family interventions and suicide 2015
TRANSCRIPT
Family Interventions and Suicidal Crisis Situations
Suzanne Lamarre MD, Psychiatric Emergencies and Crises
Service at SMHCFebruary 17, 2015
Crisis means change
• Do a little more of the same and consolidate sickening habits
• Make a real difference and help the actors to get a new way to manage problems
• The suicidal crisis can become the occasion for a real change in managing problems in the family
What to do?
• Focus on the relations rather than on the pathologies of people involved
• Accept you are now part of the problem but discover also you are given the power for new solutions
The double bind you are in
• Damned if you do, damned if you don’t
• How to free yourself while behaving in a professional way?
• By making yourself comfortable in proposing a new relation
Suicidal crisis in a patient (1-2)
• Twenty-nine year old woman, Russian born, overtired, PHQ9: 21, with death wishes, unable to work
• Ballet dancer…as a child, only child
• Lack or loss of self-esteem: wishes to be treated
Suicidal crisis (2-2)
• Actors and patterns
– Mother, selfless, self sacrificed, wants to make daughter happy
– Father abusive but repentant
– Insurers …rude
– No doctors while on antidepressant
• Trembling and yet tries to go to work
• Has not given up on suicide
Where to intervene and how?
• Medication
• Family conflicts
• Insurers
• Family doctor
• Confidentiality rule and safety
• Refer patient where?
Suicide in the light of your professional code
• No safe interventions at 100%
• Your professional code
– collaboration with patient and family
– confidentiality
– no impersonal practice
– you have to provide the means but not the results
• What notions could help now?
Relations
• Two types of interactions in regard to self- identity– Complementary
– Symmetrical
• Unhealthy relations– Schismogenic / explosive : right or wrong/ dependant or
independant
• Healthy relations– Non-schismogenic /time-out in tension / win-win/
autonomous / interdependant
• Communication – The content and the incentive
Caring relations
• Who is responsible for the safety of the suicidal pt after the assessment?
• What type of relation
– Protectionist / schismogenic
– Collaborative / non schismogenic
Protectionism
• The duo: protector and protegee controlling each other and untrusting each other while needing each other; from overprotection to rejection
• Communication: an “as if” quality– the relation is labelled good but everyone hides
realities from each other to avoid explosion
• Controlling mechanisms– Guilt and shame through overt and covert blame– Disqualification in mad or bad identities
• Multiple crises with more and more people involved
Signs of protectionism with our pt
• Mother selfless and patient cold with father
• Lack of self esteem
– She defines herself as the problem
• Does not see any issue in this context and cannot discuss the problems openly with his loved ones
Transforming protectionism into a collaborative relation (mutuality/interdependency) 1-2
The Health Care Professional (HCP) especially the doctor, the psychiatrist, has to address the relation
The “I” discourse stating one’s limits and in need to work with everyone
Disqualification (mad or bad) addressed by a proposition of a no blame approach in the 3 directions
Ethics of reciprocity: “I don’t do to others what I don’t want others do to me” to bind the patient
Transforming protectionism into a collaborative relation (mutuality/interdependency) 2-2
• Safety plan in self protection (Barbara Stanley) and in the code of “no news, good news” and someone to contact 24/7 as TRACOM
• Follow-up process on the relation and someone to contact for maintaining the healthy relation
New values for management of family problems without blame either disqualification
• No absolute security• Reequilibrium and reorganization process• Prescription for the family:
– No blame in 3 directions and
–Stop or Step back
–Take a breath
–Open on problems
–Process towards action with others
On the individual level
Roads of victimization in
a Protectionist context
Roads toward a quality of
life and ethic of
reciprocity
WHAT TO STOP DOING WHAT TO TRY
Withdraw from others when in
despair 1Reach out to others when in despair
and manage problems in a different
way
Assume that depressive ideas and
depressive mood don’t interact with
each other2
Practice mindfulness, stay grounded
in the moment, and choose one’s
thoughts
Ignore brain neuroplasticity,
communication and principles of
relations, action recursivity and final
causes
3Count on brain plasticity: new
patterns can emerge when one
becomes aware of the contexts that
maintain them
Act impulsively or emotionally 4Be aware of one’s emotion and deal
with the frustration after reflection
Roads of victimization in
a Protectionist context
Roads toward a quality of
life and ethic of
reciprocity
WHAT TO STOP DOING WHAT TO TRY
Ignore the entrance pathway towards
victimization and death 5
S (STOP ) or STEP
T (take a breath)
O (observe) or E (explore)
P (proceed towards a common plan of
action)
Change nothing and wait for someone to
die 6Put the problem on the table, mourn
losses and let the brain process the info
Ruminate on unfairness and continue with
“I should have” or avoid those thoughts in
engaging in dead ends7
Forgive: decide to choose pleasant
thoughts and moods – Get oriented to
the future “I should”
Waste time on “why” – the initial cause of
the problem – rather than identifying the
final cause (the aim)8
Switch quickly from “why” to “how” to
reorganize the situation with others and
foster collaboration to solve problems
Burn out 9Be aware of energy renewal and
feedback loops; get a perspective on
relations to maintain peaceful and
fulfilling contexts
Roads of victimization
in a Protectionist
context
Roads toward a quality
of life and ethic of
reciprocity
WHAT TO STOP DOING WHAT TO TRY
Stay cornered in a protectionnist
system (saviour’s role) by
overprotecting the suffering one10
Address oneself to a third party so as
to change from a rule of the game a
rule of collaboration and self-
protection and for the ethics of
reciprocity
Avoid or hide problems, or look for
guilty people to exclude or to punish 11A good leader acknowledges the
existence of problems and installs a
context for everyone to participate in
solutions
Maintain oneself in controlling,
manipulative behaviours through
blaming, and disqualifying others (see
the wheel of victimization)
12Become an expert in identifying
dysfunctional, explosive systems by
focusing on relations rather than on
individuals
Assume the right to bully and
humiliate another for self defence 13Exclude all violence and explosive
means for self protection and do
time-out in love in case of tension.
Blame oneself, blame others or let
others blame us 14Recognize one’s mistakes and
discuss how to repair with neither
guilt nor shame.
On the interpersonal level
Roads of victimization in
a Protectionist context
Roads toward a quality
of life and ethic of
reciprocity
WHAT TO STOP DOING WHAT TO TRY
Fall into wrongdoing that needs to be
hidden, and engage in self denial and
blackmailing15
Expect honesty and discretion and
defuse all time bombs
Force the other to agree so as to be ‘one
of us’ 16Love and collaboration does not mean
having to say “yes” to every request.
Compare oneself to others, be envious,
maintain oneself in shameful and guilty
feelings, continuously excuse oneself 17
Gain self confidence by accepting one’s
own mistakes, without assuming the
identity of the ‘bad boy’ or ‘bad girl’: be
aware there is suffering in all action, but
acting is much more interesting than
waiting for the authorization to act.
Keep trying to prove one’s value 18Learn to risk trusting others, and expect
others to reciprocate
Protected
Guilty
imposing
solutions
blaming
deaf
mute
Protector SaviourPeace
maker
Blamed
Rejected
Exploited
Submissive
Rebellious
Disqualified
Let down
Shameful
Victim
Dysfunctional means
of defence
Suzanne Lamarre, M.D.
The Victimization Wheel within a protectionist relationship: roles, feelings and means of defences
Identify in this wheel your roles, feelings and means of defences,
and the ones of your significant others, and compare your observations with theirs
Lessons to take home
• Momentum for change– 1st psychiatric contact
• Real change– Relational rule
• From controlling each other, to collaborating with each other
• From overcompensation, to partnership in reciprocity
• Who has the lever for bringing such a change?– The Health Care Professional, especially the doctor,
the psychiatrist