Monitoring problems in suicide action

There has also been a suggestion that suicide should be seen as a goal-directed process in form of action, project and career [12]. We further argued that these processes are joint and therefore social processes [13]. The view of suicide as a goaldirected action does not imply that all cases and all processes within the action-project-career frame are steered in a top down manner, as we illustrated in describing the bottom-up link of suicide action and suicide project [13]. Independently of the view whether suicide itself is a causal process or an intentional action, suicide preventive programmes require models of purposeful infl uencing and change of emotions, cognition and behaviour of the suicidal people. The proposed view of suicide as a goal-directed process in actions, projects and career presents a contrast to the conception of suicide as an illness [14]. This is an important distinction, then successful suicide preventive intervention relies on the agency processes of the suicidal clients or patients. However, it does not mean that suicide is an optimal, rational action. The goaldirected action development contains a number of distortions, mistakes, fallacies and omissions [15]. There are many parts in goal-directed processes that could go wrong. There could be goal problems (in an action, in a project, in a career), problems in the steps of action, project, career, problems in elements of action, project, career. Further there could be problems in the interrelationship of any levels of action with any levels of projects with any level of career organization. Further still, there could be problems in steering, controlling, regulation in action, project, career. Additionally, problems in energizing or in selfand actionmonitoring. Not to forget the problems in the rendering of individual and joint action. Obviously, the most important problem is, in whatever one is engaged in, discounting the highest goal of staying alive!


Self-monitoring in suicide
The distortions in the suicide action, project and career processes are often described or indicated by suicidal people in an interview. In our study using narratives and selfconfrontation interviews (a video supported recall) [15,16] we found, among other, substantial problems in self-or action-monitoring. The self-monitoring problems in suicidal people were often previously discussed within a frame of dissociation [17,18]. We suggested that 'dissociation', while labelling the phenomenon, does not contribute much to its conceptualization, as it only provides a Latin name for an otherwise English word. Thus, we propose to see some of these processes in terms of self-and action-monitoring as a part of an action theoretical conceptualization. Self-monitoring or awareness is a brain and mental function that is an important part of consciousness/cognitive processes, emotion and pain.
It is a part of action processes. It is an inherent property of a well-functioning system of action that all monitoring systems are adequately engaged when required. This does not have to be explicitly expressed as a postulate of a healthy living, but the common psychotherapy interventions directed at mindfulness, at awareness, at becoming emotionally sensitive and literate, at accepting pain (as well as many other procedures and goals in psychotherapy) suggest that [19][20][21][22].
The psychological monitoring properties were mostly discussed in the self-monitoring theory outlined by Snyder [23,24]. This implied a disposition, a habit or a process in which persons turned their attention to themselves being not only aware of their actions and their impact on others but also evaluating their own behaviour. The action selfmonitoring goes beyond this attitude toward oneself. It sees self-monitoring not only as a cognitive awareness process but also as a function of pain and emotion.

Pain in its self-monitoring function
Thus, self-and action-monitoring is seen as a function achieved by pain, emotional processes and awareness.
However, pain is not identical with monitoring systems. It has been suggested that pain can be seen as caused (sensory), as monitoring (qualities) and as having consequences or being directed at an end (damage expectation) [25]. Thus, the selfmonitoring is one of the important functions of pain. The "third way" theories of pain address this issue [26].
The problems in monitoring as physical pain and pain in general in suicide were recognized early. Orbach proposed a disposition to insensitivity towards physical pain that he saw as a manifestation of dissociation [27]. Suicidality as a motivation to escape from and to end the unbearable psychological pain was described by Shneidman [28]. Baumeister [29] assumes that suicide is an escape from intolerable emotional pain. An elevated pain tolerance in suicidal persons by habituation is also an important part of the interpersonal theory of suicide [30].
We also addressed the issue of self-and action-monitoring in suicide as described by patients a few days after a suicide attempt and found that pain monitoring among other was reduced, particularly in repeated suicide [31].
We indicated several problems in the self-monitoring function of pain in suicide.
1. Patients reported not feeling physical pain while hurting themselves [15].
2. More patients who engaged in repeated suicide attempt reported not feeling any pain than fi rst time suicide attempters [32].
3. Equally, some patients reported not feeling any pain while cutting themselves and starting to feel pain when realizing the severe consequences of their action [15].

Self-monitoring function of emotion systems
Another self-and action-monitoring function is often found in emotional systems. Generally, the emotional functions as being caused, providing a 'quick and dirty' fi rst-hand evaluation of the situation and also "emoting", causing or leading to behaviour or action, are recognized. To distinguish among these functions different terms are used. Affect is describing processes around an impact, emotion is used around the readiness to motion (e-motion) and feeling is about monitoring. Emotions are essentially a part of the generation of motor activity, for which emotional evaluations are essential [33,34]. Some theorists maintain that the ultimate function of emotions is to activate and direct goal-related behaviors [35]. However, beforehand, emotions are also seen as a feedback, that is, a monitoring system [36] that enhances learning about the situation that elicited the emotion. Another differentiation provides the distinction between bottom-up and top-down emotions [37]. However, both are relevant in their monitoring function.
Emotions have been always considered relevant for suicide [38]. It has been suggested that unbearable emotions precede a suicide attempt [39,40]. Negative feelings towards oneself may be a contributor to suicidal ideation and behavior [41]. Hopelessness is a risk factor for both suicidal ideation and behavior [42]. In addition to hopelessness, lower positive emotions and anxiety are the most signifi cant emotional predictors of suicide attempts [43].
Higher negative emotions, anger and guilt, worthlessness are associated with having suicidal ideation [44]. Lack of emotional awareness may be a potential contributor to both suicidal desire and capability [45].
The emotional problems in suicide are also often addressed as problems in emotion dysregulation [46,39]. We reported that during the suicide act many suicide attempters and, particularly, the repeated suicide attempters do not emotionally monitor the extraordinary experiences of their suicide act in an adequate manner [31]. Thus, we propose that before the issue of emotion regulation is addressed, we have to deal with the problem of emotional monitoring during the suicide process. It is of interest that the monitoring systems of pain and emotion are not only interrelating, but that they can be used in a compensatory or vicarious manner. This is the case in various processes but certainly in suicide.

It has been established that pain takes over in expressing
and embodying a strong negative emotion (psychache [40]. This also is addressed in the concept of somatizing [47].
2. Patients reported that while suffering emotional pain they did not feel physical pain [15].
3. Patients reported replacing physical pain by mental pain (as the mental pain was reported as more intensive, they suggested that this out weighted their physical pain, thus making it not accessible [15].

Awareness in its self-and action-monitoring function
The third self-and action-monitoring system could be seen in self-and action-awareness or cognitive monitoring in general. Cognition, meta-cognition [48], awareness, consciousness and self-and action-awareness and attention are distinct processes well differentiated in many models.
For our purposes it is necessary to establish the monitoring function of these systems. These processes are often disputed as whether being caused or being steering faculties. Nevertheless, their monitoring function is seldom doubted and its impact on action and learning is often underlined. "Metacognitive monitoring is the gateway to self-regulating one's learning" [49].
In addition, as in pain and in emotional processes, it often is distinguished between bottom-up and top-down processing [50].
The problems in self-monitoring function of awareness were recognized as relevant in some psychiatric diagnoses [51][52][53]. "A lack of self-monitoring will cause an inability to make the very rapid error corrections that depend upon being aware that the intended action is wrong rather than having to wait for the action to fi nish to observe its erroneous consequences" [54,55]. Consequently, a change in self-monitoring is seen as an important component in treatment of depression and suicidality. Across treatments, the most common components are psychoeducation, cognitive restructuring, activity scheduling, problem-solving, self-monitoring, and maintenance/relapse prevention, suicide risk assessment and safety planning [56]. The self-monitoring processes are not solely seen in phenomenological terms, but identifi ed within the brain functionality. The brain's self-monitoring of activities, internal and external, is a functionality referred to as awareness and is key element of consciousness [57].
Equally, being addressed as self-referential processes they also become identifi ed in neuropsychology research with practical implication for suicide prevention [58].
Once we turn to the practical implications of the concept of monitoring function of self-and action-awareness in an applied fi eld [57,59], the issue becomes much clearer.
Consequently, its positive, constructive [60] and even suicide preventive functions can be discussed [61]. Nevertheless, awareness in regard to suicide is often identifi ed as distorted or suicidal people are described as lacking emotional awareness [45]. Awareness as awareness of the suicide risks in others has also been addressed [62,63]. Although dealing in this paragraph with what generally is a cognitive realm we would like to go beyond the classifi cation of the topic in cognitive content and information processing, on the one hand, and suicide distal and proximal processes, on the other [64]. We would like to understand self-and action-monitoring as a part or a function of and in action processes [65,66]. Here it is important to acknowledge that the most important distortion in cognitive or awareness self-and action-monitoring is the inability to monitor the complex goal hierarchy during suicide projects and actions. Particularly, the highest goal of surviving, as indicated above, is fully discarded from the monitoring of action and project in suicide.
The potential of constructive changes through self-and action-monitoring in awareness were often addressed. It has been suggested that performance-monitoring enables the rapid detection of mismatches between goals or intentions and actions, as well as subsequent behavioural adjustment by means of enhanced attention control [67]. Also, its suicide preventive potential became apparent. Self-monitoring is defi ned and detailed as a skill and skill defi cit in cognitivebehavioral psychotherapy for suicidality [68].
Talking to suicidal patients or to patients after a suicidal attempt we detected certain disturbances in the awareness Here the list of self-and action monitoring could end. In the dualistic conceptualization of inner and outer processes, of cognitive-emotional basis of external behaviour it might be the case. However, we would like to add another thought to consider in connection with self-monitoring. We know, and this not only because of a different philosophical stance, that the motor processes equally impact the cognitive-emotional processes [69][70][71][72][73] and that, therefore, the concept of action, containing internal, manifest and social processes, might be more appropriate [74]. Such a concept could be seen as a noncartesian conceptualization of human behaviour [75].

Self-monitoring function of action
In the contextual action-theory informed view all psychological processes are seen as an integral part of an action. Although, distinguishing among internal, manifest and social parts, but encompassing and integrating them, action theory does not follow the Cartesian conceptualization of separating cognitive from behavioural processes. Action processes (internal, manifest (and social) are complex and contain a number of sub-processes. Some of the action subprocesses (again, internal, external (and social) can be seen as consequences of, co-occurring with and preceding to other action sub-processes. In other words, action (emotion, cognition and behaviour) can be seen as caused which seems to be the mainstream view, or as being the primary cause of other changes, which would be the view of intentionality and teleology. However, action is and can also be conceptualized as mirroring, monitoring, being in recursive relation to other processes, internal, external (and social). Thus, the actionself-monitoring processes could be seen in this function as action integral and immanent. In their content, however, they can be the consequence of or preceding to other action processes. Learning more about the suicide action we have to propose that action could also be seen in its function as an action-self-monitoring process.

Suicide as an action self-monitoring process in a group action
This particularly is the case in a joint or group action that should be seen as composed of individual and group action level [76]. We pointed out that suicide is a joint and social process [13] and thus the action monitoring of this process could be conceptualized as a joint or group processes -thus monitoring in a group or joint action.

Suicide in a place of a self-forbidden thought and action
In addition to this there also is another process invoking a caveat to a possible naïve phenomenology of all-inclusive conscious processes. This is the phenomenon and concept of "suicide action instead of a forbidden thought and action".
Thus, next to the suicide processes of "because of" as in causal model, or "in order to" as in action model, we have the view of suicide as "instead of".

Suicide as an action "instead of"
What is a suicide "instead of"?
The thesis here is that suicide action could also be seen as an action in its self-monitoring function performed instead of having a thought and action that the person cannot accept or bear: that the other person in an important relationship wishes the suicidal person dead or that the suicidal person is frightened of a possible thought wishing to kill the primary care or any other relevant other. Maltsberger [77] formulated a similar idea as a part of various personal crises within a psychodynamic conceptualization based on the original formulation by Freud [78]. Thus, this process contains a number of sub-processes or arguments: (1) Suicide action, similarly to pain, emotion and cognitive awareness, could be seen in its self-monitoring function.
(2) Self-monitoring processes could be " In contrast, it has been suggested that suicide should be understood and described in terms of goal-directed processes such as action, project and career [12,79]. Equally, this action understanding enables clinicians to employ the model of goaldirected action for framing the encounter with the suicidal person (Michel, Dey, Stadler, & Valach, 2004), for framing the suicidal narrative [80] and for scaffolding the suicide prevention [81].
This action theory informed approach to suicide allows us to understand the key processes in different terms than previously.
While the analyses of the suicidal processes, as provided and described by suicidal people, are correct and understandable, the results expectation often do not make sense. We propose, that this is because the result is that the forbidden cognition is Traditionally, pain, emotion and cognitive awareness are considered the main action-self-monitoring processes. However, the above suggestion of an action in its selfmonitoring function does occur within the action theory informed understanding of suicide and could be seen as a subgroup of the "in order to" reasoning.

Consequences for suicide preventive treatment and psychotherapy
Some of the here suggested views, propositions and conceptualizations were justifi ed by their suitability for and their facilitating effect on suicide prevention. 1) Allowing for a narrative of the suicide events will promote an action conceptualization in the joint communicative actions of a suicidal person and the psychotherapist. 2) Understanding suicide processes in action terms will enable the psychotherapists to accept this everyday common-sense action theory formulation of suicidal processes and stop them from analytically breaking down the events into probabilistic and causal chains. 3) It also promotes the view that an alternative life-related and -enhancing joint project instead of suicide project would have to be launched. Understanding the problems in selfand action-monitoring promotes strategies and procedures in psychotherapy and suicide prevention improving self-and action-monitoring. Being aware of the experiential nature of action and action change, particularly in suicidal processes in which the self-and action-monitoring is depleted, strategies and techniques would have to be used which do not exclusively rely on high level refl ection. 4) For these purposes we use the self-confrontation interview. This consists of recording of the suicide narratives, replaying it to the interviewees, stopping the recording in short intervals of a few seconds or minutes and asking the interviewees to report on any thoughts, feelings and sensations they might have had during the recording while they were telling their stories. This interview is also recorded. We experienced that this procedure increases the self-and action-monitoring of the processes in question and thus might contribute to the suicide prevention. 5) Following this, the suicidal person is better able to consider alternatives to their suicide and other self-destructive strategies. 6) As a next step they can build up specifi c implementation intentions [82] for these alternative action steps. 7) In addition, regular encounters, written or telephone reminders etc. are required, in order to keep the joint suicide-alternative or life-enhancing project active [81]. Finally, as the existentially threatening hurtful relationship memory can only seldom be directly accessed and addressed -we remember, rather than becoming aware of this aggressive wish the person chooses suicide -the improved self-and action monitoring might help to distinguish between situationally specifi c action monitoring and memories of previously experienced threatening self-and action-monitoring. It is the latter that is monitored by the suicide action. It also is the latter that could be discounted, as not being situationally relevant and thus not required for an action dealing with the issues of "here and now". However, the decisive change is that the suicidal person becomes the agent of improving action monitoring and not the psychotherapist.
Thus, the trap of psychotherapists getting involved in rescuing activities and thus promoting suicidal behaviour [83] can be avoided.

Conclusion
We proposed that suicide researchers describing suicidal people in dissociating and not feeling pain, showing problems in emotional experience and regulation and suffering cognitive biases and fallacies, overlook the larger picture, which is an action distortion as we described here in some sub-function of self-and action-monitoring. In addition, we maintain, that the turning of the aggression against themselves the suicidal people often monitor in their action a deep confl ict or a forbidden thought and action and perform a suicide action instead of threatening their primary carer or another relevant person in their life -a thought they cannot let enter their awareness. Based on this consideration we described several intervention steps (1-7) that help in improving the self-and action monitoring as well as framing the whole suicidealternative processes in terms of action and action project.
This procedure proved to be very effective, as the probability of suicide attempts in the intervention group was reduced by more than 80% (24 month follow up) compared with the controlled group [84].