The Aeschi Working Group
MEETING THE SUICIDAL PERSON
The therapeutic approach to the suicidal patient
The Narrative Action Theoretical (NAT) approach
As explained above, the clinician's primary goal must be to establish a trusting relationship that allows patients to share their inner experiences of extreme pain and shame. It can be hypothesized that the ideal interviewer would demonstrate openness towards the patient's explanations of his or her suicide action, and would be able to make sense of the patient's narrative in such a way that his or her model of understanding matches closely with the patient's own understanding.
Michel and Valach (1997) suggested that for clinicians a theoretical model which views suicide as goal-directed action might be particularly useful in reaching a shared understanding of an action of self-harm together with the patient. This model is based on the assumption that actions are the expression of continual processes of moving toward, and away from, various kinds of mental goal representations (Carver and Scheier 1998, von Cranach and Valach 1986). Actions are best understood on the background of a person's short term and long term (life-)projects, such as building a relationship (Valach et al. 1996) or establishing a family (Valach 1990). Thus, action is strongly related to life career aspects. Suicide in this context appears as a possible solution to a subjectively unbearable situation and may repeatedly throughout a person's life emerge as a possible goal when in the patient's perception major identity goals are seriously threatened ("to end a bad story").
A study (Michel et al. 2001, Michel et al. in press) on clinical interviews with suicide attempters was devised (1) to determine if an approach based on an action theoretical model of suicide would be useful in establishing a working alliance with suicidal patients, and, more specifically (2) to relate patients' perception of helping alliance to the sensitivity of the interviewer towards life-career issues related to the suicide attempt. Typically, a patient's narrative contains the person's central biographical themes (e.g. "I have great problems in coping with separation and loss") - issues that are instrumental for the breakdown of self-respect and the emergence of suicidal thoughts.
Michel et al. concluded that action theory is a useful model to understand a suicide action on the background of life projects and life career. In particular, the acknowledgement of central biographical issues fosters the development of a shared understanding of the patient's suicidality and of a therapeutic alliance between patient and interviewer. If we want to become more successful in suicide prevention we have to refine our models of understanding the patients' experience of suicidal desperation, and thus work towards a more patient-oriented understanding of suicidal behaviour. If clinicians are prepared to be open and listen to the patient's story, and if they understand suicide in a biographical context, they will be able to take an insider's view of the suicidal mind. They will be able to ask the right questions, and they will be in a better position to help the patient in re-establishing life-maintaining goals and restoring the sense of mastery. We should not forget that therapeutic alliance has emerged as the most consistent predictor of outcome across many studies in different models of psychotherapy (for an overview see Horvath and Luborsky 1993, Henry et al. 1994)
An action theoretical understanding of suicidal behaviour implies that people are agents of their actions and that they are able to explain their actions in the form of narratives. Indeed, throughout the forty interviews Michel and coworkers found that suicide attempters usually have an excellent narrative competence in explaining their act of self-harm in the context of the central life careerissues aspects, when the interviewer invites them to explain their action in their own words (Michel et al. in press). Action theory claims that it represents the way people in an everyday context understand and explain actions (Vallacher and Wegner 1987), and therefore, it may be particularly useful in reaching a shared understanding of an action of self-harm together with the patient .
A narrative based approach is no contradiction to evidence based medical practice (Greenhalgh 1999). The basis of a good therapeutic intervention is a good doctor-patient relationship, and the interview will have to include the examination of the mental state and the evaluation of risk factors (Hawton 2000, Isacsson and Rich 2001). There can be no doubt that psychiatric disorders, if present, must be properly identified and adequately treated.
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.
Carver, C.S., Scheier, M.F. (1998) On the self-regulation
of behavior. Cambridge, Cambridge University Press.
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