SuicidalityConfer – October 17, 2019

AGENDA FOR TONIGHT

PART 1: Suicidality

• Its relevance to every one of us

• The broader context

• Psychoanalytic theory

• Suicidal Crisis

PART 2: Maytree

• The model

• Outcomes

A description of the suicidal person

“…trapped in a small, dark room with no windows and high walls…. The room is

excruciatingly painful. The person searches for a door out to a life worth living but

cannot find it. Screaming and banging brings no help. Falling to the floor and trying

to shut down and feel nothing gives no relief. The only door out is the door to

death.”

(Linehan, M. 2011)

Psychotherapy with the suicidal

How to reach the unreachable?

Either:• Pursuing the art of the Impossible?

Or:• “…..trapped into techniques that forget the human. How do two

nobodies meet one another as somebody.” (Alapack, 2010)

The Broader ContextSOME NUMBERS

• 6500 suicides in UK in 2018; mainly males

• Attempts: c.30 times, ie c.200,000 p.a.; mainly females

• c.90% mental illness (mainly depression)

• c.70% of depressed linked to childhood loss

All numbers unreliable

SUICIDALITY:its universal subjective features

experienced asIsolation, trapped, no way out

i.e. rupture of all relationships

Sources of Isolation

• Society?• Cohesion, identity, belonging/community• Values and beliefs• Demographics; socio-economic• Stigma • Medicalisation; risk aversion

• Individual?• Alienation, shame, stress, • Physical or mental illness; pain• Life events, trauma, relationship ruptures• Closed rational-irrational logic • Repetition, history of violence

Suicidality and the Human Condition

• Philosophy, Religion, Culture

• Extremes and opposites; self-murder or sacrifice?

• Creativity and destructiveness

• Death the only Certainty

Suffering and Loss are unavoidable parts of life

Completed Suicide

Suicide and attempted suicide as behaviour, action:

• Impulsive, violent, destructive, murder; OR rational, planned, relief and resolution?

• Psychotic, delusional, ”mad”; OR sane, facing the inevitable?

• Death as The Ending, oblivion; OR an immortal soul?

• The “way out”, a relief to others; OR ensuring the pain of isolation and relationship failure is passed on?

Suicidality: “no way out?”

• “Someone in despair despairs over something….In despairing over something he was really despairing over himself, and he wants now to be rid of himself.” (Kierkegaard, 1849)

• "The most beautiful people we have known are thosewho have known defeat, known suffering, known struggle,known loss, and have found their way out of the depths.These persons have an appreciation, a sensitivity,and an understanding of life that fills them withcompassion, gentleness, and a deep loving concern” (Kubler-Ross, 1969)

Suicidality and Psychoanalysis

• “Death is the primary fount of psychopathology.” (Yallom, 1980)

• “No-one kills himself who has never wished the death of another” (Stekel,

1910)

• “Mourning and Melancholia” Freud (1917) ,

• The unconscious; transference; ambivalence;

• Object relations; internalized opposites and conflicts

• Death instinct and anxiety

Suicidality and Attachment Theory

• Secure Attachment and suicide: incompatible?

• From Darwin to individual experience

• Trauma, abuse, BPD, rupture and uncontained emotional regulation

• Consistent with Object Relations; each of us a unique internal world

• The significance of rejection, abandonment

• The complexity of Mourning and unresolved loss; a process to be

worked through

ISOLATIONThe dilemma

(as in the CAT model, Ryle 1990)

Feeling rejected, abandoned, a total failure, isolated, without any relationships:

• Either withdraw reinforce isolation, hide in shame, unreachable, cut off - make no contact

• Or explode/express, overwhelmed with unbearable pain, lose control, overwhelm others, invite/reinforce rejection as ‘attention-seeking’

SUICIDAL CRISIS

• “…triggered by a disturbance in or collapse of an individual’s attachment network” (Holmes, 2016)

• “a psychic trauma in which usual boundaries between internal and external worlds are no longer present” (Ladame, 2018)

• Either Intruded, overwhelmed, swallowed up; Or overwhelming, abandoned, rejected, destroyed.

THE CHALLENGE FOR THERAPISTSCrisis is Opportunity

“The task of the therapist is to somehow find a way to get into the room with the person, to see the person’s world from his or her point of view, to get inside the person so to speak……” (Linehan, 2011)

Transformative Momentsthe stranger on the train

Paraphrasing Schore (2012)

Repair, including of trauma, with change in the brain, arises in moments of deep connection of

unconscious right brain to unconscious right brain of each person .

Necessary Conditions for Therapeutic Alliance

• “Attuning”; connecting; intuitive, intersubjective

• Accepting, collaborative, safe, confidential; mutual vulnerability

• Non-judgemental, non-medical, free of doctrine

• Defined boundaries and ‘contract’

The Gap

The Strengths and Limitations of:

• Samaritans and helplines

• GPs and the medical model

• Psychiatric/mental health services

• Psychoanalysis

• Psychotherapy

• CBT

MAYTREEcontainment and compassion

Maytree is a sanctuary for those in suicidal crisis. ….. accommodates

up to 4 of the suicidal at a time, each for a maximum of four nights,

a once-only stay. ……. A community…

offers respite, non-judgemental support, a non-medical model, a

form of brief-term psychotherapy, delivered by a small professional

team and a cohort of samaritan-style volunteers.

Maytree’s Vision

• Saving lives; surviving the crisis

• Healing; connecting to the pain of isolation breaks isolation

• A ‘good enough’ ending (as opposed to suicide)

The beginning of a new beginning?

Maytreerepairing attachment, separation and loss in 100 hours

• Referral and assessment • Building the therapeutic alliance • The contract; boundaries

• Sanctuary• Respite, time and space; “pressing the pause button”; nurture and nature • Community, acceptance, ethos, values• Volunteers; giving and receiving

• Therapeutic relationship• Multiple therapists, roles, modalities • Individual, group, ‘learning’ • Reformulating; a narrative; identity• Rediscovering hope, play, curiosity, creativity

• Ending and Loss• Separation, ownership/responsibility • The Goodbye Letter• Loss, Mourning

Sanctuary: shared space, community

Sanctuary: outer space, nature

Sanctuary: inner, own space

Success and Failure

Evaluation (Briggs et al, 2007)

• Full validation of model

• Outcomes CORE

• Many (c.25%) experienced stay as transformational

Fallibility and Failure

OUTCOMES:‘CORE’better than 6 months of CBT

0

0.5

1

1.5

2

2.5

3

3.5

4

Well-being Problems Functioning Risk Mean

Dimensions

Mean

Sco

re Pre-test

Post-test

Follow -up

Transformational

‘I felt more understood than at any time in my life’

‘Maytree definitely saved my life’

‘I loved Maytree and I want to come back and be a volunteer’

‘I feel reborn, feel like a different person’

‘I am feeling surprisingly good – Maytree wouldn’t recognise me’

Failuressome personal reflections

• Not knowing

• Not listening

• The story of Max

• Burn out

• No Replication