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 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

Dr. Angelo De Gioannis


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

  • 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

  • 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

  • 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:

  • 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)

  • 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….

  • 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…..

  • 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

  • Makes us reject relevant ones

  • Impairs ability to discriminate relevance

  • Narrows attentional beam

  • impairs short-term memory

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)

  • 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

  • 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

  • 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)

  • 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….

  • ?????????

  • 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

  • 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

  • Individual and group sessions

  • Wide range of disorders treated so far

  • Strong emphasis on phenomenology

  • Focus on adjustment to change

EMT components

  • Behavioural analysis

  • Motivational interviewing

  • Psycho-education

  • Supportive psychotherapy (if change has occured)

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

  • 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

  • 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

  • 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

  • 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?”

  • 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

  • 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

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