risk - tallinna · pdf file•removing seat belts and motorbike helmets ... –to...

RiskFrom reaction to action

Hanoi traffic

www.youtube.com/watch?v=cJwJnW0k6nU

1st April 2016 [email protected] 2

Donald Trump is not driving

Hanoi cf. Tallinn• Hans Monderman

• Roadmarkings and traffic lights

• Removing seat belts and motorbike helmets

• Increased awareness of what is happening around

• Reduce speed

• Less accidents

Will this be a temporary phenomenon?


4

Mamma – I think you are carrying

us a bit too much.

Anna Freud 1969

Absence of a period of risk-taking results in problem behaviour later in life.

In ‘Adolescence as a developmental disturbance’

No Current Evidence


DefinitionRisk-taking: «Choosing the most variable option –the one with the biggest potential loss and the biggest potential gain.»

Context sensitivity of adolescent risk-taking.

Affective and/or deliberative risk-taking.– Role of impulsivity in affective type

Result can be adaptive or maladaptive, depending on rate of return.

Crone et al 2016 Neural contributions to risk-taking in adolescence –developmental changes and individual differences. JCPP, 57:3, 353-368 +

commentary 369-370.


Predicting danger

• Automatic perception of signals

• Depends on experience

– In emotionally arousing context adolescents’ affective risk-taking

– Calm -> cognitively driven choices


Predicting danger

• Automatic perception of signals

• Depends on experience

• Experience of VIPs (parents, other caregivers)

– Dissociation in a parent confuses children, who cannot identify the associated historical danger


Dissociation


A-DES

Predicting danger• Automatic perception of signals• Depends on experience

– Experience of VIPs

• Errors depend on attachment strategy– linked to contingencies of VIP responses during development

• Developmental pathway– More important than diagnostic category– Testosterone at puberty– Changes in network ventral striatum/ventromedial prefrontal

cortex from childhood to adulthood

Lead to automatic response to trigger signal• Preconscious and rapid when danger intense• Increases chance of survival

o Can lead to dangerous developmental pathway


The only information we have is from the past and the only

information that we need is about the future.

Determining priority of perceptions coming in,

based on consequences of similar previous perceptions.


«It’s a poor sort ofmemory that only works

backwords,» the Queen remarked.

in ‘Alice through the looking glass’


Avoiding risk through predicting danger

Information from the past needs to be made use of in such a way that it has the best chance of

predicting danger in the future –and sex.

In adolescence sex and danger may start to compete, leading to approach/retreat

dilemma – and risk.1st April 2016 [email protected] 15

«The idea that the future is unpredictable is undermined every day

by the ease with which the past is explained.»

Kahneman, p.218


Plausability is not the same as probability

The more dangerous the threat is believed to be, the more risk will be incurred to prevent or

overcome the threat.


• Parents – or therapists – who were exposed to danger will be on the look-out for danger

overestimate the risk of danger and threat to their adolescents / patients

• They can come to take larger risks to prevent danger.

respond rapidly/implicitly based on childhood experience

They think fast, rather than sloooow (Daniel Kahneman)

1st April 2016 [email protected]

Information can come to be distorted and transformed to have best chance of predicting

danger or procreation -

without self-awareness of the transformations.


Age and correcting misinformation

The older one is when misinformation created,

the more easily the mind will identify it,

possibility of correcting it.

• Trauma


Type A transformations of information

Age Affect Cognition

Infant Omit negative

Preschool False positive

School age Distort temporal information to favour a plausible story coherent with development


Type C transformations of information

Age Affect Cognition

Infant Omit informationon contingencies (causal info.)

Preschool Split and distort negative affect

School age Falsify causal information to favour a plausible story coherent with feeling-guided development


May be spurious association

[email protected] 24

The world’s biggest

Misanthropical ”gruk”

To appeal

To commonsense

Is the world’s biggest

Empty invitation.Piet Hein, 1940

How people explain their behaviour has no veracity.

1st April 2016

A standard form for registering risk

•What has happened before

•What triggered event – contingencies

•What increases susceptibility to trigger

•What has reduced chance of triggering

• Implications for practice

Triggering/”priming” happens below awareness,

and then shapes understanding.


Bayesian statistical reasoningHow prior beliefs should be combined with evidence.

•Need to know base rate

•Examine current evidence in light of base rate

•Estonian frequency of suicide in different age groups

•Estonian frequency of violence to staff by different sexes

•Staff familiarity with suicide/violence on the ward


Thinking, fast and slow. Kahneman, 2011

• System 1• Automatic and effortlessly speedy. • No sense of voluntary control• Tends to black/white simplicity• Self-protection

• System 2• Executive function• Allocates attention• Effortful. Associated with sense of choice, agency and

concentration• Needed to change way system 1 works

• If engaged in cognitive tasks, tired or hungry, system 1 takes over


Firth, Spanswick & Rutherford. (2009)

Managing multiple risks: Use of a concise risk assessment format. Child and Adolescent

Mental Health, 14 (1), 48-52.

Doi: 10.1111/j.1475-3588.2008.00514.x


Risk analysis (i)

Risks Previous episode

Trigger Vulnerability state

What self can do to prevent

What others can do to prevent

Dangerto self

Danger to other

Danger to things


Risk analysis (ii)

Risks Context reduced risk

Response to previous interventions

Skills to develop

Recommendation

to ward

Danger to self

Danger to other

Danger to materials


The four Ps

•Predisposing

•Precipitating

•Perpetuating

•Preventive

………………… factors

Formulation


And what triggers the staff?•Unit’s previous history of violence, suicide

• handling of guilt, shame

•Culture of Personal cf. System responsibility

•Parasuicidal behaviour cf. Suicidal behaviour

•Verbal threats of violence cf. Physical attacks

•Affects are «infectious»• In staff and patients


The emotional tail wags the rational dog.

The affect hueristic

– Answer to the easy question «how do I feel about it?», substituted for the harder question «what do I think about it?»


Memory systems

• Implicit

Like System 1

• Procedural

• Emotional

• Explicit

Like System 2

• Semantic

• Episodic


Dispositional representations in working memory

Body –dynamics and Implicit behavioural learning

Social-body-dynamics

Psycho-social-body-

dynamics


Behavioural learning principles

Family therapy

CBT, psychodynamic

therapy


Suicide

• Experience of suicide: personal/on unit

• Talking about it doesn’t increase the risk

– Questions in KiddieSADS

«There has not been any research (2000) which has indicated that suicide can be predicted or

prevented in any individual.» Goldney

Never been shown that admission prevents suicide….

but then how could you design an ethical experiment…..


Triggers and contingencies

• Loss of relationship

– After discharge from ward

• Anorexia nervosa in 6 months after termination treatment

• Loss of face

• Anniversaries

• Serious physical illness


Reduced impulse control

System 2 / Executive function reduced

• Substance use – alcohol

• Sleep disturbance

• Lack of social network

• Model from family suicide

• Access to method


Suicidal adolescents

• 50% fail to seek help from anyone after attempt

– Coherent with which attachment strategy?

• 30% from friends

• 16% family members


Self-injury• Proactive

– To force something through

– Important seen by others

– Balanced towards ‘deliberative’

• Reactive– Impulsive response triggered by the other person

– Balanced towards ‘affective’

• Non-functional interpersonally– Not part of an interpersonal transaction

– Usually kept hidden

If suicidal, get no warning - Deadly1st April 2016 [email protected] 41

Self-injury motivation scale (SIMS-A)

• Regulating affect

• Regulating feelings of rejection

• Influencing others

• Magical control

• Self-stimulation


Do standard suicide examinations breed

self-injury?

Kiddie-SADS: Lots of level 2 responses, but not level 3, suggests «emotionally unstable personality»


Violence

• Proactive– An aggressive stance taken up, independent of

bodily arousal, to force something through• Arousal secondary to stance

• Reactive– Impulsive response triggered by the other person

• Non-functional – Directed to material things and not an

interpersonal transaction


«Is behaviour coherent with what young person says about her state?»

What can any discrepancy tell you?


Aggression and GxE

• Redused MAO-A activity in boys predicts

aggression

• Neglect predicts aggression

• Togethermuch higher level aggression


Hereditary proposes, development disposes


BVC (Brøset violence checklist)

• Confusion

• Irritability

• Noisy behaviour

• Verbal threats

• Physical threats

• Hitting out at objects

Score >2 at end of each shift in connection with preparing in-coming shift

Note change


SAVRY (Structured Assessment of Violence Risk in Youth)

• Factors from history (10)

• Social/context factors (6)

• Individual/clinical factors (7)

• Protective factors (6)

– Prosocial peers

– Social support

3 or more acts of violence = high risk


Rage

Rage: explosive, uncontained outburst of anger

Component of episodic dyscontrol

Different from planned aggressive behaviours (predatory and covert aggression)

= Reactive violence


Three patterns

• At variance with general mood

• Associated with irritability

• Associated with excitability


At variance with general mood

Associated with some diagnoses:

• Tourette’s syndrome

• Autistic spectrum disorder/PDD

• Specific language impairment

• Obsessive-compulsive disorder

• Discrepant non-verbal reasoning ability. Verbal h, Non-verbal i (NVLD)


Mechanisms when discrepant from general mood

• Cognitive inflexibility

– pre-existing, fixed expectation

– transition difficulties

• High frustration “under lock and key” let loose

• Type A attachment strategy (A5-8)

• “Ina” – Intruded forbidden negative affect

• Not applied in an effective interpersonal strategy


• Type A inhibit affect instead of regulatingaffect

• Oppositional defiant disorder Dp A+ [ina]


Type A 4,7

• Unplanned ‘ina’, released by triggers

• Role of unresolved trauma


Associated with general irritability

Associated with some diagnoses:• Oppositional defiant/conduct disorder• Mood instability (cyclothymia, juvenile BPD)• Depression – not including the family of smiling

depressives• Type C 3,5,7

– Beware the Type C 4,6,8 switching to 3,5,7

• Sleep deprivation• Brain injury• PTSD or other anxious preoccupation• Substance misuse


Type C and Risk

• Confusion of present and past

• Difficulties in self-soothing

• Little interest in planning for future

• Preoccupied with own perspective

• Evocative language

• Confusion of causal sequences –perpetrator/victim confusion


Type C 7-8

• Menacing/paranoid

• Unfocussed anger – unclear about source

– More people potential targets

– More people feared

• Unexpected attacks, justified irrationally, with deceptive skill


Dialogue

What you mean to say.

What you actually say.

What the other hears.

What the other thinks he hears.

What the other says.

What you think the other is saying.

Mentalising

jan 2015Simon R Wilkinson,

[email protected]

Risk analysis (i)

Risks Previous episode

Trigger Vulnerability state

What self can do to prevent

What others can do to prevent

Dangerto self

Danger to other

Danger to things


Risk analysis (ii)

Risks Context reduced risk

Response to previous interventions

Skills to develop

Recommendation

to ward

Danger to self

Danger to other

Danger to materials


FACE Risk Profile

5 pages covering all sorts of risk and protective factors.

https://en.wikipedia.org/wiki/FACE_risk_profileLink provides useful references


https://en.wikipedia.org/wiki/FACE_risk_profile

Rules for healthcare system2

• Safety is a system property

• Transparency is necessary

• Needs are anticipated

• Waste is continually decreased

• Cooperation among clinicians is a priorityInstitute of Medicine Committee on Quality of Health Care in America 2001

Plsek, Wilson, 2001 BMJ 323, 746-9



Non-negotiables

Defining what is not open for discussion.

• Patient security on ward

– Smart phones

– Bullying

• Staff security

• A patient with AN and low BMI cannot choosewhether she will eat or not – but one can be more flexible with how and when.

Psychological first aid

• Keep the situation calm

• Facilitate feeling of security

• Aid a sense of belonging

• Enable an experience of coping

• Encourage hope


First fix the danger, then the child’s mind to the changed contingences to danger signals

1. Is there current danger or past danger treated as if currently dangerous?

2. Is child’s behaviour adaptive given the «danger»?

3. Does he know what knows, and why he doesn’t?

4. Is the child’s behaviour understandable for the parents’/therapist’s?


• Control is perceived by those who don’t have it.

• Power is experienced from the position of the powerless


They all have a strategy until they get hit.

Mike Tyson


Action speaks,

words just make noise.Rowan Atkinson tweet


[email protected]

The «Whys» and «Whats»

When parents/therapists ask ”Why” a problem arose, they need to know what to do.

When parents/therapists ask ”What to do”, theyneed to explore the ”why”.

Courtesy of Danya Glaser, 2010, Cambridge

• The role of a «risk manager» on the unit whoasks Why and What should be done– Assessing ligature points.


Assessing ligature points

• Magnetic rails in clothes cupboards

• Break-away shower heads

• Boxing-in pipes

• Magnetic brackets for curtain rails/blinds


Symptoms which get attention thrive.


[email protected]

Peter Cook & Dudley Moore

Dud: So would you say you’ve learned from your

mistakes?

Pete: Oh yes, I’m sure I could repeat them exactly.


A letter from a patient on discharge

Dear ***

I am so happy just now, it is really fantastic how happy I am just now! I feel I am ready fro the world, I feel I can manageeverything if I go for it. Think to feel it like that, think that it is possible. If it is possible for me, it ought to be possible for others. I am thinking of all the possibilities life is giving me, all the thingsI can achieve if I want to. Think that I have got to this level. I bet it is just a small part of everything that is out there in thisenormous world.


I think often of the future, think of the experiences. I will go out into the world, experience it and live out my destiny. I will find happiness, the real happiness, which few get to expereince. There arean incredible number of people who die withouthaving fulfilled their destiny, without realising theirdreams. This happens of one simple reason, theydon’t think it possible. But I know now, that it is possible. So long as one keeps tight hold of one’sdreams, and the thought that they can be reality.


I am completely clear over that terrible things happen outthere in the big wide world, but that isn’t what I am going to write about now, so I’m going to put all that to one side. Sometimes one has to put all sad things aside, if one feelshappy and just get hold of that happines you’ve found thenand there. Sad things and thoughts I can take care of later.

Life doesn’t just depend on feeling happy all the time and winning whatever the cost, neither does it depend on havingeverything served up on a silver tray without deserving it, nor being better than everyone else or the prettiest or having the best personality. But in the light of what I have been through, it depends more on feeling happy when one has the possibility, loving yourself as much as you expect to be loved, looking forwards, and when one doesn’t succeed, it depends on getting on your feet again.


Something I read once went like this ”life doesn’t concernfalling down six times, but getting up the seventh time.” Thatdescribes what I mean perfectly. In my opinion, therefore, the meaning with life, is a life with meaning.

Life can be fantastic, just if we will have it that way. I am norealist, I am a believer and just now, that functions just fine for me. Life is full of secrets, I am sitting on several of them. And many of these «secrets» aren’t really as secret as peoplethink.

But I would never have got to where I am today, without helpfrom all of you!

So thanks for everything!


She got self-compassion

risk - tallinna · pdf file•removing seat belts and motorbike helmets ... –to...

Documents