Person-centred suicide prevention (with Lyn O'Grady)

[00:00:05] Bronwyn: Hey, mental workers. You're listening to the Mental Work podcast, the podcast about working in mental health for early career mental health workers. As always, I'm your host, Bronwyn Milkins, and today we are talking about this idea of person centered suicide prevention.

Just to give you a sense of the scale of suicide in Australia, in 2023, about 3,214 Australians died by suicide, and that's about nine lives lost per day. That's nine lives, families and communities forever changed. These numbers and the impact they represent, remind us why it's vital to approach prevention with care, humanity, and connection. When faced clients in crisis, many of us default to risk checklists crisis protocols, and that's really understandable because it's often what we're trained on.

In this episode, we're going to explore a different way of how taking a person centered approach can really help the clients and communities we serve. Here to help us out with this really important topic is our guest, Lyn O'Grady. Hi Lyn.

[00:01:00] Lyn: Hi, Bronwyn. Good to be here.

[00:01:02] Bronwyn: It is such a pleasure to have you on. I'm so glad we can talk about this really important topic. Could you please start us off by telling listeners who you are?

[00:01:10] Lyn: Yeah, so I'm a community psychologist, is my area of, um, practice endorsement. And I, I do do some community type work, but I also do some clinical work as well. Particularly the last few years I've been working in private practice with a range of, of presentations, and sometimes that does include people who come to me with suicidality, but quite often it's, it's a range of, a range of people and, suicide might come up as one of the topics.

Before that I'd, I'd worked in schools for about a decade. And before that I'd worked in the community sector while I was studying psychology. So I've had these decades, actually, I've had a decade of doing the community work and then a decade schools, and then a decade almost in project work. So I worked at the Australian Psychological Society doing some project work, and now I'm into this next decade of working in private practice. So I've been to six years of that now.

So I've had these, these different places of coming in and out of, which has been really interesting. And I think, um, really kind of helpful in, in looking at things, looking back at things and seeing how things have changed and what might be the same and what might be different.

[00:02:10] Bronwyn: For our listeners who aren't sure what a community psychologist is, are you able to tell them in a nutshell what the lens and perspective of community psych is. Uh, sorry, I know that's hard and you know, there's courses on it, but...

[00:02:21] Lyn: Could be a whole, our whole conversation could go, so I'll try to be, try to be succinct. I, I think community psychologists tend to think about the systems and thinking about people in context. So even though I work with people individually at the moment, and, and that's my main kind of work, I'm, I'm really interested in thinking about them in the context of their- the world that they live in. I'm also interested in doing, um, some project type work or work at a system level. So I do do some of that work as well.

So I think it's, um, it's, it's around, you know, not just thinking about the individual and, and just the focus on the individual and people who are community psychologists often work in, in, in different ways to sort of challenge the way we do things or to try and improve the systems or to try and question some of the, some of the, you know, power struggles that are there or power differences that are there.

So we kind of fairly, um, unique kind of group. There's not a, not a whole lot of us that are, that are around, um, but we have connections internationally as well. So there are connections in the US and, and New Zealand particularly, and, um, UK as well.

So we, yeah, we, we sort of work in lots of different places and sometimes that does mean individual work as well, but trying to bring that lens, always thinking about what does this mean? So I find it difficult sometimes to work in like Medicare, because I, I wanna work beyond the individual, and so I'm always kind of having to bring that back. But it does mean that I'm, I'm keen to kind of work at, at a system level where I can, so if I'm working with children to be thinking about the school, to be thinking about what's going on in their community life as well, and their neighborhoods and all of those things, I always bring that lens to it. So I think that's how I bring it into my, my work, even at that individual level.

[00:03:59] Bronwyn: Yeah, I love community psychs perspective because we do have such a clinical dominance in Australia and it's so lovely to bring the richness of considering somebody in context, I guess, yeah, just having that variety in our psychological perspectives is really awesome. Lyn, how did you come to be interested in suicide prevention and why are you passionate about making it more person-centered?

[00:04:21] Lyn: Yeah, so I, I guess it's not disconnected from my community psychology work, I think. So it was something... suicide risk and worrying about suicide was something that has been throughout my career. So it hasn't always been front and center, but it's always been there.

And so when I was working with parents, I was sometimes working with, with parents of young people who were suicidal, and that was in the nineties. And so they would sometimes have a, have a young person who was, you know, at risk and, and would end up being hospitalized for a period would come home and the parents would be left to, to work out what to do. And I was running some support groups and providing some support at that time. Um, so that was happening in the nineties when there was a fair bit of focus on youth suicide and, and trying to reduce it. And I think that a lot of work, good work did happen at that, that time.

Then I worked in schools for that decade and suicide risk became one of the concerns as well. And sometimes postvention after suicide was, was the most challenging work, i, I think that, that I did in that time when I was doing, um, critical incident responses for a period of time, and that, that was one of the things that, that we would, as psychologists and a team of the student support people would go into school, um, and provide some support just for a short time after, um, something like that had happened and it was, yeah, it was really hard, really devastating kind of work to do.

And then it just, it just kept coming up. I was doing supervision and I was always hearing about it, so I decided, okay, I wanna tackle this a little bit more. So I enrolled in the Master of Suicidology, which Griffith Uni has. So I did that online about three years, and I, I'd do this study quietly just, just doing the study, and then at the end of that, I thought, what am I gonna do with this now? So when you, when you do commit to a course like that, you think, oh, I'll get some answers. It'll take me, you know, I'll kind of know what I'm doing. But with suicide prevention, we know that, and you, you quoted the numbers, we know that efforts going in, but we're not really getting traction. We're not reducing the numbers. And that was very much for that course as well. It's like, well, I'm getting an understanding of it, I'm sort of seeing what the research says, I'm, I'm getting connected in, into that and the work that's happening. But I, it didn't come out with, with answers. It's, it's just such a complex, difficult, um, area. But I decided I need to do something with that. I needed to honor the fact I'd spent this three years of my life doing this in my spare time.

I was working as well and I'd, I'd work in the city, I was at the Australian Psychological Society at the time, so I'd go into the city and getting early and sit in the cafe and do my study before I'd start work, 'cause I, I wanted to sort of do it in the daytime rather than doing it at nighttime. So I'd, I'd do that and then at the end I thought, okay, I need to do something.

So then I thought I'll combine it with my work that I've done with parents and combine the writing, the parenting, kind of work with the, the, um, suicide prevention. So that was where the Keeping Our Kids Alive, um, parenting a suicidal young person book came from, so that was published just at the start of COVID 2020, that book came out.

And then I developed a Facebook page with 10,000 followers from there. So that, that became a bit of a, an area of interest as well. And then started to do some more training and some more work and, and continuing really to keep, keep my interest in the area, keeping up with research and just being really curious about it.

And then of course, I started doing the private practice work. So it comes up in this work as well. And sometimes because I was open to seeing people with, with, you know, sort of current or recent suicide risk, then it meant that I had a period where I was seeing quite a few people, but I didn't want it to become the focus of my work. But in some ways, if, you know, it's kind of a bit easier to to know what you, what you're expecting. Sometimes it comes up when you're not expecting it in, in client work and that can be even more challenging, I think, if it comes up when you're not expecting it.

So it's, it's just this constant interest that I have and just keeps coming up in lots of, lots of ways and, um, it's something that, that I kind of keep to the front of my mind, but do other work as well.

[00:08:02] Bronwyn: So why do you think that we need suicide care to be more person-centered? And could you just give us a definition of person-centered care as well?

[00:08:10] Lyn: Yeah. So look, I think there's been, um, a lot of work done to look at how do we actually support people at the time of risk of suicide or when they're thinking about suicide. And I think a lot of the research that comes out, the lived experience focus is that, that people don't always feel like they're being, um, heard or that they're actually being fully listened to and that practitioners are sometimes using checklists or doing, covering themselves a little bit has been one of the criticisms that's come through. So the idea that's been around for quite a while is that we, we need to hear the story. We need to hear what's happening for the person and understanding where suicide fits in.

But I think what happens is we hear the person talk about suicide thoughts or suicide risk, or past suicidal attempts or, um, you know, experiences that people have had and, and it's difficult. And we start to worry about that and we start to then react in a way that we need to think about it as crisis or we think about it, we've gotta do a risk assessment. But the, the thinking for the last few years really has been that we need to look at the person as a whole. We need to think about how do we gather the information and then see where, where suicide risk might fit in, what's, what's leading to the suicidal thoughts coming? When do they come, how are they coming?

So the idea of formulation rather than assessment per se, but gathering information and certainly asking questions and asking those hard questions around when the thoughts come, um, whether they do have a plan, whether they've, you know, practiced, any of that prepared for any, anything that they're gonna do to hurt themselves, we certainly need to know those things, but putting it in the context, so framing it in, in the story or where it might fit in the person's life, and being open to exploring it together.

So I, I think that's, that's a point of difference. And, and, you know, that takes time. And it's, it's, um, I kind of, you've gotta manage yourself in that process. You've gotta be able to sit with it. You need to be able to gather information to work out what to do. But quite often you're not at crisis point. If you're at crisis point and the person says, I'm unsafe right now and I'm gonna hurt myself, well, that's a crisis response, and so you respond in that way. But if they're talking about these, these thoughts and they're talking about having had them for a while and, and talking about them in a way that they're not immediately going to act on it, we can then take more time to listen and, and then work towards the, the safety and work towards safety planning and talking about what else might help or who else might help.

So it's very much drawing on the skills that we have and what we might do in other situations in providing that empathy and that care and, and that chance for people to learn and reflect from, from their own experiences and being curious and, um, and having, having that supportive, um, approach that we might use in other situations that, um, that we might lose if we're too focused on, we need to, you know, determine the risk, we need to focus on that... we might lose some of our natural ability to connect with the person and maintain that rapport. And that's certainly what, um, people with lived experience do sometimes tell us. That, that's where some of the problems lie for them. So then they don't open up or they don't share, or they feel like they're not really cared about, and that way that that can actually be unhelpful for them.

[00:11:17] Bronwyn: Yeah, I find that really interesting, um, because it's like people with lived experience are sharing with us that when they tell us about their suicidality, it's almost like a computer program is executed, and we go through our checklist and it's like they can see that glaze in our eyes and it's like, okay, she's just running three questions, 1 to 10.

And I feel like in our training as well, we were trained the acute suicide risk, and so I think it's hard for us to go to, what you were describing, was that not everybody comes to us in suicide crisis, and so we need to be able to listen and explore more. I was just curious, like how did you, how did you come to be more, I guess, natural and contextual in your approach? Was it a lengthy process for you, or did you notice changes or did you reflect?

[00:12:01] Lyn: Yeah, that's an interesting question. I, I guess the training really did help me, and by the time I was doing this, this work, um, more at that clinical level like I'm doing now, I'd done that training. So I guess you, you kind of get to a point where you know the theory and you know what is there and, and you sort of have convinced yourself, I suppose, and then, and then to feel confident in what you're doing, I guess. So it, it's, you know, it's the hardest part of the work in lots of ways. I mean, there are other, other things that are difficult around risk as well, and ethical issues that we face in our, in our work as mental health professionals. But it's often, it's, um, it's not life and death, whereas when we kind of think about suicide, it, it, it can be, um, it can be that.

And, and so we're not really that well trained for it, I think is is also one of the things that, that comes through that people don't feel trained or, or people have been trained in that older risk... they need know, they need to do a risk assessment, but they don't quite know what to do. And then when you say that, you know, the evidence is saying that, you know, the risk assessment tools don't have an evidence base and then it's it's like, well, what am I meant to do then? I know I'm meant to do it, and a lot of organizations still have their policies or their protocols is around low, medium, high risk, for example. And yet that's not what the evidence is telling us is, is helpful or that we should be doing.

So then people get left with what do I do instead? And that can be very experienced, um, professionals as well, not not just early career people. It can be people that have been doing this work for quite a long time, but haven't necessarily been able to keep up with what they, what the most current thinking is and haven't sort of been aware of it until, until they get into that situation.

[00:13:34] Bronwyn: When I was trained, we were given a few articles about how to assess a suicide risk, and one of them was saying that these suicide risk tools that we currently had weren't very predictive of whether somebody would go on to suicide. And yet, when I then became employed at a hospital, that's all we did. We did low, medium, high suicide risk, and so it was really conflictual for me. And you recently released an article, it was on the Australian Psychological Society website, and in the article suggested that mental health professionals should really move beyond these simple risk categories. Could you just tell us what are some of the limitations of low, medium, high labels and why is risk formulation a better alternative?

[00:14:14] Lyn: Yeah, so I think the problem with low, medium high is that the research came out years ago, like decades ago, 1970s, I think it started to be critiqued. So it's, it's, you know, it feels like we're really way behind that. But one of the, one of the research studies early on showed that people who died from suicide had sometimes been categorized as low risk.

[00:14:33] Bronwyn: Oh?

[00:14:34] Lyn: People who are low risk can die from suicide, who are, you know, categorized in that way can die from suicide. So the high risk people didn't always die, perhaps because when it's considered high risk, then a lot of support and protections are put in. So that was what the research showed, that people had determined that, um, the client was low risk and sometimes they died from suicide.

So that was, there were studies from, you know, long time ago showing that, and I guess we, we kind of tend to categorize and we tend to wanna put people in- in categories or to make sense of it in some way and to have some way of, you know, determining what do we do next? But I think that the formulation idea is that we are looking at anybody with any kind of thoughts around suicide or past history of suicide has some, there's some kind of risk there. There's some kind of need. So it's kind of a reframing it to say, well, there's some kind of, um, risk or concern that's there. And if we, if we don't think about this low median high, we just think about it as a need or a risk, well then that helps us to go into that space of what does it mean and what does this mean for the person now, how does it compare to them previously? How does it compare to other people in their situations? So this is a formulation idea that you start to kind of gather the information from the client, draw on what else you might know, and then you work towards what do we do about that.

So your safety planning is, is kind of a useful tool or connecting in with other people or, um, providing a little bit of extra monitoring or support for periods of time if you need to. But it, it helps you to kind of sit with that, keep the conversation happening and not get caught in, well, they're low risk so I don't have to do anything. Or it's high risk or I better, you know, get them to hospital or whatever, which, which is not helpful for the client at all. It's not really meeting them with what they're telling us and not really giving us the whole picture. So that's that whole whole picture again that we're talking about.

The other thing I think that happens is that it's very dynamic and there's research that's shown this. I saw some this week an article about, um, tracking and where they did some research and had people, you know, sort of respond across the day of how they're feeling in terms of their suicidal thoughts and it, it changed quite a lot during the day. So a client can, you know, sort of be telling us that they're okay right now, so we could be thinking, okay, low risk, no plan, thoughts are not too bad at the moment, but they could walk out of our office or off our, our telehealth appointment and things can shift and change. So if we've just sort of thought about them as low risk, we don't need to do anything. We haven't actually done anything to help them be prepared for that, or we haven't actually helped them with safety planning or thought through what they could do if that does happen.

So I think the formulation idea is to recognize that dynamic aspect of it. And if there are thoughts there, then how do we sort of help people understand them? How do we do the safety planning to help them be prepared that if something does happen. What are their options? How can they do some things to calm themselves? Who else can they talk to? You know, would they call a helpline? And that's a really important question, not just you should call a helpline or call, you know, get in contact with a help service, you should, we should be asking, are they prepared to do that or have they done that before? What's their experience of that as well?

So you're having this whole conversation around what's gonna be most helpful for them. And I think you can do that at that low risk level because we don't, we don't know. That's the, the nature of it. We don't know if they're telling us the whole story. Sometimes people don't tell you and then later on they tell you, well, I was actually quite actively suicidal in that first session. I didn't tell you that. So that can happen as well. People need to trust us and take time and hear that we are gonna be comfortable to have these conversations and we're not gonna rush them off to, to emergency or call the CAT team if, if they mention anything about suicide because they, they might not. Tell us, which then leaves them without support and potentially at greater risk if they don't feel like they can talk to us about it.

[00:18:18] Bronwyn: Totally. I'm wondering how you personally cope with this uncertainty because something I've come to know through doing the podcast, and I thought it was just me who'd liked a good checklist, but I've come to realize that all of us really love good checklist. And it's quite nice if we have somebody in a category of low risk of suicide, I'm like, okay, great. I, that means that I can do these particular interventions. I don't really need to allocate too many resources. But then I'm hearing you say, oh, it can be dynamic. They might not tell us everything. How do you cope with the certain- uncertainty of that yourself?

[00:18:50] Lyn: Yeah. Yeah, I think there's, there's certain times when it's some cases or some clients it's harder than others as well. So if I'm, I'm kind of with people that are well supported... So this kind of comes back to the social determinants and some of the underlying factors, I guess. And again, as a, you know, community psychologist that comes into my mind. So if I feel like they've got good support around them and other people know what's happening, I feel a little bit more secure with that, that I'm not carrying it on my own. Whereas if it's a client that has just told me and not told anybody else, and I'm the only one that knows, that is more unsettling for me.

So it's, it's kind of like they might be the same sort of level of need or the same level of risk if you think about it in that way, but it's kind of about what's my role here? And so when I can share it and help them to talk to other people about it, and that might mean for children, young people, letting parents know which, which again, can create difficulties sometimes if, if young people don't want parents to know, that can be be tricky. But, um, that's part of it for me is who, who else needs to know and, and who, who can I share this with is really important. If it's coming through the Medicare system, does the GP know, you know, by letting the GP know, but also who else can the person talk to about this? And, and sometimes that has meant, you know, in a session calling somebody to share that the person is, is feeling this way, and doing that together is something that I have done before.

And children and adolescents trying to do that in a way that, that, particularly for the young person, children less, um, concerned, I guess, expecting that we're gonna talk to parents, whereas young people sometimes can become upset by us saying we need to talk to parents about it. Um, but building trust with them, if I can, if I can see them long enough and build trust and then something shifting and I say, okay, I think. It's time to talk to your parents about this. Um, that can work quite well. But if I haven't got that level of, um, sort of connection with them, that can, that can be not so helpful. And then I'm weighing it up, have I done the right thing by telling the parent if that's meant that there's a rupture in my relationship with the young person. So it's all of those ethical issues that we, we often deal with.

So I keep coming back to what's, what's the most important thing here and who else do I need to know? Do I have enough to, you know, break confidentiality and often I don't that there's a, there's a risk there, but it's not necessarily an immediate sort of danger to themselves or there's not necessarily anything that I, that I need to do or that I've got to act on. But how do I keep the connection with them? And then what do I need to do to feel like I've done that? That whole thing about have I done enough here?

So for me, sharing it as much as I can, and if I'm not sure, arranging to check in in a few days maybe. So again, it's not built into systems particularly well, so it's not built into Medicare that I can have a phone call and be paid for that time. But I would prioritize that if I felt I needed to do that. It might be a check-in in a few days rather than waiting until the next appointment.

So those sorts of things that, that help me feel like I'm doing enough without overdoing it and taking on. Too much responsibility as well. So it's that line of where's, where's enough and, and how do I kind of feel like I've done what I need to do, but I'm also keeping the responsibility with them, encouraging them to be doing the work they, they need to do to get their own support as well, that that's not just about me.

And having my own supervision is, is obviously a necessary important thing, although I'm not always, I know that that's there and I can always do it, but I'm not always, that's not always a focus of my sessions when I take, you know, my concerns to, to my supervisor. It's not always the top of mind things for me. So I often feel like I, I kind of can feel confident in myself with what I'm sitting with and what I feel that I can, I can kind of live with and, and be okay with is something I've developed over, over time.

[00:22:37] Bronwyn: It sounds like it's really important to keep the conversation open about suicide, and I'm just wondering if you had any tips and tricks for conversations that we can do that, because I think clients can come to us with all sorts of, um, ideas that can elicit a lot of fear or shame.

So I am thinking men, for example, may have this belief in their head that if they want to take their own life, that they're taking the quote unquote easy way out, and that can elicit a lot of shame. Likewise, people may have been admitted to inpatient hospitals if they have merely disclosed suicide in the past to healthcare professionals. So yeah, how can we keep that conversation open without eliciting some of that fear and shame, or how can we manage that?

[00:23:13] Lyn: Yeah, look, I think it's using the skills that we use in every other situation, really. What is it that helps us to encourage people to feel comfortable, to share what might be difficult? So I think we, we don't necessarily have to see it as doing something special 'cause that then takes us into a different zone, but if we come back to what is it that works for us? And I think being curious is really important. So the wondering about it. And the opening that door so that people, the person knows that you are comfortable to have this conversation. That you, you will ask the questions 'cause you, you, it shows that you're caring, but you're not gonna ask it in a way that is, is gonna be too, you know, too restrictive or mean that I'm gonna be panicking about it.

So I think it's our work on being comfortable with the conversation is really important so it comes across as, as a curious kind of question or interest in, in the person and what's happening for them. And then, you know, how are they feeling about that? Is it hard to talk about, you know, have they had conversations with other people about this? What have there been past experiences and what has helped them?

Um, so there's sorts of things we might ask with any other kind of issue that people bring to us, I think is important. So building it in and having a certain level of comfort with it, while also being alert to, is there anything here that, that I need to, to kind of, yeah, be more concerned about and what do I do about that? But collaborative, really collaborative care, um, and being with the person while, while you're doing it, I, I think is, is really important. So you're not taking over.

[00:24:40] Bronwyn: It's really reassuring to hear that the skills you already have can be taken into this setting because I think particularly a lot of early career mental health professionals, they can feel quite anxious with the topic of suicide and then I guess can come across as quite anxious to the client or the client can pick that up. Um, so really relying on the skills that we already have... that sensitivity, curiosity, uh, non-judgment as well. These are skills that we've developed quite well in our training.

[00:25:05] Lyn: Yeah, absolutely. I think that's really important. And then people pick up on that so then they can feel comfortable talking about it. And I, I think then the more they talk about it, the more open it is, the less shame comes from that. And we can kind of almost normalize that sometimes when people feel distressed, then suicidal thoughts can come. And they're probably way more common than we actually realize. And, and there is a lot of shutting down of the conversation.

So if we can try to make it a bit more of a, a part of people's lives that you have this thought, it doesn't mean that you're gonna go and act on it. It doesn't mean that there's something wrong with you... It's, it's just a, a measure of your distress perhaps, or a marker of your distress, and that can be the conversation when it comes and goes, or it escalates, or it disappears for a while and then the thoughts come back. So you can kind of be externalizing it in a way, you know, what are the thoughts telling us when, when are they coming, and, and that's part of your safety planning discussion.

So you can be having this conversation that you can then put into a safety plan rather than going through the formulaic sort of safety plan document. You can be gathering this information and, and talking about it in this conversational way, and then you can use that in the safety plan. Say, well, let's all put this together into a safety plan. So you can make it very tailored and, and very conversational in the process. But really understanding it is, it's a sign of of the distress. And so what's that about? And again, that's what we do all the time. You know, what's important to them, what matters, what leads to distress, and then the suicide thoughts might come as part of that whole experience. And then what do we do about them? But underlying factors is what we need to be working on as well. So holding onto, we want you to be safe and how are we gonna do that? And we're gonna hear and work on what's bothering you, what's leading to those suicidal thoughts and trying to understand that and then work with that as well. So it's sort of holding onto both of those things.

But if we get too stuck on the risk part and we don't hear the other part, then that doesn't leave people with, with a sense of hope, I guess, if they feel like we're just too focused on, you know, whether we need to get hospital or not or what they're going to do to keep safe, rather than being with both of those things, and understanding the distress that- that they're going through at the time.

[00:27:10] Bronwyn: I think in the general public, um, there can be some discomfort with talking about suicide and we just wanna focus or get the person to focus on the positives as fast as we can. And I think that can translate even into mental health settings where we're like, maybe if I focus too much on the suicide and I talk about it at length, that will increase their risk and make them think about suicide more. Could you just tell us whether... fact or fiction?

[00:27:33] Lyn: Yeah. Yeah. Look, look, certainly that's been shown to be, um, a, a fiction that it's not true that we talking about suicidal raising suicide doesn't mean that the person's suddenly gonna think about it or make it bigger for them. In fact, people tell us that, you know, clients would say that it's the opposite, that they feel relieved sometimes or they, they feel more comfortable talking about it.

And, and if they, if we do ask, if you had suicidal thoughts and they haven't, that's still an important question to ask. So if they're presenting again, that formulation idea, we kind of know that people with depression, people with recent, um, relationship breakup might be greater risk of suicide, so it's appropriate to ask the question in a, in a sort of sensitive way. That doesn't mean that they're gonna suddenly think about suicide if they haven't before.

So it's important to be able to ask and feel confident in asking. And that even goes for, for children and young people as well. It's been researched, but it's looked at that and say that it is, it's okay to ask. And you make it age appropriate, you make it within the context of the conversation to ask the question doesn't mean that they're suddenly gonna think about it for the first time or, or, you know, make them at greater, greater risk.

It's not to say it wouldn't be distressing for them though, like it might be difficult. So I think that we, the way we phrase it is probably really important. It's a question we ask everybody in this situation, or sometimes this situation can mean that people start to feel, you know, feel quite a lot of distress and sometimes that can mean thinking about hurting themselves or, or even dying. Does that ever happen? So being very sensitive in the way we ask it and, and very conversational I think is really important. And then watching for that reaction in terms of um, whether that is actually distressing for them.

So, but yeah, generally the, the research is pretty clear that asking the question is actually really important actually to make sure that people have the chance, 'cause they won't always tell us. It's not an easy thing to, to tell us. So we need to give them the door to open the door. And sometimes there'll be a hesitation, and I think you can pick up on that, and say, it looks like you sort of say no, but look like perhaps you've thought about it or perhaps there've been times where that might have happened. So you're trying to pick up again, using the skills that we have around what's not being said sometimes what people say, but what's not being said or what's the body language telling us as well? So having having that door open is, is really important.

And then checking that out and then documenting that we've asked the question is also really important. So again, people may or may not tell us exactly, but we've asked the question, we've gathered the information, we're doing what we can, and then we are putting that in the context of what we need.

And I sometimes talk about safety planning even for distress. So if you're distressed, then what are the things that you could do that would be a safety plan, but I don't call it the suicide prevention safety plan, just called a distress safety plan. And that feels like I'm picking up on some of those things that if they're not telling me the whole story or if it does escalate after our session, I've done a bit of that, that sort of planning with them or help them to think about, you know, what can they do to calm themselves down and what are the, who are the people that help them, or where are the environments that they feel most, most calm? Or, you know, would they ever call a, a helpline if they did feel really distressed about something? So I tend use the safety plan idea in lots of ways, really not just waiting until they're, they're telling us that there's, there's actually thoughts of suicide or an act.

[00:30:57] Bronwyn: It's occurred to me that with safety planning, I'm wondering, I guess I have a two part question around this. So with safety planning, we know with risk assessment that the research is saying to us that if you conduct like a standard risk assessment, it may not be predictive of whether someone goes onto suicide. I'm interested in whether safety planning is actually evidence-based. And then there was, I think this is an ongoing conversation, but I'm curious if you know any research around it, which is, uh, contracting with somebody around suicide. So I think this is the concept that, uh, can you promise me that you won't hurt yourself, and I just wondered your opinion on that as well. So safety planning, is it evidence-based and then contracting? Is that good or not?

[00:31:40] Lyn: Yeah. Contract is very bad, so-

[00:31:42] Bronwyn: Okay, cool.

[00:31:43] Lyn: I can tell you that straight out. Yeah, and I remember that from years ago. I remember going to suicide prevention conference in the nineties, and I remember very vividly, vividly a person, I think they were from New Zealand, actually been working with young people and, and had said, um, I found, you know, contracts don't work. We, we find that they're just, you know, they're just in the pocket of people, but they don't, they don't do anything. They don't do enough. And then they're taking away the power from the, the young person and putting, putting it into the relationship rather than about the young person. And it's not giving them anything that they can do with that. So it's, it's not helpful. So it's, yeah, they're really not evidence-based at all.

Safety planning does have some research that is there. So they've done a lot of research when... so it's been around for about, um, 2012 first came out and there was a lot of research that was done with veterans actually in America. So it's American people that, that, um, developed it. And it hasn't shifted, like the, the actual headings for it still remain the same. And there's research, so Beyond Blue developed up the Beyond Now app and website, it's now on the Lifeline website is where you find it. And there's been research that they did around it as well and finding that it was helpful and because it's, it's, the idea of it is, it's about empowering the person and it's tailored to the person and it's not about, it's not relying on... so our rapport and our relationship is important, but it's, it's not actually about that. It's not about them promising us anything. It's about us working with them to be able to get to the point where they can see a way forward for themselves without support and with others support, which is what the safety plan is doing as well. It's bringing in other people who are the other people you can talk to.

So it's removing that, that focus from us being that main support or they're doing it for us. So in the moment that they're feeling most distress, that is, that's probably not gonna be enough. We're not, we're not gonna be there, it's not enough. So having a safety plan that tells them these are the things that they think will work, that you can keep adding to or keep checking in on, and who are the people that they can call who are the actual crisis people that are there for them if they needed that, and how they're feeling about that is much more beneficial. And so it has shown to, to be helpful.

And then there's ideas around Safety Plan Plus, which is that connecting in between sessions as well. So you do your safety planning, but then a week or two weeks before the next session might feel like a lot. So there might be a way of checking in, um, between that. So that's another kind of avenue just to, to kind of provide a little bit of extra support as well.

[00:34:08] Bronwyn: The way you are describing safety planning, it sounds very empowering, hopeful, it helps them, connecting with people around them. It's much different to, I guess, a standard checklist. Um, could you just describe how you make that safety planning process, yeah, like hopeful and empowering.

[00:34:25] Lyn: Yeah, well, it's really about what they know already, what they've been doing to keep themselves safe already, so I'm building on that. And people sometimes have chronic suicidality, so they've had this forever. So it's almost like their brain just goes to that, you know, it's sort of the go-to. They get distressed and this, the suicidal thoughts come, but they've done things along the way to keep themselves safe. So what have they done when they've kept themselves safe in that way? And what are those the, you know, what are the things, what do they know about it? So again, it's about getting them to think through and to tell, tell me, and that's that conversation. And the risk assessment process is gathering that information and drawing it out from the client. And then maybe what else could they do? Have they got other ideas or, you know, what hasn't helped so well that perhaps we need to think about some other ways of thinking about it. And then you're incorporating that and you say, all right, let's write this down.

So I don't always do the, the Beyond Now app one, sometimes online, I'll use that, and then that's there and we can see it together. But if I'm in my office, I actually use an old fashioned, um, carbon book, so I have a carbon copy, and so I just write it and write it down together. Very collaborative way, and I know the headings off my heart, so I'm not pulling out a worksheet or anything. I'm, I'm, I just know what's needed, and so I'm writing it down under those headings, and then I'm, it's a safety plan.

So it's their input, and then if it looks a bit light on, I'll sometimes say, that looks like we could do a bit more work on here. You know, but this might be, does it feel like that's kind of enough for the moment and maybe we can talk some more next time about some other strategies of keeping, you know, that, managing that distress. So then it might be, we're gonna do some work in DBT strategies or, um, we're gonna think about who else, you know, how else you could talk to people or, um, you know, what it would be like to, to contact one of the, one of the support lines or, you know, whether you text or whether you'd make a phone call or if you were to make a phone call, perhaps we can write out a script for that.

People sometimes say, I don't want to, I wouldn't know what to say. So then it's working through that and coming up with a script. You'd just have to say how you're feeling, and then they would ask, they'd take it from there, if it's a phone call or if it's online, it would be the same kind of thing. You just tell them what you're feeling and they'll, they'll ask you prompting questions.

So it's trying to help them to, to see that they could do it. So it's tailored to them. The headings are there to guide us, but it's very much around them sort of giving us the information through that conversation and then plotting it into a bit of a plan that's around their safety.

[00:36:50] Bronwyn: That's really nice. So working in this area, I guess if you're working with many clients who have suicidal thoughts or behaviors, it can be anxiety provoking. You might be thinking, well, what if they do go onto suicide? Um, I'm wondering what self-care or personal professional boundaries you would recommend for clinicians who work in this space?

[00:37:12] Lyn: Yeah, I think being really clear about what you can and can't provide is important. So, um, not again that, that idea around who else knows and who else they, they can talk to. So we don't feel like we're the, we're the only person that they would be expecting to help and what our availability is, or- or isn't. So having our, um, you know, out of office responses on for every email probably is important as a reminder so that there's no expectation that, that we're going to be there and be available and letting them know that, and then being clear about who, who they can contact or what the arrangements might be, depending on the, where you're working.

Um, and I think even the, the APS ethical guidelines around working with people who are suicidal do say that we can't always, um, we can do our best, but we can't always stop the person from dying suicide. So that is important to hold onto, I think. As hard as that is, we're doing our very best, but the very nature of suicide and suicide risk and what we don't know and what's happening for people's lives means that there may be times when, when you know, a person will die from suicide and the, and they're a client of ours.

So I think having that in the back of my mind, I'll do as much as I can and I'll do the best I can. Um, but that, that is a possibility. And, and having to kind of sit with that is, is a hard thing to sit with. But having to be able to sit with that and then that sort of checking in, have I done as much as I possibly can here? You know, and if that did get to that point, do I feel like I've, I've done what, what I can and have I, the documentation's obviously part of that as well, that I'm, I'm going through a process, I've talked to people that I need to, I've asked the questions I need, need to ask. I've, I've got a sense of what's happening. I've followed this process around safety planning. I've got a written document in my, in my file that, that is around safety planning.

So, so it's kind of feeling like I've done what I can, and then that kind of, I guess the, the dignity of risk is another part of that. The, the putting people in hospital doesn't necessarily guarantee that they'll be safe. And so what else can I do here? And that dignity of risk where we're sort of developing this trust with the client is, is pretty important, I think that that we're sort of trusting them to. To be able to use that safety plan to keep themselves safe. And then we're, you know, see them again when we can see them and they've got a plan, what to do in the meantime, I think. So sitting with that is, is really important. But back of my mind is always that we don't know. We don't know what's gonna happen, and so we do need to, to be able to sit with that as well.

[00:39:46] Bronwyn: Yeah, and related to self-care in relation to our own clients, I had a question from a listener who reached out about coworker suicide, and I think this can affect mental health professionals, medical professionals, and it can be a unique and I guess, shocking loss to us. And I just wondered whether there's organizational or self-care strategies that are needed in that particular circumstance?

[00:40:08] Lyn: Absolutely. I think that that's really hard because you, you're in that situation where you perhaps saw the person and then, but you weren't in an active role to do anything. So I guess as, as mental health professionals with a client, we, we kind of have some parameters around what we're doing and what we're expected to do. But if you are kind of witnessing a person who is perhaps struggling or you didn't even know, and then you hear that they've died from suicide, that, that's incredibly distressing. So we then moving into like the postvention supports that might be there. So Support After Suicide provides some good support website and, and contact line is probably quite helpful, but I, I think it would be very, um, very difficult and I, I've certainly heard of that, that happening and talked to people about that and, and really difficult to, the making sense of, I think is really difficult. And, and like with any kind of postvention, you know, what could I have done? What should I have done? And that, you know, hindsight, you, you kind of, if you knew what was gonna happen, then maybe there might have been some things that you could have done, but if you didn't know that you couldn't, you couldn't do it. Or even if you did know, it might not have been, um, you know, within your role to do it or might not have been helpful anyway.

So I think it's a, yeah, it's a tough one. And this is this whole question around, you know, the importance of suicide prevention, but also the importance of postvention and the importance of people, um, understanding the big impact it does have. So when you said nine people a day in Australia at the moment, and then that sort of, there's talk about 135 people, per each person that dies of suicide are impacted in some way. And that can be work, colleagues, family, friends, people that knew of them. It, it can be very, very impactful. So that's the, that's why it's such a, um, devastating experience apart from the, you know, the devastating loss of the person's life, but the impact on people around them is huge, but not often talked about, you know, there's silence around it, yeah. It's hard to talk about all that fear of talking about it. So it gets a, it's one of those grief that gets a bit lost or is, um, shut down, I guess disenfranchised or what we might describe it as.

[00:42:12] Bronwyn: Yeah, no, thank you for talking to that. Um, Lena, it's been such a great conversation about suicide today. I've got two more questions for you. Um, the first is, what do you hope listeners will take away from our conversation today?

[00:42:24] Lyn: Yeah, look, I think, um, people feeling confident in this space or as confident as they can be. So drawing on the skills they have, feeling confident that they can ask the questions that they need to ask and they can respond using all of the skills that they have already. They can keep, keep learning about it, keep keep doing their own processing of the information that they're getting and the work that they're doing. And then trust that safety planning. So trusting the process of safety plan, I think is, is really important. And yeah, just feeling more confident to be able to, to do the work and, um, feel like they, they can draw on the skills that they, they have already and not feel like they've gotta do something totally different. And just that, the comfort of being able to sit and listen and, and work with the person together.

[00:43:06] Bronwyn: Wonderful. And this is a question that I ask guests who, uh, have a, have a long career in psychology, because for early career mental health professionals, sometimes we can just feel like I am learning so much. Is it gonna be like this forever? It is so hard right now. How am I gonna stay in this career? And so for you, I'm wondering what's kept you going in this career?

[00:43:26] Lyn: Yeah, look, I, I think my changes across different, um, sectors and different type of work has been really helpful. And even now I like variety. So I do some private practice work, but I do quite a bit of supervision. I do some project based work, I do some writing work, and I, I just try to keep it, kind of keep mixing it up. And I, I do think the balance between the client work and the other type of work is actually important in terms of sustaining me.

So I, I think sort of having that variety is important and, and recognizing the client work is, is really demanding. So it's, it's an emotional toll and I see that when I'm supervising, um, you know, early career, um, people doing their internship and just that emotional toll that it takes and that ability to be able to step back from that, but also to sort of look at the big picture is important.

And again, I think because I'm a community psychologist, so the big picture is good for me and thinking about my little piece of the work is here, but then what's an area that I have an interest in, like for me, the suicide prevention work and working with children and, and families and working in schools has been areas that I'm interested in. So I keep developing those areas and then I connect in, so that helps me focus my new training that I wanna do. I keep working those areas, and then anything that I'm, any work that I take, it's sort of connected back to that as well. So I'm not too scattered. I've sort of got these areas of interest and keep reinforcing that and keep building on it. And then over time sharing with others. So I think that makes it contained in that way because yeah, it's such an interesting area, psychology, is so big and there's so much new information coming out all the time that it can be overwhelming.

So I think finding areas of interest that you keep consolidating is, is really important and, and mixing it up and, and feeling confident to try new things and working in different places, I think, that we've got all these skills that we can use and it can, can work in different places. And private practice is one place, but quite demanding in, in that, that work I think. So not feeling like that's the only place to, to work and, um, thinking about what else could I do and how I balance that with across the week and, and doing some other work as well.

And writing is, is fantastic. That helps you instill, you know, get that information together and, and then share it with others is, is kind of useful. So finding ways to maybe think about that. And again, picking up on skills we studied for so long and a lot of that was, was research and writing. So continuing to draw on that, if that's something of interest so that you're sort of thinking like you're doing a lot of things that give you energy as well as, as the actual client work, then that is maybe more emotionally draining, but also can give you energy depending on, on how you're working.

[00:46:01] Bronwyn: Yeah, no, that's really wonderful. And it's reassuring to hear because I think sometimes early career folks can feel like, well, private practice is the pinnacle, and if I can go in there and then I can be my own boss, then I'll just stay there for the next 40 years. Um, but it's reassuring to hear that client work can be emotionally draining and demanding, and that variety has really helped you in being able to explore your interests and maintain that sustainable career.

[00:46:23] Lyn: Yeah. Yeah, I think it's, yeah, I think it's a real worry that people think about private practice as the place to do the work. And I'm always... the interns that I work with, or early career people, I'm often saying, try to, try not to sort of see that as just starting point, 'cause I think I, I sort of became registered when I was working in the school, so I did the four plus two and then I went on and did my doctorate as well, but I became registered through that process.

So I had these people around me, so I got to see them, how they were working once. You know, registered even I was still part of a team. I was getting to see these, these more senior people and how they were, how they operated, you know, and particularly in a school setting, you know, how did they talk to principals? How did they talk to parents? How did they engage with kids? So I was witnessing that all the time. And I had someone there all the time that if I wasn't sure I had someone to go to.

Private practice, and I'm coming up to six years now, working private practice. I'd started just before COVID started, which is not great timing, I know, shocking timing. But I decided I wanted to get, I was doing project work, wanted to get back to, you know, closer to the ground. And I find it, you know, it's very isolating, it's really demanding. It... I have to work really hard at it, and that's why, for me, it's really important that I have my, my balance have certain range of work across the week.

People respond in different ways, but I think as a first option to, to be doing it, I think you need to have good support around you so that it is finding good supervisors or good peer, um, support that you've, you've actually got if you are looking at doing it, because it's, it's very individual focused and, and you can feel quite isolated even if you're part of, you know, group practice, you're sort of passing each other, um, in, you know, as you're all your clients, you're not necessarily having a, your time together, you know, and particularly if you're subcontracted and every session, you know, you paid per session, that, that's a lot of pressure as well. So I think thinking about all of that in terms of how, what are the options is really important, I think.

[00:48:19] Bronwyn: No, totally. Thank you so much for sharing that, and thank you for this wonderful conversation about suicidality. It's so good to be able to talk about this and hear the research from you. I was very keen to learn that yeah, you've done this degree in Suicidology and you knew all about this. I was like, oh, this is really awesome! Um, so thank you so much for generously sharing that information.

[00:48:37] Lyn: No problem, Bronwyn. It's a really important topic and always happy to talk and help people with it, I know it be difficult, so, but we have to go there.

[00:48:48] Bronwyn: We do.

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That's a wrap. Thanks for listening to Mental Work. I'm Bronwyn Milkins. Have a good one to catch you next time. Bye.