Keeping it simple: understanding and treating suicidal behaviour

1. Keeping it simple: understanding and treating suicidal behaviour Dr. Angelo De Gioannis MD FRANZCP a.degioan@griffith.edu.au

2. Life Promotion Clinic • Outpatient clinic for the treatment of individuals at risk of suicide • Referred from ED, MH teams • No geographical boundaries • Free of charge

3. Population • Around 350 clients seen so far • 70-80 clients seen each week • Clinic open two days/week • MDD, PTSD, GAD, OCD, Personality disorders

4. Staff • 1 Part-Time Psychiatrists • 2 Full-Time Trainee Psychiatrists • 4 Part-Time Psychologists • 1 Full-Time Mental Health Nurse • 1 Part-time Receptionist

5. Clients • 73% Female, 27% Male • 15-76 years old Mean age=31.9 • Employed=35.9% • Only 17.8% living with spouse/partner • 66.6% year 12 or less

6. Clients • 63.3% had two or more attempts • 72.5% had high wish to die before attempt • Beck Suicide Ideation(0-42)= mean score 15.5 • Active desire to die=72.5% • Beck Hopelessness= 76.2% score>8 • DASS= over 50% in the severe range for anxiety and depression

7. Current limitations in treating suicidal clients • Management of suicidal individuals is “hard work” • Medication available only partially effective • Psychotherapies require lengthy training and supervision • One size does not fit all

8. The ideal psychotherapy • Easy to learn • Easy to deliver • Easy to tailor to suit the clients’ needs • Easy for the client to understand and apply

9. Research so far • Promising results with clients considered treatment resistant • A significant number of clinicians trained with consistent results • Randomised Controlled Trial • Drop out rate only 20%

10. Inspired by: • Latest developments in neurophysiology • Occupational psychology • Energetics • “How do we function?”

11. “Psychache” • Concept introduced by Edwin Schneidman • Refers to feelings of hurt, anguish, psychological pain • Can be current or anticipated

12. Human Performance (Kanheman, 1973) • Evaluation of demands and allocation of resources • Depending on our assessment we “activate” • Limited resources to perform, control and monitor • We all create our own benchmarks

13. That means…. • Whenever we engage in a task we make an estimate of the effort required to complete it • We also make an estimate of the level of activation (“psyching up”) that delivers the effort we think is required • The more we allocate to some tasks, the less we have for others

14. As we continue to perform….. • Reduced spare capacity (fatigue) • Fatigue leads to increase in activation required to keep performing to the detriment of efficiency • The longer we perform for and the more tasks we perform in the higher level of activation we will need • The level of arousal is an expression of how much we are operating beyond capacity

15. Arousal • Sympathetic • Motor inhibition (directional fractionation) • Causes restriction of cues used to guide action • At an appropriate level it helps reject irrelevant cues

16. Excessive arousal • Makes us reject relevant ones • Impairs ability to discriminate relevance • Narrows attentional beam • impairs short-term memory

17. Further complications…. • Sustained performance beyond capacity leads to failure in the ability to control activation (inability to reduce or withdraw effort) • It also leads to failure in the ability to monitor performance (loss of awareness/insight)

18. Sleep deprivation as model(Pilcher, 1996) • Only effort required is to stay awake and to complete lab tests • Mood changes occur first, cognitive performance follows, motor performance always fails last • Mood changes can progress to the point of significant mental illness (72 hours) • Return to functional levels only after sufficient sleep

19. Physical Effort • Easier to formulate realistic estimate of demand and allocation • Tissue damage hard to ignore • Benchmarks are visible • Body can be easily stopped if we get it wrong

20. Mental Effort • Much harder to formulate realistic estimate of demand and allocation • No tissue damage • Benchmarks are invisible • The mind is very hard to stop if we go too far

21. To maintain a functional state (ideal world) • Only activate enough to produce performance in an efficient way • Avoid irrelevant/redundant physical or mental activity • Maintain appropriate level of arousal • Withdraw/reduce effort before we lose control of it • Only start putting effort again when a fully functional state is restored

22. What our clients say…. • ????????? • Effort creates energy (agitation) • The amount of effort I put depends on the importance of the problem • If there is no discomfort it means I haven’t put enough effort • Half of the clients need at least suicide ideation to feel comfortable with “stopping”

23. Observations • No concept of excessive effort/activation • Any withdrawal/reduction of effort invested is perceived as inappropriate • Unrealistic levels of activation are considered necessary • Disregard of mental health symptoms is considered a sign of strength (“push through”)

24. Observations • Clients have variable understanding of what constitutes treatment • Clients have variable understanding of what an acceptable and functional state is supposed to be like • Clients cannot complain about symptoms that are “normal” for them or what they believe is not necessary to endure • Change can be unsettling even if for the better

25. Quotes • “How do you know you care if you do not get palpitations?” • “I’m not a sitting still person. I don’t want people to think I’m lazy” • “How can you still be sick if you are not thinking about suicide?” • “…but if I am angry is because I am passionate about the issue”

26. Effort and emotional disturbance • Emotional disturbance develops whenever there is a gap between the level of activation (mental, emotional, physical) individuals believe necessary and the resources available • The kind and severity of the emotional disturbance are expression of the kind of activation and the extent of the gap • “overthinking” and “being too wound up” • The impulsive and/or dysfunctional behaviours we observe often have the role of helping individuals reduce activation

27. Emotion Modulation Therapy • Individual and group sessions • Wide range of disorders treated so far • Strong emphasis on phenomenology • Focus on adjustment to change

28. EMT components • Behavioural analysis • Motivational interviewing • Psycho-education • Supportive psychotherapy (if change has occured)

29. Questions we ask ourselves during treatment • What is this person doing (mental activity/arousal) that I would consider unnecessary? • How many of the symptoms that I would not put up with do they endure or regard as necessary? • Why do they feel they have to perform that way? What is at stake?

30. Questions we ask clients during treatment • Is it possible to be “too alert”? • Is it possible to think “too much”? • If yes, which are the experiences should we rely on to guide us? • How do you know if you are well enough to perform?

31. Exercise • Would you ever talk to others the way you talk to yourself? • Would you ever put up with somebody talking to you the way you talk to yourself? • Would you trust talking to yourself as appropriate?

32. Observations • Emotional state patients present with consistent with what they endure • End of treatment when self-talk in line with the way they talk • Patients do not trust or think they don’t deserve treating themselves the way they treat others

33. Treatment Stage 1 • Demonstrate that the impulsive behaviour is what is required to address certain “states” • Demonstrate that the increased activation has a detrimental impact on performance and that the behaviour prevents an even worse scenario • Demonstrate that the only way to avoid the impulsive behaviour is to prevent the “states” that trigger it

34. Treatment Stage 2 • Facilitate awareness into the way the client reaches an excessive level of activation (intensity of mental activity and level of arousal) • Explore the motivation/s behind it • Discuss the pros and cons of sustaining a certain level of mental activity and/or arousal

35. Treatment Stage 3 • Help clients make the link between level of activation and the mental/physical/emotional “states” they experience • Facilitate awareness into the progression of states over time (chain reaction) • Encourage clients to reduce the intensity of activation they consider necessary

36. “What do I do?” • The only strategy discussed in treatment is: disengaging, letting go, pulling the pin, dropping the bundle, “stuff it”, etc. • It always relates to the individual making a conscious decision to put the “state” before the “activity” • “Toilet” example

37. Barriers to treatment • Clients try to apply learned strategies or new insight without changing the way they invest effort • Often clients have only partial insight into their illness • The treatment stops when the clients think they are well enough • Identification with illness

38. Thank you