The Aeschi Working Group

MEETING THE SUICIDAL PERSON

The therapeutic approach to the suicidal patient

Interviewing suicidal patients with a narrative approach allows the clinician to join the patients in their inner experience of suffering. The typical mental state immediately before the initiation of deliberate self-harm patients describe in their narratives is characterized by an acute state of anxious emotional perturbation which the individual experiences as unbearable. This is consistent with Shneidman's (Shneidman 1993) concept of unbearable mental pain ("psychache") and of the thought that the cessation of consciousness is the solution for this unbearable condition. According to Baumeister's model (Baumeister 1990) of suicide as an escape from self, negative experiences and setbacks in the biography of suicidal patients tend to result in unfavourable attributions about the self, self-blame and low self-esteem, and, finally, in an acute "cognitive deconstruction".

Patients describe a state of mind, in which the suicide action took place as "automatic, robot-like, trance-like ", and in which patients reported not to have felt pain or anxiety. Such experiences are typical for dissociative states. Dissociation has been defined as a lack of the normal integration of thoughts, feelings, and experiences into the stream of consciousness and memory (Bernstein and Putnam 1986). Dissociative reactions are characterized by a disruption of an individual's sense of identity (Nemiah 1980). In the frame of a homeostatic model of self-conservation dissociation is seen as a defence against pain, distress, or humiliation, or against the collapse of the self (Erdelyi 1994). Patients report having felt humiliated by important others prior to attempting suicide, which resulted in a feeling of worthlessness and a loss of self-respect, others report having felt emotionally abused, treated like an object, devaluated as a human being. Suicidal acts may be related to high tolerance for pain and indifference to the body (Orbach 1994, Maltsberger 1993). Our patients often reported that at the moment of the suicidal action (e.g. when cutting) they did not feel pain. Several reports have described automatisms, and feelings of numbness immediately prior to self-injury (Demitrack et al 1990, Orbach et al 1993).

References

Baumeister, R.F. (1990) Suicide as escape from self. Psychological Review 97, 1: 90-113.

Bernstein, E.M., Putnam, F.W. (1986) Development, reliability, and validity of a dissociation scale. J Nerv Ment Dis 174, 12, 727-735.

Demitrack, M.A., Putnam, F.W., Brewerton, T.D., Brandt, H.A., & Gold, P.W. (1990) Relation of clincal variables to dissociative phenomena in eating disorders. Am J Psychiatry 147: 1184-1188.

Erdelyi, M.H. (1994) Dissociation, defense, and the unconscious. In D Spiegel (ed) Dissociation: Culture, Mind, and Body, Washington DC, American Psychiatric Press, pp 3-20.

Maltsberger, J.T. (1993) Confusions of the body, the self, and others in suicidal states. In A.A. Leenaars (ed.) Suicidology: Essays in honour of Edwin S. Shneidman. Northvale, Jason Aronson Inc, pp 148-171.

Maris, R.W. (1981) Pathways to suicide: A survey of self- destructive behaviours. Baltimore, Johns Hopkins University Press.

Nemiah, J.C. (1980) Dissociative Disorders. In A.M. Freedman, H.I. Kaplan (eds), Comprehensive textbook of psychiatry (3rd ed), Baltimore: Williams & Wilkins, pp. 1544-1561.

Orbach, I., Palgi, Y., Stein, D., Har-Even, D., Lotem-Peleg, M., & Asherove, J. (1993) Pain tolerance in suicidal, psychiatric, and normal subjects. Ramat-Gan, Department of Psychology, Bar-Ilan University.

Orbach, I. (1994) Dissociation, physical pain, and suicide: A hypothesis. Suicide Life Threat Behav 24(1): 68-79.

Shneidman, E.S. (1993) Suicide as a psychache. J Nerv Ment Dis 181:3, 145-147.

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