Professor Bernhard Mitterauer
Institute of Forensic Neuropsychiatry, University of Salzburg
Depressive disorders occur in the general population with a prevalence rate of about 5%. Tragically, depressive symptoms are not only connected with suicidal ideas, but also with their commitment. Therefore, a successful treatment of depression implies suicide prevention (Lönnqvist, 2000). Suicidal behavior has a multifactorial origin. Extensive diagnosis and exact assessment of suicidality followed by a biopsychosocial therapeutic management is necessary. Most psychological therapies of depression and suicidality are based on a cognitive approach (Beck, 1976; Blackburn and Davidson, 1990; Gilbert, 1992). The present paper focuses on a new method of therapy, which I have developed and applied successfully in suicidal depressive patients over the past decade (Mitterauer, 1993). The method concerned is the action-oriented therapy of suicidal depression.
2. Narcissistic circle of absolute self-reference: preconditional factors of an existential suicidal depression
Figure 1: Narcissistic circle of absolute
Figure 1 shows the preconditional factors of an existential suicidal depression, depicted as "a narcissistic circle of absolute self-reference". Perfectionistic, intentional programs expected to be realized in an appropriate environment dominate the personality. If this is not perfectly possible, then the environment is experienced as inappropriate and is rejected according to an all-or-none logic (Pritz & Mitterauer, 1977; 1980; Mitterauer, 1984; Mitterauer, 1999). This situation creates existential threat expressed as a suicidal depressive mood. Since the intentional programs of absolute self-reference are not changed, suicide is regarded as the only possible problem solution. Thus, the circle is closed by the program: "radical change of the existential place by suicide". The original poly-thematic intentional programs are now limited to the monotheme of suicide. The narcissism exacerbates such that the cognitive and emotional confinement is intensified until a communicative break-off occurs (Mitterauer, 1981; 1989).
Therefore, the therapeutic aim is to interrupt this diabolic circle. Since we are dealing with acutely suicidal patients, almost always a biological (antidepressant) basic therapy is indicated to loosen the suicidal confinement, in order to make psychological therapies acceptable to the patient in the first place. After establishing the necessary contact with the suicidant, we start out with the action-oriented therapy.
3. Action therapeutic strategies
Which concrete steps are to be taken if the action therapy of a suicidal patient is to be effective? At the beginning of each treatment the action potential still available to the patient should be defined and evaluated.
3.1. Self-referring action steps
First of all there is
¨Self-reflection: What is the suicidal patient still able to do? And, which of these things does he still want to do? Exactly as important is
¨Self-determination: Where does he want to do what? The most appropriate place must be defined or found.
For the perfectionistic mind of a suicidal depressive patient, the existential question of the most appropriate place is synonymous with his action perfection. If some kind of activity in an appropriate place can be defined, the patient is encouraged to initiate it spontaneously. The basic problem is that the suicidal depressive patient always wants to do equally important, valuable or honorable things at the same time, a fact which overwhelms him in his depressive state. However, if a good contact is established with the patient, he will accept the fact that all he really has to do is some kind of activity. Thus, there are no banalities. For instance, if the suicidant wants to leave the room for the first time in order to watch TV for 10 minutes, then this is a good thing. One should also tell him this repeatedly.
¨ Self-experience: voluntary action in the appropriate place. Especially this seemingly minimal self-experience of still being able to do something often has an enormous effect. Frequently, this very basic experience of functioning creates a need for additional actions only after a few days. In that case, the therapist or physician must help identify and, if possible, also provide the appropriate place for each new action. As, for instance, a massage in the private room instead of in the physical institute. If the question of locality is not solvable, then it will be necessary to not include this activity - at least for the moment.
After experiencing that he is still able to do quite a lot for several days in a row, usually within one or two weeks his mood will gradually improve. This is associated with an urge for joint activities together with somebody else. Thus, he has completed all 3 self-referring action steps: self-reflection, self-determination, and self-experience.
In the second treatment step, the first one is repeated but in a communicative sense. Now the focus is on voluntary joint actions with a suitable partner.
3.2. Communicative action steps
Here we are essentially concerned with:
¨ The recognition of mutual action potentials: "what can the patient do with whom"?
¨ The analysis of joint actions: "where are we doing what? Where is the appropriate place? What is the appropriate means of communication (visual, auditory, tactile, etc.)?" Here it is important to identify the preferred sensory modality of the patient. For instance, listening to music could be annoying to a visual type being in a depressed state.
¨ The experience of joint action: we want to and we can do something together. At this stage of treatment the therapeutic strategies should be applied in a highly diversified manner. Therefore, in the first days of therapy a regular contact should take place several times a day between the patient and his therapist.
If one or more communicative actions are attempted in the sense of a mutual experience, then the principle "action is only good if it works" should be abandoned. Whereas the patient views his action-oriented steps in the first couple of days as a positive and releasing experience, very soon his rigid conscience or his perfectionistic personality will reappear. Simultaneously, depressive suicidants increasingly maintain that they want to do both more and much more important things compared to those realized during the past few days.
3.3. Therapeutic programming
Now the therapist and the patient plan an action program which is to be followed strictly. Specifically, the following aspects are emphasized:
¨ Analysis of the action potential and reflection on the intentional programs which determine the patient's history. The patient is requested to note all activities presently desired, independent of their feasibility. Thus, at first all action wishes should spontaneously be listed without regard to their importance or realizability.
For instance, after 8 days of therapy a suicidal depressive surgeon becomes aware of his enormous action potential. He lists 16 activities presently of great importance (Table 1). However, we are aware of the fact that the suicidant would like to do all these things at the same time and also in a perfect manner. If at this stage he would be requested to act, it would put him in a state of "poly-tendency" (Mitterauer, 1983), which means that all simultaneously existing action intentions would once more lead to an incapacity to act.
In the case of a suicidal depressive student the problem turned out to be his expectation to finish his master's thesis within 3 months and also to graduate with honors at the earliest date possible. In addition, he strived at becoming number one in his tennis club. After graduation he also planned to get married right away. But before that he absolutely wanted to take dancing lessons with his bride in order to show off as an exceptional couple at the wedding ceremony. Furthermore, they had already started to furnish their apartment; at that his wife-to-be would be even more fussy.
3.3.1. Consideration of the moral code in the modification of action potentials
Thus, if the intentional programs of a patient demand realization simultaneously, as is almost always the case, then his action potential should be modified together with his therapist. In doing so, first of all the biographically determined moral code should be considered. In order to identify commands ("you must") and rules ("you must not") imprinted by parents and educators, typical childhood and youth situations are reconstructed. The patient should especially attempt to recall characteristic parental expressions. It can be regularly shown that suicidal depressive patients are used to strictly adhere to such commands and rules. As a matter of fact, they really need them, since they correspond to their life conception and personality structure.
¨ Therefore, the therapeutic programming of action must be directed by such rules and commands. Since we now have reached a stage in therapy where the suicidant is liable to switch from a "no-action" to an "all-action" intentional program, a presently more effective program containing action commands and action rules should be constructed.
This therapeutic measure corresponds to the suicidal depressive personality and is no pedantry. The most critical point of the action-oriented therapy calling for extensive therapeutic experience is the definition of the correct moment for program modification. Because if this strategy is applied too late, the patient once more might fall back into a state of uneasiness, anxiety or even suicidal depression.
Based upon the above mentioned case of a surgeon (Table 1), the modification of his action potential is briefly discussed (Table 2): the patient attempts a weighting of his actions by scoring each activity from one to five. Thus, from his view the patient has now already set up a priority list. The numbers in parenthesis entail the score for all 16 activities given by his wife. As shown, some actions are scored similarly high by both partners, whereas others show discrepancies. On the basis of this self-evaluation by the patient and his spouse, those activities are cancelled, which the patient scores as not so important anyway and which also might cause conflict in the relationship due to different opinions.
(evaluation by patient and his wife; explanation in text)
At this decisive stage of therapy, first 12 activities are forbidden and only 4 are mandatory (Table 3).
¨Therapeutic program realization: now the patient is released for the day in order to realize his therapeutic program. In this manner he is able to strictly follow his action program for several days. This experience strengthens his self-understanding even more, which in turn increases his self-confidence and also serves as a mood stabilizer. From this moment on the antidepressant medication might also be markedly reduced.
3.4. Creative self-programming
After having completed his therapeutic action program for a period of several days, the patient soon wants to program his everyday activities by himself, i.e. to plan and structure them in detail. Now he has entered the stage of cognitive self-programming:
¨ Self-realization by experience is achieved. Consequently, the suicidant himself makes a first step towards ending the therapeutic process, since he has learned that his own actions led him out of the suicidal depression and restored his self-determination, as well.
¨ From now on the patient constructs his action potential by himself according to his own expectations. The suicidant not only has made the experience that he is very action-potent, but he has also learned how to use this action potential constructively. In other words: there are action alternatives other than suicide and, thus, life is regarded as meaningful again.
The aim of the action-oriented therapy is now reached, since the patient has not only regained his self-experience, but is also able to structure his everyday life in line with his action potential, thereby increasing his self-realization.
Even if most patients at this stage view their treatment as finished, a short-term ambulatory therapy is further offered. This provides the possibility to discuss problems which might arise, or to give one or the other hint on how to deal with a particular situation.
Whereas the three self-referring action steps should be strictly practiced at the beginning of therapy, the communicative action steps as well as the therapeutic programming might be scheduled individually.
4. Therapeutic aim: change from destructive narcissism into constructive narcissism
Finally, I would like to show how these therapeutic strategies might change the destructive narcissism leading to suicidality into a constructive narcissism (Table 4).
4: Therapeutic aim:
1) The suicidal rejection of an inappropriate environment has changed into a tolerance of non-fitting realities as well as a search for new possibilities.
2) An "all-or-none" logic has switched into an "and" logic in the sense of an acceptance of arguments.
3) Decrease of "less"-symptoms and increase of "full"-symptoms: the patient is not hopeless as before, but is hopefully looking into the future. As a result, his mood is stabilized.
4) Instead of destructive problem solving strategies of suicidality, creative programs are applied.
5) Finally, the circle of the destructive narcissism of absolute self-reference is interrupted by the fact that the patient has learned by experience to perform his intentional programs both with regard to the intentions of other people and to their realizability in the environment.
Suicidal persons do not find their lives meaningful any more. With care and empathy we should, therefore, attempt to help these despaired people to function again in an appropriate environment. However, the suicidal person cannot achieve this by thinking about himself, but rather by the experience of successfully accomplishing something he likes doing. In this way, life has regained its meaning.
Although I have focussed on suicidality in depression, this action-oriented therapy is applicable to all forms of depression.
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Dr. Bernhard Mitterauer is Professor of Neuropsychiatry at the University of Salzburg's Institute of Forensic Neuropsychiatry. He recived his M.D. from the University of Graz and eight years later received his academic degree in Neuropsychiatry and Psychoanalysis. Dr. Mitterauer studied Philosophy with Gotthard Gunther, the famous Philosopher of Cybernetics, in Hamburg. He developed a close friendship and intensive scientific collaboration with Gunther, whose philosophy has influenced Dr. Mitterauer's work up to this day. In 1984 Dr. Mitterauer was appointed Professor of Neuropsychiatry at the University of Graz and he has been serving as a Professor and Head of Forensic Neuropsychiatry at the University of Salzburg since 1989. Concurrently with his practical work as a Neuropsychiatrist, Dr. Mitterauer has been involved in interdisciplinary research in Biocybernetics since the beginning of his professional career. In the 1970's he published basic research studies on emotion, depression, narcissism and self-observation. Notably, in 1981 he earned the Eiselberg Award for his already internationally acknowledged research on suicide. During the 1980's he published numerous studies dealing with a new "dialectic" psychopathology. His book "Architectonics, Metaphysics of Feasibility" deals with a future-oriented interpretation of technical activities, especially the development of robots. Dr. Mitterauer decisively advanced the methodology of the assessment of criminal offenders and has published numerous pertinent basic research studies. He is the founder of the Gotthard Gunther Archives for the research and publication of the posthumous works of Gunther at the University of Salzburg
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