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