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Addressing Suicidal Thoughts and Behaviors in Substance Abuse Treatment (Updated)

Introduction

1. People with substance use disorders who are in treatment are at especially high risk of suicidal behavior for which reason?

A. They enter treatment at a point when their substance abuse is out of control, increasing a variety of risk factors for suicide.

B. They enter treatment when a number of co-occurring life crises may be occurring.

C. They enter treatment at peaks in depressive symptoms.

D. All of the above.


2. The consensus panel recommends that counselors be prepared to develop and implement a treatment plan to address suicidality and coordinate the plan with other providers.

A. True

B. False


Getting Ready to Address Suicidality

3. Which of the following is a guaranteed conversation-ending question?

A. You don’t have thoughts about killing yourself, do you?

B. Will you tell me about your suicidal thoughts?

C. Are you thinking about killing yourself?

D. What makes your suicidal thoughts worse?


4. Empirical evidence suggests that talking to a person about suicide will make them suicidal.

A. True

B. False


5. Clients should be given the impression that everything is confidential and that all types of treatment are always voluntary.

A. True

B. False


6. Interventions that successfully address major risk factors such as severe substance use, depression, and marital strife have the potential to reduce suicidal behavior.

A. True

B. False


7. A tragic outcome of death, by itself, equates to improper treatment of suicidality.

A. True

B. False


8. All clients should be screened for suicidal thoughts and behaviors as a matter of routine.

A. True

B. False


9. Which of the following actions should be taken in order to prevent clients from being exposed to life-threatening situations and to prevent the counselor and agency from being exposed to legal risk of malpractice?

A. Follow up with a client when risk has been previously documented.

B. Document suicide-related screening and interventions.

C. Communicate suicide risk to another professional or agency.

D. All of the above.


10. Even if a client really does not want to die, if his or her reports of suicidal ideation are not taken seriously, the client may act on them to “save face.”

A. True

B. False


Background Information

11. Indicators of which of the following include drafting a suicide note and taking precautions against discovery at the time of an attempt?

A. Suicidal ideation

B. Suicide plans

C. Suicidal intention

D. Suicide attempt


12. The most potent risk factor for suicidal thoughts and behaviors is:

A. Family history of suicide.

B. Prior history of suicide attempts.

C. Severe substance use.

D. Co-occurring mental disorder.


13. Protective factors:

A. May sustain someone showing ongoing signs of risk.

B. Immunize clients from suicidal behavior.

C. Afford protection in acute crises.

D. All of the above.


GATE: Procedures for Substance Abuse Counselors

14. A counselor should only attempt to manage suicide risk alone if they have substantial specialized training and education.

A. True

B. False


15. Consultation is a more formal process whereby information and advice are obtained from any of the following, except for:

A. A professional with clear supervisory responsibilities.

B. A peer.

C. A multidisciplinary team that includes professional(s) with supervisory responsibilities.

D. A consultant experienced in managing suicidal clients who have been vetted by the agency for this purpose.


16. Circumstances during treatment that require access to immediate supervision or consultation include all of the following, except:

A. Emergence or re-emergence of direct warning signs.

B. Emergence or re-emergence of indirect warning signs that, on followup questioning, suggest current risk.

C. A client with a history of suicidal thoughts or behavior experiences an acute stressful life event or a setback in treatment, but there are no accompanying warning signs or other indications to suspect current risk for suicidal behavior.

D. The client’s answers to suicide screening questions asked during the course of treatment suggest current risk.


17. All of the following require supervisory involvement or consultation, except for:

A. When clients exhibit direct suicide warning signs.

B. When clients exhibit indirect suicide warning signs.

C. When clients report at intake having made a recent suicide attempt.

D. When clients who have a history of suicidal behavior or attempts have a substance abuse relapse during treatment.


18. _____ is defined as the likelihood that a suicide attempt will occur and the potential consequences of an attempt.

A. Intention

B. Urgent

C. Seriousness

D. High-priority


19. Immediate action include all of the following, except:

A. Arranging transportation to a hospital emergency department for evaluation.

B. Contacting a spouse to have him or her arrange for removal of a gun from the home and arrange safe storage.

C. Making a referral for a client to an outpatient mental health facility for evaluation.

D. Arranging on the spot to have a mental health specialists in the program further evaluate a client.


20. With all clients with suicidal risk, consider developing with the client a written safety card that includes at a minimum:

A. A 24-hour crisis number.

B. The phone number and address of the nearest hospital emergency department.

C. The counselor’s contact information.

D. All of the above.


21. Suicidal behavior may occur in the context of substantial improvement in mood and energy, therefore, monitoring for signs of a return of suicidal thoughts or behavior is essential.

A. True

B. False


22. Documentation entails:

A. Providing a written summary of any steps taken pertaining to GATE.

B. Providing a statement of conclusions that shows the rationale for the resultant plan.

C. Both (A) and (B).

D. None of the above.


23. Even with the use of a checklist, a conclusion statement and the articulation of the plan are always needed.

A. True

B. False


Vignette 1 - Clayton

24. Which of the following is a specific point to consider when discussing suicide with a client?

A. Use clear, direct terms, not euphemisms for suicide.

B. Ask direct questions, but do so with care and compassion.

C. Ask open-ended questions that require more than a “yes” or “no” answer.

D. All of the above.


25. When a reply to a question indicates the presence of suicidal thoughts or behaviors, the counselor should follow up with open-ended questions that seek to obtain additional information.

A. True

B. False


26. The information a counselor should obtain during a current session is:

A. Information that is directly relevant to treatment planning.

B. Information that might be useful in later treatment.

C. Both (A) and (B).

D. None of the above.


27. Agencies should have a policy that specifically states that if a counselor feels he or she needs direction in a life-threatening crisis, a supervisor or other senior staff member should be contacted for input.

A. True

B. False


28. Which of the following is a step the counselor can take with family members?

A. Provide information about suicide, particularly dispelling misconceptions and providing accurate information.

B. Increasing awareness of signs and symptoms that a loved one might be experiencing suicidal thoughts and/or behaviors, especially recognizing warning signs or a significant change in risk factors.

C. Making suggestions about how to talk to a loved one who is experiencing suicidal thoughts: what to say, and what not to say.

D. All of the above.


29. Sometimes family members are not a positive force for suicide prevention and intervention, so care must be taken to assess how responsive the family members are to helping the client and if they possess the capacity to be a positive force in the client’s life at this time.

A. True

B. False


Vignette 2 - Angela

30. It is important for counselors to be aware of ongoing residential treatment and housing options for all of the following clients, except:

A. Those who have a history of homelessness.

B. Those who have co-occurring disorders.

C. Those who have a history of instability in obtaining and maintaining housing.

D. Those in need of long-term supervised care.


31. The counselor should encourage the client to be actively involved in a 12-Step or other supportive program.

A. True

B. False


32. Families should do all of the following after a client with a history of a previous suicide attempt and/or other significant risk factors has been discharged, except:

A. Family members should remain watchful for warning signs.

B. Before the patient leaves the hospital, family members should have a specific plan for whom to call and/or what to do in the event of acute warning signs.

C. Family members should presume that because a family member was just in the hospital, they are protected from suicidal behavior.

D. Family members should be involved in inpatient and outpatient treatment of their relatives.


33. Which of the following reactions from family members is counterproductive?

A. Hovering over the person to ensure that they don’t attempt again.

B. Frequently interrogating the suicidal person about their thinking.

C. Emotionally withdrawing from the suicidal person.

D. All of the above.


34. While clients may deny or minimize risk, those close to them often experience distrust and anxiety.  The counselor can address and normalize this experience and then reorient both parties back to the need for developing plans to support recovery and safety.

A. True

B. False


Vignette 3 - Leon

35. A potentially acutely suicidal client should never be left alone.

A. True

B. False


36. To develop a campus suicide prevention team:

A. Identify campus professionals who have responsibility for students at risk.

B. Identify a variety of situations and what the issues are.

C. Develop a smaller group to meet weekly to discuss at-risk students and coordinate mental health, academic, and environmental risks.

D. All of the above.


Vignette 5 - Vince

37. Men who abuse alcohol and/or drugs and are confronted with a break-up or threat to their relationship, may be prone to committing homicide followed by suicide, particularly those showing a pattern of any of the following, except for:

A. Depression

B. Jealousy

C. Domestic violence

D. Legal difficulties


Vignette 6 - Rena

38. All clients with suicide risk factors or at risk for a suicide crisis:

A. Can benefit from a Commitment to Treatment agreement.

B. Should have a safety card.

C. Both (A) and (B).

D. None of the above.


39. The first section of a safety plan should be:

A. A list of the warning signs that indicate that a crisis may be developing.

B. Coping strategies that clients can use without the help of another person.

C. Friends or family members that the client can call.

D. Telephone numbers of professionals who can be contacted in times of crisis.


40. All of the following are true with regards to the hope box, except for:

A. When clients have a new item for the hope box, they should explain to the counselor what it is, its significance, and in what way it makes them feel hopeful.

B. A commitment from the client should be elicited for them to practice thinking about one item in the hope box every day at home. They should describe to themselves how they feel when they recall the person, event, or time.

C. The client should be encouraged to add one new item to the hope box each week (or appropriate length of time).

D. After the hope box has been established, clients should be reminded to go to their hope box when they are feeling hopeless or sad, pick an item, and try to regain the feelings they have experienced in the past.


41. The hope box:

A. Is a practical exercise designed to activate reasons for living and disrupt the cycle of despair.

B. Helps reorient the client toward constructive problem solving and effective regulation of emotions.

C. Is an intervention that facilitates self-management.

D. All of the above.


42. It is more common for external events, rather than internal events, to activate the suicidal crisis.

A. True

B. False


43. “Shame-based” people often feel they don’t deserve help.

A. True

B. False


44. The most critical thing to remember about crisis phone calls is to:

A. Remain calm and patient throughout.

B. Always be oriented toward productive solutions.

C. Keep the call going as long as possible.

D. Stay focused on effective regulation of emotions and problem solving.


45. In most States, it is permissible to violate confidentiality during a suicidal crisis.

A. True

B. False


46. In order to contact family members during a crisis, the counselor needs to:

A. Have access to the appropriate phone numbers.

B. Know which family members offer healthy, supportive relationships.

C. Both (A) and (B).

D. None of the above.


Consensus Panel Recommendations for Administrators

47. Substance abuse programs should have a risk management plan that addresses the needs of clients who are suicidal.  This plan should include:

A. All clients in substance abuse treatment should be screened for suicidality.

B. The facility should meet all public health and safety codes.

C. Personal safety for clients and staff should be addressed in policies and procedures.

D. All of the above.


48. Crisis services, either as a component in the treatment program or through arrangement with other agencies, should be available:

A. 24 hours a day

B. From 8AM until 8PM

C. From 6AM until 6PM

D. From 5AM until midnight


The Benefits of Addressing Suicidality in Substance Abuse Treatment Programs

49. Screening for suicidality is not the job of a substance abuse counselor.

A. True

B. False


50. Once someone enters treatment, they are significantly less likely to have suicidal thoughts or behavior.

A. True

B. False


51. If the counselor does not ask about suicidal thoughts or behaviors, the program and the counselor will not be legally at risk if the patient attempts suicide or dies from suicide.

A. True

B. False


Levels of Program Involvement and Core Program Components

52. At a minimum, all programs providing substance abuse treatment to clients should be:

A. Level 1

B. Level 2

C. Level 3

D. Level 4


53. All of the following attributes may be found in Level 2 programs, except for:

A. The program has at least one staff member with an advanced mental health degree who is specifically skilled in providing suicide prevention and intervention services and in providing clinical supervision to other program staff working with clients with suicidal thoughts and behaviors.

B. Clinical staff can perform comprehensive suicide assessments in-house that determine level of risk, treatment needs, and necessity for legal constraint on the client.

C. The program has the capability to continue substance abuse treatment services for clients with suicidal thoughts and behaviors while monitoring those clients for suicidal symptoms and an exacerbation of psychiatric symptoms of depression, anxiety, or other co-occurring disorders.

D. The program has formalized ongoing relationships with mental health professionals trained in suicide intervention to address emergency needs.


54. Programs that offer substance abuse treatment and have the capacity to provide services to acutely suicidal clients, and are administratively linking to hospitals and inpatient psychiatric services, are:

A. Level 1

B. Level 2

C. Level 3

D. Level 4


55. If implementing a Level 1 or Level 2 program, and screening for suicide is part of the program’s routine protocol, all of the following should be reviewed, except for:

A. Are there specific questions to explore with clients with suicidal thoughts and behaviors?

B. Is there an individual or work group assigned to monitor and evaluate policies and procedures?

C. Has training been completed for all staff?

D. Is training specific to each staff member’s role?


The Role of Mid-Level Staff in Implementing and Supporting Programming for Clients With Suicidal Thoughts and Behaviors

56. Which of the following are typically the “go-to” staff when a counselor suspects that a client is suicidal?

A. Administrators

B. Clinical supervisor

C. Frontline staff

D. Support staff


Legal and Ethical Issues in Addressing Suicidality in Substance Abuse Programs

57. Standard of care is defined as:

A. The degree of care which a reasonably prudent person or professional should exercise in the same or similar circumstances.

B. The duty to exercise that degree of skill and care ordinarily employed in similar circumstances by the average clinical practitioners.

C. The duty to make reasonable and appropriate decisions using sound clinical judgment.

D. All of the above.


58. All of the following are failures in assessment, except for:

A. Failure to consider the impact of an intense substance abuse treatment environment on a client’s suicidality.

B. Failure to gather information.

C. Failure to recognize warning signs or risk factors as they emerge in treatment.

D. Failure to obtain records from other sources that would have indicated a significant risk of suicidality.


59. It is essential to properly document:

A. Warning signs, risk factors, and protective factors and steps taken to address these signs.

B. Consultation or supervision that was obtained.

C. Referrals that were considered and/or made and the client’s response to the referral.

D. All of the above.


60. Programs may be held responsible for meeting standards of care and may also be responsible for the actions of counselors employed by the program when those counselors or other professional staff do not adhere to professional standard of practice, commit a violation of law, or when the program does not provide adequate support to counselors or other professional staff.

A. True

B. False


61. Most substance abuse counselors have the skills to conduct an assessment for suicide risk.

A. True

B. False


62. It is important that substance abuse counselors, with oversight from their administrators, practice within the scope of their professional competencies and skills, as transcending the limits of acceptable practice creates malpractice liability for counselors and for their agency.

A. True

B. False


63. Generally, there is no duty to warn family members if a client is suicidal, unless that behavior threatens to harm another person.

A. True

B. False


Helping Your Program Develop and Improve Capabilities in Working With Clients Who Are Suicidal

64. A single full-day training session is preferable to shorter training sessions extending over several weeks for developing skills in working with clients who are suicidal in substance abuse treatment.

A. True

B. False


Helping Your Agency Develop and Improve Its Response to Suicidal Crises

65. Most clients experiencing suicidal thoughts and behaviors are in an acute crisis and warrant crisis management.

A. True

B. False


66. Which of the following is a kind of crisis that can occur in a program?

A. Active suicidality on the part of a client.

B. Aggressiveness, violence, threats of violence towards others.

C. Special protective issues for children and adolescents at risk for endangerment or abuse.

D. All of the above.


67. Program policies should specifically state that it is not the counselor’s role to make a final determination of whether the client is at acute or imminent risk for suicide.

A. True

B. False


68. Having both the client and counselor sign the Commitment to Treatment Statement helps promote engagement in treatment.

A. True

B. False


69. The goal of agency policy for managing clients who are acutely suicidal is to:

A. Give enough direction to clinicians and clinical supervisors to guide them in crisis situations.

B. Anticipate every kind of crisis situation related to suicidal thoughts and behaviors.

C. Both (A) and (B).

D. None of the above.


70. Every serious adverse event should result in a debriefing and postvention that considers:

A. How the event unfolded.

B. How the specific action steps facilitated or hindered resolution of the crisis.

C. How policy worked or didn’t work to address the crisis.

D. All of the above.


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