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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

Psychotherapists and their families: The effect of clinical practice on individual and family dynamics and how to prevent therapists' burnout and impairment

Posted on October 13, 2014 at 8:56 AM Comments comments (89)
****This article was published in Psychotherapy in Private Practice, 13 (1), 69-95****The Psychotherapy in Private Practice Journal is available online at:

Read the full article here 

Psychologists have paid very little attention to the effect their profession has on themselves and have consistently avoided examining its effects on their families. This paper explores the question: Are psychotherapists' families disadvantaged, or are they fortunate to have a therapist-parent who is an authority in the emotional, cognitive, and behavioral domains? Related areas that are explored are the uniqueness of psychotherapists' personalities and the effect of their practice on their personal lives. The paper focuses on the ramifications of the psychotherapists' practice on their own lives and their families', and proposes possibilities for enhancing the positive and preventing the negative effects of their careers on themselves and their intimate connections.

Psychologists have studied the effects of a variety of professions on the professions' practitioners. Physicians, career military personnel, corporate executives, political leaders, and artists are among the many who have been analyzed by psychologists. However, psychologists have failed to systematically study the effect practicing psychotherapy has on their own lives. Similarly, psychologists study the effects of every conceivable kind of family dynamic on children. They have studied the children of alcoholics and schizophrenics, disabled infants, and the children of divorce. They have compiled volumes on baby rats, infant gorillas, puppies, and bunnies. Yet they have consistently neglected to inquire into the dynamics of their own families. They have consistently avoided hypothesizing on the impact of being or living with a person who is an expert in the emotional, cognitive, and behavioral domains.
While limited attention has been given to the effect of psychotherapy on the practitioner, even less has been given to its effect on the practitioner's family. Short of a half a dozen anecdotal articles on families of psychotherapists, even fewer clinical reports on family or group therapy, a single empirical study (Goldney, Czechowicz, Bibden, Govan, Miller, & Tottman, 1979), a page or two on analysts' children in books by leading psychologists, such as Kohut (1977), Miller (1981), and Bettelheim (1976), and a thorough and thoughtful, but extremely anti-therapist biased book by Thomas Maeder (1989) titled Children of Psychiatrists and Other Psychotherapists, the field is suspiciously empty.

The resistance to attending to the complexity of psychotherapists' lives is not only reflected in the lack of comprehensive analysis, but also by the American Psychological Association's governing board and membership's reticence to set up a nationally coordinated program to identify and treat distressed psychologists and prevent burnout. Psychologists, psychiatrists, and counselors have been instrumental in the development of employee assistance programs tailored to serve the needs of other distressed or impaired professional employees. In contrast to psychotherapists, the American Medical Association (AMA) and the American Bar Association (ABA) as well as national organizations of dentists, attorneys, nurses, and pharmacists long ago established avenues for distressed professionals who are seeking help (Kilburg, Nathan, & Thoreson, 1986; Laliotis & Grayson, 1985).

The reasons for this lack of attention to the hazards of the profession are open to speculation. Many therapists claim that their professional lives have no bearing on their personal lives. Therapists may possess a prejudicial sense of grandiosity and invulnerability; they may assume they are capable of helping other professionals, but be incapable of recognizing that they themselves need help. Kottler (1987) attributes their resistance to the illusion that psychotherapy is the pure application of "scientifically tested principles and reliable therapeutic interventions" (p. 26). Other psychologists admit their reasons for not studying themselves stem from defensiveness and the professional practice of focusing all investigations on the patients (Farber, 1983).
This paper maps the complexity of the interaction between the practice of psychotherapy and the personal and familial life of the practitioner. It is based on the author's work in individual, couple, and family psychotherapy with psychotherapists and their families, and on a series of workshops conducted with such families regarding the impact of their clinical practice on their own and their families' lives. Participants were representative of all therapeutic disciplines: psychiatrists, clinical psychologists, clinical social workers, and master level trained counselors.

The clinical data gleaned from these subjects is combined with an extensive review of the literature. Together these provide a map to guide in the exploration of this rarely visited wilderland of therapists' family dynamics. This paper identifies the areas of inquiry, separates myths from realities, and critically examines the existing theories and research. In addition, to specify the strengths and weaknesses the profession brings to psychotherapists' families, the paper suggests ways of enhancing the positive and minimizing the negative effects.

The basic question posed by the paper is: Are psychotherapists' families disadvantaged, or are they fortunate to have a therapist-parent who is an authority in the emotional, cognitive, and behavioral domains?
In order to answer this, three further questions must be thoroughly investigated:
  1. What are the distinguishing characteristics of psychotherapists' personalities, and is there any truth behind the myth of the "wounded healer"?
  2. What aspects of psychotherapists' training and practice are relevant and likely to affect their personality, quality of life, and interpersonal skills?
  3. Do families parented by psychotherapists develop special dynamics due to the parents' profession? And, if yes, what is the impact of the parents' profession on their children?

Avoiding pitfalls in setting up a private practice

Posted on June 27, 2014 at 6:46 AM Comments comments (95)
James Rye 

People want a professional service that is easy to access and packaged for them. 

Mistakes I’ve made and learned from. 
- Profit equals income minus expenditure.
- I was a naïve amateur with dysfunctional beliefs about private practice
Dysfunctional beliefs
- money is dirty: no, money is important
- there is difficulty in charging for help but solicitors and doctors charge for help
- it’s OK to charge for help
- some people believe aspects of private practice is beneath them (advertising, charging, doing the accounts)
Marketing sharks
-       supermarket cards
-       voucher schemes
-       hospital/surgery cards
-       advertorial in the police service, local fire-station, hospital magazine (don’t pay as policemen can get therapy for free)
Make it easy for people to work with you
-       We need to advertise : directories, web-page
-       Multiple contact methods: webform in googledocs.
-       Handling calls professionally – virtual assistant: diverting the phone
-       Payment: buying a £50 card reader
-       Paypal link if working online
-       Avoiding the numbers: not logging all expenditure (e.g. mileage)
Unrealistic charging:
-       balancing what we’re worth, what it cost us to train, what local people charge, what is moral
-       If we are keeping people out of the welfare system, out of secondary care we are saving people a lot of money so charge.
-       Don’t subsidise people by paying for their therapy
Don’t put all your eggs in one basket
-       too many counsellors/psychologists delivering the same thing
-       why are you different/unique
-       what are you going to offer and are you the person to deliver it
-       what do clients want?
-       only 30% of his clients come from self-referral, agency referrals or EAP’s (55%)
-       Other sources of income: internet/phone, supervision, couple counselling, CBT, training, consultancy
-       How can you specialise: either in the content or the method of delivery. Be different in some way!
-       It is a mistake to not see the landscape.
-       There is a whole industry training people to see clients for a long time which is costly and people have limited resources
Seeing the landscape: reaching people through technology
-       What seems unusual now fifty years from now will be the norm
-       Accepting that online/telephone counselling is different
-       Delivery method: technology is happening whether we like it or not. Be weary of conservatism and judgements against new methods of delivery. Having to learn about new methods although. We can reach clients who we couldn’t reach otherwise (disabled, living abroad, suffering from agoraphobia)
Risk Naivety
-       house insurance companies will see more risk if you're working from home
-       personal safety (buddy system, not leaving key, emergency services on speed-dial, panic button)
-       people cross boundaries: higher proportions of complaints come from private practice and most of them are about boundary crossing.
-       Business boundaries: life/work balance is difficult to keep if working from home. Most people want to come in the evening, after 5pm. The danger is to take anyone at any time of day or night.
Link resources