Suicidality

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The term ‘suicide’ is used in reference to any self-inflicted injury resulting in death, where death was the deliberate intention [333]. Suicidality therefore relates to any behaviours, thoughts, or intentions which precede this act or suggest that death may be desired (e.g., self-harming, risk-taking behaviour, suicidal thoughts, previous attempts, current plans).

Clients of AOD treatment services are at high-risk of suicide [334]. The presence of comorbid mental health disorders further increases this risk [335-337]. A thorough assessment of suicide risk should take place in the initial consultation phase and be monitored throughout treatment. How to assess for suicide risk, and appropriate responses to varying levels of risk, is explained in depth below. Table 22 outlines the dos and don’ts in regard to the management of suicidality.

Table 22: Dos and don’ts of managing a client who is suicidal

DO:

  • Ensure the client has no immediate means of self-harm; remove weapons and potentially dangerous objects.
  • Talk to the client alone – without any family or friends present.
  • Allow sufficient time to discuss the issue.
  • Discuss limits of confidentiality.
  • Introduce suicide in an open, yet general way.
  • Be non-judgemental and empathetic.
  • Emphasise that there is help available.
  • Validate the client’s feelings and emphasise the fact that speaking with you is a positive thing.
  • Consider what the predominant concern is for the client, and how you might be able to help remedy this concern (e.g., removal of stresses, decreasing social isolation).
  • Contact the local mental health crisis team if the client appears to be at high-risk.

DON'T

  • Invalidate the client’s feelings (e.g., ‘All you have to do is pull yourself together’, ‘Things will work out’).
  • Panic if someone starts talking about their suicidal feelings. These feelings are common and talking about them is an important, encouraging first step.
  • Be afraid of asking about suicidal thoughts. Most clients are quite happy to answer such questions.
  • Worry that questions about suicide may instil the idea in the client's mind.
  • Leave a high-risk client unattended.

Adapted from NSW Department of Health [277].

The assessment of suicide risk is a process through which an AOD worker directly enquires about suicidal thoughts (frequency, intensity, plans, intent), history of suicidal behaviour and self-harm, current stressors, hopelessness, and protective factors (e.g., family, friends, other services). Discussing suicide with clients is vital and does not increase the risk of suicidal behaviour [338, 339]. Rather, sensitive questioning by a worker can be a relief for clients who have been harbouring thoughts of self-harm, and provides an opportunity to manage this risk appropriately, either within the AOD service, or in collaboration with mental health and emergency services [123].

Despite the need for suicide risk assessments, research suggests that many AOD services either have no written suicide risk assessment policy, unclear procedures regarding assessment and/or intervention, or policies and procedures of which AOD staff are not aware [340].

In response to the need for AOD staff to have access to resources that will assist with the identification and management of suicide risk, the Suicide Assessment Kit (SAK) was developed [341]. The SAK is a comprehensive assessment and policy package, specifically developed to help AOD services assess and manage suicide risk. It contains three key resources for AOD staff and managers (see Table 23):

  • A suicide risk screener.
  • A suicide risk formulation template.
  • A suicide policies and procedures pro forma.

Table 23: Suicide Assessment Kit key resources

Resource Purpose
Suicide risk screener Designed for use at specific time points in treatment (i.e., admission, transition points, discharge), or when the client is suspected to be at increased risk of suicide.
Suicide risk formulation template Designed to help AOD workers develop a comprehensive picture of background factors that may contribute to a client’s risk of suicide, as well as strengths and protective factors that can be incorporated into management and treatment.
Suicide policies and procedures pro forma Designed to help agencies develop policies and procedures for the assessment and management of suicide risk, as well as documentation regarding file and resource sharing, referral sources, and procedures.

A number of other supporting resources are included in the SAK, which may be useful to AOD workers in the identification and management of suicide risk. These, along with the full SAK resource (including training videos), may be downloaded from the SAK webpage: https://ndarc.med.unsw.edu.au/suicide- assessment-kit

It should be emphasised that although these resources can be incorporated into AOD workers’ everyday practice, it is vital that risk assessments are not conducted according to a checklist or flowchart procedure. All clinicians bring a wealth of knowledge, background, skills, and experience, all of which should inform the evaluation and assessment of an individual client’s level of risk. The screeners and templates included in this section (and in Appendix R) rely on AOD workers incorporating their knowledge, judgement, expertise, and skill in the assessment of risk. Figure 11 illustrates a shared assessment space, where both the AOD worker and client bring their respective backgrounds, and the AOD worker draws upon their expertise to conduct the assessment.

Figure 11: Shared risk assessment space between AOD workers and AOD clients

Figure 11: Shared risk assessment space between <span class= AOD workers and AOD clients" />

Assessment
Space

AOD worker
skills, knowledge, experience, background
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Client
background, needs warning signs, risk factors, protective factors