hello good afternoon and thank you for joining us today on the second of this series The Suicide Prevention webinars it's it's um it's great to have you with us um today we're going to be talking about risk assessment um specifically risk assessment in relation to Suicide um we talk about this a lot and it's something that it's important that we do talk about a lot and um hopefully today we'll continue the ongoing discussion that that needs to take place with regard to how we can um you know reflect on our practice and do our best for those uh for whom we care now as with any um of these webinars um we do appreciate that we're talking about difficult issue and some people will have um experienced or been exposed to uh suicide or or attempted suicidal self-harm in their professional lives and possibly in their personal lives in the chat Emily has put in details about the support after suicide organization and also details of your matter which is our staff wellbeing Hub and you can approach them at any time if you require support not necessarily specific to the topic we're talking about today but generally now it's a real privilege today to welcome um the co-authors of a paper we recently published around risk assessment uh specifically around therapeutic risk assessment and management and formulation and management um so we have Professor Keith Horton from the center for suicide research which many of you know and we we hear from him we're fortunate to hear from him frequently in addition we have two of the other three co-authors Alexandra Pittman who is a consultant psychiatrist and a clinical academic linked to University UCL I don't can't even remember what that stands for but it's a university in London um and she specializes in research around suicide and self-harm and we're also um joined by Steve Gilbert who uh again is an author on the paper Steve has um extensive experience of um mental illness including periods of depression and suicide attempts and hospitalization he has a diagnosis of bipolar disorder and complex PTSD the result of um psychological abuses experienced in his early years through to adulthood um so Steve was um generous with his experience in helping to guide us in the development of the Lancet paper we will put a copy of that with the webinar on the intranet Steve um was appointed as Vice chair for the mental health act review he supported the chair in making recommendations to government showing the service user and carer group and co-chairing the black African Caribbean working group he's also advised the National Suicide Prevention Alliance on the meaningful involvement of suicide attempt survivors and through his consultancy he now supports organizations implementing ambitious anti-racism programs so we're really delighted Steve to welcome you joining us today um so you will hear from Keith followed by Alexandra followed by Steve and then there will be time for question and answers so please um put your q and A's in the in the Q a chat and we will come back to them after everybody's presented and hopefully have um an interesting and constructive discussion thanks very much without further Ado I will hand over to Keith um thanks very much Karen um and uh I guess many of you would have been watching the uh very moving ceremony of uh the Queen's body being transferred from Buckingham Palace to Westminster Hall this afternoon so uh thank you thank you for joining us um after that uh occasion so if I can have the first slide please as Karen um said um a group of us have been uh working on writing an article about uh um suicide risk assessment sorry could I have the first slide please Victoria there okay thanks very much um we've been thinking about uh the problem of suicide risk assessment um in mental health practice which is obviously a major concern for all clinicians um and uh yet is associated with uh considerable problems and we ended up writing this article um assessment of suicide risk in mental health practice shifting from prediction to therapeutic assessment formulation and risk management um I guess it took us a year or so to do so but it was published about uh five weeks ago in Lance's Psychiatry could I have the next slide please this is the the actual uh article and as Karen said it will be made available on the intranet so you don't need to send me emails to have copies of it uh the next slide please now um in England uh we know from the confidential inquiry the national confidential inquiry that of people who die by Suicide which is approximately 5 000 per year some uh 25 to 30 percent have been in current contact with Psychiatric Services uh at the time of their death or in the year before their death and therefore it's very logical that in clinical practice one should try to predict those patients most at risk but this is where the major problem is suicide risk prediction largely does not work next slide please so what is the evidence for this uh next slide please now in the uh nationally and confidential inquiry reports of 2021 shown here there was Data published on clinicians retrospective assessment of um patients risk at their last clinical contact prior to Dying by Suicide next slide please and um this was over 11 years so it was included a very large number of patients and um all these patients had died by Suicide yet the clinicians estimated immediate risk at the last service contact prior to Suicide was low or absent in 85 so nearly all were thought to have been at low or nil risk of suicide and yet they died by Suicide within a relatively short short while and even when clinicians were asked their estimated long-ter longer term risk for each of these patients they thought it had been lower absent in nearly 60 60 percent text slide please in a much smaller study from the USA this is 132 patients in mental health care who died within 30 days of a clinical evaluation uh three quarters of them had denied suicidal intent when they were last asked and and yet half of these died within two days of being asked about their suicidal intent died by Suicide that is next slide please and there's many other studies showing that the majority of people who die by Suicide majority of mental health patients who die by Suicide have denied suicidal intention when last asked before their deaths these are some older studies and there's uh lots more more recent ones that show similar findings next slide please so why might this be why would people who go on to die by Suicide shortly afterwards uh deny that they were feeling suicidal that they had suicidal intention at the time of a clinical assessment well one possibility is that they feared being judged negatively uh by clinicians and and therefore hid their suicidal intention another might be that they didn't fully understand the question it might not have been put clearly another possibility is that they were asked in a manner which encouraged a negative response such as you're not feeling suicidal are you or you're not thinking of doing something silly for example um uh or they may have feared that if they'd answered positively then uh their care would have been increased in intensity and possibly there might have been sectioned or whatever um or of course they may have been wanting to hide the fact there was suicidal and be present prevented from uh engaging in a suicidal act but probably the most likely reason in the vast majority is they weren't actually suicidal at the time next slide so if we look at the um the issue of suicidal ideation and we know that suicidal thoughts are often very brief they fluctuate uh over time and as an illustration of the brevity of this there was a study by uh Dyson hammer and colleagues who um interviewed patients who attempted suicide and nearly half of them reported having thought about the act for 10 minutes or less beforehand and then in a study um by climate and colleagues uh where they did ecological momentary Assessments in other words they uh repeatedly got measures got patients to re recalled measures during the day time um and these were patients who'd attempted suicide in the previous year or in mint or mental health inpatients because of suicidal ideation they found that their suicidal ideation vary dramatically over the course of most days as did measures of hopelessness a sense of Burden being a burden and uh so a reported loneliness next slide please now one of the the issue here is that in clinical practice if no suicidal ideation is expressed by a patient at assessment uh the the risk assessment may end no suicidal ideation and then therefore their risk may be formulated as none or low um and as a result of this there are clinical priority may also be regarded as low and there are any sort of clinical intervention May well be delayed next slide please what about use of risk scales how well do they work next slide please I mean there have been many uh studies looking at suicide risk prediction scales or risk prediction tools uh some of them are looking at risk protection in general for suicide some of them looking in specific groups of patients who may regard be regarded at particularly high risk such as people who'd self-harmed next slide please and yet uh the uh outcome of these tools is extremely poor so the positive predictive value is about five percent which means that they're wrong 95 of the time in terms of the projection they provide so while um suicides are somewhat more frequent in a group of patients who are measured as being at high risk um the difference in Risk between them and I those in other risk groups are not great and importantly most suicides include occur in the much larger group of patients who are identified as a low or moderate risk and this is what we call the prevention Paradox next slide please and as a result of this evidence in the um nice self harm guidance published in 2011 and uh of which there's been an update just a week or so ago the recommendation was do not use risk assessment tools and scales to predict future suicide or repetition of self-harm so this is specifically in self-harm patients and do not use risk assessment tools and scales to determine who should be offered treatment who or who should be discharged there has been an acknowledgment that risk assessment tools can provide a structure within an assessment and as such may have some use but in terms of actual prediction they really don't work next slide please why why then are we so obsessed with risk predictions suicide risk prediction well one thing is of course that hospital organizations are are extremely echinite trusts are are very keen that uh risk prediction measures are completed um one sometimes wonders if that's more for the protection of the trust rather than the patient um given what I've told you about their poor performance Regulatory Agencies maybe drivers of um of the use of risk scales so organizations that oversee trusts or have other regulatory responsibilities corners and similar agencies may expect a risk assessment to have been completed on patients who've died by Suicide so there's sort of paradox there that the coroner May would ask well was the risk assessment completed uh and yet the patient died and of course clinicians May themselves uh be Keen to use such measures partly I guess to maintain some sort of sense of control even though the performance of these measures is pretty useless next slide please so what are the alternatives to risk prediction what is a another way forward well the first one is to obviously recognize that risk prediction is a fallacy um uh if you think about yourself can you predict exactly what you're going to be doing in a week's time I certainly can't um and and the same applies to prediction of a suicide risk but I think it's useful to think about a sort of population approach to prevention of suicidal Behavior next slide please and an analogy here is with uh blood pressure so this slide is showing um the effect of adopting a population approach to shifting blood pressure in other words reducing blood pressure in the population by a small amount just a couple of uh between two and five um millimeters of blood pressure and you bet yet you can see bottom right the impact this can have in reduction of deaths from from a range of causes and we should be thinking in the same way about suicide uh Suicide Prevention in in mental health patients so I'm going to hand over now to Alexandra who tell you a little bit more about the approach we've espoused thank you next slide please thank you so I'm going to focus now on on the process of dynamic risk formulation um next to slice please and this is an approach which allows you to really use the time liberated by no longer being preoccupied by you know categorizing people into high medium low risk to really take the time to develop um a Therapeutic Alliance with your patient and to really find us about the things that matter to them and the figure that we use in our article um which we adapted from a figure presented by some other authors we we presented this figure because we found it a useful way to organize the detailed information that you collect in a in a therapeutic risk um therapeutic assessment and the these this um structure presents things that they look like suicide risk factors but we really mean them to to um stand for factors that can cause distress in any patient presenting um for mental health care and so we've organized them into predisposing factors um strengths which sometimes we think of as protective factors but also importantly modifiable factors and these are the kind of things that we really focus on in our care plan and thinking what we can change for the patient and then still hope in them that things can change and we're also gaining a sense of what might happen to them in the future and that's why this is a really Dynamic assessment because we're anticipating where things might break down for them in the future so for example we might identify under strengths and protective factors that somebody has really good social support from a partner but in the future it may be that that relationship could break down because the relationship is is sometimes a little difficult so we need to anticipate that if it does break down or if that person is in poor health and might pass away in the future that things might change and this is something which changes over time so every time this patient is assessed by you or by by other clinicians um different factors might have different resonance at different points and if any of the factors in the top right become particularly problematic for example under the under the um the the physical health category you might have somebody Who develops acute pain and that means that they are in severe distress and feeling extremely suicidal um then this could be a warning sign that they could be at risk but the point of the approach we describe in the article is that we are thinking about these factors for every single patient attempting to reduce their distress and try and address modifiable factors to to reduce the distress and in Brackets risk of everybody who we assess next slide please and the next one please so the the time that's spent really getting to to know the patient to understand all these factors that matter to them um and organizing into this framework can help us see how a patient might typically respond um to live stresses and how that might um become very distressing for them and how that might precipitate a suicidal crisis so for example they may be in a situation where they're being bullied at work or they're under a lot of pressure and they notice that they're becoming more stressed their sleep is impaired and they're becoming more irritable and low in mood they're starting to row with people around them who would normally constitute their social support slightly alienating people around them you can see how these Dynamic factors are changing all the time they're starting to increase alcohol which might also mean that their antidepressants are less effective um and they're starting to notice negative thoughts and they become really quite suicidal so this is a really helpful way to think about where you might address a modified risk factors and where you might start to identify things breaking down early on and intervene at an earlier stage and next slide please so the next section is to think about next slide please um addressing um patients needs and thinking about interventions that are going to make an immediate difference and I think one of the things that patients who present in suicidal crisis sometimes feel is that nothing really happens as a result of attending um a crisis service and that's regardless of whether they are feeling suicidal at the time or not and a way to really reinforce that Therapeutic Alliance is to identify things that can make an immediate difference to them so if somebody is in pain you can ask somebody to review their pain perhaps refer them into a pain clinic make sure that their pain medications are optimized you might refer them as local Alcohol Services you might talk them through interventions that they can use to address their sleep so these are all things you can discuss in the moment that they can they can enact immediately to shift something in the factors that cause them to present and at the same time think about how these can be reinforced with longer term interventions and thinking about what's available locally in the trust but also in the community to think about a range of evidence-based interventions that you could refer them for or if you ask someone else to do it to make sure that happens and to ensure that there is that continuity of care because sometimes people describe it very frustrating meeting someone in a crisis situation and then the plans that are made are not followed up by colleagues within the same organization next slide please so the next thing we're going to talk about is um safety planning next slide please and this is something that we mentioned in our article because it's something that you can do in the moment with the patient and because you've spent all that time really thinking about um the very individual circumstances that they present in you can construct with them a really detailed safety plan which isn't a generic you know call a helpline if you feel suicidal it's a really thoughtful safety plan tailored to their interests their social network and the kind of things that tend to work for them so this is a very structured stepped approach in which the the first stage is to identify you know what are the kind of things that tend to precipitate Christ precipitate crises what are the things that you notice are starting to go wrong so relating that to the example in the previous slide somebody might be feeling very stressed at work they're becoming more irritable they're around people around them they're starting to drink more so these are the kind of things that you might put into the safety plan or they might write into their own safety plan that's been printed out for them so they can take this away with them the next two stages steps three two and three are very much focused on distracting somebody so that they can really tie themselves over through the crisis and these involve thinking about things that that distract them some people like um watching book sets or they like going out for a walk but you have to really think about um things that are going to be feasible so if they tend to be in crisis at four o'clock in the morning and they live in an unsafe area it's just not worth putting something in like going for a walk and this reinforces the point about tailoring it to their own needs the third step is the the the the first point at which you actually contact a human being and I think that's really important because this whole safety plan um reinforces the patient's autonomy in using steps one and two to manage the crisis by themselves before enlisting other people and the other striking thing about step three is that it doesn't actually involve telling anybody that you're having a suicidal crisis it may involve burning a friend and saying oh do you want to go for a walk together just to distract you rather than talk to them next slide thank you so it's step four is is the point at which you actually disclose to people that you are feeling suicidal and remember that these steps um are progressed through with the step before isn't working so if you've got to stage three and and the crisis is resolved and you don't need to progress to step four but it's step four you're asking people um in your Social Circle who can provide support so these are people who you've identified in your assessment that they trust and can share their problems with and would be available in times of Crisis and ideally and this is something to discuss with them they should be aware that they've been included in that safety plan and step five and notice this is the first time that professionals appear in in the safety plan this is when you might call the mental health Team your GP or any bones receptor organizations that are appealing to you so they may be specific Services they've used or that are suitable for their demographic and then the final stage is really making the environment safe and this is deliberately at the end um it's the idea of removing potential harmful means and this obviously invokes the idea that restricting access to the means of suicide is the most effective Suicide Prevention intervention and finally in red here it's so important that this is written down for the patient to take away with them that you've agreed it between you it's not something you've just created and given to the patient and something that is a live document so they can edit it every time they feel they need to next slide please and here's an example of a of a safety plan that might be suitable for use in Oxford it's got a Oxford Health um and at the bottom there but again it's really important that this is this is tailored to the individual next slide please there is evidence that safety planning is effective in reducing suicidal ideation and what's striking here that was is that the number needed to treat and the systematic review of studies evaluating the effectiveness of safety planning interventions and the nominated treat was 16 so that was um you'd need to to deliver a safety plan to 16 people and to have somebody um have a show reduction in in suicidal Behavior so I think that's very encouraging evidence next slide please involving relatives um is sometimes difficult because um even though this is good practice and it's recommended in guidelines produced by rethink and the recent nice guidelines it's really important to gain the patient's consent and sometimes patients do say look I don't want my relatives to know because I don't want to worry them and I I don't want them to know how bad things are and I don't want to that you know them to to use this as a weapon against me because things are not going very well at the time but that it's important to explain to the patient that there are a lot of advantages in this because it helps gain another perspective on their difficulties it also gives a chance to gather some information on the things that the family might be concerned about but also it brings the family in um in a collaborative role and many relatives Express frustration at not being involved more in a more collaborative way um in crisis plans so it gives them an awareness of their roles so they're not surprised in a crisis if they're suddenly contacted and it also reassures people that the person who who is distressed is getting a support next slide please so finally um next slide to focus on the therapeutic aspects of of the relationship I hope that you can see that there are really clear advantages in taking the time to convey your concern for the patient and your real interest in finding out about them and to use you know I suppose Advanced methods of of verbal and non-verbal communication to really convey empathy and the fact that you're very very interested in identifying things that you can you can help them with but also identifying their own strengths and being clear that you're motivated to address their needs to try and shift something for them next slide please so in conclusion Keith has shown very clearly that suicide risk prediction doesn't work and that it's very important that we shift the focus from trying to predict risk in these these kind of golden hour with the patient to a much more therapeutic and dynamic um formulation of their needs and an individualized risk management plan for every single patient you assess although this is a conclusion slide there are a couple more slides after this just to reinforce a couple of quotes made in our article next slide please this was a recent editorial in the times which really captures the sense of frustration that the public have when they see their loved ones attending in crisis and them being received with a rather sort of formulate hitbox approach which they really find very impersonal and um and they really feel that you know that tick box approaches should be ditched and that we should really move towards the kind of approach that we've described in this presentation next slide please there are challenges obviously to the approaches we've described here and there are implications for for training and you know for many many years Keepers published um you know Keith has published a systematic review which shows that for many years there has been qualitative evidence published showing that you know people have very bad experiences of um a e and um presenting in suicidal crisis and it's very clear that some of the attitudes of Staff um of are very difficult to contend with at times and so there's a lot of training implications there and it's also important that hospital organizations are on board with the approach we describe and don't insist on the tick box approach that is um so much maligned there is obviously a lot of paperwork involved in thinking about um you know documenting the extents of histories that are being gathered and there's also something to think about with coroners if coroners insist that you know tip tick box approaches should be followed when we're doing these kind of Assessments and finally you know in the middle of the night in a very busy a e Department it may be very difficult to find a quiet place and to find the time to do an assessment such as the one we describe but I hope that this presentation really reinforces how important this is to to at least try and do so next slide please I'm not going to hand over to Steve Gilbert um but just do read our paper because I hope that you'll find it interesting to to read what we're discussing here in more detail thank you um and I want to thank the whole team for for uh wholeheartedly and for fully involving me um in the process of writing this paper um and what I want to do is I want to I want to share a sort of experiences um so and I want to take you back to June 2008 uh and if you were with me then you'd have been living in a postgraduate house um I had been working as a supply teacher an unqualified teacher teaching science um and I lived a couple of hundred meters away from the GP surgery really nice area that I lived in and this is now the end of June and I am terribly depressed and I am convinced that I have to die and I knew I had to go to the GP I knew I had to go and talk to someone um I'd exhausted all other options I've tried to find some online support I try to find what I now know to be kind of third sector support I was an eligible or the weights lists were extremely long aren't the walk from my front door to the GP surgery is still one of the longest walks I ever took and I remember walking up and there were steps one side and there was a an accessibility ramp and there were these doors that that were on a center that opened and the first time I walked thoughts as far as I go and then I ran home and locked the door and then a few days later I mustered the strength to go back and I kind of got halfway up the ramp and then I went home and and eventually after a few days and a couple of more of the tents I actually managed to make it through the doors and one look at the receptionist and ran out I finally managed to make it all the way up the steps to the receptionist desk and I can still remember this face I can still remember having to explain why it was so urgent that I needed to see a GP I want you now to picture that there had been a camera focused on me the whole time and I didn't look like I looked now you were looking at a man who was 24 who hadn't slept properly for eight weeks you are looking at a man who hadn't eaten properly for eight weeks a man who every single waking moment was trying to figure out how do I fix my life I it was falling apart at the same time I don't want to be here and that must have been visible yeah I was having to prove that I need to see somebody after that experience I was told to go and um come back from my appointment and when I got there to go and wait in the waiting room so like so I did that's what I did um I got there early about 15 minutes early and I just sat there the whole time crying and nobody came there nobody not nobody else waiting in the waiting room came over and asked if you know if there was something they could do if I was okay none of the staff none of the administrative staff came and asked if I was okay and the reason that I'm sharing this is that it's so important to share some idea of what happens before you even get into the room and all of what we've been speaking about and you know I am could not be more behind um you know the ideas that that my colleagues are talking about whether or not we're talking about therapeutic relationships or we're talking about risk assessment you can't do anything if there is no connection you can't do anything if there is no trust and the excuse that comes back to me quite often is Steve there's only 10 minutes it takes 10 seconds to tell someone that you care it takes 10 seconds to sit there and look that person in the eye and say I do not know what you are going through but I can see that it is etched on your face with the time that we've got we are going to do what we can to keep you safe right now and to figure out what we do next foreign I feel like sometimes that gets lost I think that sometimes um process takes over now from the point of view of somebody who you know I've been uh a patient within Mental Health Services since 2008 someone who has had three very significant periods of suicidal behavior and attempts I absolutely want the best clinical care I want the person sat opposite me to be using a whole range of tools to try to formulate the best response um it's really helpful if they've got risk factor data not that they're going to use that to predict what might happen to me but to kind of go well actually we know there is something currently going on with young men um and that actually we can use some of that intelligence to think about what might be helpful for you but I absolutely want you to see me as the person stood there in front of you I saw two different GPS on I saw a GP on that occasion um and before before it even really kind of explained what I was experiencing I was handed a script for an antidepressant and that's not what I wanted I wanted someone to to be there and to see my distress I'm not saying that an antidepressant wasn't part of the answer it just wasn't the whole answer and we went back four weeks later and I say we this was my my my friend and my friend has no medical qualifications she's the person that kept me alive because she connected with me and it was only through her that I was able to then get the correct Medical Care foreign once we saw the next GDP and and we were told well if I'd been serious I'd have done it by now and I just think it's so so important for us to see The Wider that wider context and and to really understand that not that's not everybody's story and everybody comes into that that that assessment that gp's room if it's out any wherever they're coming in differently but something has happened and it it doesn't matter whether or not that person became really in well about an hour before or after it's taken them a hundred days we have to be really mindful that talking to somebody about the fact that you want to override your body's safety mechanisms and you want to take your own life is by far one of if not the most difficult thing a person may have to do the shame that's felt as part of that the saying it out loud and what does that mean when you're hearing it back and the idea that we know that we might be denied care is hugely important so that's kind of what I wanted to share um and and to really share that in my mind anything and everything that can really contribute to care to love is the foundation of Therapeutic Alliance and that has to be the right way forwards thank you so much Steve for sharing those thoughts um and experiences with us certainly what I took away from listening to you is you know for us to sort of think about everything that's happened before we're sitting alongside somebody who's in such a high level of um you know emotional psychological distress and who may also be experiencing suicidal thoughts and behaviors it's really important isn't it this hasn't just started today and I think um that's the same for our patients and services users but also their family members and friends who have been experiencing that um buildup of the crisis situation for a long time before we come into the mix um and so and the other things you know along those lines of family and friends you talked about the the connection that you had with your friend and it was your friend who got you through that um and the connection is what it that is fundamental isn't it to a good Therapeutic Alliance it's in our connection with people might be different of course to the connection they will have with family members or friends but it is nonetheless a connection and it is that connection that can really um uh be instrumental in in good care and then and if I may just quickly on that it's a connection not a transaction and I think so much of our health care is transactional and that's appropriate at certain times but this what's happened where are you now and and I'm really glad somebody said about what's coming up in the future for you it is a relationship no matter how you know that might only last for a couple of weeks it might be the start of a you know multi-year-long relationship it's not transactional yeah yeah really important point Thank you absolutely and then the other thing I got from you uh well one of the many things I got from you but you know it was that actually the knowledge is important isn't it whether we choose to call it a risk factor or another factor or or whatever we choose to call it it is knowledge and knowledge is helpful um and we can use the connection to draw on our knowledge um to help work with that patient services or and hopefully their families to think about what's important for you what's you know what's going on for you and how can we help you through this really really difficult time so so the knowledge is is important um but mustn't be diluted by that transactional approach so thank you Steve that was really helpful so we've got some time for Q and A's um do um put some into the box we've had one uh there's a there's a thank you for you Steve in the questions box but there's also um a question which I think was for you Keith when you were talking about um uh the the patients um the research that you were talking about and a question from somebody around uh the patient populations you were discussing all adults or were they also young people so I wonder if I could ask you Keith to answer that question but also of course share any Reflections um you have from uh Steve's contribution thank you uh thanks very much um well I think the uh certainly the confidential inquiry data covers um uh people of all eight of all ages who've died by Suicide so it would would it would in addition include uh Children and adolescents and I I don't think there's any reason to believe that um prediction approaches uh don't work well uh applies to uh children and adolescents in fact probably more so um because I think the changeability in thinking about uh suicide and having and the nature of suicidation suicidation is even more fluctuating uh and often briefer in in in Children and adolescents so I think all of this applies um across the board and of course only include um older people uh in that as well I mean I think the um message you know coming across from Steve has really Amplified you know Alexandra discussed and Amplified by Karen just now is this importance of human connection I mean yeah I remember somebody saying to me in a meeting you know what is the one thing that you think is most important in suicide prevention and I thought for a moment I thought well it is human connection and um it's just not it's not just being present with humans it's the nature of that psychological or the empathy uh of that of that um relationship and I think some clinicians are particularly good at doing this they in a sense um our Naturals if you like in in show feeling empathy showing empathy and so on uh for others I think training can be very helpful uh I mean Karen you do a lot of training and in relation to this area I'm sure you'd agree that one can train help people develop skills which will enhance that sense of connection and empathy in their interactions with uh with patients thank you Keith Alexander did you want to share some Reflections um at all at this point before I move on to some other questions I think it's really just that that sense I use the word kind of golden hour expression goals are now because this might be the first time someone's presenting in crisis and if you know if we fail to to really kind of be thoughtful and gain that Therapeutic Alliance we could have you know quite severe ramification that might have severe ramifications for them because they may never come back because they just learned it's completely futile so no matter how tired or overworked we are there's quite a lot of pressure on us to really enact the things we've described here because it's it is such a golden opportunity and if we also shift something for them and they end up thinking oh I'd never thought of you know staggering my pain medications like that or you know something like that then they feel God it really there is worth coming back here to get some help so it's sort of added pressure on us all as clinicians yeah and that leads me to the next question Alexandra which I'll start with you if that's okay why do you think NH staff might not take the time to care and connect with their patients and what can be done to address this well I think you can read an article like this and listen to what we're saying and agree with everything really but still feel very anxious that you might be hauled up by a trust manager or in the coroner's court and asked to account for not having filled in a load of checklist and you might know that you know you saved your your patient the ordeal of kind of sitting through this wooden questioning and and you know wasting time when you could have been actually asking them about themselves but you still carry this anxiety because it's it's it's something we've operated under for many years thank you and I can see because I can see people I can see Steve nodding Steve have you got thoughts about that question why NH staff NHS staff might not take the time to care and connect I I don't I don't think it's not necessarily that they're not caring I think it kind of goes to the point that that Keith Made that I mean you know I think I think there is something around protection against compassion fatigue I think you know when you are you know you're dealing with all different forms of distress people coming in with you know poorly children and all sorts of things there's a lot of emotion therefore stop I think actually for me that the it isn't so much about that that people are in caring I think it's what is the vehicle for caring what is the what is the tool that allows you to almost kind of systematically care um because also what I wouldn't want is somebody getting in the boat with me necessarily because that doesn't move it forward that doesn't help um so I don't I have met some really uncaring professionals but by and large I think it is more not having a way in which to care that's that's really helpful um is quite difficult and I think also if you've been if you've been a clinician or a nurse for any number of years you will have experienced a loss of patience or someone you know to suicide and that must be so incredibly difficult it must be really really really painful um so I get that you don't want to mess up I get that you you know we're trying something new here um and we're trying and that's why I don't think it's about not doing a risk assessment I think it's about expanding the process um I also think there is something about and again being really careful not to speak for all service users because that would be completely inappropriate say if I go to a GP and I've got a suspected broken toe I don't expect that GP to fix my broken toe I expect them to start that process of helping me to fix my toe and that process of going away with some information that might help in the form of a safety plan is the start of that um I think also there's something about explaining the process of well why are we doing why are we using this risk fact at all if you're if if we start to say actually it's because it might help to throw up something which can help with your plan it's about changing the Paradigm there rather than it is widely known that it's used to ration care it's used to say you're a high risk you're low risk um we're going to really care about you we're not going to care about you so I don't again I think it's not just about the tool it's about the way in which we communicate what role they are playing in that moment um and that needs some explanation and that needs us all to kind of come together and go what is it in that 10 minutes that we're trying to achieve what is it we're trying to um make sure happens thank you Steve of course in mental health people hope you know hopefully have longer than than 10 minutes but but the issue is about limited time and there's lots that we we can do and on the subject of limited time I've got a few questions to um to get through there's a couple if you don't mind I'm just going to quickly respond to because they're fairly quick um I mean we could have a whole webinar on family and friends we have had one previously we will do again but there is a question could all be done to work with family and friends to allow them to offer more support and yes absolutely they can and just to um give you some information and we do have a carer strategy Hilson is our carers lead who does um an awful lot of work around carers we do have a carer support group that runs once a month that I and I both co-facilitate that is for family members and carers of people um you know who maybe they think maybe a risk of suicide will struggle with um Regular suicidal thoughts and behaviors there is going to be a family Connections course commencing in Bucks um Family connections is a 12-week course um evidence-based course that work where for trained facilitators work with families of people predominantly people who have a diagnosis of emotional stable personality disorder but not solely that population people who struggle with self-harm and suicidal thoughts and as part of our nursing strategy we are prioritizing families and carers so watch this space and I think in the next series of webinars it would be good to devote a whole session to that very issue there's a few questions around training um there's quite a lot of work going on in the community about developing uh training for a E's non-mental Health a e staff and GP surgeries there's never enough um you know and a liaison Services also have a responsibility for delivering Services uh training which they do you know the site liaison teams um so there is a lot going on at the moment from training and I'm very happy to if anyone wants to contact me to give you some more information there's also training coming up for receptionists and administrative staff in um I think I think December uh I'm not quite sure but again email me and I'll let you know now I want to bring up a question Keith and Alexandra in the last few minutes about pain so um someone has put at Luther Street um we have lots of which is one of our local GP practices um that works with homeless people and people with substance problems Alexandra so we have lots of patients who end up dying from overdoses some accidentals some perhaps deliberate as a result they're in our very strict guidelines which prevent prescription of gabapentinoids and opiates this results in some people who are in severe pain being denied effective analgesia your suggestion of treating pain to address causes is good but in practice how to balance this against the risk of giving potentially dangerous addictive medications which may increase risk of successful or you know dangerous overdose any thoughts Alexandra yeah I mean I used to work as a oncology liaison psychiatrist and we often had situations where patients had a lot of medications but were acutely suicidal and so we used to speak to the the cancer clinicians about considering transdermal administration of pain medications because you know that they're safer than oral preparations um and so I think you know what I often do in clinical practice I work in a veterans service where a lot of the patients have got um pain is really refer them to a pain clinic where they can discuss safer options and and think about having access to a whole range of pain relief because if you only have you know one medication available to you you can't really sort of work out the routine that works for you so I think you know to know that um that you've had the full range of options explained to you including things like steroid injections and other approaches that that are safe um is really important so I think we need to use make better use of pain clinics actually thank you we do have three minutes um so Keith I've got one for you this is one close to my heart and it says I'm curious if women of a certain age have been specifically looked at in terms of suicidality and menopause yeah a very interesting and important question um and I think um overall um there hasn't been enough attention to uh how suicidal you know suicide risk if you like um self-harm and so on varies at different times during women's lives particularly times of change and particularly times of hormonal change which may for example increase um risk of depression and uh uh and have social effects which may add to uh people's distress um and in deep risk um so there is a certain amount of work and um Alexander you're probably familiar with this as well there is some evidence of uh increases in levels of suicide around uh the menopause but I think the important thing is here you know in what particular groups is the is this the case and indeed of course you know what can be done to immediate to mitigate that uh that that risk and indeed acknowledging that people may you know have increased levels of depression at these times is an important factor in making sure clinicians are aware of it and again that they can empathize uh with it um with the difficulties that women may have at these uh stages is is um extremely important um now we have lots more questions and we haven't got time to answer them all but do you know what I'm thinking um is that some of the questions are around you know really how do we balance a caring approach with individuals who present a e multiple times because it can feel like reinforcement of unhelpful contacting of Emergency Services um how can you approach the patient that you're concerned about if they've said they're not suicidal so it's striking me that perhaps um you know in our next series of webinars we need to devote one to these particular questions so we can have you know perhaps a whole webinar around some of the dilemmas in practice we know what we need to do how can we how can we how can we manage it given um some of the obstacles barriers and challenges that um that we face in clinical practice so thank you very much for those questions please keep them coming because they will inform future webinars so in our last few seconds I'd like to say thank you very much to Steve Keith and Alexandra also to Victoria uh catriona and Emily from comms without whom these webinars wouldn't happen thank you all to you for um you know for joining and for giving loads of um really interesting uh questions and food for thought and uh we will see you in two weeks time for our next webinar which is has a focus on men's Mental Health thanks very much goodbye bye