Putting it Into Practice
People with gambling problems may experience extreme financial hardships as a result of their gambling. Other common experiences include conflict in their close relationships and losses related to these relationships. They may also experience feelings of hopelessness. These can all be risk factors for suicidal thoughts and behaviours. Research tells us that rates of suicide attempts are higher for people who gamble problematically. This risk of suicide increases in people with gambling problems who have co-occurring mental health issues or substance use issues. Certain situations or circumstances are particularly risky for some clients.
Significant debt: For someone experiencing substance use problems, there is a limit to how much of a substance someone can physically consume. In contrast, gambling has no such constraints. The amount of money someone can lose in a very short time can be staggering (e.g., losing hundreds of thousands of dollars in a single night), making it difficult to recover financially. Once that much debt has been incurred, the person may feel the only solution is to “win it back” through continued gambling—compounding the problem with every attempt at a solution. The moment clients face the enormity of their financial debt can be a time of heightened suicide risk.
Disclosure of gambling problem/financial losses: Compared to substance use, the signs of problem gambling can be much more subtle and harder for family, friends and concerned others to identify. The longer gambling behaviours stay hidden, the more negative impacts can accumulate for the person and the harder it can be for clients to recover. The realization that the extent of their gambling (and the financial consequences) can no longer be hidden could be a time of heightened risk.
Intense feelings of shame, hopelessness and failure: These difficult feelings are common for people with gambling problems, especially considering the stigma surrounding problem gambling and the cyclical nature that gambling can take. These feelings can be risk factors for suicidal thoughts and behaviours, so it is important to be alert to these feelings and inquire about suicidality when appropriate.
Many institutions routinely conduct suicide risk screeners and assessments (1) during a client’s initial visit, (2) whenever the counsellor recognizes significant changes in the client’s mental status (e.g., thoughts, mood, behaviours, appearance, etc.) and (3) during times of heightened risk. This is considered best practice. When a client shows signs of heightened risk (e.g., dealing with hardships listed above) or a sudden change in mental status, a suicide risk assessment should be completed and a safety plan should be developed with the client.
If the assessment reveals that the client is at high risk for suicide, the client should be taken to the hospital for further assessment, or emergency services should be contacted.
Does suicide inquiry introduce the idea of suicide?
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. Empathetic but clear and direct inquiry, such as “Have you been thinking about ending your life?” can be very effective. More examples of how to ask about suicidal ideation are discussed below.
How to complete a suicide risk assessment
Suicide risk assessments can be important tools in identifying whether your client has been contemplating suicide. However, Perlman and colleagues (2011) reported that the current suicide assessment tools yield low predictive reliability and often result in false positive and false negative outcomes. If you choose to use these assessment tools, do so with caution, and be sure to incorporate them within the overall clinical interview with your client. Some currently used assessment tools are listed below.
The Centre for Addiction and Mental Health (CAMH) Suicide Prevention and Assessment Handbook is an extensive resource in suicide assessment. Although some of the content is specific to providing treatment in a psychiatric hospital setting, most sections are widely applicable to various contexts. Learn more about the
Crisis Assessment Template is a risk assessment questionnaire that examines whether clients are a potential danger to themselves and/or to others. This resource was developed by Sandra Cushing, MSW and Susan Boyd, BSW in the Alcohol, Drug and Gambling Services within the Social and Public Health Services Division of the City of Hamilton and Regional Municipality of Hamilton-Wentworth. Learn more about the
crisis assessment template.
Suicide Assessment Five-Step Evaluation and Triage (SAFE-T) for Mental Health Professionals is a resource that was created by the Substance Abuse and Mental Health Services Administration to inform suicide assessments. Learn more about
For clinicians, knowing how to ask about suicidal ideation as well as how to identify the client’s risk and protective factors can also be helpful. Some of the following examples have been adapted from the
CAMH Suicide Prevention and Assessment Handbook.
Examples of how to ask about suicidal ideation
- “Sometimes people experiencing stress (e.g., gambling problems, etc.) can feel like harming themselves. Is that true for you?”
- “Have you ever felt like ending your life?”
- “I am concerned about your safety. Are you thinking about suicide (killing yourself, harming yourself, taking your life)?”
- “Have you had any thoughts about suicide?”
As you can see from the above examples, it is best practice to ask about the issue directly.
Examples of reflective questions about risk and protective factors when working with a client contemplating suicide
- Does the client have the capacity to act?
Have suicidal behaviours occurred in the past?
Is the client experiencing hopelessness?
- Suicide requires the ability to organize and the energy to implement a plan.
- Suicide potential may be heightened when there is greater energy (early recovery from depression) or lowered inhibition (with intoxication or rage).
Are depression and/or despair present?
Is a diagnosable mental illness present that is correlated with suicidality?
Does the client’s physiological state (illness, intoxication, pain) increase the potential for suicide?
Are intoxicants present?
- Hopelessness is a key factor in suicidal intent and behaviour. It is often accompanied by pervasive negative expectations.
Has the client recently experienced loss, disappointment, humiliation or failure (real or imagined)? Is the client currently facing loss, disappointment, humiliation or failure (real or imagined)?
- Acute intoxication or withdrawal can lead to an acute increase in suicide risk.
- Evaluation is difficult when the client is intoxicated. A safe place should be provided until the client is no longer under the influence of substances. The client should be reassessed for suicide risk when not intoxicated.
- Chronic substance use or dependence may result in chronic risk.
- Suicide risk can be elevated when a relapse occurs.
Has the client lost or does he or she anticipate losing his or her main reason for living?
Is there any disruption in the client’s support system?
Is the client vulnerable to painful feelings such as isolation, self-contempt, shame or panic?
What are the client’s capacities for self-regulation?
- Interpersonal loss can be an important precipitant.
Is the client able to participate in treatment?
- Does the client have any history of impulsive behaviour? This is true for many people with problem gambling.
- Does he or she have the ability to use external resources to regulate self-esteem?
- Does the client verbalize his or her willingness to actively participate and/or implement the treatment plan?
- Does he or she have the capacity to make an alliance?
It is important to develop client-centred safety plans in
collaboration with people experiencing suicidal thoughts and behaviours. The service provider (including peer support workers), the person at risk, his or her close family or friends and other identified natural supports can be involved in this development. Safety plans are proactive in nature. They ensure that a detailed plan is in place in case a crisis arises. Safety plans will only work to reduce the risk of harm if the included actions are ones that the clients and/or their family and loved ones would actually do in a crisis. In addition, safety plans need to be revisited and updated regularly. The following resources can help you support your client when safety planning.
Holistic Crisis Planning is a comprehensive guide that provides information on how to develop holistic, person- and family-centred crisis plans with clients and their families. Learn more about
holistic crisis planning.
A Guide to Wellness and Comfort Activities provides information to clinicians on many different types of activities thatcan beimplementedwith clients. Learn more about the
Currently, only a few evidence-informed interventions/treatments exist that are designed to target suicide risk directly. These interventions have demonstrated effectiveness in reducing suicidal thoughts and behaviours and can be useful when working with certain populations, such as clients with chronic suicidality or multiple suicide attempts. Due to some of the inherent risks, it is important to receive training and ongoing supervision in these and other suicide-specific interventions prior to implementing them with clients.
Please note that clients who are identified as being at high risk for suicide should be brought to the hospital for further assessment.
Cognitive-Behavioural Therapy (CBT) for Suicide Prevention (CBT-SP): CBT-SP is theoretically grounded in principles of CBT, dialectical behavioral therapy (DBT) and targeted therapies for people experiencing depression and considering suicide. CBT-SP, which can be used with adults and adolescents, includes:
DBT: Research studies, including several randomized controlled trials, have shown DBT to be effective in reducing suicidal behaviours and other behavioural health issues.
Collaborative Assessment and Management of Suicidality (CAMS): CAMS is a therapeutic framework that emphasizes a collaborative assessment and treatment planning process between the person at risk of suicide and the clinician.
Motivational Interviewing: Motivational interviewing is frequently used in health care settings to facilitate behavioural change. It has been shown to increase treatment engagement and improve treatment outcomes when used as a complement to other treatments, such as CBT. Using motivational interviewing core skills, the goal is to have the client hear him or herself say, “There is a reason to live.” An adaptation called Motivational Interviewing to Address Suicidal Ideation (MI-SI) has been developed in recent years as a means to support clinicians in the Psychiatric Emergency Department in enhancing their clients’ motivation to live. Preliminary findings suggest that MI-SI has the potential to reduce the risk of suicide in certain populations; however, more rigorous trials are still needed.
- cognitive restructuring strategies
- emotion regulation strategies
- other CBT strategies, such as behavioural activation and problem-solving strategies.
While not a treatment per se, a growing body of evidence suggests that non-demand “caring contacts” or post-discharge follow-up contacts (e.g., sending a handwritten postcard) with high-risk clients may be an effective suicide prevention strategy.
Whichever model is used, interactions should always be person centred, collaborative and careful to acknowledge any ambivalence that clients contemplating suicide might feel (http://zerosuicide.sprc.org/toolkit/treat). Regardless of the availability of suicide-specific therapy, every client should be assessed for suicidality and, if warranted, should be provided with a brief, collaboratively developed safety plan as key first steps.
Working with clients through a health equity lens
Health equity helps ensure that factors such as gender, race, ethnic background, ability to speak English, sexual orientation, immigration status, income and education do not affect a person's access to or the outcomes of timely, appropriate and high-quality care. The
Health Equity Impact Assessment tool developed by the Ministry of Health and Long-Term Care (2012) recommends that all health care decision-making include evaluation of the unintended positive and negative impacts for various population groups, including:
- Indigenous peoples (e.g., First Nations and Métis peoples and Inuit)
- age-related groups (e.g., children, youth, seniors, etc.)
- people with disabilities (e.g., physical, D/deaf, deafened or hard of hearing, visual, intellectual/developmental, learning, mental illness, addictions/substance use, etc.)
- ethnoracial communities (e.g., racial/racialized or cultural minorities, immigrants and refugees, etc.)
- Francophones (e.g., new-immigrant Francophones, deaf communities using LSQ/LSF, etc.)
- people experiencing homelessness (e.g., marginally or underhoused, etc.)
- linguistic communities (e.g., uncomfortable using English or French, communication affected by literacy, etc.)
- people receiving low income (e.g., unemployed, underemployed, etc.)
- religious/faith communities (e.g., Buddhist, Muslim, Christian, etc.)
- rural, remote or inner-urban populations (e.g., geographic/social isolation, underserviced areas, etc.)
- groups defined by sex/gender (e.g., male, female, women, men, trans, transsexual, transgendered, two-spirited, etc.)
- groups defined by sexual orientation (e.g., lesbian, gay, bisexual, etc.).
Please note that this list is not exhaustive, may not be fully inclusive and/or may not reflect the preferred terminology within the listed population groups. Clients may also identify with more than one of the above. It is important that your programs/services incorporate the
Health Equity Impact Assessment tool in planning and service delivery. This website will endeavor to provide more evidence-informed content for specific population groups in the future.
Diversity, gambling and suicide
Although little research has been done on the topic of suicide and problem gambling among diverse populations (i.e., ethnoracial communities, gender- and sexually diverse populations and religious/faith communities), we do know from clinical experience that important differences exist that must be considered. This section will review some of the literature on diversity and suicide in an effort to better understand differences in suicide presentation, risk and help-seeking as well as how this may be applied in the context of problem gambling.
Access to treatment
People from some diverse communities may be less likely to access treatment for a gambling, mental health and/or substance use concern than others. This may be due to a variety of reasons, including:
- high levels of stigma within their community
- lack of awareness of available services or low service accessibility
- barriers related to language/culture
- fear of possible negative consequences of accessing services.
Disclosure of suicidal thoughts
People who do access treatment may be less likely to disclose suicidal thoughts to their treatment providers. This may relate to the stigma surrounding suicide in their community. The provider working with clients within these communities may need to use methods of suicide inquiry that decrease the potential for stigma or embarrassment. They may also need to spend more time assessing for family conflict, as this may be a very important indicator of increased suicide risk for people from interdependent cultures.
Dimensions of diversity
There are many aspects to diversity; however, this section will explore only five dimensions of diversity in relation to the development and presentation of suicidal thoughts and behaviours. These dimensions will be discussed in relation to the following populations:
- Indigenous peoples
- age-related groups: Youth
- ethnoracial communities
- religious/faith communities
- groups defined by sexual orientation
It is important to keep in mind that substantial
diversity also exists within each of these communities. People who identify with one community often also identify with others (e.g., a black youth may identify as being both gay and Muslim). These overlapping social identities are often referred to as “intersectionality”. It is crucial that service providers and services acknowledge these intersections and be aware that people do not fit into discrete identities.
In the spirit of reconciliation, the Problem Gambling Institute of Ontario at CAMH recognizes the need for culturally responsive clinical support and treatment for First Nations and Métis peoples and Inuit. Within these communities, there are diverse peoples, cultures, languages, histories and experiences. To date, little research has been conducted on the interplay between problem gambling and suicide within Indigenous communities in Canada. One study from Currie and colleagues (2013) examining Indigenous peoples living
off-reserve in Edmonton found that a higher percentage of adults with gambling problems (10.4%) attempted suicide in the past year than adults who did not gamble problematically (6.6%).
Studies have also demonstrated a higher rate of suicide in some Indigenous communities across Canada, although not directly linked to problem gambling. Due to the consequences of colonization, oppression and residential schools, Indigenous peoples continue to experience higher levels of intergenerational trauma, abuse, homelessness, co-occurring mental health and addictions issues as well as familial and social problems, which are all risk factors for suicide. A 2003 Health Canada study reported that Indigenous youth were five to six times more likely to die by suicide than non-Indigenous youth, making suicide the leading cause of death. A Statistics Canada study released in 2016 looking at First Nations living off-reserve, Métis peoples and Inuit (ages 26 to 59) found that more than one in five Indigenous peoples reported having suicidal thoughts at some point in their lives. The study also found that Indigenous peoples with mood and/or anxiety disorders, substance use and residential school experience were more likely to have suicidal thoughts.
However, suicide rates are not uniformly elevated in Indigenous communities across Canada but instead vary by community. Cultural continuity and other community factors can play a protective role, with lower suicide rates found in communities with control over land, language, cultural activities, education, governance, health and policing services.
Based on this knowledge, it is essential that all suicide prevention strategies, assessments and supports are trauma-informed, integrate traditional knowledge and wisdom, and are considerate of the diverse peoples, cultures, languages, histories and experiences within Indigenous communities across Canada.
Age-related groups: Youth
Cook and colleagues (2015) examined the relationship between gambling, substance use, mental illness and delinquency through data obtained from the
2009 Ontario Student Drug Use and Health Survey. Among Ontario students in grades seven to 12, people with problem gambling were 4.2 times more likely to report mental distress than the rest of the participants. The odds of reporting suicide attempt(s) was 17.8 times higher. Other behaviours associated with problem gambling included:
- violent and non-violent delinquency (including stealing, selling marijuana, participating in gang fights and carrying a handgun)
- substance use
- mental illness.
Most importantly, these results are similar to those seen among
adults with problem gambling. Although problem gambling during adolescence does not necessarily lead to gambling in adulthood, it is important to address this issue during adolescence in order to prevent progression. Turner and colleagues (2006) found that approximately 75% of people with gambling problems stated that their gambling had already begun by the age of 18. This further highlights the need for better understanding of adolescent gambling behaviours.
Ethnoracial communities are groups of people with similar values and experiences that shape how they view the world. Based on the literature, individuals and communities express differing views about suicide. A relationship has been shown between suicide rates in a specific country and its acceptance among the population. These diverse opinions and attitudes toward suicide suggest that the act of suicide is perceived differently based on the values that are placed on it. Therefore, suicide is subject to interpretation through social constructs. It is important to keep in mind that not all people within a specific culture, ethnicity or race will hold the same views and attitudes. Therefore, considering your client’s views on an individual basis is vital.
There is evidence to suggest that religion may protect against suicide risk. Religion is thought to help with coping, reduce the incidence of substance abuse, facilitate recovery from depression, enhance social support and give a sense of purpose and meaning to one’s life. Prior studies demonstrate that people who reported no religious affiliation were more likely to have a lifetime prevalence of suicide attempts when compared to people with strong religious affiliations. Koenig (2012) conducted a meta-analysis of 141 studies that examined the relationship between religiosity/spirituality and suicide risk. Of the studies examined, 75% reported that greater religiosity/spirituality resulted in a lowered suicide risk. Moreover, Koenig separated the 49 studies with the highest methodological rigour and found that 80% of people with greater religious/spiritual affiliations reported fewer suicide completions and attempts and held greater negative attitudes toward suicide.
The implications suicide has on the notion of “life after death” also play an important role in some religions’ views toward suicide. Overall, emphasis is placed on the value of human life, and the act of suicide is perceived as a violation of this principle. Although the relationship between religion, suicide and problem gambling has not been extensively studied, this research does point to the potential protective effects of religion and faith.
Groups defined by sexual orientation
Few research studies have examined the extent of problem gambling in gender- and sexually diverse communities, which are often referred to as lesbian, gay, bisexual and transgender (LGBT) communities. However, it has been hypothesized that for members of LGBT communities, the stresses and traumas associated with disclosing their gender differences and/or sexual preferences can be similar to the stresses of the adjustment process for immigrants in a new country. This process has been shown to be a risk factor for problem gambling. It may be that people who identify as LGBT may be more susceptible to problem gambling; however, further research is needed in this area.
Although little to no research exists on the relationship between problem gambling and suicide in LGBT communities, research on overall suicide rates does exist. The available literature—including several individual studies, reviews and two meta-analyses—conclude that people who self-identify as a sexual minority exhibit higher rates of suicide completion and attempts when compared to people who self-identify as heterosexual. These results have been replicated across nearly all studies conducted, even with different population-sampling techniques (including community- and national-based surveys) and countries examined.
Bostwick and colleagues (2014) examined pooled data between 2005 and 2007 from the Youth Risk Behaviour Surveys to examine six mental health outcomes across various ethnic groups, controlling for sexual minority status. Their results demonstrated that sexual minorities reported higher incidences of feeling sad, increased suicidal ideation (including planning and attempts) and higher rates of self-harm compared to heterosexual peers. In fact, youth who self-identify as a sexual minority are at least twice as likely as heterosexual youth to report suicidal ideation and two to seven times more likely to attempt suicide.
Additionally, research highlights that people within the LGBT community frequently experience rejection from family members, making high levels of family rejection a particularly important suicide risk factor to explore.
Working with clients who are contemplating suicide
If a client dies by suicide
Working with clients with problem gambling who are at risk for suicidal ideation or behaviour can be very stressful. In some cases, a clinician’s professional and personal beliefs about suicide and the value of life may be impacted. In addition, the ambiguity of not knowing if your client will be safe can take an enormous toll. Compassion fatigue is an occupational hazard for people working with clients who are at risk for suicidal ideation. Compassion fatigue has been defined as “an extreme state of tension and preoccupation with the suffering of those being helped to the degree that it is traumatizing for the helper” (Figley, 2002, p. 1). Clinical supervision is one way to support self-reflection, monitor and address signs of compassion fatigue and maintain a therapeutic relationship with the client.
Following a client suicide
The completed suicide of a client has a strong emotional impact on the clinicians involved in his or her care. The time immediately following a suicide is a critical period, as the initial response by staff is characterized by shock, disbelief, confusion and disorientation. The aftermath of a client suicide can be discussed in three distinct phases.
An initial staff meeting is important to ensure that all are informed of the suicide and that a practical management and communication plan is established. The focus of the initial staff meeting should not be on emotional processing of the event, which could in fact be harmful. Another essential component of the immediate aftermath of suicide is to ensure that the appropriate steps are taken to carefully document the incident.
When processing the suicide event, following the immediate shock and disbelief, staff members often experience a host of emotions, including feelings of guilt, fears of recrimination, shame or despair. This is often accompanied by feelings of anger (e.g., at the client, the family or the institution/system). Finally, this may be followed by self-doubt, depression and a search for meaning. Clinicians may feel that they can no longer rely on their clinical judgment and may feel a sense of intense isolation and loneliness. A number of activities can assist in processing these challenging thoughts and emotions, including debriefing meetings and clinical and peer supervision. Involvement in formal “rituals of death” (e.g., attending the funeral or sending a card or flowers) can also be a step in the recovery process.
When staff members have regained confidence and are once again able to work effectively with clients who are contemplating suicide, it is time to review existing processes of assessment and communication, with the goal of anticipating future incidents.
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