substance abuse treatment

- hello and welcome to thistraining video on preventing and treating suicidal behavioramong clients with substance use disorders. my name is kirk penberthy,and i'll be moderating today's discussion. joining me today are our3 distinguished panelists. dr. mary schohn, who'sdirector of the va visn 2 behavioral health care line;ms. tamekia slaughter, who's a social worker at the buffalova medical center and goes by

nikki; dr. matthew barry,who's a psychiatrist at the canandaigua va medicalcenter, whose experience includes treating frontlinetroops in afghanistan. mary, can substance abusetreatment providers play an important role in suicideprevention in the va? - yes,they certainly can. clients with substance abusedisorders are at elevated risk for suicide,particularly those with co-occurring conditions.

therefore, it is essentialthat substance abuse treatment providers be prepared torecognize and respond to suicidal thoughtsand behaviors. it is also essential thatprogram administrators provide the needed support andguidance in this effort. - mary, what are yourecommending that va substance abuse treatment providersdo to manage suicide risk? - the procedure we'rerecommending is spelled out in the treatment improvementprotocol, or tip, provided by

the center for substanceabuse treatment at samhsa. this tip, number 50, is called"addressing suicidal thoughts and behaviors insubstance abuse treatment." - i see. what's in the tip? - tip 50 explains to substanceabuse treatment providers and their supervisors how todeal with suicidal clients. next, it shows them what to dothrough detailed case examples called vignettes. finally, it providesinformation about how

a program administrator couldimplement tip 50 in a given treatment program. - mary,what are the steps in managing suicide risk? - these steps are spelledout in tip 50 using the acronym gate: g-a-t-e. gather information, accesssupervision, take action, extend the action. the first step, gatherinformation, refers to

obtaining the informationthat will be needed to develop a plan of action. - nikki,i imagine it can be tricky to gather informationfrom a suicidal veteran with a substanceabuse problem. how do you go about that? - tip recommends thatcounselors 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 fromgathering information? - anxiety about suicide cancause a counselor to avoid the issue altogether or seek falsereassurances from a client. such avoidance cantake many forms. for example, a question suchas, "you're not suicidal, are you?" is worded in a waythat conveys to the client that suicide is not a topicthat the counselor wants

to discuss. - what do you mean,"avoid being the suicide interrogator"? - anxiety about suicidecan also cause a counselor to grill a clientabout suicidality by asking rapid-fire close-endedquestions, a pattern that is referred to in thetip as becoming the suicide interrogator. substance abuse counselors areencouraged to relax as much as

possible, to take their time,to ask open-ended questions, and to allow the client thespace to explain their story in their own words. in general, counselors shouldapply their best therapeutic skills with suicidal clientsjust as they would any sensitive topic. - matt,what questions should you ask a client when you'regathering information? - that's a goodquestion, kirk.

the most critical thing toask about is suicidality itself--that is,to ask about suicidal thoughts and suicidal behaviorand to do so directly. sometimes the topic comes upspontaneously, but more often the counselor needs tointroduce the topic, and don't be afraid to do so. by and large, clients willexpect 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 screeningquestions about suicidal thoughts and suicideattempts to see if it's

an active issue. some examples of suchquestions can be found on pages 15 to 17 ofthe tip 50 manual. - once you've determinedthat suicide is an issue, what then? - you want to learn moreabout it in the way you ask about any therapeutic issue. so taking, for example,alcohol craving. in that case, a counselormight invite a client to

explain their cravings withan opening statement such as, "tell me about your cravings." and this could be followed upas needed with more specific questions such as, whatbrings the cravings on? how bad do they get? what makes them better? and how much control do youfeel you have when you're experiencing them? so the skill setis already there.

it's just applying the sameapproach to a different topic, and that topicbeing suicidality. so for example, one can startwith an invitation to explain, such as "tell me about yoursuicidal thoughts," and that can be followed up by morespecific questions as needed, such as, what brings thesuicidal thoughts on? how bad can they get? and how much control doyou feel you have when you experience them?

- and can examples like thisalso be found in tip 50? - yeah, they sure can. questions like these arelisted on pages 17 to 18 of the tip 50 manual. - you've covered askingabout suicidal thoughts. how about suicidal behavior? what types of follow-upquestions would you ask? - well, the tip 50 hasnumerous follow-up questions for suicide attempts,and these can be found on page

18 of the tip 50 manual. you'd want to askopen-ended questions about an attempt such as,"please tell me what happened" and then as needed, youcan follow it up with more specific questions, such aswhat 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 informationabout suicidal thoughts and behavior?

- it is also importantto gather information about warning signs,risk factors, and protective factors. - what's a warning sign? - warning signs areindications of acute risk. tip 50 provides a list ofwarning signs that were identified by apanel of experts. warning signs may bedirect or indirect. direct warning signs aregiven the highest priority

because they are theclearest 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 aboutindirect warning signs? - a panel of experts also cameup with a list of 10 indirect warning signs that spellout 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 followingacute stressful events--for example, following arelapse or the breakup of a partner relationship. they're also more likelyto occur when a client is

intoxicated or high. a rule of thumb is thatfollowing a stressful life event, a counselor wantsto look for warning signs. - along with warning signs,you also mentioned that risk factors are importantto consider. what do you mean by riskfactor, and how are they different from warning signs? - warning signs indicate acuterisk, whereas risk factors are indicators of morelong-term risk.

risk factors are helpful foridentifying which clients are vulnerable to become suicidalduring the course of treatment and which clients may requireadditional treatment services in order to lowertheir overall risk. risk factors may also changeover the course of time. for example, clients maybecome more depressed, and such changes are also veryimportant 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 clientstypically show more than one risk factor. - how about protectivefactors? - protective factors serveto lower risk for suicidal behavior. unfortunately, there hasnot been much research of protective factors,but here is a list of factors that appear to lowerrisk 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 factorscan help, they are not 100%

protective, and they can beoverwhelmed by warning signs and risk factors. it is a mistake to put toomuch stock in a protective factor when there areclear signs of danger. overall, it is essentialto consider all of the information pertainingto warning signs, risk factors, and protectivefactors rather than to grab on to any one pieceof information. one needs to considerthe whole picture.

- thank you for walking usthrough "gather information." matt, i understand that youhave a clip to show us that demonstrates this step. - that's right, kirk. this is a vignette aboutantonio 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 anoutpatient substance abuse

treatment at a va clinic forthe treatment of alcoholism and cannabis dependence. precipitating his treatment wasan arrest for driving while intoxicated and marijuanapossession, and that led to misdemeanor chargesand ultimately to a court diversion program. conditions of the courtdiversion program included that he work with a court casemanager and complete a course of substance abuse treatment.

so he'd been doing well inhis treatment, with good attendance and continuoussobriety, but he'd been absent for about a week and didnot return his counselor's phone calls. he did show up to hisregularly scheduled group therapy appointment, and thecounselor, whose name is jill, asked to speak withhim after group. - antonio, it was good tosee you in group again today. you know, i've been concernedbecause you've been absent

lately and i haven'theard from you. - i've been busy. - yeah? what's been going on? - just crazy busy. - would you like to fill mein 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 donewith me this time. - that must bereally hard for you. you've often talked abouthow important she is to you. - she's everything. - would you mind tellingme what brought this on?

- stuff happened, you know? - antonio, i can tell thatthis is a sensitive subject, but perhaps it might helpin some small way to talk about it. - louisa kicked me out becausei got drunk and stayed out all night. - i see. so you're not onlydealing with the stress with louisa but also thestress of a relapse. - yeah. it was stupid.

i, uh... i ran into this guy thati used to hang with, and the next thing i know,we're at this bar, and we're throwing them down, andi was out all night. i don't even rememberhow i got home. - were you able to stopdrinking after that? - i wish. - you just takeyour time, ok? - when i got home, louisawas screaming at me.

i remember that. she threatened to call thecops if i didn't leave. she barely gave me sometime to grab my stuff. i went to my sister's, andshe wasn't thrilled to see me. she wasn't thrilled to seethat i had been drinking all night, so she leanedinto me pretty hard. well, i was in no mood to sitaround for that, so i grabbed a bottle of liquor from herliquor cabinet and went to the park and got drunkall 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 ijust couldn't stop thinking about what i had done toher--louisa, even what i did to eva.

and at that moment, it just... seemed like the best way tofix everything was to get rid of the person causingthe problems, get rid of everyone'spain and anger... get rid of me. - you were in a lot ofemotional pain sitting there at that park. just take your time, antonio. i can see that this isvery difficult for you to

talk about. my gun was at mysister's, but... if i'd had it with me, i'dbe somewhere else right now. i had some evil thoughts justsitting there, and no matter how much booze i drank, ijust couldn't stop thinking about what i had done. and finally a cop came by andtold me the park was closed and to go home. - wow. that was a prettyintense couple of days.

hey, look, i'm glad to seeyou'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 grouptoday, i haven't even left my sister's. i didn't trust myself togo anywhere, and i had nowhere to go.

it felt good to be back ingroup today, although i didn't say nothing. - well,i was glad you're back, and from the looks onthe other member's faces, it was pretty clear thatthey were happy to see you, too. antonio, you had some bouts ofsuicide while you were sitting at the park. i was wondering if i couldask you a few more questions

about that. - are you gonna lock me up? - while it is true that someclients have to go to the hospital for an emergencyevaluation, 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 thati'm gonna touch base with my

supervisor before we breaktoday, just to make sure i'm not missing anythingimportant. but before we make any plans,it would be helpful to learn a bit more about how you'vebeen doing since that day - your supervisor,too? that's great. uh...i haven't thought aboutsuicide since that day. i haven't drank. i might have donesomething 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'dnever get over it, and i'd bring shameon her, too.

to her,suicide is a sin, and i just-- i couldn't do that to her. my sister would also gocrazy if i killed myself. - you really care for yourmom and your sister, and you realize how much suicide wouldhurt them, and that helps you to focus how to go onliving despite the problems with louisa? - yeah. exactly. - i'd like to ask you a fewmore questions about this.

would that be ok? - you're gonna do it anyway,so get on with it. - thanks for bearingwith me, antonio. i really appreciate it. i realize that these arevery difficult questions. at this point, do you havea plan for suicide? - no,nothing like that. i haven't thought about itsince that day in the park. - how do you account forfeeling differently now than

you did that day? - i'm only 25, and i hope tohave 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 wantto go out that way. - yeah. see? now, you've got a lot ofgood reasons to go on living. at the park, you hadsome suicidal thoughts, but fortunately, itnever went any further. have you ever hadthoughts like that before?

- once in a while, when i washammered, i had some thoughts, but nothing like thatday in the park. that was the worst by far. - have you ever actuallytried to commit suicide? - no, never have. when i was in iraq, this guyin our unit killed himself. just walked off one day andput a bullet in his head. there were a bunch of rumorsabout why he did it, but no one knows what the truth is.

i barely knew him. anyways, no, i've nevertried to kill myself. - i'm sorry to hear aboutthe guy in your unit. has anyone else you knowever tried to commit suicide? - no,just that guy. - ok. now, youmentioned a gun. 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 andyou thought of using it while you were drunk at the park. - i'm not thinkingabout it now, am i? - understood. it's good toknow those thoughts have not come back. is that your only gun? - yes. yeah. - ok. so, what areyour plans now?

just taking it oneday at a time. i hope to get my sobrietyback, maybe one day convince louisa to take me back. right now she'd probablycall the cops if i showed up. but she stuck with me throughmy last two deployments. and we were planning ongetting married and having kids, and my momand sister love her. right now i'm just gonna stayat my sister's and try to get myself together.

- how is the situationat your sister's? for example, is itjust the two of you? - no. she's there with herhusband and daughter, my niece. and my brother-in-law is cool. he's ex-military, sowe get along good. - do you feel it's a safeplace 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 neverhad a problem handling it like i did,so as long as i'm there, she'd kill him if hebrought liquor to the house. they don't do drugs,don't even smoke. actually, that's one thing ihaven't done since seeing you is smoke marijuana, so atleast that's something, right? - agreed. that is a positive. it seems as though you have apretty good situation at your

sister's for now. - have you ever had treatmentfor a mental disorder--for example, depression or ptsd? - no. i saw someone at va foran evaluation, but he said i don't need any medicationsor anything like that. i just need to stop drinkingand smoking marijuana. - well, thank youfor answering my questions, antonio. at this point, i'm gonnatake a few minutes and speak

with my supervisor about yoursituation, 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 supervisoryou're talking to? - her name is gloria johnson. i believe you met her. she covered my group acouple of times when i was on vacation.

- yeah. i remember her. - good to know the twoof you have met. ok, i'll be back to talkwith you in a few minutes. i appreciate your patience. i'm gonna have you wait in theprivate waiting room while i speak with ms.johnson, ok? - matt, that's avery moving scene. antonio is obviously havinga difficult time. - that's right, kirk.i think we can all feel for him.

antonio is clearly in alot of emotional pain. he became tearful inthe session and showed genuine sadness. from my experience, it is alsoimportant to note that many veterans in antonio'ssituation would not necessarily show tearsor be overtly sad. instead, a veteran may presentas angry or even appear stoic but still could be every bitas much a risk as antonio is. overall, suicidal clientshave many different ways

of expressing theiremotional difficulties. - i suppose that the centrallesson is that suicidal veterans are a diverse groupand they can present in many different ways. - that's well-said, kirk. i think that's exactly right. - the therapist seemed togather a lot of important information there. - agreed. i like theway she went about it.

antonio was obviouslyuncomfortable at first and hesitant to to discusshis suicidal thoughts, but the therapist made aneffort to make him more comfortable by asking open-ended questions as much as possible. she was also good atlistening and maintaining an open posture. i also really liked that sheinvited him to take his time and that she asked permissionat times before proceeding

on to the next question,and i think that giving clients a sense of controllike that can pay handsome dividends in terms of rapportand investment in the process. - along with having agood therapeutic style, the counselor also seemedto cover a lot of ground. - yes. i liked thequestions that she asked. she gathered importantinformation about suicidal thoughts, how they came about,how serious they were, and other factors related torisk, including the breakup

with his girlfriend,and his firearm. she also asked about mentalhealth treatment history, prior suicidal behavior,and any suicidal thoughts or plans since that day in thepark, all of which are very important to consider. she also clarified that thesuicidal thoughts occurred while he was intoxicated andthat they have not returned since, although there isalways a possibility that antonio is minimizingthe situation.

the counselor accomplished allthis efficiently, and indeed, the clip we just saw was onlyabout 14 minutes, yet she was able to gatheressential information in that space of time. - ok. nikki, now that thecounselor has gathered information, what's next? - the next step isaccess supervision. tip 50 describes twobroad types of supervision a clinician could access.

one is immediate supervision,and two is regular supervision. - what do you mean byimmediate supervision? - immediate supervision isrequired when the counselor has information to suggestthat there is current risk of suicidal behavior. earlier, mary reviewed directwarning 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 includedshooting himself--a deadly method of suicide. he has accessto a gun, and he has

relapsed recently. therefore, even though antoniois seeking to reassure his counselor that the crisishas passed, nonetheless the counselor recognizes thatshe should speak with her supervisor immediately. - i imagine that regularsupervision involves more routine situations. - that's right. regularsupervision refers to bringing up an issue during your weeklymeetings with your supervisor

or during your regularlyscheduled team meetings. some situations when regularsupervision 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 thisinformation can be found on page 19 of the manual.

- well,let's show the tape of the counselor accessingimmediate supervision. [knock on door] - gloria, i see thatyou're on the phone. i'm sorry to bother you,but there is a situation that i need to speakwith you about. - ok. i'll haveto call you back. something has just come up. - thanks for talking.

i did group today, and antoniorodriguez returned after being absent for a week. do you rememberantonio from group? - sure, i remember him. - ok, well, itouched base with him after group, and to make along story short, a week ago, he met an old friend, and theywent out and they got drunk. he came home. hisgirlfriend was furious. she kicked him out of thehouse, and he sat at a park

drinking and thoughtabout suicide. now, that was a week ago,and since then he has no thoughts of suicide, he'sbeen clean and sober, and is staying at his sister's house. - so where is he now? - he's in theprivate waiting area. i told the receptionist iwould come in here and talk to you and to call immediatelyif he starts to get upset or goes to leave.

- ok,good. you know, i'm glad that you came to me. tell me more aboutwhat's going on. - he sat at the park drinkingand he had the thought to shoot himselfwith his handgun. he told me that if he had hishandgun with him, he would have gone through with it. he thought drinking mightmake him feel better, but it provided no relief.

he seemed sad andwas tearful at times. he also described louisa--that's his girlfriend--as everything to him, and he'safraid he's blown it with her. - that's pretty serious. how is he doing sincethat day at the park? - as far as i can tell,a lot better. there have been nothoughts of suicide. he has no plan orintent for suicide. he's glad to be back inrecovery and hopes that louisa

might take himback eventually. - now,did you believe him, or did you think that he was justsaying those things to reassure you? - well,he was hesitant to talk at first. for example, he said that hewas afraid we'd lock him up if mentioned suicide. you know, but eventually heopened up, and i believe he

was being honest with me. - did he volunteer any reasonsnot to kill himself--for example, because it's againsthis spiritual or religious beliefs or because offamily relationships? - he said that he realizesnow that killing himself would devastate his mother andhis sister, particularly his mother. he also said that he's youngand he hopes to have many more years to live and he doesn'twant to go out that way.

- has he been suicidal before? - he says he has had thoughtsbefore but nothing as intense as his thoughts at the park. - has he ever triedto kill himself? - no. he's nevermade an attempt. when i asked him thatquestion, he mentioned that a member in his unit had shothimself, although he barely knew the man, and he saidthat's the only person he's known who's committed suicide.

- so,what's his mental health situation? - he did have an eval when hecame in for treatment, and as i recall, the doctor saidthat his problems were mostly substance-related andhe didn't need mental health treatment. - did he see any combatin iraq, any trauma? - i actually don'tknow about that. he doesn't really talkabout his deployments.

he mostly talks about hisrelationship, his legal situation, plus the factthat he's looking for a job. - so how do you feel abouthis living situation with his sister? - i feel goodabout it, you know. it's a sober and supportivearrangement, as best as i can tell. - now,you mentioned his gun. where does he keep it?

- it's in his bagat his sister's. - so do you know ifit'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 hasammunition based on what he said could have happenedhad he had the gun with him plus he saidthat'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 workand looking for a job. - anything else that'simportant to consider? - i have a good workingrelationship with him, and he's very popularwith the group. they were happy tosee him come back. - ok,let's quickly make

a plan so that you cango back and talk to him. he may start to feelanxious if you're away too much longer. - mary,the therapist didn't hesitate to come into her supervisor'soffice and ask to talk to her. - yes. this was really no timeto be tentatively knocking on the door or patientlywaiting for the supervisor to finish her call. she really needed to speakwith the supervisor then

and there and made thisclear in an assertive though respectful way. - the therapist seemedwell-prepared to describe the situation and answer thesupervisor's questions. - she certainly did. she spelled out theinformation efficiently and hit all of the majorpoints, including that antonio relapsed recently,the intensity of his suicidal thoughts at the park,the recent breakup with his

girlfriend and how much shemeans to him, his access to a firearm, and histearfulness in the session and overall sadness. she also mentioned protectivefactors, including his close relationship with his motherand sister and that the counselor and antonio have agood therapeutic relationship. - the supervisor seemedwell-organized with her questions as well. - absolutely. she is obviouslyexperienced with this issue

and guided the counselorthrough the key points in an efficient manner. i noticed that she also askedwhere antonio was to confirm that he is in a privatewaiting area and that the receptionist will call inimmediately if he starts to get anxious orbegins to leave. - mary,the therapist has gathered key information andaccessed supervision. now what?

- the next step, as spelledout in tip 50, is take action. there are many differentactions that can be taken to lower the risk for suicide. the general principle is thatthe action should make good sense given the level ofrisk in a situation. for example, clients at highacute suicidal risk require intensive, immediate action,whereas clients at lower risk would require lessintensive actions that are less immediate.

it is when there is a mismatchbetween the severity of risk and the level of actionthat there is a problem. for example, in antonio'scase, it would not be sufficient to simply welcomehim back to group without taking any additionalsteps to lower risk. mismatches can alsowork the other way. for example, sending a clientto the emergency department for an evaluation simplybecause of a prior history of suicide attempt is amismatch because it is

an over-response to thatsituation that wastes resources and can underminethe treatment relationship. - nikki, so, what are theactions that could be taken with a suicidal client? - here's a list of actionsthat are listed in tip 50. they include gatheringmore information, arranging emergency or outpatientevaluation, increasing frequency of contact,involving the suicide prevention coordinator,involving a care provider or

case manager, as well asrestricting access to means of suicide, involving familymembers, promoting attendance at self-help meetings,observing for signs of return to risk, and conductinga formal safety plan. a complete list of thesepotential actions can be found on pages 21 and 22 of tip 50. - nikki, that's alot of options. how does the counselorknow where to start? - yes, it can feeloverwhelming to a counselor,

but that's where gettingsupervision can be really critical to help thecounselor sort through the various options. this next clip will show youhow the counselor and supervisor developed a planof action together. - as far as we can tell,antonio has not been suicidal since the incident in the park. he's future-oriented, and histemporary living situation is sober and supportive.

he's also connectedto you and the group. i mean, overall,he appears to pose no acute danger to himself. i believe thatan outpatient-based plan is appropriate at this time. - that's how i see it, too. outpatient is sufficientright now. - you know, we alwayshave the option of having him gofor an emergency eval

if the situation worsens. you'll definitely needto do the standard va safety plan with him. you know him better than i. what else comes to mindthat might be helpful? - well, i'd feel a lot betterabout the situation if he got anothermental health eval. - well, sounds good. do you think he'llgo for another eval?

- well, he'll probably give mea bit of a hard time at first, but i think he'll eventuallyagree and follow through. he's fairly compliantwith treatment. - great. it will also be veryimportant to address the gun. - agreed. although dealingwith that makes me the most nervous. - it's a really tough issue. you know, makingthe environment safe is the last thing that comes upin the safety plan,

and by that time,perhaps, he'll be feeling pretty comfortable with the plan and then be more willingto address the gun. - so what do you suggest i do? - could he be persuadedto have a family member take the gun and store itin a safe and secure place for the time being? - well, he mentioned hissister's husband is ex-military and they have a fairlygood relationship,

and i assume he's experienceddealing with weapons and he might be willing tohelp us out with this situation. - best case scenario isto give his sister a call before he leaves today. that way there's no riskthat he'll change his mind before he gets home. now, in the call, you couldexplain the situation and then haveher and her husband take care of the gun.

- yes, i spoke withhis sister before and already obtaineda signed release. what if he's notwilling to do that? - well, he may surprise you and allow a callwith his sister. i mean, it's certainlyworth a try. if he won't go for that,there are other possibilities, including getting his commitment to give his weaponto his brother-in-law

when he gets home. if he insists onholding on to the gun, we also have a free gun lockthat we can provide him, although it would be much better if he'd be willingto part with the gun for now. - i'll try my best.so in a nutshell, the plan is to refer himfor another mental health eval, do the safety plan with him, and end the sessionby addressing the gun.

- i think you've got it. would you like for me to come in and, you know, work outthis plan with you? - i think he might bea little more comfortable if i work with him one on one, so let me see if i cando this on my own. - ok. that's fine.i'll be right hereand available to help if you get stuck. now, you want to bedirect and clear with him.

it's also very importantto be collaborative. if he doesn't feel likehe has a say in the plan, he's going to be less likelyto follow through. so along these lines,you might start out the session by asking what he would thinkwould be helpful before spelling outyour recommendations. - will do.i'll call you if i get stuck.thanks. - matt, what are your thoughts about the plan thatthey came up with?

- it's a real solid plan, kirk. they basically intendto take 3 actions. number one is to arrangea mental health evaluation. number w, develop a standardva safety plan with antonio. and number 3, address his accessto a firearm. so far his treatment is focusedon the substance abuse, but the possibility ofa mental health problem should be revisited. assuming he's willing,jill will set antonio up

for an appointment witha behavioral health professional to determine ifa mental health condition, such as depression or ptsd, requires treatment withmedications or therapy. another action is to dothe standard va safety plan that we'll discuss in moredetail a little later. they also wantto address the factthat antonio has a pistol, because firearms are the mostlethal method of suicide. - they concludedthat he doesn't need

an emergency evaluationat the hospital. what do you think of that? - their decision is sound,because as far as we know, no suicidal thoughtshave occurred since he wasintoxicated in the park. he's expressing reliefthat he did not kill himself and can providereasons for living. he and the therapist have asolid therapeutic relationship, and up until recently,he had done well in treatment.

and he is stayingwith his sister, who is a good, sober support, therefore, there areenough positive signs to indicate that an outpatientplan would be sufficient. - i noticed at the endof the clip the supervisor encouraged jillto be collaborative. - that's exactly right,and although it's easyfor clinicians to fall into the trapof dictating a plan, clients are much more likelyto follow through

if they have a real say indeveloping their specific plan. as well, clientscan come up with really good ideasto keep them safe, and these might be ideasthat appeal to themon a personal level or ones that the counselormight not even think of. along these lines,the supervisor encouraged jill to start off the meetingby getting antonio's ideas, which will help sent the tonefor collaboration. another thing that will help isthat the standard va safety plan

is done collaborativelywith the client, and that collaborationcannot be overemphasized. - here's the next clipthat 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 evaluationat the hospital is needed today.

- you guys would havehad to drag me there. - i think we're gonnahave to handle thisthe old-fashioned way-- by talking it through. although we don't thinkan emergency eval is necessary, you and i have to havea discussion to come up with a plan to dealwith the suicidal thoughts. - what plan? - any plan we'll make together. - i don't think i need a plan.

- antonio, i have to admitthat i see it differently. you've been through an awful lotin the past week, and you've been througha lot of pressure-- the stress with louisaand the relapse. plus, those thoughtsthat you had at the parkare really scary. it's very reassuring that thosethoughts have not come back. and you took a big stepin coming here today. i really admire you for beingso honest with me. all of that says a lot aboutyour commitment to recovery.

and all of thatmakes me really optimistic that we can make a good plan. i feel strongly thatwe should make a plan. it's not gonna be goodfor you to just pretend that this didn't happen. - yeah. whatever. - antonio...i feelreally strongly about this. - ok. ok.what do you want me to do? - ms. johnson and icame up with a few ideas,

but i'd like to knowif 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 liketalking in group. those guys are ok,but i don't want to talk about my personal stuff with them. i like--i like talkingto you more. - yeah. we have somereally good, honest,

one-on-one conversations. you really use these individualtherapy sessions very well. - yeah, it's justeasier talking to you. - ok, so, why don't weup our sessions to once a week? would that work for you? - i suppose. - ok. so i'll see you once aweek for our individual sessions for the next month, and then we'll seewhere you're at.

- what else do i have to do? - well, one thing i would like is to set you up for anothermental health eval. - i told you i was not crazy.i just got drunk one day and i'm ok now. - would you be willingto hear me out and i'll explainthe recommendation to you? - yeah, yeah, whatever.go for it. - thanks forhearing me out, antonio.

look, you've been throughan awful lot lately... and i believe you. i really do believe youwhen you tell me that you had suicidal thoughtsat the park and only at the park, and you haven'thad them since then. i also do notthink you're crazy. but you've been throughan awful lot. and when you go throughsomething like that,

seeing a mental healthprofessional might be helpful for you,you know? seeing a doctor or a therapist. might be worthgetting their opinion. at this point, it's justgonna be an evaluation. we don't know whatthe doctor's gonna say. maybe he'll recommend treatment.maybe not. maybe he'llrecommend medications.maybe not. you know?who knows?

it's just after whatyou've been through, it's a really good ideato get checked out. maybe talking to somebody else will proveto help you even more. - what choice do i have?the court says i have to do what you say. - well, the court does keepan eye on things, doesn't it? but to be perfectlyhonest with you, ms. johnson and iwere not thinking about that.

we're thinking aboutwhat would best suit somebody in a situationlike you, you know? what's best to help you, regardless ofthe legal situation. you were in a lot of pain thatday, a lot of emotional pain, and we don't everwant to see you back at the park like that. nobody should ever haveto suffer the way you did. - i suppose you'll tellthe doctor what happened.

- i'll give him a brief summary but i'll leave it for youto fill in the details. ok? - is that it, then? - well, there are a few otherthings i'd like to cover. for one thing,i would like to go through a step-by-step safety planwith you first. would that be all right? - whatever. - mary, what stands out to youas you watch the tape?

- she did a nice job. she opened the sessionby asking for antonio's input and picked up on his comfortwith the individual sessions by offering to increasethe frequency of these meetings. that got the meetingoff on the right foot. she was clear and firmthat she is recommending a mental health evaluation, and being clear and firmwith 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 bestto normalize it, which is really important,given antonio's fear of being considered crazy. as well, they touched onthe major issues that are weighing on his mind, including the breakupwith the girlfriend and his legal situation.

- the counselor also mentioneddoing a safety plan. - that's right, kirk.the va has a standardsafety plan that has to be donewith suicidal clients. here's the template for the plan that goes rightin the treatment record. we will not elaborateon the plan here, and we did notshow the counselor doing the safety planwith antonio, because an excellenttraining tape that showsthe va safety plan

is already available. viewers interested in learningmore about the safety plan should watch the safety plantraining video. - as i recall,there's also the issue of antonio's firearm. - that's correct. here's the clip of the therapistaddressing this issue. - antonio, the last partof the safety plan that i would liketo discuss with you

is keepingyour environment safe. you've been really fortunateto live with eva and her family, and i met eva when we firststarted doing recovery together, and i was really impressedwith how much she knew about recovery and addiction and howsupportive she is of you. - yeah. we're a close family. the only thing i'mreally concerned aboutin your environment is your gun. - what about my gun?

- look, it's certainlyyour right to have a gun. nobody's arguing that. however, given what happenedin the park and that you'reonly just beginning to reestablish your sobriety, i wonder if we couldwork out a way to lessen any riskassociated with the gun. - what are you saying? - well, i'd like to workon 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 explainwhere i'm coming from. would you at least bewilling to hear me out? - go for it. - ok. thanks for being willing. do you remember when you firststarted your program and we worked out a planwhere you would get rid of

all the liquor and marijuanain your place? - yeah.- it's basically the sameprinciple here. in early recovery,people tend to have moments when they're craving, or their judgmentisn't very good, and in those moments,having a substance nearbywithin easy reach could be the differencebetween relapsing and making it throughclean and sober. you know, this alsoapplies to suicide.

for example, if youwere to have a day when you got downand got bad news from louisa or you relapsed, well, then having a gun nearbycould pose a risk. you wouldn't needto give up the gun forever, but for now, it would bea good precaution. - ok. if it'll make you happy,i'll give it to a friendto hold on to. - actually, i was thinkingof your brother-in-law.

- yeah. sure.he's ex-military. he knows how to handle weapons. - good. would it be ok with youif we gave your sister a call and arranged foryour 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-lawwhen i get home. there's no reason to call eva.

- antonio, if you insistthat i not call your sister and you make the commitmentto give your gun to your brother-in-lawto hold on to when you get home, you know, i would certainlygo along with that. in fact, that would bea really important step and make the situationmuch safer than it is now. however, first i'd liketo briefly explore with you why you don't want to makethe call to your sister. would you be willing to at leasttalk about that some more?

- talk as much as you want.we're not calling her. - well, thanks for being willingto hear me out, antonio. you know, this is just a guess,but i'll ask anyway. is the reason you don'twant to call your sister because you don'twant to scare her? - you know, i know how mucheva cares about you and how invested she isin your recovery. i'm really guessingthat she would much prefer to know what's going on

rather than be left in the dark. you know, even if it didcause her to worry a little bit. we could do our bestto talk about it in a way that doesn't alarm her, but rather presents it assomething more of a precaution. you know, i could explain to herthat the thoughts of suicide entered your mindwhen you were drinking after the breakup with louisa,but they're gone now. and that temporarilymoving the gun

is just a precaution,just in case another crisis hits. you know, no doubt she's gonnahave some worries, but i can also let her knowof the positive thingsyou are doing and just reassure her once againthat this is just a precaution. - like i said, i will give myglock to my brother-in-law. you win. - i appreciate your willingness. you know, that's a reallyimportant commitment.

now, how about my suggestionto make the call to your sister? is that something you'll do? i realize i'm pushingthe idea a bit, but it's only becausei think it would be helpful. the good thing about a call is that it would beover and done with and there'd be no worriesabout changing your mindon the way home or a crisis coming upbefore you have a chance to give it toyour brother-in-law.

there's really nothing liketaking care of somethingright away and getting it over with. - all right.you can--you can call her. - you know, actually...i was thinking we could call heron the speakerphone. that way you could participatein 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 abusecounselor. - yeah. hi.- hi. do you have just a coupleminutes to talk? - sure. sure.what's this about? - sis, uh, my counseloris worried about my gun

and wants victor to take itso i don't shoot myself. - what? what's going on?how did this come up? - see? i told youshe'd go crazy. - hi, eva.i can see howyou'd be worried. let me take a minute to explainthe situation to you. as you know, antonio relapsedand 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 thatthe suicidal thoughts

only happened on one daywhen he was drinking and there have beenno thoughts since then. also, in terms of the good news, antonio came backto treatment today and we had a good session, and we made some solid plansto get him back on track. overall, i feel goodabout our plan. however, dealing withantonio's gun could make the situation safer

in case there is a relapseor another crisis with louisa. so therefore, i'm recommendingthat as a precaution, someone take the gunand store itout of his whereabouts for the time being. i thought that your husband might be ableto help out with this because he has experiencehandling guns. - there--there area million things running through my headright now.

i'm--i'm a little scared.um...yes, yes. of course.victor--victor willtake care of the gun. antonio, where is it? - uh, it's in my bagin one of the side compartments. it's not loaded but there'ssome ammo in there, too. - ok. ok.uh, victor will be home soon and i'll have him take careof it when he gets home. - thanks, eva.that would be very helpful. um, could you please make surehe stores it in a safe place?

- ok. ok.he's got a safe wherehe keeps his guns and i'm sure he'll put this onein there with them. - eva, you seema little shook up, and that is very understandable. you know, i'm sorryto scare you like this. i don't have a crystal ball,and i certainly don't know if antonio would everuse the gun. but he's feeling much betterand he really wants to get back on trackwith his recovery.

and this is a positive sign. this step is justa safety precaution, although it's onethat makes good sense. - ok. ok.um, that's--that's good to hear. um, i know we talked once whenantonio started his treatment, but would it be possible for meto come talk to you in person? - well, what do youthink, antonio? can eva cometo our next session? - sure, sis, you can comeand you can meetmy 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 imaginewhat this would do to mamaif you killed yourself? not to mentionhow it would affect me. just--just do whatyour counselor tells you to do. um...all right.so when is this meeting? - antonio, could youboth 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 casethere's ever a problem, let me give youa couple of phone numbers. do you have a pen? - uh, yeah.got one.go ahead. - ok. my numberhere at the office is 462-3516.

and also, the nationalsuicide prevention hotline is 1-800-273-8255. you know, they take callsfrom concerned family members as well as people in a crisisanytime, 7 days a week, 24 hours a day. - ok. all right.i got it. antonio, are youon your way home now? - yeah. i'll be therein a few minutes. - ok. good.any questionson our plans, eva,

or are you all set? - um, no, i thinki understand everything. um, victor isgoing to store the gun and i'll see you next thursdaywith antonio for the meeting, and if i have any otherquestions, i have your number. - that sounds great.looking forward to see you thursday at 2. - ok.thanks. bye. - bye.

- matt, antonio washesitant about the issue, but ultimatelywent along with a plan to remove the firearm. did the counselor do anythingto make it turn out so well? - she sure did.jill did a great job and had she jumped inon the firearm issue earlier, it may have gonemuch differently. but by the time she raised it, she had offered to increasetheir individualcounseling sessions,

picking up on antonio'scomforts with these meetings. she also took the timeto listen to antonio and did her bestto align with him, and they worked outa safety plan collaboratively. as a result, she was in a goodplace to introduce the topic. i admire the fact thatshe did not give up at the first sign of resistance or even the secondsign of resistance but really hung in thereand explained

where she was coming fromin a supportive yetplain-spoken manner. drawing a parallelbetween reducing accessto the firearm now and reducing accessto alcohol and drugswhen he first got sober seemed to help. this parallel probablyhelped antonio to frame this in a positive wayas part of his recovery, rather than more negativelyas a type of surrender or a loss of freedom. if taking a precautionwith a firearm can be reframed,

it often goes a long way inenlisting a client's agreement. - it was fortunate that antoniohad the option of turning to his sisterand her husband to help in this situation. - yes, kirk, it wasextremely helpful. in situations like these,it is often the best option to have a trustworthy personremove and secure the weapon if at all possible. in this case, antonio'sbrother-in-law's experienced

handling and storing firearms, and was a good choice. an added benefitof the call to his sister is that it mobilizedher involvement in treatmentas well. - what if antonio refusedto make the call to his sister? - the counselor was preparedto use an alternative strategy, including having antonio commit to give the weaponto his brother-in-law for safe storagewhen he got home.

if he had refused to do that, another alternativewould have been to provide antonioa gun safety lock along with giving instructionon how to use it. another option,was not mentioned, could be to getantonio's commitment to take the firearmto the nearest police station after confirming that the policewould be willing to store and secure the weapon.

it's also important to mentionthat firearm laws differ among statesand localities. therefore, it's incumbentupon the program administrators to have a firearmpolicy in place that maximizes clients' safety, that bears in mindstate and local laws. - nikki, what's the next step? - the next step isto extend the action. this is the step that ismost likely to be missed,

but it is every bit as importantas the other steps. "extend the action" refersto the follow-up actions that are done to ensurea client safety plan on an ongoing basis. - what types of extended actionsdo you recommend? - here's a list of waysof extending the action. continuing to check inwith your supervisor; confirming the patient has keptreferral appointments; following up with anyemergency providers;

coordinating withother providers; communicating with suicideprevention coordinator; monitoring suicidal thoughtsand behavior; involving family;confirming the clienthas a safety plan; assessing changes in accessto methods of suicide; following up in case of relapse; preparing the client for anydifficult situations; monitoring and updatinga treatment plan; and documenting everything.

a longer list of potentialextended actions can be found on page 23of the tip 50 manual. - now let's take a look ata clip of antonio's counselor extending the action in theirnext counseling session. - it's good to see youtoday, antonio, and it's nice to meet youin 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 appointmentsand has been staying sober. at least as best i can tell. - i'm on the straightand narrow now. you can piss test meif you like. you'll find no alcohol.no marijuana. - that's great to hear. although we're not gonna giveyou 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 hadany cravings. i stick pretty closeto my sister's place except when i makemy appointments. it keeps me out of trouble. - it's good to hear you haven'thad any cravings. if you do, and it will happen,don't hesitate to let me know, because it's a normal partof recovery

and it's really goodto talk about it. eva, you mentionedthat he's doing very well with his appointmentsand his sobriety. do you have any otherobservations or comments you'd like to add about that? - sometimes antonio mopes. i assume he'sthinking about louisa. and he has a lot of time on hishands right now, not working. he mostly stays home,and he plays with my daughter,

and she really loves him. my husband victor and hewent to a baseball game and victor treated,and antonio seemedto really appreciate that. and i warned victor,"no beer at the game," and i'm confidenthe went along with that. - antonio, what do you think? - i guess i do mope sometimes, but i don't really let myselfsink into it. i usually distract myselfwith watching tv

or playing a video game. playing with my nieceor whatever. - have any of the suicidalthoughts returned? - no. nothing. - do you have any commentsalong these lines? - well, i certainlycan't read his mind. i really don't know.but he hasn't said anything that would make me thinkhe's thinking about suicide. - that's good to hear.

often when peopleare having suicidal thoughts, they make comments that suggestthey're thinking of suicide, which is like a warning sign forfamily members to pick up on. it can be something obviousor not so obvious, from hopelessness to"life is not worth living," you know, anythingalong those lines. - well, i'll--i'llcertainly listen for things like that, but i haven't heardanything like that.

- jill, the education on suicideis 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 thinksi'm blowing thisout of proportion, but from my standpoint, it'sbetter to err on the safe side. may i ask about the gun? - victor took care of itand locked it in his safe.

um, antonio doesn'tknow the combination and i never remember itmyself, so, anyway, it's--its locked away. - ok. antonio, how do youfeel about that? - i'm ok.i'm not worried about the gun. i've got plenty of other thingsto worry about. - may i ask aboutyour 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 whenyou hear loud noises? you know, just stuff like that. he said he wanted to see you. - ok. great.i'll look forwardto speaking with him. - do you think that antonioneeds mental health treatment? - i honestly don't know, but i am looking forwardto speaking to the doctor antonio saw about it.

- yes. i look forward to hearingwhat he has to say as well. - antonio, do you still haveyour written safety plan? - yeah. it's in my wallet. - ok, you let me knowif you lose it and i'll make you another copy. - and i still have the numbersthat you gave me as well. - ok, great.i'd like to switchgears right now and talk aboutsome other topics. - nikki, the counselor seemedprepared in that meeting

to follow up on all the thingsthat she'd discussed with antonio and his sisterin the previous session. - that's exactly right.she checked in with antonioand his sister about the key issues,including his sobriety, any return to suicidal thoughts, the mental health evaluation,and the gun. overall, the counselorfeels like the situation is stabilizedfor the time being and is prepared to move onto other topics

for the remainderof the session. she might go on to discusshow antonio can handle it when he has contactwith louisa again, for example, by phone or textmessage, which is inevitable. another good topic would bea review of the assistance that the va can provide himin his job search. she will also wantto discuss ways to strengthen his recovery, including the use of self-helpmeetings such as a.a. or n.a.

- mary, so, does thatpretty much wrap upthe case of antonio? - they've certainly dealtwith the immediate situation. in future sessions,the counselor will look for changes in warning signsand risk factors, keep her supervisor up to dateon what's happening, and remain in communicationwith antonio's other providers. jill also has established goodrapport with antonio's sister, who can support himas well as help watch for indications of risk.

all of theseare ways the counselor can extend the action. - mary, i'm guessing thatin this brief training, you were not able to coverall the material in tip 50. - yes, that's certainly true. we've only coveredthe highlights of tip 50, particularly the recommendedsteps of gate. gather information,access supervision, take action, extend the action.

there are also severalcase vignettes in the tip that provide additional examplesfor counselors and supervisors to draw from. we encourage va substance abuseclinicians and supervisors to order the tipso that they can learn more about gate as well as the additional informationin the tip. as well, having the tip handyprovides an ongoing resource when suicidal situations arise,

which may come up whenyou least expect them. although the tip is not written with the vaspecifically in mind, the guidelines in the tiptranslate very well to the va setting. - in the last few minutes,i wonder if each of you could make one additional pointabout suicide prevention with substance abuse clients, either something from tip 50that you've not mentioned yet

or a point that you believeis particularly relevant to suicide prevention effortswith veterans from your experience. - mm-hmm.i really want to emphasize the importance ofseeking supervision. talking about suicide isuncomfortable for most of us. supervision can helpby providing a forum to learn and practicenew clinical skills and to provide a place to geta second or third opinion

on how to handle a difficultclient situation. even staff with substantialexperience can benefit from opportunities to accessconsultation at times. - thank you, mary. nikki? - remember to make surethat your local suicideprevention coordinator is aware of any veteransthat are at high risk because the hospitalhas an alert system to flag these veterans' charts. also, work with your spcto ensure the veteran's safety

as they will monitor the veteran aside from their regularbehavioral health visits. also, remember to letyour veterans know about the nationalsuicide hotline, as it can be used asextra support for them, especially after hours, and it is specificallyfor veterans. that number is 1-800-273-talk. - thank you, nikki. matt.

- thanks, kirk.in addition to the resourcesand getting supervision, i'd really like to emphasizethe importance of collaboration between therapistsand their clients. this goes hand in handwith the recovery philosophy and it makes sense, particularlyin this challenging population, in which suicidality will arisefrom time to time. you'll get better outcomesand have a greater impact as a therapist if you involve the clientand 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 dedicationto this important work. also, thanks to the centerfor substance abuse treatmentat samhsa for providing tip 50,which serves as the basisfor this training. here's the informationon how to obtain tip 50. it can be downloadedas a pdf file as well as orderedas a paper manual.

the good news is thatthe manual is completely free and indeed,from samhsa's perspective as well as the va's, the morecounselors, supervisors, and administrators that ordertip 50, the better. hopefully, this overviewhas helped provide guidance on the complex topicof suicide prevention. remember--tip 50is your keystone guide to helping you help veteransat a crossroads.

that's all the timewe have for today. thanks for joining us.