The Aeschi Working Group

MEETING THE SUICIDAL PERSON

The therapeutic approach to the suicidal patient

Antoon A. Leenaars, Ph.D.

Psychotherapy With Suicidal People:
A Person-Centred Approach
Antoon A. Leenaars
2004

JOHN WILEY & SONS, LTD
Chichester • New York • Weinheim • Brisbane • Singapore • Toronto

Summary

The World Health Organization (WHO) has estimated that there are almost a million people who die by suicide yearly worldwide. The sheer numbers have made suicide prevention a major health target. Suicide is complex, more complex than most of us imagine. It is a multidimensional malaise; this complexity calls for an equally complex response. Psychotherapy is one effective response. Filling a crucial need, this volume is an unrivalled book on psychotherapy with lethal suicidal people. It follows the dictum: “We ought to know what we are treating.”

There are discernible stages of development in Leenaars’ approach to psychotherapy with suicidal people. He believes that, in the study of large issues like suicide, there should be a natural progression from conceptualization to understanding, and then to applications and practice. This book allows the reader to know and then to treat the suicidal person and it does so in a research-based manner. World-renowned researcher-clinician, Antoon A. Leenaars, offers a multicomponent approach, with rich clinical data to guide the reader in a step-by-step fashion, but also outlines general treatment strategies. Based on decades of research across the globe, the volume provides the knowledge interwoven with the skills to treat the lethal suicidal person – the reader will meet such people in the volume as Vincent van Gogh, Sylvia Plath, Jennifer and Joe. If you want to know about suicide and its prevention, about what really goes on in the suicidal mind, about what works effectively with the suicidal person, whether in Russia, UK, India, US, and so on, this is your book. This book takes a significant step forward at heeding the call to action by the WHO to prevent suicide. It details the actual workings of the suicidal mind, from the young to the elderly, and avoids the dry statements of the illusionary average case. It is based on pioneering research on the actual last stories or narratives of suicides, their suicide notes. They are a unique window to the suicidal mind. There is no better way to know and thus, to treat a person. The book also offers the reader international reflections on ethical and legal issues that confront the interventionist working with high-risk patients around the world. The volume is a person-centred book.

It is a book, mainly about psychotherapy with suicidal people written by a leading world recognized researcher and clinician. For the reader who needs to know the inside therapeutic facts about suicide, and useful practice with suicidal patients, this is your book.

A plethora of special features makes this volume an international classic and include:

• Reflections of many suicidologists such as Heraclitus, Plato, Sigmund Freud, Emile Durkheim and Edwin Shneidman

• Empirically supported definition, with applications across age, gender, historical time, as well as culture

• The report of the International Working Group on Ethical and Legal Issues in Suicidology

Essential reading for psychologists, psychiatrists, social workers, nurses, Samaritans, general practitioners and their trainees, and all clinicians who work with suicidal people.

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0-470-86342-0 Paper 480pp 30.00 pounds/45.00 Euro

0-470-86341-2 Cloth 480pp 64.00 pounds/96.00 Euro

Author’s Outline and List of Chapters

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-centred – this is as true in psychotherapy, as medication and hospitalization.

Psychotherapy is a human exchange. Effective psychotherapy, I believe, should be person-centred – or, if one prefers, patient-centred. Person-centred psychotherapy, whether cognitive or otherwise, is derived from the focus on the individual – the individual in his or her entirety, i.e., biological, psychological, sociological and so on.

Given the complexity of suicide, the treatment should be multicomponent (or multimodal). This simply means that it is not only psychotherapy alone – cognitive, interpersonal, whatever – that is most useful, but in combination with medication, may be even more effective in some cases, and if you remove the gun from the home, even more effective, etc.

This book outlines a person-centred, multicomponent psychotherapy, highlighted by an array of case studies. This book is, however, not only in the idiographic (case study) tradition, but also the nomothetic (tabular, common) one.

Suicide is complex, more complex than most of us imagine. It is a multidimensional malaise, with both conscious and unconscious elements. That is why this book begins (in section I and II) with some introductory chapters on suicide and its complexity to suggest a frame or template – a template with some cross-cultural applications – to understand and assess the suicidal person. The heart of the book is section III, Applications and Psychotherapy (see Outline).

Karl Menninger taught that, “The patient is always right.” Much of our treatment of suicidal people is figuring out how they are right, even if they wear a mask (dissembling). The way to understand how the patient is right is in the natural progression from understanding to application and to practice. Once one knows the person, then therapy comes naturally.

The proof of the suicidal pudding is in the “ventions” – what we do effectively to prevent suicide; here most focused on intervention; specifically, psychotherapy. In other words, the main payoff of all our research and training activities lies primarily in making our clinical efforts more effective. That is what counts in the psychotherapy room. The chapters in section III repeat some of the earlier ideas, but they come at the topic from a different direction, idiographic or case study, and show some of the special aspects of psychotherapy with suicidal patients, based on our theoretical understanding – both the general and the unique – of the suicidal person. They cast some new light.

When I asked Edwin Shneidman, what I should tell my readers about psychotherapy with suicidal patients, he said the following: “Our treatment, psychotherapy, whatever, should address the person’s story, not the demographic, nosological categories or this or that fact. It is not what the clinician knows. It is the clinician’s understanding of the person’s story; each individual’s own story. It says, please tell me who you are…what hurts.”

The first two chapters outline the application of our theory for crisis intervention and for psychotherapy, both person-centred. The latter chapter is the core of the pudding. It is what I have learned to be useful and life saving in the psychotherapy room.

I am a developmentalist. In my day-to-day practice, I see children, adolescents and adults. The youngest suicidal patient (Justin) that I saw, was a 4-year-old; the oldest was 92. The works of E. Erickson, A. Freud, and J. Piaget, among others, have given me some of my best education. The cases in this book reflect the life span, from Justin to Joe, who at age 65, when he finally retires and loses his wife, falls into the suicidal abyss. I will never forget his pain, stated in a few words in his narrative, “When my wife was alive, I could dance, now I can’t even walk.” The studies are as follows: Justin; Jeff, a youth who kills himself; Jennifer, a teen who attempted suicide; Susan, a young adult, who, while attempting to survive her pain, must cope with her father’s suicide; Peter, a man who must cope with narcissistic loss; and Joe.

These cases, I hope, will allow one to progress from conceptualization to understanding and then to psychotherapy. I hope one will learn that psychotherapy, echoing Shneidman, “is concerned with what kind of person that individual is.” It is a person-centred approach. One learns not only about the suicidal patient, but also, I hope, about better intervention.

The book is not armchair speculation but evidence-based practice. A task force of the American Psychological Association (APA), Division of Psychotherapy (Task Force on Empirically Supported Therapeutic Relationship, 2001) identified some key elements that make psychotherapy effective: therapist rapport (or alliance), therapist empathy and patient-therapist goal consensus and collaboration. This book is based on this evidence-based approach. A person-centred approach meets these criteria. We need to know what works with Sylvia or Vincent and this book meets that need.

No psychotherapy with suicidal people can be isolated; intervention may require medication, hospitalization and direct environmental controls. Psychotherapy with suicidal people should use a multicomponent (or multimodal) approach. The final chapter in section III provides a few ideas on each of these topics.

The final chapters in section IV examine some empirical facts, ethics and legal issues around the world and include a final reflective essay on Munch, Dostoevsky, van Gogh, and a little bit of Melville.

The Table of Contents is as follows:

Psychotherapy with Suicidal People:
A Person-Centred Approach
Antoon A. Leenaars

Preface

I Understanding

1. Suicide
2. Suicide: A Multidimensional Malaise
3. Unconscious Processes
4. Cognition, Communication and Suicide Notes
   
   II Suicide Risk Assessment
   
5. Clinical Evaluation of Suicide Risk
6. Thematic Guide for Suicide Prediction (TGSP)
7. TGSP: Practice on Suicide Notes, Psychotherapy Protocols & Poems
8. Sylvia Plath: A Protocol Analysis of Her Last Poems (Dying is an Art, Like Everything Else I Do It Exceptionally Well)
9. Rick: A Suicide in a Young Adult (And No-One Knew Who Rick Was)
10. Scott: Suicide or Homicide? (He Loved Her a Lot, But Not Wisely)
    
    III Applications and Psychotherapy
    
11. Applications for Crisis Intervention with Highly Lethal Suicidal People
12. Applications for Psychotherapy with Suicidal People
13. Justin: A Suicide Attempt in a Four-Year-Old Boy (His Mother Often Talked about Hanging Herself)
14. Jeff: A Youth’s Suicide (And Then He Killed Himself)
15. Jennifer: A Teen’s Attempted Suicide (And Then Her Mother Killed Herself)
16. Susan: A Young Adult’s Isolation (And Then Her Father Killed Himself)
17. Peter: An Adult’s Suicidal Pain (I Now Understand the Words of My Brother’s Suicide Note, “No One Loves Me”)
18. Joe: An Older Adult’s Suicidal Pain (When My Wife Was Alive I Could Dance, Now I Can’t Even Walk)
19. Adjuncts to Psychotherapy: Medication, Hospitalization and
    Environmental Control
    
    IV Implications
    
20. This Is What I Have Learned
21. Ethical and Legal Issues (With the International Working Group on Ethical and Legal Issues in Suicidology)
22. Munch, Dostoevsky, van Gogh and a Little Bit of Melville

References

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