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Working with suicidal clients

Posted on October 17, 2014 at 5:02 PM Comments comments (98)
Presentation given by Dr. Eoin Galavan at the Psychological Protection Society, at Aislin Hotel Dublin, 17/10/2014

Here are my notes from this workshop. 

Between 20%and 50% of mental health practitioners will lose a client to suicide during our professional life, depending on the context in which we work. 
What characterises the suicidal mind is: they always want to live and they always want to die. We can get caught up in the thinking that because a client called out the ambulance after ingesting medication she didn’t really want to die. It’s important to keep this in mind: both wanting to live and wanting to die.
The way we approach suicidality has to be thought out. We can’t throw everything we have at someone. It can be confusing and overwhelming. We do it because we want to be covered.
Thomas Joiner model from "Why people die by suicide"
Perceived burdensomness+thwarted belongingness combined with developed fearlessness and ability leads to serious attempt or death by suicide
Development of fearlessness – the suicide person has gone through a journey that has allowed them to override the natural instinct for self-preservation and to overcome fear.

Fearlessness of physical injury is developed by habituation – getting used to threat of bodily harm to the point that it no longer provokes fear but may induce states that are pleasurable. One has to suppress or depress the fear response. 
Reduction of the fear response through repeated exposure to violence/injury/physical pain/provocation/abuse. Emergence of an opponent process which is the exact opposite reaction to the same stimulus. Eventually overtime the idea of self-harm does no longer evoke the fear response, it evokes feelings of pleasure or calm.
Anorexia nervosa is a good example of how habituation works
There is a high rate of suicide in AN (a study looked at 240 women. 9 died of suicide. This is very high). This is because they have already been through a process of habituation and are likely to use incredibly lethal means because they are habituated thr
Different channels for habituation: Numbing of the body sensations in young children who are neglected. Physical abuse early in life leaves people with a high level of tolerance for physical pain but little tolerance for psychological pain.
It is important to decouple biological death and lethal self injury from the suicidal risk. A ‘slow graceful swan dive into nothingness’ is NOT the same as jumping off a cliff. Suicidal people are not thinking about the actuality of what they are doing. A realistic description awakens the fear response.
Societal and cultural expectations and in some countries (US) legal statues which almost state that a counsellor must  stop a suicidal person from killing themselves as if we have that innate capacity.  It works its way up into the legislative and complaint process. In fact, we don’t have that capacity to stop people from killing themselves. We should stop being anxious about that and stop buying into this fantasy. 7% of all suicides occur in psychiatric hospitals under increased surveillance.
“Perhaps what makes all of this so complicated is the fact that unlike medicine, surgery or dentistry the mental health clinician is the instrument of care – there is no equipment failure, no pathogen, no virus to otherwise blame. We are the instrument of care; it does not get any more personal than that” (Jobes, 2011)
This impacts on how we feel towards the patient and the therapeutic relationship, which is the most precious thing we have.
Israel Orbach – “Therapeutic empathy with the suicidal wish”.
Two elements are always required when we work with the suicidal person. It is important both to empathise with the suicidal wish and at the same time to confront the self-destructiveness and state that biological death is not a solution to life’s problem.
Outdated model of working with suicidal people was reductionistic. Suicide was seen as symptom of depression involved but this is an insufficient explanation.. The clinician was seen as the ‘expert’ and in a one-up position. Inpatient hospitalization, treating the psychiatric disorder and using of ‘no-suicide’ contracts.
There is no evidence that inpatient stays are in and of themselves effective treatment for suicidality. In fact they become risk factors. In fact people are more suicidal when they come out of hospital. The group in society most likely to die by suicide are those who have just left psychiatric hospital. 3 out of 100 will kill themselves. The general population is 15 out of 100.000
There is a belief going around that we can stop people from killing
Using the CAMS (Collaborative Assessment and Management of Suicidality) model authored by prof. David Jobes
This is an overall process of clinical assessment, treatment planning and management of suicidal risk with suicidal outpatients.
Key component
-       clinical assessment of risk
-       treatment planning around what is most relevant to a person with suicidality.
-       management of suicidal risk
-       advocates a collaborative stance: sitting side by side and putting suicide on the table
-       suicide status form: pain, stress, agitation, hopelessness, self hate
-       identifying reasons for living vs reasons for dying.
-       intensive outpatient care that is suicide specific
-       developing other means of coping and problem solving
-       systematically eliminating the need for suicidal coping
Risk assessment:
-       Individual rating their own risk of suicide. We are really bad at guessing where the individual think they are
-       Crisis response plan
-       Separate risk assessment from predition. Risk assessment is NOT prediction.  We are terrible at predicting suicide. It’s such a rare behaviour that it’s very hard to predict even with people who are in a high risk category
-       How invested are they in the plan? What is the intent? Have they got access to means?
-       A risk assessment is simply a best guess – current and static risk factors
-       Clinician’s ‘gut’ intuition needs to be contextualised
-       Risk assessment will dictate the type of treatment and the frequency of contact
-       Most designated high risk are unlikely to kill themselves! (3 out of 100 of those who just come out of psychiatric hosp will kill themselves, but WHICH 3? That is impossible to predict) Many who kill themselves are designated low risk. It’s extremely difficult behaviour to predict.
-       We can’t make people divulge what is going on internally!
-       We shouldn’t be too hard on ourselves if we get it wrong.
When should hospitalisation be considered
   - extremely high risk of suicide
-       is the person at clear and imminent danger of risk
-       person is unwilling to work collaboratively and work at resolving problems and putting suicide behaviour ‘off the table’
When are we negligent?

-       If there is clear and imminent danger by death and we do nothing to try and avert this, that is negligent

The myth of mental illness.

Posted on January 18, 2013 at 10:38 AM Comments comments (4)
The myth of mental illness is a classic anti-psychiatry article authored by Thomas Szatz and published in the 1960. Read it here

Limits to the quantum uncertainty and assessments for psychotherapy

Posted on January 15, 2013 at 7:24 PM Comments comments (3)
New experiments with weak measurement techniques challenge the predictions of Heisenberg's Indeterminacy or uncertainty principle (1927). 
This principle states that in our attempts to measure small particles like photons we cannot but disturb the reality we are observing. 

Heisenberg famously said "The "path" [of a particle] only comes into existence when we observe it." My understanding is that this is because all observation at the smallest level of reality (quantum level) normally require a direct interaction with the quantum particles, they require a small scale "collision", which changes the path and the momentum of the particle. At quantum level, where any presence is extremely influential, to measure something is to change the course of what you are observing. The observing "device" becomes part of the reality being observed. 

These two articles are based on original research paper by Lee Rozema, Ardavan Darabi, Dylan Mahler, Alex Hayat, Yasaman Soudagar, Aephraim Steinberg. Violation of Heisenberg’s Measurement-Disturbance Relationship by Weak MeasurementsPhysical Review Letters, 2012; 109 (10) DOI: 10.1103/PhysRevLett.109.100404

Why does quantum physics matter to psychotherapists?

Quantum physics and the uncertainty principle have been hugely influential in the way we think about our attempts to understand reality through observation. 

The question of validity of observation was raised for me during the one year I spent as an assessor for the Metanoia Counselling and Psychotherapy Clinic. During that time I assessed one hundred individuals who had been referred or self-referred to the clinic for counselling and psychotherapy. 

My role as far as I could tell was that of a gate-keeper and match-maker. I had to make sure that the clients who were offered therapy were also likely to benefit from treatment. As an assessor I needed to learn enough about the nature of the client's symptoms, their relational patterns and history, their availability for dialogue and motivation for change. Based on this information which I would gather in fifty minutes, I would make a decision about whether a short to medium term humanistic therapy with a trainee therapist may be helpful. I had to enlist the client's cooperation in this process - their willingness to answer a somewhat structured interview, covering presenting issues, current situation, history, previous therapy and diagnosis (if available), medication, was essential. 

But my assessment was never made based on the information volunteered by the client. I also payed attention to my observations of their behaviour in the room, as well as my internal responses (countertransference). I began to wonder how much of what I was observing was linked to the context in which we were meeting and to my presence in the role of the assessor. 

An assessment is a stress inducing situation for both therapist and client. The client finds themselves in an unfamiliar environment, with a person they haven't met before. The schedule is pretty tight, and the time we can spend on warm-up niceties is reduced to a minimum. There are unfamiliar forms to fill-out asking very personal questions such as: "Do you sometimes think of harming yourself or others?" 

Although the therapist is familiar with the environment, they do not know who is going to walk through the door. There is no filter. To me every assessment felt like going on a blind date. The client may be distressed, psychotic, extremely unwilling to participate in the task or violent. This only happened with five out of one hundred clients (so an incidence of 5%) but it is impossible to predict whether the next encounter will be a difficult one or not. 

So the client who is stressed is interacting with a possibly stressed therapist. The client will unconsciously pick up on this and this will affect their behaviour. By and large I have found this to be diagnostic in that the client's ability to deal with the stress-inducing situation and the vulnerability of the therapist is a great predictor of their ability to tolerate the stress of engaging with another in therapy. 

There are times however when the clients seek to over-adapt in order to fulfil the criteria for being accepted for therapy and because of their need and my power to deny them access to what they think they need, they may decide to withhold information, give false information, exaggerate, downplay and act. I have to take the client's words at face value, and may not know if I am being lied to. 

What I rely on, is the felt sense I get from being with the client. Whether I feel calm, friendly, scared or angry - these are all clues about the client's internal experience and the roles they take or make others take in relationships. 

Although the existence of the DSM is an attempt to inject certainty and precision in assessment and diagnosis, fundamentally we cannot always be certain. People don't always fit neatly into diagnostic categories, their realities and personalities cannot be neatly put in a box.

Intuition and categorisation

I think that assessment is a very delicate process, that starts with the therapist's curiosity and their intuition. Intuition is a very different process from categorising. These are two functions which are lateralised in our brain. Intuition involves the right hemisphere which is adept at reading between the lines as well as welcoming information from the body about feeling states present in the presence of the client. Intuition about danger is neuroceptive, not perceptive. "Neuroception" is a term invented  by Stephen Porges to describe a cognitive process that is bodily based and may not involve conscious thought. Berne speaks about "primal image" and "primal judgement". It may be a gut feeling or an image that says something about the client - we may not fully understand what. 

Diagnosis is a process of synthesising intuitive knowledge with data from the client's narrative and other measures to create a 3D model and to place the client's presentation into a category of functioning. Categorising is a function of the left hemisphere. 

Ultimately the written assessment is the therapist's narrative, not the client's. We can see how at every step we encounter uncertainty and the possibility of error. This is not exact science and it may not always be a faithful description of the client's reality. The diagnosis and decision to take the client on for therapy is hardly foolproof. 

Because he takes on the role of a gatekeeper the assessor may nevertheless be seen to "know" and "be right", particularly by trainee practitioners who may be less experienced. I felt I had to challenge this perception. By doing this I wanted to invite the clinicians to be their own authority, to always take the assessment report as a provisional story about the client, but no more than that. They need to conduct their own assessment of whether they can work with a client. They need to trust their own judgement.

Affective neuroscience: Pro-social behaviour

Posted on January 11, 2013 at 5:07 PM Comments comments (106)
Stephen W. Porges is one of the world's leading experts in the autonomic nervous system, and author of a book titled "Polyvagal Theory - Neurophysiological foundations of emotions, attachment, communication and self-regulation". The book is basically a collection of articles published during a career spanning 40 years. 

Telluride conference on compassion 
I first learned about his work a couple of months ago when I watched the YouTube posted footage of the Compassion science conference organised by CCARE Stanford in Telluride, Colorado, in July 2012. Watching him deliver his presentation, Mr. Porges impressed me as an anxious, vulnerable man who self-admitted to feeling a bit lost as he couldn't see the faces of his audience and said he found it difficult without being able to gauge the feedback from facial expressions. The organisars duly turned on the lights and offered him a glass of water and he saluted this act of "pro-social behaviour". 

Porges' theory combines observations on comparative anatomy about the development of the nervous system from fish to reptiles to mammals, with the study of the nervous system of newborns, insights from psychiatric conditions in which pro-social behaviour is impaired (autism, depression). Porges states that his scope is both scientific and humanistic - in that he wants to promote better, more humane care practices amongst clinicians, that honour the healing power of human relationships. 

Autonomic nervous system
Porges focuses on a part of the Autonomic Nervous System - the para-sympathetic nervous system (PNS), which traditionally was believed has an antagonistic relationship with the sympathetic system (SNS). The PNS consists of cranial nerves that have efferent (taking information to the body and internal organs) and afferent branches (that bring information from the body and the internal organs). 

The vagus nerve
The thenth cranial nerve (X), also called the vagus nerve is of particular interest. This nerve has two pathways - an unmyelinated one, which originates in the dorsal motor nucleux (DMNX) and a myelinated one, which originates in the nucleus ambiguus (NA). Myelinated nerves transmit information much faster. The myelinated vagus is a mammal "invention". Reptiles do not have it. What reptiles do have, is an unmyelinated vagus. The role of this nerve is to massively slow the heart's pacemaker - an important part of death-feigning. For mammals it is extremely dangerous to resort to death-feigning as a strategy to escape danger. A massive slow-down in breathing and heart-beat can cause cause serious damage to the mammalian oxygen-hungry brain and body. So mammals also have a myelinated vagus nerve, which makes sure that the unmyelinated nerve does not stop the heart.

Myelinated vagus, a mammal invention
What is interesting about the vagus nerve is that it's branches do not only innervate the heart, but also the facial muscles, the larynx, the pharynx and the inner ear muscles. This means in effect that engaging in pro-social behaviour - communicating with our face and voice, listening also has the effect of maintaining our heart beat within the normal range and preventing us from going into a state of mobilization (sympathetic activation characterized by flight, fight or freeze behaviour) or immobilization - death feigning). Basically it's like a neural brake that stops us  from "literally bouncing off the walls" (Porges, p.31) 

Hierarchy of behavioural responses
Vagal tone is highest when we are in a non-threatening situation. If we detect danger in the environment, then vagal tone withdraws and the body is now under the influence of the sympathetic nervous system, which gears it through hormones such as norepinephrine (noradrenaline) and cortizol to send all available energy into the muscles in order to fight or freeze, or run away. A state of mobilization is incompatible with pro-social behaviour. Traumatized clients which are easily triggered to feel angry or scared may not be available to be contacted through conversation and reasoning. 

Misreading the environment
What is interesting is that not only does the environment affect our internal state, our internal state also "colours" the way we interpret our environment. Traumatized individuals who are constantly in a state of agitation, are also more likely to "misread" cues from the environment and interpret them as dangerous. This is why working with clients diagnosed with borderline personality disorder is so difficult. No matter how benign and benevolent the therapist believes she is, the client easily mis-reads and mis-interprets her actions. The transactional analysis cathexis school calls this phenomenon "re-framing" (Schiff). Reframing, far from being a conscious process seems more likely that is "wired" into bodily responses which were geared to deal with harmful, dangerous environments. 

If the situation is interpreted to be imminently life-threatening and the emotional response triggered is one of terror, then the unmyelinated vagus takes over and slows the heart right down. The result is immobilization (fainting, dissociative state). In transactional analysis language, client becoming immobilized is an indication that they are cathecting a severely traumatic Child ego-state. 

Porges basically says that in any given situation we will employ the evolutionarily newest neural systems - those involved in pro-social behaviours. If this strategy fails then the sympathetic system will activate to promote flight, fight or freezing and if that fails as well, we will go into immobilization (fainting, dissociation). 

Other important researchers
If I had a criticism of Porges is that like any researcher absorbed by his area of focus he tends to downplay the importance of other neural areas involved in the process. He barely mentions the work of Damasio, LeDeux, Richardson and Sapolsky. Damasio talks about the importance of the medial-prefrontal cortex in self-control. LeDeux talks about the way in which "news" of possible danger hit the amygdala before the prefrontal cortex through a "fast and dirty way", which means that we react before we've had time to assess what it is that we are reacting to. Richardson focuses amongst other things on the insula, involved in representing bodily states and Sapolsky is an expert in stress and the sympathetic activation and its effects on the hippocampus. 

Implications for practice
I think Porges' theory supports humanistic practices such as person centred and body-based psychotherapy as facial expressiveness, a positive warm presence and caring attitude which are valued in these types of therapies are also proven to promote states of calm and healing. I think that this theory challenges traditional psychoanalytic approaches such as neutral stance and non-disclosure which I think can trigger mobilization in already traumatized individuals. It also challenges health professionals in general - doctors and nurses, who traditionally are more concerned with performing the tasks and operations needed to maintain and promote bodily function and are less concerned with how they relate to their patients and the potentially harmful impact of their distant stance.  

Can time structuring be used for differential diagnosis?

Posted on November 26, 2012 at 11:03 AM Comments comments (215)
A fellow TA trainee asked this interesting question: 

When putting together a differential diagnosis of personality disorder in therapy, has anyone used time structuring to choose one diagnosis over another? She said that her instinct was that someone with a narcissistic personality structure would spend more time in games while someone with obsessive compulsive personality structure more time in rituals.

I think this is an extremely interesting question but we need to be careful about how we use terms such as "ritual" or "withdrawal" which have different meaning in DSMIV from that in which we use them in transactional analysis. 

"Ritual" as a concept in TA to my mind is not the same as the sense in which it is used in the DSM IV. Rituals play a major part in Obsessive Compulsive Disorder (OCD), but these are not social rituals in the sense that we understand them in TA. They are repetitive compulsive behaviours. Rituals also play some part in Obsessive Compulsive Personality Disorder (OCPD) but to a lesser degree. Also, OCPD should not be confused with OCD. OCPD clients are concerned with rules, order, hoarding and overworking. OCD clients may not in fact have a personality disorder but an anxiety and compulsion disorder. OCD is on Axis I. OCPD is on Axis II.

A client with obsessive compulsive structure will feel entitled to a game of Uproar if someone else interferes with their order or rules (and perhaps in their thinking is playing Schlemiel -messing things up). They may constantly play this game with their partner.

I think Berne's concept of time structure is useful diagnostically. Enquiring about how a client structures their time in a social sense, alerts the therapist and the client to whether the client is mixing in all the ingredients that make her feel she's doing the things she wants to do in life and relationships. 

However, I would be cautious though about linking this with the personality diagnosis as I don't think the correlation is straightforward to make and one could end up with generalisations that don't fit all clients with the same diagnosis. Perhaps it's better to keep time structure as a useful diagnostic tool, but not insist on an over-arching theory that links it with personality disorders. 

The truth is we all need and do a combination of withdrawal, rituals, pastiming, games and intimacy and this is very much guided by our temperament (introverts will shy away from too much stimulation from other people) and culture (some cultures value separateness more than others). 

This is the first time I've ever considered what an extreme preference for one form of time structuring would look like, but here it is: 

Generally others will not allow us to persist with one form of social structure beyond what the unspoken norms dictate. Therefore, I do think that that someone whose entire time is structured around one activity only may be extremely mentally disturbed. 

For instance, a client with catatonic schizophrenia will be in complete withdrawal and not acknowledge another in any way. Deeply traumatised clients, clients suffering with PTSD or clients on the autistic spectrum may also show extreme withdrawal. Again - caution - this isn't the withdrawal we talk about in TA terms. Social withdrawal at a gathering may simply mean that you're burying your head in a book and not that you've literally left your body as happens in dissociation.

Rituals and pastimes
Can one be a pathological ritualizer or pastimer (in the social sense not the OCD or eating disordered sense)? I remember talking with someone suffering from dementia, who spent most of the hour re-setting our conversation at the stage of ritual. She kept saying "Hello" and "What is your name?" as she couldn't remember that we'd already covered this. 

Clients addicted to the thrills of violent of three degree games may well have an antisocial personality disorder or borderline personality disorder or be addicted to mind-altering substances. 

How about when clients are incapable of playing games? I think they do exist. Such clients may suffer from a form of learning difficulty (perhaps retardation as lying requires intelligence) or be on the autistic spectrum (not adept at picking ulterior transactions or transacting at an ulterior level because they are limited in making sense of subtle non-verbal communication such as facial expressions.) 


Can an excessive preference for intimacy be indicative of something gone wrong? Someone who is prematurely intimate in the sense of being uninhibited in disclosing the entire content of their mind from the word "go" without any concern about censorship. This could again be a patient with Schizophrenia (but again you also have to watch out for cultural differences). 

A proposal to classify happiness as a psychiatric disorder

Posted on November 21, 2012 at 5:09 AM Comments comments (2)
Here's a very funny also strangely spooky scientific satire by Richard Bentall, who makes a tongue-in-cheek proposal that happiness be classified as a psychiatric disorder. Or at least I think it is tongue-in-cheek. He might be serious. (Read it here)

Bentall's argument is seductive, wildly entertaining but also strangely spooky because it shows how seemingly impecable logical sequencing of arguments can nevertheless lead to an absurd conclusion. It simply turns all arguments for considering aspects of mental life symptoms of psychiatric disorders on their head. 

Bentall is obviously having a justified dig at the proliferation of psychiatric disorders, and whether there's anything there at all to prevent all human emotions being conceived as abnormal. Bentall proves that one certainly can rake up the arguments to do so and how useful to the task are conceptually vague concepts such as "normality" and "function".