How do you feel when a patient begins to speak about suicide?

Suicidal threats and attempts raise some of the most acute questions for the psychotherapist:

• How does one remain within the therapeutic role when the patient’s life is at risk?
  
  
• How can we distinguish genuine imminent risk from communicative or manipulative uses of suicidal expressions?
  
  
• Is it possible to withstand the pressure when a patient, directly or indirectly, attempts to compel the therapist to assume responsibility for their life?

These challenges are particularly intense in work with borderline patients, where the drama of love and hate, the need for fusion, the fear of abandonment, hatred triggered by the demand for love and the coercion to comply with certain actions often reach their peak. 

The threat of self-destructive and suicidal behavior is the most powerful issue in the treatment of borderline patients and is the topic that most often leads therapists to deviate from their role in exploratory psychotherapy. Despite the multiplicity of meanings that suicidal ideation may represent, a few general statements may be made. 

Suicidal Behaviour as a Challenge to Maintaining the Therapeutic Role:

If the self-destructive and suicidal behavior comes up shortly after the beginning of treatment, it is often a test on the part of the patient to see if the therapist will adhere to the role he or she defined for himself or herself in the contract.

Many patients, even if they intellectually grasp and embrace the idea of exploratory work, function on the basis of intense primary longings for—alternating with fear of or rage against—closeness, merging, and caretaking. In light of this, patients may act in a way that deviates from their stated commitment to the exploratory process in an effort to see whether the therapist will deviate from his or her defined role to assume an overt caretaking role vis-à-vis the patient.

Suicidal Behaviour as an Attempt at Control:

Suicidal ideation may also represent an expression of rage, an attempt to control, a means of torture, or a sign of distress. 

Because suicidal ideation is so full of meaning, discussion about it is an important part of the exploratory process. 

When the patient makes any mention of suicide, the therapist’s first priority is to establish whether the suicidal ideation is in the context of a major depressive episode, which would call for other interventions, such as medication or hospitalization. 

Once it has been established that no major depressive episode is present, it is important to deal with suicide as both an intrapsychic issue and an interpersonal one and to try to understand the roles of aggressor and victim in the suicide scenario. 

The therapist should keep in mind the following questions: 

Who, in the patient’s internal world or external reality, is the target of aggression? 

What function, at this point in time and in this interpersonal context, does the emergence of suicidal ideation serve?

Suicidal Behaviour as the Patient’s “Trump Card”:

Finally, although we know that suicidality is a multifaceted phenomenon, in some instances it plays a particular role in interpersonal interactions—a trump card. 

The unpredictability of borderline patients’ behavior often means that the threat of suicide can come and go unexpectedly. 

Especially when chronic threats of suicide have become incorporated into the patient’s way of life, the therapist should make it clear before beginning the therapy—to the patient and, if indicated, to the family—that the patient is chronically at risk of suicide, indicating that the patient has a serious psychiatric illness with a risk of mortality. 

The therapist should express to those concerned the willingness to engage in a therapeutic effort to help the patient overcome the illness but should not guarantee protection from suicide. 

Ways of Safeguarding Therapy:

Realistically discussing the limits of the treatment may be the most effective way to protect the therapeutic relationship from the possibility that the patient may try to control the therapy by inducing in the therapist a countertransference characterized by guilt feelings and/or paranoid fears regarding third parties. 

It is important for patients to learn that their threat of suicide has no inordinate power over the therapist (i.e., it is important to eliminate the secondary gain). 

The therapist should make it clear that although he or she would feel sad if the patient died, the therapist would not feel responsible and his or her life would not be significantly altered by such an event. 

The therapist’s acceptance of the possibility of a negative outcome with a patient is a crucial element in the treatment of patients with severe suicide potential. 

The patient’s unconscious or conscious fantasy that the therapist could not tolerate the patient’s death, and that the patient therefore has power over the therapist—or that the therapist has the magical power to save the patient—needs to be explored and resolved. 

Every attempted or completed suicide involves the activation of intense aggression not only within the patient but also within the immediate interpersonal field. The therapist who seems to react only with sorrow and concern for the suicidal patient is denying his or her counteraggression and other possible reactions. Openness to countertransference feelings will enable the therapist to empathize with the patient’s suicide temptations, with the despair, with the longing for peace, with the excitement of self-directed aggression, with the pleasure in taking revenge against significant others, with the wish to escape from guilt, and with the exhilarating sense of power involved in suicidal urges. Only that kind of empathy on the part of the therapist may permit the patient to explore these issues openly in the treatment.

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(c) Yuliia Holopiorova,

Ukrainian Association of Transference-Focused Psychotherapy