This the course given in the context of Psychiatry residents weekly courses

1. Family Interventions and Suicidal
Crisis Situations
Suzanne Lamarre MD,
Psychiatric Emergencies and Crises
Service at SMHC
February 17, 2015

2. 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

3. 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

4. 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

5. 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

6. 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

7. Where to intervene and how?
• Medication
• Family conflicts
• Insurers
• Family doctor
• Confidentiality rule and safety
• Refer patient where?

8. 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?

9. 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

10. Caring relations
• Who is responsible for the safety of the
suicidal pt after the assessment?
• What type of relation
– Protectionist / schismogenic
– Collaborative / non schismogenic

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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 1
Reach 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 other
2
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
3
Count on brain plasticity: new
patterns can emerge when one
becomes aware of the contexts that
maintain them
Act impulsively or emotionally 4 Be aware of one’s emotion and deal
with the frustration after reflection

17. 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 6 Put 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 ends
7
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 9
Be aware of energy renewal and
feedback loops; get a perspective on
relations to maintain peaceful and
fulfilling contexts

18. 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 one
10
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 11
A 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)
12
Become 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 13
Exclude 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 14
Recognize one’s mistakes and
discuss how to repair with neither
On the interpersonal level

19. 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
blackmailing
15 Expect honesty and discretion and
defuse all time bombs
Force the other to agree so as to be ‘one
of us’ 16 Love 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 18 Learn to risk trusting others, and expect
others to reciprocate

20. Protected
Guilty
imposing
solutions
blaming
deaf
mute
Protector Saviour
Peace
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

21. 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

22. 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