The therapeutic alliance is a moderating factor for outcome of any kind of therapeutic interaction. It is defined as “the active and purposeful collaboration between patient and therapist”. A crucial prerequisite is that patients and health professionals find a shared model of understanding. When dealing with suicidal patients, the medical, risk-factor-based model of suicide and the subjective inner experience of the suicidal person do not match. Health professionals who understand suicide as a consequence of mental disorders will ask questions about symptoms of depression, etc., while patients have their own experiential understanding of what got them to think of suicide as a possible solution to an unbearable painful experience, often coupled with self-hate and self-rejection. Medical professionals and suicidal patients use, so to speak, different “suicide languages”. A medical, risk-factor based approach cannot accommodate the suicidal person’s subjective inner experience. When patients feel that the interviewer will not understand their inner turmoil, they will keep their suicidal thoughts and plans to themselves. The typical medical consultation with the suicidal patient has aptly been characterized as “dancing without touching.”
Therapeutic alliance and treatment engagement require a true person-centred approach. A model of suicide as a goal-directed action with a personal background posits that patients have a narrative competence and that they are well able to explain their suicidal dynamic in a biographical context, including their vulnerabilities and suicide triggers. In this treatment model, psychiatric disorders are seen as suicide risk factors, not the cause of suicide. The patient’s narrative is the first step to create a therapeutic alliance, involving patients in a collaborative therapy process. However, conducting a narrative interview requires therapists to have good listening skills.
The presentation will include a short overview of studies investigating the role of the therapeutic alliance in relation to therapy outcome with suicidal patients.