Deliberate Self Harm and Suicide, GP, 300507.pdf

Suicide, Psychodynamics and
the Individual
Dr Gerti Stegen
Consultant Psychiatrist in Psychotherapy
Warneford Hospital, Oxford

Is it a Problem?
• 1 in 15 doctors will be dependant on drugs
and/or alcohol
• 28% of doctors have above threshold levels of
stress vs 18% in general population
• Doctors suffer a higher burden of mental illness
than those in equivalent professional careers
• Doctors have higher stress, anxiety and
depression rates than comparable professional
groups
• Doctors have an increased risk of committing
suicide vs general population and other
professional groups

Is it a Problem for GPs?
• About half of GPs have borderline or more
severe anxiety
• A quarter of GPs diagnosed with at least
borderline depression
• More GPs than consultants report suicidal
thoughts
• General Practice (as speciality) has higher
suicide rate than general medicine

Why is it a Problem?
• Research focus on ‘stressors’
• High expectations of others, adverse media
publicity, working environment, dealing with
problem patients, worry about complaints,
finding a locum, arranging hospital admissions,
dealing with terminal illness
• GPs overbook, start surgeries late, over-commit,
do not allow for emergency patients, allow
inappropriate interruptions

What is behind the Problem
• Shifting NHS structure
• Organisational dynamics within surgery
• The doctor:
“Wanted – Medical staff: High achievers only; strong
perfectionist and self critical traits preferred; 5
years training in booze-soaked student culture; sleepdeprivation
and long hours in your twenties; regular
exposure to death and human misfortune; neverending
exams and lifelong study required; constant,
onerous responsibility for other people’s health and
wellbeing; strict, hierarchical, conservative training
with a hint of bullying and intimidation; well-paid job,
held in high regard by public, rewarding vocation;
easy access to pharmaceuticals”

‘Medical Personality Traits’?
– Perfectionism (e.g. portray healthy image)
– Compulsivity
– Highly self critical
– Confidentiality worries
– Isolate self (e.g. not registered with GP)
– Self-prescribe and own solutions (e.g.
alcohol)
– Work when sick (GPs > consultants)

‘Medical or General Personality Traits’?
– Mental health problems as a result of working in
medicine or increased likelihood of psychologically
vulnerable personalities before medical schools?
– Doctors with least stable childhood most vulnerable to
occupational stress (e.g. correlation between
interpersonal difficulties with seniors and perception
of strict, intolerant, hard-to-please father)
– Unconscious drives and unresolved childhood
conflicts motivate the study of medicine to increase
own well-being by healing others (e.g. making good of
sibling rivalries)
– Quality of early relationships with parents predicts
development of job stress and attitude to work

Potential Psychological Dynamics
• Transference: Earlier feelings derived from a
past relationship (mostly parents) are transferred
to a current relationship, e.g. the doctor, friends,
partners, therapist; ubiquitous, unconscious
• Countertransference: Transference of the
therapist/doctor to the patient; a response to the
patient (diagnostic) or derived from within the
therapist/doctor; unconscious
• Defence mechanisms: Almost entirely
unconscious; ubiquitous; essential for mental
health; pathological if overused

Some Defence Mechanisms
• Displacement: Basis of transference; redirection of
feelings towards a relatively less cared-for person
(‘kicking the cat’)
• Repression: An unacceptable internal idea, affect,
impulse is removed from consciousness
• Intellectualisation: Excessive use of intellectual
processes to avoid emotional expression and experience
• Humour: Emotional conflict and stressors are dealt with
by emphasising amusing, ironic aspects (cynicism)

•Projection: Attribution of one’s own feelings or
wishes to someone else (‘sad cat’); basis of
paranoid states, paranoid personality disorder,
prejudice
•Splitting: Split external+internal world into
‘good’/ ‘bad’
•Denial: Allows for control of response to
external events; involves splitting: cognitive
acceptance of a painful event whilst associated
painful emotions are repudiated
•Turning on the self: An unacceptable idea,
affect, impulse is directed against the self whilst
related to another person

Assumptions about Suicide
• Seen to be part of a
depressive state
• A cry for help
• Manipulative
• Solitary, suicide of anomie

Psychodynamics of Suicide
• “No one kills himself who has never
wanted to kill another or at least wished
the death of another”
• Homicidal anger turned against the self
• Acting out of an emotion (short cut of
unconscious impulse direct to action
bypassing conscious thought and feeling)
• Conflict resolution by use/destruction of
the body

• Practical solutions
What could help?
• Being aware of own transferences and
defences can help
• Consider possibility of being the recipient
of someone else’s transferences and
defence mechanisms can also help
• Exploring psychodynamic issues in
seminars and counselling