The working group was unanimous
in the view that current emergency room and clinic approaches to suicidal
patients are too unempathic and unhelpful to succeed in drawing out patients'
accounts of extreme pain and suffering in such a way so that the nature
of their experience becomes clear, and a therapeutic alliance established.
In clinical practice patients must be understood to act in order to escape
intrapsychic pain, and their behavior put in the perspective of their
The working group proposes that the following points should be taken into
account if we want to improve the approach toward the patient who attempted
or considers suicide.
1. The clinician's task is to
reach, together with the patient, a shared understanding of the patient's
The working group holds the view that the goal for the clinician must
be to reach, together with the patient, a shared understanding of the
patient's suicidality. This goal stands in contrast to a traditional medical
approach where the clinician is thought to be the expert in identifying
the causes of a pathological behaviour and to make a diagnostic case -
formulation. It must be made clear, however, that in the working group's
understanding a psychiatric diagnosis is an integral part of the assessment
interview and must adequately be taken into consideration in the planning
of further management of the patient. The active exploration of the mental
state, however, should not be placed early in the interview.
2. The clinician should be aware
that most suicidal patients suffer from a state of mental pain or anguish
and a total loss of self-respect.
Patients therefore are very vulnerable and have a tendency to withdraw.
Experience suggests, however, that after a suicide attempt there is a
"window" in which patients can be reached. Patients at this
moment are open to talk about their emotional and cognitive experiences
related to the suicidal crisis, particularly if the clinician is able
to explore the intrasubjective meaning of the act with the patient.
3. The interviewer's attitude
should be non-judgmental and supportive.
For this the clinician must be open to listen to the patient. Only the
patient can be the expert of his or her own individual experiences. Furthermore,
the first encounter with a mental health professional determines patient
compliance to future therapy. An open non-pejorative approach is essential
to support patients in reconsidering their goals.
4. The interview should start
with the patient's self-narrative.
A suicidal crisis is not just determined by the present, it has a history.
Suicide and attempted suicide are inherently related to biographical,
or life career aspects and should be understood in this context. Therefore,
the interview should start with the patient's self-narrative ("I
should like you to tell me, in your own words, what is behind the suicide
attempt...."). Explaining an action, and making understood to another
person what made the individual do it puts a suicidal crisis into perspective
and can be instrumental in re-establishing the individual's sense of mastery.
5. The ultimate goal must be
to engage the patient in a therapeutic relationship.
The meaningful discourse with another person can be the turning point
for the patient in that life-oriented goals are re-established. This requires
the clinician's ability to empathize with the patient's inner experience
and to understand the logic of the suicidal urge. An interview in which
the patient and the interviewer jointly look at the meaning of the suicidal
urge sets the scene for the dealing with related life-career or identity
themes. The plan of a therapy is so to speak laid out.
6. We need new models to conceptualize
suicidal behaviour that provide a frame for the patient and clinician
to reach a shared understanding of the patient's suicidality.
An approach that does not see patients as objects displaying pathology
but as individuals that have their good reasons to perform an act of self-harm
will help to strengthen the rapport. The most common motive is to escape
from an unbearable state of mind (or the self). A theoretical model that
understands suicide actions as goal directed and related to life-career
aspects may prove to be particularly useful in clinical practice.
The group strongly feels that purely reductionist, quantitative research
alone cannot fully reveal the complex processes that give rise to a person's
suicidal behaviour. While quantitative research has helped guide clinical
interventions, there is an increasing need for qualitative research focusing
on the patients' own internal suicidal processes ass well as on interactive
processes with professional helpers. We can expect that such research
will add new dimensions to the existing knowledge of the suicidal process.