The Sacrifice, The Labyrinth and the Minotaur

1. The Sacrifice, The Labyrinth and the Minotaur Silvia Baba Neal silviababaneal-psychotherapy.co.uk/mindspace

2. Your Secret Question ? [what you really want to know about client suicide but wouldn’t dare to ask out loud]

3. Ariadne

4. Facts provided by the American Association of Suicidology • Many beginning clinicians are unaware that suicide is an occupational hazard • Approximately 1 in 5 psychotherapists (and as many as 1 in 2 psychiatrists and psychiatric trainees), lose a patient to suicide during the course of their career • Novice clinicians have been found to experience higher rates of suicide among their clients than more seasoned clinicians. • Experiencing the loss of a client by suicide can be psychologically traumatic for the provider, and may even become a career-ending event. • Unfortunately, few training institutions or graduate programs prepare students for this possible traumatic loss.

5. The clinician as survivour • To Survive: be left, bear, carry on, come through,  endure, go the limit, holdout, keep afloat,  live on, recover, remain alive, withstand

6. Trauma • is “a sudden and violent emotion capable of provoking a permanent alteration of psychic activity” (Devoto and Oli, 1990 p. 2002 in Mazetti, 2008, p.285) • significantly impacts the neurological structures in the limbic system related to implicit memory and emotional life (thalamus, amygdala, hippocampus, and prefrontal cortex) • the learning involved in trauma is resilient or “fixated” (Cozolino, 2010)

7. Traumatic Ego states Berne (1961)– a traumatic stimulus modifies an ego state in an abrupt way. The metaphor of “a warped coin, which would skew the pile” Contemporary translation, incorporating neuroscience findings and polyvagal theory: Stressful stimulus  Amygdala and sympathetic activation  Traumatic Ego state (a system of thoughts, feelings, behaviours associated with the stressful stimulus) Stressful stimulus + attachment stimulus (Glaser, 2007, Porges, 2012) Amygdala andSympathetic activation promptly followed by de-activation Integrated Ego state

8. McEwen et al 2009

9. Five stages of grief model (On Death and Dying, 1969) “The stages were never meant to help tuck messy emotions into neat packages. They are responses to loss that many people have, but there is not a typical response to loss as there is no typical loss. Our grief is as individual as our lives.” (Elisabeth Kübler-Ross & David Kessler)

10. www.suicidology.org/suicide-clinician-survivors Clinician 1 “Through shock little vibrations trickle through my body, a sinking feeling comes into my heart, then my stomach. I can not move. My mouth goes dry. Thoughts start tumbling through the air-landing on my body -- how, when, what does this mean, what will happen, will I be blamed, what is going on, how will I get through the day, don't scream must act professional, get concrete, O.K. I have a client waiting, stop the tears, act AS IF.”

11. http://mypage.iu.edu/~jmcintos/therapists_mainpg.htm Clinician 2 “ His death made absolutely no sense to me. After all, I had carefully assessed his suicidality during our last session and there was nothing there to alarm me. Yet, he was dead, and with his death, a part of me died as well. After the total shock and disbelief began to diminish, I started to sob, sobbing uncontrollably at times. I experienced extreme anxiety, gross sleep disturbances, and profound sadness. I was spiraling downward quickly, and I was emotionally paralyzed. “

12. Clinician 3 “Day 46: The feeling of loss has been very strong lately. I lost Mary. I lost being a member of the elite who has never lost a client to suicide. Already, I lost many hours of my time -- planning, fretting, and talking. I lost sleep. I lost confidence. I may have lost part of my joy in being a therapist.” 7 months later: I still think of Mary. The waves of loss are farther between and much less overwhelming but the undercurrent is still there. Her suicide has touched me on many levels. During these past months, one professional implied that clinicians are not affected by a client's suicide and brushed me aside. I felt very invalidated and angry. Another colleague insisted that anti-suicide contracts really work. I felt defensive. I had taken this step and others, but it was not enough to save Mary's life.”

13. Clinician 4 “I must say at the start that this is a very difficult case to discuss. In 25 years I have not publicly talked about it. This is a case where it is important to tell you all about my credentials as an analyst, as a senior university faculty member, etc. Notice that I included the word "Senior ." Can you believe that? After 25 years I still need to armor myself?”

14. Impact on professionals(Farberow, 2005) • Shock, dismay, sadness, rejection, grief • Fear of being blamed and punished • Anger directed at the client but also supervisors, managers, trainers • Feeling like a failure, incompetent, deskilled • Unwillingness to take on clients with suicidal thoughts • Using rules rigidly and defensively to prevent another suicide Some authors have suggested that therapists in training may experience reactions even stronger than do their qualified colleagues (Brown, 1987; Kleespies et al., 1990, 1993) Trainees may be less able to separate “personal failure from the limitations of the therapeutic process” (Foster & McAdams, 1999, p. 24)

15. What if you feel… Understanding: “Itis a reasonable solution to a desperate situation” “Everyone has the right to decide how and when to die” Relief: “At least their suffering (or mine) is at an end” Admiration: “The client was clearly intelligent, thoughtful, organised and determined” Are these feelings acceptable to you, your supervisors, colleagues, your profession or society at large?

16. Impasses (Mellor, 1980)

17. Sticks to beat yourself up with(factors that may contribute to development of impasse) • Your own Script System: core beliefs about yourself, others and the world. (Erskine, 2010) Antidote: Porges, 2012 • Your Parent Ego state (P2): Rigid views about suicide influenced by religion, philosophy, public policy. Antidote: Tim Bond, 2000 • The “prevention-prediction culture” associated with the medical model views every completed suicide “a failure at instiutional or individual level” Antidote: Reeves, 2010 and Szatz, 2011, Mental Capacity Act, 2005, Suicide Act, 1961 • Prescriptive, unchallenged, TA practices formally and informally handed down to the therapist i. e. “no-suicide” contracts Antidote: Erskine, 2009, Little, 2009, Hargaden and Stuart, 200o debate

18. Tasks Self care is paramount! • Activating attachment systems • Take time and space to grieve • Self- soothing strategies • Assessment of workload

19. Tasks • Cooperating with the police investigation • Psychological autopsy (Marshall, 1980) • Submitting a report to the coroner (if requested) • Notify your insurance company • Notify the Course Director or the person who organized your placement (if appropriate) • Calls of condolence (There is a GP/psychiatrist/social worker out there going through the same experience!) • Decide how to respond if you receive calls from family members or friends of the deceased • Attending the Coroner’s Inquest

20. If a clinician confides in you… • Listen with compassion (that is with the desire to help relieve their suffering) • Accept and mirror their feelings non-defensively: even racket anger or envy • Let them set the pace and determine how much information they want to share • Allow yourself to be emotionally impacted by their story – don’t model “Be Strong” • Never say “It has never happened to me” • Reassurance is never reassuring (P. Casement) • If you’re the supervisor – acknowledge the shared responsibility and be willing to talk about your own experience with suicide if asked.

21. Bibliography • Se the full list of books/articles in the ‘notes’ below