWARD
TO SPEAKING TO THE DOCTOR ANTONIO SAW ABOUT IT. – YES. I LOOK FORWARD TO HEARING
WHAT HE HAS TO SAY AS WELL. – ANTONIO, DO YOU STILL HAVE
YOUR WRITTEN SAFETY PLAN? – YEAH. IT’S IN MY WALLET. – OK, YOU LET ME KNOW
IF YOU LOSE IT AND I’LL MAKE YOU ANOTHER COPY. – AND I STILL HAVE THE NUMBERS
THAT YOU GAVE ME AS WELL. – OK, GREAT.
I’D LIKE TO SWITCH
GEARS RIGHT NOW AND TALK ABOUT
SOME OTHER TOPICS. – NIKKI, THE COUNSELOR SEEMED
PREPARED IN THAT MEETING TO FOLLOW UP ON ALL THE THINGS
THAT SHE’D DISCUSSED WITH ANTONIO AND HIS SISTER
IN THE PREVIOUS SESSION. – THAT’S EXACTLY RIGHT.
SHE CHECKED IN WITH ANTONIO
AND HIS SISTER ABOUT THE KEY ISSUES,
INCLUDING HIS SOBRIETY, ANY RETURN TO SUICIDAL THOUGHTS, THE MENTAL HEALTH EVALUATION,
AND THE GUN. OVERALL, THE COUNSELOR
FEELS LIKE THE SITUATION IS STABILIZED
FOR THE TIME BEING AND IS PREPARED TO MOVE ON
TO OTHER TOPICS FOR THE REMAINDER
OF THE SESSION. SHE MIGHT GO ON TO DISCUSS
HOW ANTONIO CAN HANDLE IT WHEN HE HAS CONTACT
WITH LOUISA AGAIN, FOR EXAMPLE, BY PHONE OR TEXT
MESSAGE, WHICH IS INEVITABLE. ANOTHER GOOD TOPIC WOULD BE
A REVIEW OF THE ASSISTANCE THAT THE VA CAN PROVIDE HIM
IN HIS JOB SEARCH. SHE WILL ALSO WANT
TO DISCUSS WAYS TO STRENGTHEN HIS RECOVERY, INCLUDING THE USE OF SELF-HELP
MEETINGS SUCH AS A.A. OR N.A. – MARY, SO, DOES THAT
PRETTY MUCH WRAP UP
THE CASE OF ANTONIO? – THEY’VE CERTAINLY DEALT
WITH THE IMMEDIATE SITUATION. IN FUTURE SESSIONS,
THE COUNSELOR WILL LOOK FOR CHANGES IN WARNING SIGNS
AND RISK FACTORS, KEEP HER SUPERVISOR UP TO DATE
ON WHAT’S HAPPENING, AND REMAIN IN COMMUNICATION
WITH ANTONIO’S OTHER PROVIDERS. JILL ALSO HAS ESTABLISHED GOOD
RAPPORT WITH ANTONIO’S SISTER, WHO CAN SUPPORT HIM
AS WELL AS HELP WATCH FOR INDICATIONS OF RISK. ALL OF THESE
ARE WAYS THE COUNSELOR CAN EXTEND THE ACTION. – MARY, I’M GUESSING THAT
IN THIS BRIEF TRAINING, YOU WERE NOT ABLE TO COVER
ALL THE MATERIAL IN TIP 50. – YES, THAT’S CERTAINLY TRUE. WE’VE ONLY COVERED
THE HIGHLIGHTS OF TIP 50, PARTICULARLY THE RECOMMENDED
STEPS OF GATE. GATHER INFORMATION,
ACCESS SUPERVISION, TAKE ACTION, EXTEND THE ACTION. THERE ARE ALSO SEVERAL
CASE VIGNETTES IN THE TIP THAT PROVIDE ADDITIONAL EXAMPLES
FOR COUNSELORS AND SUPERVISORS TO DRAW FROM. WE ENCOURAGE VA SUBSTANCE ABUSE
CLINICIANS AND SUPERVISORS TO ORDER THE TIP
SO THAT THEY CAN LEARN MORE ABOUT GATE AS WELL AS THE ADDITIONAL INFORMATION
IN THE TIP. AS WELL, HAVING THE TIP HANDY
PROVIDES AN ONGOING RESOURCE WHEN SUICIDAL SITUATIONS ARISE, WHICH MAY COME UP WHEN
YOU LEAST EXPECT THEM. ALTHOUGH THE TIP IS NOT WRITTEN WITH THE VA
SPECIFICALLY IN MIND, THE GUIDELINES IN THE TIP
TRANSLATE VERY WELL TO THE VA SETTING. – IN THE LAST FEW MINUTES,
I WONDER IF EACH OF YOU COULD MAKE ONE ADDITIONAL POINT
ABOUT SUICIDE PREVENTION WITH SUBSTANCE ABUSE CLIENTS, EITHER SOMETHING FROM TIP 50
THAT YOU’VE NOT MENTIONED YET OR A POINT THAT YOU BELIEVE
IS PARTICULARLY RELEVANT TO SUICIDE PREVENTION EFFORTS
WITH VETERANS FROM YOUR EXPERIENCE. – MM-HMM.
I REALLY WANT TO EMPHASIZE THE IMPORTANCE OF
SEEKING SUPERVISION. TALKING ABOUT SUICIDE IS
UNCOMFORTABLE FOR MOST OF US. SUPERVISION CAN HELP
BY PROVIDING A FORUM TO LEARN AND PRACTICE
NEW CLINICAL SKILLS AND TO PROVIDE A PLACE TO GET
A SECOND OR THIRD OPINION ON HOW TO HANDLE A DIFFICULT
CLIENT SITUATION. EVEN STAFF WITH SUBSTANTIAL
EXPERIENCE CAN BENEFIT FROM OPPORTUNITIES TO ACCESS
CONSULTATION AT TIMES. – THANK YOU, MARY. NIKKI? – REMEMBER TO MAKE SURE
THAT YOUR LOCAL SUICIDE
PREVENTION COORDINATOR IS AWARE OF ANY VETERANS
THAT ARE AT HIGH RISK BECAUSE THE HOSPITAL
HAS AN ALERT SYSTEM TO FLAG THESE VETERANS’ CHARTS. ALSO, WORK WITH YOUR SPC
TO ENSURE THE VETERAN’S SAFETY AS THEY WILL MONITOR THE VETERAN ASIDE FROM THEIR REGULAR
BEHAVIORAL HEALTH VISITS. ALSO, REMEMBER TO LET
YOUR VETERANS KNOW ABOUT THE NATIONAL
SUICIDE HOTLINE, AS IT CAN BE USED AS
EXTRA SUPPORT FOR THEM, ESPECIALLY AFTER HOURS, AND IT IS SPECIFICALLY
FOR VETERANS. THAT NUMBER IS 1-800-273-TALK. – THANK YOU, NIKKI. MATT. – THANKS, KIRK.
IN ADDITION TO THE RESOURCES
AND GETTING SUPERVISION, I’D REALLY LIKE TO EMPHASIZE
THE IMPORTANCE OF COLLABORATION BETWEEN THERAPISTS
AND THEIR CLIENTS. THIS GOES HAND IN HAND
WITH THE RECOVERY PHILOSOPHY AND IT MAKES SENSE, PARTICULARLY
IN THIS CHALLENGING POPULATION, IN WHICH SUICIDALITY WILL ARISE
FROM TIME TO TIME. YOU’LL GET BETTER OUTCOMES
AND HAVE A GREATER IMPACT AS A THERAPIST IF YOU INVOLVE THE CLIENT
AND WORK IN COLLABORATION IN ALL STAGES OF TREATMENT. – MY THANKS TO DR. MARY SCHOHN,
MS. NIKKI SLAUGHTER, AND DR. MATTHEW BARRY FOR THEIR TIME AND DEDICATION
TO THIS IMPORTANT WORK. ALSO, THANKS TO THE CENTER
FOR SUBSTANCE ABUSE TREATMENT
AT SAMHSA FOR PROVIDING TIP 50,
WHICH SERVES AS THE BASIS
FOR THIS TRAINING. HERE’S THE INFORMATION
ON HOW TO OBTAIN TIP 50. IT CAN BE DOWNLOADED
AS A PDF FILE AS WELL AS ORDERED
AS A PAPER MANUAL. THE GOOD NEWS IS THAT
THE MANUAL IS COMPLETELY FREE AND INDEED,
FROM SAMHSA’S PERSPECTIVE AS WELL AS THE VA’S, THE MORE
COUNSELORS, SUPERVISORS, AND ADMINISTRATORS THAT ORDER
TIP 50, THE BETTER. HOPEFULLY, THIS OVERVIEW
HAS HELPED PROVIDE GUIDANCE ON THE COMPLEX TOPIC
OF SUICIDE PREVENTION. REMEMBER–TIP 50
IS YOUR KEYSTONE GUIDE TO HELPING YOU HELP VETERANS
AT A CROSSROADS. THAT’S ALL THE TIME
WE HAVE FOR TODAY. THANKS FOR JOINING US.

2 thoughts on “Addressing Suicidal Thoughts and Behaviors in Substance Abuse Treatment”

Leave a Reply

Your email address will not be published. Required fields are marked *