suicide risk assessment & crisis intervention
TRANSCRIPT
SUICIDE RISK ASSESSMENT& CRISIS INTERVENTIONDR JOHN ROBERTSON
BARCELONA 14/7/19
MOTIVATIONS FOR THIS TALK
• “We need to recognise that risk assessment as risk predictionis a total fallacy. We cannot predict which of our patients aregoing to suicide and which aren’t”
Kapur College Congress Adelaide 2017, quoted in RANZCP 2017 Annual Review
• Superficial ‘Risk assessments’ are too commonplace
OBJECTIVES
• 1. To dispel the myths that “Suicide is not predictable/preventable”and that “Risk assessment is a waste of time”
• 2. To demonstrate that psychodynamic principles are not a set of abstrusetheories for a ‘select few’, but a set of practical guidelines to guide us all inour everyday practice, and particularly when assessing suicidality.
SUICIDALITY
• Suicidality is not a Yes/No dichotomy
• Those presenting are usually AMBIVALENT in the moment, whileexperiencing a fluctuating, reactive trajectory of severity over time
• Stress – Diathesis model => MULTIFACTORIAL etiology, but alsoscope for intervention
SUICIDE RISK ASSESSMENT
• Questionnaire: Actuarial checklist of static predisposing vulnerabilities.Bland categorisation, with poor predictive value
• Conversation: Collaborative, personalised narrative of dynamic events,feelings, thoughts, intent and needs. Provides a more accurate, meaningfulappraisal and leads to active interventions.
• Nomothetic v Idiographic. “Search and rescue” metaphor
“THE FACTS”
•Most ‘High Risk’ individuals don’t suicide,Most who suicide are ‘Low/Medium Risk’ !
‘RISK ASSESSMENT’ BY MH STAFF FOLLOWING SELF HARMKAPUR BMJ 2005
• Manchester 1997-2001. n=3828
• How many repeated within 12 months? n = 549 = 14%
• Lo 1721 -> 165 Repeated = 30% of all repeaters
• Med 1738 -> 289 Repeated = 53%
• Hi 369 -> 95 Repeated = 17%
‘RISK ASSESSMENT’ BY MH STAFF FOLLOWING SELF HARMKAPUR BMJ 2005
• Manchester 1997-2001. n=3828
• How many repeated within 12 months? n = 549 = 14%
• Lo 1721 -> 165 Repeated = 30% of all repeaters 10% of Lo’s
• Med 1738 -> 289 Repeated = 53%. 16% of Med’s
• Hi 369 -> 95 Repeated = 17%. 25% of Hi’s
‘RISK ASSESSMENT’ BY MH STAFF FOLLOWING SELF HARMKAPUR BMJ 2005
• Manchester 1997-2001. n=3828
• How many repeated within 12 months? n = 549 = 14%Suicide
• Lo 1721 -> 165 Repeated = 30% of all repeaters 10% of Lo’s 3
• Med 1738 -> 289 Repeated = 53%. 16% of Med’s 13
• Hi 369 -> 95 Repeated = 17%. 25% of Hi’s 2
OBSERVATIONS
• Greater proportion of ‘Highs’ did repeat
• Study was naturalistic: ‘High Risk’ individuals would have received more input – therebylowering numbers of repeats
• Statistically, suicide is a rare event, leading to high NNT for effective outcomes, butscreening questionnaires can help identify vulnerable individuals, in need of closer scrutiny
• We need to move away from a focus on riskassessment and start talking about this in terms of a
patient’s needs assessment” Kapur
RISK FACTORSPREDISPOSING FACTORS -VULNERABILITIES• Sex Paterson 1983
• Age
• Depression
• Previous attempt
• Ethanol abuse
• Rational thinking loss (psychosis)
• Social supports lacking
• Organised plan
• No Spouse
• Sickness
• Sex and Age Robertson 2000
• Unemployed <
• Isolated
• Crisis* <
• Illness
• Depression / psychosis / eating disorder
• Alcohol and Drugs
• Lethality: Past attempts*Current Plan, Intent & Means *
• ? FHx, Past trauma, aggression, impulsivity
RICHER ASSESSMENT
• Predisposing, Precipitating, Accelerating factors
• Affective flooding, Loss of coping self
• Fantasies, Fixation.
• Intent, Plan, Access to means
• Protective Factors
PREDISPOSING,
• Developmental deficits. Early trauma/separation/loss, Insecure attachment
• Impaired sense of Self and World.Narcissistic wound/vulnerability: ‘unlovable’, with compensatory ‘False self ’.Perfectionism. Idealisation/Devaluation (of self & others), with unrealisticexpectations. Brittle dependency.
• Inevitable failures -> Disappointment, rejection, conflicted anger (love/hate) &guilt. Passive-aggression, impulsivity, self-harm (seeking mastery over trauma).
• Past attempts -> Acquired capacity
PRECIPITATING & ACCELERATING FACTORS
• Why Now? Seemingly overwhelming, insurmountable, difficulty:Conflict, Loss (relationship/role), Anniversary, Failure.Recent admission/discharge*.Meaning? Often a symbolic repetition of past trauma.Needs thereby expressed?
• Abortive solution finding. Substance abuse, Non-adherence.Relationship conflict/withdrawal -> further loss of supports
AFFECTIVE FLOODING, LOSS OF COPING SELF
• Overwhelmed by unbearable hurt, pain, rejection, fear, shame, anger
• Negative ruminations: Triad - Self, World, Future.Aloneness (Thwarted belongingness), Sense of burden‘No-one cares/understands’, ‘Better of without me’
• Fragmentation, Dissociation
• Rigid, concrete, dichotomous thinking: ‘All or nothing’
• Hopeless desperation, despair, dread, defeat.
FANTASIES (SHIFT FROM ‘COMFORT’ TO GOALS)
• Relief - from pain
• Rescue – by others (in the act and subsequent care)
• Recognition - (of suffering/specialness) by grieving survivors
• ‘Remorse’/Shame – Self Punishment. ‘Anger turned inwards’,Guilt re neediness & anger. Expel/Kill-off bad part of self
• Rebirth/Reunion - of good part with lost loved ones
• Revenge - on bad objects
FIXATION
• Suicide as only solution
• Tunnel vision, narrowed attention
• Intent, Plan, Access to Means
• Beware calm demeanor
PROTECTIVE FACTORS
• Reasons for living
• Coping strategies
• Supports
CLINICIAN ATTITIDE, CONFIDENCE & SELF CARE
• See struggling subject (not pathological object)
• Genuine human concern -> Supportive alliance
• Not fearful / omnipotent / dismissive
• Self monitoring - Counter-transference (esp. ‘Malignant Alienation’)
• - Self Care
CRISIS INTERVENTION
• Full Psychiatric History and MSE
• Connect, Define the problem & Explore depth of suicidality
• Active empathic listening, human connection, therapeutic alliance
• Hear and acknowledge their story of pain, anguish and despair
• Enquire sensitively, sequentially and specifically about suicidal ideation
• Explore depth of commitment: Intent, plan and means
• Explore Ambivalence (Urge to die/live: Parts of self) & Protective factors (esp Supports)
• Construct Safety Action Plan
PRACTICAL SAFETY ACTION PLAN
• Trigger ->
• Warning signs
• Internal coping strategies ‘Self help’– psychol., sensory (family photos), exercise
• Social contacts and settings – distraction & reconnection
• Help (informal) from family and friends -> resolve the crisis
• Expert (formal) help: Mental health services. Who to call? Where to go? What to say?
• Safety of environment: Remove means (and alcohol)
• Obtain confirmation and commitment. Review appointment