LivedExperiences: Survivingand ThrivingAfterA SuicideAttempt

ChrisBowden Lecturer SchoolofEducationStudies VictoriaUniversityof Wellington

2006 SPINZ Symposium: Understanding Suicidal Behaviour: Update Your Knowledge and Practice Dunedin, 28 Nov 2006

ImprovingtheCareofthosewho EngageinSuicidalBehaviour
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Improvingthecareofthosewhomakesuicideattempts willinvolveclinicians,families/whnauandcommunity agenciesdevelopingandevaluatingmoreeffective methodsoftreatment,management,aftercareand support. Littleisknownaboutthelivedexperiencesofthosewho attemptsuicide,howtheyviewtheinterventionsofothers aroundtheattemptandwhatexpertisetheyhave developedasrecipientsoftheinterventionsofothers. Theperceptions,storiesandlivedexperiencesofpeople whohaveattemptedsuicideconstitutevaluable knowledgeforresearchersandpractitionerswithinthe contextofsuicideinterventioninitiativesandthe promotionofwellbeing.

UpdatingKnowledgeandPractice KeyQuestions
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BiggerQuestions
Whatcountsasknowledge? Whosknowledgeisvalued? Howisknowledgeproducedandreproduced? Whenshouldknowledgebechallenged?
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Whatdoweknowabouttheexperienceofbeingsuicidal? Whatdoesitmeanforapersontosurviveasuicideattempt? Whatdoweknowabouthowpeoplewhohaveengagedinnonfatal suicidalbehaviourperceivetheinterventionstheyreceive? Whatspecificaspectsofinterventionsarehelpfulandunhelpfuland whyaretheyperceivedashelpful/unhelpful? Whatdoweknowaboutwhatisrequiredforapersontostop engaginginsuicidalbehaviour?Whatdotheyneedtosurvive? Whatdoweknowaboutisrequiredforapersontorecoverfrom suicidalbehaviourandwhatprotectsthemfromfuturesuicidal behaviour?

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SocialConstructionistPosition:knowledgedoesnotcomethrough theobjective,scientificstudyofphenomenasuchassuicidalbehaviour butthroughademocraticprocesswherebypeoplediscussanddebate knowledge,itsmeaning,importanceandthatknowledgeissocially andculturallyconstructed. Knowledgeisalsousedtopositionpeopleandknowledgeisalso connectedtopower.Someformsofknowledgeareseenasmorevalid andusefulthanothers.Somepeoplewhoholdknowledge (gatekeepers)sothattheycanretainpositionsofauthority,expertise andpower. Itisthroughinterdisciplinaryandintegrativestudiesthatwecan generatenewresearchquestions,expandandsituateknowledge withinabroadercontextandimproveourresponsetopressinghuman problems.

TheScholarshipofIntegration
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Boyer(1990)identifiedfourseparatebutoverlappingfunctionsofscholarly activity: ScholarshipofDiscovery ScholarshipofIntegration ScholarshipofApplication ScholarshipofTeaching Messagesfromtheedge Scholarshipmeansdoingoriginalresearchbutalsomeanssteppingback fromoneinvestigation,lookingforconnections,buildingbridgesbetween theoryandpractice,andcommunicatingonesknowledgeeffectively(Boyer, 1990). Thescholarshipofintegrationmeansinterpreting,drawingtogether, andbringingnewinsighttobearonoriginalresearch.Itinvolvesfitting onesownresearchortheresearchofothersintoalargercontextand perspective. Thoseengagedinthescholarshipofdiscoveryask,Whatistobe known,whatisyettobefound?whereasthosewhoareengagedin integrationask,Whatdothefindingsmean?Itisitpossibleto interpretwhatsbeendiscoveredinwaysthatprovidealarger,more comprehensiveunderstanding? (Boyer,1990,p.19)

IntegratingStandpointTheory,Lived ExperienceandSuicideResearch
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StandpointTheory isextremelyinfluentialwithinthesocialsciences (particularlysociology)andisbothinsightfulandcontroversial. Astandpointcanbeconceptualisedasaperspective:aplaceintimeand spacefromwhichanindividualviewstheworldaroundthem.Itprovidesa lenstoseetheworldandinfluenceshowanindividualandgroupsof individualssociallyconstructtheworld.Astandpointdetermineswhatwe focusonaswellaswhatisobscuredfromus. Suicideattemptershavestandpoints,sodopractitionersandresearchers (therearenotoftenacknowledgedormadeexplicit). Standpointtheorists(e.g.,Harding,1991W ood,1982)suggestthatsocietal inequalitiesgeneratedifferentaccountsofnature,theworldandsocial relationships. Theworldlooksdifferentdependingonwhereyouviewitandthosewho engageinnonfatalsuicidalbehaviourwillseeandunderstandtheworldin waysthataredifferenttofamily,friends,professionalsandresearchers. Bygainingaccesstotheknowledgeandperspectivesofsuicideattempters wewillbeinabetterpositiontocritiquetheknowledgearoundsuicide,and whatareeffectiveformsofinterventionandprevention.

LivedExperience
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Standpointtheorysuggestsweshouldaccessthesemarginalised groupsperspectivesandthatweshouldvaluetheirknowledgeand expertisebecausetheyareprivilegedtocertaininsightscomparedto othergroups. Becauseunderstandinganindividualsperceptionofthe worldmayshedlightonwhyasuicidaldecisionismade,it isimportantinparticulartoexplorethemeaningthatthe suicidalindividualgivestothesuicidalact(Ketelaar& Ohara,1989,p.393).

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Livedexperienceisafilterthroughwhichexperiencesandevents aremadesenseof.Likeastandpointitisinfluencedbygender,age, developmentalstage,class,culture,priorlearning,knowledgeand experienceetc.Itinvolvesconscious,subconsciousandunconscious processes(Brown,2000). Itistheresultoflivingthroughtheexperience,itisconstructedand isnotjustaperceptionofthatexperience(Gadamer,1975). Apersonswayofbeingintheworld(ornotwantingtobeintheworld inthecaseofthesuicidalperson)isreflectedinhisorhereveryday livedexperiences. The perceptions, stories and lived experience of people who have engaged in suicidal behaviour constitute a valuable source of knowledge for researchers and practitioners. Provides experts with a potentially powerful means of developing knowledge about the suicidal process and what makes a difference to people in their recovery and growth. Why dont we ask them? brings us back to the big questions: what counts as knowledge? Whos knowledge counts? Suicidal people are often seen as irrational.

SuicideResearch
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Quantitativevs.Qualitative
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Whilesomeresearchreviews(e.g.,Gould,Greenberg,Veltingand Shaffer,2003)haveidentifiedapproachesandinterventionsthatmay reduceriskofsuicidalbehaviourandsuicideBeautrais(2006)states that: despiteourvastlyincreasedknowledgeaboutthecausesof suicidalbehaviourweknowrelativelylittleaboutwhatismost effectiveinpreventingsuicide(p.2). Understandingthelivedexperiencesnearfatalsuicideattemptersand thefactorsthatcontributedtotheirattemptandsurvivalmayhelp preventnotonlysuicidalbehaviourbutsuicide(OCarrolletal.,2001). Cutliffe(2003)arguesformorephenomenologicalstudiesofsuicide attemptsandthatthereisanurgentneedtobetterunderstandthe particularlifeexperiencesandthemeaningsoftheindividuals experiencesinordertodesigninterventionstohelpreducethesuicide rate. Studyingthelivedexperienceofsuicidalbehaviourmaycontributeto ourknowledgeofwhatcausessuicideandprotectspeoplefrom suicidebutitmaycontributetothedevelopmentofmoreresponsive andeffectivepracticebysheddinglightonwhatworksandwhy.

Identifyingthenumberofsuicideattempterswhoexperience decreasesinsuicidalthinkingandbehaviourasaresultof intervention,treatmentandcarethroughasurveyormeasuringthe reductionoflevelsofsuicidality,depression,andassociatedstatesby meansofaquestionnairewillnotbringusindirectcontactwiththe livinginordertocapturetheexperientialqualityofthelivesofthose whohaveengagedinsuicideattempts. Indecontextualizinganindividualsexperiencesofsuicide,treatment andrecovery,welosesightofthefullnessoflifeandwhatitmeansto survive,andtherefore,risklosingthemeaningwehopetocapture. Thecomplexitiesofhumanexperienceprecludetheuseofsuch reductionistapproachesinansweringquestionsofmeaning.A questionofmeaningcallsforamethodthattrulyexploresthelivesof thesuicidalastheyarecaredfor,comfortedandhelpedtorecover. Bylisteningtosuicideattemptersvoicesandtheirstories,itbecomes possibletocomeclosertolifeassuicideattemptersliveit"ratherthan asweconceptualize,categorizeortheorizeaboutit"andinthisway thepossibilityofuncoveringandcapturingadeeper understandingofthenatureormeaningofwhatitmeansto surviveasuicideattemptandthrive(vanManen,l984).

SomeSelectedStudies
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CogganandBennett(2002)youngPakehasuicideattempters(NZ), experienceofrecovery. ChesleyandLoringMcNulty(2003)experiencesofattempts,what helpedthemstopandwhathelpedrecover. CrockwellandBurfod(1995)youngfemalesuicideattempters, experiencesofintervention. Curtis(2003)femalesuicideattempters(NZ),cessation&recovery. GairandCammilleri(2003)youngsuicideattemptersandhelp seekingbehaviours. Heckler(1994)adultsuicideattempters,focusesonsuicidalprocess andrecovery. Hill(1995)youngsuicideattemptersandsuicides,focusesonrisk factorsandexperiencesoftreatmentandsupport. Sderberg(2004)adultsuicideattempterswithandwithoutBPD, focusesontreatmentexperiences,stabilisation&recovery. Tzeng(2001)Taiwanesesuicideattempters,suicidalexperienceand needs.
Tendtobesmallersamplepopulations,qualitative,issuesof retrospectionbuttradeoffisrichdescriptions,explanationsanddata.

WhatContributedtoSuicidal Behaviour? Themes from the

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Seriesofevents(relational,instrumentaland healthproblems)butsomewereimpulsiveacts (Gair&Cammilleri,2003). Childhoodabuseincludingsexualabuse(Curtis, 2003Sderberg,2004). Overwhelmingandmultiplelosses:traumatic, dysfunctional,alienation(Heckler,1994). Earlyunaddressedpain(Heckler,1994). Mentalhealthproblems(Hill,1995). Aneventthatcementstheconvictionthatthereis nohopeorrecourseotherthansuicide(Heckler, 1994). Unrecogniseddepressionandviewoflimited agency (Bennett,Coggan&Adams,2003). Feelingtrapped(Tzeng,2001),unbearable thoughtsand/orunbearablesituation,loneliness (Sderberg,2004).

Research

Wellthemain reasonItriedtokill myselfwasbecause mygirlfriendleftme andtookmykidaway frommesoIgot reallydepressed.I didntthinkIcould takeitsoIjustdidnt wanttoliveIjust tookacocktailof tablets(Brad,22 yearsold)(Gair& Cammilleri,2003, p.87).

IntentandMotive
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ClearMotives&Ambivalence
Themes from the Research
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GairandCamilleri(2003) foundintentwasunique toindividualsbut reflectsthosereported intheresearch. Someoftheparticipants describedsomeattempts thatwere moreserious andwhentheyjustdidnt wanttolivewhileother attemptsweredescribed asjustmoreaboutgetting outandjustdidntwantto beintheworldfora while.

Gina)Todieortogethelp. (Wendy)IthoughtIreally wantedtodiebutI wantedhelp. (Darlene)EverytimeI wantedtodie. (Darlene)Iwanted someonetoknowhow frustratedIwas. (Crockwell&Burford, 1995,p.6)

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Toescapeinescapablepain. Communicatedistressand aboutintolerablesituation (Heckler,1994). Suicidewasseenasasolution,a comfortingandattractivesolution whentheywereexperiencing despair,lowselfesteemand powerlessness. Tomanagepain(Heckler,1994). Somechangetheirmindsafteran attemptbutatthetimeofthe attempttheywereseriousabout endingtheirlife(Curtis,2003). Hill(1995)foundthatforsome youngsuicideattemptersactions intendedtobelethaldonot alwayshavethatoutcomes,and somenotintendedtobelethalstill conveysuicidalintent:

Themes from the Research

Upuntilthatpoint,Ijusthadthis hopelessness,this powerlessnessandtheonly powerIhadwasknowingthatI wasgoingtotakemyownlife. ThatwastheonlythingIcould seeandtheonlystrengthIhad. (Ian)(Heckler,1994,p.112). Itriedtocommitsuicidefourtimes. Islashedmyhands,wristsand arms.Ijustfeltsomuchmental paininside.Whentheblood cameoutitfeltlikeallthepain comingout.Ifeltcalm.Istill dontknowwhetherIwastrying tokillmyselforjusthurtmyself. (Maxine)(Hill,1995,pp.126).

TheSuicidalProcess
Itsaterriblethingwhenyou wakeupinthemorning andyoudontwanttobe alive.Igenuinelywantedto die.Itsjustsomethingyou cantgetawayfrom.Life seemssopointless.You cannotthinkaboutthepain youmightcauseanybody else.Thatsnotevena consideration,because youfeelsounimportantin yourselfyoudontthinkit willaffectanyoneelse.I didntwanttobehere.I wassureIddie.(Hill, 1995,p.129). Idecidedrightthen:I alreadyfeltdead. EverythingIdid,Ifelt moredead.Nothing feltaliveandnothing wouldhelp.Ijustfeltit wouldbemore congruenttobedead. Justnottohavethis bodytokeepbeingin (Karen)(Heckler, 1994,p.67).

WhyDidTheySurvive?
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Impromptuorsoughtrescueor intervention. Unsolicitedandunexpected intervention(Heckler,1994). Lethalityofmeanschosen. Givingupwhentheybecame alarmedbyunexpectedphysical distressincreasedheartrates, uncontrollablemusclespasms, shortnessofbreathandcallinghelp. Interventionofanotherperson (49%,n=33). Changedtheirmindsafter initiatingasuicideattemptand thensoughthelp(22%,n=15). Nottakenenoughmedication ornonlethalmeans(18%, n=12)Chesley&Loring McNulty,2003).

Themes from the Research

ItoldhimIwasfine,but Imsurehecouldhear somethinginmyvoice. Hewasoverherein minutes,dressedina tux!Ididntwantto openthedoor,butit seemedlikeprovidence hadsteppedin.I thoughtWhoamIto fuckwiththeuniverse? (Deborah)(Heckler, 1994,p.124)

HowDidTheyFeelAboutSurviving?
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ChesleyandLoringMcNulty(2003)foundthatsuicideattemptersexpressed arangeoffeelingsinthetimeimmediatelyaftertheirsuicideattempt. Sad,depressed,disappointed,empty(31%,n=25) Angry(17%,n=14) Embarrassed,ashamed(14%,n=11) Happiness,relief(12%,n=10) Scared(11%,n=9) Senseoffailure(9%,n=8) Other(ambivalent,unabletoremember)(5%,n=4) 55%(n=30)currentlyreportedfeelinggladorgratefulabouthaving survivedtheirsuicideattempt. Highlystressfulandemotionaltimeforattempterandfamily(Coggan& Bennett,2002). PhysicalsymptomsandfeelingofemptinessTzeng(2001). Comingtotermswiththephysicaldamagecausedtothebodyalossof privacy acknowledgingonesvulnerabilityanger,reproachandcondescensionfrom onesfamily,physicians,nursesandotherhealthprofessionals(Heckler, 1994).

TheSuicidalTranceisBroken
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AsHeckler(1994)describes,forsometheattemptfails andyetthetranceanddesiretoendtheirlivesremains. Othersexperiencethebeginningsofachange,either duringorjustaftertheharrowingepisode. Whenthedevotionforthesuicidalquestwanes,itleaves avacuum. Heckler(1994)claimsthathowthatvacuumisfilled stronglyinfluencesthetrajectoryoftheindividuals recoveryorwhetherasCurtis(2003)pointsoutthereis oftenonlyabriefmomentofcessation. Thequalityandnatureofsupportandintervention receivedaffectswhetherornotanindividualwill stopmakingsuicideattemptsandgoontorecover.

Cessationvs.Recovery
n Curtis(2003)makesanimportant

ReasonsforStopping

Themes from the Research

distinctionbetweencessationand recovery. n Shearguesthatcessationrelatesmoreto adecreaseinsuicidalbehaviour(butthe possibilityofstillexperiencingsuicidality), whereasrecoveryentailsanindividual developingcopingstrategies,problem solvingskillsthatleadtoareductioninthe suicidality.

ChesleyandLoringMcNulty(2003)found: n Treatmentwithaprofessional(14%,n=13)(contactwithprimary healthprovider,hospitalstaff,oramentalhealthprofessional) n Senseofselfempowerment(10%,n=10)(developingastronger senseofself,improvingselfesteem,orincreasingpersonalpower) n Newoutlookonlife(10%,n=10) n Personal/professionalsuccess(10%,n=10) n Concernforchildren(9%,n=9) n Medication(8%,n=8) n Spirituality(7%,n=7) n Relationshipwithsignificantother(6%,n=6) n Relationshipwithfamily/friends(5%,n=5) n Improvedmood(4%,n=4) n Maintainingsobriety(3%,n=3) n Sharingfeelingswithothers(2%,n=2) n Emotionalmaturity(2%,n=2) n Other(7%,n=7)

NarrativesofDiscontent:What Themes from the DidntHelp? Research

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NarrativesofDiscontent
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Themes from the Research

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Malerolesandhelpseekingseenas weakness,stigmaofhavingamental illness,nothavingenoughtimewith mentalhealthprofessionals(Gair& Camilleri,2003). Havingsomeoneelsedoallthetalking, peoplenotlistening(Hill,1995). UnhelpfulstatementsYouvegot heapstolookforwardto(Hill,1995). Inflexiblecrisissupport(Hill,1995). SilencingFamilyandfriends pretendingnothinghashappened(Hill, 1995). RecriminationandRidiculelookwhat youaredoingtous(Hill,1995). MinimisingandChastisingyousilly patheticgirlitsjustcryforhelp(Hill, 1995)

WhenIgotoutofhospitalit waslikenothing happened.Nothingwas eversaidaboutitagain.It waslikeIdjustcome homefromschoolforthe day.NobodyaskedifI wasallright.Iwasinbed forafewdaysandthey treatedmelikeIdgota sorethroatorsomething. Justnothingwassaid. Whichmakesitquitehard whenyoure12(Debbie) (Hill,1995,p.176).

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Maintainingprofessional distanceandnotrespectingthe individualsrights(Crockwell& Burford,1995Sderberg,2004). Interventionsthatreinforce feelingsoflackofcontrol (Curtis,2003). Difficultieswithmedication (Curtis,2003). Parentsandfamilynot knowinghowtosupport cessationorrecovery(Curtis, 2003). Alackofmutual understanding(Sderberg, 2004).

Ifeltuncomfortableshesaid nothing,onlylistened.Ihad needofsomeguidance,not justhearingmyselftalk (Thetherapist)wascoldand distant,seemedlikeshefelt burdenedbyanother depressedmiddleaged man.Ifeltabandoned (Sderberg,2004,p.68).

NegativeExperiencesasMotivation Themes from the forChange Research

Ididitmyselfgotagrip onmylife,createdanew lifesituation.Ihadlet myselfbesickbefore, hadwaitedforothersto doitallformebut nothingchanged,inspite ofalltheresourcesthat weremobilised.(woman, BPD,abused). (Sderberg,2004,p.60). Thesecondsuicideattempt wasaturningpoint,a shockIfeltIdontwant togothroughthisagain. Therewasnochange untilItookadecisionof myowntotakeaholdof thesituation.Ithink thingscouldhavegotten muchworseifIhad waitedforatherapistto fixit.(man,BPD) (Sderberg,2004,p.60).

NarrativeofContentment:What Themes from the HelpedThemStop? Research

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Familymembersproviding accesstoinformationon depressionandmaking contractsaroundhelpseeking sayinggoodbyes(Gair& Camilleri,2003). Feelinglovedandvalued (friendsandfamily)feeling guiltyformakingparentsangry orworriedoranabsenceof reactionfromsignificant others(nonsuccessful manipulationorcommunication) (Curtis,2003). Beinghospitalisedorbeing stigmatisedhelpedstop(Curtis, 2003Hill,1995). Reachingaturningpointand havingtomakeadecision (Sderberg,2004).

Before,IthoughtIcouldnt managelifesoIdidnttry, becauseIdidntdare.ThenI foundthingssodestructive,I hadreachedrockbottom.Then Isatdownandthoughtabout whatIreallyneeded,and decidedthingslikethatshould neverhappenagain.(woman, BPD,notabused).(Sderberg, 2004,p.60). Idecidedtoworkthingsthrough topopenup,talktomyfriends.I hadkeptitalllockedupbefore. NowadaysItreatsituations quitedifferentlywhenIcometo aconflictoracrisisIgo straightatit.(man,NoBPD). (Sderberg,2004,p.60).

NarrativeofContentment:What Themes from the HelpedThemStop? Research

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MixedPerceptionsof Interventions
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Themes from

the Research

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Thinkingpositively,andfocusing onpositiveaspectsofthefuture. Notlosingsightofthebalance betweenpositiveandnegative experiencesinlife. Realisingthatproblemsare frequentlyatemporary experience(Coggan&Bennett, 2002). Talkingaboutfeelingswhichled tobeingabletoidentify problems(Hill,1995). Exploringsuicidalfeelingsand assessingdanger(Hill,1995) Recognisingwhentheywere experiencingaproblemand seekinghelp(Hill,1995).

Itsnotworthit[attempting suicide]becauseitjust doesgetbetter.Youre notgoingtostaylikethat throughyourwholelife. Andevenifitisbadlike kindofalot,theres alwaysgoodtimesand thingsyoucanmisswith yourfriends(Emma) (Coggan&Bennett, 2002,p.20)

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Hospitalisationkeptthemfromharming themselves(andcontributedtocessation)butdid notcontributetorecovery(Curtis,2003). SomestafffromCATTeams,counsellors, therapists,psychologists,andpsychiatriststobe helpful.Communitybasedorganisationsand counsellingwerereportedmorebeneficialthan otherorganisations(Curtis,2003). Sometreatmentapproachesashelpful particularlythosethatencouragedlearningcoping strategiesandproblemsolvingskillsthatwouldbe usefulinthelongterm.TheseincludedCognitive BehaviouralTherapy,DialecticalBehaviour TherapyandNarrativeTherapy(Curtis,2003). Medicationcanbehelpfulbutwhenmixedwith counselling(Curtis,2003). Wantingadviceandguidancebutalsogreater selfcontrol(Corckwell&Burford,1995).

[Theyshouldtell me]whatIshould dowhenIget suicidal tendencies,whatI shoulddowhenI gettheflashbacks, howImsupposed togetoverthe abuse(Darlene) (Crockwell& Burford,1995,p.7)

NegativePerceptionsof Interventions
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Themes from the Research

KeyFeaturesofCounselling/Therapy ThatHelped Themes from the

Research
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Notfittingthemodel (Sderberg,2004). Notmatchingthetherapeutic methodtothepersonalqualities, expectationsandvaluesof patients(Sderberg,2004). Relianceontherapeutic methodinsteadoftherapeutic alliance(Sderberg,2004). Expertlanguagethathas labelledthemsymptomsand experiencesthathavethepower tocontrolthem(Sderberg, 2004).

Ifitthemodel,butthemodel didntfitme(Sderberg, 2004,p.69) Theystartpracticingtheirideas aboutwhathelpIneed andonlyaftertheyvecome toadeadendtheystart askingmewhatweshould do(Sderberg,2004,pp.69 70).

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Anempathiccounsellor. Asenseofcontrolorpartnershipinthecounselling process. Feelinglistenedto. Notfeelingblamed/invitedtofeelguiltyfortheir actions. Notfeelingjudged. Notfeelinglikeaburden,ascomparedtotryingtotalk tofamilyandfriendsandhavingtocensorwhatwas saidforfearofworryingorhurtingthem Feelingthecounsellorcouldrelatetowhattheywere sayingsimilarageand/orbackgroundand/or experience. Feelingthecounsellorgenuinelycared. Feelingthecounsellorcouldbetrustedthiswas particularlyimportantissueforwomenwhofelt betrayedbyanumberofpeopleintheirlivesincluding parentsandpreviouscounsellors(Curtis,2003,p.261) Acceptanceandlistening(Hill,1995).

Hemetmelike anequalhuman being.IfeltlikeI wasbeingseen andheard ShesawI neededtomake changesinmy life,andshe supportedmein theprocess.I felthersupport andIfeltIwas safewithher (Sderberg, 2004,p.66).

OtherImportantAspects
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Gettingtoknowthepersonand acknowledgingwhatthe Theguyjustwantedthefactsbut individualhasbeenthrough shewaslikeIcouldhowland (Crockwell&Burford,1995). shewouldsaydontworry Socialworkerslisteningtoyoung aboutbeingupset,justcryif peoplesuniquestories(Gair& youwantto.Youhaveevery Camilleri,2003) righttocry,youvebeen Socialworkersfillingamate throughhellandjustvalidation role(Gair&Camilleri,2003) ofyourfeelingsandshegot Regularcontact(Gair& moreintowheredidIcome Camilleri,2003). fromwhatkindofthingshave leduptoit?butsothatwas Honestandforthrightanswers reallynicebutthenIwentto sothatfalsepromises(e.g., [socialworker](Darlene) everythingwillbeOK)arenot (Crockwell&Burford,1995, madeCrockwell&Burford,1995). pp.910).

Themes from the Research

NarrativesofContentment:What Themes from the HelpedRecovery? Research

CogganandBennett(2002)reportthatfortheyoungpeoplethey interviewedreportedanumberoffactorsthatcontributedtothemnot engaginginfurthersuicidalbehaviour.Theseincluded: n Achangeinselfimage,theabilitytoperceivethemselvesinamore positivelight. n Havingresponsibilitiesandcommitments. n Makingaconnectionwiththefuture. n Decreasingasenseofsocialisolationandreconnectingwithfriends. n Personalcounsellingthatenabledthemtodevelopinterpersonal skillstoreconnectwithotherswhocouldprovidethemwithgood thingsintimesofcrisis. n Asenseofselfresponsibilityinseekingeffectivehelp. n Achangeofcircumstancesandlivingenvironmentthatprovides greaterpersonalsafetyandautonomy.

WhatHelpedRecovery?
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WhatHelpedRecovery?
Themes from the Research

Themes from the Research

Achangeinperspectiveorstandpointon life. Mentalstabilitythroughpsychiatriccare (particularlyforthosewithseriousmental illness)(Sderberg,2004). Achangeinsituation(e.g.,leavinga destructiverelationship)(Sderberg,2004, p.56). Regainingcontrolandlearningnewskills. Takingcontrolofselfharmingbehaviour, emotions(e.g.,feelingsofhopelessnessand helplessness)andonesbodyseemedto contributetocessationandalsolearning positivecopingstrategiesandinterpersonal problemsolvingskillsresultedinenhanced selfesteem,copingskillsandincreasedsense ofcontrolwhichseemstohavecontributedto (recovery)areductioninthelikelihoodof repeatedsuicideattempts(Curtis,2003).

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Thelastfewyears havebeenquite OK.WhatIwent throughgaveme anewperspective onmylife,andmy priorities changed.Imtruly gratefulImalive (manNoBPD) (Sderberg,2004, p.55).

ChesleyandLoringMcNulty(2003)askedtheirparticipantshowthey learnedtocopewithsuicidalfeelingsandthisquestiongenerateda widerangeofresponses: n Medicaltreatment(12%,n=18)(withhealthprofessionalorhealth careprovider) n Sharingfeelingswithothers(10%,n=14) n Involvementinactivities/hobbies(10%,n=14) n Relationshipswithfriends(7%,n=10) n Improvedselfesteem(7%,n=10) n Spirituality(5%,n=8) n Recognisingthatsuicidalthoughtsaretransient(5%,n=8) n Involvementinsupportgroups(5%,n=7) n Senseofcontrolovertheirlife(4%,n=6) n Medication(3%,n=5) n Journaling(3%,n=5) n Professionalsuccess(3%,n=5)

Heckler(1994)FiveStagesof Recovery
1.

Heckler(1994)FourAttitudinalShifts EssentialForRecovery
Theseshiftsincludea movementfrom: n Powerlessnessto authorship. n Lossoffaithtoaworking relationshipwiththe spiritual. n Beingorfeelingstuckto becomingunstuck,and n Alackofbelongingtoa senseofplace. Justlookathowmylife haschangedsofar, andthisisjustthe firstyearofmy promise.Iknow terriblethingscould happeninthefuture, butinaway,Iwant toseeit.Iwantto seeallofitnow.Im trulylookingforward towhathappens next(Ruth)(Heckler, 1994,p.291).

2.

3.

4. 5.

DissolvingtheSuicidalTrancepersondiscoversthat itisthesuicidalcontext,nottheindividual,thathasto die.Thisinvolvesthepersonsuspendingdoubt,grieving, andlearningtotrust&lettinggoofdying. Rebuildingtheselffocusesonhealingthepast,taking responsibilityforonesactions,anddiscoveringnew answerstothequestionWhoamI?exploringoneself throughcreativework,andcultivatinganopennessto life. Buildinganewrelationshipwithoneself.Person reachesout(theoppositetotheisolationofthesuicidal trance)learnstoaskforhelp,beingwillingtobeseen, Allowingothersinandinvitingtheintimacyofothers. Givingback.Theindividualhavinglearnedtoreceive fromothersinnewandhealthyways,nowmustlearnto offerwhattheyhavelearnedbacktotheircommunity.

ExperiencesRequiredforPeopleto Recover?
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WhatIstheDifferenceThatMakesA Difference? Challenging

Dominant Ideas & Practice

Mirroring Seeingabiggerpicture Experiencingthehumannessof others, Extendingtofamily (Heckler,1994).

Heckler(1994)writes: Someoftheseexperienceswillbe serendipitousandunexpected,while otherswillbeconsciouslysoughtand hardwon.Nevertheless,theyconstitute majorturningpointsintheprocessof rebirth.Andwhilenoteveryonepasses throughvariousstagesinthesamelinear progression,peoplewhorecoverdo experiencemostofthematsomepoint duringtheroadback(p.168).

Ineededtohear thatthereare otheroptions besideskilling myself. (Deborah) (Heckler,1994, p.252).

TherapeuticAlliance
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Therapeuticcontactandatherapeuticalliancethat allowsthepersontotakeanewperspectiveor standpoint(Sderberg,2004). Findingadifferentperspectiveinlifethathas modulatedtheiridentityselfconcept(Sderberg,2004, p.71).

TherapeuticAlliance
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Challenging Dominant Ideas & Practice

PersonalCommitmenttoChange
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Thetherapeuticallianceis importantforalleviatinga suicidalindividuals senseofpowerlessness tochangehimselforherself ortheenvironment,and facilitatetheexperienceof successandmasteryin dealingwithhis/her situation. Theaimofthisalliance shouldbetohelpthe individualfindadifferent perspectiveonthe situation(Sderberg, 2004).

Idontknowwhat happenedthatnight, butsomething clicked.IthinkIjust gotthingsinto perspective.Itscared methatIdgotso depressed.Ithought Ivegottogetonand sortmyselfout.IfIfail finals,Ifail.Ican alwaystakethem again(Karen)(Hill, 1995,p.161).

Changeisalwaysdependent upontheperceptionofthe individual,andcannotbe implementedfromwithout. Thechangecame Itfollows,thathelpinganindividual whenIrealizedI couldchange identifyhisorherstandpointand things,Iwasnt perspective,aswellasshowing helpless. him/herthatthereareother standpointsandperspectivesmight (Sderberg,2004, p.73). beapromisingstartingpointfor change. Makinganactivedecision. Acknowledgingthatreliefand changeneedtobeachievedand notmerelyreceived(Sderberg, 2004).

Challenging Dominant Ideas & Practice

Empowerment
n

Freedomthrough empowermentsothe individualcanmakeself directedchangesintheirown life. Thetherapeuticrelationship, whetheritexistswithinthe contextoftherapy,treatment, careorsupportcallsfora perspectiveofcollaboration thatenablestheindividualto definetheirownneeds,usea languagethatmakessense tothemandtheirsignificant otherandempowersthemto takecontroloftheirlife.

Challenging Dominant Ideas & Practice

Relationships
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Challenging Dominant Ideas & Practice

Istartedtoseethatevery problemintherelationship wasntmyfault.Shegave methestrength[]to makeastand(Sderberg, 2004,p.67). Youstarttheprocess,you getsomeoneshelpand finallyitchanges,although italwaystakestime (Sderberg,2004,p.71)

Longtermstablepersonal relationshipswithsomeone theycantrust,who understandsthem. Thesupporttotakeadifferent standpointandmaintainthe change. Achievingachangein perspectiveorstandpoint requiresthepresenceofpersons thatcanbecomesignificant otherswhohavean instrumentalroleinhelpingthe persondevelopanewidentity andreinforcetheirnewapproach totheworld. Theserelationshipscarrythe potentialforadevelopmentof selfesteemandselfworthand buildonanactivedecisionand personalcommitmentforchange (Sderberg,2004).

Itsbasicallyaquestionof attachmentrelationshipisthe basisforchange(Sderberg, 2004,p.71). Nomatteriftheparasuicidewas relatedtoseverementalproblems leadingtoextensivepsychiatric treatmentoranactofdespairdue toacrisissituationinlife,thecore featureforsubsequent stabilisationwasdescribedtobe reliablerelationshipsthatcould furtherenhanceselfesteemand selfworth,orgettingridof relationshipsthatwithheldsucha development.Theprocesshas resultedintheintegrationofa differentunderstandingofthe possibilitiesandlimitationsinlife (Sderberg,2004,p.75).

TheNeedtoMeettheExpert Challenging Dominant Within Ideas & Practice

n

TheNeedforMoreResearchand TranslationofFindingsintoModels
n

Suicidalpeoplearevaluablesourcesofexpertiseandknowledge andthatifpractitionershavewelldevelopedcommunicationskills, andarewillingtoseepastthesuicidalbehaviourtomeetthe expertwithintheindividualtheyaremorelikelytofindtheanswers towhatthepersonneedstostoptheirsuicidalbehaviourandrecover andthrive(Crockwell&Burford,1995). Thereisaneedforprofessionalstobuildmoretrusting relationshipswithpeople. Thereisaneedtomoveawayfromaloofprofessionalismto developingtherapeuticallianceswithtroubledpeopledefinedbya bond,wherefriendshipisofferedbutnegotiatedinrelationto providingrelevantresources. Theimportanceofestablishingatherapeuticalliancewiththesuicidal personisalsosomethingrecognisedwithinNewZealandguidelines (NZGG,2003)assomethingthatcanfacilitatethedisclosureof informationandasenseofhopefulnessandconnectedness.

Itisonlythroughthismutualunderstandingcantheindividualand practitionerunderstandandworktowardsresolvingtheissuesthat haveledthepersontosuicide(Crockwell&Burford,1995). Thereisalsoaneedtotranslatefindingsfromresearchinto workablemodelsandmethodsofmeasuringrecoverythattake intoaccounttheperspectivesandmeaningsofindividuals.For example,theStagesOfRecoveryInstrument(STORI)(Andreson, Caputi&Oades,2006)whileacknowledgingthecomplexandnon linearnatureofrecoveryfrommetalillnessandpsychological traumaidentifiesfourkeyprocessesofrecoveryandfivestagesor phasesofrecovery. Thismodelhasimplicationsforpromotingrecoveryandresilience andtrainingofmentalhealthprofessionals.Itmaybethatasimilar modelcouldbeproposedforthosewhoexperiencecessationand recoveryfollowingasuicideattempt.

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STORIStagesofRecovery Instrument
Thefourcomponentprocessesofrecoveryidentifiedfromthethematic analysesofpersonalaccountsofrecoveryare: 1. findingandmaintaininghope 2. thereestablishmentofapositiveidentity 3. findingmeaninginlifeand 4. takingresponsibilityforoneslife. Thefivestagesofrecoverythatwereproposedinthemodelare: 1. Moratorium:Atimeofwithdrawalcharacterisedbyasenseof lossorhopelessness. 2. Awareness:Realisationthatallisnotlost,andthatafulfilling lifeispossible. 3. Preparation:Takingstockofpersonalstrengthsandlimitations regardingrecovery,andstartingtoworkonlearningand developingrecoveryskills. 4. Rebuilding:Activelyworkingtowardsapositiveidentity,setting meaningfulgoalsandtakingcontrolofoneslife. 5. Growth:Livingafullandmeaningfullife,characterisedbyself managementoftheillness,resilienceandapositivesenseof self(Andresenetal.,2006,p.973).

Recovery&Resilience

Ungar (2004)

TheExperienceofResilience
n

AConstructionistDiscourse
n

Ungar(2004)claimstheecologicalapproachto understandingresilience,(onethatisinformedby SystemsTheorythatemphasisespredictable relationshipsbetweenriskandprotectivefactors,circular causalityandtransactionsbetweentheindividualand theenvironment) isinadequateforexplainingthediversityof peoplesexperiencesofresilience.

Ungar(2004)suggestswetakeaconstructionistapproachwherewe lookattheexperienceandmeaningofresiliencefortheindividual. Accordingtothepostmodernviewofresilience,whatisimportantis: Thelanguagethatpeopleusetodescribetheirresilienceafter suicide Resilienceistheoutcomeofnegotiationsbetweenpeopleand theirenvironmentsfortheresourcestodefinethemselvesas healthy,achievingetcdespiteconditionsthataredefinedbyothers asadverse. Resilienceresearchshouldlookatthemultiplewaysthatwellbeing andresiliencecanbedefined. Aconstructionistinterpretationofresilienceexplicitlytolerates diversityinthewayresilienceisnurturedandmaintained.Italso asksustoconsidertheeffectsofage,class,race,genderandsoforth ontheabilityofyouthtomaintainhealthyfunctioning.

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Therelationshipsbetweenriskandprotectivefactorsare oftenchaotic,complex,relativetotheindividualorgroup andcontextual.

AvailabilityofResources
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Thedifferencethatmakesthedifferencebetweenthosewhoare consideredresilient(healthy)andthosewhoarelabelledvulnerableis theavailabilityofresourcestosustaintheirownwellbeingand theirresultingselfconstructionsashealthy(Ungar,2004). Inordertomakesuicideinterventionmoreeffectiveweneedto considertheneedsofsuicideattemptersandtheresourcesand powertheyrequiretorepositionthemselvesandmaintaintheirown senseofwellbeing. Aconstructionistapproachtoresiliencealsofitswellwithgrowing interestinstrengthbasedperspectivestotreatment,youthworketc (Ungar,2004). Suicideattemptersrequireatherapeuticalliance,mutual understandingandempowermenttobeabletofindtheirown strengthsanddeveloptheirownresourcesthatcanleadtorecovery andresilience.

Conclusions:Interventions should
Strivetobemultisystemic,addressingindividual,family,whanauand communityissues, n Enhancecompetenciesandprotectivefactors, n Reduceriskfactors,andtreatdisorders. n Takeintoaccountdiversityofexperienceanddifferencesin accesstoresources. n Attemptingtoprovideaquickfix,andfixonethingatatimewont workprotectiveandriskfactorsareinteractiveandoften interdependent.
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Focusonidentifyingthedifferencethatmakesadifferencefor thatindividual. Provideaccesstoandacknowledgethestandpointsofthe suicidal. Takeintoaccountthemeaningfortheindividualandhis/her perspective.

Conclusions
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References
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Thestandpointsandperspectivesofsuicideattemptersshould beacknowledgedandstudied. Theyprovideimportantinformationaboutintention,theunique aspectsofsuicideattempts,whatimpedeshelpseeking,whataspects oftreatmentandcareareeffectiveandwhy,andtheyrevealthat workerslisteningtothepersonsuniquestoryisimportantforthat personandforhis/herrecovery. Weneedtostoptreatingsuicideattemptersasahomogenous groupwithsimilarbackgroundsandexperiencesandstarttreating themasindividualswithuniqueexperiencesandinsightsintotheir ownbehaviourandneeds. Identifyingtheprocessesthathelpsthepersonfindthedifferencethat makesthedifferenceshouldbeinfocusoffuturepsychiatricresearch andattheheartofpsychiatricsupportandtreatmentafterparasuicide, toenablethepatientstofindtheirownstrengthsandresourcesandin thiswaybeabletoleaveitallbehind(Sderberg,2004,p.viii)

References
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