JournalofFumzly Therupy(1984)6: 113-129

A strategic assessment of deliberate self-harm

David Aldridge” and Jacqueline Rossitert

This paper describes how patients are interviewed in the context of a general hospital after they have been involved in an episode of self-harm. The interview schedule is structured upon the principles of brief therapy, and uses the ‘neutral’ approach of the Milan Team (Weakland 1974; Palazzoli et al. 1980). The schedule provides information for referring on and has proved to be ‘therapeutic’ in itself. The method of interviewing has been used in other hospital contexts with families where a member has been referred ‘in a crisis’ threatening, or indicating suicidal behaviour. It is suggested that the identification of who is involved systemically is of paramount importance, and that this may not involve ‘the family’ but significant others in the social network. The important systemic involve- ment of the general practitioner is recognized.

Introduction

This strategic assessment schedule was developed as part of the authors’ research into the systemic understanding of deliberate self-harm (Aldridge 1982a, 6 ) . Part of this research is involved with interviewing patients after an episode of self harm in a general hospital. It was soon discovered that an interview no matter how ‘neutrally’ performed was putting information into the systems of both the patient and the ward staff and that the observers were influencing their results with such information (Rosenthal, 1976). By asking questions about ‘what happened and ‘who was involved the authors are presenting a different perspective on the problem. At the end of preliminary research inter- views some patients had said spontaneously that the interview had been helpful. Now this was initially perplexing as in similar circumstances in other therapeutic contexts where ‘being helpful’ was the aim then there were no such overt messages nor did it seem that the process was bringing about any change. When therapeutic interventions were made some- times they were successful and sometimes they were not; when deliberately trying to be ‘neutral’ then the authors felt more comfortable

Received 18 January 1983. * Southwood House, King Square, Bridgwater, Somerset TA6 3DQ.

Tone Vale Hospital, Nr Taunton, Somerset. 113

0163-4445/84/020113+ 17$03.00/0 @ 1984 The Association for Family Therapy

114 D. Aldridge and J . Rossiter

but the therapeutic process still did not feel correct. When this method of gathering information was used for assessment for research rather than for therapy the process seemed to be more relaxed for therapists and clients.

The researchers as therapists

In our ward work we had discovered that the gatekeeping function of admission and discharge to the psychiatric hospital was crucial to the prevention of patterns of esclating self-harm in the psychiatric hospital (Aldridge, 19826). One of our aims was to prevent the hospitalization of patients when they could be managed within the context of their own families. Dr Rossiter is responsible as the visiting psychiatrist to the general hospital ward for the future referral of the patient and this function is explained and incorporated into the research interview.

The interview is presented to the patient as gathering information for assessment both for research and for discharge. This is carefully stated and both researchers are introduced according to their respective status; as a research psychologist who will ask questions and as the psychiatrist responsible for the discharge and future referral of the patient and it is she who will make decisions. This joint work has been practised since January 1982.

Reasons for the schedule

Patients seen in the general hospital had been previously referred on to other professionals or returned to the community. We wanted to elaborate the opportunities for further therapeutic intervention within the day hospital we worked in and to provide an alternative description of family process to other professionals who were involved with the patient and their family which encompassed a systemic understanding of deliberate self-harm. We were anxious to make links with community practitioners who used different paradigms for making therapeutic interventions without our taking a ‘holier-than-thou’ systems perspective. We always scrupulously ensure that the other community agencies involved are notified of our involvement and of what we are offered as therapeutic interventions. This has proved to be effective in the development of our work, as the G.P., social worker or probation officer is a vital element of the patient’s ecosystem (Keeney and Sprenkle, 1982; Keeney, 1979; Auerswald, 1968)

Assessment of self-harm 115

Which system

At the general hospital we will inevitably be presented with one person as the identified patient. We take what we are offered by whatever system is in operation and from that point we try to discover by asking questions what the interactive system is. Literally we take what the system gives us, but we arrange our data, and discover our data, according to our systemic epistemology, (Keeney, 1979). Although we will initially only see one person we will attempt to discover what organizational closure exists as a pattern of communication (Varela, 1976) i.e. how the word gers round about distress, who tells whom. Once we have discovered who is immediately involved and at what systemic level we are able to work at then we will arrange for another assessment interview. This time the other significant people will be involved. We realize that the emergent property of the system is often, different from that which we are first presented with by an individual.

However, we initially take what we are given. If the system presents its distress located in one member and by that member harming himself we will begin our work there. This we would argue is a way of negotiating a joint epistemology

research presented therapist patient (Dallos and Aldridge, 1982) system system

When we work in other contexts where suicidal behaviour is threatened we always invite the complainant and their significant others to our initial interview. Thismeans that we can make a systemic understanding but do not prescribe an artificial system of ‘family’ and ignore other systemic contexts, thus avoiding a reification of ‘the family’.

Before the interview we read the hospital notes and gather any in- formation we can so that a preliminary hypothesis can be made (Palazolli, 1980). This establishes a starting point for the investigation from which we can develop our standard data.

The epistemological arrangement for collecting data is that described by Weakland et al. (1974). We concentrate

(a) predominantly on current problems and how those problems are

(b) the concrete manifestation of ‘what is wrong’ as it is presented; (c) the situational and interactional nature of problems;

maintained by behavioural interactions:

1 1 6 D. Aldridge and J . Rossiter

(d) what life changes have been made, or are imminent, or are recognized by the person presenting the problem (Haley, 1973);

(e) what solutions have been developed to cope with the problem(s).

The principles for interviewing which we use are based more-or-less on those recommended by Palazolli (1 980) and are

(a) hypothesizing: where we make an unproved supposition about the

(b) circularity: where we ask for specific interactive behaviour to gain

(c) neutrally: where we take a. position of ‘assessment’ not change,

interactive systemic nature of the behaviour

a full systemic understanding, and

and metaphorically take ‘one step back’.

The schedule (see Figure 1)

Basic demographic data are collected such as name, address, age, gender, general practitioner and marital status. This gives basic data to compare results with the work of other researchers, and from which we can make our initial hypothesis.

Means of referral

This category gives clues to how the patient arrived in the present situation. It give systemic clues to which significant others were instrumentally involved and that there may be a complainant other than the patient. Sometimes we find that it is one member of the family who has strenuously encouraged another to seek help from a general practitioner and it will be necessary to include this ‘other’ in our further assessment interviews. Further to this we gain some idea of what previous attempted solutions have been made (Watzlawick, 1974).

Family map

Our questions revolve around who lives under the same roof and gets away from an immediate family perspective to a broader systems perspective. From this question then we can elaborate our map to ask questions about the location of a spouse, or partners, parents, or children. By asking simple questions such as, ‘Do you have a spouse?’, ‘Is your parent still alive?’, we find that we gain secondary information. This is usually information about the nature of the relationship such as ‘my partner was living with me but left after a row last night’ or ‘my

Assessment of sev- harm 1 17

father lives next door with his girlfriend’. This not only gives clues to the structure of the system but the relationship between elements of the system. We also find that life-cycle stages are usually recognizable here e.g. if we see a married couple in their mid-thirties who have been married for ten years we may ask if they have any children. Although seemingly normative we often gain secondary information about one partner wanting a child and the other partner not wanting a child, or both wanting children but not being able to produce any.

A Strategic Assessment Schedule for Deliberate Self-Harm

Name Age Sex Date

Address Tel : G.P. Relationship

Means of referral Other agency

Family map, including significant others

Life Events

Details of Episode

Problem as presented

Attempted solutions (Side one)

Change expected

Observations (behaviour, structure, process, constructs)

Hypothesis

Response of significant others

Future action

Response of Professional Staff (Side two)

Figure 1.

118 D. Aldridge andJ. Rossiter

Lzfe events

The previous literature on deliberate self-harm (Morgan, 1979; Farmer and Hirsch, 1980) has always included life events and this data is collected here for a number of reasons. Firstly, although we are concerned with making a systemic understanding of deliberate self- harm we believe it is necessary to make bridges between other research no matter how epistemologically different that research has been. The arrogance of alienating other researchers and other practitioners we believe is not helpful in the larger systemic context of psychotherapy and community practice (Palazzoli, 1982).

Secondly, by asking questions about ‘what has happened’ we gain an understanding of how the patient construes the problem (Hawton, 1982). If we are told that the recent episode occurred after a series of escalating rows then we begin to know in what direction our therapeutic offer will be made. If we are given the patient’s understanding that the episode has occurred after a history of protracted pain with an exhaustion of medical responses we know the patient’s position on the problem and in which direction not to go.

Essentially we aim to discover the patient’s epistemology. At such time if the patient talks about loss we can ask about any other losses; if rows are mentioned we ask about any other conflicts using the understanding to gain further information about others involved in the system.

Details of the episode

This entails a step-by-step account of the episode concentrating on concrete details of ‘what happened’, ‘who was present’, ‘what was said’ and ‘then what happened?’

Firstly, it gives valuable information about those who are instru- mentally involved with the patient. Secondly, it gets away from the individual and indicates how messages are handled by the system in question. Thirdly, it often discloses the degree of true suicide intent, for example, it becomes clearer whether the act of deliberate self-harm occurred as an event in a sequence of social interactions or as a serious attempt to commit suicide when the patient was alone. Fourthly, it gives clues to how the circularity of interaction can be interrupted with an alternative solution. This alternative can be made viable for the family by the information gained from the previous section concerned with the patient’s epistemology. For example, if the patient and the family talk about ‘being strong’ or ‘being weak’ we can talk about ‘being strong’ in

Assessment of sev- harm 1 1 9

different ways, that sometimes excessive strength may be a weakness or that ‘giving in’ is a particular sign of ‘being strong’.

The problem as presented

When we see patients in the hospital we are told quite directly what the problem is when we ask. Rarely are we told that the problem is wanting to die. Most frequently we are told of a particular discrete problem. When we are given a problem as ‘depression’ we ask how it shows itself or how it is a problem. It appears that the critical period of hospitalization crystallizes the process and gives a valuable opportunity for recognizing the problem both for us and the patient who may have taken the time to think things through. It seems as if for a moment the communication process is governed by a temporary rule of ‘openness’ which allows overt and direct messages to be communicated in safety (Black, 1981) and sometimes permits a series of events to be interpreted in a different way. It is also the time at which the system chooses to present its distress.

Attempted solutions

We make an exhaustive attempt to discover the previous solutions to the presented problem, again by asking for concrete details. ‘What was done’, ‘by whom’ and ‘who suggested that course of action?’ are the questions asked. This gives us further indications of how the problem has been construed. Sometimes the problem has been construed medically and helps us not to fall into the twin traps of ‘more of the same’ solutions or solutions which may not be accessible to the patient and the system. For example, we recently saw a young girl and her mother after the girl had overdosed. She had been examined over a period of two-and-a-half years for stomach pain.. The pain had increased in intensity, the investigations had increased in complexity until there was found to be no recognizable organic genesis for the pain. At this point the girl was considered to be illegitimately sick and manipulative by her general practitioner. It had been suggested to this mother and daughter before the overdose that (a) that mother was over-protecting the daughter, and (b) the problem was psychological. We know then that a direct strategy of psychotherapeutic help must be avoided or a referral for hypno- therapy (which in some cases has proved to be beneficial in the manage- ment of chronic pain) as the psychological explanation had been power- fully rejected before.

120 D. Aldridge and J . Rosszter

The expected change

We ask the patient what smallest possible change would indicate that the situation had improved or is improving, again concentrating on concrete manifestations of improvement. One particular way is to say, ‘If we visited you in three months time at home and sat down in your living room, what would you tell me had changed to make things better?’ (Weakland, 1982). This gives us an indication of which direction the patient is willing to go, and of the profile of recovery the patient constructs for him/herself. It constantly reinforces concrete small objectives within the epistemology of the patient which the patient identifies and can obtain.

When we see more than one person then we will ask all members present what they would expect to change in both self and other(s). This process often involves negotiating a change in a family between them- selves. At the end of this section we would check with the individual or family what they had concretely stated to make sure we understood that we had heard them correctly. We would say, ‘So you are saying that if you could sit down and talk for five minutes without being interrupted no matter what you said then that would be an improvement?’ The time, location and personnel involved in this would then be discovered by questioning those involved (Haley, 1980; Madanes, 1981).

Observations

This is a section for all those bits of information which seem important at the time and appear to the interviewers as pertinent, particularly as to how the subject structures his living (Bateson, 1976). In this section we note the style of communication of the participant(s). Usually meta- phors are noted when used by the participants and this style may be used therapeutically at a later date (Saposnet, 1980). If a person communi- cates abstractly despite our concrete style then we may respond later at an abstract level, if we assess that we are being communicated with ‘paradoxically’ we may respond ‘paradoxically’. In the family therapy literature concerned with attempted suicide several recurring themes are discussed.

(a) patterns of maladaptive communication (Williams and Lyons

(b) marked expressions of hostility (Richman and Rosenbaum, 1976);

1970);

Assessment of self-harm 121

(c) apprehension about loss or death and intolerance of crisis

(d) a progressive isolation from social network and peers (Morrison (Richman and Rosenbaum 1970);

and Collier 1969); (e) a pathological homeostasis with a need for ‘change’ (Richman,

1979); ( f ) family disorganization (Tuckman and Youngman, 1964).

In this section any such identified themes are notes for the possible development of future hypotheses and research.

Hypothesis

We make a number of tentative systemic hypotheses about what is happening using different systems perspectives until we find a hypothesis which appears to fit and include all the instrumental others in the ‘episode’ section. We do not immediately discard other hypotheses until we have interviewed the wider system of other significant people. This ‘best’ hypothesis is tested at the next interview & la Palazzoli (Palazzoli, 1980).

Response of signzyicant others

We are aware that to try and engage a family too quickly can be a way of ‘blaming’ the family or marital partner so we take care to see what the responses are of the other significant people to our questions. It appears that an invitation for therapy to all present is an implicit condemnation of the family. An invitation for others to participate in assessing the problem is far more ‘neutral’. By accepting the family’s presentation of distress located and manifested in one individual member we accept what they offer but take care to develop an interactive understanding (Framo, 1970; Weakland, 1977).

Future action

In this section we note what follow-up or what intervention we will make, to whom, when and who will do it.

What happens next

(1) The general practitioner is informed of our interview and briefly of our systemic understanding. If we are to follow-up for further assessment

122 D. Aldridge andJ. Rossiter

he is informed. We have found that is is vitally important to close this system of professional involvement by including involved professionals. It is easy to disregard another professional and then later accuse the patient of playing one practitioner off against another. It also helps to prevent the patient and his or her family being overloaded with different, at times conflicting, messages. We inform other practitioners of what we are willing to offer to the individual or family and give them opportunity to approve and provide additional information. So far our intervention has always been approved, and often we find that where previously the practitioner has exhausted all available resources for dealing with the patient (Richman, 1970) this involvement gives a pragmatic alternative.

(2) We offer the individual and hidher family an appointment for further assessment at the psychiatric day hospital for us to gain a better understanding. The problem is located firmly within an interactive context but is not labelled as ‘therapy’. Even such neutral questioning and data gathering can be mishandled and recently while asking what happened between a man and a woman the man said we made it sound as if somehow it had something to do with their marriage and really it was his wife’s illness.

(3) Occasionally we see individuals who insist again that they will kill themselves and when this happens we have a number of secondary questions we ask and we will discuss these later in the paper. If we can locate members of the family then we negotiate with the significant others the return of their suicidal member. Our general approach is that psychiatric hospitals are not the best place for them; not only are they disturbing, but certainly they can be dangerous places to live in. Should our anxieties be so great that an admission is necessary or we cannot immediately locate the people necessary to negotiate a return home then we insist upon a family meeting as soon as possible at the psychiatric hospital. We never offer this as treatment but as temporary asylum. In no cases (in the general hospital study) has anyone been admitted where a family is immediately available for contact.

(4) A benefit of this assessment has been

(a) increased co-operation by the general hospital staff to hold a patient overnight so we can see the family in the general hospital;

(b) a neutral framing of self-harming patients by the general hospital staff as the length of stay for self-poisoning patients has been reduced to a time encompassed by their physical fitness to leave;

Assessment of self-harm 123

(c) a reduction in psychiatric admissions and a correlated reduction of ward disturbance involving self-mutilation (Aldridge, 19826);

(d) a subsequent reduction of pressure to admit to psychiatric hospital by the general hospital staff;

(e) a developing co-operative relationship with general practitioners in the immediate community who refer to the psychiatric day hospital.

(5) Initially after assessment we would follow a pattern of referrals as follows:

(a) if we felt we had an accurate systemic understanding of the problem we would offer therapeutic help or discharge;

(b) if a therapist was already involved and the patient requested a particular therapeutic involvement we would pass them back to their therapy of choice;

(c) if we failed to gain an accurate systemic understanding then we would refer on to family therapy if the family were agreeable.

(d) some patients were discharged home with the offer of contact if they needed help in the future, but this happened in only three cases out of twenty-nine.

The referral on to family therapy proved to be unsuccessful for a number of reasons:

(i) The referral was a precocious assessment and communication to those involved that it was a ‘family’ problem,

(ii) too long a time elapsed between referral and take-up; it seems that the crisis is the time to intervene before the bid for change made at the episode is encompassed by the family homeostasis.

(iii) Some patients resent being ‘passed on’ and we seemed to indiczte by meta-communication that they could not be helped or were not worth helping.

Now we engage such families without referring on. We always insist on all referrals to ourselves that further sessions are labelled as information gathering and later as ‘therapy’. The label ‘therapy’ is used if we are overtly asked for help. The label ‘assessment’ is used for further interviews where the initial episode is taken as a request for further systemic intervention. No attempt to make ‘change’ is tried. All assessment or therapy is offered usually with an appointment date but no attempt is made to coerce or chase the patient should they not wish to take up the offer.

124 D. Aldridge and J . Rossiter

Questions about attempted suicide and dying

The next section will undoubtedly raise a number of professional hackles. We feel it is necessary to add the rider that these following questions are not asked lightly or glibly and certainly with no intention of tricking the patient or family. As a cautionary note we add that these questions are only made once we have an understanding of the system and are not meant to be a set of prescriptive questions as in the first part of the schedule. These following questions are about dying and have proved to be powerful in dealing with families where a member is actively suicidal or threatening such behaviour. Any such questions used without a systemic understanding are doomed to failure if not disaster. Nor should they be used without accepting the fact that in some seriously depressed patients they can clarify the issues in a way that may make it obvious to them and us that they see suicide as the only way out and in such cases we have had to be prepared urgently to admit these patients to a psychiatric hospital- compulsorily, if necessary. Because we are taking a neutral stand and allowing the patient the existential right to die, and often agreeing with the patient, it will change nothing. We explain that admission is something we need to offer to protect ourselves in law and to relieve our anxieties rather than a therapeutic intervention. We would add that if you have qualms about such questions then do not use them. This may sound patronizing but some therapists conversant with our work have tried the questions without the systemic understanding and we would rather risk our reputations than your patients.

The questions

These are asked usually in the presence of the family or another significant person. We state that there is no way we can prevent someone killing themselves if they so desire, and that everyone has their existential right to live or die. The questions are mainly practical questions:

(1) ‘Have you made arrangements for the funeral?’ ‘Do you know what sort of service you would want, what sort of flowers, which friends, burial or cremation, hymns or songs?’ (Whitaker, 1973).

All present are asked this. We say that these are important details, it is an opportunity to get these vital facts established. If we cannot help some- one to live the best we can do is to give them a good send off and let their dying be dignified.

Assessment of self-harm 125

(2) ‘What will happen to your clothes, your personal effects, your children?’. ‘How would you like your children brought up; would you like them in a children’s home or fostered?’ ‘Have you any messages for them or for those who will have to look after them?’ ‘Is there anything the children should know when you are gone, how would you like your life described to them?’

This is not an attempt to be excessively cruel but a realistic focusingon death and dying. There are these practical considerations to make. It is also a time to assess how much the person does for hidher child and others without overtly saying so, and how much they are needed. We rarely say this, but encourage them to discover it.

(3) ‘Have you made a will recently, are you insured?’

We use this regularly with patients who are complaining of depression or that life is not worth living, or that they are a burden (Watzlawick, 1974). We always say that even if they feel a burden now they can reduce that burden when they are gone by a reasonable life insurance. In fact we urge spouses to check the insurance out later at home, and make sure it is adequate to meet their needs should their partner die (Haley, 1973).

(4) ‘Who will this death affect the most?’ (Palazzoli, 1980). ’

This is checked out with the family, and each member is asked who will perform the missing person’s functions. We also ask here

‘Who would fight less?’ and check it out, and ‘Who would be too busy to notice, to care or be affected?’

Not only is this further information for us but brings an opportunity to make overt communication about important family functions. Here we may also ask about ‘who would take your place’ as we have the suspicion that systemic distress is manifested by one person but this may be a means of involving another in therapy.

(5) If we cannot gain immediate access to other significant people we may ask

‘How would you like the news broken to your spouse/partner?’ ‘What would have to be said?’ ‘Who would you nominate to say it?’ (Segal, 1982).

126 D. Aldridge and J . Rossiter

(6) If we see someone who has overdosed before, or engaged in repetitious self-mutilation or is anorectic we may ask each member of the family how long it will be before that person dies. Should we discover an elderly person in the system we will often ask who will die first and check it out with the family. If there is a member with a heart complaint and a member exhibiting suicidal behaviour we will ask again who will die first, and how long the family believe it will be (Farrelly and Brandsma, 1974).

It at the end of such questioning we find that active plans have been made for dying and that these plans have been carefully elaborated then we can be satisfied that we have recognized suicidal ideation (Pallis et al . , 1982). What happens in most cases is that there is a rejection of the questioning by the person identified.as suicidal. We are told that we have got it quite wrong and that they have no intention of dying. On follow-up these patients have said that these questions helped them realize the consequences of their actions. It also makes clear to the other significant people that we are taking the matter seriously and certainly consider death as a possible outcome. This is certainly not our intention: we are concerned with making an accurate understanding of the arrangements made for dying and taking dying seriously. This will look to many of you to be a paradoxical technique (Frankl, 1960; Haley, 1963: Watzlawick, 1974; Soper and L’Abate, 1977).

We are aware of the paradoxical nature of this intervention but in this context -of ‘assessment’- then we do not give a paradoxical inter- vention as part of a therapeutic technique. It may well be that we are occupying a metacommunicating stance which Palazzoli et al. (1980) describe as ‘neutrality’. I t does mean that we do not engage precipitately in overtly practising psychotherapy, and may well be prescribing covertly ‘do not change’ to those we see. Certainly by asking questions in a different way we are putting new information into the system.

Conclusion

By arranging our post-episodic intervention to collect interactive data to gain a systemic understanding of the phenomenon of deliberate self- harm we appear to have found a useful technique for assessment.

This has meant that fewer psychiatric hospitalizations are made, the community practitioners are involved and informed and individuals and their family and friends are offered help should they request i t . This technique has been used for assessing those who appear at the psychiatric day hospital ‘in crisis’, or threatening suicidal behaviour and has proved

Assessment of self-harm 127

to be useful in giving a focus during what could be distracting and distressing circumstances. By concentrating on concrete problems then we can know if such a thing as improvement occurs by a mutually agreed concrete goal. This is not ‘band-aid’ therapy, nor does it involve pulling many more families into the realms of psychotherapy but it does offer a means of gaining access to problems in their systemic context as presented by particular individuals interacting systems.

Wells (1981) suggests that:

More often, however, ‘suicidal behaviour’ is foreshadowed by consultations with general practitioners. In this context it has been argued that more successful G. P. identification of individuals carrying the risk factors outlined in this paper, an increased involvement of other primary care professionals and a greater willingness on the part of the patients themselves to discuss the causes of their distress might play an important part in reducing the annual incidence of D.S.H. and suicide (pp. 51-52).

We argue that in this form of assessment the general practitioner and other community professionals are involved in the systemic under- standing of the problem of deliberate self-harm. By offering a psychiatric day-hospital facility where we offer both ‘Family Therapy’ and this form of systemic crisis assessment then community practitioners become willing to refer early and possibly avoid an episode of deliberate self-harm. The results of this research are being prepared as a separate paper, and this will contain some case examples. The manifestation of systemic distress is met as it is presented, and at the time it is presented. We are careful not to interrupt any systemic change which the episode itself brings while at the same time being careful to detect an escalating process of distress.

References

ALDRIDGE, D. (1982a) Research as therapy. A paper delivered to the Psychology Dept of

ALDRIDGE, D. (19826) The strategicmanagement of aself-mutilatingpatient (submitted the Open University at a Postgraduate Conference, 16 October.

for publication). AUERSW~LD, E. (1968) Interdisciplinary versus ecological approach. Family Process, 7:

202-215. BATESON, G . (1976) Some components of socialization for trance. In: T. Scharz (ed.),

Socialization as Cultural Communication, pp. 51-63. Univerity of California. BLACK, D. (1981) Children and parasuicide. British MedicalJournal, 283: 331-336. DALLOS, R. and ALDRIDCE D. (1982) Towards a ‘Taxonomy of change (submitted for

publication).

128 D . Aldridge and J . Rossiter

FARRELLY, F. and BRANDSMA, J. (1974) Promcatiue Therapy. Cupertino, Calif., Meta

FARMER, R. D. T. and HIRSCH, S. R. (1980) The Suicide Syndrome. London. Croom

FRAMO, (1970) Symptoms from a family transaction viewpoint. In: N. Ackerman (Ed.),

FRANKL, V. (1960) Paradoxical intention: a logotherapeutic technique. American

HALEY, J. (1963) Strategies ofPsychotherapy. New York. Grune and Stratton. HALEY, J. (1973) Uncommon Therapy New York W. W. Norton. HALEY, J. (1980) Leauing Home. The Therapy of Disturbed Young People. New York.

McGraw-Hill. HAWTON, K , COLE, D., O'GRADY, J. and OSBORNE, M. (1982) Motivational aspects of

deliberate self-poisoning in adolescents. British Journal of Psychiatry, 141: 286-291.

Publications.

Helm.

Family Therapy in Transition,, pp. 125-171. I.P.C.

Journal of Psychotherapy, 14: 520-535.

MADANES, C. (1981) Strategic Family Therapy. San Francisco. Jossey Bass. MORGAN, H. G. (1979) Death Wishes? The Understanding and Management of

Deliberate SelfHarm. New York. John Wiley. MORRISON, G. and COLLIER, S. G. (1969) Family treatment approaches to suicidal

children and adolescents. Journal of American Academy of Child Psychiatry, 8:

KEENEY, B. (1979) Ecosystemic epistemology: an alternative paradigm for diagnosis. Family Process, 18: 117-129.

KEENEY, B. P. and SPRENKLE, D. H. Ecosystemic epistemology: critical implications for the aesthetics and pragmatics of family therapy. Family Process, 21: 1-19.

PALAZZOLI, M. S. (1980) Paradox and Counterparadox. New York. Jason Aronson. PALAZZOLI, M. S. (1982) A paper presented at the Cardiff Institute for Family Therapy,

28 October. PALAZZOLI, M. S., BOSCOLO, L., CECCHIN, G. and PRATA, G. Hypothesizing-circu-

larity-neutrality: three guidelines for the conductor of the session. Family Process,

PALLIS, D. J.. BARRACLOLJCH, B. M., LEVEY, A. B. JENKINS J. S. and SAINSBURY, P. (1982) Estimatingsuicide risk among attempted suicides: I The development of new clinical scales. British,Journa/ ofPsychiatry, 141: 37-44.

RICHMAN, J. (1970) The family doctor and the suicidal family. Pyychiatry in Medicine, 1A: 27-35.

RICHMAN, J. (1979) The family therapy of attempted suicide Family Process, 18: 131- 142.

RICHMAN, J. and ROSENBAUM, M. (1970) A clinical study of the role of hostility and death wishes by the family and society in suicidal attempts. The Israel Annals of Psychiatry and Related Disciplines, 8: 213-231.

ROSENTHAL, R. (1976) Experimenter Effects in Behavioural Research. Harvard University. Irvington Publishers.

SAPOSNET, D. T. (1980) Aikido: A model for brief strategic therapy. Family Process, 19: 227- 237.

SEGAL, L. (1982) Personal communication at Brief Therapy Conference organized by

SOPER, P. H. and L'ABATE, L. (1977) Paradox as a therapeutic technique: a review.

140-153.

19: 3-1 1.

Southwest Association for Family Therapy, Bristol, 21-22 May.

InternationalJournal of Family Counselling, 5: 10-21.

Assessment of s e y - h a r m 129

TUCKMAN, J. and YOUNGMAN, W. F. (1964) Attempted Suicide and family disorganiza-

VARELA. F. and JOHNSON, D. (1976) On observing natural systems. Co-Evolution

WA-IZLAWICK, P, , WEAKLAND, J. and FISCH, R. (1974) Change: Principles of Problem

WEAKLAND, J. (1977) Family somatics: a neglected edge. Family Process, 16: 263-280. WEAKLAND, J. (1982) From a paper presented at a conference organized by the Cardiff

Institute of Family Therapy, 29 June. WEAKLAND, J . , FISCH, R. WATZLAWICK, P. and BODIN, A. (1974) Brieftherapy: focused

problem resolution. Family Process, 13: 141-168. WELLS, N. (1981) Suicides and Deliberate Self-Harm. Office of Health Economics

No. 69. WHITAKER, C. (1973) My philosophy of psycotherapy.Journa1 ofContemporury Psycho-

therapy, 6: 49--52. WILLIAMS, C. and LYONS, C. M. (1976) Family interaction and adolescent suicidal

behaviour: a preliminary investigation. Australia and New Zealand Journal of Psychiatry, 10: 243-252.

tion. TheJournal of Genetic Psychology, 105: 187-193.

Quarterly, 10: 26-31.

Formation and Problem Resolution. New York: W. W. Norton.