The Aeschi Working Group
MEETING THE SUICIDAL PERSON
The therapeutic approach to the suicidal patient
We all make sense of the actions of others' through a person's narrative related to the action. Narratives have been described as representing a series of events and their associated meaning for the teller, and meaning is accomplished interactionally, between teller and listener. Therefore, in the clinical interview, the interviewer must become the participant (although observant) of the patient's narrative, and in this respect he is not the expert whose role is to find the cause or the pathology of the patient's self-harm. The patient's narrative is the basis of a shared understanding. A narrative approach requires openness towards the patient as the agent of his own actions who is well able to explain the subjective logic behind an act of deliberate self-harm
In a self-narrative, patients typically do not explain their suicide attempts with a single cause, but with a story which explains the short term development preceding the attempt, linking it with the relevant parts of the life history. Thus, the narrative contains (1) immediate action related aspects as well as (2) relevant life-projects and (3) central aspects of a person's biography, or life-career.
When asked to explain a suicide action, patients often ask: "How far back do you want me to go?", or "where do you want me to start?". They usually start with a life project relevant for the action in question. After the clinician's opening question, patients usually continue with their self-narrative which in its first part may often last between 5 and 15 minutes without significant interruption by the interviewer. However, clinical experience has shown that it is absolutely essential that right from the start of the of the clinical interview the interviewer asks the patient to tell his or her own story.
Adler (1997) in a paper about narrative clinical reasoning, wrote: "When we are able to formulate the right story, and it is heard in the right way by the right listener, we are able to deal more effectively with the experience". A candid and comprehensive history is generally best obtained by an interviewer who is able to take an insider's view. If clinicians are prepared to be open and listen, they can empathically put themselves in the patient's predicament, and it will be relatively easy to ask the most productive questions and to provide the most helpful responses. The patient and the physician then become fellow travellers on a journey undertaken through the patient's narrative.
A narrative based approach is no contradiction to evidence based medical practice (Greenhalgh 1999). The patient's narrative helps to establish a good doctor-patient relationship, and the interview will have to be completed by the examination of the mental state and the evaluation of risk factors (Hawton 2000, Michel 2000). There can be no doubt that psychiatric disorders must be properly identified and adequately treated. However, based on a joint understanding of the patient's suicidality, therapeutic measures will become a matter of shared decision making.
The endpoint in the suicidal person's narrative is either suicide or life. When the story is retold to a sensitive listener the endpoint may change from death orientation to life orientation. Thus, the narrative of the suicidal patient will not only have a beginning, a middle and an end, but also a future. Only if we are prepared to listen, and if we can join patients in their individual, and often extreme experience of pain, can we become influential in changing the course of actions and in re-establishing life-oriented goals.
Adler, H.M. (1997) The history of the present illness
as treatment: Who is listening and why does it matter? J American Board
Familiy Pract, 10: 28-35.
Mr. T.'s narrative
From a paper submitted for publication:"The narrative of the suicidal patient, K. Michel, P. Dey, L. Valach.
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