KONRAD MICHEL, MD

Research

Konrad Michel, M.D., is a clinical psychiatrist, affiliated with the University of Bern, and has devoted a major part of his research and clinical activities to suicide and suicide prevention. In his work he developed a special interest in the possibilities of the clinician to prevent suicide. His first study on this topic dealt with suicide risk factors and was published in the British Journal of Psychiatry (1). Further publications dealt with general practitioners’ attitudes and knowledge about suicide (2, 3), characteristics of young suicide attempters (4), “Suicide with Psychotropic Drugs in Switzerland” (5), a comparison of contacts of suicide attempters with GPs prior to the event in Stockholm and Bern (6), and patients’ explanations of suicidal behavior  (7).

The work led to a study which evaluated changes in knowledge and attitudes in general practitioners after specific teaching rounds: “Spreading the Gospel to General Practitioners” (8). Konrad Michel gave the opening lecture at the European Symposium on Suicidal Behaviour entitled “General problems in planning and implementing prevention and intervention programmes” (9). He also contributed a chapter on “Suicide Prevention and Primary Care” to the International Handbook of Suicide and Attempted Suicide (10).

During these years, K.M. developed a growing interest in the special aspect of communication in the patient-doctor relationship. This interest arose out of repeated experience from interviews with suicide attempters, and the increasing conviction that one major obstacle in suicide prevention lies in the fact that medical doctors by their training are ill equipped to empathically relate to the individual who is in a suicidal state. This led to studies that focused on a patient-oriented understanding of suicidal behaviour: “Understanding deliberate self-harm: The patients’ views” (11), “Do we understand the patients’ reasons?” (12). Together with Ladislav Valach, Ph.D., an innovative research psychologist with a background of social psychology, and expert in action theory, the patient-oriented understanding was further developed with a novel model of “suicide as goal-directed action” (13). This model was met with great interest on international conferences. Konrad Michel and Ladislav Valach contributed a chapter to the book on “Understanding Suicidal Behaviour: the Suicidal Process Approach to Research and Treatment” (14). This was followed by study funded by the Swiss National Science Foundation (NF-Nr: 32-49313.96) on the feasibility of a clinical application of an approach to suicidal patients based on an action theoretical model: “Towards a better understanding of suicidal behaviour: Suicide as goal-directed action”. In this study, interviews conducted by a number of clinical psychiatrists with suicide attempters were video recorded, replayed to the patient (self-confrontation technique), transcribed, and the patients’ narratives analyzed according to an action theoretical hierarchical model. Electrodermal activity was measured throughout the interview. The authors showed that the patients’ satisfaction with the therapeutic working relationship was significantly better when interviewers used a patient-oriented, narrative approach and particularly when in their interventions they acknowledged the patients’ emotional life career issues emerging from the suicide narratives (15). Other publications from this study have appeared in the book “Action Theory Primer for Applied Research in the Social Sciences; a qualitative research” (16) and in “Suicide Risk and Protective Factors in the New Millenium” (17), as well as in Counseling Psychology Quarterly (18).

The Narrative Action Theoretical approach developed by the Bernese group led to the foundation of an international working group of suicide researchers with similar interests (i.e. emphasizing the need for a patient- and behaviour-oriented approach to the suicidal patient as opposed to the traditional illness-oriented approach). The working group has published a joint paper on the principles of a patient-oriented approach (“Discovering the Truth in Attempted Suicide”, American Journal of Psychotherapy 2002 (19)) and has since the year 2000 in a conference hotel in a Swiss mountain village organized biennual international conferences known as Aeschi Conferences (http://www.aeschiconference.unibe.ch). In these professional meetings, well-known international experts on suicide and clinical suicide prevention have been meeting for three days, sharing, discussing and developing patient-oriented models for the treatment of suicidal individuals. After 10 years of the successful Aeschi Conferences, Konrad Michel, together with David A. Jobes, edited an international multi-author volume for health professionals involved in clinical suicide prevention, with a focus on the various aspects of the therapeutic relationship with the suicidal patient (20). The „philosophy“ behind this has now internationally become known as the „Aeschi-model“. After the last Swiss Aeschi Conference in March 2011, J. Michael Bostwick and Timothy W. Lineberry, both Professors of Psychiatry at the Mayo Clinic, Rochester MN, decided to continue with the tradition of the Aeschi Conferences. Since then the Aeschi Conferences have continued Vail, Colorado, and are organized biennially by the Mayo Clinic.
The narrative-action theoretical model was further developed into a clinical short intervention program for patients seen after a suicide attempt. This program (Attempted Suicide Short Intervention Program ASSIP), consisting of three sessions followed by regular letters over two years, has been evaluated in a RCT with 24 months follow-up (25, open access). The group treated with ASSIP in addition to treatment as usual had an approx. 80% lower risk of repeating suicidal behavior compared with the group receiving the usual clinical treatment. The ASSIP group spent 75% fewer days in hospital during follow-up. Furthermore, the results indicate that in the ASSIP group better therapeutic alliance was a moderating factor in lowering suicidal ideation during 12 months follow-up (26).
A concept paper (27, open access) describes the therapeutic elements used in ASSIP, and discusses possible implications for future directions in clinical suicide prevention.

The narrative-based clinical approach has been merged with a biological approach to suicidality, using the technique of script-driven recall to measure brain activity of the suicidal crisis in an fMRI pilot study (22). This approach is original in that it uses the concept of the suicidal crisis as a state condition (the suicidal mode), which will be activated by a specific trigger event. The results support a model of suicidal behavior as a state-dependent condition. From the findings we assume that after a first suicide attempt, the suicidal mode is stored in the neural circuitry and can be “switched on” by the recall of the mental pain experience (as in the fMRI study) or by another triggering experience. The results also suggest that the suicidal mode has the quality of a traumatic state, with a deactivation in frontal cortical areas. Planning and acting out suicidal impulses is associated with increased activation in the medial prefrontal cortex, the cingulate cortex, and the hippocampus.

Other areas of interest are media reporting on suicide (23) and the association of early exposure to suicide with later suicidal behavior (24).

Konrad Michel is a member of the International Academy of Suicide Research and of the International Association of Suicide Prevention (IASP). He was a principle researcher for the WHO/EURO Multicenter Study on Suicide and Suicidal Behaviour. He was chairman of the multidisciplinary Swiss working group on suicide and suicide prevention (Ipsilon Suicide Research Group). As emeritus professor he is providing regular psychotherapy supervision at the University Hospital of Psychiatry Bern, and he has an active private practice. He advises psychiatric institutions in clinical suicide prevention. He is involved in training, supervising, and supporting teams in the clinical use of ASSIP in treatment centres in Europe and overseas. He is a scientific advisor in research projects on the clinical effectiveness of ASSIP in several countries. Recently, he was senior author in a cost-effectiveness study of ASSIP at the London School of Economics (Park et al. 2018 (28)).

Publications cited in the text:

Konrad Michel on ResearchGate (https://www.researchgate.net/profile/Konrad_Michel/)