The idea that people who look like they are trying to end their lives might instead be attempting a desperate form of communication is one with a history that goes back much further than the middle of the 20th century in the UK. However, the work of Erwin Stengel and colleagues in the 1950s on this phenomenon – suicidal behaviour as a ‘cry for help’ – solidifies what is a diffuse and folksy interpretation of ‘attention-seeking’ or ‘the suicidal gesture’ into a coherent psychiatric object (signs and symptoms). The work culminates in the forgotten classic Attempted Suicide: Its Social Significance and Effects (Stengel Reference Stengel, Cook and Kreeger1958), a work that still influences the way self-harm and attempted suicide are considered in psychiatry.
One of the most important – and initially confusing – things about Attempted Suicide is that it is not actually about attempted suicide, strictly speaking. The authors note early on that ‘The survivor of a suicidal attempt is regarded by the public as having either bungled his suicide or not being sincere in his suicidal intention […]. It is taken for granted that the sole aim of the genuine suicide attempt is self-destruction’ (Stengel Reference Stengel, Cook and Kreeger1958: p. 19). Stengel, Cook and Kreeger are determined to undermine the self-evidence of these assumptions.
In my PhD on the history of suicidal and self-harming behaviour, I quickly realised that this Maudsley Monograph was one of the most important texts in solidifying psychiatric interest in this phenomenon. It also further promoted an influential model (a paradigm in the original sense) for constructing a robust empirical basis for social psychiatric research. Almost all psychiatrists who wrote about suicidal behaviour (also called self-poisoning or parasuicide) in the 1960s and 1970s in the UK credit this monograph with establishing ‘communicative self-harm’ as a coherent psychiatric object of concern. In two major textbooks, Henderson & Gillespie (Reference Henderson and Gillespie1927) (10 editions, the last in 1969) and Mayer-Gross, Slater & Roth (Reference Mayer-Gross, Slater and Roth1954) (3 editions, the last in 1969) ‘attempted suicide’ does not have a precisely differentiated entry until after 1958 – even though there is considerable prior psychiatric work analysing people who survive attempted suicide (e.g. Frederick Hopkins in the 1930s in Liverpool and Ivor Batchelor in the 1950s in Edinburgh).
The authors
Stengel is by far the most famous of the three authors of Attempted Suicide. He studied medicine in Vienna in the 1920s, fleeing the Nazis in the late 1930s and entering the UK with the help of Ernest Jones and the British Psychoanalytical Society. According to one commentator, he was ‘one of the most famous and successful of the psychiatric immigrants’ from Central Europe (Peters Reference Peters, Freeman and Berrios1996). He was a research fellow at the Crichton Royal Hospital in Edinburgh in 1942, Director of Research at the Graylingwell Hospital in Chichester in 1947 and Reader in Psychiatry at the Institute of Psychiatry (IoP) in 1949, as well as a consultant at the Maudsley Hospital (Jenner Reference Jenner, Harrison and Goldman2004). Michael Shepherd recalled that Stengel was invited to the IoP because although the Institute's head Aubrey Lewis ‘was always sceptical about the theory and practice of psychoanalysis he felt that it should be represented in an academic setting’ (Shepherd Reference Shepherd2009). In any case, according to Lewis's memorable phrase, Stengel was ‘only singed by psychoanalysis’ (Jenner Reference Jenner, Harrison and Goldman2004).
Nancy Gwendolen Cook is almost completely invisible in the scholarly record; she emerges as having co-authored this monograph and at least one other article with Stengel. She also potentially moved institutions with Stengel when he left the IoP to go to Sheffield, although I am not totally certain about this.Footnote a Her relative invisibility is doubtless due to the pervasive (and substantially misogynist) marginalisation of psychiatric social workers in a professional sense. Psychiatric social worker Noel Timms notes in 1964 that despite their roles being outwardly appreciated by psychiatrists, many considered the psychiatric social worker role to be subordinate and trivialised activities such as communication and follow-up in a gendered sense as ‘chores’ (Timms Reference Timms1964: pp. 112–113). Regardless, Cook's role is incredibly important in the psychiatric object as it is constituted at the time.
Irving Kreeger is a psychoanalytically influenced psychiatrist who provides (alongside Cook) follow-up interviews after an attempted suicide has been identified from records. (Cook interviews relatives and Kreeger the ex-patients.) There is not much material on Kreeger in the historical record, but he continued to write on attempted suicide into the 1960s, and held positions at the Maudsley and Kings College Hospital.
A masterpiece of empirical research
It is one thing to assume that suicidal behaviour might be some form of communication or expression of distress. As casualty consultant T.H. Lowden blithely writes in 1955: ‘Young girls who make a half-hearted attempt to commit suicide because they have misbehaved and missed a period may often be returned to the vigilance of their parents’ (Lowden Reference Lowden1955: p. 254). It is quite another to do what Stengel, Cook and Kreeger did, which was to work assiduously backwards from a presentation of attempted suicide at an accident and emergency department to document and provide substantial empirical backing for such a claim.
Attempted Suicide is built on a number of distinct groups of patients – some from records held at observation wards, the Maudsley Hospital and Dulwich Hospital, among other places. After attempted suicide cases are identified, assiduous follow-up is attempted (the patients are interviewed by Kreeger, as psychiatric research assistant, the relatives by Cook, the psychiatric social worker). Many of these groups are subjected to follow-up in the form of interviewing patients, family members and friends, sometimes years after the recorded attempt, to try to construct the ‘social setting’ or ‘social constellation’ around the attempt. Underlying these interviews is their explicit assumption that ‘the appeal character of the suicidal attempt, which is usually unconscious, [is] one of its essential features’ (Stengel Reference Stengel, Cook and Kreeger1958: p. 22).
Using observation-ward records and Cook and Kreeger's follow-up allows a substantial social setting to be recovered for the attempt. As well as sifting through ward records, the patients, their relatives, friends and even employers are interviewed, subject to patient consent. The interview schedules are reproduced in the text; they emphasise questions on matters presumably not found consistently in hospital records and case notes. The focus of the questioning is an exceptionally meticulous attempt to chart the present social environment through the repercussions of the attempt, showing how much work is needed to bring the social setting into prominent focus:
‘Changes in patient's human relationships and environment since attempt. The patient's views on the rôle of the attempt in bringing about changes in (a) social adjustment, (b) work and financial circumstances, (c) emotional adjustment, (d) sexual and marital adjustment – change in status, further children, etc., (e) change in mode of life of members of his family or friends’ (Stengel Reference Stengel, Cook and Kreeger1958: p. 41).
The psychiatric social worker's schedule (for relatives) contains clear emphasis on the patient's relationships with other family members. The very existence of a schedule explicitly for relatives shows research practice designed to produce an idea of interpersonal relationships related to an attempt at suicide. Most of these informants are seen ‘in their own homes, as visits were regarded as essential for full information’. This is acknowledged as extremely time-consuming in 1952 (in the write-up of a preliminary study, which features as Group I in the book); Stengel is unsurprised that this kind of study has not been previously attempted:
‘Only a small proportion of patients were in a mental hospital at the time of the follow-up. The rest had to be traced and their co-operation and that of their relatives had to be won. They proved a very elusive group and we came to understand why such a follow-up had never been carried out before in this country. I wish to pay tribute to my co-workers who overcame difficulties which often appeared insurmountable’ (Stengel Reference Stengel1952, p. 616).
In light of all this effort, Attempted Suicide's most quoted passage reads slightly differently:
‘There is a social element in the pattern of most suicidal attempts. Once we look out for the element we find it without difficulty in most cases [ … ]. In most attempted suicides we can discover an appeal to other human beings’ (Stengel Reference Stengel, Cook and Kreeger1958: p. 22).
The idea of looking for the social element, the discovery of an appeal: these are dependent on huge amounts of work. The social field is produced through this work – finding relatives years after an event, sending letters asking for an interview, asking permission to speak to the former patient. It is quite a practical achievement to produce a credible social, interpersonal space from the paper record of an attempted suicide.
The legacy of Attempted Suicide
This book is important for a number of reasons – as one element of a real flourishing of a socially focused psychiatry. But more than that, this book, with its three authors, shows how much work it takes to construct a social setting around a presentation at hospital. It shows the different disciplines that are needed, principally psychiatric social workers in tandem with research psychiatrists. (Such collaborations were by no means invented by Stengel, Cook and Kreeger: Eliot Slater (psychiatrist) and Moya Woodside (psychiatric social worker) wrote Patterns of Marriage (Reference Slater and Woodside1951) based on this collaborative relationship too.)
After Stengel, Cook and Kreeger's work is published, a number of other psychiatrists take up work on communicative attempted suicide – principally Neil Kessel and then Norman Kreitman in Edinburgh – who both attempt to revise the confusing terminology (Kessel with ‘self-poisoning’ and Kreitman with ‘parasucide’). Stengel's move to Sheffield in 1957 actually pre-dates the publication of Attempted Suicide, and Stengel does continue to investigate the phenomenon. The social focus of Stengel's initial contributions, and the interdisciplinary and trans-institutional nature of the work, endures in Kessel and Kreitman's work – which is substantially carried out in a Medical Research Council Unit in Edinburgh under the direction of George Morrison (‘Morris’) Carstairs. Psychiatric social work remains central to this socially focused interpretation. It is not until the 1980s in Britain that ideas of self-harm (specifically self-cutting and self-burning) substantially complicate the picture around suicidal and self-harming behaviour and its communicative aspects. Attempted Suicide still stands as paradigmatic of a robust and empirical attempt to provide evidence for social psychiatry that goes beyond speculation and plausible assumption about social settings and interpersonal relationships.
Funding
This work received no specific grant from any funding agency, commercial or not-for-profit sectors.
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