The Aeschi Working Group
MEETING THE SUICIDAL PERSON
The therapeutic approach to the suicidal patient
WHAT'S NEW: A PATIENT-ORIENTED APPROACH
In our view, what suicide research has largely neglected is the factor of the therapeutic relationship between suicidal patient and medical professional. We believe that a necessary prerequisite for the prevention of suicide is a good and trusting patient-doctor relationship. Only then can the communication of suicide intent be expected or the physician's enquiring about suicidal thoughts become possible. This does in no way diminish the importance of medical competence in the assessment of the mental state and in establishing a psychiatric diagnosis.
Therefore, mental health professionals faced with a patient at risk have a dual and difficult task. On the one hand they must have the empathy to understand the patient as a human being - a human being with his or her reasons for an act of deliberate self-harm, on the other hand they must act as an observer gathering clinical information, searching for suicide risk factors and finally come to a case formulation.
Most of us are not taught how to understand other persons' actions, and how people - i.e. patients that come to see us - think about and explain their actions. We have been taught that the art of helping depends on our knowledge and skills and that patients can contribute little to the understanding of their present condition. However, when we try to imagine what would help patients to share their thoughts about suicide and their motives, it becomes obvious that one prerequisite must be a shared frame of understanding how suicidal intentions develop.
Various approaches can be helpful for this purpose. Some authors have proposed a developmental view, i.e. that suicide should be understood in the context of a person's life. Maris (1981) used the concept of a suicide career. This model stresses that repeated painful experiences lead to an increasing feeling of unhappiness, or clinical depression, both resulting in a more internalized interpretation of life difficulties. He points out that suicide is neither perverse nor odd. "In fact it is normal and common". In describing intrapsychic experience, Baumeister (1990) suggests that in the biography of suicidal patients negative experiences and setbacks tend to result in unfavourable attributions about the self, leading to self-blame and low self-esteem. The essence of self-awareness is the comparison of the self with a person's standards.
In a psychodynamic view the ego-ideal constitutes a model toward which a person reaches and attempts to conform. Negative experiences lead to a loss of integrity and positive self-regard (Maltsberger 1997). Suicide is seen as an escape from aversive mental states and negative self-awareness.
Leenaars (1988) from the study of suicide notes concluded that suicide often appears as a solution to the present interpersonal situation as well as the individual's history. Leenaars (1994) takes up Shneideman's (1993) notion that a suicide act is an intentional and conscious act but adds that it involves substantial unconscious processes, thus proposing an action model of suicide in which both conscious and unconscious processes are present.
Orbach (in press) suggests that the life narrative of a suicidal person can be formulated in terms of a sequence of losses, their nature, and their essence. From such an orientation it is possible for the therapist and the patient to review the past together to learn how the patient's life and the perspectives for the future have become unendurable. Empathic understanding allows therapists, and patients with them, to grasp how it is that suicide seemed the only available alternative.
A central element is unbearable mental pain prior to the suicide act. The related negative cognitions include the belief that a person is unneeded and useless. Emotionally, the negative perception of the self results in actual self-hate, rage and shame, or, as Orbach puts it: a total mental offense on the self. Orbach & Mikulincer (2000) in a phenomenological investigation into mental pain concluded that the mental pain syndrome constitutes experiential aspects such as a sense of loss of control, emotional freezing and estrangement, emotional flooding, a sense of irreversibility of pain, etc. The fragmentation of the self, and, in particular, the dissociation of mind and body is a common intrapsychic mechanism found in suicidal states (Maltsberger 1993). Dissociation characterized by disengagement from one's self from body sensation (such as physical pain) and numbness may facilitate the actual physical attack on the body (Orbach 1994, 1996).
Jobes (2000) and colleagues have developed an assessment and treatment protocol called the Collaborative Assessment and Management of Suicidality (CAMS). This approach is designed to create a working partnership between the patient and the clinician. The patient's experience is conceptualized as the "gold standard"; the clinician's job is to understand that experience. In this sense, the assessment tool becomes the vehicle through which a joint construction of the meaning of the patient's suicidality is achieved. The assessment thus becomes interventive and the seeds of a viable alliance are sown.
Michel and Valach (1997) developed and clinically applied a model based on the theory of goal-directed action. Suicide in this view appears as a solution to a subjectively unbearable situation and may emerge as a possible goal ("to end a bad story") when a person's major identity goals are seriously threatened. Thus, the model contends that suicidal behaviour is strongly related to life career aspects. Suicidal behaviour is seen as part of a person's life story, emerging as a possible solution in times of crisis due to unsolvable difficulties, failures, or conflicts. An action theoretical model implies that people who have attempted suicide, or who are about to, can explain their actions. In a series of video-recorded interviews Michel and Valach (2001) have found that therapeutically effective narratives can be elicited in interviews when the clinician concentrates on helping the patient tell his or her story. An empathic therapist can help a suicide attempter explain himself in substantial, personally meaningful accounts in the first psychiatric interview after the attempt.
Baumeister, R.F. (1990) Suicide as escape from self.
Psychological Review 97, 1: 90-113.
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