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- HELLO AND WELCOME TO THIS TRAINING VIDEO ON PREVENTING AND TREATING SUICIDAL BEHAVIOR AMONG CLIENTS WITH SUBSTANCE USE DISORDERS. MY NAME IS KIRK PENBERTHY, AND I'LL BE MODERATING TODAY'S DISCUSSION. JOINING ME TODAY ARE OUR 3 DISTINGUISHED PANELISTS. DR. MARY SCHOHN, WHO'S DIRECTOR OF THE VA VISN 2 BEHAVIORAL HEALTH CARE LINE; MS. TAMEKIA SLAUGHTER, WHO'S A SOCIAL WORKER AT THE BUFFALO VA MEDICAL CENTER AND GOES BY NIKKI; DR. MATTHEW BARRY, WHO'S A PSYCHIATRIST AT THE CANANDAIGUA VA MEDICAL CENTER, WHOSE EXPERIENCE INCLUDES TREATING FRONTLINE TROOPS IN AFGHANISTAN. MARY, CAN SUBSTANCE ABUSE TREATMENT PROVIDERS PLAY AN IMPORTANT ROLE IN SUICIDE PREVENTION IN THE VA? - YES, THEY CERTAINLY CAN. CLIENTS WITH SUBSTANCE ABUSE DISORDERS ARE AT ELEVATED RISK FOR SUICIDE, PARTICULARLY THOSE WITH CO-OCCURRING CONDITIONS. THEREFORE, IT IS ESSENTIAL THAT SUBSTANCE ABUSE TREATMENT PROVIDERS BE PREPARED TO RECOGNIZE AND RESPOND TO SUICIDAL THOUGHTS AND BEHAVIORS. IT IS ALSO ESSENTIAL THAT PROGRAM ADMINISTRATORS PROVIDE THE NEEDED SUPPORT AND GUIDANCE IN THIS EFFORT. - MARY, WHAT ARE YOU RECOMMENDING THAT VA SUBSTANCE ABUSE TREATMENT PROVIDERS DO TO MANAGE SUICIDE RISK? - THE PROCEDURE WE'RE RECOMMENDING IS SPELLED OUT IN THE TREATMENT IMPROVEMENT PROTOCOL, OR TIP, PROVIDED BY THE CENTER FOR SUBSTANCE ABUSE TREATMENT AT SAMHSA. THIS TIP, NUMBER 50, IS CALLED "ADDRESSING SUICIDAL THOUGHTS AND BEHAVIORS IN SUBSTANCE ABUSE TREATMENT." - I SEE. WHAT'S IN THE TIP? - TIP 50 EXPLAINS TO SUBSTANCE ABUSE TREATMENT PROVIDERS AND THEIR SUPERVISORS HOW TO DEAL WITH SUICIDAL CLIENTS. NEXT, IT SHOWS THEM WHAT TO DO THROUGH DETAILED CASE EXAMPLES CALLED VIGNETTES. FINALLY, IT PROVIDES INFORMATION ABOUT HOW A PROGRAM ADMINISTRATOR COULD IMPLEMENT TIP 50 IN A GIVEN TREATMENT PROGRAM. - MARY, WHAT ARE THE STEPS IN MANAGING SUICIDE RISK? - THESE STEPS ARE SPELLED OUT IN TIP 50 USING THE ACRONYM GATE: G-A-T-E. GATHER INFORMATION, ACCESS SUPERVISION, TAKE ACTION, EXTEND THE ACTION. THE FIRST STEP, GATHER INFORMATION, REFERS TO OBTAINING THE INFORMATION THAT WILL BE NEEDED TO DEVELOP A PLAN OF ACTION. - NIKKI, I IMAGINE IT CAN BE TRICKY TO GATHER INFORMATION FROM A SUICIDAL VETERAN WITH A SUBSTANCE ABUSE PROBLEM. HOW DO YOU GO ABOUT THAT? - TIP RECOMMENDS THAT COUNSELORS BE DIRECT AND CLEAR, REMAIN EMPATHETIC AND SUPPORTIVE, AND USE OPEN BODY LANGUAGE. ALSO, ALTHOUGH A COUNSELOR MAY FEEL ANXIOUS ABOUT THE TOPIC OF SUICIDE, IT IS IMPORTANT NOT TO ALLOW ANXIETY TO PREVENT ONE FROM GATHERING INFORMATION OR LEAD ONE INTO THE TRAP OF BECOMING A "SUICIDE INTERROGATOR." - WHAT DO YOU MEAN BY NOT LETTING A COUNSELOR'S ANXIETY PREVENT THEM FROM GATHERING INFORMATION? - ANXIETY ABOUT SUICIDE CAN CAUSE A COUNSELOR TO AVOID THE ISSUE ALTOGETHER OR SEEK FALSE REASSURANCES FROM A CLIENT. SUCH AVOIDANCE CAN TAKE MANY FORMS. FOR EXAMPLE, A QUESTION SUCH AS, "YOU'RE NOT SUICIDAL, ARE YOU?" IS WORDED IN A WAY THAT CONVEYS TO THE CLIENT THAT SUICIDE IS NOT A TOPIC THAT THE COUNSELOR WANTS TO DISCUSS. - WHAT DO YOU MEAN, "AVOID BEING THE SUICIDE INTERROGATOR"? - ANXIETY ABOUT SUICIDE CAN ALSO CAUSE A COUNSELOR TO GRILL A CLIENT ABOUT SUICIDALITY BY ASKING RAPID-FIRE CLOSE-ENDED QUESTIONS, A PATTERN THAT IS REFERRED TO IN THE TIP AS BECOMING THE SUICIDE INTERROGATOR. SUBSTANCE ABUSE COUNSELORS ARE ENCOURAGED TO RELAX AS MUCH AS POSSIBLE, TO TAKE THEIR TIME, TO ASK OPEN-ENDED QUESTIONS, AND TO ALLOW THE CLIENT THE SPACE TO EXPLAIN THEIR STORY IN THEIR OWN WORDS. IN GENERAL, COUNSELORS SHOULD APPLY THEIR BEST THERAPEUTIC SKILLS WITH SUICIDAL CLIENTS JUST AS THEY WOULD ANY SENSITIVE TOPIC. - MATT, WHAT QUESTIONS SHOULD YOU ASK A CLIENT WHEN YOU'RE GATHERING INFORMATION? - THAT'S A GOOD QUESTION, KIRK. THE MOST CRITICAL THING TO ASK ABOUT IS SUICIDALITY ITSELF--THAT IS, TO ASK ABOUT SUICIDAL THOUGHTS AND SUICIDAL BEHAVIOR AND TO DO SO DIRECTLY. SOMETIMES THE TOPIC COMES UP SPONTANEOUSLY, BUT MORE OFTEN THE COUNSELOR NEEDS TO INTRODUCE THE TOPIC, AND DON'T BE AFRAID TO DO SO. BY AND LARGE, CLIENTS WILL EXPECT AND/OR BE RELIEVED IF THE SUBJECT IS BROUGHT UP. AND WE'D RECOMMEND THAT THE COUNSELORS OPEN THE TOPIC WITH A BRIEF STATEMENT SUCH AS "NOW I'M GOING TO ASK YOU SOME QUESTIONS ABOUT SUICIDE" OR "I "HAVE SOME QUESTIONS TO ASK YOU "ABOUT SUICIDAL THOUGHTS AND BEHAVIOR." THEN YOU SHOULD ASK SCREENING QUESTIONS ABOUT SUICIDAL THOUGHTS AND SUICIDE ATTEMPTS TO SEE IF IT'S AN ACTIVE ISSUE. SOME EXAMPLES OF SUCH QUESTIONS CAN BE FOUND ON PAGES 15 TO 17 OF THE TIP 50 MANUAL. - ONCE YOU'VE DETERMINED THAT SUICIDE IS AN ISSUE, WHAT THEN? - YOU WANT TO LEARN MORE ABOUT IT IN THE WAY YOU ASK ABOUT ANY THERAPEUTIC ISSUE. SO TAKING, FOR EXAMPLE, ALCOHOL CRAVING. IN THAT CASE, A COUNSELOR MIGHT INVITE A CLIENT TO EXPLAIN THEIR CRAVINGS WITH AN OPENING STATEMENT SUCH AS, "TELL ME ABOUT YOUR CRAVINGS." AND THIS COULD BE FOLLOWED UP AS NEEDED WITH MORE SPECIFIC QUESTIONS SUCH AS, WHAT BRINGS THE CRAVINGS ON? HOW BAD DO THEY GET? WHAT MAKES THEM BETTER? AND HOW MUCH CONTROL DO YOU FEEL YOU HAVE WHEN YOU'RE EXPERIENCING THEM? SO THE SKILL SET IS ALREADY THERE. IT'S JUST APPLYING THE SAME APPROACH TO A DIFFERENT TOPIC, AND THAT TOPIC BEING SUICIDALITY. SO FOR EXAMPLE, ONE CAN START WITH AN INVITATION TO EXPLAIN, SUCH AS "TELL ME ABOUT YOUR SUICIDAL THOUGHTS," AND THAT CAN BE FOLLOWED UP BY MORE SPECIFIC QUESTIONS AS NEEDED, SUCH AS, WHAT BRINGS THE SUICIDAL THOUGHTS ON? HOW BAD CAN THEY GET? WHAT MAKES THEM BETTER? AND HOW MUCH CONTROL DO YOU FEEL YOU HAVE WHEN YOU EXPERIENCE THEM? - AND CAN EXAMPLES LIKE THIS ALSO BE FOUND IN TIP 50? - YEAH, THEY SURE CAN. QUESTIONS LIKE THESE ARE LISTED ON PAGES 17 TO 18 OF THE TIP 50 MANUAL. - YOU'VE COVERED ASKING ABOUT SUICIDAL THOUGHTS. HOW ABOUT SUICIDAL BEHAVIOR? WHAT TYPES OF FOLLOW-UP QUESTIONS WOULD YOU ASK? - WELL, THE TIP 50 HAS NUMEROUS FOLLOW-UP QUESTIONS FOR SUICIDE ATTEMPTS, AND THESE CAN BE FOUND ON PAGE 18 OF THE TIP 50 MANUAL. YOU'D WANT TO ASK OPEN-ENDED QUESTIONS ABOUT AN ATTEMPT SUCH AS, "PLEASE TELL ME WHAT HAPPENED" AND THEN AS NEEDED, YOU CAN FOLLOW IT UP WITH MORE SPECIFIC QUESTIONS, SUCH AS WHAT METHOD DID YOU USE TO ATTEMPT SUICIDE? ANOTHER GOOD QUESTION IS, WHAT HAPPENED AS A RESULT? SO FOR EXAMPLE, DID YOU RECEIVE ANY TREATMENT OR HAVE TO GO TO THE HOSPITAL? YOU WOULD ALSO WANT TO LEARN IF THERE WAS ANY OTHER ATTEMPTS OR IF THERE HAVE BEEN OTHERS IN THE PAST. - MARY, IS THAT IT, THEN? TO GATHER INFORMATION ABOUT SUICIDAL THOUGHTS AND BEHAVIOR? - IT IS ALSO IMPORTANT TO GATHER INFORMATION ABOUT WARNING SIGNS, RISK FACTORS, AND PROTECTIVE FACTORS. - WHAT'S A WARNING SIGN? - WARNING SIGNS ARE INDICATIONS OF ACUTE RISK. TIP 50 PROVIDES A LIST OF WARNING SIGNS THAT WERE IDENTIFIED BY A PANEL OF EXPERTS. WARNING SIGNS MAY BE DIRECT OR INDIRECT. DIRECT WARNING SIGNS ARE GIVEN THE HIGHEST PRIORITY BECAUSE THEY ARE THE CLEAREST SIGNALS OF DANGER. THESE CONSIST OF SUICIDAL COMMUNICATION, WHERE A CLIENT EXPRESSES OR ALLUDES TO THOUGHTS OR PLANS FOR SUICIDE; SEEKING ACCESS TO A METHOD-- FOR EXAMPLE, ACQUIRING A STASH OF PILLS OR SEEKING OUT A GUN OR A MEANS FOR HANGING; AND MAKING PREPARATIONS FOR SUICIDE--FOR EXAMPLE, REHEARSING A SUICIDAL ACT, SAYING GOOD-BYE TO LOVED ONES, OR GETTING AFFAIRS IN ORDER. - WHAT ABOUT INDIRECT WARNING SIGNS? - A PANEL OF EXPERTS ALSO CAME UP WITH A LIST OF 10 INDIRECT WARNING SIGNS THAT SPELL OUT THE ACRONYM ISPATHWARM. ALTHOUGH INDIRECT WARNING SIGNS MAY INDICATE ACUTE SUICIDE RISK, THIS IS NOT ALWAYS THE CASE. FOR EXAMPLE. MANY SUBSTANCE ABUSE CLIENTS SHOW ANGER, RECKLESSNESS, OR ANXIETY, BUT THIS DOES NOT NECESSARILY MEAN THAT THEY ARE SUICIDAL. THEREFORE IT IS IMPORTANT TO CONSIDER THESE INDIRECT WARNING SIGNS IN THE CONTEXT OF OTHER INDICATORS OF RISK. - WHEN DO WARNING SIGNS TEND TO OCCUR? - THEY OFTEN OCCUR FOLLOWING ACUTE STRESSFUL EVENTS--FOR EXAMPLE, FOLLOWING A RELAPSE OR THE BREAKUP OF A PARTNER RELATIONSHIP. THEY'RE ALSO MORE LIKELY TO OCCUR WHEN A CLIENT IS INTOXICATED OR HIGH. A RULE OF THUMB IS THAT FOLLOWING A STRESSFUL LIFE EVENT, A COUNSELOR WANTS TO LOOK FOR WARNING SIGNS. - ALONG WITH WARNING SIGNS, YOU ALSO MENTIONED THAT RISK FACTORS ARE IMPORTANT TO CONSIDER. WHAT DO YOU MEAN BY RISK FACTOR, AND HOW ARE THEY DIFFERENT FROM WARNING SIGNS? - WARNING SIGNS INDICATE ACUTE RISK, WHEREAS RISK FACTORS ARE INDICATORS OF MORE LONG-TERM RISK. RISK FACTORS ARE HELPFUL FOR IDENTIFYING WHICH CLIENTS ARE VULNERABLE TO BECOME SUICIDAL DURING THE COURSE OF TREATMENT AND WHICH CLIENTS MAY REQUIRE ADDITIONAL TREATMENT SERVICES IN ORDER TO LOWER THEIR OVERALL RISK. RISK FACTORS MAY ALSO CHANGE OVER THE COURSE OF TIME. FOR EXAMPLE, CLIENTS MAY BECOME MORE DEPRESSED, AND SUCH CHANGES ARE ALSO VERY IMPORTANT TO PAY ATTENTION TO. HERE IS A LIST OF RISK FACTORS: PERSONAL OR FAMILY HISTORY; SEVERE SUBSTANCE ABUSE; CO-OCCURRING MENTAL DISORDER; CHILDHOOD SEXUAL ABUSE; STRESS; ACCESS TO FIREARM; AGGRESSION, IMPULSIVITY, ANGER, OR ANXIETY; CHRONIC MEDICAL PROBLEMS; PERCEPTION OF NOT BELONGING; AND PERCEPTION OF BEING A BURDEN. SUICIDAL CLIENTS TYPICALLY SHOW MORE THAN ONE RISK FACTOR. - HOW ABOUT PROTECTIVE FACTORS? - PROTECTIVE FACTORS SERVE TO LOWER RISK FOR SUICIDAL BEHAVIOR. UNFORTUNATELY, THERE HAS NOT BEEN MUCH RESEARCH OF PROTECTIVE FACTORS, BUT HERE IS A LIST OF FACTORS THAT APPEAR TO LOWER RISK FOR SUICIDE. PROTECTIVE FACTORS INCLUDE HAVING REASONS FOR LIVING, STAYING CLEAN AND SOBER, RELIGIOUS ATTENDANCE OR SPIRITUAL BELIEFS AGAINST SUICIDE, PRESENCE OF A CHILD IN THE HOME OR CHILD-REARING RESPONSIBILITIES, AN INTACT MARRIAGE, A TRUSTING THERAPEUTIC RELATIONSHIP, SOCIAL SUPPORT, EMPLOYMENT, AND A GENERALLY HOPEFUL OUTLOOK. - SO IF A CLIENT HAS PROTECTIVE FACTORS, THEN ARE THEY SAFE? - NO. IT ISN'T THAT SIMPLE. ALTHOUGH PROTECTIVE FACTORS CAN HELP, THEY ARE NOT 100% PROTECTIVE, AND THEY CAN BE OVERWHELMED BY WARNING SIGNS AND RISK FACTORS. IT IS A MISTAKE TO PUT TOO MUCH STOCK IN A PROTECTIVE FACTOR WHEN THERE ARE CLEAR SIGNS OF DANGER. OVERALL, IT IS ESSENTIAL TO CONSIDER ALL OF THE INFORMATION PERTAINING TO WARNING SIGNS, RISK FACTORS, AND PROTECTIVE FACTORS RATHER THAN TO GRAB ON TO ANY ONE PIECE OF INFORMATION. ONE NEEDS TO CONSIDER THE WHOLE PICTURE. - THANK YOU FOR WALKING US THROUGH "GATHER INFORMATION." MATT, I UNDERSTAND THAT YOU HAVE A CLIP TO SHOW US THAT DEMONSTRATES THIS STEP. - THAT'S RIGHT, KIRK. THIS IS A VIGNETTE ABOUT ANTONIO RODRIGUEZ, WHO IS A 25-YEAR-OLD OIF VETERAN, AND HE COMPLETED HIS MILITARY SERVICE ABOUT TWO YEARS PRIOR, AND SINCE THAT TIME, HE'S HAD A DIFFICULT ADJUSTMENT. HE'S CURRENTLY IN AN OUTPATIENT SUBSTANCE ABUSE TREATMENT AT A VA CLINIC FOR THE TREATMENT OF ALCOHOLISM AND CANNABIS DEPENDENCE. PRECIPITATING HIS TREATMENT WAS AN ARREST FOR DRIVING WHILE INTOXICATED AND MARIJUANA POSSESSION, AND THAT LED TO MISDEMEANOR CHARGES AND ULTIMATELY TO A COURT DIVERSION PROGRAM. CONDITIONS OF THE COURT DIVERSION PROGRAM INCLUDED THAT HE WORK WITH A COURT CASE MANAGER AND COMPLETE A COURSE OF SUBSTANCE ABUSE TREATMENT. SO HE'D BEEN DOING WELL IN HIS TREATMENT, WITH GOOD ATTENDANCE AND CONTINUOUS SOBRIETY, BUT HE'D BEEN ABSENT FOR ABOUT A WEEK AND DID NOT RETURN HIS COUNSELOR'S PHONE CALLS. HE DID SHOW UP TO HIS REGULARLY SCHEDULED GROUP THERAPY APPOINTMENT, AND THE COUNSELOR, WHOSE NAME IS JILL, ASKED TO SPEAK WITH HIM AFTER GROUP. - ANTONIO, IT WAS GOOD TO SEE YOU IN GROUP AGAIN TODAY. YOU KNOW, I'VE BEEN CONCERNED BECAUSE YOU'VE BEEN ABSENT LATELY AND I HAVEN'T HEARD FROM YOU. - I'VE BEEN BUSY. - YEAH? WHAT'S BEEN GOING ON? - JUST CRAZY BUSY. - WOULD YOU LIKE TO FILL ME IN A LITTLE MORE ON THAT? - IF YOU MUST KNOW... MY GIRLFRIEND KICKED ME OUT. - YOU MEAN LOUISA? - YEAH. - OH, I'M SORRY TO HEAR THAT. WHERE ARE YOU STAYING NOW? - AT EVA'S--MY SISTER'S. LOUISA WON'T RETURN MY CALLS. I THINK SHE'S DONE WITH ME THIS TIME. - THAT MUST BE REALLY HARD FOR YOU. YOU'VE OFTEN TALKED ABOUT HOW IMPORTANT SHE IS TO YOU. - SHE'S EVERYTHING. - WOULD YOU MIND TELLING ME WHAT BROUGHT THIS ON? - STUFF HAPPENED, YOU KNOW? - ANTONIO, I CAN TELL THAT THIS IS A SENSITIVE SUBJECT, BUT PERHAPS IT MIGHT HELP IN SOME SMALL WAY TO TALK ABOUT IT. - LOUISA KICKED ME OUT BECAUSE I GOT DRUNK AND STAYED OUT ALL NIGHT. - I SEE. SO YOU'RE NOT ONLY DEALING WITH THE STRESS WITH LOUISA BUT ALSO THE STRESS OF A RELAPSE. - YEAH. IT WAS STUPID. I, UH... I RAN INTO THIS GUY THAT I USED TO HANG WITH, AND THE NEXT THING I KNOW, WE'RE AT THIS BAR, AND WE'RE THROWING THEM DOWN, AND I WAS OUT ALL NIGHT. I DON'T EVEN REMEMBER HOW I GOT HOME. - WERE YOU ABLE TO STOP DRINKING AFTER THAT? - I WISH. - YOU JUST TAKE YOUR TIME, OK? - WHEN I GOT HOME, LOUISA WAS SCREAMING AT ME. I REMEMBER THAT. SHE THREATENED TO CALL THE COPS IF I DIDN'T LEAVE. SHE BARELY GAVE ME SOME TIME TO GRAB MY STUFF. I WENT TO MY SISTER'S, AND SHE WASN'T THRILLED TO SEE ME. SHE WASN'T THRILLED TO SEE THAT I HAD BEEN DRINKING ALL NIGHT, SO SHE LEANED INTO ME PRETTY HARD. WELL, I WAS IN NO MOOD TO SIT AROUND FOR THAT, SO I GRABBED A BOTTLE OF LIQUOR FROM HER LIQUOR CABINET AND WENT TO THE PARK AND GOT DRUNK ALL OVER AGAIN. UH... AS I WAS SITTING THERE... AS I WAS SITTING THERE, I WAS RUNNING THE ARGUMENT WITH LOUISA OVER IN MY MIND. SHE LOVES ME, YOU KNOW? GOD, I LET HER DOWN. I LET HER DOWN AGAIN, AND I JUST COULDN'T STOP THINKING ABOUT WHAT I HAD DONE TO HER--LOUISA, EVEN WHAT I DID TO EVA. AND AT THAT MOMENT, IT JUST... SEEMED LIKE THE BEST WAY TO FIX EVERYTHING WAS TO GET RID OF THE PERSON CAUSING THE PROBLEMS, GET RID OF EVERYONE'S PAIN AND ANGER... GET RID OF ME. - YOU WERE IN A LOT OF EMOTIONAL PAIN SITTING THERE AT THAT PARK. JUST TAKE YOUR TIME, ANTONIO. I CAN SEE THAT THIS IS VERY DIFFICULT FOR YOU TO TALK ABOUT. - YEAH. MY GUN WAS AT MY SISTER'S, BUT... IF I'D HAD IT WITH ME, I'D BE SOMEWHERE ELSE RIGHT NOW. I HAD SOME EVIL THOUGHTS JUST SITTING THERE, AND NO MATTER HOW MUCH BOOZE I DRANK, I JUST COULDN'T STOP THINKING ABOUT WHAT I HAD DONE. AND FINALLY A COP CAME BY AND TOLD ME THE PARK WAS CLOSED AND TO GO HOME. - WOW. THAT WAS A PRETTY INTENSE COUPLE OF DAYS. HEY, LOOK, I'M GLAD TO SEE YOU'VE MADE IT THROUGH IN ONE PIECE. HOW YOU BEEN DOING SINCE THEN? - [SIGH] WELL, NO DRINKING, IF THAT'S WHAT YOU MEAN. UH, UNTIL COMING TO GROUP TODAY, I HAVEN'T EVEN LEFT MY SISTER'S. I DIDN'T TRUST MYSELF TO GO ANYWHERE, AND I HAD NOWHERE TO GO. IT FELT GOOD TO BE BACK IN GROUP TODAY, ALTHOUGH I DIDN'T SAY NOTHING. - WELL, I WAS GLAD YOU'RE BACK, AND FROM THE LOOKS ON THE OTHER MEMBER'S FACES, IT WAS PRETTY CLEAR THAT THEY WERE HAPPY TO SEE YOU, TOO. ANTONIO, YOU HAD SOME BOUTS OF SUICIDE WHILE YOU WERE SITTING AT THE PARK. I WAS WONDERING IF I COULD ASK YOU A FEW MORE QUESTIONS ABOUT THAT. - ARE YOU GONNA LOCK ME UP? - WHILE IT IS TRUE THAT SOME CLIENTS HAVE TO GO TO THE HOSPITAL FOR AN EMERGENCY EVALUATION, THERE ARE OFTEN OTHER SAFE ALTERNATIVES. - YEAH? LIKE WHAT? - WELL, FOR EXAMPLE, ANY PLAN WE MAKE TODAY, WE'LL MAKE TOGETHER. I WANT TO LET YOU KNOW THAT I'M GONNA TOUCH BASE WITH MY SUPERVISOR BEFORE WE BREAK TODAY, JUST TO MAKE SURE I'M NOT MISSING ANYTHING IMPORTANT. BUT BEFORE WE MAKE ANY PLANS, IT WOULD BE HELPFUL TO LEARN A BIT MORE ABOUT HOW YOU'VE BEEN DOING SINCE THAT DAY AT THE PARK. - YOUR SUPERVISOR, TOO? THAT'S GREAT. UH...I HAVEN'T THOUGHT ABOUT SUICIDE SINCE THAT DAY. I HAVEN'T DRANK. I MIGHT HAVE DONE SOMETHING CRAZY THAT DAY, BUT I'M OK NOW. - WELL, I'M GLAD THAT YOU'VE BEEN ABLE TO STAY SOBER SINCE THAT DAY, AND I'M GLAD THAT YOU'RE FEELING BETTER. LOOKING BACK ON WHAT HAPPENED, HOW DO YOU FEEL ABOUT IT NOW? - WELL, KILLING MYSELF WOULD BE LIKE KILLING MY MOM. I'M HER ONLY SON. MY FATHER'S DEAD, AND SHE'D NEVER GET OVER IT, AND I'D BRING SHAME ON HER, TOO. TO HER, SUICIDE IS A SIN, AND I JUST-- I COULDN'T DO THAT TO HER. MY SISTER WOULD ALSO GO CRAZY IF I KILLED MYSELF. - YOU REALLY CARE FOR YOUR MOM AND YOUR SISTER, AND YOU REALIZE HOW MUCH SUICIDE WOULD HURT THEM, AND THAT HELPS YOU TO FOCUS HOW TO GO ON LIVING DESPITE THE PROBLEMS WITH LOUISA? - YEAH. EXACTLY. - I'D LIKE TO ASK YOU A FEW MORE QUESTIONS ABOUT THIS. WOULD THAT BE OK? - YOU'RE GONNA DO IT ANYWAY, SO GET ON WITH IT. - THANKS FOR BEARING WITH ME, ANTONIO. I REALLY APPRECIATE IT. I REALIZE THAT THESE ARE VERY DIFFICULT QUESTIONS. AT THIS POINT, DO YOU HAVE A PLAN FOR SUICIDE? - NO, NOTHING LIKE THAT. I HAVEN'T THOUGHT ABOUT IT SINCE THAT DAY IN THE PARK. - HOW DO YOU ACCOUNT FOR FEELING DIFFERENTLY NOW THAN YOU DID THAT DAY? - I'M ONLY 25, AND I HOPE TO HAVE A LOT OF YEARS OF LIFE LEFT, AND I JUST--I COULDN'T-- I COULDN'T DO THAT TO MY MOM. LIKE I SAID, I DON'T WANT TO GO OUT THAT WAY. - YEAH. SEE? NOW, YOU'VE GOT A LOT OF GOOD REASONS TO GO ON LIVING. AT THE PARK, YOU HAD SOME SUICIDAL THOUGHTS, BUT FORTUNATELY, IT NEVER WENT ANY FURTHER. HAVE YOU EVER HAD THOUGHTS LIKE THAT BEFORE? - ONCE IN A WHILE, WHEN I WAS HAMMERED, I HAD SOME THOUGHTS, BUT NOTHING LIKE THAT DAY IN THE PARK. THAT WAS THE WORST BY FAR. - HAVE YOU EVER ACTUALLY TRIED TO COMMIT SUICIDE? - NO, NEVER HAVE. WHEN I WAS IN IRAQ, THIS GUY IN OUR UNIT KILLED HIMSELF. JUST WALKED OFF ONE DAY AND PUT A BULLET IN HIS HEAD. THERE WERE A BUNCH OF RUMORS ABOUT WHY HE DID IT, BUT NO ONE KNOWS WHAT THE TRUTH IS. I BARELY KNEW HIM. ANYWAYS, NO, I'VE NEVER TRIED TO KILL MYSELF. - I'M SORRY TO HEAR ABOUT THE GUY IN YOUR UNIT. HAS ANYONE ELSE YOU KNOW EVER TRIED TO COMMIT SUICIDE? - NO, JUST THAT GUY. - OK. NOW, YOU MENTIONED A GUN. - YEAH. IT'S A GLOCK. IT'S IN MY BAG AT MY SISTER'S. SO WHAT? - WELL, I MENTION IT BECAUSE I'M CONCERNED FOR YOUR SAFETY AND YOU THOUGHT OF USING IT WHILE YOU WERE DRUNK AT THE PARK. - I'M NOT THINKING ABOUT IT NOW, AM I? - UNDERSTOOD. IT'S GOOD TO KNOW THOSE THOUGHTS HAVE NOT COME BACK. IS THAT YOUR ONLY GUN? - YES. YEAH. - OK. SO, WHAT ARE YOUR PLANS NOW? - [SIGH] JUST TAKING IT ONE DAY AT A TIME. I HOPE TO GET MY SOBRIETY BACK, MAYBE ONE DAY CONVINCE LOUISA TO TAKE ME BACK. RIGHT NOW SHE'D PROBABLY CALL THE COPS IF I SHOWED UP. BUT SHE STUCK WITH ME THROUGH MY LAST TWO DEPLOYMENTS. AND WE WERE PLANNING ON GETTING MARRIED AND HAVING KIDS, AND MY MOM AND SISTER LOVE HER. RIGHT NOW I'M JUST GONNA STAY AT MY SISTER'S AND TRY TO GET MYSELF TOGETHER. - HOW IS THE SITUATION AT YOUR SISTER'S? FOR EXAMPLE, IS IT JUST THE TWO OF YOU? - NO. SHE'S THERE WITH HER HUSBAND AND DAUGHTER, MY NIECE. AND MY BROTHER-IN-LAW IS COOL. HE'S EX-MILITARY, SO WE GET ALONG GOOD. - DO YOU FEEL IT'S A SAFE PLACE TO STAY CLEAN AND SOBER? - WELL, THERE'S NO ALCOHOL IN THE HOUSE. MY SISTER SAW TO THAT. SINCE I TOOK THAT BOTTLE, SHE GOT RID OF ALL OF IT. AND MY BROTHER-IN-LAW NEVER HAD A PROBLEM HANDLING IT LIKE I DID, SO AS LONG AS I'M THERE, SHE'D KILL HIM IF HE BROUGHT LIQUOR TO THE HOUSE. THEY DON'T DO DRUGS, DON'T EVEN SMOKE. ACTUALLY, THAT'S ONE THING I HAVEN'T DONE SINCE SEEING YOU IS SMOKE MARIJUANA, SO AT LEAST THAT'S SOMETHING, RIGHT? - AGREED. THAT IS A POSITIVE. IT SEEMS AS THOUGH YOU HAVE A PRETTY GOOD SITUATION AT YOUR SISTER'S FOR NOW. - YEAH. - HAVE YOU EVER HAD TREATMENT FOR A MENTAL DISORDER--FOR EXAMPLE, DEPRESSION OR PTSD? - NO. I SAW SOMEONE AT VA FOR AN EVALUATION, BUT HE SAID I DON'T NEED ANY MEDICATIONS OR ANYTHING LIKE THAT. I JUST NEED TO STOP DRINKING AND SMOKING MARIJUANA. - WELL, THANK YOU FOR ANSWERING MY QUESTIONS, ANTONIO. AT THIS POINT, I'M GONNA TAKE A FEW MINUTES AND SPEAK WITH MY SUPERVISOR ABOUT YOUR SITUATION, AND THEN I'LL COME BACK AND WE'LL MAKE A PLAN. IT'LL JUST BE A FEW MINUTES, SO PLEASE BE PATIENT, OK? - WHO'S THIS SUPERVISOR YOU'RE TALKING TO? - HER NAME IS GLORIA JOHNSON. I BELIEVE YOU MET HER. SHE COVERED MY GROUP A COUPLE OF TIMES WHEN I WAS ON VACATION. - YEAH. I REMEMBER HER. - GOOD TO KNOW THE TWO OF YOU HAVE MET. OK, I'LL BE BACK TO TALK WITH YOU IN A FEW MINUTES. I APPRECIATE YOUR PATIENCE. I'M GONNA HAVE YOU WAIT IN THE PRIVATE WAITING ROOM WHILE I SPEAK WITH MS. JOHNSON, OK? - MATT, THAT'S A VERY MOVING SCENE. ANTONIO IS OBVIOUSLY HAVING A DIFFICULT TIME. - THAT'S RIGHT, KIRK. I THINK WE CAN ALL FEEL FOR HIM. ANTONIO IS CLEARLY IN A LOT OF EMOTIONAL PAIN. HE BECAME TEARFUL IN THE SESSION AND SHOWED GENUINE SADNESS. FROM MY EXPERIENCE, IT IS ALSO IMPORTANT TO NOTE THAT MANY VETERANS IN ANTONIO'S SITUATION WOULD NOT NECESSARILY SHOW TEARS OR BE OVERTLY SAD. INSTEAD, A VETERAN MAY PRESENT AS ANGRY OR EVEN APPEAR STOIC BUT STILL COULD BE EVERY BIT AS MUCH A RISK AS ANTONIO IS. OVERALL, SUICIDAL CLIENTS HAVE MANY DIFFERENT WAYS OF EXPRESSING THEIR EMOTIONAL DIFFICULTIES. - I SUPPOSE THAT THE CENTRAL LESSON IS THAT SUICIDAL VETERANS ARE A DIVERSE GROUP AND THEY CAN PRESENT IN MANY DIFFERENT WAYS. - THAT'S WELL-SAID, KIRK. I THINK THAT'S EXACTLY RIGHT. - THE THERAPIST SEEMED TO GATHER A LOT OF IMPORTANT INFORMATION THERE. - AGREED. I LIKE THE WAY SHE WENT ABOUT IT. ANTONIO WAS OBVIOUSLY UNCOMFORTABLE AT FIRST AND HESITANT TO TO DISCUSS HIS SUICIDAL THOUGHTS, BUT THE THERAPIST MADE AN EFFORT TO MAKE HIM MORE COMFORTABLE BY ASKING OPEN- ENDED QUESTIONS AS MUCH AS POSSIBLE. SHE WAS ALSO GOOD AT LISTENING AND MAINTAINING AN OPEN POSTURE. I ALSO REALLY LIKED THAT SHE INVITED HIM TO TAKE HIS TIME AND THAT SHE ASKED PERMISSION AT TIMES BEFORE PROCEEDING ON TO THE NEXT QUESTION, AND I THINK THAT GIVING CLIENTS A SENSE OF CONTROL LIKE THAT CAN PAY HANDSOME DIVIDENDS IN TERMS OF RAPPORT AND INVESTMENT IN THE PROCESS. - ALONG WITH HAVING A GOOD THERAPEUTIC STYLE, THE COUNSELOR ALSO SEEMED TO COVER A LOT OF GROUND. - YES. I LIKED THE QUESTIONS THAT SHE ASKED. SHE GATHERED IMPORTANT INFORMATION ABOUT SUICIDAL THOUGHTS, HOW THEY CAME ABOUT, HOW SERIOUS THEY WERE, AND OTHER FACTORS RELATED TO RISK, INCLUDING THE BREAKUP WITH HIS GIRLFRIEND, AND HIS FIREARM. SHE ALSO ASKED ABOUT MENTAL HEALTH TREATMENT HISTORY, PRIOR SUICIDAL BEHAVIOR, AND ANY SUICIDAL THOUGHTS OR PLANS SINCE THAT DAY IN THE PARK, ALL OF WHICH ARE VERY IMPORTANT TO CONSIDER. SHE ALSO CLARIFIED THAT THE SUICIDAL THOUGHTS OCCURRED WHILE HE WAS INTOXICATED AND THAT THEY HAVE NOT RETURNED SINCE, ALTHOUGH THERE IS ALWAYS A POSSIBILITY THAT ANTONIO IS MINIMIZING THE SITUATION. THE COUNSELOR ACCOMPLISHED ALL THIS EFFICIENTLY, AND INDEED, THE CLIP WE JUST SAW WAS ONLY ABOUT 14 MINUTES, YET SHE WAS ABLE TO GATHER ESSENTIAL INFORMATION IN THAT SPACE OF TIME. - OK. NIKKI, NOW THAT THE COUNSELOR HAS GATHERED INFORMATION, WHAT'S NEXT? - THE NEXT STEP IS ACCESS SUPERVISION. TIP 50 DESCRIBES TWO BROAD TYPES OF SUPERVISION A CLINICIAN COULD ACCESS. ONE IS IMMEDIATE SUPERVISION, AND TWO IS REGULAR SUPERVISION. - WHAT DO YOU MEAN BY IMMEDIATE SUPERVISION? - IMMEDIATE SUPERVISION IS REQUIRED WHEN THE COUNSELOR HAS INFORMATION TO SUGGEST THAT THERE IS CURRENT RISK OF SUICIDAL BEHAVIOR. EARLIER, MARY REVIEWED DIRECT WARNING SIGNS THAT INCLUDE SUICIDAL COMMUNICATION, SEEKING A METHOD, AND MAKING PREPARATIONS FOR SUICIDE. THE PRESENCE OF ANY OF THESE DIRECT WARNING SIGNS INDICATES THE NEED TO OBTAIN IMMEDIATE SUPERVISION. IMMEDIATE SUPERVISION SHOULD ALSO BE OBTAINED IN ANY INSTANCE WHERE THE COUNSELOR SUSPECTS THAT THERE IS CURRENT RISK, WHETHER OR NOT THERE IS A DIRECT RISK FACTOR SUCH AS YOU SEE ON YOUR SCREEN. FOR EXAMPLE, IN ANTONIO'S CASE, IMMEDIATE SUPERVISION IS REQUIRED BECAUSE SUICIDAL THOUGHTS OCCURRED RECENTLY. THESE THOUGHTS INCLUDED SHOOTING HIMSELF--A DEADLY METHOD OF SUICIDE. HE HAS ACCESS TO A GUN, AND HE HAS RELAPSED RECENTLY. THEREFORE, EVEN THOUGH ANTONIO IS SEEKING TO REASSURE HIS COUNSELOR THAT THE CRISIS HAS PASSED, NONETHELESS THE COUNSELOR RECOGNIZES THAT SHE SHOULD SPEAK WITH HER SUPERVISOR IMMEDIATELY. - I IMAGINE THAT REGULAR SUPERVISION INVOLVES MORE ROUTINE SITUATIONS. - THAT'S RIGHT. REGULAR SUPERVISION REFERS TO BRINGING UP AN ISSUE DURING YOUR WEEKLY MEETINGS WITH YOUR SUPERVISOR OR DURING YOUR REGULARLY SCHEDULED TEAM MEETINGS. SOME SITUATIONS WHEN REGULAR SUPERVISION WOULD MAKE THE MOST SENSE WOULD BE WHEN INDIRECT WARNING SIGNS ARE PRESENT BUT FOLLOW-UP QUESTIONS SUGGEST NO CURRENT RISK, RISK FACTORS ARE PRESENT BUT FOLLOW-UP QUESTIONS SUGGEST NO CURRENT RISK, AND WHEN THERE'S A HISTORY OF SUICIDAL THOUGHTS OR SUICIDE ATTEMPTS BUT FOLLOW-UP QUESTIONS SUGGEST NO CURRENT RISK. OF COURSE, AS WE'RE LEARNING, THE TIP 50 MANUAL IS COMPREHENSIVE, AND THIS INFORMATION CAN BE FOUND ON PAGE 19 OF THE MANUAL. - WELL, LET'S SHOW THE TAPE OF THE COUNSELOR ACCESSING IMMEDIATE SUPERVISION. [KNOCK ON DOOR] - GLORIA, I SEE THAT YOU'RE ON THE PHONE. I'M SORRY TO BOTHER YOU, BUT THERE IS A SITUATION THAT I NEED TO SPEAK WITH YOU ABOUT. - OK. I'LL HAVE TO CALL YOU BACK. SOMETHING HAS JUST COME UP. - THANKS FOR TALKING. I DID GROUP TODAY, AND ANTONIO RODRIGUEZ RETURNED AFTER BEING ABSENT FOR A WEEK. DO YOU REMEMBER ANTONIO FROM GROUP? - SURE, I REMEMBER HIM. - OK, WELL, I TOUCHED BASE WITH HIM AFTER GROUP, AND TO MAKE A LONG STORY SHORT, A WEEK AGO, HE MET AN OLD FRIEND, AND THEY WENT OUT AND THEY GOT DRUNK. HE CAME HOME. HIS GIRLFRIEND WAS FURIOUS. SHE KICKED HIM OUT OF THE HOUSE, AND HE SAT AT A PARK DRINKING AND THOUGHT ABOUT SUICIDE. NOW, THAT WAS A WEEK AGO, AND SINCE THEN HE HAS NO THOUGHTS OF SUICIDE, HE'S BEEN CLEAN AND SOBER, AND IS STAYING AT HIS SISTER'S HOUSE. - SO WHERE IS HE NOW? - HE'S IN THE PRIVATE WAITING AREA. I TOLD THE RECEPTIONIST I WOULD COME IN HERE AND TALK TO YOU AND TO CALL IMMEDIATELY IF HE STARTS TO GET UPSET OR GOES TO LEAVE. - OK, GOOD. YOU KNOW, I'M GLAD THAT YOU CAME TO ME. TELL ME MORE ABOUT WHAT'S GOING ON. - HE SAT AT THE PARK DRINKING AND HE HAD THE THOUGHT TO SHOOT HIMSELF WITH HIS HANDGUN. HE TOLD ME THAT IF HE HAD HIS HANDGUN WITH HIM, HE WOULD HAVE GONE THROUGH WITH IT. HE THOUGHT DRINKING MIGHT MAKE HIM FEEL BETTER, BUT IT PROVIDED NO RELIEF. HE SEEMED SAD AND WAS TEARFUL AT TIMES. HE ALSO DESCRIBED LOUISA-- THAT'S HIS GIRLFRIEND--AS EVERYTHING TO HIM, AND HE'S AFRAID HE'S BLOWN IT WITH HER. - THAT'S PRETTY SERIOUS. HOW IS HE DOING SINCE THAT DAY AT THE PARK? - AS FAR AS I CAN TELL, A LOT BETTER. THERE HAVE BEEN NO THOUGHTS OF SUICIDE. HE HAS NO PLAN OR INTENT FOR SUICIDE. HE'S GLAD TO BE BACK IN RECOVERY AND HOPES THAT LOUISA MIGHT TAKE HIM BACK EVENTUALLY. - NOW, DID YOU BELIEVE HIM, OR DID YOU THINK THAT HE WAS JUST SAYING THOSE THINGS TO REASSURE YOU? - WELL, HE WAS HESITANT TO TALK AT FIRST. FOR EXAMPLE, HE SAID THAT HE WAS AFRAID WE'D LOCK HIM UP IF MENTIONED SUICIDE. YOU KNOW, BUT EVENTUALLY HE OPENED UP, AND I BELIEVE HE WAS BEING HONEST WITH ME. - DID HE VOLUNTEER ANY REASONS NOT TO KILL HIMSELF--FOR EXAMPLE, BECAUSE IT'S AGAINST HIS SPIRITUAL OR RELIGIOUS BELIEFS OR BECAUSE OF FAMILY RELATIONSHIPS? - HE SAID THAT HE REALIZES NOW THAT KILLING HIMSELF WOULD DEVASTATE HIS MOTHER AND HIS SISTER, PARTICULARLY HIS MOTHER. HE ALSO SAID THAT HE'S YOUNG AND HE HOPES TO HAVE MANY MORE YEARS TO LIVE AND HE DOESN'T WANT TO GO OUT THAT WAY. - HAS HE BEEN SUICIDAL BEFORE? - HE SAYS HE HAS HAD THOUGHTS BEFORE BUT NOTHING AS INTENSE AS HIS THOUGHTS AT THE PARK. - HAS HE EVER TRIED TO KILL HIMSELF? - NO. HE'S NEVER MADE AN ATTEMPT. WHEN I ASKED HIM THAT QUESTION, HE MENTIONED THAT A MEMBER IN HIS UNIT HAD SHOT HIMSELF, ALTHOUGH HE BARELY KNEW THE MAN, AND HE SAID THAT'S THE ONLY PERSON HE'S KNOWN WHO'S COMMITTED SUICIDE. - SO, WHAT'S HIS MENTAL HEALTH SITUATION? - HE DID HAVE AN EVAL WHEN HE CAME IN FOR TREATMENT, AND AS I RECALL, THE DOCTOR SAID THAT HIS PROBLEMS WERE MOSTLY SUBSTANCE-RELATED AND HE DIDN'T NEED MENTAL HEALTH TREATMENT. - DID HE SEE ANY COMBAT IN IRAQ, ANY TRAUMA? - I ACTUALLY DON'T KNOW ABOUT THAT. HE DOESN'T REALLY TALK ABOUT HIS DEPLOYMENTS. HE MOSTLY TALKS ABOUT HIS RELATIONSHIP, HIS LEGAL SITUATION, PLUS THE FACT THAT HE'S LOOKING FOR A JOB. - SO HOW DO YOU FEEL ABOUT HIS LIVING SITUATION WITH HIS SISTER? - I FEEL GOOD ABOUT IT, YOU KNOW. IT'S A SOBER AND SUPPORTIVE ARRANGEMENT, AS BEST AS I CAN TELL. - NOW, YOU MENTIONED HIS GUN. WHERE DOES HE KEEP IT? - IT'S IN HIS BAG AT HIS SISTER'S. - SO DO YOU KNOW IF IT'S LOADED OR IF HE HAS AMMUNITION WITH IT? - YOU KNOW, I'M SORRY. I DIDN'T ASK THAT QUESTION, ALTHOUGH I GET THE SENSE THAT IT IS LOADED OR HE HAS AMMUNITION BASED ON WHAT HE SAID COULD HAVE HAPPENED HAD HE HAD THE GUN WITH HIM AT THE PARK. PLUS HE SAID THAT'S HIS ONLY GUN. - ANY OTHER STRESSORS? - WELL, HE IS COURT-MANDATED FOR TREATMENT, AND I'M IN TOUCH WITH HIS CASE MANAGER. HE'S ALSO OUT OF WORK AND LOOKING FOR A JOB. - ANYTHING ELSE THAT'S IMPORTANT TO CONSIDER? - I HAVE A GOOD WORKING RELATIONSHIP WITH HIM, AND HE'S VERY POPULAR WITH THE GROUP. THEY WERE HAPPY TO SEE HIM COME BACK. - OK, LET'S QUICKLY MAKE A PLAN SO THAT YOU CAN GO BACK AND TALK TO HIM. HE MAY START TO FEEL ANXIOUS IF YOU'RE AWAY TOO MUCH LONGER. - MARY, THE THERAPIST DIDN'T HESITATE TO COME INTO HER SUPERVISOR'S OFFICE AND ASK TO TALK TO HER. - YES. THIS WAS REALLY NO TIME TO BE TENTATIVELY KNOCKING ON THE DOOR OR PATIENTLY WAITING FOR THE SUPERVISOR TO FINISH HER CALL. SHE REALLY NEEDED TO SPEAK WITH THE SUPERVISOR THEN AND THERE AND MADE THIS CLEAR IN AN ASSERTIVE THOUGH RESPECTFUL WAY. - THE THERAPIST SEEMED WELL-PREPARED TO DESCRIBE THE SITUATION AND ANSWER THE SUPERVISOR'S QUESTIONS. - SHE CERTAINLY DID. SHE SPELLED OUT THE INFORMATION EFFICIENTLY AND HIT ALL OF THE MAJOR POINTS, INCLUDING THAT ANTONIO RELAPSED RECENTLY, THE INTENSITY OF HIS SUICIDAL THOUGHTS AT THE PARK, THE RECENT BREAKUP WITH HIS GIRLFRIEND AND HOW MUCH SHE MEANS TO HIM, HIS ACCESS TO A FIREARM, AND HIS TEARFULNESS IN THE SESSION AND OVERALL SADNESS. SHE ALSO MENTIONED PROTECTIVE FACTORS, INCLUDING HIS CLOSE RELATIONSHIP WITH HIS MOTHER AND SISTER AND THAT THE COUNSELOR AND ANTONIO HAVE A GOOD THERAPEUTIC RELATIONSHIP. - THE SUPERVISOR SEEMED WELL-ORGANIZED WITH HER QUESTIONS AS WELL. - ABSOLUTELY. SHE IS OBVIOUSLY EXPERIENCED WITH THIS ISSUE AND GUIDED THE COUNSELOR THROUGH THE KEY POINTS IN AN EFFICIENT MANNER. I NOTICED THAT SHE ALSO ASKED WHERE ANTONIO WAS TO CONFIRM THAT HE IS IN A PRIVATE WAITING AREA AND THAT THE RECEPTIONIST WILL CALL IN IMMEDIATELY IF HE STARTS TO GET ANXIOUS OR BEGINS TO LEAVE. - MARY, THE THERAPIST HAS GATHERED KEY INFORMATION AND ACCESSED SUPERVISION. NOW WHAT? - THE NEXT STEP, AS SPELLED OUT IN TIP 50, IS TAKE ACTION. THERE ARE MANY DIFFERENT ACTIONS THAT CAN BE TAKEN TO LOWER THE RISK FOR SUICIDE. THE GENERAL PRINCIPLE IS THAT THE ACTION SHOULD MAKE GOOD SENSE GIVEN THE LEVEL OF RISK IN A SITUATION. FOR EXAMPLE, CLIENTS AT HIGH ACUTE SUICIDAL RISK REQUIRE INTENSIVE, IMMEDIATE ACTION, WHEREAS CLIENTS AT LOWER RISK WOULD REQUIRE LESS INTENSIVE ACTIONS THAT ARE LESS IMMEDIATE. IT IS WHEN THERE IS A MISMATCH BETWEEN THE SEVERITY OF RISK AND THE LEVEL OF ACTION THAT THERE IS A PROBLEM. FOR EXAMPLE, IN ANTONIO'S CASE, IT WOULD NOT BE SUFFICIENT TO SIMPLY WELCOME HIM BACK TO GROUP WITHOUT TAKING ANY ADDITIONAL STEPS TO LOWER RISK. MISMATCHES CAN ALSO WORK THE OTHER WAY. FOR EXAMPLE, SENDING A CLIENT TO THE EMERGENCY DEPARTMENT FOR AN EVALUATION SIMPLY BECAUSE OF A PRIOR HISTORY OF SUICIDE ATTEMPT IS A MISMATCH BECAUSE IT IS AN OVER-RESPONSE TO THAT SITUATION THAT WASTES RESOURCES AND CAN UNDERMINE THE TREATMENT RELATIONSHIP. - NIKKI, SO, WHAT ARE THE ACTIONS THAT COULD BE TAKEN WITH A SUICIDAL CLIENT? - HERE'S A LIST OF ACTIONS THAT ARE LISTED IN TIP 50. THEY INCLUDE GATHERING MORE INFORMATION, ARRANGING EMERGENCY OR OUTPATIENT EVALUATION, INCREASING FREQUENCY OF CONTACT, INVOLVING THE SUICIDE PREVENTION COORDINATOR, INVOLVING A CARE PROVIDER OR CASE MANAGER, AS WELL AS RESTRICTING ACCESS TO MEANS OF SUICIDE, INVOLVING FAMILY MEMBERS, PROMOTING ATTENDANCE AT SELF-HELP MEETINGS, OBSERVING FOR SIGNS OF RETURN TO RISK, AND CONDUCTING A FORMAL SAFETY PLAN. A COMPLETE LIST OF THESE POTENTIAL ACTIONS CAN BE FOUND ON PAGES 21 AND 22 OF TIP 50. - NIKKI, THAT'S A LOT OF OPTIONS. HOW DOES THE COUNSELOR KNOW WHERE TO START? - YES, IT CAN FEEL OVERWHELMING TO A COUNSELOR, BUT THAT'S WHERE GETTING SUPERVISION CAN BE REALLY CRITICAL TO HELP THE COUNSELOR SORT THROUGH THE VARIOUS OPTIONS. THIS NEXT CLIP WILL SHOW YOU HOW THE COUNSELOR AND SUPERVISOR DEVELOPED A PLAN OF ACTION TOGETHER. - AS FAR AS WE CAN TELL, ANTONIO HAS NOT BEEN SUICIDAL SINCE THE INCIDENT IN THE PARK. HE'S FUTURE-ORIENTED, AND HIS TEMPORARY LIVING SITUATION IS SOBER AND SUPPORTIVE. HE'S ALSO CONNECTED TO YOU AND THE GROUP. I MEAN, OVERALL, HE APPEARS TO POSE NO ACUTE DANGER TO HIMSELF. I BELIEVE THAT AN OUTPATIENT-BASED PLAN IS APPROPRIATE AT THIS TIME. - THAT'S HOW I SEE IT, TOO. OUTPATIENT IS SUFFICIENT RIGHT NOW. - YOU KNOW, WE ALWAYS HAVE THE OPTION OF HAVING HIM GO FOR AN EMERGENCY EVAL IF THE SITUATION WORSENS. YOU'LL DEFINITELY NEED TO DO THE STANDARD VA SAFETY PLAN WITH HIM. YOU KNOW HIM BETTER THAN I. WHAT ELSE COMES TO MIND THAT MIGHT BE HELPFUL? - WELL, I'D FEEL A LOT BETTER ABOUT THE SITUATION IF HE GOT ANOTHER MENTAL HEALTH EVAL. - WELL, SOUNDS GOOD. DO YOU THINK HE'LL GO FOR ANOTHER EVAL? - WELL, HE'LL PROBABLY GIVE ME A BIT OF A HARD TIME AT FIRST, BUT I THINK HE'LL EVENTUALLY AGREE AND FOLLOW THROUGH. HE'S FAIRLY COMPLIANT WITH TREATMENT. - GREAT. IT WILL ALSO BE VERY IMPORTANT TO ADDRESS THE GUN. - AGREED. ALTHOUGH DEALING WITH THAT MAKES ME THE MOST NERVOUS. - IT'S A REALLY TOUGH ISSUE. YOU KNOW, MAKING THE ENVIRONMENT SAFE IS THE LAST THING THAT COMES UP IN THE SAFETY PLAN, AND BY THAT TIME, PERHAPS, HE'LL BE FEELING PRETTY COMFORTABLE WITH THE PLAN AND THEN BE MORE WILLING TO ADDRESS THE GUN. - SO WHAT DO YOU SUGGEST I DO? - COULD HE BE PERSUADED TO HAVE A FAMILY MEMBER TAKE THE GUN AND STORE IT IN A SAFE AND SECURE PLACE FOR THE TIME BEING? - WELL, HE MENTIONED HIS SISTER'S HUSBAND IS EX-MILITARY AND THEY HAVE A FAIRLY GOOD RELATIONSHIP, AND I ASSUME HE'S EXPERIENCED DEALING WITH WEAPONS AND HE MIGHT BE WILLING TO HELP US OUT WITH THIS SITUATION. - BEST CASE SCENARIO IS TO GIVE HIS SISTER A CALL BEFORE HE LEAVES TODAY. THAT WAY THERE'S NO RISK THAT HE'LL CHANGE HIS MIND BEFORE HE GETS HOME. NOW, IN THE CALL, YOU COULD EXPLAIN THE SITUATION AND THEN HAVE HER AND HER HUSBAND TAKE CARE OF THE GUN. - YES, I SPOKE WITH HIS SISTER BEFORE AND ALREADY OBTAINED A SIGNED RELEASE. WHAT IF HE'S NOT WILLING TO DO THAT? - WELL, HE MAY SURPRISE YOU AND ALLOW A CALL WITH HIS SISTER. I MEAN, IT'S CERTAINLY WORTH A TRY. IF HE WON'T GO FOR THAT, THERE ARE OTHER POSSIBILITIES, INCLUDING GETTING HIS COMMITMENT TO GIVE HIS WEAPON TO HIS BROTHER-IN-LAW WHEN HE GETS HOME. IF HE INSISTS ON HOLDING ON TO THE GUN, WE ALSO HAVE A FREE GUN LOCK THAT WE CAN PROVIDE HIM, ALTHOUGH IT WOULD BE MUCH BETTER IF HE'D BE WILLING TO PART WITH THE GUN FOR NOW. - I'LL TRY MY BEST. SO IN A NUTSHELL, THE PLAN IS TO REFER HIM FOR ANOTHER MENTAL HEALTH EVAL, DO THE SAFETY PLAN WITH HIM, AND END THE SESSION BY ADDRESSING THE GUN. - I THINK YOU'VE GOT IT. WOULD YOU LIKE FOR ME TO COME IN AND, YOU KNOW, WORK OUT THIS PLAN WITH YOU? - I THINK HE MIGHT BE A LITTLE MORE COMFORTABLE IF I WORK WITH HIM ONE ON ONE, SO LET ME SEE IF I CAN DO THIS ON MY OWN. - OK. THAT'S FINE. I'LL BE RIGHT HERE AND AVAILABLE TO HELP IF YOU GET STUCK. NOW, YOU WANT TO BE DIRECT AND CLEAR WITH HIM. IT'S ALSO VERY IMPORTANT TO BE COLLABORATIVE. IF HE DOESN'T FEEL LIKE HE HAS A SAY IN THE PLAN, HE'S GOING TO BE LESS LIKELY TO FOLLOW THROUGH. SO ALONG THESE LINES, YOU MIGHT START OUT THE SESSION BY ASKING WHAT HE WOULD THINK WOULD BE HELPFUL BEFORE SPELLING OUT YOUR RECOMMENDATIONS. - WILL DO. I'LL CALL YOU IF I GET STUCK. THANKS. - MATT, WHAT ARE YOUR THOUGHTS ABOUT THE PLAN THAT THEY CAME UP WITH? - IT'S A REAL SOLID PLAN, KIRK. THEY BASICALLY INTEND TO TAKE 3 ACTIONS. NUMBER ONE IS TO ARRANGE A MENTAL HEALTH EVALUATION. NUMBER W, DEVELOP A STANDARD VA SAFETY PLAN WITH ANTONIO. AND NUMBER 3, ADDRESS HIS ACCESS TO A FIREARM. SO FAR HIS TREATMENT IS FOCUSED ON THE SUBSTANCE ABUSE, BUT THE POSSIBILITY OF A MENTAL HEALTH PROBLEM SHOULD BE REVISITED. ASSUMING HE'S WILLING, JILL WILL SET ANTONIO UP FOR AN APPOINTMENT WITH A BEHAVIORAL HEALTH PROFESSIONAL TO DETERMINE IF A MENTAL HEALTH CONDITION, SUCH AS DEPRESSION OR PTSD, REQUIRES TREATMENT WITH MEDICATIONS OR THERAPY. ANOTHER ACTION IS TO DO THE STANDARD VA SAFETY PLAN THAT WE'LL DISCUSS IN MORE DETAIL A LITTLE LATER. THEY ALSO WANT TO ADDRESS THE FACT THAT ANTONIO HAS A PISTOL, BECAUSE FIREARMS ARE THE MOST LETHAL METHOD OF SUICIDE. - THEY CONCLUDED THAT HE DOESN'T NEED AN EMERGENCY EVALUATION AT THE HOSPITAL. WHAT DO YOU THINK OF THAT? - THEIR DECISION IS SOUND, BECAUSE AS FAR AS WE KNOW, NO SUICIDAL THOUGHTS HAVE OCCURRED SINCE HE WAS INTOXICATED IN THE PARK. HE'S EXPRESSING RELIEF THAT HE DID NOT KILL HIMSELF AND CAN PROVIDE REASONS FOR LIVING. HE AND THE THERAPIST HAVE A SOLID THERAPEUTIC RELATIONSHIP, AND UP UNTIL RECENTLY, HE HAD DONE WELL IN TREATMENT. AND HE IS STAYING WITH HIS SISTER, WHO IS A GOOD, SOBER SUPPORT, THEREFORE, THERE ARE ENOUGH POSITIVE SIGNS TO INDICATE THAT AN OUTPATIENT PLAN WOULD BE SUFFICIENT. - I NOTICED AT THE END OF THE CLIP THE SUPERVISOR ENCOURAGED JILL TO BE COLLABORATIVE. - THAT'S EXACTLY RIGHT, AND ALTHOUGH IT'S EASY FOR CLINICIANS TO FALL INTO THE TRAP OF DICTATING A PLAN, CLIENTS ARE MUCH MORE LIKELY TO FOLLOW THROUGH IF THEY HAVE A REAL SAY IN DEVELOPING THEIR SPECIFIC PLAN. AS WELL, CLIENTS CAN COME UP WITH REALLY GOOD IDEAS TO KEEP THEM SAFE, AND THESE MIGHT BE IDEAS THAT APPEAL TO THEM ON A PERSONAL LEVEL OR ONES THAT THE COUNSELOR MIGHT NOT EVEN THINK OF. ALONG THESE LINES, THE SUPERVISOR ENCOURAGED JILL TO START OFF THE MEETING BY GETTING ANTONIO'S IDEAS, WHICH WILL HELP SENT THE TONE FOR COLLABORATION. ANOTHER THING THAT WILL HELP IS THAT THE STANDARD VA SAFETY PLAN IS DONE COLLABORATIVELY WITH THE CLIENT, AND THAT COLLABORATION CANNOT BE OVEREMPHASIZED. - HERE'S THE NEXT CLIP THAT SHOWS THE COUNSELOR GOING BACK TO MEET WITH ANTONIO. LET'S SEE HOW IT PLAYS OUT. - THANKS FOR WAITING, ANTONIO. - WHAT'D YOU GUYS COME UP WITH? AM I GONNA GET LOCKED UP? - MS. JOHNSON AND I DO NOT THINK AN EMERGENCY EVALUATION AT THE HOSPITAL IS NEEDED TODAY. - YOU GUYS WOULD HAVE HAD TO DRAG ME THERE. - I THINK WE'RE GONNA HAVE TO HANDLE THIS THE OLD-FASHIONED WAY-- BY TALKING IT THROUGH. ALTHOUGH WE DON'T THINK AN EMERGENCY EVAL IS NECESSARY, YOU AND I HAVE TO HAVE A DISCUSSION TO COME UP WITH A PLAN TO DEAL WITH THE SUICIDAL THOUGHTS. - WHAT PLAN? - ANY PLAN WE'LL MAKE TOGETHER. - I DON'T THINK I NEED A PLAN. - ANTONIO, I HAVE TO ADMIT THAT I SEE IT DIFFERENTLY. YOU'VE BEEN THROUGH AN AWFUL LOT IN THE PAST WEEK, AND YOU'VE BEEN THROUGH A LOT OF PRESSURE-- THE STRESS WITH LOUISA AND THE RELAPSE. PLUS, THOSE THOUGHTS THAT YOU HAD AT THE PARK ARE REALLY SCARY. IT'S VERY REASSURING THAT THOSE THOUGHTS HAVE NOT COME BACK. AND YOU TOOK A BIG STEP IN COMING HERE TODAY. I REALLY ADMIRE YOU FOR BEING SO HONEST WITH ME. ALL OF THAT SAYS A LOT ABOUT YOUR COMMITMENT TO RECOVERY. AND ALL OF THAT MAKES ME REALLY OPTIMISTIC THAT WE CAN MAKE A GOOD PLAN. I FEEL STRONGLY THAT WE SHOULD MAKE A PLAN. IT'S NOT GONNA BE GOOD FOR YOU TO JUST PRETEND THAT THIS DIDN'T HAPPEN. - YEAH. WHATEVER. - ANTONIO...I FEEL REALLY STRONGLY ABOUT THIS. - OK. OK. WHAT DO YOU WANT ME TO DO? - MS. JOHNSON AND I CAME UP WITH A FEW IDEAS, BUT I'D LIKE TO KNOW IF YOU HAVE ANYTHING THAT YOU THINK MIGHT BE HELPFUL. - I GOT NOTHING. - YOU SEEM TO HAVE A THOUGHT. MAYBE HAVE AN IDEA THERE? - WELL, I...I DON'T LIKE TALKING IN GROUP. THOSE GUYS ARE OK, BUT I DON'T WANT TO TALK ABOUT MY PERSONAL STUFF WITH THEM. I LIKE--I LIKE TALKING TO YOU MORE. - YEAH. WE HAVE SOME REALLY GOOD, HONEST, ONE-ON-ONE CONVERSATIONS. YOU REALLY USE THESE INDIVIDUAL THERAPY SESSIONS VERY WELL. - YEAH, IT'S JUST EASIER TALKING TO YOU. - OK, SO, WHY DON'T WE UP OUR SESSIONS TO ONCE A WEEK? WOULD THAT WORK FOR YOU? - I SUPPOSE. - OK. SO I'LL SEE YOU ONCE A WEEK FOR OUR INDIVIDUAL SESSIONS FOR THE NEXT MONTH, AND THEN WE'LL SEE WHERE YOU'RE AT. - WHAT ELSE DO I HAVE TO DO? - WELL, ONE THING I WOULD LIKE IS TO SET YOU UP FOR ANOTHER MENTAL HEALTH EVAL. - I TOLD YOU I WAS NOT CRAZY. I JUST GOT DRUNK ONE DAY AND I'M OK NOW. - WOULD YOU BE WILLING TO HEAR ME OUT AND I'LL EXPLAIN THE RECOMMENDATION TO YOU? - YEAH, YEAH, WHATEVER. GO FOR IT. - THANKS FOR HEARING ME OUT, ANTONIO. LOOK, YOU'VE BEEN THROUGH AN AWFUL LOT LATELY... AND I BELIEVE YOU. I REALLY DO BELIEVE YOU WHEN YOU TELL ME THAT YOU HAD SUICIDAL THOUGHTS AT THE PARK AND ONLY AT THE PARK, AND YOU HAVEN'T HAD THEM SINCE THEN. I ALSO DO NOT THINK YOU'RE CRAZY. BUT YOU'VE BEEN THROUGH AN AWFUL LOT. AND WHEN YOU GO THROUGH SOMETHING LIKE THAT, SEEING A MENTAL HEALTH PROFESSIONAL MIGHT BE HELPFUL FOR YOU, YOU KNOW? SEEING A DOCTOR OR A THERAPIST. MIGHT BE WORTH GETTING THEIR OPINION. AT THIS POINT, IT'S JUST GONNA BE AN EVALUATION. WE DON'T KNOW WHAT THE DOCTOR'S GONNA SAY. MAYBE HE'LL RECOMMEND TREATMENT. MAYBE NOT. MAYBE HE'LL RECOMMEND MEDICATIONS. MAYBE NOT. YOU KNOW? WHO KNOWS? IT'S JUST AFTER WHAT YOU'VE BEEN THROUGH, IT'S A REALLY GOOD IDEA TO GET CHECKED OUT. MAYBE TALKING TO SOMEBODY ELSE WILL PROVE TO HELP YOU EVEN MORE. - WHAT CHOICE DO I HAVE? THE COURT SAYS I HAVE TO DO WHAT YOU SAY. - WELL, THE COURT DOES KEEP AN EYE ON THINGS, DOESN'T IT? BUT TO BE PERFECTLY HONEST WITH YOU, MS. JOHNSON AND I WERE NOT THINKING ABOUT THAT. WE'RE THINKING ABOUT WHAT WOULD BEST SUIT SOMEBODY IN A SITUATION LIKE YOU, YOU KNOW? WHAT'S BEST TO HELP YOU, REGARDLESS OF THE LEGAL SITUATION. YOU WERE IN A LOT OF PAIN THAT DAY, A LOT OF EMOTIONAL PAIN, AND WE DON'T EVER WANT TO SEE YOU BACK AT THE PARK LIKE THAT. NOBODY SHOULD EVER HAVE TO SUFFER THE WAY YOU DID. - I SUPPOSE YOU'LL TELL THE DOCTOR WHAT HAPPENED. - I'LL GIVE HIM A BRIEF SUMMARY BUT I'LL LEAVE IT FOR YOU TO FILL IN THE DETAILS. OK? - IS THAT IT, THEN? - WELL, THERE ARE A FEW OTHER THINGS I'D LIKE TO COVER. FOR ONE THING, I WOULD LIKE TO GO THROUGH A STEP-BY-STEP SAFETY PLAN WITH YOU FIRST. WOULD THAT BE ALL RIGHT? - WHATEVER. - MARY, WHAT STANDS OUT TO YOU AS YOU WATCH THE TAPE? - SHE DID A NICE JOB. SHE OPENED THE SESSION BY ASKING FOR ANTONIO'S INPUT AND PICKED UP ON HIS COMFORT WITH THE INDIVIDUAL SESSIONS BY OFFERING TO INCREASE THE FREQUENCY OF THESE MEETINGS. THAT GOT THE MEETING OFF ON THE RIGHT FOOT. SHE WAS CLEAR AND FIRM THAT SHE IS RECOMMENDING A MENTAL HEALTH EVALUATION, AND BEING CLEAR AND FIRM WITH SUCH A KEY RECOMMENDATION IS IMPORTANT. BUT AT THE SAME TIME, SHE ALSO TOOK THE TIME TO EXPLAIN THE REASON FOR IT, AND TRIED HER BEST TO NORMALIZE IT, WHICH IS REALLY IMPORTANT, GIVEN ANTONIO'S FEAR OF BEING CONSIDERED CRAZY. AS WELL, THEY TOUCHED ON THE MAJOR ISSUES THAT ARE WEIGHING ON HIS MIND, INCLUDING THE BREAKUP WITH THE GIRLFRIEND AND HIS LEGAL SITUATION. - THE COUNSELOR ALSO MENTIONED DOING A SAFETY PLAN. - THAT'S RIGHT, KIRK. THE VA HAS A STANDARD SAFETY PLAN THAT HAS TO BE DONE WITH SUICIDAL CLIENTS. HERE'S THE TEMPLATE FOR THE PLAN THAT GOES RIGHT IN THE TREATMENT RECORD. WE WILL NOT ELABORATE ON THE PLAN HERE, AND WE DID NOT SHOW THE COUNSELOR DOING THE SAFETY PLAN WITH ANTONIO, BECAUSE AN EXCELLENT TRAINING TAPE THAT SHOWS THE VA SAFETY PLAN IS ALREADY AVAILABLE. VIEWERS INTERESTED IN LEARNING MORE ABOUT THE SAFETY PLAN SHOULD WATCH THE SAFETY PLAN TRAINING VIDEO. - AS I RECALL, THERE'S ALSO THE ISSUE OF ANTONIO'S FIREARM. - THAT'S CORRECT. HERE'S THE CLIP OF THE THERAPIST ADDRESSING THIS ISSUE. - ANTONIO, THE LAST PART OF THE SAFETY PLAN THAT I WOULD LIKE TO DISCUSS WITH YOU IS KEEPING YOUR ENVIRONMENT SAFE. YOU'VE BEEN REALLY FORTUNATE TO LIVE WITH EVA AND HER FAMILY, AND I MET EVA WHEN WE FIRST STARTED DOING RECOVERY TOGETHER, AND I WAS REALLY IMPRESSED WITH HOW MUCH SHE KNEW ABOUT RECOVERY AND ADDICTION AND HOW SUPPORTIVE SHE IS OF YOU. - YEAH. WE'RE A CLOSE FAMILY. THE ONLY THING I'M REALLY CONCERNED ABOUT IN YOUR ENVIRONMENT IS YOUR GUN. - WHAT ABOUT MY GUN? - LOOK, IT'S CERTAINLY YOUR RIGHT TO HAVE A GUN. NOBODY'S ARGUING THAT. HOWEVER, GIVEN WHAT HAPPENED IN THE PARK AND THAT YOU'RE ONLY JUST BEGINNING TO REESTABLISH YOUR SOBRIETY, I WONDER IF WE COULD WORK OUT A WAY TO LESSEN ANY RISK ASSOCIATED WITH THE GUN. - WHAT ARE YOU SAYING? - WELL, I'D LIKE TO WORK ON AN ARRANGEMENT WITH YOU SO THAT FOR THE TIME BEING, SOMEONE ELSE TAKES THE GUN AND STORES IT SAFELY. - THAT'S NOT NECESSARY. - LET ME TRY TO EXPLAIN WHERE I'M COMING FROM. WOULD YOU AT LEAST BE WILLING TO HEAR ME OUT? - GO FOR IT. - OK. THANKS FOR BEING WILLING. DO YOU REMEMBER WHEN YOU FIRST STARTED YOUR PROGRAM AND WE WORKED OUT A PLAN WHERE YOU WOULD GET RID OF ALL THE LIQUOR AND MARIJUANA IN YOUR PLACE? - YEAH. - IT'S BASICALLY THE SAME PRINCIPLE HERE. IN EARLY RECOVERY, PEOPLE TEND TO HAVE MOMENTS WHEN THEY'RE CRAVING, OR THEIR JUDGMENT ISN'T VERY GOOD, AND IN THOSE MOMENTS, HAVING A SUBSTANCE NEARBY WITHIN EASY REACH COULD BE THE DIFFERENCE BETWEEN RELAPSING AND MAKING IT THROUGH CLEAN AND SOBER. YOU KNOW, THIS ALSO APPLIES TO SUICIDE. FOR EXAMPLE, IF YOU WERE TO HAVE A DAY WHEN YOU GOT DOWN AND GOT BAD NEWS FROM LOUISA OR YOU RELAPSED, WELL, THEN HAVING A GUN NEARBY COULD POSE A RISK. YOU WOULDN'T NEED TO GIVE UP THE GUN FOREVER, BUT FOR NOW, IT WOULD BE A GOOD PRECAUTION. - OK. IF IT'LL MAKE YOU HAPPY, I'LL GIVE IT TO A FRIEND TO HOLD ON TO. - ACTUALLY, I WAS THINKING OF YOUR BROTHER-IN-LAW. - YEAH. SURE. HE'S EX-MILITARY. HE KNOWS HOW TO HANDLE WEAPONS. - GOOD. WOULD IT BE OK WITH YOU IF WE GAVE YOUR SISTER A CALL AND ARRANGED FOR YOUR BROTHER-IN-LAW TO GET YOUR GUN TODAY? - NO. THAT'S NOT OK. I TOLD YOU I WILL-- I WILL GIVE MY GUN TO MY BROTHER-IN-LAW WHEN I GET HOME. THERE'S NO REASON TO CALL EVA. - ANTONIO, IF YOU INSIST THAT I NOT CALL YOUR SISTER AND YOU MAKE THE COMMITMENT TO GIVE YOUR GUN TO YOUR BROTHER-IN-LAW TO HOLD ON TO WHEN YOU GET HOME, YOU KNOW, I WOULD CERTAINLY GO ALONG WITH THAT. IN FACT, THAT WOULD BE A REALLY IMPORTANT STEP AND MAKE THE SITUATION MUCH SAFER THAN IT IS NOW. HOWEVER, FIRST I'D LIKE TO BRIEFLY EXPLORE WITH YOU WHY YOU DON'T WANT TO MAKE THE CALL TO YOUR SISTER. WOULD YOU BE WILLING TO AT LEAST TALK ABOUT THAT SOME MORE? - TALK AS MUCH AS YOU WANT. WE'RE NOT CALLING HER. - WELL, THANKS FOR BEING WILLING TO HEAR ME OUT, ANTONIO. YOU KNOW, THIS IS JUST A GUESS, BUT I'LL ASK ANYWAY. IS THE REASON YOU DON'T WANT TO CALL YOUR SISTER BECAUSE YOU DON'T WANT TO SCARE HER? - YEAH. EXACTLY. - YOU KNOW, I KNOW HOW MUCH EVA CARES ABOUT YOU AND HOW INVESTED SHE IS IN YOUR RECOVERY. I'M REALLY GUESSING THAT SHE WOULD MUCH PREFER TO KNOW WHAT'S GOING ON RATHER THAN BE LEFT IN THE DARK. YOU KNOW, EVEN IF IT DID CAUSE HER TO WORRY A LITTLE BIT. WE COULD DO OUR BEST TO TALK ABOUT IT IN A WAY THAT DOESN'T ALARM HER, BUT RATHER PRESENTS IT AS SOMETHING MORE OF A PRECAUTION. YOU KNOW, I COULD EXPLAIN TO HER THAT THE THOUGHTS OF SUICIDE ENTERED YOUR MIND WHEN YOU WERE DRINKING AFTER THE BREAKUP WITH LOUISA, BUT THEY'RE GONE NOW. AND THAT TEMPORARILY MOVING THE GUN IS JUST A PRECAUTION, JUST IN CASE ANOTHER CRISIS HITS. YOU KNOW, NO DOUBT SHE'S GONNA HAVE SOME WORRIES, BUT I CAN ALSO LET HER KNOW OF THE POSITIVE THINGS YOU ARE DOING AND JUST REASSURE HER ONCE AGAIN THAT THIS IS JUST A PRECAUTION. - LIKE I SAID, I WILL GIVE MY GLOCK TO MY BROTHER-IN-LAW. YOU WIN. - I APPRECIATE YOUR WILLINGNESS. YOU KNOW, THAT'S A REALLY IMPORTANT COMMITMENT. NOW, HOW ABOUT MY SUGGESTION TO MAKE THE CALL TO YOUR SISTER? IS THAT SOMETHING YOU'LL DO? I REALIZE I'M PUSHING THE IDEA A BIT, BUT IT'S ONLY BECAUSE I THINK IT WOULD BE HELPFUL. THE GOOD THING ABOUT A CALL IS THAT IT WOULD BE OVER AND DONE WITH AND THERE'D BE NO WORRIES ABOUT CHANGING YOUR MIND ON THE WAY HOME OR A CRISIS COMING UP BEFORE YOU HAVE A CHANCE TO GIVE IT TO YOUR BROTHER-IN-LAW. THERE'S REALLY NOTHING LIKE TAKING CARE OF SOMETHING RIGHT AWAY AND GETTING IT OVER WITH. - ALL RIGHT. YOU CAN--YOU CAN CALL HER. - YOU KNOW, ACTUALLY... I WAS THINKING WE COULD CALL HER ON THE SPEAKERPHONE. THAT WAY YOU COULD PARTICIPATE IN THE CONVERSATION. HMM? GOOD. WHAT'S HER NUMBER? - HER CELL IS 703-462-8559. [BUTTONS ON TELEPHONE BEEPING] [TELEPHONE RINGING] [RINGING] - HELLO? - HELLO, EVA? - YES? - THIS IS JILL CARLTON-- ANTONIO'S SUBSTANCE ABUSE COUNSELOR. - YEAH. HI. - HI. DO YOU HAVE JUST A COUPLE MINUTES TO TALK? - SURE. SURE. WHAT'S THIS ABOUT? - SIS, UH, MY COUNSELOR IS WORRIED ABOUT MY GUN AND WANTS VICTOR TO TAKE IT SO I DON'T SHOOT MYSELF. - WHAT? WHAT'S GOING ON? HOW DID THIS COME UP? - SEE? I TOLD YOU SHE'D GO CRAZY. - HI, EVA. I CAN SEE HOW YOU'D BE WORRIED. LET ME TAKE A MINUTE TO EXPLAIN THE SITUATION TO YOU. AS YOU KNOW, ANTONIO RELAPSED AND LOUISA BROKE UP WITH HIM, AND IN REACTION TO THAT CRISIS, HE CONFIDED IN ME HE WAS THINKING OF SUICIDE. NOW, THE GOOD NEWS IS THAT THE SUICIDAL THOUGHTS ONLY HAPPENED ON ONE DAY WHEN HE WAS DRINKING AND THERE HAVE BEEN NO THOUGHTS SINCE THEN. ALSO, IN TERMS OF THE GOOD NEWS, ANTONIO CAME BACK TO TREATMENT TODAY AND WE HAD A GOOD SESSION, AND WE MADE SOME SOLID PLANS TO GET HIM BACK ON TRACK. OVERALL, I FEEL GOOD ABOUT OUR PLAN. HOWEVER, DEALING WITH ANTONIO'S GUN COULD MAKE THE SITUATION SAFER IN CASE THERE IS A RELAPSE OR ANOTHER CRISIS WITH LOUISA. SO THEREFORE, I'M RECOMMENDING THAT AS A PRECAUTION, SOMEONE TAKE THE GUN AND STORE IT OUT OF HIS WHEREABOUTS FOR THE TIME BEING. I THOUGHT THAT YOUR HUSBAND MIGHT BE ABLE TO HELP OUT WITH THIS BECAUSE HE HAS EXPERIENCE HANDLING GUNS. - THERE--THERE ARE A MILLION THINGS RUNNING THROUGH MY HEAD RIGHT NOW. I'M--I'M A LITTLE SCARED. UM...YES, YES. OF COURSE. VICTOR--VICTOR WILL TAKE CARE OF THE GUN. ANTONIO, WHERE IS IT? - UH, IT'S IN MY BAG IN ONE OF THE SIDE COMPARTMENTS. IT'S NOT LOADED BUT THERE'S SOME AMMO IN THERE, TOO. - OK. OK. UH, VICTOR WILL BE HOME SOON AND I'LL HAVE HIM TAKE CARE OF IT WHEN HE GETS HOME. - THANKS, EVA. THAT WOULD BE VERY HELPFUL. UM, COULD YOU PLEASE MAKE SURE HE STORES IT IN A SAFE PLACE? - OK. OK. HE'S GOT A SAFE WHERE HE KEEPS HIS GUNS AND I'M SURE HE'LL PUT THIS ONE IN THERE WITH THEM. - EVA, YOU SEEM A LITTLE SHOOK UP, AND THAT IS VERY UNDERSTANDABLE. YOU KNOW, I'M SORRY TO SCARE YOU LIKE THIS. I DON'T HAVE A CRYSTAL BALL, AND I CERTAINLY DON'T KNOW IF ANTONIO WOULD EVER USE THE GUN. BUT HE'S FEELING MUCH BETTER AND HE REALLY WANTS TO GET BACK ON TRACK WITH HIS RECOVERY. AND THIS IS A POSITIVE SIGN. THIS STEP IS JUST A SAFETY PRECAUTION, ALTHOUGH IT'S ONE THAT MAKES GOOD SENSE. - OK. OK. UM, THAT'S--THAT'S GOOD TO HEAR. UM, I KNOW WE TALKED ONCE WHEN ANTONIO STARTED HIS TREATMENT, BUT WOULD IT BE POSSIBLE FOR ME TO COME TALK TO YOU IN PERSON? - WELL, WHAT DO YOU THINK, ANTONIO? CAN EVA COME TO OUR NEXT SESSION? - SURE, SIS, YOU CAN COME AND YOU CAN MEET MY COUNSELOR HERE. I TOLD HER IT WAS NOT NECESSARY, BUT SHE PRETTY MUCH INSISTED. - ANTONIO, I'M GLAD SHE TOLD ME. I WANT TO KNOW WHAT'S GOING ON. I MEAN, CAN YOU IMAGINE WHAT THIS WOULD DO TO MAMA IF YOU KILLED YOURSELF? NOT TO MENTION HOW IT WOULD AFFECT ME. JUST--JUST DO WHAT YOUR COUNSELOR TELLS YOU TO DO. UM...ALL RIGHT. SO WHEN IS THIS MEETING? - ANTONIO, COULD YOU BOTH MAKE IT THURSDAY AT 2:00 FOR A MEETING? - I'M NOT WORKING, SO I DON'T EXACTLY HAVE A LOT OF OTHER PLANS. - HOW IS THAT WITH YOU, EVA? - YEAH. YEAH, THAT WORKS GREAT. - GOOD. NOW, JUST IN CASE THERE'S EVER A PROBLEM, LET ME GIVE YOU A COUPLE OF PHONE NUMBERS. DO YOU HAVE A PEN? - UH, YEAH. GOT ONE. GO AHEAD. - OK. MY NUMBER HERE AT THE OFFICE IS 462-3516. AND ALSO, THE NATIONAL SUICIDE PREVENTION HOTLINE IS 1-800-273-8255. YOU KNOW, THEY TAKE CALLS FROM CONCERNED FAMILY MEMBERS AS WELL AS PEOPLE IN A CRISIS ANYTIME, 7 DAYS A WEEK, 24 HOURS A DAY. - OK. ALL RIGHT. I GOT IT. ANTONIO, ARE YOU ON YOUR WAY HOME NOW? - YEAH. I'LL BE THERE IN A FEW MINUTES. - OK. GOOD. ANY QUESTIONS ON OUR PLANS, EVA, OR ARE YOU ALL SET? - UM, NO, I THINK I UNDERSTAND EVERYTHING. UM, VICTOR IS GOING TO STORE THE GUN AND I'LL SEE YOU NEXT THURSDAY WITH ANTONIO FOR THE MEETING, AND IF I HAVE ANY OTHER QUESTIONS, I HAVE YOUR NUMBER. - THAT SOUNDS GREAT. LOOKING FORWARD TO SEE YOU THURSDAY AT 2. - OK. THANKS. BYE. - BYE. - MATT, ANTONIO WAS HESITANT ABOUT THE ISSUE, BUT ULTIMATELY WENT ALONG WITH A PLAN TO REMOVE THE FIREARM. DID THE COUNSELOR DO ANYTHING TO MAKE IT TURN OUT SO WELL? - SHE SURE DID. JILL DID A GREAT JOB AND HAD SHE JUMPED IN ON THE FIREARM ISSUE EARLIER, IT MAY HAVE GONE MUCH DIFFERENTLY. BUT BY THE TIME SHE RAISED IT, SHE HAD OFFERED TO INCREASE THEIR INDIVIDUAL COUNSELING SESSIONS, PICKING UP ON ANTONIO'S COMFORTS WITH THESE MEETINGS. SHE ALSO TOOK THE TIME TO LISTEN TO ANTONIO AND DID HER BEST TO ALIGN WITH HIM, AND THEY WORKED OUT A SAFETY PLAN COLLABORATIVELY. AS A RESULT, SHE WAS IN A GOOD PLACE TO INTRODUCE THE TOPIC. I ADMIRE THE FACT THAT SHE DID NOT GIVE UP AT THE FIRST SIGN OF RESISTANCE OR EVEN THE SECOND SIGN OF RESISTANCE BUT REALLY HUNG IN THERE AND EXPLAINED WHERE SHE WAS COMING FROM IN A SUPPORTIVE YET PLAIN-SPOKEN MANNER. DRAWING A PARALLEL BETWEEN REDUCING ACCESS TO THE FIREARM NOW AND REDUCING ACCESS TO ALCOHOL AND DRUGS WHEN HE FIRST GOT SOBER SEEMED TO HELP. THIS PARALLEL PROBABLY HELPED ANTONIO TO FRAME THIS IN A POSITIVE WAY AS PART OF HIS RECOVERY, RATHER THAN MORE NEGATIVELY AS A TYPE OF SURRENDER OR A LOSS OF FREEDOM. IF TAKING A PRECAUTION WITH A FIREARM CAN BE REFRAMED, IT OFTEN GOES A LONG WAY IN ENLISTING A CLIENT'S AGREEMENT. - IT WAS FORTUNATE THAT ANTONIO HAD THE OPTION OF TURNING TO HIS SISTER AND HER HUSBAND TO HELP IN THIS SITUATION. - YES, KIRK, IT WAS EXTREMELY HELPFUL. IN SITUATIONS LIKE THESE, IT IS OFTEN THE BEST OPTION TO HAVE A TRUSTWORTHY PERSON REMOVE AND SECURE THE WEAPON IF AT ALL POSSIBLE. IN THIS CASE, ANTONIO'S BROTHER-IN-LAW'S EXPERIENCED HANDLING AND STORING FIREARMS, AND WAS A GOOD CHOICE. AN ADDED BENEFIT OF THE CALL TO HIS SISTER IS THAT IT MOBILIZED HER INVOLVEMENT IN TREATMENT AS WELL. - WHAT IF ANTONIO REFUSED TO MAKE THE CALL TO HIS SISTER? - THE COUNSELOR WAS PREPARED TO USE AN ALTERNATIVE STRATEGY, INCLUDING HAVING ANTONIO COMMIT TO GIVE THE WEAPON TO HIS BROTHER-IN-LAW FOR SAFE STORAGE WHEN HE GOT HOME. IF HE HAD REFUSED TO DO THAT, ANOTHER ALTERNATIVE WOULD HAVE BEEN TO PROVIDE ANTONIO A GUN SAFETY LOCK ALONG WITH GIVING INSTRUCTION ON HOW TO USE IT. ANOTHER OPTION, WAS NOT MENTIONED, COULD BE TO GET ANTONIO'S COMMITMENT TO TAKE THE FIREARM TO THE NEAREST POLICE STATION AFTER CONFIRMING THAT THE POLICE WOULD BE WILLING TO STORE AND SECURE THE WEAPON. IT'S ALSO IMPORTANT TO MENTION THAT FIREARM LAWS DIFFER AMONG STATES AND LOCALITIES. THEREFORE, IT'S INCUMBENT UPON THE PROGRAM ADMINISTRATORS TO HAVE A FIREARM POLICY IN PLACE THAT MAXIMIZES CLIENTS' SAFETY, THAT BEARS IN MIND STATE AND LOCAL LAWS. - NIKKI, WHAT'S THE NEXT STEP? - THE NEXT STEP IS TO EXTEND THE ACTION. THIS IS THE STEP THAT IS MOST LIKELY TO BE MISSED, BUT IT IS EVERY BIT AS IMPORTANT AS THE OTHER STEPS. "EXTEND THE ACTION" REFERS TO THE FOLLOW-UP ACTIONS THAT ARE DONE TO ENSURE A CLIENT SAFETY PLAN ON AN ONGOING BASIS. - WHAT TYPES OF EXTENDED ACTIONS DO YOU RECOMMEND? - HERE'S A LIST OF WAYS OF EXTENDING THE ACTION. CONTINUING TO CHECK IN WITH YOUR SUPERVISOR; CONFIRMING THE PATIENT HAS KEPT REFERRAL APPOINTMENTS; FOLLOWING UP WITH ANY EMERGENCY PROVIDERS; COORDINATING WITH OTHER PROVIDERS; COMMUNICATING WITH SUICIDE PREVENTION COORDINATOR; MONITORING SUICIDAL THOUGHTS AND BEHAVIOR; INVOLVING FAMILY; CONFIRMING THE CLIENT HAS A SAFETY PLAN; ASSESSING CHANGES IN ACCESS TO METHODS OF SUICIDE; FOLLOWING UP IN CASE OF RELAPSE; PREPARING THE CLIENT FOR ANY DIFFICULT SITUATIONS; MONITORING AND UPDATING A TREATMENT PLAN; AND DOCUMENTING EVERYTHING. A LONGER LIST OF POTENTIAL EXTENDED ACTIONS CAN BE FOUND ON PAGE 23 OF THE TIP 50 MANUAL. - NOW LET'S TAKE A LOOK AT A CLIP OF ANTONIO'S COUNSELOR EXTENDING THE ACTION IN THEIR NEXT COUNSELING SESSION. - IT'S GOOD TO SEE YOU TODAY, ANTONIO, AND IT'S NICE TO MEET YOU IN PERSON, EVA. - NICE TO MEET YOU, TOO. - GREETINGS, SUPER COUNSELOR. - IF ONLY THAT WERE TRUE. HA. SO, HOW'S IT GOING? - SO FAR, SO GOOD. ANTONIO'S BEEN GOING TO HIS TREATMENT APPOINTMENTS AND HAS BEEN STAYING SOBER. AT LEAST AS BEST I CAN TELL. - I'M ON THE STRAIGHT AND NARROW NOW. YOU CAN PISS TEST ME IF YOU LIKE. YOU'LL FIND NO ALCOHOL. NO MARIJUANA. - THAT'S GREAT TO HEAR. ALTHOUGH WE'RE NOT GONNA GIVE YOU A URINALYSIS TEST TODAY. WE DO THEM RANDOMLY OVER TIME, AS PER NORMAL PROCEDURE. - YEAH. OK. - SO, HOW YOU DOING? - NOT TOO BAD. HAVEN'T REALLY HAD ANY CRAVINGS. I STICK PRETTY CLOSE TO MY SISTER'S PLACE EXCEPT WHEN I MAKE MY APPOINTMENTS. IT KEEPS ME OUT OF TROUBLE. - IT'S GOOD TO HEAR YOU HAVEN'T HAD ANY CRAVINGS. IF YOU DO, AND IT WILL HAPPEN, DON'T HESITATE TO LET ME KNOW, BECAUSE IT'S A NORMAL PART OF RECOVERY AND IT'S REALLY GOOD TO TALK ABOUT IT. EVA, YOU MENTIONED THAT HE'S DOING VERY WELL WITH HIS APPOINTMENTS AND HIS SOBRIETY. DO YOU HAVE ANY OTHER OBSERVATIONS OR COMMENTS YOU'D LIKE TO ADD ABOUT THAT? - SOMETIMES ANTONIO MOPES. I ASSUME HE'S THINKING ABOUT LOUISA. AND HE HAS A LOT OF TIME ON HIS HANDS RIGHT NOW, NOT WORKING. HE MOSTLY STAYS HOME, AND HE PLAYS WITH MY DAUGHTER, AND SHE REALLY LOVES HIM. MY HUSBAND VICTOR AND HE WENT TO A BASEBALL GAME AND VICTOR TREATED, AND ANTONIO SEEMED TO REALLY APPRECIATE THAT. AND I WARNED VICTOR, "NO BEER AT THE GAME," AND I'M CONFIDENT HE WENT ALONG WITH THAT. - ANTONIO, WHAT DO YOU THINK? - I GUESS I DO MOPE SOMETIMES, BUT I DON'T REALLY LET MYSELF SINK INTO IT. I USUALLY DISTRACT MYSELF WITH WATCHING TV OR PLAYING A VIDEO GAME. PLAYING WITH MY NIECE OR WHATEVER. - HAVE ANY OF THE SUICIDAL THOUGHTS RETURNED? - NO. NOTHING. - DO YOU HAVE ANY COMMENTS ALONG THESE LINES? - WELL, I CERTAINLY CAN'T READ HIS MIND. I REALLY DON'T KNOW. BUT HE HASN'T SAID ANYTHING THAT WOULD MAKE ME THINK HE'S THINKING ABOUT SUICIDE. - THAT'S GOOD TO HEAR. OFTEN WHEN PEOPLE ARE HAVING SUICIDAL THOUGHTS, THEY MAKE COMMENTS THAT SUGGEST THEY'RE THINKING OF SUICIDE, WHICH IS LIKE A WARNING SIGN FOR FAMILY MEMBERS TO PICK UP ON. IT CAN BE SOMETHING OBVIOUS OR NOT SO OBVIOUS, FROM HOPELESSNESS TO "LIFE IS NOT WORTH LIVING," YOU KNOW, ANYTHING ALONG THOSE LINES. - WELL, I'LL--I'LL CERTAINLY LISTEN FOR THINGS LIKE THAT, BUT I HAVEN'T HEARD ANYTHING LIKE THAT. - JILL, THE EDUCATION ON SUICIDE IS REALLY IMPRESSIVE, BUT IT'S REALLY NOT NECESSARY. - WELL, FROM YOUR STANDPOINT, IT MAY NOT SEEM NECESSARY, BUT IT IS HELPFUL TO ME. IT IS. I REALLY APPRECIATE IT. - I CAN SEE HOW ANTONIO THINKS I'M BLOWING THIS OUT OF PROPORTION, BUT FROM MY STANDPOINT, IT'S BETTER TO ERR ON THE SAFE SIDE. MAY I ASK ABOUT THE GUN? - VICTOR TOOK CARE OF IT AND LOCKED IT IN HIS SAFE. UM, ANTONIO DOESN'T KNOW THE COMBINATION AND I NEVER REMEMBER IT MYSELF, SO, ANYWAY, IT'S--ITS LOCKED AWAY. - OK. ANTONIO, HOW DO YOU FEEL ABOUT THAT? - I'M OK. I'M NOT WORRIED ABOUT THE GUN. I'VE GOT PLENTY OF OTHER THINGS TO WORRY ABOUT. - MAY I ASK ABOUT YOUR MENTAL HEALTH EVAL? - YEAH. IT WENT FINE. SAW HIM YESTERDAY. ANSWERED SOME QUESTIONS. FILLED OUT SOME QUESTIONNAIRES. DO YOU HEAR THINGS? DO YOU FREAK OUT WHEN YOU HEAR LOUD NOISES? YOU KNOW, JUST STUFF LIKE THAT. HE SAID HE WANTED TO SEE YOU. - OK. GREAT. I'LL LOOK FORWARD TO SPEAKING WITH HIM. - DO YOU THINK THAT ANTONIO NEEDS MENTAL HEALTH TREATMENT? - I HONESTLY DON'T KNOW, BUT I AM LOOKING FORWARD TO SPEAKING TO THE DOCTOR ANTONIO SAW ABOUT IT. - YES. I LOOK FORWARD TO HEARING WHAT HE HAS TO SAY AS WELL. - ANTONIO, DO YOU STILL HAVE YOUR WRITTEN SAFETY PLAN? - YEAH. IT'S IN MY WALLET. - OK, YOU LET ME KNOW IF YOU LOSE IT AND I'LL MAKE YOU ANOTHER COPY. - AND I STILL HAVE THE NUMBERS THAT YOU GAVE ME AS WELL. - OK, GREAT. I'D LIKE TO SWITCH GEARS RIGHT NOW AND TALK ABOUT SOME OTHER TOPICS. - NIKKI, THE COUNSELOR SEEMED PREPARED IN THAT MEETING TO FOLLOW UP ON ALL THE THINGS THAT SHE'D DISCUSSED WITH ANTONIO AND HIS SISTER IN THE PREVIOUS SESSION. - THAT'S EXACTLY RIGHT. SHE CHECKED IN WITH ANTONIO AND HIS SISTER ABOUT THE KEY ISSUES, INCLUDING HIS SOBRIETY, ANY RETURN TO SUICIDAL THOUGHTS, THE MENTAL HEALTH EVALUATION, AND THE GUN. OVERALL, THE COUNSELOR FEELS LIKE THE SITUATION IS STABILIZED FOR THE TIME BEING AND IS PREPARED TO MOVE ON TO OTHER TOPICS FOR THE REMAINDER OF THE SESSION. SHE MIGHT GO ON TO DISCUSS HOW ANTONIO CAN HANDLE IT WHEN HE HAS CONTACT WITH LOUISA AGAIN, FOR EXAMPLE, BY PHONE OR TEXT MESSAGE, WHICH IS INEVITABLE. ANOTHER GOOD TOPIC WOULD BE A REVIEW OF THE ASSISTANCE THAT THE VA CAN PROVIDE HIM IN HIS JOB SEARCH. SHE WILL ALSO WANT TO DISCUSS WAYS TO STRENGTHEN HIS RECOVERY, INCLUDING THE USE OF SELF-HELP MEETINGS SUCH AS A.A. OR N.A. - MARY, SO, DOES THAT PRETTY MUCH WRAP UP THE CASE OF ANTONIO? - THEY'VE CERTAINLY DEALT WITH THE IMMEDIATE SITUATION. IN FUTURE SESSIONS, THE COUNSELOR WILL LOOK FOR CHANGES IN WARNING SIGNS AND RISK FACTORS, KEEP HER SUPERVISOR UP TO DATE ON WHAT'S HAPPENING, AND REMAIN IN COMMUNICATION WITH ANTONIO'S OTHER PROVIDERS. JILL ALSO HAS ESTABLISHED GOOD RAPPORT WITH ANTONIO'S SISTER, WHO CAN SUPPORT HIM AS WELL AS HELP WATCH FOR INDICATIONS OF RISK. ALL OF THESE ARE WAYS THE COUNSELOR CAN EXTEND THE ACTION. - MARY, I'M GUESSING THAT IN THIS BRIEF TRAINING, YOU WERE NOT ABLE TO COVER ALL THE MATERIAL IN TIP 50. - YES, THAT'S CERTAINLY TRUE. WE'VE ONLY COVERED THE HIGHLIGHTS OF TIP 50, PARTICULARLY THE RECOMMENDED STEPS OF GATE. GATHER INFORMATION, ACCESS SUPERVISION, TAKE ACTION, EXTEND THE ACTION. THERE ARE ALSO SEVERAL CASE VIGNETTES IN THE TIP THAT PROVIDE ADDITIONAL EXAMPLES FOR COUNSELORS AND SUPERVISORS TO DRAW FROM. WE ENCOURAGE VA SUBSTANCE ABUSE CLINICIANS AND SUPERVISORS TO ORDER THE TIP SO THAT THEY CAN LEARN MORE ABOUT GATE AS WELL AS THE ADDITIONAL INFORMATION IN THE TIP. AS WELL, HAVING THE TIP HANDY PROVIDES AN ONGOING RESOURCE WHEN SUICIDAL SITUATIONS ARISE, WHICH MAY COME UP WHEN YOU LEAST EXPECT THEM. ALTHOUGH THE TIP IS NOT WRITTEN WITH THE VA SPECIFICALLY IN MIND, THE GUIDELINES IN THE TIP TRANSLATE VERY WELL TO THE VA SETTING. - IN THE LAST FEW MINUTES, I WONDER IF EACH OF YOU COULD MAKE ONE ADDITIONAL POINT ABOUT SUICIDE PREVENTION WITH SUBSTANCE ABUSE CLIENTS, EITHER SOMETHING FROM TIP 50 THAT YOU'VE NOT MENTIONED YET OR A POINT THAT YOU BELIEVE IS PARTICULARLY RELEVANT TO SUICIDE PREVENTION EFFORTS WITH VETERANS FROM YOUR EXPERIENCE. - MM-HMM. I REALLY WANT TO EMPHASIZE THE IMPORTANCE OF SEEKING SUPERVISION. TALKING ABOUT SUICIDE IS UNCOMFORTABLE FOR MOST OF US. SUPERVISION CAN HELP BY PROVIDING A FORUM TO LEARN AND PRACTICE NEW CLINICAL SKILLS AND TO PROVIDE A PLACE TO GET A SECOND OR THIRD OPINION ON HOW TO HANDLE A DIFFICULT CLIENT SITUATION. EVEN STAFF WITH SUBSTANTIAL EXPERIENCE CAN BENEFIT FROM OPPORTUNITIES TO ACCESS CONSULTATION AT TIMES. - THANK YOU, MARY. NIKKI? - REMEMBER TO MAKE SURE THAT YOUR LOCAL SUICIDE PREVENTION COORDINATOR IS AWARE OF ANY VETERANS THAT ARE AT HIGH RISK BECAUSE THE HOSPITAL HAS AN ALERT SYSTEM TO FLAG THESE VETERANS' CHARTS. ALSO, WORK WITH YOUR SPC TO ENSURE THE VETERAN'S SAFETY AS THEY WILL MONITOR THE VETERAN ASIDE FROM THEIR REGULAR BEHAVIORAL HEALTH VISITS. ALSO, REMEMBER TO LET YOUR VETERANS KNOW ABOUT THE NATIONAL SUICIDE HOTLINE, AS IT CAN BE USED AS EXTRA SUPPORT FOR THEM, ESPECIALLY AFTER HOURS, AND IT IS SPECIFICALLY FOR VETERANS. THAT NUMBER IS 1-800-273-TALK. - THANK YOU, NIKKI. MATT. - THANKS, KIRK. IN ADDITION TO THE RESOURCES AND GETTING SUPERVISION, I'D REALLY LIKE TO EMPHASIZE THE IMPORTANCE OF COLLABORATION BETWEEN THERAPISTS AND THEIR CLIENTS. THIS GOES HAND IN HAND WITH THE RECOVERY PHILOSOPHY AND IT MAKES SENSE, PARTICULARLY IN THIS CHALLENGING POPULATION, IN WHICH SUICIDALITY WILL ARISE FROM TIME TO TIME. YOU'LL GET BETTER OUTCOMES AND HAVE A GREATER IMPACT AS A THERAPIST IF YOU INVOLVE THE CLIENT AND WORK IN COLLABORATION IN ALL STAGES OF TREATMENT. - MY THANKS TO DR. MARY SCHOHN, MS. NIKKI SLAUGHTER, AND DR. MATTHEW BARRY FOR THEIR TIME AND DEDICATION TO THIS IMPORTANT WORK. ALSO, THANKS TO THE CENTER FOR SUBSTANCE ABUSE TREATMENT AT SAMHSA FOR PROVIDING TIP 50, WHICH SERVES AS THE BASIS FOR THIS TRAINING. HERE'S THE INFORMATION ON HOW TO OBTAIN TIP 50. IT CAN BE DOWNLOADED AS A PDF FILE AS WELL AS ORDERED AS A PAPER MANUAL. THE GOOD NEWS IS THAT THE MANUAL IS COMPLETELY FREE AND INDEED, FROM SAMHSA'S PERSPECTIVE AS WELL AS THE VA'S, THE MORE COUNSELORS, SUPERVISORS, AND ADMINISTRATORS THAT ORDER TIP 50, THE BETTER. HOPEFULLY, THIS OVERVIEW HAS HELPED PROVIDE GUIDANCE ON THE COMPLEX TOPIC OF SUICIDE PREVENTION. REMEMBER--TIP 50 IS YOUR KEYSTONE GUIDE TO HELPING YOU HELP VETERANS AT A CROSSROADS. THAT'S ALL THE TIME WE HAVE FOR TODAY. THANKS FOR JOINING US.