The Aeschi Working Group

MEETING THE SUICIDAL PERSON

The therapeutic approach to the suicidal patient

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Managing Suicidal Risk
A Collaborative Approach
David A. Jobes, Foreword by Edwin S. Shneidman
Publication Date: August 2006, Guilford Press

This clinical manual offers essential tools and guidance for therapists of any orientation faced with the complex challenges of assessing and treating a suicidal patient. In a large, ready-to-photocopy format, the book provides step-by-step instructions and reproducible forms for evaluating suicidal risk, developing a suicide-specific outpatient treatment plan, and tracking clinical progress and outcomes using documentation that can help to reduce the risk of malpractice liability. In addition to providing a flexible structure for assessment and intervention, The Collaborative Assessment and Management of Suicidality (CAMS) approach is designed to strengthen the therapeutic alliance and increase patient motivation. Highly readable and user-friendly, the volume builds on 15 years of empirically oriented clinical research.

http://www.guilford.com/cgi-bin/cartscript.cgi?page=pr/jobes.htm&dir=pp/paci&cart_id=

Orbach I, Gilboa-Schechtman E, Sheffer A, Meged S, Har-Even D, Stein D: Negative bodily self in suicide attempters. Suicide Life Threat Behav. 2006 Apr;36(2):136-53.

Abstract

In the present study we investigated the relationship between suicidal behavior and aspects of bodily perception and parental care. Measures of bodily perception included measures of tactile sensitivity, body attitudes, and body experiences. Measures of parental care included parental bonding, negative and positive touch, and early maltreatment. One hundred and two adolescents (suicidal and nonsuicidal inpatients, and a control group) participated in the study. It was hypothesized that suicidal adolescents would (1) have higher tactile sensation thresholds, and more negative body attitudes and experiences; and (2) report less parental care, lower positive and higher negative parental touch, and higher parental maltreatment. It was also hypothesized that bodily sensitivity would mediate the relationship between suicidal tendencies and perceived negative early care. These hypotheses were confirmed. The role of a negative bodily self in suicidal behavior is proposed and discussed.

Orbach I, Mikulincer M, Gilboa-Schechtman E, Sirota P: Mental pain and its relationship to suicidality and life meaning. Suicide Life Threat Behav. 2003 Fall;33(3):231-41.

Abstract

Shneidman (1996) proposed that intense mental pain is related to suicide. Relatedly, Frankl (1963) argued that the loss of life's meaning is related to intense mental pain. The first goal of this research was to test Shneidman's proposition by comparing the mental pain of suicidal and nonsuicidal individuals. Meaning in life and optimism are the polar opposites of suicidality and hopelessness, and the examination of these variables in relation to mental pain was undertaken to provide a test of Frankl's proposition. In two studies, a relationship between a newly developed measure of mental pain--the Orbach & Mikulincer Mental Pain Scale, 2002 (OMMP; see also Orbach, Mikulincer, Sirota & Gilboa-Schechtman, 2002)--and suicidal behavior and life meaning were examined. Results confirmed both propositions. Implications for the study of mental pain and suicide are discussed.

Jobes DA and Drozd, JF: The CAMS Approach to Working with Suicidal Patients. Journal of Contemporary Psychotherapy, Vol. 34, No. 1, Spring 2004.

Abstract

The Collaborative Assessment and Management of Suicidality (CAMS) is a novel clinical protocol designed to quickly identify and effectively engage suicidal outpatients in their own clinical care. The CAMS approach emphasizes a thorough and collaborative assessment of the patient's suicidality that then leads to problem-solving treatment planning that is coauthored by the clinician and the patient. This approach is specifically designed to launch a strong therapeutic alliance creating an effective treatment trajectory. The CAMS approach is designed to modify and change clinician behaviors in terms of how they initially identify, engage, conceptualize, assess, treatment plan, and manage suicidal outpatients. Critically, however, CAMS does not usurp clinical judgment or dictate treatment modality. Preliminary research has shown that CAMS leads to faster resolution of suicidality and may decrease nonmental health medical utilization. Given the challenges of clinical work with suicidality, increased concerns about malpractice liability, and the decreased use of inpatient hospitalization, CAMS provides a potentially important new approach to working with suicidal individuals on an outpatient basis. http://springerlink.metapress.com/openurl.asp?genre=article&issn=0022-0116&volume=34&issue=1&spage=73

Antoon A. Leenaars: Psychotherapy with Suicidal People: A Person-Centred Approach. JOHN WILEY & SONS, LTD, Chichester, 2004.

Suicide is a complex event. There are biological, psychological and sociological influences on suicide and suicidal behavior. Suicide risk is multidetermined. There are so many factors that influence who is at risk and who carries through with suicide. The complexity of suicide calls for an equally complex set of solutions. There is no one solution, but psychotherapy has played a pivotal role in response to these many needless deaths.

Edwin Shneidman, the respected suicidologist, provided the following guidance: ”We ought to know what we are treating.” He believes that we will treat mental health problems, for example, suicide, more effectively, only when we develop a clear and distinct understanding of the suicidal person. ”Our treatment, psychotherapy,” he guides us, ”should address the person’s story.” Our treatment must be person-centered – this is as true in psychotherapy, as medication and hospitalization.

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http://www.wiley.com/WileyCDA/WileyTitle/productCd-0470863412,descCd-authorInfo.html

Michel K, Dey P, Stadler K, Valach L: Therapist Sensitivity towards Emotional Life-career Issues and the Working Alliance with Suicide Attempters. Archives of Suicide Research 2004, 8,203-213.

Abstract

This study investigated the usefulness of an action theoretical model of suicide in interviewing suicide attempters. Eighteen interviews were video-recorded and transcribed. The patients' narratives were reconstructed and life-career issues relevant for the patient's suicidality formulated. Skin conductance reactivity was used to determine narrative content associated with actualized emotions. Scores of the patients' ratings of helping alliance experienced in the interview were positively associated with the therapists' sensitivity towards emotionally relevant life-career issues. Furthermore, relationship satisfaction was related to a narrative interviewing style. We conclude that working alliance in clinical interviews with suicide attempters can be improved when the interviewer uses a patient-oriented approach aimed at understanding the patient's suicidality in the context of personal life-career, or identity issues.

http://taylorandfrancis.metapress.com/openurl.asp?genre=article&issn=1381-1118&volume=8&issue=3&spage=203

Valach L, Michel K, Young RA, & Dey P: Attempted Suicide Stories: Suicide Career, Suicide Project and Suicide Action. In: Valach L, Young R A Lynam M. J: Action theory. A primer for applied research in the social sciences. CT: Praeger, Westport 2002.

Abstract

Chapter 6 contains a report on a research project dealing with people after a suicide attempt. Using the action theoretical methodology as described in this book and discussing the obtained documents, we argue that suicide processes follow the career-project-action order proposed in the action theoretical conceptualization. Consequently, any professional encounter with people after a suicide attempt can be considered as a part of these goal directed systems. The career-project-action organization is illustrated with two cases obtained in the described project. Some of the issues of this research project were described in more detail elsewhere (Michel, & Valach, 1997).

Valach L, Michel K, Dey P & Young RA: Self-confrontation interview with suicide attempters. Counselling Psychology Quarterly 2002, 15(1), 1-22.

Abstract

Psychiatric and psychological assessment after parasuicide is characterized by a number of difficulties. The interview is a strategically complex task for the patients trying to accommodate the wishes of the psychiatrist/psychologist and their own goals. The psychiatrist/psychologist on the other hand needs to gain information about the event and the patient's mental state, has to assess the risk of further suicidal behaviour, and has to motivate the patient for treatment. In our experience a routine video prompted recall or self confrontation interview, can be a helpful means of talking with the patient about his or her feelings and cognitions during the interview. Furthermore, it allows clarification of the processes leading to parasuicide. The procedure of administering a self confrontation interview is described, the theoretical background for interpreting the results is outlined and some examples of patient interviews are presented. It is demonstrated that this method allows access to additional information on the patients' thinking and emotions during the interview and that it also provides more details of the suicidal process.

Michel K, Dey P, Valach L: Suicide as goal-directed action. In: Understanding Suicidal Behaviour: the Suicidal Process Approach to Research and Treatment (Ed. K. van Heeringen), Wiley & Sons, Chichester, 2001.

Abstract

The generally disappointing results of systematic evaluations of the treatment of suicidal behaviour including the prevention of repeated suicide attempts as described in the previous chapter, indicate the need for a new approach towards the suicidal patient. An obvious prerequisite for establishing a trustful working relationship must be that patient and therapist have a mutual understanding of the reasons for suicidal thoughts or deliberate self-harm. Traditionally, suicidal behaviour has been understood within the frame of the biomedical illness model. This model implies that the health professional has to find the cause of the patient’s pathology and then treat the disorder. However, suicide and attempted suicide both are actions that are planned and carried out by individuals, involving conscious processes, and they are thus not mere signs of illness and pathology. An approach based on action theory may well provide an alternative framework to understand suicidal behaviour and to establish a meaningful communication between health professionals and suicidal patients. Fundamental to this approach is the assumption that a better therapeutic relationship with suicidal patients will help health professionals to become more effective in preventing suicide.

Actions are associated with cognitive and emotional processes, which involve planning, steering, monitoring, and decision-making. Actions are part of mid- and long-term systems consisting of projects and life-career aspects, or life-goals. These processes are influenced by external and internal factors, such as cultural setting, early individual experiences, or psychiatric disorder. Action theory not only provides a model for the study of processes resulting in an action, but it also represents the way we communicate and explain our actions in everyday life, or how we make sense of actions of others.

This chapter will address an action theoretical view of suicidal behaviour by describing, among others, preliminary results of a qualitative study of interviews with suicide attempters. Three aspects can be distinguished. First, suicide attempters in general have an impressive narrative competence. However, to allow patients to develop their narratives, the interviewer must respect the patient as the expert of his or her own actions. This requires a definition of the roles of patient and professional helper that differs from the definition as it is used in the biomedical model. Second, patients understand their suicide action as a part of broader systems, which may include life career aspects and projects, and which are goal-oriented and meaningful to the patient. Suicide thus appears as a (usually temporary) goal, a possible solution, when the accomplishment of long-term goals and projects is seriously threatened. Third, the immediate goal of suicidal action is to escape from an unbearable state of mind and of psychic pain, which may amount to a state of traumatic stress, associated with dissociation, automatisms, and analgesia, due to negative and often humiliating experiences. The suicide action therefore must be understood as an attempt to preserve an individual’s self-respect, or identity.

In action theoretical terms, talking to a suicidal patient is a joint action. In a discourse about the background of a suicidal action, the interviewer becomes the co-author of the patient’s narrative. An action theoretical approach should enable patients and therapists to explore new behavioural strategies in times of emotional crises.

Michel K, Valach L.: Suicide as goal-directed action. Archives of Suicide Research (1997) 3,213-221.

Abstract

There is a crucial difference between the understanding of a person’s action primarily in terms of ”because of” explanations and the understanding in terms of ”in order to”. The ”because of” explanations imply a deterministic and causal view which abandons the autonomy of the patient for responsible actions. The ”in order to” explanation offers a teleonomical view, i.e. an understanding of human action as a goal directed process. Consequently, the approach of a professional helper to his patient will differ in that he will perceive the patient as basically autonomous in so far as he tries to understand the subjective logic for his actions.

An action theoretical approach is based on the assumption that we all have goals that direct actions in our lives. These goals are usually conscious in connection to actions which are related to these goals. In our life-careers we are bound to encounter obstacles and failures in the achievement of these goals. In such critical moments of our life, suicide can appear as a possible solution, a possible alternative goal to our life-goals.

Orbach I: Therapeutic Empathy with the Suicidal Wish: Principles of therapy with Suicidal Individuals. American Journal of Psychotherapy 2001, VOL.55(2), 166-184.

Abstract

Several principles of therapeutic work with suicidal individuals are described. These principles represent different aspects of therapeutic empathy with the suicidal wish. They are based on a theoretical model that presents suicide as an end result of unbearable mental pain. Mental pain is believed to emerge from reciprocal interactions between biochemical imbalances, life stress, personality factors, pain-producing inner patterns (e.g., self-hate, sense of being dispensable), and facilitators and inhibitors of self-destructive behavior. The therapeutic approach is characterized by an empathic experiential encounter with the death wish, the pain-producing inner patterns, self-destructive tendencies, and the exploration of the most dreadful and frightening inner experiences. An empathic attitude toward the wish to die, coupled by an uncompromised confrontation of self-destructiveness, can provide the hope of discovering a path of compromise with life’s difficulties.

Orbach I, Stein D, Shani-Sela M, and Har-Even D: Body Attitudes and Body Experiences in Suicidal Adolescents. Suicide and Life-Threatening Behavior 2001, 31(3), 237-249.

Abstract

The relationships between cognitive and affective attitudes toward the body, body experiences (dissociation, insensitivity, and lack of control), and suicidal tendencies were examined as a derivative of the hypothesis that bodily attitudes and experiences may facilitate suicidal acting out. Three groups of adolescents (aged 14-18), including suicidal (made a suicide attempt) and nonsuicidal inpatients and controls, were compared with regard to suicidal tendencies, various body aspects, and depression and anxiety. A series of MANOVAs, discriminant analysis, Pearson correlations, and regressions were employed. The results show that the suicidal group differed from the two nonsuicidal groups in feelings toward the body, body protection, and body dissociation. Some aspects of bodily measures discriminated between suicidal and nonsuicidal subjects. In addition, various bodily measures were associated with and statistically predicted suicidal tendencies. The discussion focuses on the web of associations between body attitudes and experiences and their role in suicidal behavior.

Jobes, DA: Collaborating to Prevent Suicide: A Clinical-Research Perspective. Suicide and Life-Threatening Behavior 2000, 30, 8-17.

Abstract

It is argued that suicidality is essentially a relational phenomenon; the presence or absence of certain key relationships paradoxically can be both suicide causing and suicide preventive. The relational aspects of suicide are especially poignant in clinical work with suicidal patients. However, when suicidality is involved, there are a number of issues that can interfere with effective clinical practice. Fortunately, a new paradigm has begun to emerge in contemporary clinical suicidology, which objectifies suicidality and emphasizes the phenomenology of suicidal states. Moreover, from an increasingly empirical perspective, this approach is creating new and better ways to effectively assess and treat suicidal conditions.

Valach L, Young RA, & MJ Lynam. Action theory. A primer for applied research in the social sciences. Westport, CT: Praeger 2002.

The following paragraphs are brief quotations from the above book.

Suicide as a System of Goal Directed Action Processes

… we proposed that suicide processes can be interpreted in terms of goal-directed actions (Michel, & Valach, 1996b, 1997). This view is based on assumptions that range from the nature of human beings as autonomous persons socially engaged in goal directed systems to methodological postulates described in previous chapters.

The conceptualization of suicide as a goal-directed and socially and biographically embedded human action helps in understanding the processes that precede suicide and suicide attempts, specifies the dangers of the act of suicide itself, and helps in suicide prevention. Furthermore, an action theoretical understanding of suicide provides the basis for conceiving reliable, theoretically well-grounded, and empirical research on suicide. In applying a framework that incorporates longer-term joint or group action as projects and career, researchers and clinicians can assess the role of others in this process and conceptualize preventive interventions more compatible with the everyday lives of suicide attempters. This approach also underlines the extent of the personal responsibility of others who participate in suicide projects in some way. This perspective shifts one's understanding of the participation of others in a suicide attempt from an element in a causal relation to possibly an actor in a joint action, project or career. As such, these persons can have substantial potential for preventive influence and the promotion of other life projects. Finally, this perspective makes one realize that a suicide is just the last step of action in very differing streams of actions and events.(pp 103-104)

Action Theoretical Conceptualization

Action theory can be seen as a language for use in researching applied tasks that humans engage in their everyday lives (Valach, Young, & Lynam, 1996; Young, Valach, & Collin, 1996). As a theory, it includes, in addition to language, concepts, rules, and prescriptions intended to assist the researcher in accessing human action. Action theory offers concepts distinct from those related to the dynamic of non living objects (Frese, & Sabini, 1985; George, & Johnson, 1985). It is obvious that people use different everyday conceptual language when talking about things than when talking about people. While things lie, stand or are moved around, people rest, wait and intentionally go somewhere. This language is shared among groups of people in their belief systems, is rooted in what has been recently conceptualized as social representation (Farr, & Moscovici, 1984; von Cranach, & Valach, 1983) and is used particularly in the description of action (Heider, 1958, Vallacher, & Wegner, 1987). The term “social representation” implies that using concepts in thinking and describing what people are doing is shared in communities and also is of social origin (Valach, von Cranach, & Kalbermatten, 1988, Valach, 1990/1). As such, these concepts also are a part of the linguistic encoding of cognitive processes (von Cranach, Maechler, & Steiner, 1985). They can be ordered and defined for systematic scientific analysis (Kalbermatten, & Valach, 1985). An action theoretical conceptualization also suggests that this language and these concepts are a part of our planning, steering, controlling and interpreting our own action. This conceptualization addresses issues of context, that is, how actions are embedded in situations. In dealing with human behavior we, as scientists, should utilize and systematize people's everyday conceptualizations about action. By doing so in action theory, it can address the social meaning, manifest behavior, and subjective processes of individuals and groups.(pp 4-5)

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