AWARD PAPERS: BALINT AWARD 2014
Year : 2015 | Volume
: 31 | Issue : 2 | Page : 84--87
Understanding emotional turmoil and resolution of disturbed family relationship issues in a suicidal patient
Gurvinder Pal Singh
Department of Psychiatry, Gian Sagar Medical College and Hospital, Banur, Patiala, Punjab, India
Gurvinder Pal Singh
Department of Psychiatry, Gian Sagar Medical College and Hospital, Ramnagar, Chandigarh.Patiala Highway, Banur, Patiala, Punjab
In this article, a truly personal experience of a therapist-patient relationship is being described. This is the experience with a patient Ms. A, who attempted a suicidal act. The nature of demands, difficulties, and emotions the therapist was exposed to while managing this patient is depicted. The therapist-patient relationship was believed to influence critical care of the patient, and a positive therapeutic relationship was associated with continuity of care and favorable treatment response. Human emotions are based on ideas, and control of emotional turmoil may be achieved by changing one's ideas. This presentation will describe the need for us to focus on the specific integrative skills required in handling relationship issues in suicidal patients. The intervention efforts focused on decreasing the suffering experienced, while simultaneously building a patient's capacity to cope with difficulties from an emotional perspective.
|How to cite this article:|
Singh GP. Understanding emotional turmoil and resolution of disturbed family relationship issues in a suicidal patient.Indian J Soc Psychiatry 2015;31:84-87
|How to cite this URL:|
Singh GP. Understanding emotional turmoil and resolution of disturbed family relationship issues in a suicidal patient. Indian J Soc Psychiatry [serial online] 2015 [cited 2021 Sep 29 ];31:84-87
Available from: https://www.indjsp.org/text.asp?2015/31/2/84/173289
”Life is not a matter of milestones but moments” (Rose Kennedy).
Being the 1st day as the head of Psychiatry Department in a teaching institution gives you much of a chance to learn new challenges. Clinical work with suicidal patients is often identified as one of the most challenging and anxiety provoking areas. The therapist-patient relationship with suicidal patients has narrow and minute boundaries. Interaction in a therapeutic setting with survivors of suicidal attempt is quite intense. The therapy sessions are influenced with therapist experience in handling crisis situations. The options available with suicidal patients are limited, and the patients have a myopic vision. The therapist has to take prompt decisions so that chances of survival of the patients are enhanced. I learned many skills through interactions with the patients that will probably guide me through my future career.
Suicide has become a major public health problem. The suicidal patients are mostly in a crisis and are passing through acute emotional distress. Suicide is an act of sheer desperation. It is a 180-degree reversal of aggression toward self. Across the world, more than 2000 people kill themselves every day. Medications in a large number of cases are partially effective or ineffective. The pace of today's life acts as a catalyst to this action. However, suicide in majority is not an impulsive act as killing oneself is a very tough and painful decision. A person harboring such an idea gives enough cues before he/she finally decides to quit his/her life. The case presented here is a common one and usually encountered in the clinical practice of every therapist. Life is a roller coaster to each individual but to the indexed patient its downside has been very bumpy.
On the very 1st day in January 2012 at night (11:45 p.m.,), I received a referral call from the two emergency unit about a 24-year-old female patient admitted with drug overdose. The doctor on duty reported that patient Ms. A came to Emergency unit in a stupor. On receiving the call I was a little apprehensive about the event, but I tried to recollect the case. She was examined in the morning in the psychiatry outdoor unit. The patient Ms. A had come with her mother, and I had suggested the mother to strictly supervise and advised hospitalization. Her mother insisted that she will follow all the precautions and will take care of the patient at home. In the emergency unit, I gathered history of present illness, and retrieved the information for further decisions from Ms. A's mother. She told me that Ms. A was sent to her hostel and she had consumed the prescribed medications.
Medical consultation and critical care of the patient was taken up in the intensive care unit of our hospital. The next day at 2:00 p.m., my receptionist came to my outdoor room and informed me that patient Ms. A with her mother had come for consultation. I was surprised to see the patient's extremely frightened mother. She guided me to one of the rooms where Ms. A was sitting on a chair glaring at the wall of the room. It was my third encounter with this patient, who was not responding to any questions or any other means of interaction. It was a matter of relief for me as her visit in my unit ensured that she was medically stable. I noticed that after some moments, she started to look around; blinking often and she looked straight at me. I sought information from the patient about her well-being. I allocated adequate time to the patient, showed willingness to understand her, and tried to establish a positive rapport.
I was surprised when the patient who was just sitting on a chair looking blankly at me started talking to me about last night's event. I had been avoiding the topic but she told me that this plan was going on in her head for over many months. Now as a therapist, I was supposed to help the patient come out of the painful reality. I allowed the patient to speak for herself and encouraged a free flow of speech. I overcame gaps with difficulty when they lasted too long by gestures, hums, or by repeating the words pronounced by the patient. The patient rushed too quickly into difficult topics about her personal life. In between I lost the initiative and control of the interview process. It was more complicated because the patient had undergone a suicidal act which according to me made things even worse for the family members. Her class mates were scared of her and her teachers were also avoiding her due to her instable mood and recurrent suicidal threats. She told me that she had chosen to leave this world to make the life of her family and friends comfortable. Momentarily she tried to convince me that her last suicidal attempt had failed and now onwards she will live a new life with no suicidal thoughts.
She always felt inferior and she developed impulsivity, emotionally instability, had religious and moral preoccupations, emotional outbursts, and violent behavior. She was very sensitive by nature and had a tendency to get upset for days together over trivial matters. She used to get mood swings and has been suffering from premenstrual dysphonic disorder for the last 6 years. Trying to put her life back on wheels the patient took up a job as a part time worker in a private school. She worked for 2 years and did not enjoy good relationship with her colleagues. Ultimately she was terminated from her job.
She reported that as a child, she was very attached to her father. Her position in the family was that of comfort and lot of attention in an average middle-class family. She had poor relationship with her schoolmates since her seventh grade. She had repeated failures in her academic career. She wanted to become a physician but her family members did not believe in her abilities. After the death of her father 4 years ago, she felt that no one in the family understands her emotional turmoil. She also felt alienated from her mother and sister as they wanted her to pursue her graduation. She had a persistent sadness of mood, decreased interest in work, and other activities of daily life. After the death of her father, she started avoiding even her best friends. Her anxiety increased and feelings of sadness became an integral part of her personality. From the end of year 2011 to early months of year 2012, the thoughts about suicide started building up. The suicidal ideation/thoughts were continuously harbored in her mind. She said “she would keep it secret and it will be more methodical, she would even make a suicide note before executing her plan”.
Her mother repeatedly asked me to save the life of her daughter as most of the people are unable to understand her daughter's emotional turmoil. They had visited most of the health settings in the region with many types of medications and psychological therapies, but the results were a therapeutic failure. In addition, the patient had guilt feelings that she did not follow the precautions which I had explained to her in the last meeting. I just listened to her and used a supportive stance. Ms. A nodded her head and told that she will not repeat the self-harm.
The purpose of the sessions was to provide her with an opportunity where she could express and understand her behavior, thinking, feelings, and make sense of herself. I explained that she needed help in solving the emotional turmoil so that this suicidal crisis could be avoided in future. I continued saying that I know that she looked very upset and we all can help her to tide over this crisis, and she should avoid living alone. The objective was to maintain a therapeutic alliance as one-to-one contact and contract of the transaction with her was possible. I explained how emotional disturbance is caused by our attitudes about events, and we can reduce misery by working hard to change our irrational thinking.
During first few sessions, she reported that she had made a suicidal gesture that was not serious. At the time of the suicidal act, she told that she was very much distressed. In the session, I frequently encouraged her to communicate her emotional turmoil freely. Though, she apparently cooperated for interview, I kept my cool, had lots of patience, did not get irritated with her behavior. She promised to follow-up regularly. During the sessions Ms. A frequently explained about her disturbed relationship with her sister and mother. Occasionally, she would bring death wishes and suicidal ideas in the course of sessions. Sometimes she would exclaim “today is my last day, you will not see me next time, my sister will be happy after my death.” In some sessions she showed sudden changes in her attitudes or erratic and unexpected shifts in her behavior. I was concerned about the safety and wellbeing of the patient. I expressed a variety of emotions like anxiety, ambivalence, frustration, and feeling of helplessness in handling these unexpected shifting in her behavior. I felt partially responsible for the condition of the patient. I was feeling more and more inadequate and inexperienced as a therapist and thought of termination of sessions.
In subsequent sessions I took an empathetic approach and created therapeutic compromise with the patient. I explained to the patient that her mother and sister planned to help her build her coping abilities in dealing with negative emotions. I further explained to the patient that she was probably facing a situation in which an irrational belief was clouding her thinking. She was asked to attend integrative therapy sessions. In these sessions she was educated how to avoid altercation with her sister and how to control an impulsive urge to harm her. I explained to the patient that right now her relationship with her family members is not healthy but her family members find her affectionate. I told the patient that her conclusion that her family members are unlovable is contraindicated by quite a bit of evidence. During the sessions she had felt varied range of emotion about her sister. No efforts were made to confront her in the therapy sessions. Empathy, emotional support, and encouraging expressiveness of feeling facilitated outlining the relationship issues in the patient. I explained to her a few brief integrative techniques,, and emphasized that she should feel free to be inventive in these techniques.
I encouraged Ms. A to focus attention on the present moment, noting thoughts, feelings, images, and sensations without judging them. Ms. A started observing the contents of her thinking as they appeared or disappeared without reacting to them, this type of techniques helped the patient become detached from what was going in her mind. I suggested her to use a coping mantra such as she is well; she is safe; calm, and surrounded by support. I asked her mother and sister to participate in these sessions and we all worked together and they continued this practice sessions in their home and her sister told me on telephone about their progress on a regular interval. During the next six sessions she continued to participate actively in the sessions.
In the follow-up sessions substantial and persistent improvement was noticed in her mood and her interpersonal relationship. She did not miss her appointments without prior information. One day before the therapy session, I regularly received confirmation call from the patient. The patient's family members tried to support her in all possible ways. During another therapy session, her normally bold mother began to weep as she had fears in her mind that what would happen to their family if the patient died of suicide. In response to her mother's behavior, the patient flushed, her expression softened and tears rolled down her cheek as she watched her mother's face. Her mother then left. I slowly invited Ms. A to notice what was happening and to let it happen. Later on Ms. A told me that this is very strange, and she is in agony. I asked Ms. A to just focus on our breathing for some moment and not to force anything; but just observe and see what was happening. Ms. A nodded and took interest in this task and she closed her eyes and started participating in the session.
Ms. A continued to come regularly for further visits. In the 6 months that followed, Ms. A returned several times for therapy sessions and therapeutic efforts were showing success. She started taking interest in her studies. Her medications were also revised and it was planned that she would travel by bus to the place of her education and for the initial period will not stay in the hostel. Her supervision at home was observed by her sister and mother. After several visits, a pattern to our encounters emerged. I realized that all of our efforts were showing good results. My evaluation of her complaints and relationship issue with family members was fruitful and Ms. A continued to return to my hospital for follow-up. I received a telephone call from her mother that Ms. A has got 68% marks in her final examination and she is showing improvement and has adequate therapeutic response.
Many human beings are not able to cope up with the daily pressures of the fast paced and ever increasing expectations of modern life. In a developing country like India with limited financial resources and limited mental health professionals, timely help and support can prevent emotional trauma suffered by the patients. There are many individuals who try to harm themselves as an impulsive act when situation becomes uncontrollable in complex life situations. Many lives can be saved if timely help is available. Thus, such integrative therapy sessions can play a crucial role in saving precious lives. If our sincerity in the therapeutic alliance is transmitted to the patient, the patient goes through a “corrective emotional experience” and chances of the patients maintaining the therapeutic alliance increases.
Indian patient are more ready to expect and accept dependency relationship and are ready to accept overt situational support. The idealized support is the family, and cohesiveness in the families. As the individual grows up she progresses through an unending series of dependency relationship with family members although with varying degree of intensity and duration. In Indian environment, the ideal of maturity is, satisfying the continuous dependency relationship that satisfies the requirement of the Indian family system.
We can provide better therapeutic care to such type of patients and can assure them the benefits of survival by mind body practices and adopting integrative and mindfulness skills. For establishing an effective therapist-patient relationship process the crucial factor is time period as the process can take time, but it is well worth the effort. Ms. A told me that she has made a suicidal gesture that was not serious and no one understood her emotional turmoil for the last 15 years. In such situations one needs to take into consideration the emotional needs of the patient. The patient needs to be assured that the therapist is trying to understand her painful experience. The therapist-patient relationship is a two-way channel and is more a need than a choice.
Continuity of mental health care depends on therapist-patient relationship. Modern training during post-graduation is lacking in many institutes as it does not address the relationship issues in suicidal patients in its true spirit, and needs review by the health policy planners. The necessary training in this area should be incorporated at all levels of education. Learning good therapist-patient relationship is an art and specific skills can be learned with proper training. Each therapist, after training, needs to further hone and develop the basic and advanced specific skills. In the present case described above, the patient was told that acquiring and practicing mindfulness skills was a learning process and the sessions primarily focused on the utility of thinking, deciding, questioning, doing, and redeciding. The role of a therapist is to promote corrective experiences that lead patient to learn new specific skills.
Mind-body practices can facilitate progress in therapy sessions. Identifying effective mind-body practices in suicidal patient is vital in mental health care. It is nowadays asserted that every mental health professional should be competent enough to minimize the suicidal tendencies in the person who is seeking help. There is always something that can be done. Proper handling of this group of patients and their relationship issues has many clinical implications in patient care. Suicidal patients create emotional discomfort in those around them. Suicide rate has not declined despite the widespread use of traditional and new generation of medications. Some suicidal patients may be unusually needy and demanding and may violate rules of social behavior. We should be actively open-minded, searching for all possible views of a problem. Such group of patients with proper management could experience greater well-being and life satisfaction, cope better with stress and are much less likely to commit suicide. I believe I was able to learn from this experience, and, as my career advanced, became better in carrying out my duties in crisis management with suicidal patients. This most appropriate tool empowered me in the current career and played an important role in my understanding of the pattern of emotional life of the patients.
In conclusion, therapists must be aware of every aspect of a patient's emotional state and its association with relationship issues in the life span of the suicidal patients. Continuity of therapeutic care depends on adequate therapist-patient relationship which is the trademark of our profession. By maintaining a proper communication platform and helping the patient to learn integrative therapy techniques we can help the patient to come out of their emotional turmoil. The indexed case management suggests that integrative therapy might have broader range of antisuicidal. Despite advances in the treatment of psychiatric disorders, the risk of suicide is still a major challenge in current clinical practice. It warrants optimal intervention strategies to avoid human loss during productive period. Albert Einstein famously said, “Problems cannot be solved by the level of awareness that created them. Look around and find those people who are engaged in solutions rather than creating problems”.
”Learning takes place only in a mind that is innocent and vulnerable” (J. Krishnamurti).
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
|1||Hill CL, Undegraft JA. Mindfulness and its relationship to emotional regulation. Emotion 2012;12:81-90.|
|2||Robbins CJ, Keng SL, Ekblad AG. Effects of mindfulness based stress reduction on emotional experience and expression: A randomized controlled trial. J Clin Psychol 2012;68:117-31.|
|3||Hanh TN. You are Here. Discovering the Magic of the Present Moment. 1st ed. Boston, London: Shambhala Publications, Inc.; 2009.|