Therapy for self-harm, depression and suicidal behaviour Professor Stephen Briggs University of East London and Stephen Briggs Consulting

The relationship between depression, self-harm and suicidal behaviour Suicidal ideation and behaviour Self-harm

What is TAPP? TAPP’s structure TAPP’s rationale TAPP is a manualised time-limited psychodynamic therapy for young people between 14 and 25 (30) It has a usual structure of 4 sessions assessment followed by 16 sessions treatment, with a follow up-review session 6-8 weeks after the end of treatment TAPP’s rationale The developmental process in adolescence is a powerful force for change and growth Therapeutic focus on developmental difficulty/disturbance can recover the individual’s capacity to meet her/his developmental challenges Therapeutic structures of time and focus can help young people manage development and transitions in their social and cultural contexts Versus cognition or ‘diagnosis’

Depression, self-harm and suicidal thoughts Suicidal thoughts can be traumatic “The adolescent who attempts suicide is left with a dead part inside himself; this dead part remains there until the person finds active means of understanding what happened at the time of the attempt and why it needed to be carried out” (Laufer 1985, page 80) ‘Subjectivation’: ownership of the adult sexual body thoughts drives, fantasies, impulses, alongside a process of becoming more separate from parental figures.

The meaning of depression “During adolescence it is common to encounter depression. What happens during its course depends on a bewildering variety of factors” (Williams 1978). Loss in adolescence: “The ego is required to examine every aspect of the lost object – the lost relationship – to pick up each particular aspect of the relationship, explore it, remember it and face the loss in order to let it go” (Anderson and Dartington 1998)

Depression in adolescence Being overwhelmed by and retreating from emotional contact with depressive feelings Suicidal feelings represent a failure of ‘time-future’, of hope of coming into a better place eventually self-harm by cutting often has the meaning of a relief – temporary and momentary from the (depressing) feelings, or alternatively not feeling.

Melancholia and narcissistic depression “The shadow of the object falls on the ego” (Freud 1917) “the quality of impotent rage, or of helplessness-hopelessness in connection with the breakdown of an idealized self-concept….. with subsequent feelings of shame and humiliation” (Midgely et al 2013)

Adolescent suicide and self-harm Self harm rates in adolescence: Madge et al (2008) – Child and Adolescent Self-harm in Europe (CASE) found 10% lifetime prevalence Brunner et al (2014) – study in 11 European countries – found 28% lifetime prevalence Suicide rates in recent years in UK: 8 per 100,000 for all ages (1 death every 2 hours; 4,200 deaths in 2010 (WHO 2014) Suicide rates are gender constructed higher for males than females (11-12 male v 3 female per 100,000) but females self-harm more than males (5:1) Changes in suicide rates are driven by social change Current association between rise in male unemployment post 2008 and rise in male suicides (Barr et al 2012) Current stability/fall in adolescent and young men suicide in UK (Webb and Kapur 2015)

Understanding adolescent suicidal groups Who gets into suicidal groups? The characteristics of young people (risk factors), and why? How to better understand how suicidal behaviour is transmitted between individuals? Evidence for mechanisms/importance of contexts ‘contagion’ and ‘homophily’ What are the dynamics in these groups, the roles individuals take up, and patterns of relatedness in the groups? How can professionals and communities effectively intervene to prevent group suicidal behaviour?

Understanding group suicidal behaviour in adolescence: group dynamics Boston group UK group ‘hanging out’ in one college Electronic media– texting each other about suicide attempts Self-harm method All self-poisoning Goldblatt et al 2015 Complex patterns of contact between group members living in one area: Social contact, schools, online (Facebook, Tumblr) Multiple forms of self-harm cutting, self-poisoning jumping

Suicidal group relatedness The dynamics in these groups are complex individuals take up diverse roles in the group, including: suicide encouraging, preventing/rescuing, agreeing/imitating, conforming to group norms Groups include face-to-face and online contact Groups have different ways of relating to suicide Explicit discussions of suicide: making overt suicidal agreements Acting on shared assumptions, about suicide, which may not be explicit (or conscious) Thus influencing others’ suicidal behaviour in some way (may include contagion) Adults/professionals are (partly) excluded from knowing about group dynamics/relationship patterns in the groups These can thus seem to constitute ‘secret networks’, beyond comprehension Groups may form a (malfunctioning) attempt for YP to gain separateness from adults/parental figures Problematic subjectivation

The implications of self-harm and suicidal behaviour the individual is changed by the act of self-harm. Thus the focus needs to be placed not only on the factors which precipitate an episode of self-harm, but also on the consequences- or implications –of the attempt/episode after self-harm (young) people can appear to be traumatised; in a frozen state, frightened by the feelings that had been encountered, the ferocity of their own violence they may display emotions not fitting the events the need for containment, rather than reenactment Therapists/professionals can be pulled into (re)enacting the suicidal struggle Need for reflective spaces – in the therapist’s mind, supervision and in organisations Structured therapies which focus on providing sufficient containment Either time limited (to provide structure) or ‘wrap around’ care for young people, family members

TAPP

The therapist’s priorities when using TAPP Adopting a stance that provides a containing therapeutic space which is thus both supportive and promoting possibilities for exploration and which is relevant to the young person’s social and cultural contexts Working with a developmental focus Working in depth, particularly through the transference and counter-transference Support for the therapist is through supervision/seminar group focussing on the meaning of the therapist’s emotional experiences Working with time-limits Which means working with ending and separating, and working through the young person’s experiences of separating and developing

Working with the developmental process Theorisation of the developmental process in adolescence underpins the formulations of a developmental focus for each case: The presence of anti-developmental factors that reduce the capacity to engage with current life tasks and relationships, and/or The absence or weaknesses of resources that can promote growth and development The developmental focus relates closely to the young person’s own account of themselves and their struggles and anxieties, and to encompass a sense of becoming, of encouraging curiosity about self and others. it is not worked with programmatically, once formulated and agreed it should be possible for the therapy to proceed in the usual way in which the therapist and young person together relate to the material brought to each session by the young person,

“Anxieties about engagement (beginning) and separation (ending) are always present to an extent, and the therapeutic work then consists of linking these anxieties to the therapeutic process through the transference” (2011, p423) “There are particular tensions to manage: to not hurry in the face of limited time, and also to not slow down change through recognising developmental shifts” (2013)

Working with depth and time Osimo’s matrix: Good Slowness Good Quickness Bad Slowness Bad Quickness “The therapist has to overcome and eschew the temptation to become caught up with an anxiety to work quickly and cover breadth. Instead, the aim is to work in depth, repeatedly returning to the key themes to explore them in greater depth and thus to understand the meaning of these for development”

Working with the ending Beginning Beginning with ending: time limit Focus on depth, working with the relationship, Using the counter-transference as a powerful way of understanding emotionality and relatedness Middle Cooperative working on agreed aims Relative familiarity of process, pattern, content Anxieties may be more depressive (but- the middle may never arrive!) Ending Intensification of anxieties about ending: containing these Addressing the effects of therapy (as perceived etc) Assessing future options (and linking this with the review)

Contact and further information Stephen Briggs stephenbriggs04@gmail.com s.briggs@uel.ac.uk www.stephenbriggsconsulting.co.uk Please contact me for further information including Copy of the manual for TAPP Training and supervision in TAPP Research of the application of TAPP Service consultation for introducing and using TAPP

References Anderson, R., & Dartington, A. eds. (1998) Facing It Out: Clinical Perspectives on Adolescent Disturbance, London, Duckworths/Tavistock Clinic Series Bell, D (2008) Some notes on the internal phenomenology of suicide in Briggs, S., Lemma, A. and Crouch, W. eds Relating to self-harm and suicide; psychoanalytic perspectives on practice, theory and prevention, London, Routledge Blos, P. (1967) ‘The Second Individuation Process of Adolescence’. Psychoanalytic Study Journal of Social Work Practice of the Child, 22, 162-186, Briggs, S. (2008) Working with Adolescents and Young Adults; a contemporary psychodynamic approach, Basingstoke, Palgrave Macmillan S Briggs (2010) Suicide prevention and working with suicidal people; the contribution of psychoanalysis in Patrick, M and Lemma, A. Off the Couch: Contemporary Psychoanalytic Applications London, Routledge Briggs, S. (2013) Manual for Time Limited Adolescent Psychodynamic Psychotherapy (TAPP) Briggs, S. and Lyon, L. (2011) A developmentally focussed time-limited psychodynamic psychotherapy for adolescents and young adults: origins and applications, Revue Adolescence, no.76, 415-434

S Briggs and L Lyon (2012) Time limited psychodynamic psychotherapy for adolescents and young adults, in Lemma, A. ed. Contemporary Developments in Adult and Young Adult Therapy, The work of the Tavistock and Portman Clinics, London, Karnac S Briggs, M Goldblatt, R. Lindner, JT Maltsberger and G Fiedler (2012) Suicide and Trauma; a case discussion, Psychoanalytic Psychotherapy, 26,1,13-33 Cottrell, D. & Kroom, A. (2005) Growing Up? A History of CAMHS (1987–2005) Child and Adolescent Mental Health, 10, 3, 111–117 M. Goldblatt, S Briggs, R. Lindner, (2015) Destructive Groups: The Role of Projective Identification in Suicidal Groups of Young People, British Journal of Psychotherapy, 31,1, 38-53 Kennedy, R. (2000) ‘Becoming a Subject: Some Theoretical and Clinical Issues’. International Journal of Psychoanalysis, 81, 875-892 Ladame, F. (2011) Du nouveau sous le soleil, Revue Adolescence, 29, 2, 231-235 Lemma, A., Target, M., Fonagy, P. (2011) Brief Dynamic Interpersonal Therapy ; a Clinician’s Guide, Oxford, Oxford University Press Midgley, N., Cregeen, S., Hughes, C., Rustin, M. (2013) Psychodynamic Psychotherapy as Treatment for Depression in Adolescence, Child and Adolescent Psychiatric Clinics of North America 22, 67–82 Waddell, M. (2006) Narcissism- an adolescent disorder? Journal of Child Psychotherapy 32, 1, 21-34 Williams, A.H. (1978) ‘Depression, Deviation and Acting-out in Adolescence’ Journal of Adolescence, 1, 1978, 309-317.