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RiskFrom reaction to action
Hanoi traffic
www.youtube.com/watch?v=cJwJnW0k6nU
1st April 2016 SimonRWilkinson@gmail.com 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?
1st April 2016 SimonRWilkinson@gmail.com 3
4
Mamma – I think you are carrying
us a bit too much.
5
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
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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.
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Predicting danger
• Automatic perception of signals
• Depends on experience
– In emotionally arousing context adolescents’ affective risk-taking
– Calm -> cognitively driven choices
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9
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
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Dissociation
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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
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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.
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«It’s a poor sort ofmemory that only works
backwords,» the Queen remarked.
in ‘Alice through the looking glass’
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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 SimonRWilkinson@gmail.com 15
«The idea that the future is unpredictable is undermined every day
by the ease with which the past is explained.»
Kahneman, p.218
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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.
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• 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 SimonRWilkinson@gmail.com
Information can come to be distorted and transformed to have best chance of predicting
danger or procreation -
without self-awareness of the transformations.
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Age and correcting misinformation
The older one is when misinformation created,
the more easily the mind will identify it,
possibility of correcting it.
• Trauma
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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
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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
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May be spurious association
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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.
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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
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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
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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
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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
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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
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The four Ps
•Predisposing
•Precipitating
•Perpetuating
•Preventive
………………… factors
Formulation
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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
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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?»
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Memory systems
• Implicit
Like System 1
• Procedural
• Emotional
• Explicit
Like System 2
• Semantic
• Episodic
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Dispositional representations in working memory
Body –dynamics and Implicit behavioural learning
Social-body-dynamics
Psycho-social-body-
dynamics
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Behavioural learning principles
Family therapy
CBT, psychodynamic
therapy
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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…..
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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
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Reduced impulse control
System 2 / Executive function reduced
• Substance use – alcohol
• Sleep disturbance
• Lack of social network
• Model from family suicide
• Access to method
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Suicidal adolescents
• 50% fail to seek help from anyone after attempt
– Coherent with which attachment strategy?
• 30% from friends
• 16% family members
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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 SimonRWilkinson@gmail.com 41
Self-injury motivation scale (SIMS-A)
• Regulating affect
• Regulating feelings of rejection
• Influencing others
• Magical control
• Self-stimulation
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Do standard suicide examinations breed
self-injury?
Kiddie-SADS: Lots of level 2 responses, but not level 3, suggests «emotionally unstable personality»
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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
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«Is behaviour coherent with what young person says about her state?»
What can any discrepancy tell you?
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Aggression and GxE
• Redused MAO-A activity in boys predicts
aggression
• Neglect predicts aggression
• Togethermuch higher level aggression
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Hereditary proposes, development disposes
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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
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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
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Rage
Rage: explosive, uncontained outburst of anger
Component of episodic dyscontrol
Different from planned aggressive behaviours (predatory and covert aggression)
= Reactive violence
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Three patterns
• At variance with general mood
• Associated with irritability
• Associated with excitability
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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)
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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
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• Type A inhibit affect instead of regulatingaffect
• Oppositional defiant disorder Dp A+ [ina]
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Type A 4,7
• Unplanned ‘ina’, released by triggers
• Role of unresolved trauma
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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
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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
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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
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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,
simonrwilkinson@gmail.com60
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
1st April 2016 SimonRWilkinson@gmail.com 61
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
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FACE Risk Profile
5 pages covering all sorts of risk and protective factors.
https://en.wikipedia.org/wiki/FACE_risk_profileLink provides useful references
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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
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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
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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?
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• Control is perceived by those who don’t have it.
• Power is experienced from the position of the powerless
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They all have a strategy until they get hit.
Mike Tyson
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Action speaks,
words just make noise.Rowan Atkinson tweet
jan 2015Simon R Wilkinson,
simonrwilkinson@gmail.com73
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.
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Assessing ligature points
• Magnetic rails in clothes cupboards
• Break-away shower heads
• Boxing-in pipes
• Magnetic brackets for curtain rails/blinds
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Symptoms which get attention thrive.
jan 2015Simon R Wilkinson,
simonrwilkinson@gmail.com80
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.
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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.
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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.
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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.
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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!
1st April 2016 SimonRWilkinson@gmail.com 85
She got self-compassion
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