Skip Ribbon Commands
Skip to main content

Suicide

Suicide is the act of intentionally causing one’s own death (APA, 2013​). People who gamble problematically have higher rates of suicide, with research showing a strong link between problem gambling and suicidal thoughts and attempts. Performing on-going suicide assessments for all people presenting with problem gambling is vital.

Yellow ribbon ​​​​​

Suicide

Although the vast majority of people with a mental illness do not die by suicide, over 90% of people who do die by suicide have a diagnosable mental illness. People who gamble problematically have higher rates of suicide, with research showing a strong link between problem gambling and suicidal thoughts and attempts. The risk increases in people with co-occurring mental illness and/or substance use issues. Therefore, performing ongoing suicide assessments for all people presenting with problem gambling is vital. In this evidence-informed practice section, we explore the link between problem gambling and suicide and discuss risk factors, protective factors, assessments, safety plans, treatments andself-care.

Key Concepts

Suicidal behaviour is complex. It involves the interaction of biological, psychological, social, cultural and spiritual factors. A significant relationship exists between suicide and mental illness. Although the vast majority of people with a mental illness do not die by suicide, over 90% of people who do die by suicide have a diagnosable mental illness.

People who gamble problematically experience higher rates of suicide than people in the general population. Research shows a strong link between problem gambling and suicidal thoughts and attempts—and that the risk increases in people who have a co-occurring mental illness and/or substance use issue. According to the CAMH Suicide Prevention and Assessment Handbook (2015), “the more diagnoses present, the higher the risk of suicide” (p. 1).


Statistics

According to current research, prevalence estimates for suicidal ideation among people with gambling problems are between 12% and 19%. Rates for suicide attempts are highly variable and range in the literature from 4% to 40%, likely due to differences in study samples and inconsistencies with the definition of what constitutes a suicide attempt (such as whether suicide completions are included as “attempts”). However, this may not reflect what is seen clinically. Suicidal ideation presents itself far more frequently than suicide attempts in a clinical setting. Despite these differences, it is clear that an emphasis on suicide prevention, assessment and treatment is needed for people with gambling problems.

Newman and Thompson (2003) found statistically significant associations between problem gambling and history of suicide attempt(s). But this relationship disappeared when other mental health issues were taken into consideration, suggesting that the link between problem gambling and suicide may in fact be due to a common mental illness factor. In practice, it is important to be aware of the strong link between problem gambling, suicide and concurrent disorders.


Suicide assessment

The Substance Abuse and Mental Health Services Administration has produced the Suicide Assessment Five-Step Evaluation and Triage for Mental Health Professionals. This model stipulates that suicide assessments should be conducted at first contact and should cover the following areas:

  1. Risk factors, including prior suicide attempts or self-injurious behaviours, mental illness, family history of suicide, triggering events, stressors, ongoing medical illness, change in treatment and access to lethal means, such as firearms.
  2. Protective factors, including ability to cope with stress, religious beliefs, responsibility to children or beloved pets, social supports and positive therapeutic relationships.
  3. Suicide inquiry, including suicidal ideation, specifics related to any plan, past attempts at suicide or other behaviours, the intent with which the person expects to carry out the plan and the belief that the plan will be lethal.
  4. Risk level/intervention, including an assessment of risk (e.g., high, moderate, low) based on clinical judgment. At this stage, a treatment and/or safety plan is developed.
  5. Documentation of the risk level, rationale and treatment plan to reduce the risk of harm as well as any follow-up plan(s).


The importance of ongoing suicide assessments

Ongoing suicide assessments can help identify suicidal thoughts and/or plans and provide the message that counselling is a safe space to talk about these thoughts. In addition, the collaborative development of safety plans can help empower clients to develop strategies that will keep them safer during distressing moments. Involving, when appropriate, family members and/or other natural supports in the treatment/safety planning of clients with suicidal thoughts and behaviours is a best practice.

Suicide assessments should be completed with ALL clients who present with problem gambling. Reassessments should be conducted when significant changes occur, including:

  • following significant life events, such as losses (especially losses related to employment, careers, finances, housing, marital relationships, physical health and social status)
  • with any change in clinical status (e.g., occurrence of suicidal ideation/behaviour, including talking directly or indirectly about suicide or death, putting affairs in order or changing mental health symptoms/mental status)
  • before transitions in care from one service to another
  • during psychological states of acute or extreme distress (especially humiliation, despair, guilt and shame).


Risks and protective factors for suicide in people with problem gambling

Some risk factors are known to be associated with increased suicide rates. The risk factors frequently found in people with problem gambling include:

  • previous suicide plans or attempts
  • recent severe, stressful life events, such as interpersonal loss or conflict (breakup or death of a loved one), job loss, financial problems, legal problems and/or change of residence
  • specific personal characteristics, such as male, widowed, divorced, single, white, Indigenous and/or lesbian, gay, bisexual, transgender (LGBT)
  • concurrent substance abuse
  • mental illness, such as major depression, depression with psychosis, borderline personality disorder and antisocial personality disorder
  • adverse life events, especially within 12 months of the death of loved one(s).

Important protective factors may include:

  • children in the home, except among clients with postpartum psychosis
  • responsibility to others
  • pregnancy
  • personal, social, cultural and religious beliefs that discourage suicide and support self-preservation
  • ability to reality check
  • positive coping skills
  • positive social support
  • positive therapeutic relationship
  • hope for future
  • self-efficacy
  • supportive living arrangements
  • fear of the act of suicide
  • fear of social disapproval.


Safety plans

Another best practice is to develop client-centred safety plans in collaboration with people experiencing suicidal thoughts and behaviours. Involve the service provider (including peer support workers), the person at risk, his or her close family or friends and other natural supports when developing a plan. Safety plans are proactive in nature, as they ensure that a detailed plan is in place in the event a crisis arises. Safety plans will only work to reduce the risk of harm if the included actions are ones the person and/or his or her loved ones would actually do in a crisis.

Safety planning can be a stand-alone intervention used during crises or as part of an ongoing treatment relationship. Typically, effective safety plans include:

  • recognizing warning signs of an imminent crisis
  • using internal coping skills that can help reduce distress
  • listing who should be involved in his or her care and what role they should play
  • reaching out to family or friends to help manage the crisis
  • contacting mental health professionals or emergency resources (e.g., hotlines)
  • reducing access to potential lethal means
  • addressing practical concerns, such as who will pay rent or feed pets if the person is hospitalized.

Following the completion of a safety plan, it is helpful to ask a few questions to ensure that the person will use the plan:

  • Picture a crisis unfolding. Are all the right names and numbers at your fingertips?
  • Does this plan include what you want it to include? If not, let’s modify it.
  • On a scale of one to 10, how useful do you think this plan will be for you?
  • Can you see yourself taking the actions you have identified? If not, what seems more doable?

It is important to revisit safety plans on an ongoing basis in order to ensure they are still relevant and include any new information or interventions the client has acquired. Also important is to provide copies of the safety plan to clients and to the people involved in their care to ensure they have access to the plan if/when needed. Encouraging your clients to have multiple copies of the safety plan and to place them in locations that are easily accessible during a crisis, such as a wallet, nightstand or Smartphone, are also critical.


​​​

Research Snapshot

Ongoing debate surrounds the relationship between problem gambling and suicidal behaviours and thoughts. Some theorists propose that problem gambling is a symptom of deeper psychological distress whereby gambling is used as a coping mechanism to escape from one’s problems (Hodgins et al., 2006; Ledgerwood & Petry, 2004; Newman & Thompson, 2003; Blaszczynski & Nower, 2002). Others contend that the risk of suicide and/or suicidal ideation in problem gambling arises out of gambling-related stressors, such as family conflict, criminal acts and bankruptcy (Kim et al., 2016; Petry & Kiluk, 2002).


So which theory is correct?

Newman and Thompson (2003) found statistically significant associations between problem gambling and history of suicide attempt(s). However, this relationship disappeared when other mental health concerns were taken into consideration. Therefore, the link between problem gambling and suicide may in fact be due to a common mental illness factor. Moreover, Hodgins and colleagues (2006) found that suicidal ideation preceded the onset of problematic gambling by an average of more than 10 years. Over half of the participants reported multiple suicide attempts, with almost all attempts occurring while experiencing depression and more than half made while under the influence of alcohol and/or other substances. More research is needed to understand the relationship between problem gambling and suicide; however, these studies do point to the idea that mental illness may precede problem gambling.


Prevalence rates

Rates of suicidal ideation and attempts among people with problem gambling vary greatly within the literature. Prevalence estimates for suicidal ideation among people with gambling problems range between 12% and 19%, while rates for suicide attempts range from 4% to 40% (Bland et al., 1993; Beaudoin & Cox, 1999; Frank et al., 1991; Sullivan, 1994; Schwarz & Lindner, 1992; Martins et al., 2004; Kausch, 2003; Thon et al., 2014).

In an Ontario-based study, Cook and colleagues (2015) found that the odds of high school students with gambling problems also reporting past-year suicidal ideation was about four times higher when compared to the rest of the student population surveyed. In addition, high school students with gambling problems also reporting past-year suicide attempts was about 18 times higher (Cook et al., 2015).

The large variability in these statistics is largely due to inconsistencies in study sample characteristics and reporting periods between studies. Notably, few of these studies distinguish between gambling-related suicide attempts and suicide attempts related to other factors, further confounding the results (Hodgins et al., 2006). Moreover, Moghaddam and colleagues (2015) confirm that the gross discrepancies in these statistics are largely due to the non-specific terms used to refer to suicidal ideation, suicidal attempts and problem gambling.


Highlights in the current literature

Substance use + mood/anxiety disorder + problem gambling = increased risk of suicide

According to the Canadian Community Health Survey Cycle 1.2 in 2002, a significantly higher proportion of people with problem gambling had contemplated suicide in the past year when compared to people without gambling problems (18% versus 3%). Furthermore, people with substance use and co-occurring mood or anxiety disorders were twice as likely to report problem gambling (Statistics Canada, 2003). Presumably, when these three factors (mood or anxiety disorder, substance use and problem gambling) are present, people experience more severe gambling issues, poorer emotional and physical health and an increased risk of suicide (Public Health Agency of Canada, 2006; Statistics Canada, 2003).

Hodgins and colleagues (2006) assessed a community sample of people with problem gambling who had reported a recent quit attempt. Their results showed that 28.7% had no history of suicide ideation or attempts, 38.6% experienced suicidal ideation and 32.7% had previously attempted suicide. Hodgins and colleagues (2006) also reported the following results:​

​Suicide ideation + problem gambling

Among people who r​​eported previous suicidal ideation:

  • suicidal ideation preceded the onset of problem gambling by an average of 10 years or more
  • suicidal ideation was increasingly more prevalent in people with more severe gambling issues
  • 72.7% were more likely to have a history of a mood disorder.
Suicide attempt + problem gambling

Among people who reported a previous suicide attempt:

  • 71.8% were more likely to have a history of a mood disorder
  • 60.6% were drinking and/or using other substances during their attempt
  • only 21.2% reported that their suicide attempt was gambling related (7% of the total sample).

Alcohol use, problem gambling and suicide risk

Kim and colleagues (2016) found an increased risk of suicidal ideation in people with co-occurring problem gambling and frequent alcohol use. They also reported that greater problem gambling severity resulted in an 8% increase in suicidal ideation even when controlling for daily alcohol consumption. Lastly, reports of suicidal ideation did not differ with changes in average daily alcohol consumption in people with low problem gambling severity. However, people with a higher severity of problem gambling revealed that the greatest prevalence of suicidal ideation occurred when their average daily alcohol consumption was high (five or more standard drinks per day), highlighting the impact of co-occurring substance use (Kim et al., 2016).​


​​​​​​​​​​​​​​

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 handbook.
  • 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 SAFE-T.

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

  1. Does the client have the capacity to act?
    • 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).
  2. Have suicidal behaviours occurred in the past?
  3. Is the client experiencing hopelessness?
    • Hopelessness is a key factor in suicidal intent and behaviour. It is often accompanied by pervasive negative expectations.
  4. Are depression and/or despair present?
  5. Is a diagnosable mental illness present that is correlated with suicidality?
  6. Does the client’s physiological state (illness, intoxication, pain) increase the potential for suicide?
  7. Are intoxicants present?
    • 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.
  8. 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)?
    • Interpersonal loss can be an important precipitant.
  9. Has the client lost or does he or she anticipate losing his or her main reason for living?
  10. Is there any disruption in the client’s support system?
  11. Is the client vulnerable to painful feelings such as isolation, self-contempt, shame or panic?
  12. What are the client’s capacities for self-regulation?
    • 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?
  13. Is the client able to participate in treatment?
    • 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?


Safety planning

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 guide.


Suicide-oriented treatment

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.

  1. 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:
    • cognitive restructuring strategies
    • emotion regulation strategies
    • other CBT strategies, such as behavioural activation and problem-solving strategies.
  2. DBT: Research studies, including several randomized controlled trials, have shown DBT to be effective in reducing suicidal behaviours and other behavioural health issues.
  3. 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.
  4. 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.

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 d​eveloped 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.


Indigenous Peoples​

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 re​sidential 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

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.


Religious/faith communities

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.


Phase one:

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.


Phase two:

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.


Phase three:

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.​


​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​

Handouts for Clients

A safety plan may keep your client safe if he or she is feeling overwhelmed and having thoughts of suicide. There are many differ​ent templates you and your client can use to create a safety plan. These plans can range from a simple list of phone numbers of people to contact when in crisis to plans that have space for more details about what your client wants to do in a crisis and wants others to do to help. Many suicide prevention apps are also available to support safety planning. However, it is important to note that some apps might use triggering language and, depending on your client's location, may have a locator map th​at may not work.

Whether using a paper template, a dedicated app or any other version, it is recommended that you and your client work together in creating the safety plan.

It is also important for your client to share his or her plan with loved ones (so your client can receive support) and to keep the plan somewhere easily accessible. If your client's needs or triggers change, safety plans must be updated. Below are some safety plan templates that may be helpful for your clients.​

  • My Support Numbers​ (PDF)​ provides a safet​y plan template to help your clients identify and list contact numbers needed during a time of crisis. This template is part of the Wellness and Comfort Activities Toolkit created by the Centre for Addiction and Mental Health's Portico Network, with resources also available in French.​
  • The Patient Safety Plan Template created by B. Stanley and G.K. Brown provides another example of a safety plan template that can be helpful for your clients. Please note that in addition to contacting the Suicide Prevention Lifeline listed in the template, your client can also contact his or her local crisis centre withi​n Canada.
  • Helping you create an effective plan: Tips for individuals/families​ (PDF) provides a holistic safety plan template that can help your clients during times of crisis​. This template is ​part of the Holistic Crisis Planning Resources developed by the Centre for A​​ddiction and Mental Health's Portico Network, with resources also​ available in ​French, Punjabi, Urdu and Polish​.​
  • The Be Safe app is an Ontario-based mobile app designed for and by young people that:
    • allows your client to create a digital safety plan
    • informs your client about mental health and addiction resources in his or her local community
    • directs your client to the best options for his or her needs through a decision-making aid
    • creates a personal “get help script” that helps your client find the words to reach out
    • empowers your client​ to reach out safely.​
    The Be Safe app is available as a free download for both IOS and Android platforms.

Activities that promote wellness can also support people who are having distressing thoughts and feelings, such as suicidal ideation. It can be empowering for clients to identify tools and use strategies to help them cope with suicidal thoughts. Below are wellness handouts that may be helpful for your clients.​​

  
  
Supporting a Loved One with Suicidal Thoughtssuicide-supporting-a-loved-one-with-suicidal-thoughts
Soutenir un proche qui a des pensées suicidaires                                                                supporting-a-loved-one-with-suicidal-thoughts-fr

Clinical simula​tion vid​eo​

 


This video clip shows a fictitious therapist and client session for teaching purposes.

In this scenario, the therapist and client (Joseph) have worked together for many months, have developed a trusting therapeutic relationship and have already listed a number of emergency contacts, since he has presented as passively suicidal in the past. In the video clip, the client presents with a flat affect and with thoughts of suicide. The therapist asks the client directly about the frequency of his suicidal thoughts and assesses any plans. After this inquiry, the therapist reviews options for further support and helps the client come up with a list of appropriate coping strategies, including breathing and grounding techniques.

​After providing the necessary referrals and supports, the therapist will continue to check in with the client regularly, closely monitor his mental status, document the plan thoroughly and provide an update to the inter-professional team (including the psychiatrist) about the client’s current risk level and plan.

​​​​​​​​​​​​​​​​