NDARC Technical Report No. 315 (2010)
Suicide is a leading cause of death among people who misuse drugs and alcohol. The annual prevalence of attempted suicide among dependent drug users is equivalent to the lifetime prevalence in the general population. Clearly suicide represents a major clinical challenge to those treating drug dependent users, yet little is known about how suicide risk is currently managed in Australian drug and alcohol treatment settings.
Research has identified a number of risk factors for suicide and established that individuals with drug and alcohol use disorders have a very high prevalence of these risk factors. As suicide risk is a dynamic phenomenon it needs to be assessed continuously throughout treatment, from intake through to discharge. Currently there is no tool available that reliably predicts suicide. The most valid method of determining risk is to conduct a thorough assessment of the individual.
A Treatment Improvement Protocol (TIP) for addressing suicidal thoughts and behaviours in substance misuse treatment settings has recently been developed in the United States. As a minimum requirement the TIP consensus panel recommends that all programs providing substance misuse treatment have the basic capacity to identify clients who are at risk and make appropriate referrals for formal risk assessment. In addition, it recommends that all programs have clear policies and procedures for the management of suicide crises.
The current study sought to examine current suicide risk assessment practices in Australian residential drug and alcohol treatment settings. Specifically, the aims of the study were:
- To examine existing suicide risk assessment and intervention strategies used by drug and alcohol staff in residential rehabilitation programmes across Australia;
- To determine the extent of staff training in suicide risk assessment;
- To assess staff knowledge of suicide risk factors;
- To describe the barriers to conducting suicide risk assessments;
- To identify additional and/or under-utilised opportunities for intervention; and
- To outline the core components of a potential suicide risk assessment tool for drug and alcohol workers, and make recommendations about the dissemination of the tool in order to maximise its usefulness.
The study employed a cross-sectional design. Semi-structured interviews (30 minutes duration) were conducted with managers and staff responsible for case management/treatment of clients at drug and alcohol residential rehabilitation services across Australia. Seventy-one residential rehabilitation services were identified and invited to participate in the study. Of these, 64 (90%) agreed to participate. At each participating agency a request was made for 1 manager and 3 staff volunteers to participate in the interview. In total, 64 manager interviews and 142 staff interviews were conducted.
The Manager Interview assessed agency policy and procedures around suicide risk assessment (SRA), agency staffing and capacity, perceived needs in terms of assessment tools, and staff training in SRA. In addition, managers were asked to provide a copy of the organisation’s current SRA policy or guidelines, any assessment tools used to assess acute suicide risk, and any general tools used as part of routine clinical assessment. The Staff Interview assessed knowledge of suicide risk factors, the frequency and extent of current screening practices, personal experiences of managing clients deemed to be a
high suicide risk, barriers to conducting SRAs, and perceived needs in terms of assessment tools.
Data from interviews was analysed using the Statistical Package for the Social Sciences (SPSS). Descriptive analyses were used to report current practices for assessing and managing suicide risk. Inferential statistics (t-test and chi square analyses) were used to examine group differences.
Characteristics of the residential rehabilitation services/staff
Participating agencies fell in to three broad categories; hospital based residential services (HBRR; n=8), religion based services (RBRR; n=18), and Therapeutic Communities and other residential rehabilitation services (TCRR; n=38). The majority (84%) of services employed paraprofessionals, and approximately half employed Allied Health (53%) or Medical/Nursing (45%) staff. The median proportion of Aboriginal and Torres Strait Islander (ATSI) clients reportedly seen was 5% (range 0-99%).
Formal training in SRA
According to managers, 25% of agencies had not provided staff with training in SRA. Consistent with this, 23% of staff interviewed reported they had never been formally trained in SRA. The majority of staff (77%) had received SRA training on a median of 2 occasions, typically around 12 months prior to interview. The majority of staff (94%) reported being confident or very confident in SRA, however, 96% acknowledged they would gain some benefit from further training.
Suicide risk assessment policy
Two thirds of agencies reportedly had a written policy relating to the management of suicide risk. A review of the policy documents indicated that 35% of these did not clearly document the procedure for assessing and responding to suicide risk. In agencies where the manager indicated there was a policy relating to SRA, 26% of staff were unaware of the policy’s existence, and 30% of staff were not at all familiar with it.
Suicide risk assessment practices
Typically staff reported assessing suicide risk in response to an observation of the client (87%) and/or at a procedural time-point in treatment (68%). The majority of SRAs were conducted either prior to treatment (often for referral purposes), or early in treatment. Most staff (81%) reported having had a client at some stage whom they considered to be a high suicide risk. A fifth of staff (20%) reported having lost a client to suicide, at a median of 36 months prior to interview (range 1-360 months). The majority of managers and staff expressed a willingness to use a new tool to assess acute suicide risk if one were developed. Approximately two-thirds of managers and half of staff interviewed reported some form of barrier to conducting suicide risk assessment with clients.
Knowledge of risk and impact of training on knowledge
Staff scored a mean of 7.4 correct responses when asked 10 knowledge questions on suicide risk factors. Fourteen per cent of staff correctly answered 5 or fewer questions. Staff who had undergone SRA training endorsed significantly more factors when asked what information they would gather from a client they believed to be acutely suicidal. Staff who had not undergone SRA training were more likely to hold the view that raising the topic of suicide with a client would increase the likelihood of them attempting suicide.
The major findings of the study were that:
- A third of agencies have no documented policy for managing suicide risk;
- A quarter of staff have never been formally trained in SRA;
- One in five staff report having lost a client to suicide;
- In more than a third of agencies, staff are not expected to use structured assessment tools when assessing acute suicide risk; and
- To varying degrees, agencies are gathering information about psychiatric comorbidity but this information does not appear to be routinely integrated into the client’s SRA.
The current study confirms the challenging role of front-line drug and alcohol workers, who work with clients at high risk for suicide, often without regular formal training and clear policies/procedures in SRA.
The study results identified a clear need for regular training in SRA for drug and alcohol staff. Almost a quarter of staff reported never having received formal training in the area, a significant proportion were unaware of important risk factors for suicide, and the majority of participants indicated that further training in SRA would be beneficial. Staff reported numerous logistical difficulties in accessing training, such as being located in rural/remote areas. The provision of computerised training in SRA, which staff could complete when convenient, is one way these difficulties could be overcome. According to the study participants, SRAs are not conducted consistently throughout treatment, with discharge being a particularly neglected time-point despite being a significant transition period. The use of structured SRA measures was not routine across participating agencies, however, almost all Managers indicated that if a new tool was designed for assessing acute suicide risk their agency would be likely to use it. While agencies typically reported that only a small proportion of their clients were of ATSI background, staff made several suggestions for modifying SRA practices for this client group. SRA among this group requires considerable cultural sensitivity on the part of the drug and alcohol worker.
Recommendations for the development of new resources
The current study identified the need for several new resources to improve the management of suicide risk in residential drug and alcohol treatment settings: a Suicide Policies and Procedures Pro-forma (Suicide–PPP), an Acute suicide risk Screener (Suicide-AS), and a standardised Suicide Risk Formulation Template (Suicide-RFT).
To integrate all of the available information in order to identify the known risk factors for a particular client, to determine how these risk factors are being addressed by the current treatment plan (where possible), and to highlight what risk factors are yet to be assessed. The template would also be useful in conveying information to external services about a client’s known suicide risk factors.
Development and pilot-testing of resources
The Suicide-PPP, Suicide-AS and Suicide-RFT should be designed in consultation with the Network of Alcohol and other Drug Agencies (NADA). A brief information booklet should be produced explaining why suicide screening is important and raising awareness of the new resources. An instruction manual should be produced to accompany the resources. It is also recommended that a pilot study be conducted with a random selection of residential rehabilitation services from across Australia as a means of determining the acceptability of the Suicide-AS, and Suicide-RFT.
This study confirms that suicide is an important clinical issue confronting drug and alcohol treatment staff, and highlights several gaps in suicide risk assessment practice. Many services are lacking clearly documented policies and procedures relating to the management of suicide risk, and do not provide staff with access to regular suicide risk assessment training. Staff in residential drug and alcohol services have a unique opportunity to gather information about a client’s acute and chronic suicide risk, and to involve other services in treatment as appropriate. The development of structured assessment tools for use in residential drug and alcohol treatment settings would significantly assist staff in fulfilling this important role.
Citation: Ross, J., Darke, S., Kelly, E. and Hetherington, K. (2010) Suicide risk assessment and intervention strategies: Current practices in Australian residential drug and alcohol rehabilitation services, Sydney: National Drug and Alcohol Research Centre.