Frank is 45 years old, unemployed, and undergoing court-ordered residential treatment for cocaine dependence following his arrest for drug possession. He reports that he began drinking heavily and using cocaine and marijuana on a regular basis during his late teens. He also reports experiencing frequent “up and down” moods that coincide with his drug use. He has been in numerous romantic relationships, many of which involved physical and verbal altercations.
Frank has received inpatient treatment for his addictions in the past. On one occasion, he left treatment early; he completed treatment twice, only to relapse within a week. Frank has made 2 suicide attempts. In previous treatment, he mentioned his suicide attempts, but the response was either focused on his safety (eg, assigning him a “buddy” to accompany him to the restroom) or an antidepressant or mood stabilizer was prescribed.
We added 8 sessions of CBT (2 sessions a week for 4 weeks) for suicidal thoughts and behaviors to standard residential drug treatment. We took a detailed history of Frank’s earlier suicide attempts and identified his perception of the link between his substance abuse, his feelings of frustration or anger, and his suicidal thoughts and behaviors. Much of this work was focused on helping him conceptualize suicidal thoughts as something that he could manage and that does not require him to take action.
With our help, Frank was able to develop a detailed list of steps that he could take to keep himself safe when he is feeling suicidal. Frank and the therapist also discussed reasons to be hopeful and ways that he could remember these reasons posttreatment. The final CBT sessions involved an imaginary exposure exercise during which Frank was asked to recall his most recent suicide attempt and then envision himself seeking help before making the attempt.
Overall, Frank seemed to appreciate the intervention, and he described the focus on his suicidal behavior as unique and helpful. The relative safety and stability of a residential addictions treatment facility allowed us to focus directly on content related to Frank’s suicidal thoughts, plans, and suicide attempts. Frank stayed for the full 60 days and plans to stay with his brother after discharge. He is part of an ongoing pilot CBT trial and will be followed up 3 months after leaving treatment.
Research indicates that substance misuse is consistently associated with suicidal thoughts, suicide attempts, and suicide mortality. The risk of suicide is likely to be greater in persons with more severe levels of substance abuse as well as in those with depression. In addition, a propensity to engage in interpersonal violence is an important suicide-related risk factor. These findings reinforce the need for increased suicide assessment and intervention efforts to address co-occurring problems in individuals with substance use disorders and/or interpersonal violence.
Dr Ilgen is a psychologist at the Ann Arbor VA hospital and assistant professor in the department of psychiatry at the University of Michigan Medical School in Ann Arbor. Ms Kleinberg is a research associate with the Ann Arbor VA hospital and the department of psychiatry at the University of Michigan Medical School. The authors report no conflicts of interest concerning the subject matter of this article.
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