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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

Compassion Based CBT workshop with Prof Paul Gilbert

Posted on January 9, 2014 at 12:09 PM Comments comments (0)
This is a workshop delivered by Prof Paul Gilbert at Palo Alto University in 2013 about the scientific premise and technique of Compassion Focused Therapy. 

Overview of Compassion Focused Therapy and the process of change with compassion. 

CFT is a psychological model, although it uses elements of CBT, humanistic and psychodynamic therapies. CFT started with Prof Gilbert's interest in patients who were struggling with standard therapies (diagnosis of Borderline Personality Disorder). These patients were focused on shame and self-criticism, which is linked to poor outcomes. He wanted to understand evolutionary mechanisms which maintained emotional problems. 

Cognitive Behaviour Therapy traditionally focuses on replacing on unhelpful thoughts and behaviour with helpful thoughts and behaviour. However some clients say they see the logic of the alternative thoughts but do not feel reassured or helped at the emotional level. They also say: "I know I am not to blame but I still feel to blame"

We need to feel congruent emotion in order for our thoughts to be meaningful to us. Emotions "tag" meaning onto experiences. In order to be reassured by the thought "I am loveable", this needs to be linked with the experience of 'being loveable'. Many patients who come from traumatic backgrounds have few memories of being loveable or soothed and thus may struggle to feel reassured and safe by alternative thoughts. 

Compassion focused therapy targets the activation of the soothing system so that it can be more readily accessed and used to help regulate threat-based emotions of anger, fear, disgust and shame. 

Evolutionary model of psychopathology 

We are an emergent species in the 'flow of life' so our brains, with their mechanisms for motives, emotions and competencies are products of evolution, designed to function in certain ways. 

Anxiety disorders are related to how cognitions trigger innate defences - fight, flight, demobilisation (Marks, 1987) or danger modes (Beck, 1996)

Depressions are related to evolved mechanisms for coping with defeats and loss (Beck, 1987; Gilbert, 1992)

Personality disorders are related to the under or over development of innate strategies (e.g. cooperation vs. competition) (Beck, Freeman et al. 1990; Gilbert, 1987)

The social circumstances of our lives, over which we have no control, have major implications for the kinds of minds we have, the way our genes become expressed, the kids of brains we end up with, the kind of person we become, the values we endorsed and the lives we live. 

How new psychologies emerged in the world
500 mil years ago - Reptilian psychology (territory, fear, aggression, sex, hunting)
120 mil years ago - Mammalian psychology (capacity for caring, group, alliance building, play, status)
2 mil years ago - Human psychology emerged (capacity for symbolic thought and self-identity, theory of mind, meta-cognition)
1 mil years ago - Human capacity for extended caring (looking after the old or the sick) 

Why we have complex brains and minds that are difficult to understand and regulate

The Old Brain: Emotions (anger, anxiety, sadness, joy, lust); Behaviours (fight, flight, withdraw, engage) Relationships (sex, status, attachment, tribalism)
New Brain: Imagination, fantasise, look back and forward, collating and integrating vast amounts of information from different modalities- sensory emotional, plan, ruminate. 
Social Brain: Need for affection and care 

The brain has a number of built-in biases. Biased learning (fear of snakes, heights). Biases can be implicit or explicit. We tend to be self-focused, kin-focused and exhibit in-group preferences. 

We have a capacity to become aware of being awareness. Mindfulness is the capacity to observe one's mind and it naturally calms us down. Compassion comes is a motivating system rooted in the caring system. Compassion has to be understood as an interaction - it depends also on the other being responsive to being cared for. 

The mind is primarily a social signalling system (See Tronick's 'still face' experiment, Joseph Campos experiment on the role of non-verbal communication guiding behaviour in babies) 

Humans have fundamentally have a desire to be helpful( Warneken and Tomasello experiments in compassion in babies). 

Evolutionary functional analysis 

There are three types of emotions, which act as motivators: 
-those that focus on threat and self-preservation
-those that focus on doing and achieving 
-those that focus on contentment and feeling safe. 

The threat system is the dominant system in your brain. It is designed to over-rule and switch off everything else. Attention becomes narrow-focused, scans for threats, moves towards thinking about what could go wrong. In anger and anxiety the body feelings overlap. Borderline patients are not able to distinguish between tension and anxiety. 

Resources on 'dissociation'

Posted on April 22, 2013 at 6:48 AM Comments comments (94)
From Louis Cozolino “The Neuroscience of Psychotherapy” [2o1o] 

Dissociation is a result of high levels of stress associated with traumatic experiences. It occurs when the fight or flight response would be maladaptive, or when there is no response to one’s distress. It is a switch from hyper-arousal to hipo-arousal. In infants it is manifested as a gradual lack of protest [this is the reason why until recently it was believed that infants were insensitive to pain and so surgery was performed on infants without anaesthesia It is characterized by “a disconnection among thoughts, behaviours, sensation and emotions; dissociation demonstrates that the coordination and integration of these functions is an active neurobiological process.” [p. 2o-21] 

“Dissociation allows the traumatised individual to escape the trauma via a number of biological and psychological processes”. [p.269] The brain releases endogenous opioids which create a sense of wellbeing. The explicit processing of overwhelming traumatic situations is decreased [hippocampus]. “Derealization and depersonalization reactions allow the victim to avoid the reality of his or her situation, or watch it as a detached observer. These processes can create an experience of leaving the body, travelling to other worlds, or immersing oneself in other objects in the environment…” [p.27o] 

“General dissociative defences resulting in an aberrant organization of networks of memory, fear, and the social brain contribute to deficits of affect regulation, attachment and executive functioning. The malformation of these interdependent systems result in many disorders that spring from extreme early stress. Compulsive disorders related to eating or gambling, somatization disorders in which emotions are converted into physical symptoms, and borderline personality disorder all reflect complex adaptations to early trauma” [van der Kolk, 1996 in Cozolino, 2o1o, p. 27o]

The neuroscience of borderline personality disorder [p.282-283] [Also see Zero degrees of empathy by Simon Baron-Cohen]
-       An overactive amygdala, primed to react to any indication of abandonment.
-       Easily triggered fight or flight reaction [hypothalamus- pituitary –adrenal axis resulting in the release of adrenaline and cortisol]
-       Orbitofrontal cortex inadequately developed so it cannot successfully inhibit the amygdala. Self-soothing is not possible.
-       Orbitofrontal dissociation may result in disconnection between right and left hemisphere and top-down processing leading to dramatic shifts between positive and negative appraisals of relationships.
-       The absence of internalized models of affect regulation so the patient cannot draw on these to self-soothe
-       Rapid fluctuations between sympathetic and parasympathetic states
-       Chronic high levels of stress hormones [cortisol] which compromise the functioning of the hippocampus, decreasing declarative, explicit memory and the capacity to control the amygdala.
-       Lower levels of serotonin resulting in greater risk of depression and irritability.-       Self-harming results in endorphin release and sense of calm 


“Dissociation in reaction to trauma represents a breakdown of neural integration and plasticity. In therapy, we use moderate levels of arousal to access cortical mechanisms of plasticity in controlled ways with specific goals. The safe emergency of therapy provides both the psychological support and the biological stimulation necessary for rebuilding the brain. Much of neural integration and reorganization takes place in the association areas of the frontal, temporal and parietal lobes, serving to coordinate, regulate and direct multiple circuits of memory and emotion… narratives embedded within an emotionally meaningful relationship are capable of resculpting neural networks throughout life. Through the use of autobiographical memory, we can create narratives that bridge processing from various neural networks into a cohesive story of the self” [Cozolino, 2o1o, p. 343]

From Daniel Siegel’s “The Mindful Threapist: A clinician’s Guide to Mindsight and Neural Integration”“Dissociation involves various elements along a spectrum including a sense of being unreal, feeling numb or disconnected from one’s body, feeling depersonalization or a kind of distance from being grounded in oneself, and outright amnesia for events in one’s ongoing life.” [Siegel, 2o11, loc. 1377] 

These experiences recur mainly under stress and are associated with unresolved trauma and loss and a disorganized attachment style. Dissociation is a protective state in a situation in which there is no escape from terror  or “fear without solution” [Main, Hesse, Yost-Abrams and Rifkin, 2oo3 in Siegel 2o11]
The opposite of a dissociated or disorganized state is an integrated state. There are different levels of integration, just as there are different levels of dissociation.
Vertical integration – mind/body is facilitated by interoceptive awareness [posterior insula] Being aware of what is happening inside one’s body and using this information to make sense of our reality
Bilateral integration – left hemisphere/right hemisphere [logic, verbal/metaphoric, implicit, non-verbal] 
Being able to use logic but also metaphor. [See Iain McGilchrist- the Master and his Emissary]
Memory integration – implicit memory/explicit memory [amygdala/hippocampus]
Narrative integration- the existence of a coherent autobiographical story

Additional resources:  “The History of Dissociation and Trauma in the UK and its impact on treatment by Remy Aquarone and William Hughes” available online at:
Stephen Porges - "The polyvagal theory". Porges talks about incapacitation [fainting, passing out] as a distinctive coping mechanism, neurologically very different from sympathetic arousal [fight or flight response]