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Working with suicidal clients
Posted on October 17, 2014 at 5:02 PM |
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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 |
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****This article was published in Psychotherapy in Private Practice, 13 (1), 69-95****The Psychotherapy in Private Practice Journal is available online at:
http://www.informaworld.com. Read the full article here
Abstract 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:
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Avoiding pitfalls in setting up a private practice
Posted on June 27, 2014 at 6:46 AM |
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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 |
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