Contents
When you receive a request for an urgent consultation, the first task that you face is to decide whether an urgent consultation is indicated in this case? And what are the criteria for making this decision? Let’s discuss, discuss possible scenarios and start with the most unpleasant.
Suicide
Let’s talk more about the most difficult. After all, the first thing that comes to mind when we talk about the need for an urgent consultation is precisely the danger of suicide. A psychologist-consultant who, in his work, has encountered the topic of suicide, first of all needs to be aware of the following:
- External (visible) suicidal behavior, regardless of its type (demonstrative suicide, true, hidden) is a consequence / final phase of internal suicidal behavior (which, in turn, has its own stages of development).
- External suicidal behavior always has some kind of psychopathology under it.
- Not all auto-aggressive behavior is a suicidal attempt. There is a so-called non-suicidal auto-aggressive behavior, i.e. such forms of intentional self-harm, the purpose of which is not to die and the implementation of which is not life-threatening.
- Counseling a person after a suicide attempt, you are not counseling a suicidal person, but a post-suicidal person.
Conclusions:
It is necessary to focus on internal suicidal behavior as the main target of the consultation.
It is necessary to identify, understand and, at least in general terms, describe psychopathology.
Suicide is an extreme form of auto-aggressive behavior, but it is far from always a direct consequence and result of the development of non-suicidal auto-aggressive behavior.
Who is not eligible for urgent psychological counseling?
Acute suicide
Let’s start with a definition. Acute suicide is a compulsive action against the background of an affectively narrowed consciousness, aimed at the speedy reduction/cessation of mental pain. It arises as a reaction to an extraordinary psychotraumatic effect that exceeds the compensatory forces of the personality. The likelihood of such people consciously asking for help is extremely low. However, people in this state can be deterred relatively easily from self-injurious acts by avoiding contact with the suicidal weapon and by having someone close to them. The role of specialists is minimal. Active, warm-emotional listening from a sympathetic position is needed.
Examples: death of significant relatives, news of an incurable disease (or severe consequences of the disease), acts of physical (including sexual) violence, social events catastrophic for the individual (partings, quarrels, divorce, dismissal, sports and creative failures).
It is necessary to recognize and understand the difference between acute psychotrauma and acute suicide as a result of acute psychotrauma. It is quite possible and even necessary to consult an acute psychotrauma with elements of internal suicidal behavior. Counseling acute suicide is unlikely to succeed.
Psychosis
Without delving into the definition of the term and the types of psychoses, I will say that psychological counseling is not indicated (useless) when you observe:
Imperative hallucinations. This is when «voices» order a person to do this or that auto-aggressive action. If the client at the consultation reports that “voices” or people insist that he, for example, jump from the 9th floor, then you should:
- interrupt the consultation
- call the psychiatric team
- try, under a plausible pretext, to keep the client until the SMP arrives.
(Of course, other signs of psychosis should also be clearly visible, but don’t worry about that. With imperative hallucinations, there will be a bunch of other signs that you won’t pass by.)
automatisms
This is if the client reports that someone else controls his body (thoughts, actions, sensations), and he himself cannot always (or not at all) control himself. The algorithm of actions is the same as in paragraph «A».
Manic state
A maniacally excited person is not at all a murderous maniac from thrillers. This is a very cheerful (and / or angry), loud, often hypersexual person who chatters incessantly, but it is difficult to catch the meaning of his words. Expresses different ideas of his own strength, great opportunities, talents, connections, etc. He believes in himself infinitely, almost does not sleep, does 100 things at the same time, not completing a single one. I must say that manic suicide is now extremely rare. Such a patient will not have a true suicide, but he may well … tell you that he is going, for example, to jump from the roof of a 20-story building with a parachute of his own original design.
About the suicide of melancholic will not. It is now also rare, its motives and psychopathology can be considered in the section on depression.
Algorithm of actions:
It is necessary to terminate the consultation as soon as possible and, if possible, immediately refer the client to a psychiatrist (it is desirable to have a psychiatrist acquaintance).
All of these examples are suicidal attempts (or intentions) carried out / expressed by mentally ill people. They do not need to consult a psychologist. The consultation itself will consist in diagnosing the observed psychopathology and actions to terminate the consultation in any appropriate way.
Who needs urgent psychological counseling?
What are the most common things that psychologists and psychiatrists encounter when identifying or encountering suicidal behavior?
We answer: with depression, with demonstrative suicides, with insoluble and/or prolonged conflicts that exceed the compensatory capabilities of the individual. Let’s talk in more detail.
Depression
I would conditionally divide into suicidal and non-suicidal. Why conditionally? Strictly speaking, the following classification of depression is clinical, outdated and is not currently used in diagnosis. At least there are no such diagnoses in the ICD-10. However, it is convenient, is still used by doctors, especially in the post-Soviet space, and has explanatory power, i.e. for the algorithmization of psychological counseling is the best fit.
- Suicidal non-dangerous depression: dysphoric, hysterical, senesto-hypochondriac, somato-vegetative, anxious, obsessive;
- Suicidal dangerous depressions: anesthetic, adynamic, bipolar, melancholy, hidden, smiling (“ironic”).
The format of the article does not allow writing about the counseling algorithm for each of the types in more detail.
The general algorithm of actions is as follows:
- Independently study these types of depressions (the most general descriptions are enough).
- Formulate consultation questions in such a way as to broadly understand the psychopathology of depression in a particular client.
- If, in your opinion, depression falls into the category of suicidal danger or the fact of suicidal attempts in the past is established, suggest that the patient manage it together with a psychiatrist.
Demonstrative suicide
The main thing you need to know about demonstrative suicide: it is … demonstrative. Those. — in the vast majority of cases is not associated with a real intention to die. Only in a small number of cases, demonstrative suicide can be the last chance to influence a traumatic / conflict situation, an extreme attempt to influence the environment, to declare something or … to take revenge.
Algorithm of actions:
Determine motives. As a rule, the suicidal person talks about it a lot and easily.
To determine the degree of manipulativeness of both suicidal behavior and the personality as a whole. The definition is qualitative, not quantitative. The more manipulative the client is, the suicidal danger is … less.
Ask openly about the frequency, prescription, nature of non-suicidal auto-aggressive actions. They tend to be present in the client’s life long before the suicide attempt.
Then work in the manner in which you work with borderline clients.
Irresolvable/protracted conflicts/chronic trauma
The most complex and responsible section of counseling for suicidal behavior. This section concentrates the largest number of cases of true suicide. Suicide rational, carefully considered, taken seriously.
As a rule, his specific psychopathological background is a suicidal dangerous type of depression. The two main processes that a consultant must have are calmness and warm, concentrated attention. Clearly expressed sympathy is optional!
Algorithm of actions:
Find out the circumstances that led to the suicidal attempt (intentions, thoughts).
Find out how the client relates to their own actions / thoughts (degree of criticality).
To identify the absence/presence/degree of depression.
Ask (!) about further suicidal intentions.
Skype consultation
… has one distinctive feature that will significantly affect all subsequent work. This feature is the absence of a direct physical meeting in a certain territory (usually the consultant’s territory). In relation to suicidological counseling, this means the following:
Responsibility
There is no doubt that a specialist who is faced with the topic of suicide in a session (whether real or remote) finds himself in a situation where there is responsibility for the life and well-being of the applicant. Moreover, this responsibility is not a voluntary act for the psychologist, but is assigned to him automatically, based on the very context of the situation.
Limitations of Liability
At the same time, it is necessary to be aware that responsibility can become a productive and really helpful basis for consultation, subject to certain conditions, namely: 1) sufficient professional skills, 2) the physical possibility of their implementation, 3) the presence of a minimum amount of reliable information about the client.
So, during suicidological, especially urgent counseling on Skype, the psychologist almost completely lacks the opportunities (tools) to realize his own responsibility (which we, people in the helping profession, oh how easily we take on!). Leaving out of the brackets such a component of the boundaries and limitations of a psychologist as professional skills, let’s talk briefly about the same as before, but in relation to Skype counseling.
The first thing to do is to conduct… an inventory of your capabilities to realize your own responsibility. This is where the terminology of boundaries, widely used in the Gestalt approach, comes in very handy.
Let’s consider the limits and possibilities of Skype in the previously described consultative cases in more detail. Who is not shown urgent psychological counseling via Skype?
Acute suicide
Oddly enough, but a Skype consultation is more possible than a real one. It’s all about the ease of the call. Just imagine… Would you, feeling an acute desire to die: get ready, leave the house, go by car or public transport (and there are traffic jams!) to a psychotherapist? And if you just call on Skype, especially since I (for example) already go to someone and can easily contact this someone?
In this case, the psychologist can be recommended the same as in a real consultation, with the addition of a paragraph on the inventory of the possibilities for realizing one’s own responsibility.
Psychosis
Based on the above-described variants of psychotic disorders in which suicide is possible, we can say that the main task of the consultation should be to understand … one’s own boundaries and limitations, i.e., again, the point is this inventory of one’s capabilities:
- what do I see, what kind of psychopathology?
- what should i do?
- What can I do?
- What do I know about the client for sure? First name, last name, place of residence, phone number, place of work, other data?
If an inventory (and a quick one) of your own capabilities shows that you can do little, then … your responsibility in this situation simply does not come. If you continue to feel it, clearly understanding your limitations, then this is the fruit of your personal fantasy, the result of professional deformation and … in short, with this for personal therapy.
If you see, for example, that a person has imperative hallucinations, and you do not know his first and last name, do not know his relatives and friends and / or ways of contacting them, do not know the current location of the client and cannot physically hold him, then it is necessary stop such a consultation, clearly and clearly informing the client why you are doing this. Still it is necessary to strongly recommend to address to the psychiatrist immediately.
The situation is slightly different if you personally know the client, his environment, his living conditions, marital status, location, and so on. This knowledge is a tool for realizing your responsibility. For example, if the client is talking from home, get someone from your family to approach the camera. If you know your relatives and their contacts — contact, talk, convince …
Conclusions
The circle of clients who are not shown an urgent consultation on Skype is almost identical to that of an urgent consultation in real space, with the exception, perhaps, of acute suicide. The main mechanism and algorithm for such a consultation is an inventory of one’s capabilities.