Keeping it simple understanding and treating suicidal behaviour
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Keeping it simple: understanding and treating suicidal behaviour. Dr. Angelo De Gioannis MD FRANZCP [email protected] Life Promotion Clinic. Outpatient clinic for the treatment of individuals at risk of suicide Referred from ED, MH teams No geographical boundaries Free of charge.

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Keeping it simple: understanding and treating suicidal behaviour

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Keeping it simple understanding and treating suicidal behaviour

Keeping it simple: understanding and treating suicidal behaviour

Dr. Angelo De Gioannis


[email protected]

Life promotion clinic

Life Promotion Clinic

  • Outpatient clinic for the treatment of individuals at risk of suicide

  • Referred from ED, MH teams

  • No geographical boundaries

  • Free of charge



  • Around 350 clients seen so far

  • 70-80 clients seen each week

  • Clinic open two days/week

  • MDD, PTSD, GAD, OCD, Personality disorders



  • 1 Part-Time Psychiatrists

  • 2 Full-Time Trainee Psychiatrists

  • 4 Part-Time Psychologists

  • 1 Full-Time Mental Health Nurse

  • 1 Part-time Receptionist



  • 73% Female, 27% Male

  • 15-76 years old Mean age=31.9

  • Employed=35.9%

  • Only 17.8% living with spouse/partner

  • 66.6% year 12 or less



  • 63.3% had two or more attempts

  • 72.5% had high wish to die before attempt

  • Beck Suicide Ideation(0-42)= mean score 15.5

  • Active desire to die=72.5%

  • Beck Hopelessness= 76.2% score>8

  • DASS= over 50% in the severe range for anxiety and depression

Current limitations in treating suicidal clients

Current limitations in treating suicidal clients

  • Management of suicidal individuals is “hard work”

  • Medication available only partially effective

  • Psychotherapies require lengthy training and supervision

  • One size does not fit all

The ideal psychotherapy

The ideal psychotherapy

  • Easy to learn

  • Easy to deliver

  • Easy to tailor to suit the clients’ needs

  • Easy for the client to understand and apply

Research so far

Research so far

  • Promising results with clients considered treatment resistant

  • A significant number of clinicians trained with consistent results

  • Randomised Controlled Trial

  • Drop out rate only 20%

Inspired by

Inspired by:

  • Latest developments in neurophysiology

  • Occupational psychology

  • Energetics

  • “How do we function?”



  • Concept introduced by Edwin Schneidman

  • Refers to feelings of hurt, anguish, psychological pain

  • Can be current or anticipated

Human performance kanheman 1973

Human Performance (Kanheman, 1973)

  • Evaluation of demands and allocation of resources

  • Depending on our assessment we “activate”

  • Limited resources to perform, control and monitor

  • We all create our own benchmarks

That means

That means….

  • Whenever we engage in a task we make an estimate of the effort required to complete it

  • We also make an estimate of the level of activation (“psyching up”) that delivers the effort we think is required

  • The more we allocate to some tasks, the less we have for others

As we continue to perform

As we continue to perform…..

  • Reduced spare capacity (fatigue)

  • Fatigue leads to increase in activation required to keep performing to the detriment of efficiency

  • The longer we perform for and the more tasks we perform in the higher level of activation we will need

  • The level of arousal is an expression of how much we are operating beyond capacity



  • Sympathetic

  • Motor inhibition (directional fractionation)

  • Causes restriction of cues used to guide action

  • At an appropriate level it helps reject irrelevant cues

Excessive arousal

Excessive arousal

  • Makes us reject relevant ones

  • Impairs ability to discriminate relevance

  • Narrows attentional beam

  • impairs short-term memory

Further complications

Further complications….

  • Sustained performance beyond capacity leads to failure in the ability to control activation (inability to reduce or withdraw effort)

  • It also leads to failure in the ability to monitor performance (loss of awareness/insight)

Sleep deprivation as model pilcher 1996

Sleep deprivation as model(Pilcher, 1996)

  • Only effort required is to stay awake and to complete lab tests

  • Mood changes occur first, cognitive performance follows, motor performance always fails last

  • Mood changes can progress to the point of significant mental illness (72 hours)

  • Return to functional levels only after sufficient sleep

Physical effort

Physical Effort

  • Easier to formulate realistic estimate of demand and allocation

  • Tissue damage hard to ignore

  • Benchmarks are visible

  • Body can be easily stopped if we get it wrong

Mental effort

Mental Effort

  • Much harder to formulate realistic estimate of demand and allocation

  • No tissue damage

  • Benchmarks are invisible

  • The mind is very hard to stop if we go too far

To maintain a functional state ideal world

To maintain a functional state (ideal world)

  • Only activate enough to produce performance in an efficient way

  • Avoid irrelevant/redundant physical or mental activity

  • Maintain appropriate level of arousal

  • Withdraw/reduce effort before we lose control of it

  • Only start putting effort again when a fully functional state is restored

What our clients say

What our clients say….

  • ?????????

  • Effort creates energy (agitation)

  • The amount of effort I put depends on the importance of the problem

  • If there is no discomfort it means I haven’t put enough effort

  • Half of the clients need at least suicide ideation to feel comfortable with “stopping”



  • No concept of excessive effort/activation

  • Any withdrawal/reduction of effort invested is perceived as inappropriate

  • Unrealistic levels of activation are considered necessary

  • Disregard of mental health symptoms is considered a sign of strength (“push through”)



  • Clients have variable understanding of what constitutes treatment

  • Clients have variable understanding of what an acceptable and functional state is supposed to be like

  • Clients cannot complain about symptoms that are “normal” for them or what they believe is not necessary to endure

  • Change can be unsettling even if for the better



  • “How do you know you care if you do not get palpitations?”

  • “I’m not a sitting still person. I don’t want people to think I’m lazy”

  • “How can you still be sick if you are not thinking about suicide?”

  • “…but if I am angry is because I am passionate about the issue”

Effort and emotional disturbance

Effort and emotional disturbance

  • Emotional disturbance develops whenever there is a gap between the level of activation (mental, emotional, physical) individuals believe necessary and the resources available

  • The kind and severity of the emotional disturbance are expression of the kind of activation and the extent of the gap

  • “overthinking” and “being too wound up”

  • The impulsive and/or dysfunctional behaviours we observe often have the role of helping individuals reduce activation

Emotion modulation therapy

Emotion Modulation Therapy

  • Individual and group sessions

  • Wide range of disorders treated so far

  • Strong emphasis on phenomenology

  • Focus on adjustment to change

Emt components

EMT components

  • Behavioural analysis

  • Motivational interviewing

  • Psycho-education

  • Supportive psychotherapy (if change has occured)

Questions we ask ourselves during treatment

Questions we ask ourselves during treatment

  • What is this person doing (mental activity/arousal) that I would consider unnecessary?

  • How many of the symptoms that I would not put up with do they endure or regard as necessary?

  • Why do they feel they have to perform that way? What is at stake?

Questions we ask clients during treatment

Questions we ask clients during treatment

  • Is it possible to be “too alert”?

  • Is it possible to think “too much”?

  • If yes, which are the experiences should we rely on to guide us?

  • How do you know if you are well enough to perform?



  • Would you ever talk to others the way you talk to yourself?

  • Would you ever put up with somebody talking to you the way you talk to yourself?

  • Would you trust talking to yourself as appropriate?



  • Emotional state patients present with consistent with what they endure

  • End of treatment when self-talk in line with the way they talk

  • Patients do not trust or think they don’t deserve treating themselves the way they treat others

Treatment stage 1

Treatment Stage 1

  • Demonstrate that the impulsive behaviour is what is required to address certain “states”

  • Demonstrate that the increased activation has a detrimental impact on performance and that the behaviour prevents an even worse scenario

  • Demonstrate that the only way to avoid the impulsive behaviour is to prevent the “states” that trigger it

Treatment stage 2

Treatment Stage 2

  • Facilitate awareness into the way the client reaches an excessive level of activation (intensity of mental activity and level of arousal)

  • Explore the motivation/s behind it

  • Discuss the pros and cons of sustaining a certain level of mental activity and/or arousal

Treatment stage 3

Treatment Stage 3

  • Help clients make the link between level of activation and the mental/physical/emotional “states” they experience

  • Facilitate awareness into the progression of states over time (chain reaction)

  • Encourage clients to reduce the intensity of activation they consider necessary

What do i do

“What do I do?”

  • The only strategy discussed in treatment is: disengaging, letting go, pulling the pin, dropping the bundle, “stuff it”, etc.

  • It always relates to the individual making a conscious decision to put the “state” before the “activity”

  • “Toilet” example

Barriers to treatment

Barriers to treatment

  • Clients try to apply learned strategies or new insight without changing the way they invest effort

  • Often clients have only partial insight into their illness

  • The treatment stops when the clients think they are well enough

  • Identification with illness

Thank you

Thank you

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