Book Club: Developing a Shared Understanding with Konrad Michel’s ‘The Suicidal Person’

Disclaimer: The following transcript has been autogenerated and may contain occasional errors or inaccuracies resulting from the automated transcription process.

Content warning (00:00):

This podcast discusses content that may be distressing. For some listeners, please refer to the episode description for details about the topics covered.

Host (00:08):

Hi there. Welcome to Mental Health Professionals Network podcast series. MHPN’s aim is to promote and celebrate interdisciplinary collaborative mental health care.

Nicholas Procter (00:26):

Hello and welcome to this episode of MHPN Presents Book Club. My name’s Nicholas Procter, coming to you from the traditional lands of the Kaurna people, the traditional custodians of the Adelaide Plains and Adelaide region. It’s a real pleasure to be here today with Dr. Conrad Newman. My role is at the University of South Australia. I’m the chair of mental health nursing, director of Mental Health and Suicide Prevention Research. So we are based in Adelaide and as host today, I’ve chosen a book which Conrad Newman, who’s our guest today, is intimately connected with as well. It’s called The Suicidal Person, A New Look at a Human Phenomenon by Konrad Michel. So we have two Conrads today we have Dr. Conrad Newman in the studio, Dr. Konrad Michel, who’s the author of this book, the Suicidal Person, A new look at a Human Phenomenon. Hi, Conrad, welcome.

Conrad Newman (01:17):

Hi Nicholas, thanks for inviting me. It’s lovely to be here.

Nicholas Procter (01:20):

And Conrad, you were the first person I thought of when I was considering who would like to join me today because you were the person who opened my eyes, my thinking to a philosophy and approach, which is embedded in this book by Konrad Michel, the Aeschi approach. So can you take us back to when you first got involved in the Aeschi approach and tell us about Aeschi as well.

Conrad Newman (01:49):

So it’s some years ago Nicholas, and one of the things that happened is I’d been out of psychiatric practise for a number of years working in it and decided to come back into psychiatry and was interested in how approaches have changed to dealing with a number of things in psychiatry. First and foremost, how we were approaching the suicidal person. And I came across a conference in Aeschi in Switzerland, a little town in Switzerland, and beautiful countryside, which was started by Konrad Michel and David Jobes, another eminent suicidologist. The conference was limited to 80 people, so it was a small conference held at a little hotel in a Aeschi, went to it and was absolutely amazed at the discussions that were happening. They talked about a way of approaching the suicidal person that was far different to what was being practised at that point in time in Australia. And I remember coming back from the conference, very excited and telling you about it and saying to you, you have to come to this conference the next time that you’re able.

Nicholas Procter (03:05):

And I did. In fact, the conference moved to Vail, Colorado, so I flew with you to Colorado, and I attended three additional conferences in Colorado. The group had moved to there, and again, it was a group, an intimate gathering of around 70 or 80 people.

Conrad Newman (03:22):

With a different philosophy around suicide and the suicidal person to what we were used to. And I don’t think there are many conferences I’ve been to over the course of my career where I can say that every speaker had something inspiring to say, but it was really that calibre.

Nicholas Procter (03:41):

And Conrad, it was the depth that I recall that stood out for me, the depth of the discussion. And we’re going to come to that discussion and think a bit more about that, but our connection is expansive in the sense. Now you enrolled in PhD studies and you’ve been doing some work around that. Could you speak briefly about your PhD work?

Conrad Newman (04:02):

Yeah, my PhD work has been about listening to a series of recordings to a mental health triage line by men or people concerned about these men where all of the men went on to die by suicide. And a really deep dive into what happens in the dialogue between a emergency telephone clinician and a man who’s suicidal.

Nicholas Procter (04:31):

I guess that’s a good reminder too that today we are talking about the sensitive topic of suicide. If you’re listening to this podcast and today’s discussion evokes a particular reaction or a feeling or a concern within you, please reach out if you’re listening to this podcast, reach out to the many excellent resources and services and supports around the globe, not just across Australia where we are right now, but services and supports around the globe. So just a warning, and we’ll also have something up on the website linked to today’s podcast. Can you tell me, Conrad then, what is it about the approach that stands out for you and why it stands out for you?

Conrad Newman (05:10):

I think what stood out for me was the traditional approach and the way that I was trained in psychiatry was really putting the diagnosis first and foremost in the interaction with the person. So taking a traditional history, focusing on their mood, how they’re sleeping, how they’re eating their energy level, and seeing suicide as just another component of that. Whereas I think the Aeschi approach and what Konrad Michel definitely talks to in his book is making suicide the first and foremost point of discussion and gripping primacy to the person’s own narrative about their experience of being suicidal.

Nicholas Procter (06:00):

And the Aeschi approach, and we’ll talk about this a little bit further as well, but the goal is to reach a shared understanding of the person’s suicidology, their conceptualization of suicide related distress. And there is a window of opportunity to address suffering and mental pain there. Two of the elements, and there are elements that I think are not restricted to one discipline, and I’m in nursing, you’re in psychiatry, so nursing and medicine specialist, psychiatry coming together. What do you think about the interdisciplinary perspective and nature of some of these concepts?

Conrad Newman (06:32):

I think that’s a very good point, Nicholas. And what I think is common across disciplines is finding the ability to talk about the person’s emotional pain. And Schneiderman was the first person to talk about psychache. And Konrad Michel references his work in the book, identifying what the emotional pain is about and what are the drivers for the person to be suicidal. I think the other thing across disciplines now is rather than it being the expert, the psychiatrist or the mental health nurse and the patient being sort of a passive recipient of that expertise is much more joining together, working side by side to understand the suicidality.

Nicholas Procter (07:17):

And that to me is one of the core features or elements of Konrad Michel’s book, his way of conceptualising the story of how things came to this. So a person’s suicidality doesn’t exist in an autobiographical vacuum is essentially one of the key arguments. So storytelling and the story of how things got to this mirrors the Aeschi approach, the Aeschi philosophy, and I’ll just read out another bit of that. The person is not a specimen defined by symptoms psychopathology. The goal from the first interview is to form a therapeutic relationship, which requires empathy and understanding, taking into consideration a person’s logic related to the suicidal urge to know that you go back in time to some extent, but you also bring into conscious play the present. What do you make of that philosophy?

Conrad Newman (08:19):

I think it’s such an important philosophy and I think it informs a lot of things that I would do nowadays in terms of teaching with medical students or psychiatric registrars or nursing students, social work students is allowing the person the time and it might be 20 minutes, 30 minutes, just to tell their story in terms of how did they get to this point that they felt suicide was the solution. And so much will emerge from just allowing people to tell their story as opposed to going in with, I’ve got a task to do, which is to come up with a diagnosis. And unfortunately, I think still in a lot of mental health systems, diagnosis determines disposition rather than the emotional state of the patient.

Nicholas Procter (09:07):

And Conrad, your read of that at a very practical clinical level, your use of these skills and these ways of knowing, let’s call ’em ways of knowing and clinical practise, how does that play out in clinical practise? What does clinical practise for Conrad Newman look and sound like when these philosophies and ideas are put forward.

Conrad Newman (09:27):

I think it probably looks and sounds very different to how it would’ve been 20 years ago or longer ago than that. I think nowadays it’s much more a joint effort in terms of let’s work together to understand why things are this way. Diagnosis is still important but less so than what it would’ve been 20 years ago. And this I think borrows from principles of DBT, which is helping the person to live with being suicidal rather than dying from being suicidal.

Nicholas Procter (10:02):

And I think of things when you speak Conrad, I think of person-centred practise. I think of storytelling and I guess the idea of explaining our actions through our stories and that notion of explaining our actions through our stories can be obscured or invisibilised to some extent if we just go with an instrumental moment of diagnosis and disposition. Is that how you read it?

Conrad Newman (10:28):

Yes, very much so.

Nicholas Procter (10:30):

How do we get to this point now then? Do you think that there’s a greater emphasis on stories and side by side collaborative approaches? You mentioned 20 years ago things were very different. How did we get to this place now?

Conrad Newman (10:45):

I think in terms of where we are moving to is because of a recognition that the way that we’ve done things hasn’t worked. The suicide still is a global problem. The rates vary in different places, but we need to do something differently. That being said, I think it’s also important to say that I work from a premise that suicide is preventable, but not every suicide can be prevented. We are still unfortunately going to lose people to suicide. But I think this newer approach, this newer philosophy has the potential to engage people at a much deeper level than what we have over the past couple of decades.

Nicholas Procter (11:25):

And I think that your thinking around that is reflected in the book as well. Konrad Michel takes us in various ways to understanding the contributions from various discipline perspectives, how there is a place for pharmacological treatment at times, how there is a place for deep listening and talking and conversation around the story of somebody’s life and how things got to this, how a person came to the point of wanting to harm themself. And I think what comes through to me in the book, and I think comes through to me when you speak as well, is that we can do this together in a person-centred, compassionate way that is collaborative and we can join together to discover the drivers of suicide, but also what to do next for future or potential future episodes for suicide survivors. And do you think that this is something that’s evolved because of a particular change in society or has psychiatry, psychology and other disciplines shifted their perspectives? What do you think?

Conrad Newman (12:32):

I dunno. It’s a very interesting question. I think there’s been a swing back towards more human centred approaches in psychiatry and mental health in general that we sort of lost. I guess it might be reductionist to say, but I think we’re emerging from a very biologically centric period of time in mental health and people’s recognition that that’s just not enough.

Nicholas Procter (13:00):

Yeah. And is there also a parallel process in society where perhaps suicide and help offering and help seeking is coming out of the shadows to such in some extent?

Conrad Newman (13:13):

I think so.

Nicholas Procter (13:14):

And what does that mean, the notion of living with being suicidal? You mentioned that a moment ago. How has that intersected with the thinking of Konrad Michel for example, in his take on suicide and supporting?

Conrad Newman (13:28):

I think it’s very much part of his thinking. As you would remember at the Aeschi conferences, he would show videotapes of him interviewing people who had attempted suicide. And what he has done is develop a therapeutic strategy, I guess out of that called Aeschi, which I think is very interesting. And what happens is you get the person to tell their story, you ask some clarifying questions, that’s all videotaped, and then the next day you watch that through with the patient and help them understand what happened and get their insights into what happened. A very powerful and different approach to what we usually do.

Nicholas Procter (14:08):

And when you say that, and I do recall those videos, and when you say that now I think about the person’s experience being brought into conscious play and there’s a potential to learn something about the events and experiences leading up to that crisis, the events and experiences that took place in someone’s reaction to that. Why is that important?

Conrad Newman (14:35):

I think it’s important because, and what I personally think as one of the mechanisms in that kind of approach is you are providing the person who’s attempted suicide with some distance from their own suicidality and understanding it and almost strengthening the metacognitive ability to look at a problem and think about it and see it differently rather than being completely immersed in being suicidal.

Nicholas Procter (15:02):

And why is that important?

Conrad Newman (15:09):

Number one, I think it empowers people to a certain extent, and I think it also is really giving the message that this is something that can be solved, that this is something that people can work on.

Nicholas Procter (15:16):

And is it also something that by having that sort of metacognitive distance as you describe it, Conrad, is it also an opportunity to take a look at a phenomena that was part of me was something that happened and now I can better know how to mitigate that or prevent the circumstances from reemerging? Is that –

Conrad Newman (15:40):

Very much so –

Nicholas Procter (15:41):

Part of that safety side of it?

Conrad Newman (15:43):

It is a safety side of it and it’s kind of what do I need in my toolkit to be able to get through this because it will happen again. We know that people don’t just usually experience one episode of suicidality. It quite often recurs.

Nicholas Procter (15:56):

And Conrad, just going back to that, Aeschi philosophy, which Konrad Michel has embedded into his book, the Suicidal Person, a new look at a human phenomena and I quote the goal from the first interview is to form a therapeutic relationship which requires empathy and understanding the person’s logic related to the suicidal urge. Why do you think that’s important? What’s the story here?

Conrad Newman (16:21):

I think that part of that story is the fact that a lot of people who attempt suicide don’t have any compassion for themselves. And then in this approach, while compassion is not a word that comes up a lot in the a Aeschi approach, it is very much embedded in it. And I think it models for the patient that it is possible to have a compassionate approach to how they feel.

Nicholas Procter (16:47):

What does compassion bring to suicide suffering or suicidal suffering?

Conrad Newman (16:52):

I think it eases the pain and gives people who have no sense of a future for themselves some hope. I think it can shift the way that a person views the interaction with a professional.

Nicholas Procter (17:09):

What does hope bring to suicidal suffering and prevention of suicide?

Conrad Newman (17:15):

A really interesting question, and I think one of the things for people who feel hopeless is that they, number one, feel that they don’t have the agency to be able to get to where they want to be. And they also have impaired problem solving. In my practise, I quite often come across people who’ve attempted suicide and I might ask them, you encountered this problem in the past and you got through it. What was different this time? Why couldn’t they bring to bear the problem solving ability that they had in the past? But it seems to be impaired. So I think very much embedded in this approach is being in essence the auxiliary hope giver for the patient by helping them to find a pathway forward and getting them to feel that they can solve the problems that they feel are insurmountable.

Nicholas Procter (18:06):

And when you say that, I think of the words there, auxiliary hope, and you are kind of going side by side and we are seeing this together and doing this together. Can you speak to that? What’s going on?

Conrad Newman (18:18):

I always come back to, so the other person who founded the Aeschi group was David Jobes, and I always have the mental image from his books of the traditional approach is the clinician facing the patient and coming up with a diagnosis, whereas the Aeschi approach is sitting side by side. And David Jobes actually talks about doing that and Konrad Michel also talks about doing that sitting side by side, but with the patient. So this is a problem that we’re going to solve together.

Nicholas Procter (18:50):

That’s right. And of course, Jobes in his work has those rudimentary drawings in his very first expression of these approaches, he has those two people sitting side by side. In fact, I remember you introduced that to me. I did. You’ve introduced a lot of ideas and I think it’s great that you are such a good communicator around these ideas. What does it mean for clinical teams and what does it mean for services to embrace a side-by-side collaborative approach, looking at the drivers of distress and looking at ways to support people that is a shift from 20 years ago or even 10 years ago. What does it mean in practise to do that at teamwork?

Conrad Newman (19:32):

It’s definitely shifted and what I think is really interesting is it’s almost like people feel that they’re given permission to do what they actually think they want to do. Like people go into mental health primarily with the view that they have compassion and they want to help other people, but they’re sort of trained up to operate in a certain way. I think this gives people permission and the tools to be able to do it differently.

Nicholas Procter (20:00):

Yes. And Konrad Michel in his book talks about a global movement away from risk stratification. Risk stratification of so-called categories of low, medium, and high risk. What’s happened here? There’s been a shift around that. What do you think has driven that shift and what does it mean for practitioners of today?

Conrad Newman (20:22):

It’s really interesting how long that risk stratification model has persisted in practise and policy because we don’t have any clear definitions of what low, medium, or high are. And I don’t think there’s quite often not agreement if you get two clinicians to rate somebody’s risk using that model is there’ll be two very different ratings. I think where I’ve landed on this, and I think the Aeschi approach as well is anybody who’s attempted suicide, there’s definitely a higher potential compared to their peers in the general population. Someone who’s on an inpatient unit having attempted suicide is never going to be low risk for suicide. The risk for suicide from a single overdose can persist for up to 35 years. What I’m hoping is that that model of low, medium, high disappears. What’s interesting is how some clinicians, when it’s been proposed that be taken out of practise, have almost protested and said, no, we need to keep it. That’s the way we’ve always done it.

Nicholas Procter (21:32):

And I noticed even across Australia, the federal government’s policy settings are reflective of this shift. So we are seeing that. I know in our own jurisdiction in South Australia and also the NGO, the national NGO non-government organisations across Australia are also responding to that shift. And Konrad Michel links the shift with two things. He links it with fluctuating states. So things shift within the life of a person and the potential for rapid intensification of suicidal thoughts and urges. And the other thing, and I’m keen for your thoughts and reflections on the idea of having reasons for living and the importance and significance of reasons for living. Why are they important?

Conrad Newman (22:20):

Just to touch on fluctuating states initially, because that’s a concept that you introduced me to.

Nicholas Procter (22:26):

Oh!

Conrad Newman (22:27):

Exactly. Which I think is so interesting because the traditional model of low, medium, high is do a risk assessment once a week and the person’s going to be low, medium, or high for the next week till we do it again, which makes no sense in terms of how human beings operate and how things fluctuate, reasons for living, I think is really interesting. And Konrad Michel talks about it. David Jobes talks about it. It’s embedded I think in the Aeschi philosophy as well as examining what are people’s reasons for dying. But I always ask it now, what is it that keeps you going? Is there anything that keeps you going? And when people are able to identify with me reasons for living, I always ask, is that enough to keep you alive? So it’s not just identifying the reasons for living, but it’s examining with the person, the potency of them.

Nicholas Procter (23:20):

That is such an interesting question to ask. And I guess what sits, when I hear you ask that question, my reflection back to you is that when we have reasons for living, when we are clear about reasons for living, we are less likely to take action that threaten that or place that at risk or take that away from us in some way. And I remember reading one of the Aeschi participants, someone who Konrad Michel refers to in his book, Craig Bryan talking about that as well. And he sometimes says, look, you might find people really don’t find the words, they can’t find the words about reasons for living. And he will say, in certain circumstances with some people, imagine it’s a bit like you’ve lost your car keys. They’re not lost, they’re somewhere we’ve got to just go back and find them to just retrace your steps. And the metaphor of retracing and going back and thinking about that, I think has the potential to open up fresh lines of possibility, fresh sight lines of understanding and having an enlargement of focus. Bringing a wide angle lens to circumstances seems to be also part of that as well.

Conrad Newman (24:40):

I think it is. And I think what that reminds me, Nicholas, is these more contemporary approaches. It’s asking the question, but it has a therapeutic strategy embedded within it. It actually brings about change as well as asking the question. So there’s additional questions we might ask, how are you sleeping? How are you’re eating? How’s your energy? Don’t necessarily have a therapeutic focus to them. But as you just described how Craig Bryan poses it, it’s a therapeutic strategy.

Nicholas Procter (25:12):

Yes. And in Konrad Michel’s book, he refers to Craig quite a bit and that work and the way that he has been inspired by it as well. But you’re right, it opens up fresh ways of thinking and fresh possibilities, whereas traditional questioning might be about neurovegetative features, for example, or some kind of biological anchor point rather than a fresh possibility opening up, developing a relationship, finding a place of rapport and connection between the worker and the person in distress.

Conrad Newman (25:45):

Very much so. And I think the other thing that fits with what you were saying earlier about fluctuating states is not making the assumption that reasons for living stay static. A patient I’m looking after at the moment in hospital who was profoundly depressed a week ago, her son was a reason for living last night. When I saw her, it was no longer a reason for living.

Nicholas Procter (26:30):

Yes. And Conrad, the other important part of these discussions and thinking about that is working with suicidal people and supporting them and supporting their family is work that can be emotionally demanding. How do you take care of yourself when you do this work?

Conrad Newman (26:27):

What have you noticed? It’s a very good question, and I think because of my interest in suicidality, I’m referred a lot of people who are very high risk. I think it’s anchoring myself in life and what are my reasons to keep going and how do I get pleasure? I think there’s also a great satisfaction in seeing people from not wanting to be alive, to feeling that they can move forward. I think the other thing that I’ve done over the past probably 20 years is equip myself with strategies that can be useful to people. I use the analogy when I’m teaching that if you’re a lifeguard and if someone comes to the pool and they jump in the pool and they’re suddenly drowning, then you rescue them, you pull them out, and then you might notice the next day they come to the pool once again, they jump in, they’re drowning, you rescue them, you pull them out. I think that’s how mental health services have worked in many areas with suicidal people. What is better to do is to teach the person how to swim, and then they’re able to manage without needing to be rescued all the time.

Nicholas Procter (27:46):

And teaching and supporting and going with them side by side, which Konrad Michel does explain very nicely in his book, the Suicidal Person, and new look at a human phenomena, which was, I guess what I’m kind of coming back to your own studies and your own discoveries that you have landed on where you’ve listened to the intimate moments really of people’s stories when they’ve sought assistance through those recordings and the way in which we can lean in and listen in and support somebody so that they can find a better place or reconnect with things that are important to them, which is about skills and qualities that can get them to a much different place or a better place in some way.

Conrad Newman (28:35):

Exactly. And not losing the compassion in the interaction with people in some of the recordings that I’ve listened to is a striking lack of compassion to the extent of hearing one recording where the worker was telling the young man he was suicidal to grow up. That’s not helpful.

Nicholas Procter (28:55):

Conrad, one thing I will ask you is having read the book as I have, does it leave you with any questions? Does it leave you with any things that you would like to know more?

Conrad Newman (29:05):

Yeah, the thing that it leaves me with is, and we were talking about this before we started recording, was the Aeschi group is looking for a host for the conference. It was in Aeschi in Switzerland. It was then in Vail Colorado, and then the funding, which was through the Mayo Clinic.

Nicholas Procter (29:24):

The Mayo Clinic hosted the American ones that I attended, the three day events.

Conrad Newman (29:29):

So I think what I’m left with is I want to continue the connection with Konrad Michel that we have, and also think, is there some possibility in the future that we could have an Aeschi down under?

Nicholas Procter (29:44):

I think that would be amazing. And particularly given that Adelaide is such a desirable location in terms of global city rankings and lifestyle and visitor experience. So that’s a little bit of a possible plug.

Conrad Newman (29:58):

Exactly.

Nicholas Procter (30:00):

And I think the timing, the opportunity and the timing around some of these concepts, given the progressive nature of how we are now conceptualising suicide and supporting people during critical moments of the suicidal experience. Is there anything else, Conrad?

Conrad Newman (30:17):

No, I think, I just feel fortunate that I encountered this kind of thinking when I did, because it really has enabled me to have a fulfilling professional life for the past 20 years in the face of a lot of adversity and in the face of patient suicide as well. It’s re-examining little reasons to keep going and to think about why this work is important.

Nicholas Procter (30:41):

That’s a big statement. That is a very powerful statement, Conrad, to reflect on because you have brought your best thinking, the best of who you are, the best of what you know, and the best that your organisation can support and enable you to be able to provide to some very difficult and complex circumstances. And just to be able to capture that in a way that is reflective seems to be important, seems to be important in its own right. Well, thank you for joining us on this episode of MHPN Presents Book Club. You’ve been listening to me, Nicholas Procter

Conrad Newman (31:24):

And me Conrad Newman.

Nicholas Procter (31:26):

We hope that you’ve enjoyed this conversation about the book, the Suicidal Person, a new look at a Human phenomena by Konrad Michel, and a much wider discussion along the way. As much as we have. If you want to learn more about myself or Conrad, our bios will be found on the landing page for this episode. On the landing page, you’ll find a link to the book along with a review of the book, which I authored and which was published by Hogrefe eContent, as well as links to other references that we’ve been making in this podcast. MHPN values your feedback. Please follow the link and let us know whether you found this episode helpful, give us comments, provide comments and suggestions to help shape future of MHPN podcasts. And if you like this episode, look out for an MHPN Presents episode, a conversation about the importance of deep listening in suicidal crisis. We will be back to talk about that. So stay up to date with future book episodes about other MHPN podcasts, and don’t forget to subscribe to MHPN presents. Thank you for your commitment and engagement with interdisciplinary person-centered mental health care. And it’s a goodbye from me and –

Conrad Newman (32:37):

From me.

Nicholas Procter (32:38):

Thank you very much.

Host (32:40):

Visit mhpn.org.au to find out more about our online professional programme, including podcasts, webinars, as well as our face-to-face interdisciplinary mental health networks across Australia