Suicidality

The term ‘suicide’ is used in reference to any self-inflicted injury resulting in death, where death was the deliberate intention [528]. 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). The term ‘commit’ suicide is a remnant from when the act of suicide was a criminal offence and also has religious associations (i.e., to ‘commit’ a crime or a sin). The last Australian jurisdictions to decriminalise suicide were the Australian Capital Territory in 1990 and the Northern Territory in 1996 [529]. Just as non-stigmatising language should be used when referring to a person with an AOD use disorder or a mental disorder (e.g., not using the terms ‘addict’ or ‘schizophrenic’), it is important that discussions involving suicide remain non-stigmatising. Clients of AOD treatment services are at high-risk of suicide [530–532]. The presence of co-occurring mental disorders further increases this risk [533–537]. A thorough assessment of suicide risk should take place in the initial consultation phase. However, suicide risk should also be assessed and monitored throughout treatment, particularly at pivotal points in treatment and at times of increased risk (e.g., during periods of instability, when experiencing additional stressors), as suicide risk is a dynamic process that is subject to change over time [389]. If a person presenting to treatment is not at risk of suicide at intake, it should not be assumed their low level of risk will remain the same. How to assess for suicide risk, and appropriate responses to varying levels of risk, is explained in depth below. Table 29 outlines the dos and don’ts in regard to the management of suicidality.

Adapted from NSW Department of Health [431] and Stone et al. [389].

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). While self-harming behaviour is a risk factor for suicide, it should be noted that self-harm may not always be indicative of suicide risk. For some people, self-harm may function as a mechanism for coping with distress without there being an intention to die. Irrespective of intention, it is important to consider the lethality of self-harm behaviours in assessing risk. 

Discussing suicide with clients is vital and does not increase the risk of suicidal behaviour [389, 538, 539]. Rather, sensitive questioning by a healthcare worker can be a relief for clients who have been harbouring thoughts of self-harm or suicide, and provides an opportunity to manage this risk appropriately, either within the AOD service, or in collaboration with mental health and emergency services [540, 541].

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 [542, 543].

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 [544, 545]. The SAK is a comprehensive assessment and policy package, specifically developed to help AOD services assess and manage suicide risk. It contains four key resources for AOD staff and managers (see Table 30):

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

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 Z) rely on AOD workers incorporating their knowledge, judgement, expertise, and skill in the assessment of risk. Figure 13 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.