The Aeschi Working Group

MEETING THE SUICIDAL PERSON

The therapeutic approach to the suicidal patient

The need for a shared understanding of the patient's suicidality has been stressed by a number of authors (Leenaars 1991, Eddins and Jobes 1994, Jobes 2000; Orbach, in press). Indeed, difficulties in establishing a working relationship with suicidal patients may be the main reason for the sobering results of treatment evaluations (Hawton et al. 1998). In fact, the first encounter with a health professional largely determines patient adherence to subsequent therapy. Psychotherapy research has established that the patient's early evaluation of the relationship with the therapist determines compliance to psychotherapy (Dyck et al. 1984, Luborsky et al. 1985, Gerstley et al. 1989). Morgan et al. (1982) indicated that a good working relationship is possible in a first session. Therapeutic alliance in psychotherapy has been found to be related to the quality of therapist interventions (Crits-Christoph et al. 1988, Horvath and Luborsky 1993, Silberschatz et al. 1986). In particular, therapeutic alliance is associated with the accuracy of therapist interventions in relation to central issues in a person's life (Luborsky and Crits-Christoph 1990, Crits-Christoph et al. 1993).

In suicidal patients, accuracy of therapist interventions is particularly relevant because the suicidal mind is characterized by a total collapse of self-esteem (Baumeister 1990, Maltsberger 1997). Suicidal patients are very vulnerable, and therefore, 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.

Michel et al (2004) in study on interviews with suicide attempters were able to show that working alliance in interviews with suicide attempters can be improved when the interviewer uses a narrative approach aimed at an understanding of the patient's suicidality in the context of emotional life career issues (abstract)

References

Leenaars A.A. (1991) Suicide notes and their implications for intervention, Crisis 12/1, 1-20.

Eddins CL, Jobes AJ (1994) Do you see what I see? Patient and clinician perceptions of underlying dimensions of suicidality. Suicide and Life-Threatening Behavior, 24, 170-173.

Jobes D: Collaborating to prevent suicide: A clinical research perspective. Suicide and Life Threatening Behavior 2000; 30(1):8-17.

Orbach l: Therapeutic empathy with the suicidal wish: Principles of therapy with suicidal individuals. Submitted for publication,

Hawton K, Arensman E, Townsend E, Bremner S, Feldman E, Goldney R, Gunnell D, Hazell P, van Herringen K, House A, Owens D, Sakinofsky I, Träskman-Bendz L: Deliberate self-harm: systematic review of efficacy of psychological and pharmacological treatments in preventing repetition. BM J, 317: 441-7, 1998.

Dyck R.J, Joyce A.S., Azim H.F.A. (1984) Treatment noncompliance as a function of therapist attributes and social support. Canadian Journal of Psychiatry, 29: 212-216.

Luborsky L., McLellan A.T., Woody G.E., O'Brien C.P., Auerbach A. (1985) Therapist success and its determinants. Arch Gen Psychiatry 42,602-611.

Gerstley L., McLellan A.T., Alterman A.L., Woody G.E., Luborsky L, Prout M. (1989) Ability to form an alliance with the therapist: a possible marker of prognosis for patients with antisocial personality disorder. American Journal of Psychiatry 146,508-512.

Morgan R., Luborsky L., Crits-Christoph P, Curtis H., Solomon J. (1982) Predicting outcomes of psychotherapy by the Penn helping alliance rating method. Archives of General Psychiatry, 39, 397-402.

Crits-Christoph P., Cooper A., & Luborsky L. (1988) The accuracy of therapists' interpretations and the outcome of dynamic psychotherapy. Journal of Consulting and Clinical Psychology, 56, 490-495.

Horvath AO & Luborsky L (1993) The role of the therapeutic alliance in psychotherapy. Journal of Consulting and Clinical Psychology 64, 561-573.

Silberschatz G., Fretter P., Curtis J (1986) How do interpretations influence the process of psychotherapy? Journal of Consulting and Clinical Psychology 54, 646-652.

Luborsky L. & Crits-Christoph P. (1990) Understanding transference. The CCRT method. New York: Basic Books.

Crits-Christoph P, Barber J.P., Kurcias J.S. (1993) The accuracy of therapist's interpretations and the development of the alliance. Psychotherapy Research 3, 25-35.

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.

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