Abstract
The creation and maintenance of the therapeutic alliance is of the utmost importance when treating suicidal patients. This can be challenging, because there is a strong link between dissociation and suicide. This chapter defines dissociation and describes its manifestations, developmental roots, and the relationship between dissociation and suicide. A suicidal patient’s ability to dissociate is often the result of attachmentdifficulties in childhood, stemming from “adverse childhood events,” early traumatic experiences. Traumatized children identify with the aggressor and take in destructive attitudes toward themselves. They develop an anti-self that is turned against the self andcontributes to self-destructive behavior and, at its ultimate end, suicide. The trust issues, negative expectations of others, and dissociative tendencies that result from experiencing interpersonal trauma can make it difficult for these patients to develop a strong therapeutic alliance. Effective psychotherapies with suicidal patients require the therapist be able to provide a relational experience, where the suicidal person is respected, and their experience is listened to in a compassionate, empathetic manner.Therapists who can provide the patient with a sense of safety, a feeling of being “seen” as whohe/she really is,and soothing to alleviate unbearable psychological pain, help heal the patients’ attachment system byproviding a secure base from which the patient can explore their pain, understand its roots, and learn to regulate and tolerate it without the need to dissociate. Research has shown that a number of suicide specific therapies which embody these principles are effective in treating suicidal patients.
The suicidal state of mind is the monstrous enemy of the suicidal patient, which cannot be fought alone. Therapists can unite with their patients in the struggle against the pain by means of language. I tend to use the plurals us and we instead of I and you (e.g., “We have to go through this; let us look at this from another perspective”; “This is good for us”). I believe that this use of language creates an atmosphere of togetherness and of joining forces against a common assailant, ultimately empowering the patient.
—Orbach (2011, p. 124)
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References
Adam KS, Sheldon-Keller AE, West M (1996) Attachment organization and history of suicidal behavior in clinical adolescents. J Consult Clin Psychol 64(2):264–272. doi:10.1037//0022-006x.64.2.264
Alvarez A (1971) The savage god. W.W. Norton & Company, Inc., New York, NY
Anda R, Felitti V, Bremner J, Walker J, Whitfield C, Perry B, Dube S, Giles W (2005) The enduring effects of abuse and related adverse experiences in childhood. Eur Arch Psychiatry Clin Neurosci 256(3):174–186. doi:10.1007/s00406-005-0624-4
Beck A (1996) Beyond belief: a theory of modes, personality, and psychopathology. In: Salkovskis P (ed) Frontiers of cognitive therapy. Guilford Press, New York, NY, pp 1–25
Bedics JD, Atkins DC, Comtois KA, Linehan MM (2012) Treatment differences in the therapeutic relationship and introject during a 2-year randomized controlled trial of dialectical behavior therapy versus nonbehavioral psychotherapy experts for borderline personality disorder. J Consult Clin Psychol 80(1):66–77. doi:10.1037/a0026113
Berk M, Henriques G, Warman D, Brown G, Beck A (2004) A cognitive therapy intervention for suicide attempters: an overview of the treatment and case examples. Cogn Behav Pract 11:265–277
Bordin E (1994) Theory and research on the therapeutic working alliance: new directions. In: Horvath A, Greenberg L (eds) The working alliance: theory, research, and practice, 1. Wiley, New York, NY, pp 13–37
Brand BL, Loewenstein RJ, Spiegel D (2014) Dispelling myths about dissociative identity disorder treatment: an empirically based approach. Psychiatry 77(2):169–189. doi:10.1521/psyc.2014.77.2.169
Briere J, Runtz M (1987) Post sexual abuse trauma: data and implications for clinical practice. J Interpers Violence 2:367–379
Brown J, Cohen P, Johnson JG, Smailes EM (1999) Childhood abuse and neglect: specificity and effects on adolescent and young adult depression and suicidality. J Am Acad Child Adolesc Psychiatry 38:1490–1496
Brown G, Tenhave T, Henriques G, Xie S, Hollander J, Beck A (2005) Cognitive therapy for the prevention of suicide attempts: a randomized controlled trial. JAMA 294:563–570. doi:10.1001/jama294.5.563
Chu JA (2011) Rebuilding shattered lives: treating complex PTSD and dissociative disorders. John Wiley & Sons, Hoboken, NJ
Chu JA, Dill DL (1990) Dissociative symptoms in relation to childhood physical and sexual child abuse. Am J Psychiatr 147:887–892
Chu J, Dell P, Van der Hart O, Cardeña E (2011) Guidelines for treating dissociative identity disorder in adults, third revision. J Trauma Dissociation 12:115–187. doi:10.1080/15299732.2011.537247
Cloitre M, Stovall-Mcclough KC, Nooner K, Zorbas P, Cherry S, Jackson CL, Gan W, Petkova E (2010) Treatment for PTSD related to childhood abuse: a randomized controlled trial. Am J Psychiatr 167(8):915–924. doi:10.1176/appi.ajp.2010.09081247
Cronin E, Brand B, Mattanah J (2014) The impact of the therapeutic alliance on treatment outcome in patients with dissociative disorders. Eur J Psychotraumatol. doi:10.3402/ejpt.v5.22676
Eagle M (2003) Clinical implications of attachment theory. Psychoanal Inq 23:27–53
Farber SK (2007) Dissociation, traumatic attachments, and self-harm: eating disorders and self-mutilation. Clin Soc Work J 36(1):63–72. doi:10.1007/s10615-007-0104-6
Ferenczi S (1988) Confusion of tongues between adults and the child. Contemp Psychoanal 24(2):196–206. doi:10.1080/00107530.1988.10746234
Firestone L (2006) Suicide and the inner voice. In: Ellis T (ed) Cognition and suicide: theory, research and therapy. American Psychological Association, Washington, DC, pp 119–147
Firestone RW, Firestone L (2002) Suicide reduction and prevention. In: Feltham C (ed) What’s the good of counseling and psychotherapy? Sage Publications, London, pp 48–80
Fonagy P, Target M (1997) Attachment and reflective function: their role in self-organization. Dev Psychopathol 9(4):679–700. doi:10.1017/s0954579497001399
Freud A (1966) The ego and the mechanisms of defence, revised edn. International Universities Press, Madison, CT. (Original work published 1936)
George C, Kaplan N, Main M (1985) The Adult Attachment Interview. Unpublished manuscript. University of California, Berkeley, CA
Gysin-Maillart A, Schwab S, Soravia L, Megert M, Michel K (2016a) A novel brief therapy for patients who attempt suicide: a 24-months follow-up randomized controlled study of the Attempted Suicide Short Intervention Program (ASSIP). PLoS Med 13(3):e1001968. doi:10.1371/journal.pmed.1001968
Gysin-Maillart AC, Soravia LM, Gemperli A, Michel K (2016b) Suicide ideation is related to therapeutic alliance in a brief therapy for attempted suicide. Arch Suicide Res 21:213–226. doi:10.1080/13811118.2016.1162242
Hesse E, Main M, Abrams KY, Rifkin A (2003) Unresolved states regarding loss or abuse can have “second-generation” effect: disorganization, role inversion, and frightening ideation in the offspring of traumatized, non-maltreating parents. In: Solomon MF, Siegel DJ (eds) Healing trauma: attachment, mind, body, and brain. W. W. Norton, New York, NY, pp 57–106
Horvath A, Bedi R (2002) The alliance. In: Norcross J (ed) Psychotherapy relationships that work: therapist contributions and responsiveness to patients. Oxford University Press, New York, NY, pp 37–69
Horvath AO, Re AD, Flückiger C, Symonds D (2011) Alliance in individual psychotherapy. Psychotherapy 48:16–19. doi:10.1093/acprof:oso/9780199737208.003.0002
Howell EF (2014) Ferenczi’s concept of identification with the aggressor: understanding dissociative structure with interacting victim and abuser self-states. Am J Psychoanal 74(S1):48–59. doi:10.1057/ajp.2013.40
Jamison KR (1999) Night falls fast: understanding suicide. Vintage Books, New York, NY
Jobes DA (2000) Collaborating to prevent suicide: a clinical-research perspective. Suicide Life Threat Behav 30(1):8–17. doi:10.1111/j.1943-278X.2000.tb01061.x
Jobes DA (2012) The Collaborative Assessment and Management of Suicidality (CAMS): an evolving evidence-based clinical approach to suicidal risk. Suicide Life Threat Behav 42(6):640–653. doi:10.1111/j.1943-278x.2012.00119.x
Jobes DA (2015) The CAMS approach to suicide risk: philosophy and clinical procedures. Suicide Suicidol 14(1):3–7. doi:10.5617/suicidologi.1978
Jobes DA, Ballard E (2011) The therapist and the suicidal patient. In: Michel K, Jobes DA (eds) Building a therapeutic alliance with the suicidal patient. American Psychological Association, Washington, DC, pp 50–61
Jobes DA, Wong SA, Conrad AK, Drozd JF, Neal-Walden T (2005) The collaborative assessment and management of suicidality versus treatment as usual: a retrospective study with suicidal outpatients. Suicide Life Threat Behav 35(5):483–497. doi:10.1521/suli.2005.35.5.483
Jobes DA, Comtois K, Brenner L, Gutierrez P, O’Connor S (2016) Lessons learned from clinical trials of the collaborative assessment and management of suicidality (CAMS). In: O’Connor C, Pirkis J (eds) The international handbook of suicide prevention, 2nd edn. Wiley-Blackwell, Chichester, pp 431–449
Jollant F, Lawrence NS, Olie E, O'daly O, Malafosse A, Courtet P, Phillips ML (2010) Decreased activation of lateral orbitofrontal cortex during risky choices under uncertainty is associated with disadvantageous decision-making and suicidal behavior. NeuroImage 51(3):1275–1281. doi:10.1016/j.neuroimage.2010.03.027
Klomek AB, Zalsman G, Apter A, Meged S, Har-Even D, Diller R, Orbach I (2007) Self-object differentiation in suicidal adolescents. Compr Psychiatry 48(1):8–13. doi:10.1016/j.comppsych.2006.06.001
Lamagna J, Gleiser KA (2007) Building a secure internal attachment: an intra-relational approach to ego strengthening and emotional processing with chronically traumatized clients. J Trauma Dissociation 8(1):25–52. doi:10.1300/j229v08n01_03
Lanius RA, Vermetten E, Loewenstein RJ, Brand B, Schmahl C, Bremner JD, Spiegel D (2010) Emotion modulation in PTSD: clinical and neurobiological evidence for a dissociative subtype. Am J Psychiatr 167(6):640–647. doi:10.1176/appi.ajp.2009.09081168
Lieb K, Zanarini M, Schmahl C, Linehan M, Bohus M (2004) Borderline personality disorder. Lancet Semin 364. doi:10.1016/S0140-6736(04)16770-6
Linehan MM (1993) Cognitive-behavioral treatment of borderline personality disorder. Guilford Press, New York, NY
Linehan MM, Comtois KA, Murray AM, Brown MZ, Gallop RJ, Heard HL, Korslund K, Tuter D, Reynolds S, Lindenboim N (2006) Two-year randomized controlled trial and follow-up of dialectical behavior therapy vs therapy by experts for suicidal behaviors and borderline personality disorder. Arch Gen Psychiatry 63(7):757. doi:10.1001/archpsyc.63.7.757
Liotti G (2004) Trauma, dissociation, and disorganized attachment: three strands of a single braid. Psychother Theory Res Pract Train 41(4):472–486. doi:10.1037/0033-3204.41.4.472
Liotti G (1992) Disorganized/disoriented attachment in the etiology of the dissociative disorders. Dissociation: Progress in the Dissociative Disorders 5:196–204. doi:1994-05679–001
Lyons-Ruth K (2006) The interface between attachment and intersubjectivity: perspective from the longitudinal study of disorganized attachment. Psychoanal Inq 26(4):595–616
Main M, Solomon J (1986) Discovery of an insecure-disorganized attachment pattern. In: Brazelton TB, Yogman MW (eds) Affective development in infancy. Ablex Publishing, Norwood, NJ, pp 95–124
Maltsberger JT (2008) Self break-up and descent into suicide. In: Briggs S, Lemma A, Crouch W (eds) Relating to self-harm and suicide: psychoanalytic perspectives on practice, theory, and prevention, 1st edn. Routledge, New York
Maltsberger JT, Buie D (1974) Countertransference hate in the treatment of suicidal patients. Arch Gen Psychiatry 30(5):625. doi:10.1001/archpsyc.1974.01760110049005
Maltsberger JT (1993) Confusion of the body, the self and other in suicidal states. In: Leenaars AA, Berman AL, Cantor P, Litman RE, Maris RW (eds) Suicidology: essays in honor of Edwin S. Shneidman. Jason Aronson, Northvale, NJ, pp 148–171
McLaughlin A, Keller S, Feeny N, Youngstrom E, Zoellner L (2014) Patterns of therapeutic alliance: rupture-repair episodes in prolonged exposure for posttraumatic stress disorder. J Consult Clin Psychol 82:112–121. doi:10.1037/a0034696
Michel K, Jobes DA (2011) Building a therapeutic alliance with the suicidal patient. American Psychological Association, Washington, DC
Michel K, Dey P, Stadler K, Valach L (2004) Therapist sensitivity towards emotional life career issues and the working alliance with suicide attempters. Arch Suicide Res 8:203–213
Orbach I (1994) Dissociation, physical pain, and suicide: a hypothesis. Suicide Life Threat Behav 24:68–79
Orbach I (2003) Suicide and the suicidal body. Suicide Life Threat Behav 33:1–8
Orbach I (2006) The body-mind of the suicidal person. In: Ellis TE (ed) Cognition and suicide theory, research, and therapy. American Psychological Association, Washington, DC, pp 193–214. doi:10.1037/11377-009
Orbach I (2011) Taking an inside view. In: Michel K, Jobes DA (eds) Building a therapeutic alliance with the suicidal patient. American Psychological Association, Washington, DC, pp 111–128
Orbach I, Gilboa-Schechtman E, Sheffer A, Meged S, Har-Even D, Stein D (2006) Negative bodily self in suicide attempters. Suicide Life Threat Behav 36(2):136–153. doi:10.1521/suli.2006.36.2.136
Pape JC, Binder EB (2016) The role of genetics and epigenetics in the pathogenesis of posttraumatic stress disorder. Psychiatr Ann 46(9):510–518. doi:10.3928/00485713-20160729-02
Parr G (2008) Dynamics of suicide: understanding and treating suicidal individuals: an interview with Dr. Israel Orbach. Glendon Association, Santa Barbara, CA
Pinto RZ, Ferreira ML, Oliveira VC, Franco MR, Adams R, Maher CG, Ferreira PH (2012) Patient-centred communication is associated with positive therapeutic alliance: a systematic review. J Physiother 58(2):77–87. doi:10.1016/s1836-9553(12)70087-5
Porges SW (2003) Social engagement and attachment: a phylogenetic perspective. Ann N Y Acad Sci 1008:31–47
Reisch T, Seifritz E, Esposito F, Wiest R, Valach L, Michel K (2010) An fMRI study on mental pain and suicidal behavior. J Affect Disord 126:321–325
Ressler KJ (2016) The intersection of environment and the genome in posttraumatic stress disorder. JAMA Psychiat 73(7):653. doi:10.1001/jamapsychiatry.2016.0349
Rudd MD, Joiner T, Rajab MH (2001) Treating suicidal behaviour: an effective, time-limited approach. Guilford Press, New York, NY
Rudd D, Bryan C, et al. (2015) Brief cognitive-behavioral therapy effects on post-treatment suicide attempts in a military sample: results of a randomized clinical trial with 2-year follow-up. 172(5):441-449. doi:10.1176/appi.ajp.2014.14070843
Sachs-Ericsson N, Orden KV, Zarit S (2015) Suicide and aging: special issue of aging & mental health. Aging Mental Health 20(2):110–112. doi:10.1080/13607863.2015.1099037
Safran JD, Muran JC (1996) The resolution of ruptures in the therapeutic alliance. J Consult Clin Psychol 64(3):447–458. doi:10.1037/0022-006x.64.3.447
Safran JD, Crocker P, Mcmain S, Murray P (1990) Therapeutic alliance rupture as a therapy event for empirical investigation. Psychother Theory Res Pract Train 27(2):154–165. doi:10.1037/0033-3204.27.2.154
Safran JD, Muran JC, Samstag LW, Stevens C (2001) Repairing alliance ruptures. Psychother Theory Res Pract Train 38(4):406–412. doi:10.1037//0033-3204.38.4.406
Sar V (2011) Epidemiology of dissociative disorders: an overview. Epidemiol Res Int 2011:Article ID 404538. doi:10.1155/2011/404538.
Schechter M, Goldblatt M, Maltsberger JT (2013) The therapeutic alliance and suicide: when words are not enough. Br J Psychother 29(3):315–328. doi:10.1111/bjp.12039
Shneidman ES (1985) Definition of suicide. John Wiley, New York, NY
Siegel DJ (2001) Toward an interpersonal neurobiology of the developing mind: attachment relationships, “mindsight,” and neural integration. Infant Mental Health J 22(1–2):67–94. doi:10.1002/1097-0355(200101/04)22:13.0.co;2-g
Siegel DJ (2010) The mindful therapist: a clinician’s guide to mindsight and neural integration. W.W. Norton, New York, NY
Siegel DJ (2012) The developing mind, 2nd edn. The Guilford Press, New York, NY
Siegel DJ (2017) Mind: a journey to the heart of being human. W.W. Norton & Company, New York, NY
Siegel DJ, Hartzell M (2003) Parenting from the inside out: how a deeper self-understanding can help you raise children who thrive. J.P. Tarcher/Putnam, New York, NY
Stanley B, Brown G (2012) Safety planning intervention: a brief intervention to mitigate suicide risk. Cogn Behav Pract 19(2):256–264. doi:10.1016/j.cbpra.2011.01.001
Van der Hart O, Nijenhuis E, Steele K (2006) The haunted self: structural dissociation and the treatment of the chronic traumatization. Norton, New York, NY
Van der Kolk B, Perry J, Herman J (1991) Childhood origins of self-destructive behavior. Am J Psychiatry 148(12):1665–1671
Van Heeringen K, Van den Abbeele D, Vervaet M, Soenen L, Audenaert K (2010) The functional neuroanatomy of mental pain in depression. Psychiatry Res Neuroimaging 181:141–144
Weinberg I (2000) The prisoners of despair: right hemisphere deficiency and suicide. Neurosci Biobehav Rev 24(8):799–815. doi:10.1016/s0149-7634(00)00038-5
Wenzel A, Brown G, Beck A (2009) Cognitive therapy for suicidal patients: scientific and clinical application. American Psychological Association, Washington, DC
Winnicott DW (1958) Collected papers: through paediatrics to psycho-analysis. Tavistock Publications, London
Yann A (2012) P-986 – post-traumatic stress disorder (PTSD) as a consequence of the interaction between an individual genetic and psychopathogenic susceptibility, a traumatogenic event and a social context. Eur Psychiatry 27:1. doi:10.1016/s0924-9338(12)75153-2
Zoroglu S, Tuzun U, Sar V, Tutkun H, Savacs HA, Ozturk M, Alyanak B, Kora M (2003) Suicide attempt and self-mutilation among Turkish high school students in relation with abuse, neglect and dissociation. Psychiatry Clin Neurosci 57:119–126
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Firestone, L. (2018). Dissociation and Therapeutic Alliance. In: Pompili, M. (eds) Phenomenology of Suicide. Springer, Cham. https://doi.org/10.1007/978-3-319-47976-7_10
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