Some risk factors are known to be associated with increased suicide rates. These risk factors are frequently found in problem gamblers. They are worthy of alert:
- previous suicide plans or attempts
- male, especially if young
- concurrent substance abuse
- unemployment, acute financial stress
- mental illness, such as major depression, depression with psychosis
- unstable personalities, such as Borderline Personality Disorder, Antisocial Personality Disorder
- adverse life events, especially within 12 months of death of close ones.
Problem gamblers are unlikely to report suicidal feelings or plans — they are usually socially isolated, mistrusted by their family, struggling with low self-esteem, hopelessness, guilt, self-hate, anxiety and despair. Their gambling troubles typically worsen their previously existing problematic traits; their repeated attempts to change or quit gambling often fail, leading to the desire to “end it all.” Careful inquiry at all times regarding suicidality is crucial.
Make inquiry of suicide a regular part of your screening and assessment. Feel free to ask about suicidality — some clinicians may worry that inquiry into suicidality will put the idea into the client’s head and therefore increase the risk. This is misguided. Empathic but clear and direct inquiry such as “Have you been thinking about ending your life, or killing yourself?” can be very effective. Many clients who have been contemplating suicide will actually feel relieved that another person is willing and capable of listening, and the subject is out in the open.
DUTY TO WARN: A counsellor may have the experience in which a client reveals startling information about the crimes he or she is planning or has committed during therapy. While clinicians are bound by the terms of confidentiality, there are exceptional circumstances that warrant reporting. As well, these circumstances also call for a referral to other professionals. These situations commonly occur when:
a) the safety of the client is threatened (e.g., suicidal)
b) the safety of the therapist is threatened
c) a child or person of minor status is in danger of abuse
d) the threat of safety of a third party is specific and the plan is clear, and,
e) the safety of the public is endangered in a clear and circumscribed fashion (e.g., threat of blowing up a bus/plane).
Issues to Consider while Counselling
Increased monitoring as an outpatient or, if judged to be unsafe, inpatient stay at a psychiatric ward for safe-keeping when the option is available and concurrent disorder treatment must be considered.
General approach to making a referral to a mental health specialist
The counsellor is increasingly expected to recognize and treat clients who have a multitude of complex problems. At times, due to time constraints or a lack of comfort with some specific areas of mental health, having a clear sense of when and how to refer to other experts is also an essential skill.
In each of the following concurrent psychiatric disorders discussed, there will be a section on “When to refer for a psychiatric assessment.” Here I will describe some general issues.
- Make distinctions between a consultation and treatment referral — the former is a seeking of some expert opinion on a specific area (e.g., Should one start a medication? Is this a psychotic breakdown?; whereas the latter is a transfer of care to the other professional. Needless to say, it is often easier to get a consultation opinion than finding ongoing treatment elsewhere.
- The client should be part of the consenting decision to make a referral — as the process should be seen as an effort to help, rather than a sign of rejection or abandonment. Many problem gamblers are extremely reluctant to come to any counselling in the first place — a referral of any kind should be handled delicately.
- Some clients may request to have referrals. Reassuring the client that you will try to co-ordinate this and provide follow-up support, after discussing the reasons and concerns with the client, will help to build rapport and alliance, without damaging the counsellor’s sense of competence.
- Develop contacts and networks with colleagues and other professionals. Clients generally find consultations/referrals with persons who know the counsellor more reassuring and trustworthy. In general, a consultant who is accessible, communicates well, and answers specifically the questions asked, is a valuable resource that should be actively cultivated.
- Clear and concise description, in written form, of the reasons and findings that led you to believe a referral is necessary is an essential ingredient of a successful referral. Ask specific questions whenever possible. Vague questions often result in vague answers. Pre-referral and post-referral phone calls to establish mutual understanding with the consultant is very helpful.
- Offer your own expert perception and experience in gambling counselling to enrich the referral process. Others would most likely welcome a mutual learning experience.
- Feel free to call upon the consultant again if the recommended strategies do not work. A good consultant will appreciate such feedback and will be able to discuss potential shortcomings.
- Urgent and emergency referrals (e.g., suicidal, homicidal — see also “Duty to Warn,” p. 88) should not be left to clients alone. Calling ahead to ers or referral sites and accompanying clients for such visits is advisable.
- In situations where the counsellor feels that a referral is a must, but the client refuses to accept a referral, it is permissible — and advisable — for the counsellor to personally take the client to an er (with the help of the police if necessary) if the situation is urgent. With others who refuse, clinical judgment is needed on an individual basis. Consulting with colleagues is a good first step. Sometimes refusing to give counselling unless the client seeks the recommended help is permissible and necessary to convey the urgency of your intent.
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