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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

Confidentiality in therapeutic practice

Posted on June 27, 2014 at 8:24 AM Comments comments (97)
Presentation delivered at the Psychologists Protection Society 40th  anniversary Symposium on the 27th of June 2014 by Ian Gilman-Smith
The speaker is a psychotherapist and social worker with experience as an expert witness. He is involved in the process of making a decision in the case of someone who lacks legal capacity


Do’s and don’t’s of confidentiality
-       There is no neat script that can be handed out to assist us in dealing with professional issues around confidentiality
-       There are different issues to a degree depending of context: private practice, organisational work
-       There is a lot of conflicting information about policies
-       The therapeutic relationship is not only with our clients. We don’t work in a vacuum, isolated from the rest of the world.
-       Clients come to therapy because they want to, are referred by GP, family members, have been sent by court order,
-       Working with multi- or inter-disciplinary teams. Liaising with other members of the client’s professional team
-       The backdrop of social-media. The information is shared potentially with the rest of the world.
-       Care program approach was developed to support professionals in communicating with each-other (Baby P. was seen by 51 professionals, sex abuse scandals involving celebrities
How do we deal with confidentiality
-       A mantra that professionals refer to is “sessions are confidential
-       Do we know what we mean when we use the word ‘confidential’? Sometimes we don’t.
-       Clients agree to proceed as if statements about confidentiality are the small print on a mortgage contract
-       Our intentions are to form a trusting relationship in which they can disclose and find relief from the issues that bring them to therapy
-       Are we merely using the term to reassure ourselves and our clients
From a legal perspective confidentiality is highly complex. Legal documents include
-       Freedom of Information Act
-       Human Rights Act
-       Mental Capacity Act
-       Access to Medical Reports Act
-       Terrorism Act
In our adversarial legal system barristers are not necessarily on the therapist's side. They are highly skilled at understanding the nuances of these different documents.
There is a common law duty to confidentiality
-       patient information should only be disclosed with the patient’s consent.
What is it to be reasonable in how we practice
-       they judge professionals by the standards of other professionals
-       are your actions accepted as common practice?
-       Would your peers do the same? On what grounds do you make that judgement?

What is negligence
-       the omission to do something which a prudent and reasonable man would do
-       clear reporting of risk and risk management
What is a confidential document in the eyes of the law
-       English law does not recognise privilege just because a document is considered confidential by a party of another
-       Information that could incriminate a third party, diplomatic papers – nothing else is
-       Documents cannot be made privileged by simply attaching a label
-       One of the roles of the therapist is to hold and make sense of complex information
-       Taking the pre-emptive view that we need to be informed about confidentiality and not to do so would be negligent.
-       Looking at worse-case scenarios because they help us bring into sharp focus the issues around confidentiality.
Are we exempt from meddling  if we work in private practice
-       court order to give written evidence as to the course of therapy in county courts, criminal courts, coroner’s courts
-       such requests are legally enforceable and they can be enforced by being fined or sent to prison in contempt of court
Thresholds to confidentiality
1. What do I think
-       risk-assessment: risk is so easily overlooked.
-       Consider a number of domains of risk: not just risk to self or others in broader terms: intentional self harm, unintentional self-harm, risk from others, risk of exploitation from others or society, risk to others, ability to survive (resources and living skills), psychological risk (thinking feeling and behaviour), social risk (problems with activities or in relationship with other people).
-       Can public good be achieved by disclosing the risks identified. If there a risk to life of limb – that decision is easier to make
-       Client disclosing something of concern such as ‘I can’t go on anymore’
2. What do I do
   -  if you identify risk but decide not to contact next of   kin, GP, emergency services then reason:  What did I think of that information? What allowed you to make an informed decision? What was your thinking? Was this the action that would have been taken on the reasonable therapist?
3. What do I write
-  struck by the sweeping generalisations that therapists make about their clients i.e.: he drinks “far too much”
- clear documented process helps account for our actions in a courtroom setting
- written records do not need to be voluminous but need to be thorough
- fact finding: the judge wants to know the facts of the case: client presentation, level of risk, historical account, your professional views
- professionals becoming incompetent or highly hostile in court, contradicting themselves
- the private practitioner is far more vulnerable:
- responsibility for: managing the issues of confidentiality pre, during and post therapy
- responsibility for being professional CPD, supervision DBS check, indemnity, CPD, registration with the ICO.
Any risk identified needs to be made explicit in the therapy session
-       supporting the client in  managing risk themselves
-       contacting another agency
-       using the resource of the therapy encounter
-       what if the client does not support you in contacting the GP
-        implications of breaking confidentiality: risk not to uphold the right human rights, risk damaging the therapeutic therapy, right to privacy
-       implications of not breaking confidentiality may have severe consequences: fail to protect the rights and freedom of others, minimising harm to vulnerable adults and children
-       it is clinician’s responsibility to report abuse of vulnerable adults or children. What is “vulnerable person” (is or may be in need of community services, unable to take care or protect himself against significant harm or exploitation, mental disorder, age)
How do we protect confidentiality?
-       Clinicians with widely different views: ‘destroy notes’, or ‘keep no notes’, ‘record everything’, ‘write report as if I was going to be cross-examined’
-       Whatever confidentiality goes beyond one’s mind can be requested
-       It’s your judgement call how you record and account
-       Notes should be accurate, secure, processed in line with client’s rights, kept no longer than necessary
-       Complaints can be made within 5 years since the alleged incident. Claims of negligence can be made within 6 years since the alleged incident
-       Registering with ICO. Information governance if we keep reports on our computers.

The Institue of Psychiatry
TAG with 6 domains of risk

A new way of thinking about the nature of reality

Posted on February 6, 2013 at 7:15 PM Comments comments (101)

The clock is an archetype of the old classical physics. What we have in the quantum mechanics is something that is not at all like that. A new way of thinking is required. 

Relativity theory
Einstein was at the crosswords between the old world and the new one. He said: "Behind the tireless efforts of the investigator there lurks a stronger, more mysterious drive: it is existence and reality that one wishes to comprehend." (Einstein, 1934) We all wish to comprehend reality, but what is our expectation about how that reality will show up?

Intrinsic properties have been defined as unique enduring properties that identify an object. Galileo made a distinction between primary and secondary qualities. He wrote" I think that tastes, odours, colours and so on are no more than mere names and they reside only in consciousness. Hence if the living creature were removed, all these qualities would be wiped away and annihilated." Secondary qualities are colour, smell, taste, sound, warmth.  Primary qualities are size, shape, location, movement, contact, mass.

The failure of classical realism
The mystery is from the point of view of quantum physics: are these primary qualities truly primary? Is there a world of intrinsic objects or is the world intrinsically subjective - is it the world of experience?

Two great theories of modern physics
Relativity, which is a revolution in our understanding of space and time and simultaneity becomes significant only at high velocity. Quantum mechanics, which has revolutionised our understanding of light and matter becomes relevant only at small scales such as atoms.

Thought experiment. A relativistic challenge. To fit a 25cm pole in a 20cm long barn. Classically it is impossible because the pole is too long to fit in the barn. However at 75% the speed of light, the pole shrinks when seen from the barn to 18cm. If the barn is observed moving at 75% the speed of light towards the pole, the barn will shrink to 14 cm. Any object that moves becomes shorter in the direction of moving. Viewed from the barn the pole fits inside. Viewed from the pole, the pole is too long. These two views are classically inconsistent, but consistent from a relativistic point of view both are true, but with respect to two different observers, two different frames of reference.  

What you are looking for is always in a context, a relationship. When you are asking what is the single true state of affairs you are presuming there can be a view from nowhere - no person just a situation with its own truth. When we forget the context we come into great difficulties. Difference reference frames create different contexts and lead to different understandings. The vantage point is absolutely important to even something like size. Every primary property is affected by relativity. From a standpoint of physics we have to keep into account the frame of reference of the observer. There is no privileged reference frame. Each observer has the same claim to truth. 

Length shortening, time slowing and the relativity of simultaneity make analysis in terms of objects inappropriate and this becomes the new framework for understanding the new physics. David Bohm: "The analysis of the world into constituent objects has been replaced by its analysis in terms of events and processes" (Special theory of relativity) We so much want the world to be made up of objects - cells, neurons, atoms but this is a wrong view. We have phenomena and processes arise in time and they give the appearance of objects of enduring nature, but what is primary is the process. 

It is a wrong view to look for a single objective state of affairs that everyone will see in a consistent way.There is a fundamental observer dependence (real or imagine). There is always a vantage point. To forget the observer is a fallacy. We find that primary atributes are relative. Properties are relational - they depend on the relationships that we experience. We are always looking for the objective reality beyond experience, we are looking for something other than experience to support experience, but this, on the basis of Einstein's theory is not a good choice. When you look ever more deeply you find context dependent relationships that give rise to phenomena that may be more and more subtle. What one has context dependent experience and there is no need for any foundation other than that. We need to not be stuck in a vantage point. If you get stuck on a vantage point you see everything from your own side and you fight from that truth. 
A reality which you circle - you actually learn to take the point of view and position of others. Engaging with something different gives a fresh view on reality.

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.