Journal of Family Therapy (1986) 8: 243-252

Distinguishing families where suicidal behaviour is present from families where suicidal behaviour is absent

David Aldridge* and Rudi Dallos

Twenty families are observed during the first interview for family therapy. In families where suicidal behaviour occurs there are three variables which distinguish them from families where no such behaviour occurs. These variables are;

(i) the threat of immediate break up of the family relationship i.e. someone is about to leave, (ii) a situation of mutual negative connotation where no matter what anyone tries to do it is seen as being ‘wrong’, (iii) a tradition of symptoms being used at times of crisis to keep the family together. Suicidal behaviour is seen as a strategic move to keep the family together

in the face of developmental change.

The authors have been researching suicidal behaviour in families and other social contexts where people are intimately involved. Our aims are to offer a systemic description of suicidal behaviour which takes into account how different people talk about suicidal behaviour, to discover the process of ‘becoming’ suicidal and to offer guidelines for therapeutic intervention based upon systems understanding. As yet there is no satisfactory account of suicidal behaviour in families. There are numerous traditional approaches to the understanding of suicidal behaviour but these concentrate on the characteristics of the person who is suicidal. Even when these approaches admit that the problem is something to do with a key relationship they focus on the characteristics of the other person involved in that relationship rather than the nature of that relationship.

Accepted version received January 1985. * 7 Knightstone Court, Obridge Road, Taunton, Somerset TA2 7QA.

243 0163-4445/86/030243 + lO$OS.OO/O 0 1986 The Association for Family Therapy

244 D. Aldridge and R. Dallos

A note on the methodology

The general approach is ethnographic. It is concerned with a qualitative description of suicidal behaviour as it occurs in particular families. The meaning which people give to their activities is not readily categorized or counted. The research is also concerned with a description of family process which when fragmented loses its essential qualities.

The research began by testing the loose hypothesis that suicidal behaviour is a systemic phenomenon concerned with managing personal and familial change (Aldridge, 1984). This hypothesis was tested and refined in varying social contexts e.g. the psychiatric hospital ward, the general hospital ward and in a psychiatric day hospital (Aldridge, 1 9 8 5 ~ ) .

This reflects the way in which we work as family therapists. We develop a loose hypothesis about the behaviour of the patient in the context of the family. We then test out this hypothesis by observing the family in the clinic. This process of research mirrors the process of family therapy used by the Milan Associates (Selvini Palazzoli et al., 1980).

What follows then, is a middle order description of suicidal behaviour as it occurs in families. It is not a definitive study of suicidal behaviour using a rigorously controlled study. Nor is it simply anecdotal. The propositions about suicidal behaviour are based upon careful and systematic observation. These observations have been discussed with and validated by our clinical peers.

From this study other researchers will be able to develop more formal hypotheses and subject them to rigorous trial. Our perspective is that a preliminary investigation, which this study is, is vital for studying any family interaction. Only by testing propositional hypotheses by live observation can we know what is to be investigated. To engage precipi- tately in a statistical and orthodox study without preliminary fieldwork would surely be a folly. It is also ‘unscientific’ to pursue our work without questioning our methods and being rigorous in developing appropriate methods. Only by discovering what is to be controlled can we attempt to formulate a controlled study.

The hypotheses

Commentators in the literature about suicidal behaviour in families suggest that suicidal behaviour occurs in a relational context of change and conflict (Aldridge, 1984). A review of newspaper descriptions during the period that these research data were collected shows that attempted suicide is seen as an illegitimate act (Aldridge, submitted).

Suicidal behaviour in families 245

People who attempt suicide are seen as weak and deviant persons. There are no accounts which propose that attempted suicide is located within a sequence of events in the context of a difficult relationship.

A similar negative connotation of suicidal behaviour is made by those persons involved in the management of such behaviour on a psychiatric hospital ward. Women who become suicidal are seen as unco-operative and illegitimately occupying the status ‘sick even within the context of mental illness. Becoming suicidal in these contexts highlights the social context of interpersonal conflict.

When individuals are asked to describe what happens to them when they become suicidal they locate their individual problems within an interpersonal context of conflict (Aldridge, submitted). This view is also evident in interviews after an episode of attempted suicide when patients are seen on the ward of a general hospital (Aldridge and Rossiter, 1985).

From our preliminary investigations we formed the hypothesis that suicidal behaviour is a systemic move to keep a family together at a time of change and in a context of escalating conflict. Several important factors appear to be present.

(a) the situation worsens and conflict escalates, (b)one family member comes to be construed as deviant, and all

(c) there is a family history of change being accommodated by one

(d) someone is about to leave the family, (e) symptoms regulate the interpersonal distance between family

members (Byng Hall, 1980) i.e. becoming sick prevents people separating, or in some cases prevents people coming closer together.

family members begin to find fault with each other,

member becoming sick,

The procedure for studying the families

The families were videotaped in family therapy clinics at a psychiatric day hospital. All the families were informed that they were participating in a research project and could refuse to participate if they wished.

The families were referred after a weekly clinical meeting at the day hospital. No special clinic was arranged to collect this data. The head of each family therapy clinic was asked to save on videotape the first interview of the particular family assigned to their clinic. Consent was gained from the families to gain access to their case notes and hospital records to discover any previous episodes of attempted suicide.

An hypothesis was made before the family was seen using the referral

246 D. Aldridge and R . Dallos

form supplied by the referring consultant and the case notes. This hypothesis was generated by the team who were responsible for the family. The videotape, the team notes and case notes were gathered together by one of the authors after each session.

It was originally intended to gather two groups of families. One group of ten families where there was suicidal behaviour present, and another group where there was no evidence of suicidal behaviour. However, after the two groups of ten families were collected, evidence was discovered either in the hospital records of the families or during the family interviews, that there had been an episode or threat of suicidal behaviour.

To accommodate this the videotape material was subdivided into four

(a) a recent suicide attempt, (b) a previous threat of suicide, ( c ) a suicide attempt in recent family history discovered from the

(d) no discovered suicide attempt or evidence of ‘suicidal’ behaviour

This altered the data. From presenting two groups of ten families we had one group of fourteen families where suicidal behaviour was recog- nized and another group of six families where no such behaviour was recognized.

groups:

hospital records or during interview,

(see Table 1) .

TABLE 1 The principal problem as presented by the families ~ ~~ ~ ~ ~~ ~~

Principal presenting attempt attempt attempt present problem

~ ~~

Suicide Threatened Previous Not Tot a1

Overt marital 3 1 - - 4 conflict

Psychological 3 3 1 5 12 problems

Physical symptoms 1 1 - - 2

Legal problem - - 1 1 2

Total 7 5 2 6 20

Suicidal behaviour in families 247

Analysis of the videotape data

The videotapes were transcribed by one of the authors. Both authors would then study the transcripts, case notes, session notes and videotapes together and make systemic hypothesis about the presented problem (Fisch et a l . , 1982; Selvini Palazzoli et al., 1980). From the tape data we pieced together episodes which dealt with how the family handled the problem (Aldridge 1985a; Pearce and Cronen, 1980; Harre and Secord, 1973). The families were asked which one of their problems they believed it was most important to change (see Table 1 ) .

Results

The principal problems presented are those of behavioural/psychological problems. The second group of problems is concerned with marital difficulty. This is not surprising. Within the context of a psychiatric day hospital, psychological problems are likely to be prominent. The presence of marital problems may be an artefact of the referral process where patients are referred to a family therapy clinic if a persistent marital problem is expressed.

Relational conflict and escalation

All the cases exhibit conflict in personal relationships. This conflict also ap,pears to be escalating. A pattern emerges where a family attempt to solve a problem over and over again.

At each attempt at resolution the behaviour temporarily responds to treatment but then reappears even stronger. More of behaviour A leads to more of behaviour B, which leads to more of behaviour A in a cycle of escalating distress. Bateson (1973) refers to this process as schizmogenesis. A pattern of behaviour which attempts to promote stability leads to ‘runaway’. The process escalates and the situation worsens.

In the families studied the more one person does to convince, cajole, influence, bargainor demand, the more the other(s) demur, object, reject fight back or withdraw. The more one person refuses, the more the other person demands. This conflict is not located within one person, it resides in the pattern of interaction in which those people repetitively engage (Sluzki, 1981). Escalation does not distinguish the two broad groups of families one from another. All the families show a pattern of worsening symptoms, attempts to solve their problems which fail, more symptoms, more attempted solutions and referrals from one practitioner to another.

Table 2 presents the three categories which distinguish families where suicidal behaviour is present from those where suicidal behaviour is

248 D. Aldridge and R . Dallos

absent. The categories are (i) the threat of the family about to break up, (iii) the presence of negative connotation and (iii) a family tradition of conflict management by a person becoming sick. These categories are described in greater detail below. Note that these categories are not discrete, they interact one with another.

TABLE 2 Three categories for distinguishing families where suicidal behaviour is present from families where suicidal behaviour is absent

connotation (iiz) A family tradition of conflict management by a person becoming sick

(z) The threat of the family about to break up; (iz) The presence of negative

(i)* (ii)t (iii)$

Someone No threat Negative Partial Tradition No about to connotation negative of sickness tradition

leave of all connotation behaviour

Suicidal 14 - 14 - 13 1 Non-suicidal - 6 1 5 2 4

* X 2 < 0 . 0 0 5 Fisher Yates. N = 20. t X 2 < 0 . 0 0 5 Fisher Yates. N = 20. $ X 2 < 0 . 5 Fisher Yates test ofsignificance in 2 X 2 contingency tables(Finney, 1948). N = 20.

Total negative connotation

An important part of the process of becoming suicidal is when, during the escalation of conflict, one person is seen as ‘totally deviant’ i.e. everything they do is ‘wrong’. For example, a seventeen-year-old man and his family were seen after an episode of self-poisoning.

PETER Well it seems like it was getting to the stage where whatever Z did was wrong, that’s what it seemed to be, things seemed to be getting worse during the last three months.

If I tried to do something right, say, unload some shopping and pack the stuff away without being asked to do it, I’d put it in the wrong place, and everything I did was wrong.

Everything that Peter does is seen as wrong in this family. However, this negative construing of behaviour is mutual. No matter what Peter’s

Suicidal behaviour in families 249

parents try to do Peter sees them as being wrong. The negative connotation of behaviour is mutual and resides in the relationship between those involved. No matter how altruistic any member tries to be these very acts are construed negatively.

The negative case in Table 2 is interesting in that i t refines the category of negative connotation. In this family although the adolescent daughter is construed as deviant, and not being able to do anything right, there is;

(a) no threat of the daughter leaving or being asked to leave, and (b) no evidence of the daughter having a history of sickness in the form of a regular contact with her General Practitioner or a hospital consultant. Significantly it is the parents who are the complainants and the

mother of the girl who is the identified patient.

The threat that the family is about to break up

The category which demarcates those families where suicidal behaviour is present from the other families is a threat of the complete breakdown of the immediate family system. One person is about to leave, has left or is being told to leave. This situation arises in a context of escalating conflict (things are getting worse) and negative connotation (everything done is ‘wrong’). For example, in the family referred to earlier;

MOTHER Peter and I don’t get on too bad, we do have our disagreements because I was nagging him . . . then I got to the point at Christmas where I couldn’t stand it anymore and if he was going to continue then i t would be better i fhe moued out.

Once more we can see a process of escalating conflict and a threat of Peter having to leave. Leaving home is an important issue in this family as the eldest daughter is about to get married. The whole episode of suicidal behaviour is raising the issue of family change.

Previous researchers into suicidal behaviour have noted the presence of a breakdown in relationship (Hawton and Catalan, 1982; Morgan, 1980) but have not located this behaviour in a sequence of interactions as a process. These researchers see the breakdown of a relationship and suicidal behaviour as impulsive.

We propose that human behaviour only appears to be impulsive if viewed in a narrow individualistic context. In a wider context of family interaction and reciprocal relationship suicidal behaviour becomes understandable. Rather than seeing the behaviour as an example of

250 D. Aldridge and R . Dallos

personal deviance the behaviour is seen as part of a patter of behaviours. In this light suicidal behaviour is a strategy to maintain a relationship at a time when that relationship is about to break up. Suicidal behaviour then, can be seen as a benevolent move to promote reconciliation rather than yet another event in a series of deviant behaviours.

A tradition of distress management

Where suicidal behaviour is present in a family there is a repertoire of distress management where symptoms are used to manage conflict. The presentation of symptoms occurs when conflict within the family escalates (Aldridge, 1984. Haley, 1980, 1976).

For example in the family referred to earlier, Peter, the identified patient, had a long history of bedwetting. He had been to hospital many times for a whole range of treatments from the physical to the psychological. Bed wetting appeared to occur at times when his mother took extra interest in him and his father began spending more time away from the family. After an episode of bedwetting his father would become more involved with parenting Peter and his mother would cease her rigorous scrutiny of his personal hygiene (see Figure 1).

I. Mother scrutinizes

Peter \ 8. Peter settles down. Father withdraws 2. Peter withdraws

I 7. Peter wets bed or attempts suicide. Father more Involved. Mother wlthdraws

2 6. Peter's fother

unite to regulate Involved and parents

hls behaviour

5. Mother becomes distressed

3. Mother sees this as further deviance and nags

k 4. Peter becomes 'defiant', stays out, wlthdraws to room, becomes Independent

Figure 1. A circular description of symptoms regulating relational distance.

Suicidal behaviour in families 251

Both parents would take time to escort Peter to his hospital appointments particularly following an episode of bedwetting. The episode of suicidal behaviour fell into this very same pattern.

At one level (the personal) his behaviour is problematical. At another level (the familial) his behaviour maintains family cohesion. At yet another level (the cultural) his behaviour is inappropriate for a seventeen-year-old (Reiss and Oliveri, 1983; Reiss, 1981).

For the families where no suicidal behaviour is evident there does not appear to be a family tradition of conflict being managed by symptomatic behaviour. In two cases (see Table 2 (iii) this does not hold true. The symptoms of depression in these cases occur in a context of interpersonal conflict but rather than keeping the partners together the symptoms prevent the partners from coming closer.

Where a family tradition of distress management using symptoms keeps a family together and resolves conflict then suicidal behaviour may occur at a threat of separation. When symptoms keep partners separate then separation is not a critical issue, togetherness is problematical. It may be easier for us as therapists to see separation as an issue rather than staying and coming closer together as an issue.

For the families in this study suicidal behaviour occurs when three interactive variables are present.

(1) When family members see each others behaviour as ‘wrong’ no matter what they try to do.

(2) One member traditionally becomes symptomatic when conflict escalates.

(3) Someone is about to leave the family, has been told to leave or has recently left.

The ramification of this understanding is that practitioners can play a r61e in the prevention of suicidal behaviour. First, they can understand persistent or intractable symptoms in the context of family behaviour. Then offer a systemic intervention which takes into account previously attempted solutions and involve all family members living together. Second, they can positively connote all family members as trying to do their best for the family and avoid a negative connotation of the symptomatic person. Third, practitioners can be willing to consider that when a person is unwilling to change then the symptoms are part of a systemic ecology which the therapeutic interventions have failed to address (Aldridge and Rossiter, 1985).

These descriptions are essentially qualitative. This paper does what the authors set out to do i.e. to refine their systemic hypotheses about suicidal behaviour in family contexts. It is for a more formal research project to test out the accuracy of these three hypothesized variables.

252 D. Aldridge and R. Dallos

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