A Conversation About… Emergency Psychiatry – Part 2

Disclaimer: The following transcript has been autogenerated and may contain occasional errors or inaccuracies resulting from the automated transcription process.

Host (00:01):

Hi there. Welcome to Mental Health Professionals Network podcast series MHPN’s aim is to promote and celebrate interdisciplinary collaborative mental health care.

Professor Mark Creamer (00:18):

Hello, and welcome to this episode of MHPN Presents A Conversation About, my name’s Mark, Mark Creamer. I’m a clinical psychologist and a professorial fellow in the Department of Psychiatry at the University of Melbourne. My particular specialty is the mental health effects of trauma, but I’m also very interested in emergency mental health. I worked in public sector psychiatry for many years, so it gives me great pleasure to be hosting this three-episode series in which we are exploring some aspects of emergency mental health. In our first episode, I was joined by Dr. Song Chan and we chatted about how best to deescalate a mental health crisis. Today I am delighted to be joined by Dr. Tad Tietze. Tad is a psychiatrist based in New South Wales. He’s currently in the Illawarra region. He’s got a long interest and buckets of experience in emergency mental health and in suicidality in particular. Hi Tad, thank you very much for joining me today.

Dr. Tad Tietze (01:19):

Hi, Mark. It’s a pleasure.

Professor Mark Creamer (01:21):

We’re gonna spend the whole time talking about emergency mental health, but you know, I do think it’s really important that we have things outside of work to keep us happy and to de-stress. So before we get into it, perhaps you could just say a little bit about what you enjoy doing when you’re not on the front line of psychiatry.

Dr. Tad Tietze (01:36):

In those precious moments that I get, I’m a bit of a cinema obsessive. I’m known to be watching obscure arthouse movies at all times of day or night. And I have been known to DJ similarly obscure disco and house music,

Professor Mark Creamer (01:51):

Disco and house. Well, I’m a big fan of music, but not that particular genre, I’m afraid. <laugh>, today we’re gonna be talking about suicidality. We’re, we’re going to be getting some tips and strategies from you Tad, on how to manage someone who is suicidal. But for many clinicians, and I certainly include myself in this, it is a difficult area. It’s not something about which we feel particularly comfortable. So, I’m kind of fascinated to know a bit about your experience and I guess in particular, what is it that’s so interested you and, and fascinated you in such a complex area?

Dr. Tad Tietze (02:24):

I think it’s probably the result of seeing it as a challenge that is both part of everybody’s psychiatry training in Australia and New Zealand. There is no way you can avoid meeting patients who are suicidal. It’s a central part of the work, and it’s particularly a central part of the work in emergency departments. But, initially, I found it a huge struggle to deal with this group of patients. There’s a lot of stress and worry about the risk associated with these presentations. But then I was fortunate enough to go and work in consultation, liaison, psychiatry at St. Vincent’s Hospital as a registrar. And because they had to deal with such a huge number of these kinds of very acute presentations in their emergency department, I actually was able to learn a great skillset about how to deal with these emergencies and no longer felt in over my head.

(03:15):

And I thought it was worth pursuing that and then started to really understand the complexity of the, the presentation with suicidality, because it’s not just one thing. It’s not just one illness that we give one treatment for. It’s a very, very complex presentation, but it’s, I think, one of the most rewarding challenges in psychiatry because if you actually help these people through these crises, what is a potentially lethal situation becomes much less so, or sometimes entirely not so, and that’s a lot of reward in a very short period of time often.

Professor Mark Creamer (03:46):

Absolutely. Absolutely. I understand that entirely. Although you raised an issue there that I wanna come back to towards the end, which is that you had the opportunity there to get lots of experience of working with this population. And I guess, you know, you were talking there about ED or emergency departments but we are not only talking about that, of course, as mental health clinicians, we can encounter this kind of thing in a range of settings in community mental health, in CL psychiatry and in our consulting rooms. And I guess that’s, that’s perhaps the point that we don’t get necessarily a lot of experience.

Dr. Tad Tietze (04:18):

Hopefully the experience that I have had, I can put across some of that because I think a lot of the skills that I learned, really they apply in every situation. And I think there are skills that are quite easily learned and that this doesn’t need to feel as daunting as it sometimes does for clinicians in every setting.

Professor Mark Creamer (04:33):

Ah, good. Okay, well we’re definitely gonna come back to that one. You can reassure us on that one. But let’s start off with what I suppose is probably the beginning. My first thought as a clinician, I guess is what do you think are the signs or the red flags that we should be looking for that might indicate that someone is suicidal?

Dr. Tad Tietze (04:51):

I think apart from like the really obvious things that the person has expressed that they’re suicidal or they’ve tried to harm themselves in some way, I think beyond that, really the, the red flags come in, in the level of distress that the patient is experiencing and in how much you are able to learn about their current situation, how overwhelmed they are by that situation, whatever the specific set of circumstances that they’re dealing with. So looking for that distress, and also I think when, when patients want to minimise what is clearly a distressing situation, want to try and solve it all themselves, that’s often a big red flag for me.

Professor Mark Creamer (05:27):

Sorry, I was just gonna say that. Well, are we talking about significant life stressors, I guess, you know, like maybe a breakup of a relationship or a loss of a job or something?

Dr. Tad Tietze (05:34):

So, it’s a whole variety of things. It’s from those kinds of big stressors like relationship breakdowns, job losses, accommodation problems, work, stress, overwork, all that kind of stuff. But also some people are overwhelmed by things that might surprise you. Things that perhaps you wouldn’t think are overwhelming, but they are obviously very distressed by a certain set of circumstances. And then there’s a group of patients who clearly have some kind of significant mental illness or disorder, which is having some kind of relapse. So I think it’s a, it’s a whole variety of things that we are looking at.

Professor Mark Creamer (06:06):

But not necessarily a mental health condition. Obviously people with depression or whatever at higher risk, but not necessarily. Is that right?

Dr. Tad Tietze (06:13):

That’s right. I think in my experience actually the vast majority of suicidal crises I’ve seen, you’d be hard pressed to come up with a definite diagnosis of depression or psychosis or anything like that. Most of these people are in a predicament and they’re finding it hard to find an alternative way outta the predicament and to resolve their predicament. And the only thing they can see suddenly is that ending their life will at least end that predicament. That’s their root of escape. And in fact, I think that’s like a general rule. When people are in predicaments, they feel they cannot escape. Suddenly suicide can seem like an option for escape for some

Professor Mark Creamer (06:47):

People. Mm. Quite. How concerned are you about substance abuse? I’m thinking particularly alcohol. Is, is that a contributing factor do you think?

Dr. Tad Tietze (06:54):

Yeah, I think when patients are using substances to manage their predicament or to manage their emotions, they’re at much greater risk. Alcohol is probably the number one factor that we see. And it can play different roles. An alcohol problem can be the backgrounds to becoming suicidal. It can be a means of getting the courage up to commit suicide. It can be a catalyst to people who get drunk, who’ve been thinking about suicide, are more likely to act impulsively on those thoughts and urges. So we see alcohol in very complicated relationship. And it’s true with a bunch of other medications, for example, benzodiazepines are quite a common factor. And then people, if they’ve got other drug problems, the effects of those, whether they be withdrawal or intoxication states can also play a role.

Professor Mark Creamer (07:34):

I wonder if some clinicians are perhaps a little bit hesitant to ask the person straight out about suicidal ideation or whatever. It’s, is that something we should be concerned about? Is it okay to just ask someone?

Dr. Tad Tietze (07:45):

Look, I think as long as you’re not rude and horrible about it, it’s absolutely essential to actually ask those kinds of questions. I remember in my training overcoming that nervousness about asking those questions. But there’s a way to lead into it once you have some suspicion that a patient might be suicidal, you can ask, first of all whether they’ve been so distressed that they’ve have thoughts that life’s no longer worth living. You could ask if that is the case, have they thought about harming themselves or taking their life? Have they made any plans? Have they actually tried to act on any of those plans? You can kind of go step by step into that process.

Professor Mark Creamer (08:17):

Yeah, sure. Which actually leads me on to what I wanted to ask next. I’m kind of guessing that if you do suspect that someone is suicidal, that one of the first things we might do is to try and assess the level of risk. Would that be right? How much of a risk is it?

Dr. Tad Tietze (08:30):

So I think the problem is that once you identify that the patient may be suicidal, actually going further and identifying the level of risk is probably not really useful at all. Perhaps machine learning or artificial intelligence will eventually give us nice calculations about each patient. But actually when you’ve got a patient in a clinical setting in front of you, once they are presenting and you’ve got that, that suspicion, you should consider them at, at considerably higher risk than the rest of the population. And at that point, you shouldn’t worry about whether it’s low, medium, or high risk. You should just be thinking about, well this is someone who actually needs some good clinical care. And we could talk about the statistics around it. The main problem is that most people who we would assess would actually be if we did those calculations, be technically at low risk.

(09:14):

But we see so many of the people in the low risk group compared with a higher risk group that actually, unfortunately probably more people in the low risk group end up taking their own lives than in the much smaller high risk group. It’s just simply a matter of the numbers. So making these calculations I’ve found, I think it’s a dead end and I think really it’s thinking about how can you help this person with the actual risk factors that are leading them to be suicidal or at risk of suicide. And I think that’s really the clinical model of assessment and formulation that I’d recommend.

Professor Mark Creamer (09:46):

Yeah, absolutely. So I do wanna build on that cause I think that’s really important. So the idea that perhaps many of us were brought up with, which is that you should spend a lot of time talking about the plan, how realistic the plan is, how viable is, how lethal it is. You wouldn’t necessarily worry too much about that.

Dr. Tad Tietze (10:03):

Look, I think it’s important to know what the patient is saying about their intent. It’s important to know how close they’ve gotten to actually enacting something or whether they actually have enacted some form of self-harm. But ultimately I think the bigger issue and so practical issue is how do we get them out of this crisis to decrease that risk? And there’s a series of things that we need to do and we have to have a very clear assessment and formulation of how they got in this place in order to know how to target the right kinds of interventions in order to actually reduce that

Professor Mark Creamer (10:32):

Risk. Well let’s go on, cause I do wanna talk about what kind of interventions we might have. But first of all, I wonder if you could say a bit more about this idea of formulation, cuz I think it’s so important, but obviously you think it’s important in, I guess in terms of driving our interventions, driving what we might do.

Dr. Tad Tietze (10:47):

Yeah, I think ultimately because we can’t treat risk itself, risk is just an abstract concept, we can actually intervene around each of the factors that has led this patient to that point. And formulation, I think is the idea of trying to understand why has this patient come with this problem at this time under these circumstances. And I think bringing those kinds of things together helps you understand how you can help sort of tip the balance of risk versus protective factors in a particular patient.

Professor Mark Creamer (11:17):

And when you talk about formulation, we’re talking about our all a traditional model of the four or five P’s, I suppose, predisposing, precipitating, et cetera.

Dr. Tad Tietze (11:26):

Perpetuating, yeah. Protective. Yes. So I only know four Ps so you’re ahead of me. <laugh>.

Professor Mark Creamer (11:30):

No, I think, I think my fifth is just presenting problem

Dr. Tad Tietze (11:33):

<laugh>. Oh, very good. Yes. Well that’s true. So I, I think the precipitating factors it’s useful to just think about it as current stressful as things that have happened in the very short term that are leading this person to feel overwhelmed. And they can be interpersonal, they can be job, they can be accommodation, financial, you name it. And they can also actually be that they’ve got a current illness going on. So a person who does have, let’s say a relapse of schizophrenia, a much rarer cause of suicide in the bigger scheme of things, that patient, you know, if they’re having a relapse, that might be the precipitant. In terms of the predisposing factors, that’s really just talking about the longer term underlying things that are going on for this person. And it’s a mixture of things like whether they have got a substance use disorder, they have got a longer term mental health condition, but also looking at their coping skills.

(12:25):

And we psychiatrists, you know, we have many different names for problems with coping skills. We can talk about maladaptive coping skills, we can talk about attachment issues, we can talk about personality vulnerabilities. But these things are often really important for understanding why these stresses are affecting this particular person at this time. So any sense of that background, and even though they’re longer term, some of these things can also be addressed and looked at in various ways. One of the commonest sort of maladaptive coping strategies is compulsive emotional self-reliance. A person gets overwhelmed by some emotional problem and rather than, like most of us thinking, oh, I better reach out to someone who cares about me, who I can talk with, actually they think, right, I’ve gotta double down and work harder by myself to actually solve this problem all by myself. In fact, they sometimes even actively push other people away as they’re trying to solve the problem.

(13:20):

And you know, once we see them for example you know, in a PEC unit so I work in emergency departments and psychiatric emergency care centres in that environment, we sometimes say to them, you have to get a friend in to talk about these problems with, to strategize with them to get some support. And sometimes patients, you know, dig their heels in and say, I’d rather not have anyone to talk to even once they’ve already ended up in hospital in this crisis. So we actually try to address those longer term things as well.

Professor Mark Creamer (13:47):

And that kind of predisposing stuff may also influence, I’m thinking about our perpetuating factors that perhaps, you know, toxic poor relationships or lack of social support or whatever may be fed into.

Dr. Tad Tietze (13:58):

Absolutely. And so addressing those is often part of our plan for the patient. It’s not just about addressing those immediate stressors. The protective factors are really important cuz if a patient is in front of you, they not only got weaknesses in how they deal with things, they’ve got strengths. Everyone brings their own strengths with them and trying to mobilise those things, including things they aren’t using right now, but have been able to use in the past, whether it’s, you know, strategies to overcome distress whether it’s problem solving abilities and so on. Trying to bring that out. But one of the most important protective factors, I think is their ability to have people they can confide in about what’s going on and people who can support them and actually mobilising those supports, not just, you know, finite information from them, but to be an active part of this person’s recovery I think is absolutely central. So it’s a protective factor you can certainly do something about.

Professor Mark Creamer (14:53):

Absolutely. And it leads us on very nicely to my next question, which is, well what do we do? What are our strategies to, to for intervention? And it sounds like that idea of activating the social support networks is, is a pretty important first step. Yeah,

Dr. Tad Tietze (15:07):

So that’s absolutely key, but I think because we’ve done this job of formulating this, of trying to understand this patient’s predicament holistically, we can actually look in each of the P’s for things to do. So definitely one of the essential interventions is for us in the emergency setting. But I think it’s also true if you see someone in a general practise or in a community setting of another kind, is to mobilise some supports but also to think about what are the right supports to mobilise. Because sometimes, for example, if it’s a relationship breakdown and lots of relationship turmoil, you wouldn’t necessarily ask that person’s partner or ex-partner to be the key support. You might look outside that field and think more creatively about who else could be supportive and be there to, to help them through their crisis. Similarly I think I talked a bit about sort, sort of interventions around people’s maladaptive coping strategies, their problematic coping strategies.

(16:01):

You can look at each of those and say, well you’ve been doing this, it’s kind of your banging your head against the brick wall doing this. Why don’t you try something different? You know, try a slightly different strategy to address these issues, get other people involved, think about, you know, alternative way of problem solving things. And then of course the stress laws and the precipitants themselves. Some of these can be addressed through simple social interventions like around accommodation or finances. They might actually need the intervention of a social worker or if it’s a domestic violence situation of appropriate domestic violence services. So it’s about trying to think about each of these PS that lead to the formulation and rather than having to start from scratch again with the intervention, you’re just addressing those things you’ve already identified in the formulation.

Professor Mark Creamer (16:43):

Sure. Is there a place for thinking that I, I guess that the person is probably feeling quite out of control for sort of putting some boundaries around things and perhaps even some reassurance or some, you know, safety if you like.

Dr. Tad Tietze (16:54):

Yeah, I think it’s one of the important things as, especially in outside of hospital settings is the consideration of when is this something I can address in this clinical setting or is this something that needs to go to a more structured kind of environment, you know, for with a greater level of safety. So for example, for GP’s there’ll be the question of when do I send this patients to the emergency department? And in any situation where the person is socially isolated, where they’re not able to make a simple safety plan with contingencies around if they’re feeling more overwhelmed, they know someone to reach out to. If you haven’t started ’em down the track of addressing some of these problems, the things that have led them to feel suicidal, haven’t really been addressed in any systematic way and it’s not possible to do that in the general practise or another community setting, then sending them to the emergency department is perfectly reasonable. We have resources in that setting that are simply not available in other settings and we can solve problems very quickly.

Professor Mark Creamer (17:53):

I was just gonna say it’s very reassuring actually Tad cuz I’m old enough to remember when I started working in public sector, psychiatry and community mental health, we could pretty much just pick up the phone and get someone admitted. It was not difficult at all. Now to get someone admitted is of course not easy. And so it’s an interesting point you make that actually through the ED is perhaps as good a route as any

Dr. Tad Tietze (18:12):

Look if there’s nothing else available. If things feel more contained that there’s less worry about things immediately going off the rails of there being immediate danger, contacting the mental health acute care team via whatever the particular contact numbers in in your state are, would be a completely reasonable thing to do. And then at the other end, if this is a patient who’s severely distressed, you may have even given them some medication or used some of the strategies that Song’s podcast last time talked about. If that stuff’s not working and you are really worried about this patient’s safety, then getting them straight to hospital even calling an ambulance is sometimes necessary. And that’s not necessarily gonna end up with a patient being admitted, but it means that the mental health services in the emergency setting will be able to deal with this, will be able to work through this stuff in a way that’s not possible in in other sort of primary care setting.

Professor Mark Creamer (19:02):

And that idea of treating some of the acute symptoms where possible, whether it’s by psychological interventions or perhaps by some medication, that’s a legitimate kind of path as well if it’s indicated.

Dr. Tad Tietze (19:13):

Absolutely. I mean the situation, if the situation’s feeling out of control for the patient, you don’t have to be controlling. I try to avoid being controlling without patients but actually I think it’s really important to provide a sense of stability and control about the intervention that’s happening. So you know, trying to provide that, that calm environment, talking through the options, but in the end also having to put your foot down. If you think this is a very highly dangerous situation then subcontracting to the people who deal with that emergency services, emergency departments, acute psychiatry is the place to go.

Professor Mark Creamer (19:47):

Yeah, absolutely. And I guess it’s a difficult line that we all walk as clinicians is about assessing where the person is and not minimising the amount that I can actually do in my consulting room to stabilise this person or whatever equally not overestimating that and making a, a bad decision about sending someone away when they’re at risk.

Dr. Tad Tietze (20:06):

I’d like to add one thing, which is I think the process of the assessment when you’re trying to figure out this formulation often as you are trying to think through how has all this come about, what are we gonna do actually it’s incredibly helpful for the patient to go through that process with you. They often are able to rethink where they’ve been at and actually come to some of these conclusions themselves even in the, in the course of that conversation. And one of the things we find when patients are admitted is we so ’em sit down and just ask them about their life story and try to pull a few things together and they’re problem solving in front of us straight away in ways they couldn’t before because they were so overwhelmed. So actually just being good at listening and trying to reflect what you’re hearing and try to pull things together can be very important.

(20:50):

Absolutely. And going back to that point that we were talking about before, about helping the person feel a bit more in control, that being able to do that problem solving actually can give them a whole lot of control, can a whole lot of sense of control. Yeah. Presumably these interventions we wouldn’t see them in isolation. They’re part of a broader management plan for the patient presumably. So I guess in ED, if you are seeing ’em in that situation, you are liaising with the, their normal treater, their treating doctor or whatever.

(21:18):

Yeah, that’s one of the things we have to do is we kind of reconnect them not only with the immediate people in their life but we try to reconnect them with all the social and medical and other clinical supports they’ve already got. So it’s very normal for us to then during an admission to be calling clinical psychologists, GP’s, psychiatrists, really trying to pull together information, work out a collaborative plan in the emergency department setting, clearly much more time constrained. There’s less of that that we can do but we always wanna feed back directly to the referrer, particularly if we’ve been able to resolve stuff in the emergency department, we wanna make sure there’s good documentation sent back from emergency. Similarly, I think, you know, even though it’s probably a bit mysterious and not well known, most GP’s for example, can call hospitals. They will be put through to a psychiatric doctor if they’re really wanting to ask for advice and so on. There often aren’t very well worked out systems at various hospitals for this kind of thing. But ultimately if you really need advice and but it’s not a big enough emergency to just send the patient to hospital, you can often get through and get some advice.

Professor Mark Creamer (22:20):

Yeah, that’s critical isn’t it? And that we shouldn’t be afraid to do that. We shouldn’t be afraid to get on the phone and ask for some advice or get a second opinion. Cuz the other thing I was thinking, you know, talking about linking in with their care, existing care team and so on, it’s not only about getting this person through the current crisis, it’s also about striving to reduce the future suicide risk presumably and as you said, you know, trying to eliminate some of the factors that have actually led the person there today.

Dr. Tad Tietze (22:44):

Yeah, I think it’s very common for us to start looking at, well what is the kind of specific long-term intervention this person might need to in the longer term figure out, well I keep coping in this catastrophic way when I get under certain kinds of pressure, what new skills can I learn? And so we often try to match, make with specific types of psychological therapy and psychiatric treatment and so on.

Professor Mark Creamer (23:10):

Yeah, there’s a wealth of good advice there Tad, but if I can just put you on the spot, how good are we at preventing suicide? What, what does the evidence say? Have we got an evidence base that tells us what to do to prevent suicide?

Dr. Tad Tietze (23:22):

We do have an evidence base, and I guess the good news is there is an evidence base with well-designed studies, you know, around a, a series of interventions. The bad news is that, you know, even with the best of will, you’d have to say that each of these interventions has a very small effect and we’ve never really pulled together the data to show that by combining the, these small effects of these various interventions, that we are suddenly gonna get a bigger effect. So we are still partly in the dark around this and if we want to be strictly scientific, we’d have to say there is an evidence base, but there are sort of no magic bullets in this evidence base, no quick fixes. So for example, a very big thing that we do, which I think is very reasonable and can be translated to community settings, is doing safety plans sitting down with a, with a patient sometimes with their carers or family going through a bunch of contingency plans.

(24:17):

Well if you’re feeling distressed, who can you talk to? What can you do to help with your distress? What works for you? Right up to things are really outta control. I feel this overwhelming urge to kill myself. Well that’s when we dial triple zero and, and get you to hospital. And these safety plans I think are a good example of the evidence around safety plans is they have a small but real effects like high quality evidence. But on the other hand it’s still a relatively small effect. I think it’s actually though very good clinical care because it’s about activating the patient’s ability to think about, well what are the alternatives to my predicament in each situation? Cuz I guess our starting point, when you’re at the pointy end, you kind of realise that no matter how awful the situation someone is in there is always an alternative.

(25:04):

Not always the most palatable alternative, but there’s always an alternative way out of the predicament that doesn’t involve the death of the person. There are always alternatives. Some of them might be hard work, some of them might, you know, be painful in the short term, but there are always different ways out to address these problems and we wanna activate that positive side in our patients and these safety plans, I think they model that kind of thing. There’s a bunch of other interventions, there’s no point in me going through them cuz none of them are like the intervention to do, just thinking about understanding the patient’s predicament, trying to address the factors that have contributed to the predicament, trying to socially reconnect them and mobilise those social supports. That’s even at, at the pointing end where I work. That’s 95% of what we do.

Professor Mark Creamer (25:48):

Yeah. And as you said earlier, you know, a, a good formulation to begin with is going to direct your intervention and I look, I am pleased because it sounds like, you know, so obviously some people are gonna be naturally better at this than others, but the fact is we can learn these skills, presumably they are skills we can learn.

Dr. Tad Tietze (26:05):

Yeah, I think it starts from actually being curious and engaged with your patient. I found that when I learned these skills, part of it was just listening and trying to understand what were the circumstances, what was the actual chronological set of events that led this person to this point of crisis where they thought this was the only option to even try to understand their thinking. And once you really get into that thinking, thinking can seem, you know, a bit crazy sometimes. I don’t mean in a psychotic sense, but people say things like, well rather just keep battling myself even though that makes me feel suicidal rather than reaching out to someone, even though I have all these friends who, who I’m sure would come and see me, but people get in these predicaments and start to think in this way that doesn’t really make sense once you stand back from it.

(26:50):

So trying to think about those kinds of discrepancies, trying to understand all those factors, just trying to be empathetic about it. You don’t have to agree with the person’s conclusion that they should kill themselves as the only option that would be a mistake to be sympathetic to their suicide plan. It’s about having empathy for their predicament, trying to understand how they got themselves in this position and what external circumstances got them there. And once you try to understand that, I think it becomes a lot easier to see, well these are the things that can be changed. And that’s such a huge part of the job and doesn’t have to be super technical.

Professor Mark Creamer (27:24):

Okay. Yeah, so lots of good advice there. The fact is though, I assume that if we work in mental health for long enough, sooner or later, it’s likely that there will be a successful suicide. And I’m wondering, you know, following that, there’ll be informal and formal inquiries and so on. Do you have any advice about if we are working with someone who we think is suicidal extra sort of precautions that we would take? I’m thinking lesser to be honest about looking after their suicidality and more about protecting ourselves as it were.

Dr. Tad Tietze (27:52):

I think it’s important to document really well, like if a person in your estimation is at significant risk of suicide and you are assessing and planning some kind of intervention, you need to have very clear contemporaneous documentation that goes through your reasoning about various things. If you felt the need to ask for advice, which is entirely reasonable. If you’re feeling out of your depth, absolutely ask for advice. Don’t let a patient go home. When you are feeling out of your depth and worried that this person’s gonna kill themselves, that’s the time to ask for advice and to escalate matters. You shouldn’t take on things that you don’t feel qualified to do or that you don’t feel that you’re in control of what needs to be happening. But that clear and contemporaneous documentation, documentation of any advice that you seek, documentation of any actions that you take, that’s by far the most important.

(28:41):

You know, coronials and other investigations can be scary for a clinician, but ultimately they wanna see that you are acting in good faith with reasonable clinical judgement and taking precautions as necessary. That if you have the, for example, the powers to act under the mental health act as some clinicians do, doctors and others, that you use that appropriately if you were really worried about the situation. Because ultimately the reality is many, many suicides, a very high proportion occur without that person having been in direct contact with mental health services or any other health services. And similarly with the best will in the world. There are some situations where no matter what interventions we do, some patients end up being so committed to the project that no matter what we do, eventually they end up taking their lives. And so these are things to be prepared for. And I think most of the investigating authorities are actually pretty reasonable about this. Where they’re more worried is if basics of assessment and formulation and intervention planning weren’t done, where a person obviously stated they were suicidal or that wasn’t taken seriously.

Professor Mark Creamer (29:47):

Yes, absolutely. A final very quick question, cause I’m afraid we’re running outta time through all this while we’re trying to manage this suicidal patient, it’s frightening and it’s stressful for the clinician and so on. Yes. do you have any advice for us as clinicians while we’re in that highly stressful situation about managing our own arousal or our own feelings?

Dr. Tad Tietze (30:07):

Well, I think one of the things is if you do practise this more, you just get used to it. So actually learning to ask questions that I talked about, you know, the sort of the screening questions about suicide, learning to hear those answers. The more you do that, the less the whole process will be stressful because it’ll become part of a regular clinical process. But I think ultimately seeking, whether it be supervision or peer support, is really important. These are extremely hot encounters at times. They do stir up lots of powerful emotions inside the clinician. And unless you’re talking with other people and debriefing after this has happened, then you’re gonna be bottling all this. And in a sense, doing what some of our patients do, taking a huge weight of other people on your shoulders and then trying to manage it all yourself without actually opening up and talking about those feelings.

(30:56):

There is absolutely no shame in talking through this stuff because this is tough stuff to talk through. And in some ways the fact that these patients are largely not people with these big mental illnesses like schizophrenia or bipolar disorder, but in many ways seem like you and me in terms of being able to cope most of the time until this crisis actually can make it more confronting. So talking this stuff through seeking help and ultimately seeking your own psychological or counselling support if you’re feeling overwhelmed by this stuff, totally reasonable things to do it, it can be tough

Professor Mark Creamer (31:29):

Work. Yeah, absolutely. Absolutely. And in fact, we’re going to look at that briefly in our next episode, so that’s very good timing. Look, we could easily have talked for another hour Tad, that was so interesting and valuable. I, I have no doubt that our listeners will have got a great deal from that. So I appreciate enormously thank you so much for your time today, Tad.

Dr. Tad Tietze (31:46):

Thanks for having me on.

Professor Mark Creamer (31:47):

Yeah, pleasure. Look, I do encourage everybody to listen to our next episode, whereas I say we will be talking about, I guess, recognising and responding to distress and anxiety in our peers. If you wanna learn more about Tad or me, or if you want to access some resources, go to the landing page of this episode. And also on the landing page, you’ll find the feedback survey. We really do value it. Please follow the link. Let us know what you thought about this episode, provide comments, suggestions about how MHPN might be able to better meet your needs and so on. But for now, it’s thank you again, Tad and goodbye from Tad

Dr. Tad Tietze (32:22):

Goodbye. Thank you very much Mark,

Professor Mark Creamer (32:24):

And it’s good goodbye from me. So don’t forget to join us for our next conversation in this series. But in the meantime, thank you all very much indeed for joining us today and listening to the podcast. Bye for now.

Host (32:37):

Visit mhpn.org.au to find out more about our online professional programme, including podcasts, webinars, as well as our face-to-face interdisciplinary mental health networks across Australia.

Host (00:01):

Hi there. Welcome to Mental Health Professionals Network podcast series MHPN’s aim is to promote and celebrate interdisciplinary collaborative mental health care.

Professor Mark Creamer (00:18):

Hello, and welcome to this episode of MHPN Presents A Conversation About, my name’s Mark, Mark Creamer. I’m a clinical psychologist and a professorial fellow in the Department of Psychiatry at the University of Melbourne. My particular specialty is the mental health effects of trauma, but I’m also very interested in emergency mental health. I worked in public sector psychiatry for many years, so it gives me great pleasure to be hosting this three-episode series in which we are exploring some aspects of emergency mental health. In our first episode, I was joined by Dr. Song Chan and we chatted about how best to deescalate a mental health crisis. Today I am delighted to be joined by Dr. Tad Tietze. Tad is a psychiatrist based in New South Wales. He’s currently in the Illawarra region. He’s got a long interest and buckets of experience in emergency mental health and in suicidality in particular. Hi Tad, thank you very much for joining me today.

Dr. Tad Tietze (01:19):

Hi, Mark. It’s a pleasure.

Professor Mark Creamer (01:21):

We’re gonna spend the whole time talking about emergency mental health, but you know, I do think it’s really important that we have things outside of work to keep us happy and to de-stress. So before we get into it, perhaps you could just say a little bit about what you enjoy doing when you’re not on the front line of psychiatry.

Dr. Tad Tietze (01:36):

In those precious moments that I get, I’m a bit of a cinema obsessive. I’m known to be watching obscure arthouse movies at all times of day or night. And I have been known to DJ similarly obscure disco and house music,

Professor Mark Creamer (01:51):

Disco and house. Well, I’m a big fan of music, but not that particular genre, I’m afraid. <laugh>, today we’re gonna be talking about suicidality. We’re, we’re going to be getting some tips and strategies from you Tad, on how to manage someone who is suicidal. But for many clinicians, and I certainly include myself in this, it is a difficult area. It’s not something about which we feel particularly comfortable. So, I’m kind of fascinated to know a bit about your experience and I guess in particular, what is it that’s so interested you and, and fascinated you in such a complex area?

Dr. Tad Tietze (02:24):

I think it’s probably the result of seeing it as a challenge that is both part of everybody’s psychiatry training in Australia and New Zealand. There is no way you can avoid meeting patients who are suicidal. It’s a central part of the work, and it’s particularly a central part of the work in emergency departments. But, initially, I found it a huge struggle to deal with this group of patients. There’s a lot of stress and worry about the risk associated with these presentations. But then I was fortunate enough to go and work in consultation, liaison, psychiatry at St. Vincent’s Hospital as a registrar. And because they had to deal with such a huge number of these kinds of very acute presentations in their emergency department, I actually was able to learn a great skillset about how to deal with these emergencies and no longer felt in over my head.

(03:15):

And I thought it was worth pursuing that and then started to really understand the complexity of the, the presentation with suicidality, because it’s not just one thing. It’s not just one illness that we give one treatment for. It’s a very, very complex presentation, but it’s, I think, one of the most rewarding challenges in psychiatry because if you actually help these people through these crises, what is a potentially lethal situation becomes much less so, or sometimes entirely not so, and that’s a lot of reward in a very short period of time often.

Professor Mark Creamer (03:46):

Absolutely. Absolutely. I understand that entirely. Although you raised an issue there that I wanna come back to towards the end, which is that you had the opportunity there to get lots of experience of working with this population. And I guess, you know, you were talking there about ED or emergency departments but we are not only talking about that, of course, as mental health clinicians, we can encounter this kind of thing in a range of settings in community mental health, in CL psychiatry and in our consulting rooms. And I guess that’s, that’s perhaps the point that we don’t get necessarily a lot of experience.

Dr. Tad Tietze (04:18):

Hopefully the experience that I have had, I can put across some of that because I think a lot of the skills that I learned, really they apply in every situation. And I think there are skills that are quite easily learned and that this doesn’t need to feel as daunting as it sometimes does for clinicians in every setting.

Professor Mark Creamer (04:33):

Ah, good. Okay, well we’re definitely gonna come back to that one. You can reassure us on that one. But let’s start off with what I suppose is probably the beginning. My first thought as a clinician, I guess is what do you think are the signs or the red flags that we should be looking for that might indicate that someone is suicidal?

Dr. Tad Tietze (04:51):

I think apart from like the really obvious things that the person has expressed that they’re suicidal or they’ve tried to harm themselves in some way, I think beyond that, really the, the red flags come in, in the level of distress that the patient is experiencing and in how much you are able to learn about their current situation, how overwhelmed they are by that situation, whatever the specific set of circumstances that they’re dealing with. So looking for that distress, and also I think when, when patients want to minimise what is clearly a distressing situation, want to try and solve it all themselves, that’s often a big red flag for me.

Professor Mark Creamer (05:27):

Sorry, I was just gonna say that. Well, are we talking about significant life stressors, I guess, you know, like maybe a breakup of a relationship or a loss of a job or something?

Dr. Tad Tietze (05:34):

So, it’s a whole variety of things. It’s from those kinds of big stressors like relationship breakdowns, job losses, accommodation problems, work, stress, overwork, all that kind of stuff. But also some people are overwhelmed by things that might surprise you. Things that perhaps you wouldn’t think are overwhelming, but they are obviously very distressed by a certain set of circumstances. And then there’s a group of patients who clearly have some kind of significant mental illness or disorder, which is having some kind of relapse. So I think it’s a, it’s a whole variety of things that we are looking at.

Professor Mark Creamer (06:06):

But not necessarily a mental health condition. Obviously people with depression or whatever at higher risk, but not necessarily. Is that right?

Dr. Tad Tietze (06:13):

That’s right. I think in my experience actually the vast majority of suicidal crises I’ve seen, you’d be hard pressed to come up with a definite diagnosis of depression or psychosis or anything like that. Most of these people are in a predicament and they’re finding it hard to find an alternative way outta the predicament and to resolve their predicament. And the only thing they can see suddenly is that ending their life will at least end that predicament. That’s their root of escape. And in fact, I think that’s like a general rule. When people are in predicaments, they feel they cannot escape. Suddenly suicide can seem like an option for escape for some

Professor Mark Creamer (06:47):

People. Mm. Quite. How concerned are you about substance abuse? I’m thinking particularly alcohol. Is, is that a contributing factor do you think?

Dr. Tad Tietze (06:54):

Yeah, I think when patients are using substances to manage their predicament or to manage their emotions, they’re at much greater risk. Alcohol is probably the number one factor that we see. And it can play different roles. An alcohol problem can be the backgrounds to becoming suicidal. It can be a means of getting the courage up to commit suicide. It can be a catalyst to people who get drunk, who’ve been thinking about suicide, are more likely to act impulsively on those thoughts and urges. So we see alcohol in very complicated relationship. And it’s true with a bunch of other medications, for example, benzodiazepines are quite a common factor. And then people, if they’ve got other drug problems, the effects of those, whether they be withdrawal or intoxication states can also play a role.

Professor Mark Creamer (07:34):

I wonder if some clinicians are perhaps a little bit hesitant to ask the person straight out about suicidal ideation or whatever. It’s, is that something we should be concerned about? Is it okay to just ask someone?

Dr. Tad Tietze (07:45):

Look, I think as long as you’re not rude and horrible about it, it’s absolutely essential to actually ask those kinds of questions. I remember in my training overcoming that nervousness about asking those questions. But there’s a way to lead into it once you have some suspicion that a patient might be suicidal, you can ask, first of all whether they’ve been so distressed that they’ve have thoughts that life’s no longer worth living. You could ask if that is the case, have they thought about harming themselves or taking their life? Have they made any plans? Have they actually tried to act on any of those plans? You can kind of go step by step into that process.

Professor Mark Creamer (08:17):

Yeah, sure. Which actually leads me on to what I wanted to ask next. I’m kind of guessing that if you do suspect that someone is suicidal, that one of the first things we might do is to try and assess the level of risk. Would that be right? How much of a risk is it?

Dr. Tad Tietze (08:30):

So I think the problem is that once you identify that the patient may be suicidal, actually going further and identifying the level of risk is probably not really useful at all. Perhaps machine learning or artificial intelligence will eventually give us nice calculations about each patient. But actually when you’ve got a patient in a clinical setting in front of you, once they are presenting and you’ve got that, that suspicion, you should consider them at, at considerably higher risk than the rest of the population. And at that point, you shouldn’t worry about whether it’s low, medium, or high risk. You should just be thinking about, well this is someone who actually needs some good clinical care. And we could talk about the statistics around it. The main problem is that most people who we would assess would actually be if we did those calculations, be technically at low risk.

(09:14):

But we see so many of the people in the low risk group compared with a higher risk group that actually, unfortunately probably more people in the low risk group end up taking their own lives than in the much smaller high risk group. It’s just simply a matter of the numbers. So making these calculations I’ve found, I think it’s a dead end and I think really it’s thinking about how can you help this person with the actual risk factors that are leading them to be suicidal or at risk of suicide. And I think that’s really the clinical model of assessment and formulation that I’d recommend.

Professor Mark Creamer (09:46):

Yeah, absolutely. So I do wanna build on that cause I think that’s really important. So the idea that perhaps many of us were brought up with, which is that you should spend a lot of time talking about the plan, how realistic the plan is, how viable is, how lethal it is. You wouldn’t necessarily worry too much about that.

Dr. Tad Tietze (10:03):

Look, I think it’s important to know what the patient is saying about their intent. It’s important to know how close they’ve gotten to actually enacting something or whether they actually have enacted some form of self-harm. But ultimately I think the bigger issue and so practical issue is how do we get them out of this crisis to decrease that risk? And there’s a series of things that we need to do and we have to have a very clear assessment and formulation of how they got in this place in order to know how to target the right kinds of interventions in order to actually reduce that

Professor Mark Creamer (10:32):

Risk. Well let’s go on, cause I do wanna talk about what kind of interventions we might have. But first of all, I wonder if you could say a bit more about this idea of formulation, cuz I think it’s so important, but obviously you think it’s important in, I guess in terms of driving our interventions, driving what we might do.

Dr. Tad Tietze (10:47):

Yeah, I think ultimately because we can’t treat risk itself, risk is just an abstract concept, we can actually intervene around each of the factors that has led this patient to that point. And formulation, I think is the idea of trying to understand why has this patient come with this problem at this time under these circumstances. And I think bringing those kinds of things together helps you understand how you can help sort of tip the balance of risk versus protective factors in a particular patient.

Professor Mark Creamer (11:17):

And when you talk about formulation, we’re talking about our all a traditional model of the four or five P’s, I suppose, predisposing, precipitating, et cetera.

Dr. Tad Tietze (11:26):

Perpetuating, yeah. Protective. Yes. So I only know four Ps so you’re ahead of me. <laugh>.

Professor Mark Creamer (11:30):

No, I think, I think my fifth is just presenting problem

Dr. Tad Tietze (11:33):

<laugh>. Oh, very good. Yes. Well that’s true. So I, I think the precipitating factors it’s useful to just think about it as current stressful as things that have happened in the very short term that are leading this person to feel overwhelmed. And they can be interpersonal, they can be job, they can be accommodation, financial, you name it. And they can also actually be that they’ve got a current illness going on. So a person who does have, let’s say a relapse of schizophrenia, a much rarer cause of suicide in the bigger scheme of things, that patient, you know, if they’re having a relapse, that might be the precipitant. In terms of the predisposing factors, that’s really just talking about the longer term underlying things that are going on for this person. And it’s a mixture of things like whether they have got a substance use disorder, they have got a longer term mental health condition, but also looking at their coping skills.

(12:25):

And we psychiatrists, you know, we have many different names for problems with coping skills. We can talk about maladaptive coping skills, we can talk about attachment issues, we can talk about personality vulnerabilities. But these things are often really important for understanding why these stresses are affecting this particular person at this time. So any sense of that background, and even though they’re longer term, some of these things can also be addressed and looked at in various ways. One of the commonest sort of maladaptive coping strategies is compulsive emotional self-reliance. A person gets overwhelmed by some emotional problem and rather than, like most of us thinking, oh, I better reach out to someone who cares about me, who I can talk with, actually they think, right, I’ve gotta double down and work harder by myself to actually solve this problem all by myself. In fact, they sometimes even actively push other people away as they’re trying to solve the problem.

(13:20):

And you know, once we see them for example you know, in a PEC unit so I work in emergency departments and psychiatric emergency care centres in that environment, we sometimes say to them, you have to get a friend in to talk about these problems with, to strategize with them to get some support. And sometimes patients, you know, dig their heels in and say, I’d rather not have anyone to talk to even once they’ve already ended up in hospital in this crisis. So we actually try to address those longer term things as well.

Professor Mark Creamer (13:47):

And that kind of predisposing stuff may also influence, I’m thinking about our perpetuating factors that perhaps, you know, toxic poor relationships or lack of social support or whatever may be fed into.

Dr. Tad Tietze (13:58):

Absolutely. And so addressing those is often part of our plan for the patient. It’s not just about addressing those immediate stressors. The protective factors are really important cuz if a patient is in front of you, they not only got weaknesses in how they deal with things, they’ve got strengths. Everyone brings their own strengths with them and trying to mobilise those things, including things they aren’t using right now, but have been able to use in the past, whether it’s, you know, strategies to overcome distress whether it’s problem solving abilities and so on. Trying to bring that out. But one of the most important protective factors, I think is their ability to have people they can confide in about what’s going on and people who can support them and actually mobilising those supports, not just, you know, finite information from them, but to be an active part of this person’s recovery I think is absolutely central. So it’s a protective factor you can certainly do something about.

Professor Mark Creamer (14:53):

Absolutely. And it leads us on very nicely to my next question, which is, well what do we do? What are our strategies to, to for intervention? And it sounds like that idea of activating the social support networks is, is a pretty important first step. Yeah,

Dr. Tad Tietze (15:07):

So that’s absolutely key, but I think because we’ve done this job of formulating this, of trying to understand this patient’s predicament holistically, we can actually look in each of the P’s for things to do. So definitely one of the essential interventions is for us in the emergency setting. But I think it’s also true if you see someone in a general practise or in a community setting of another kind, is to mobilise some supports but also to think about what are the right supports to mobilise. Because sometimes, for example, if it’s a relationship breakdown and lots of relationship turmoil, you wouldn’t necessarily ask that person’s partner or ex-partner to be the key support. You might look outside that field and think more creatively about who else could be supportive and be there to, to help them through their crisis. Similarly I think I talked a bit about sort, sort of interventions around people’s maladaptive coping strategies, their problematic coping strategies.

(16:01):

You can look at each of those and say, well you’ve been doing this, it’s kind of your banging your head against the brick wall doing this. Why don’t you try something different? You know, try a slightly different strategy to address these issues, get other people involved, think about, you know, alternative way of problem solving things. And then of course the stress laws and the precipitants themselves. Some of these can be addressed through simple social interventions like around accommodation or finances. They might actually need the intervention of a social worker or if it’s a domestic violence situation of appropriate domestic violence services. So it’s about trying to think about each of these PS that lead to the formulation and rather than having to start from scratch again with the intervention, you’re just addressing those things you’ve already identified in the formulation.

Professor Mark Creamer (16:43):

Sure. Is there a place for thinking that I, I guess that the person is probably feeling quite out of control for sort of putting some boundaries around things and perhaps even some reassurance or some, you know, safety if you like.

Dr. Tad Tietze (16:54):

Yeah, I think it’s one of the important things as, especially in outside of hospital settings is the consideration of when is this something I can address in this clinical setting or is this something that needs to go to a more structured kind of environment, you know, for with a greater level of safety. So for example, for GP’s there’ll be the question of when do I send this patients to the emergency department? And in any situation where the person is socially isolated, where they’re not able to make a simple safety plan with contingencies around if they’re feeling more overwhelmed, they know someone to reach out to. If you haven’t started ’em down the track of addressing some of these problems, the things that have led them to feel suicidal, haven’t really been addressed in any systematic way and it’s not possible to do that in the general practise or another community setting, then sending them to the emergency department is perfectly reasonable. We have resources in that setting that are simply not available in other settings and we can solve problems very quickly.

Professor Mark Creamer (17:53):

I was just gonna say it’s very reassuring actually Tad cuz I’m old enough to remember when I started working in public sector, psychiatry and community mental health, we could pretty much just pick up the phone and get someone admitted. It was not difficult at all. Now to get someone admitted is of course not easy. And so it’s an interesting point you make that actually through the ED is perhaps as good a route as any

Dr. Tad Tietze (18:12):

Look if there’s nothing else available. If things feel more contained that there’s less worry about things immediately going off the rails of there being immediate danger, contacting the mental health acute care team via whatever the particular contact numbers in in your state are, would be a completely reasonable thing to do. And then at the other end, if this is a patient who’s severely distressed, you may have even given them some medication or used some of the strategies that Song’s podcast last time talked about. If that stuff’s not working and you are really worried about this patient’s safety, then getting them straight to hospital even calling an ambulance is sometimes necessary. And that’s not necessarily gonna end up with a patient being admitted, but it means that the mental health services in the emergency setting will be able to deal with this, will be able to work through this stuff in a way that’s not possible in in other sort of primary care setting.

Professor Mark Creamer (19:02):

And that idea of treating some of the acute symptoms where possible, whether it’s by psychological interventions or perhaps by some medication, that’s a legitimate kind of path as well if it’s indicated.

Dr. Tad Tietze (19:13):

Absolutely. I mean the situation, if the situation’s feeling out of control for the patient, you don’t have to be controlling. I try to avoid being controlling without patients but actually I think it’s really important to provide a sense of stability and control about the intervention that’s happening. So you know, trying to provide that, that calm environment, talking through the options, but in the end also having to put your foot down. If you think this is a very highly dangerous situation then subcontracting to the people who deal with that emergency services, emergency departments, acute psychiatry is the place to go.

Professor Mark Creamer (19:47):

Yeah, absolutely. And I guess it’s a difficult line that we all walk as clinicians is about assessing where the person is and not minimising the amount that I can actually do in my consulting room to stabilise this person or whatever equally not overestimating that and making a, a bad decision about sending someone away when they’re at risk.

Dr. Tad Tietze (20:06):

I’d like to add one thing, which is I think the process of the assessment when you’re trying to figure out this formulation often as you are trying to think through how has all this come about, what are we gonna do actually it’s incredibly helpful for the patient to go through that process with you. They often are able to rethink where they’ve been at and actually come to some of these conclusions themselves even in the, in the course of that conversation. And one of the things we find when patients are admitted is we so ’em sit down and just ask them about their life story and try to pull a few things together and they’re problem solving in front of us straight away in ways they couldn’t before because they were so overwhelmed. So actually just being good at listening and trying to reflect what you’re hearing and try to pull things together can be very important.

(20:50):

Absolutely. And going back to that point that we were talking about before, about helping the person feel a bit more in control, that being able to do that problem solving actually can give them a whole lot of control, can a whole lot of sense of control. Yeah. Presumably these interventions we wouldn’t see them in isolation. They’re part of a broader management plan for the patient presumably. So I guess in ED, if you are seeing ’em in that situation, you are liaising with the, their normal treater, their treating doctor or whatever.

(21:18):

Yeah, that’s one of the things we have to do is we kind of reconnect them not only with the immediate people in their life but we try to reconnect them with all the social and medical and other clinical supports they’ve already got. So it’s very normal for us to then during an admission to be calling clinical psychologists, GP’s, psychiatrists, really trying to pull together information, work out a collaborative plan in the emergency department setting, clearly much more time constrained. There’s less of that that we can do but we always wanna feed back directly to the referrer, particularly if we’ve been able to resolve stuff in the emergency department, we wanna make sure there’s good documentation sent back from emergency. Similarly, I think, you know, even though it’s probably a bit mysterious and not well known, most GP’s for example, can call hospitals. They will be put through to a psychiatric doctor if they’re really wanting to ask for advice and so on. There often aren’t very well worked out systems at various hospitals for this kind of thing. But ultimately if you really need advice and but it’s not a big enough emergency to just send the patient to hospital, you can often get through and get some advice.

Professor Mark Creamer (22:20):

Yeah, that’s critical isn’t it? And that we shouldn’t be afraid to do that. We shouldn’t be afraid to get on the phone and ask for some advice or get a second opinion. Cuz the other thing I was thinking, you know, talking about linking in with their care, existing care team and so on, it’s not only about getting this person through the current crisis, it’s also about striving to reduce the future suicide risk presumably and as you said, you know, trying to eliminate some of the factors that have actually led the person there today.

Dr. Tad Tietze (22:44):

Yeah, I think it’s very common for us to start looking at, well what is the kind of specific long-term intervention this person might need to in the longer term figure out, well I keep coping in this catastrophic way when I get under certain kinds of pressure, what new skills can I learn? And so we often try to match, make with specific types of psychological therapy and psychiatric treatment and so on.

Professor Mark Creamer (23:10):

Yeah, there’s a wealth of good advice there Tad, but if I can just put you on the spot, how good are we at preventing suicide? What, what does the evidence say? Have we got an evidence base that tells us what to do to prevent suicide?

Dr. Tad Tietze (23:22):

We do have an evidence base, and I guess the good news is there is an evidence base with well-designed studies, you know, around a, a series of interventions. The bad news is that, you know, even with the best of will, you’d have to say that each of these interventions has a very small effect and we’ve never really pulled together the data to show that by combining the, these small effects of these various interventions, that we are suddenly gonna get a bigger effect. So we are still partly in the dark around this and if we want to be strictly scientific, we’d have to say there is an evidence base, but there are sort of no magic bullets in this evidence base, no quick fixes. So for example, a very big thing that we do, which I think is very reasonable and can be translated to community settings, is doing safety plans sitting down with a, with a patient sometimes with their carers or family going through a bunch of contingency plans.

(24:17):

Well if you’re feeling distressed, who can you talk to? What can you do to help with your distress? What works for you? Right up to things are really outta control. I feel this overwhelming urge to kill myself. Well that’s when we dial triple zero and, and get you to hospital. And these safety plans I think are a good example of the evidence around safety plans is they have a small but real effects like high quality evidence. But on the other hand it’s still a relatively small effect. I think it’s actually though very good clinical care because it’s about activating the patient’s ability to think about, well what are the alternatives to my predicament in each situation? Cuz I guess our starting point, when you’re at the pointy end, you kind of realise that no matter how awful the situation someone is in there is always an alternative.

(25:04):

Not always the most palatable alternative, but there’s always an alternative way out of the predicament that doesn’t involve the death of the person. There are always alternatives. Some of them might be hard work, some of them might, you know, be painful in the short term, but there are always different ways out to address these problems and we wanna activate that positive side in our patients and these safety plans, I think they model that kind of thing. There’s a bunch of other interventions, there’s no point in me going through them cuz none of them are like the intervention to do, just thinking about understanding the patient’s predicament, trying to address the factors that have contributed to the predicament, trying to socially reconnect them and mobilise those social supports. That’s even at, at the pointing end where I work. That’s 95% of what we do.

Professor Mark Creamer (25:48):

Yeah. And as you said earlier, you know, a, a good formulation to begin with is going to direct your intervention and I look, I am pleased because it sounds like, you know, so obviously some people are gonna be naturally better at this than others, but the fact is we can learn these skills, presumably they are skills we can learn.

Dr. Tad Tietze (26:05):

Yeah, I think it starts from actually being curious and engaged with your patient. I found that when I learned these skills, part of it was just listening and trying to understand what were the circumstances, what was the actual chronological set of events that led this person to this point of crisis where they thought this was the only option to even try to understand their thinking. And once you really get into that thinking, thinking can seem, you know, a bit crazy sometimes. I don’t mean in a psychotic sense, but people say things like, well rather just keep battling myself even though that makes me feel suicidal rather than reaching out to someone, even though I have all these friends who, who I’m sure would come and see me, but people get in these predicaments and start to think in this way that doesn’t really make sense once you stand back from it.

(26:50):

So trying to think about those kinds of discrepancies, trying to understand all those factors, just trying to be empathetic about it. You don’t have to agree with the person’s conclusion that they should kill themselves as the only option that would be a mistake to be sympathetic to their suicide plan. It’s about having empathy for their predicament, trying to understand how they got themselves in this position and what external circumstances got them there. And once you try to understand that, I think it becomes a lot easier to see, well these are the things that can be changed. And that’s such a huge part of the job and doesn’t have to be super technical.

Professor Mark Creamer (27:24):

Okay. Yeah, so lots of good advice there. The fact is though, I assume that if we work in mental health for long enough, sooner or later, it’s likely that there will be a successful suicide. And I’m wondering, you know, following that, there’ll be informal and formal inquiries and so on. Do you have any advice about if we are working with someone who we think is suicidal extra sort of precautions that we would take? I’m thinking lesser to be honest about looking after their suicidality and more about protecting ourselves as it were.

Dr. Tad Tietze (27:52):

I think it’s important to document really well, like if a person in your estimation is at significant risk of suicide and you are assessing and planning some kind of intervention, you need to have very clear contemporaneous documentation that goes through your reasoning about various things. If you felt the need to ask for advice, which is entirely reasonable. If you’re feeling out of your depth, absolutely ask for advice. Don’t let a patient go home. When you are feeling out of your depth and worried that this person’s gonna kill themselves, that’s the time to ask for advice and to escalate matters. You shouldn’t take on things that you don’t feel qualified to do or that you don’t feel that you’re in control of what needs to be happening. But that clear and contemporaneous documentation, documentation of any advice that you seek, documentation of any actions that you take, that’s by far the most important.

(28:41):

You know, coronials and other investigations can be scary for a clinician, but ultimately they wanna see that you are acting in good faith with reasonable clinical judgement and taking precautions as necessary. That if you have the, for example, the powers to act under the mental health act as some clinicians do, doctors and others, that you use that appropriately if you were really worried about the situation. Because ultimately the reality is many, many suicides, a very high proportion occur without that person having been in direct contact with mental health services or any other health services. And similarly with the best will in the world. There are some situations where no matter what interventions we do, some patients end up being so committed to the project that no matter what we do, eventually they end up taking their lives. And so these are things to be prepared for. And I think most of the investigating authorities are actually pretty reasonable about this. Where they’re more worried is if basics of assessment and formulation and intervention planning weren’t done, where a person obviously stated they were suicidal or that wasn’t taken seriously.

Professor Mark Creamer (29:47):

Yes, absolutely. A final very quick question, cause I’m afraid we’re running outta time through all this while we’re trying to manage this suicidal patient, it’s frightening and it’s stressful for the clinician and so on. Yes. do you have any advice for us as clinicians while we’re in that highly stressful situation about managing our own arousal or our own feelings?

Dr. Tad Tietze (30:07):

Well, I think one of the things is if you do practise this more, you just get used to it. So actually learning to ask questions that I talked about, you know, the sort of the screening questions about suicide, learning to hear those answers. The more you do that, the less the whole process will be stressful because it’ll become part of a regular clinical process. But I think ultimately seeking, whether it be supervision or peer support, is really important. These are extremely hot encounters at times. They do stir up lots of powerful emotions inside the clinician. And unless you’re talking with other people and debriefing after this has happened, then you’re gonna be bottling all this. And in a sense, doing what some of our patients do, taking a huge weight of other people on your shoulders and then trying to manage it all yourself without actually opening up and talking about those feelings.

(30:56):

There is absolutely no shame in talking through this stuff because this is tough stuff to talk through. And in some ways the fact that these patients are largely not people with these big mental illnesses like schizophrenia or bipolar disorder, but in many ways seem like you and me in terms of being able to cope most of the time until this crisis actually can make it more confronting. So talking this stuff through seeking help and ultimately seeking your own psychological or counselling support if you’re feeling overwhelmed by this stuff, totally reasonable things to do it, it can be tough

Professor Mark Creamer (31:29):

Work. Yeah, absolutely. Absolutely. And in fact, we’re going to look at that briefly in our next episode, so that’s very good timing. Look, we could easily have talked for another hour Tad, that was so interesting and valuable. I, I have no doubt that our listeners will have got a great deal from that. So I appreciate enormously thank you so much for your time today, Tad.

Dr. Tad Tietze (31:46):

Thanks for having me on.

Professor Mark Creamer (31:47):

Yeah, pleasure. Look, I do encourage everybody to listen to our next episode, whereas I say we will be talking about, I guess, recognising and responding to distress and anxiety in our peers. If you wanna learn more about Tad or me, or if you want to access some resources, go to the landing page of this episode. And also on the landing page, you’ll find the feedback survey. We really do value it. Please follow the link. Let us know what you thought about this episode, provide comments, suggestions about how MHPN might be able to better meet your needs and so on. But for now, it’s thank you again, Tad and goodbye from Tad

Dr. Tad Tietze (32:22):

Goodbye. Thank you very much Mark,

Professor Mark Creamer (32:24):

And it’s good goodbye from me. So don’t forget to join us for our next conversation in this series. But in the meantime, thank you all very much indeed for joining us today and listening to the podcast. Bye for now.

Host (32:37):

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