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Working with Self-injury, Suicide & Risk


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Working with Self-injury, Suicide & Risk

  1. 1. Working with Self-Injury, Suicide & Risk July 2015 Tutor: Patrick Doyle, Training Innovations Copyright Training Innovations 2014
  2. 2. Introductions & House-keeping Copyright Training Innovations 2014
  3. 3. Aims 1. To equip candidates with a greater awareness and understanding of the complexity of/ and challenges faced when working with Suicide and Self Injury. 2. To enhance the skills of candidates when caring for patients who engage in self injurious behaviour and attempt suicide, including risk assessment and management Copyright Training Innovations 2014
  4. 4. Objectives On completion of this workshop candidates should be able to: 1. Describe the unique challenges faced when caring for people who self injure & engage in suicidal behaviour 2. Empathise and understand the nature of the historical events (social determinants) that may have shaped the lives of patients who engage in self-injurious and/ or suicidal behaviour; 3. Further develop knowledge and skills in order to treat people who engage in self injurious and suicidal behaviour using a range of evidence- based interventions, including the assessment and management of risk Copyright Training Innovations 2014
  5. 5. Exercises The Experience Continuum 5 Things: Colour; Time of Day; Season; Place; Object and Why? Copyright Training Innovations 2014
  6. 6. Definitions: World Health Organisation • Self-harm: ‘non-accidental behaviour which causes physical or emotional harm to the self, in the short and long-term, without suicidal intent: including: ’smoking, worrying, taking a lot of risks, not getting enough sleep etc’. • Self-injury: non-accidental behaviour which causes immediate, tangible, physical injuries to the body, without suicidal intent. – for example, ‘cutting, burning, scalding, or scratching one’s own body in order to cause injury’, that may escalate • Suicide: Escalation of the above? • Parasuicide: ‘near’ or ‘resembling’ suicide that is not fatal Copyright Training Innovations 2014
  7. 7. Responses to Self-injury & Suicide? • Shock, horror and disgust • Incomprehension • Fear and anxiety • Distress and sadness • Anger and frustration • Powerlessness and inadequacy • What do you notice about your own responses and the feeling of your patients? • Often these feeling though a natural response may prevent further understanding • Often we have to manage our own emotional responses as well as trying manage the patient’s* Copyright Training Innovations 2014
  8. 8. Why? • This is an important question to ask! • Understanding the function of a behavior, especially one driven by extreme emotions is key to helping patients who exhibit self injurious behaviour and suicidal intent. • Exercise: Emotion Quiz • So what caused these extreme emotions? Copyright Training Innovations 2014
  9. 9. Childhood Experiences taken from Arnold (1995) “Women and Self-Injury” Bristol Crisis Service for Women SEXUAL ABUSE 49% NEGLECT 49% EMOTIONAL ABUSE 43% LACK OF COMMUNICATION 27% PHYSICAL ABUSE 25% LOSS/SEPARATION 25% PARENT ILL/ALCOHOLIC 17% OTHER e.g. bullying, racism + sexuality issues 19% Copyright Training Innovations 2014
  10. 10. Adult Experiences RAPE/SEXUAL ABUSE 22% ABUSIVE PARTNER 14% LACK OF SUPPORT/COMMUNICATION 14% LOSS OF/UNABLE TO HAVE A CHILD 10% OTHER e.g. break up of a relationship, admission to secure setting – prison or psychiatric hospital. 17% Copyright Training Innovations 2014
  11. 11. Feelings preceding self-injury Overwhelming emotional pain 57% Self-hatred, guilt, shame, ‘dirtiness’, ‘badness’ 51% Anger, frustration or sense of powerlessness 50% Anxiety, panic, fear or tension 34% Feeling needy, unsupported or unheard by others 30% Feelings of unreality, numbness or ‘deadness’ 9% Copyright Training Innovations 2014
  12. 12. Functions served by self-injury RELIEF OF FEELINGS 57% SELF-PUNISHMENT 37% CONTROL 33% COMMUNICATION 15% COMFORT 13% TO FEEL REAL OR ALIVE 6% Copyright Training Innovations 2014
  13. 13. Samaritans Suicide Statistics Report Highlights • Last year’s report shows: • Male suicide rates are on average 3-5 times higher than female rates and men aged 30-44 are the group with the highest rate. • In the ROI men are also the group with the highest suicide rate, it is approximately 5 times that of females, and highest for men aged 45-49. Copyright Training Innovations 2014
  14. 14. Samaritans Report • Compared to previous years: • The suicide rate for males in the UK is its highest since 2002. • The female rate has also significantly increased since 2007. • Overall, between 2010 and 2011 there was a significant increase in the UK suicide rate.
  15. 15. Risk Factors • Certain factors are known to be associated with increased risk of suicide: • drug and alcohol misuse • unemployment • social isolation • poverty • poor social conditions • imprisonment • violence • family breakdown. • People with a diagnosed mental health condition are at particular risk. Around 90% of suicide victims suffer from a psychiatric disorder at the time of their death.
  16. 16. Risk Factors • Those at the highest risk of suicide are people suffering from alcoholism, clinical depression or schizophrenia. Previous suicide attempts are also an indication of particular risk. • Up to 20% of survivors try again within a year, and as a group they are 100 times more likely to go on to complete suicide than those who have never attempted suicide.
  17. 17. Youth Suicide • Rates of attempted or completed suicide are high within western societies • Suicide contagion? Internet? Social Media? Bullying? • Depression, bereavement and uncertainty about sexual identity are major causes. Bullying, family turmoil, mental health problems, unemployment and a family history of suicide can also play a part in increasing the risk of suicide. • Amongst the young, 80% of suicides are male, and one in three young people who take their lives are intoxicated at the time of death. • Young people who feel connected, supported and understood are less likely to commit suicide Copyright Training Innovations 2014
  18. 18. Your Patients’ Characteristics • History of trauma, abuse or adversity • Separation, poor or disorganised attachment • Societal expectations of gender roles • Forensic background more prevalent in males • Lack of adaptive coping • Reliance in maladaptive coping
  19. 19. Other Characteristics • History of trauma, adversity, abuse, social/ economic disadvantage. • Dysfunctional coping strategies – a history of self injury and/ or substance abuse. • Frequent suicide attempts. • Fire-setting, convictions for drug related crimes, burglary, robbery, and criminal damage?*. • Diagnosis of Personality Disorder/Schizophrenia/PTSD • Significant physical health needs • In short one of the most difficult and challenging patient groups to look after. Copyright Training Innovations 2014
  20. 20. Invalidation • Linehan (1993) describes two types: • Overt Invalidation: where it is apparent there is physical, sexual and emotional abuse occurring within a family environment. • Covert Invalidation: where there is subtle invalidation within a seemingly perfect family, where children are taught not to express their emotion through conditioning often by threat: • “Stop crying or I’ll give you something to cry about!” Copyright Training Innovations 2014
  21. 21. Trauma • A large number of the men/ women you’re working with may have experienced significant abuse in the past and may experience flashbacks, intrusive thoughts and dreams; exhibit avoidant behaviours, irritability, sleep disturbance; and use maladaptive coping strategies such as drug misuse, criminogenic behaviour. • How else do you think these experiences would effect someone? And how as a member of staff would you approach this? Copyright Training Innovations 2014
  22. 22. Case Study 1 • How would you assess: what would you need to look at? • How would you help: what interventions would you use?
  23. 23. What have we covered so far?
  24. 24. Strategy • Trust • Rapport and respect • Understand • Search for the meaning • Teleology
  25. 25. Nursing in Secure Environments (UKCC, 1999) • ‘Incident-based Practice’: Reactive and not Proactive • ‘Opinion-based Practice’: “I’m right; you’re wrong…” • ‘Experience-based Practice’: “…I’ve been nursing twenty-five years and never had to use a psychometric assessment tool…” • ‘Inquiry-based’: Fallon, etc, etc.. • Discussion/ Opinion* v. Empirical Evidence… • Services are typically under resourced and rarely specifically tailored to meet needs Copyright Training Innovations 2014
  26. 26. Power Struggles • Staff don’t work in a vacuum and feeling the need to control patients can be exacerbated by working in settings that are risk averse*. • Power struggles, and issues of blame often start when a service identifies women as engaging in ‘socially unacceptable behaviour’.* However when these are the ways she copes and communicates her distress, the attempts of staff to stop her from using such strategies, commonly result in power struggles which do not contribute to recovery.* (Hayward et al, 2005) Copyright Training Innovations 2014
  27. 27. Copyright Training Innovations 2014 Carol’s Story • Please read Carol’s story and in two groups answer the following: 1. What could the staff have done differently? 2. What could Carol have done differently? 3. What would you do differently?* 4. If Carol came to you tomorrow, what would you say/ do?
  28. 28. How should I respond? DON’T: panic- self-injury doesn’t mean that someone is crazy, or that they will kill themselves or harm other people. DO: stay calm. You may be feeling shocked and angry – these feelings should be taken to supervision/debriefing/staff counselling. Copyright Training Innovations 2014
  29. 29. DON’T: be afraid of asking or talking about self-injury. It won’t make the person more likely to harm themselves. DO: offer understanding: make it clear that self-injury is something that can be understood, there are reasons for it and other people do it too. Copyright Training Innovations 2014
  30. 30. DON’T: dismiss the distress behind the self-injury/ suicidal intent, for instance, by explaining actions as ‘only superficial’ or ‘just attention-seeking’ DO: show concern for the distress behind any injuries, as well as for the injuries themselves Copyright Training Innovations 2014
  31. 31. DON’T: judge the person who is self- injuring, e.g. calling them ‘selfish’ or ‘manipulative’. They are coping with extreme distress in the best way they can. DO: show respect for the fact that they have managed to cope with extreme distress. Copyright Training Innovations 2014
  32. 32. DON’T: force the person who is self- injuring to accept help (as far as possible). DO: make it clear that support is available, when and how the person wants to access it. Copyright Training Innovations 2014
  33. 33. DON’T: punish the person for self-injury – for example, by being hostile to them or withdrawing support. DO: offer acceptance: tell the person who has self-injured that it is ok to talk, it is something that you know about and can handle. Copyright Training Innovations 2014
  34. 34. DON’T: force someone to give up self- injured before they are ready DO: accept that they may not want or be able to stop. Work to reduce the risk inherent in their self-injury. Copyright Training Innovations 2014
  35. 35. DON’T: overlook your limits DO: provide information about appropriate resources and sources of further help, advice and support. Copyright Training Innovations 2014
  36. 36. DON’T: think you know better than the person who self-injuring. They are the experts in their own life. DO: work collaboratively with the person who self-injures – listen to what they have to say, communicate clearly with them, arrive at decisions together. Copyright Training Innovations 2014
  37. 37. DON’T: approach any person or any issue as ‘hopeless’ or ‘untreatable’. DO: remind yourself and the person you are supporting that lots of people who self-injure or try to kill themselves will eventually feel happier Copyright Training Innovations 2014
  38. 38. DON’T: overlook your own needs. DO: take responsibility for looking after yourself- including seeking proper support and supervision from your work place. Copyright Training Innovations 2014
  39. 39. ….and remember – your response has great potential to make a positive difference. Copyright Training Innovations 2014
  40. 40. Listening • Promote empowerment, choice and self determination. • Place importance on the underlying causes and context of their distress in addition to their symptoms. • Address important issues relating to their familial roles, the need for safe accommodation and access to education, training and work opportunities. • Value their strengths, abilities and potential for recovery. Copyright Training Innovations 2014
  41. 41. Empowerment? “Empowerment is a social process of recognition, promoting and enhancing people’s ability to meet their own needs, solve their own problems and mobilise the necessary resources in order to feel in control of their own lives” Dooher & Byrt (2002) Participation is the key to empowerment for all women receiving care in psychiatric settings - thus the emphasis on relational security. Copyright Training Innovations 2014
  42. 42. Relational Security • What is relational security? • ‘the balance between intrusiveness and openness; trust between patients and professionals’ • ‘the staff-to-patient ratio and amount of time spent in face-to-face contact’ • “Relational security is the knowledge and understanding staff have of a patient and of the environment; and the translation of that information into appropriate responses and care”. Copyright Training Innovations 2014
  43. 43. Creative Engagement • Plan A-Z • ‘Person-First’ Approach • Promote recovery, foster hope • Practice ‘Therapeutic Optimism’ (with caution!) • Sense of humour and enthusiasm (the ‘Patch Adams’ approach) • Be creative, research and try new approaches • Challenge existing practice with solutions; not with criticism, blame or fault-finding • Utilise all your skills and hidden talents (tightrope- walking, juggling, calligraphy, magic tricks*, etc.) • Promote the same in others! Copyright Training Innovations 2014
  44. 44. Risk Assessment and Management • In order to assess and manage risk, we need to understand how our psychology affects our view of reality • How do we really interact with the reality of the world? • How might this impact on clinical practice? • There is no spoon!
  45. 45. Perception Conception! The reality of human conception is that without analysis it is an unreliable and inaccurate representation of the nature of reality, plagued by cognitive bias and assumption failure….
  46. 46. Cognitive Bias • A cognitive bias is a pattern of deviation in judgment, whereby inferences about other people and situations may be drawn in an illogical fashion. • We create our own "subjective social reality" from conception of an input.
  47. 47. Drift • All human endeavour suffers: • Information & • Task drift • Prediction: 18 + or – 5%
  48. 48. Memory Test (Lockard, 1971) • Verbal verses visual strategies • Differences in narrative culture • Highlights phenomenon of task and information drift
  49. 49. Risk? • What is Risk? • The probability of an event/ behaviour occurring • Static and Dynamic Risk Factors • Protective Factors may decrease risk • Risk assessment/management is a relational and procedural, fluid process
  50. 50. Risk Models & Concepts • Unstructured Clinical Judgement: based merely upon knowledge and experience based practice • Actuarial: based upon empirically found risk factors; standardized, mostly static factors, designed to predict • Structured Professional Judgement: integration of the above: using consensus model Copyright Training Innovations 2014
  51. 51. Maladaptive Coping • Passive - Unassertive – Assertive – Aggressive • Maladaptive coping responses are often the result of a lack of appropriate and adaptive coping skills and my progress toward criminal behaviour • Often our responses and interventions, including risk management occur along a continuum: • Reactive - Proactive - Ignoring Copyright Training Innovations 2014
  52. 52. General (+ Essential) Therapeutic Strategies 1. Build + Maintain a Collaborative Relationship 2. Maintaining a Consistant Therapeutic Process 3. Validation Strategies 4. Build + Maintain Motivation (Livesley APA 2009) Copyright Training Innovations 2014
  53. 53. Collaborative Relationship • Essential + crucial for change • May require considerable efforts 1. “How patients see the treatment and staff – we need to build our credibility” - Radical Optimism, support, respect, understanding, hope - Reflective understanding - Joint settings of goals - Highlight change/progress however small 2. Collaborative working - Identify when patient utilises skills learnt in therapy - “we” + “together” – strengthen bond - Identify shared experiences + understanding - Monitor the alliance (+ ruptures!!) - Acknowledge mistakes Copyright Training Innovations 2014
  54. 54. 2. A Consistent Treatment Process • All staff should interact with patient in ways congruent with the process • Awareness of the nature, presentation and pathology of mental illness for staff • Staff communication • Reflective practice • Supervision • Transferences + Counter-transferences – Accept, discuss + manage • Case discussions • Awareness of staff of personal stress, personality, history and “job satisfaction” on every patient interaction Copyright Training Innovations 2014
  55. 55. 3. Validation • Active strategy using interventions that recognise the legitimacy of the patient’s experiences • These interventions strengthen alliances and contribute to change • Attitude – attentive, non-judgemental • Allow opportunity for patient to express • Listen and observe • Reflect • “Direct Validation” / Search for meaning Copyright Training Innovations 2014
  56. 56. 4. Build + Maintain Motivation • Seek Advice • Remove barriers • Choice + Options • Decrease “desirability” of maladaptive behaviours • Practice empathy • Feedback • Clarifying goals • Active helping • NB Confrontation may increase resistance Copyright Training Innovations 2014
  57. 57. It all boils down to this….
  58. 58. Change? • What will you do differently? • Will you change anything in your practice? • Care plans/assessments? • Will you ask your manager’s to change anything? • What intervention’s will you use? Copyright Training Innovations 2014
  59. 59. Summary! • Working with patients who engage in self-injury and suicide is often highly challenging. Be mindful of both the Risk and the Person. • At the very least listen to and be with! • The more you look the more you find! • Everyday you will be dealing with someone’s daughter, son, mother, father, sister, brother, grandmother, grandfather - so tread carefully and treat them exactly for what they are: PEOPLE, with similar hopes, fears, and aspirations to you! Copyright Training Innovations 2014
  60. 60. Your Learning doesn’t stop here… • You should have an idea how to find out more about Suicide, Self-Injury and Risk… • We will be back soon to help evaluate and develop your action plan, care-plans, and risk assessment further
  61. 61. • Any questions? • Please take some time to complete the course evaluation - Thank you… • • • Twitter: @Traininnovate • Facebook: Innovations-Ltd
  62. 62. Thankyou!
  63. 63. Further Reading: NHS Suicide Prevention Preventing Suicide in England: 119/Annual_Report_FINAL_revised.pdf