DiscoverCounselor Toolbox PodcastCrisis Intervention in Substance Abuse Treatment
Crisis Intervention in Substance Abuse Treatment

Crisis Intervention in Substance Abuse Treatment

Update: 2020-09-26


Crisis Intervention in Substance Abuse Treatment

Based in part on SAMHSA TIP 50 Addressing Suicidal Thoughts and Behaviors in Substance Abuse Treatment

Dr. Dawn-Elise Snipes PhD, LPC-MHSP

AllCEUs Counselor Continuing Education

CEUs Available at:


• Explore crisis/ disaster counseling

• Articulate helpful tips for dealing with client suicidality.

• List 6 Positive Attitudes and Behaviors towards clients dealing with suicidal thoughts.

• Identify warning signs for suicidality using the acronym IS PATH WARM.

• Know statistics related to suicide in order to better identify potentially suicidal clients.

• Become familiar with the GATE Procedures for substance abuse counselors.

• Suicidality issues at different levels of care

Statistics Related To Suicide

– Suicide danger zones: Between age 10 and 24 years and after age 70

– More than 90% of persons who die from suicide satisfy the criteria for one or more psychiatric disorders (including adjustment disorder)

– Anxiety disorders are associated with a six- to 10-fold increase in suicide risk

– Alcohol abuse or dependence is present in 25%–50% of those who died by suicide

– When trauma and substance abuse are combined, the risk for suicide jumps to 42%

– Impending interpersonal losses and comorbid psychiatric disorders, have been specifically linked to suicide in alcoholic individuals.

Characteristics of Crisis

– Complicated

– Generally does not have one simple cause

– Beliefs may be operating when an emotion or reaction seems out of proportion to what you’re thinking in the heat of the moment

– Precipitating events may impact many different areas of life

– No Panaceas or Quick Fixes

– May provide temporary, immediate relief

– Ensure they do not make problem worse

– Necessity of Choice

– Making a choice requires action

– Choosing not to act is a still a choice

Types of Crisis & Risk Factors

– Physical (Illness, addiction)/Developmental (Life stages)

– Affective (anxiety, depression, bipolar)

– Cognitive (Alzheimer’s, Dementia, Psychotic (schizophrenia, Parkinson’s)

– Environmental/Financial

– Job Loss

– Homelessness

– Cabin Fever

– Changes in levels of care

– Relational (breakups, death, abuse history, isolation)

– Spiritual (loss of meaning)

Addiction and Suicidality

• People with substance use disorders who are in treatment are at especially high risk of suicidal behavior for many reasons, including:

• Entering treatment when their substance abuse is out of control and a number of co-occurring life crises may be occurring (e.g., marital, legal, job)

• They enter treatment at peaks in depressive symptoms

• Mental health problems 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).

Mitigating Factors

– Physical

– Sleep

– Nutrition

– Sunlight/Circadian Rhythms

– Affective: Emotional regulation and psychological flexibility

– Cognitive: Hope, commitment, control/empowerment, challenge (Hardiness, Kobasa 1977)

– Environmental: Safety and Positive Triggers

– Relational: Social support, effective interpersonal skills (boundaries, communication)

6 Positive Attitudes and Behaviors

– Provide an array of biopsychosocial services

– Screen and communicate status and interventions

– All expressions of suicidality indicate significant distress and increased vulnerability

– Be aware of indirect signs including those warning signs unique to the client (agitation, giving away things, no future plans)

– Explore past suicide attempts and ideation to identify exacerbating and mitigating factors

– Make sure all clients have the number of a suicide hotline and/or a procedure for addressing suicidal or self-injurious thoughts.

Warning Signs: IS PATH WARM

– Ideation

– Substance Abuse

– Purposelessness

– Anger

– Trapped

– Hopeless/Helpless

– Withdrawing

– Anxiety

– Recklessness

– Mood Change

GATE Procedures

– Gather information

– Early identification of warning signs, and asking follow-up questions

– Focus on the nature, frequency, intensity, duration and triggers of suicidal thoughts and context in which they are occurring.

– If the patient does not report a plan, ask whether there are certain conditions under which the patient would consider suicide

– Access supervision

– Take responsible action

– Extend the action

– Vulnerable clients may relapse into suicidal thoughts or behaviors. Continue to observe and check in

Inpatient settings

– There are not specific risk factors unique to the inpatient setting

– Fewer than half of the patients who die by suicide in the hospital were admitted with suicidal ideation

– Extreme agitation or anxiety or a rapidly fluctuating course is common before suicide.

– Many people report a state of extreme calm immediately preceding the attempt

– Each suicidal crisis must be treated as new with each admission and assessed accordingly.

Outpatient settings

– Initial evaluation should be comprehensive and include a suicide assessment including strengths, vulnerabilities, stressors and development of a safety plan

– Be aware that suicidality may wax and wane in the course of treatment.

– Sudden changes in clinical status, which may include worsening or unexpected improvements in reported symptoms, require that suicidality be reconsidered

– Risk may also be increased by

– The lack of a reliable therapeutic alliance

– The patient's unwillingness to engage in psychotherapy or adhere to medication treatment

– Inadequate family or social supports

Long-term care facilities

– Indirect self-destructive acts are found among both men and women are a common manifestation of suicide in institutional settings

– Physical illness, functional impairment, and pain are associated with increased risk for suicide

– Hopelessness and personality styles that impede adaptation to a dependent role also play a role

Jail and correctional facilities

– Suicide is one of the leading causes of death in correctional settings.

– Persons who die by suicide in jails tend to be young, white, single, intoxicated substance abusers

– Suicide in correctional facilities generally occurs by hanging

– Isolation may increase suicide

– Suicidal behaviors increase

– Immediately on entry into the facility

– After new legal complications with the inmate's case (e.g., denial of parole)

– After inmates receive bad news about loved ones

– After sexual assault or other trauma

Helpful Tips

– People who are suicidal are often ambivalent

– Crisis is an opportunity and a risk

– Suicide risk assessment and regular screening is vital

– Prevention must be ongoing

– Suicide contracts are NOT recommended

– Many clients will be at risk of suicide even after getting clean


– Suicidality is not uncommon

– It is important to regularly screen all clients for suicidality (e.g. check in sheets, monitoring logs)

– Suicidality is an opportunity for change

– A variety of different issues can contribute to suicidality.

– Early recovery is a period of extreme vulnerability for many people and treatment plans should always contain a suicide prevention plan (does not substitute for active monitoring)









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Crisis Intervention in Substance Abuse Treatment

Crisis Intervention in Substance Abuse Treatment

Charles Snipes