Michel / Gysin-Maillart ASSIP – Attempted Suicide Short Intervention Program

A Manual for Clinicians
1., 2015
ISBN: 978-1-61334-476-7
Verlag: Hogrefe Publishing
Format: EPUB
Kopierschutz: 6 - ePub Watermark

E-Book, Englisch, 114 Seiten

An innovative and highly effective brief therapy for suicidal patients – a complete treatment manual
Attempted suicide is the main risk factor for suicide. The Attempted Suicide Short Intervention Program (ASSIP) described in this manual is an innovative brief therapy that has proven in published clinical trials to be highly effective in reducing the risk of further attempts. ASSIP is the result of the authors’ extensive practical experience in the treatment of suicidal individuals. The emphasis is on the therapeutic alliance with the suicidal patient, based on an initial patient-oriented narrative interview. The four therapy sessions are followed by continuing contact with patients by means of regular letters.
This clearly structured manual starts with an overview of suicide and suicide prevention, followed by a practical, step-by-step description of this highly structured treatment. It includes numerous checklists, handouts, and standardized letters for use by health professionals in various clinical settings.

Zielgruppe

For psychiatrists, psychologists, counselors, and public health workers, and all
others concerned with suicide prevention

Autoren/Hrsg.

Michel, Konrad

Gysin-Maillart, Anja

Fachgebiete

• Sozialwissenschaften Psychologie Psychotherapie / Klinische Psychologie
• Medizin | Veterinärmedizin Medizin | Public Health | Pharmazie | Zahnmedizin Medizinische Fachgebiete Psychiatrie, Sozialpsychiatrie, Suchttherapie

Leseproben

[33]3ASSIP Therapist Manual 3.1Therapeutic Concepts in ASSIP 3.1.1Treatment Engagement: Building a Therapeutic Alliance The therapeutic relationship is vital to effective treatment of suicidality. The best techniques applied without error at precisely the right time are of limited, if any, value when an adequate therapeutic relationship and treatment alliance does not exist. Rudd, Joiner, and Rajab (2001, p. 13) A major difficulty in the effective treatment of patients who have attempted suicide is treatment engagement, defined as commitment in the therapeutic process and active participation in a collaborative relationship between therapist and patient (Lizardi & Stanley, 2010). Suicide attempters constitute a special group of patients. They are not, like other patients, admitted to a hospital because of an illness or an accident. Their admission is the consequence of an action, which usually involves planning and decision making. Various investigators have found serious problems in the therapeutic relationship between suicide attempters and health professionals (Hawton & Blackstock 1976; Weinberg, Ronningstam, Goldblatt, & Maltsberger, 2011). For instance, suicidal patients have repeatedly been reported describing health professionals as unhelpful or even ignoring them (Hawton & Blackstock, 1976; Wolk-Wasserman, 1987; see also Section 2.5.1). Experts agree that there is no reason to be afraid that talking about suicide with a person at risk could trigger a suicidal act. It obviously is much more dangerous when persons in crisis have no one they can talk to openly about their current situation, and when they consequently withdraw and isolate themselves. We also know that suicidal people often do not want to talk about their suicidal intentions. When individuals see suicide as a potential way out of an unbearable situation or an unbearable state of mind, they often keep it as something very personal, something that they don’t want to have taken out of their hands. People in crisis will not abandon their suicidal thoughts for the sake of another person who is trying to talk them out of suicide. They will distance themselves from suicide once they see life-oriented goals again. We must bear in mind, however, that suicidal patients often have very low self-esteem as well as a tendency to withdraw, due to a sensitivity to being hurt by the people around them (including health professionals). [34]In a survey of patients mentioned earlier (Section 2.5.1), 1 year after their suicide attempt, only 10% stated that a medical doctor or psychotherapist would have been able to help (Michel et al., 1994). Half of them said that no one could have helped. This in our view indicates that a suicide attempt cannot be understood as just a cry for help. It is crucial to understand the collaborative aspect of a therapeutic alliance as an interactive, recursive, and creative process, directed toward shared goals (Michel, 2011). As a broad concept, a therapeutic alliance has been characterized as “the active and purposeful collaboration between patient and therapist” (Gaston, Thompson, Gallagher, Cournoyer, & Gagnon, 1998). Horvath, Gaston, and Luborsky (1993) distinguished three universal aspects of a therapeutic alliance: (a) the patient’s perception that the interventions offered are both relevant and potent; (b) congruence between the patient’s and the therapist’s expectations of the short- and medium-term goals of therapy; (c) the patient’s ability to forge a personal bond with the therapist as a caring, sensitive, and sympathetic helping figure. An early therapeutic alliance has consistently been reported to have a significant influence on therapy outcomes (Horvath & Symonds, 1991). Saltzman et al. (1976) found that ratings of alliance in the third session were most predictive of persistence in treatment. This was interpreted as meaning that, while the limited experience of therapist and client with each other at the end of the first session was generally not enough to predict the future course of events, in the third session, the viability of the therapeutic relationship was evident, with the alliance having taken root. But the finding also indicates that a therapeutic alliance can be established very early in treatment. Two established scales for measuring a therapeutic alliance, the Vanderbilt Therapeutic Alliance Scale (VTAS; Hartley & Strupp, 1983), and the Penn Helping Alliance Questionnaire (Alexander & Luborsky, 1986) may serve as examples for some practical aspects of therapeutic alliance building. Both scales share certain assumptions, which are relevant for the therapeutic relationship with the suicidal patient. These are 1.Acknowledgment of the patient’s own thoughts and feelings. Understanding the experience of failure, self-hate, and mental pain from the patient’s perspective and communicating one’s awareness of understanding requires an empathic stance. 2.Recognition of the patient’s goals and the patient’s need for autonomy. Patients have their own conscious or unconscious beliefs and goals, which need to be respected and understood. While trying to reach an empathic understanding of the patient’s goal of death by suicide, the therapist should carefully probe for the client’s life-oriented goals and facilitate the client’s movement toward them. 3.Working together in a joint effort. A meaningful working alliance requires a shared model of understanding of the patient’s vulnerabilities and the development toward suicide. 4.The therapist’s engagement and competence. The therapist conveys a nonjudgmental attitude, providing a sense of safety and trust, and uses his/her professional skills in maintaining a meaningful therapeutic relationship. Patients in a suicidal crisis need someone who cares and who is not frightened by suicidal plans. A major challenge in the therapy of suicidal patients is the therapist’s skills in affectively attuning to the patient’s subjective experience of an existential life-threatening crisis, and to show empathy for the patient’s suicidal wish, refraining from trying to talk the patient out of it. Psychotherapy with suicidal patients may evoke strong countertransfer[35] ence reactions, including intense feelings of anger, helplessness, and the urge to withdraw (Maltsberger & Buie, 1974). Yet the therapist’s genuine effort to understand and accept the patient’s subjective experience, without attempting to change it, is crucial to the patient’s capacity to explore the meaning of mental pain, which in the suicidal crisis appeared to be unbearable (Orbach, 2011). When, in a self-help group, patients who had attempted suicide were asked what would have been helpful to them before they attempted suicide, their answer was unanimous: “We would have needed someone to listen to us, who would let us talk freely, and not being afraid of suicidality.” Understanding and acceptance are essential for establishing a treatment alliance that give patients an opportunity to sustain hope in the face of unbearable anguish and hopelessness. The empathic therapist communicates verbally and nonverbally that the patient’s extreme emotional experience is understandable. The therapist who validates patients in a fundamental way demonstrates the belief that it is possible to bear these feelings and to uncover nonsuicidal choices (Schechter & Goldblatt, 2011). The therapist sees and reflects the capacity that the patient cannot yet experience, and maintains hope when the patient feels hopeless about the possibility of change. Figure 3. The collaborative approach. Adapted from Jobes (2000, p. 14). [36] Being empathic with the suicidal wish means assuming the suicidal person’s perspective and “seeing” how this person has reached a dead end[,] without trying to interfere, stop, or correct the suicidal wishes. This means that the therapist attempts to empathize with the patient’s pain experience to such a point that he/she can “see” why suicide is the only alternative available to the patient…. Instead of working against the suicidal stream and trying to instantly increase the patient’s motivation to live by persuasion or commitment to a contract, the therapist takes an empathic stance with the suicidal wish and brings it to full focus. (Orbach, 2001, p. 173) In contrast to the traditional medical approach, the ASSIP therapist uses a patient-oriented therapeutic approach, in the sense of David Jobes’s “collaborative approach” (Jobes, 2006) – that is, patient and therapist work together toward a shared understanding of the meaning of the suicidal crisis (Jobes, 2011). In Jobes’s words: “I want to see it through your eyes” (Jobes, 2000; see also Figure 3 and Box “Suicide Status Form” in Section 3.4.3). In such an approach, the suicidal patient is seen as the “expert” of his or her own life story, while when it comes to the assessment and treatment of mental health problems, the clinician is the expert. Therefore, in dealing with suicidal patients, mental health professionals need to feel comfortable in both professional roles. 3.1.2The Provision of a Secure Base: Long-Term Anchoring In clinical experience, safety measures such as telephone numbers and addresses of important others are usually some of the first items on the list of behavioral strategies. On their first admission to our crisis intervention unit, many suicide attempters have said that they had not been aware that they could have sought help at this address. Most...