The Sacrifice, The Labyrinth and the Minotaur

The Sacrifice, The Labyrinth and the Minotaur

Silvia Baba Nealsilviababaneal-psychotherapy.co.uk/mindspace

Facts provided by the American Association of Suicidology

Many beginning clinicians are unaware that suicide is an occupational hazardApproximately 1 in 5 psychotherapists (and as many as 1 in 2 psychiatrists and psychiatric trainees), lose a patient to suicide during the course of their career (McAdams and Foster, 2000, McIntosh, 2003, Ruskin et al., 2004)Novice clinicians have been found to experience higher rates of suicide among their clients than more seasoned clinicians. Experiencing the loss of a client by suicide can be psychologically traumatic for the provider, and may even become a career-ending event.Unfortunately, few training institutions or graduate programs prepare students for this possible traumatic loss (Reeves, 2010)

Ariadne

The clinician as survivourSignificant emotional impact (Kleepsies, and Dettmer,

2000) Therapists have described client suicide as “the most profoundly disturbing event of their professional careers” (Hendin, et al. 2000) Fear of being blamed by supervisors, managers or trainers, and the client’s family (Farberow, 2005) May cause the therapist to seriously doubt their skills and competence therapist to consider abandoning a career in psychotherapy (Farberow, 2005) Therapist begins to use rules rigidly and defensively to prevent another suicide

Therapists in training • Some authors have suggested that therapists in training may experience

reactions even stronger than do their qualified colleagues

(Brown, 1987; Kleespies et al., 1990, 1993)• Trainees may be less able to separate

“personal failure from the limitations of the therapeutic process”

(Foster & McAdams, 1999, p. 24)

Five stages of grief model (On Death and Dying, Kübler-Ross, 1969)

“The stages were never meant to help tuck messy emotions into neat packages. They are responses to loss that many people have, but there is not a typical response to loss as there is no typical loss. Our grief is

as individual as our lives.” (Kübler-Ross and Kessler, 2006)

www.suicidology.org/suicide-clinician-survivors

Clinician 1

“Through shock little vibrations trickle through my body, a sinking feeling comes into my heart, then my stomach. I can not move. My mouth goes dry. Thoughts start tumbling through the air-landing on my body -- how, when, what does this mean, what will happen, will I be blamed, what is going on, how will I get through the day, don't scream must act professional, get concrete, O.K. I have a client waiting, stop the tears, act AS IF.”

http://mypage.iu.edu/~jmcintos/therapists_mainpg.htm

Clinician 2

“His death made absolutely no sense to me. After all, I had carefully assessed his suicidality during our last session and there was nothing there to alarm me. Yet, he was dead, and with his death, a part of me died as well. After the total shock and disbelief began to diminish, I started to sob, sobbing uncontrollably at times. I experienced extreme anxiety, gross sleep disturbances, and profound sadness. I was spiraling downward quickly, and I was emotionally paralyzed.“

Clinician 3“Day 46: The feeling of loss has been very strong lately. I lost Mary. I lost being a member of the elite who has never lost a client to suicide. Already, I lost many hours of my time -- planning, fretting, and talking. I lost sleep. I lost confidence. I may have lost part of my joy in being a therapist.”7 months later: I still think of Mary. The waves of loss are farther between and much less overwhelming but the undercurrent is still there. Her suicide has touched me on many levels. During these past months, one professional implied that clinicians are not affected by a client's suicide and brushed me aside. I felt very invalidated and angry. Another colleague insisted that anti-suicide contracts really work. I felt defensive. I had taken this step and others, but it was not enough to save Mary's life.”

Clinician 4

“I must say at the start that this is a very difficult case to discuss. In 25 years I have not publicly talked about it. This is a case where it is important to tell you all about my credentials as an analyst, as a senior university faculty member, etc. Notice that I included the word "Senior ." Can you believe that? After 25 years I still need to armor myself?”

Trauma Trauma is “a sudden and violent emotion capable of provoking a permanent alteration of psychic activity” (Devoto and Oli, 1990 p. 2002 in Mazzetti, 2008, p.285)

Prolonged stress following unprocessed trauma significantly impacts the neurological structures in the limbic system related to implicit memory and emotional life (thalamus, amygdala, hippocampus, and prefrontal cortex) (McEwen et al., 2009)

the learning involved in trauma is resilient or “fixated” (Cozolino, 2010)

Traumatic ego-states (Berne, 1961/2005)

Berne (1961)– a traumatic stimulus modifies an ego state in an abrupt way. A traumatic ego-state is like “a warped coin, which would skew the pile” (1961/2005, p. 52)

Penfield’s experiments (Penfield and Perot, 1963 in Milner, 1977)

• Summary maps indicating all points

from which electric stimulation of theexposed cortex has elicited complex auditory experiences in patients undergoinga surgical operation for epilepsy

Trauma, stress response and the brain

Psycho-social stress and the brain, (McEwen et al., 2009)

Amygdala and hippocampus neurons exposed to chronic stress (Davidson

and McEwen, 2012)

One dendrite synapses (www.harvard.edu)

Memory systems (Allen, 2011)

Impasses: developmentalperspective (Mellor, 1980)

P2

A2

A1

P1

A0

P0

C0

Type 1

Type 2

Type 3C2

Type 3 impasseWhen Mellor described his model of impasse, he suggested that third degree impasses can also develop later, whenever someone is:

“(…) so traumatized or otherwise overloaded at the time they develop impasses that their current levels of functioning give way to earlier levels. This type of response results in the development of higher levels of impasse at ages when their development would no longer be possible if a strict developmental ordering would apply.” (Mellor, 1980, p. 218)

Factors that may contribute to development of Type 3 impasse

Your own Script System: core beliefs about yourself, others and the world (Erskine, 2010) and personality styleYour Parent Ego state (P2): Rigid views about suicide influenced by religion, philosophy, public policy. Antidote: Tim Bond, 2000, Anddrew Reeves 2010

The context: “prevention-prediction culture” associated with the medical model views every completed suicide “a failure at instiutional or individual level” Antidote: Reeves, 2010 and Szatz, 2011, Mental Capacity Act, 2005, Suicide Act, 1961

Prescriptive, unchallenged, TA practices formally and informally handed down to the therapist i. e. “no-suicide” contracts Antidote: Erskine, 2009, Little, 2009, Hargaden and Stuart, 2000/2001 debate

Psychological modifiers of stress-response (Sapolsky, 2004)

Outlets for frustrationA sense of predictability and controlSocial support A perception of life improving

Self- Care• Activate support systems.

• Let it out: express feelings of anger, rage, despair, grief in a safe and appropriate context

(therapy, supervision, peer supervision). • Take control: manage workload, be proactive in

seeking information and support, deal with the tasks of writing reports, informing the relevant

people etc. • Silver lining: How can you use this experience

to teach and support others? How can you improve your practice and the general pool of

knowledge?

Ethical considerations around:

Collaborating with police investigation Case review- psychological autopsy (Marshall, 1980) Coroner’s reportNotifying insurance company Letting the relevant people know (course director, placement facilitator)Calls of condolence (There is a GP/psychiatrist/social worker out there going through the same experience!)Receiving calls from family members or friends of the deceasedAttending the Coroner’s InquestPossibly attending the funeral, depending on circumstance

(Bond and Mitchels, 2008) Bond, 2010, Gabriel and Casemore, 2009)

Supervisers’ helpful/unhelpful responses

The response of the immediate supervisor to the (supervisee’s) client’s suicide is a critical factor in influencing how the event personally or professionally affects trainee development (Foster & McAdams, 1999)Talking with a colleague who knew the patient or who had had a similar experience with a patient was beneficial in reducing isolation and providing support (Hendin et al., 2000)Providing emotional support and an intellectual context for understanding and growing from the experience of a client suicide (Brown, 1987)Supervisors helpful if they assured trainees that the way in which the trainee reacted to the suicide was clinically appropriate and if the supervisor shared responsibility for the outcome of the case (Kleespies et al. 1990, 1993) Unhelpful those supervisors who prematurely requested that trainees talk about their cases or immediately barraged them with stories of their own patients who suicided when the trainees were not ready (Kolodny et al., 1979) Need sufficient time to prepare themselves for the painful but necessary task of a “psychological autopsy” (Marshall, 1980)

Recommendations for supervision (Knox et al., 2006)

Allow supervisees to control when, where, how, and with whom they process the suicideAllow supervisees to access extra supervision, consultation, therapy Continue to provide a supportive time and place for supervisees to work through the client suicide even after the immediate responses seem to have abatedAcknowledge/normalize that the effects of a client suicide, both short term (e.g., more thorough assessment for suicide) and long term (e.g., awareness of therapeutic responsibilities of suicidal clients, lingering feelings), may be painfully learned growth

Bibliography• American Association of Suicidology [founded in 1997 to support

clinician survivours] • Clinician survivours testomonies: http://mypage.iu.edu/~jmcintos/

therapists_mainpg.htm• Comprehensive bibliography on suicide impact:

http://mypage.iu.edu/~jmcintos/Surv.Ther.bib.htm• Berne, E. (1961/2005) Transactional Analysis in Psychotherapy,

London: Souvenir Press• Bond, T. (2010) Standards and Ethics for Counselling in Action (third

edition), London: Sage (Kindle edition)• Bond, T. and Mitchels, B. (2008) Confidentiality and Record Keeping in

Counselling and Psychotherapy, London: Sage• Brown, H. N. (1987) The impact of suicide on therapists in training, in

Comprehensive Psychiatry, 28(2): 101-112• Davidson, R. J. and McEwen, B. (2012) Social influences on

neuroplasticity: stress and interventions to promote wellbeing, in Nature Neuroscience, 15: 689-695, Available online: http://www.nature.com/neuro/journal/v15/n5/full/nn.3093.html (Accessed 13 Nov. 2013)

• Erskine, R. (2009) The culture of transactional analysis: theory, methods and evolving patterns, in TAJ, Vol. 39, no. 1

• Erskine, R. (2010) The Script system in Life Scripts [Richard Erskine, ed]

• Farberow, N. L. (2005, February). The mental health professional as suicide survivor. Clinical Neuropsychiatry: Journal of Treatment Evaluation, 2(1), pp. 13-20

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