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

References

• Gregory Bateson: interactions and relations; schismogenic relations and double bind

• John H Weakland: the new communication and self identity

• Paul Watzlawick: axioms of the communication

• Lyman Wynne: Pseudomutuality / As if / The rubber fence