Psychodynamic Psychotherapies: Suicidality
Retrospective studies have clearly established that well over 90% of persons who commit suicide have a diagnosable psychiatric illness, usually depression (Asnis et al. 1993). Treatment of the suicidal depression must begin with an adequate dosage of an antidepressant drug that is not lethal when taken in an overdose. Several other risk factors should also be assessed, including the following: feelings of hopelessness, severe anxiety or panic attacks, substance abuse, recent adverse events, financial problems or unemployment, living alone, being widowed or divorced, being male, and being 60 years or older (Clark and Fawcett 1992; Hirschfeld and Russell 1997). If the patient has a definite plan and appears to be intent on taking immediate action, emergency psychiatric hospitalization is required. If the risk of suicide is substantial but not imminent, a family member or other close person should be involved. The availability of firearms in the home or elsewhere should be assessed. Literature reviews (Cummings and Koepsell 1998; Miller and Hemenway 1999) provide strong evidence that the availability of a gun increases the risk of suicide to a substantial degree. Regular communication is essential in such circumstances, and substance abuse must be investigated as well. In cases of intense anxiety or panic, the use of a benzodiazepine should definitely be considered (Hirschfeld and Russell 1997). Psychotherapy may also be of extraordinary importance in understanding why the patient wants to die and what he or she expects will happen after death.

When the depressed patient is intensely suicidal, the therapist faces extraordinary challenges. Few clinical experiences elicit countertransference feelings as extreme as those generated by long-term intensive psychotherapeutic work with chronically suicidal patients. These patients often struggle with an internal object relationship characterized by an interaction between a tormented victim and a sadistic tormentor (Gabbard 2000; Gabbard and Wilkinson 1994). This internal relationship paradigm is frequently externalized so that the therapist and patient are coerced into playing roles in an intrapsychic drama. Therapists often feel that a suicidal patient holds the threat of suicide over the therapist’s head like the sword of Damocles. Indeed, Karl Menninger (1933) noted that the wish to die is often accompanied by the wish to kill.

The aggression inherent in the act of suicide is readily apparent to the survivors left behind. Family members often feel that they were the target of the suicide and that the patient seemed to want to destroy their lives by the act. In fact, the suicidal patient’s wish to kill someone else may be directed at either an external figure or an internal object, or both. As the transference-countertransference developments intensify, therapists may feel that the patient’s suicidal wishes represent an attack on them.

A patient’s wish to die may be experienced by therapists as the ultimate abnegation of their value and usefulness. Therapists may then begin to experience feelings of countertransference hate (Maltsberger and Buie 1974) that lead them to dread seeing the patient. Unconscious wishes that the patient would die so that the torment would stop may threaten to emerge into consciousness, and many therapists respond to the anxiety produced by such unconscious wishes with increased zeal to rescue the patient from suicide.

Although there are commendable and altruistic motives for wanting to save the patient from suicide, clinicians who become overinvested in rescuing the patient to the point of becoming the patient’s savior may actually be embarking on an ill-advised course. The therapist who falls into that trap may be unwittingly colluding with the patient’s transference tendency to transform the therapist into the dominant other. The patient is then expected to live for the therapist, thus replicating the situation with a dominant person in the patient’s outside life. Hendin (1982) identified the tendency to make others responsible for providing meaning and purpose in life as one of the most lethal features of suicidal patients.

Many patients who exhibit suicidal behavior harbor a rigidly held fantasy that somewhere an unconditionally loving mother exists who will take care of them. Therapists who try to fulfill that fantasy by providing round-the-clock availability and attempting to gratify the patient’s wishes to be taken care of raise false hope in the patient. In fact, a psychotherapist in a professional relationship cannot possibly fulfill the functions of an idealized parent, and it is only a matter of time until the effort fails. At that point the patient’s suicidality may actually increase. Moreover, countertransference hate that is denied by the therapist may be split off and projectively disavowed. When such hate is projected into the patient, then the patient must deal with the therapist’s aggressive wishes on top of the suicidal impulses with which he or she is already struggling (Gabbard 2000). A more sensible therapeutic approach to such patients is to take reasonable precautions to protect the patient while making a sincere effort to understand and analyze the psychological meanings of the patient’s suicidal wishes and the origins of those wishes. The wish to die has multiple determinants, and each patient has a unique set of motives. In some cases strong dependency yearnings related to object loss fuel the fires of suicidal behavior (Dorpat 1973). In other cases suicide may be regarded as a magical reunion with an idealized and unconditionally loving parental figure (Fenichel 1945). Indeed, empirical data suggest a statistically significant correlation between the anniversary of a parent’s death and suicide (Bunch and Barraclough 1971).

Psychotherapists cannot read minds. The way that most therapists become aware of suicide risk in a patient is either through the patient’s suicidal behavior or through his or her verbalized expression of ideation. Although verbal contracts are commonly used in which therapists extract an agreement from the patient not to commit suicide, many patients who are determined to kill themselves will simply not inform their therapists of their intent or even agree to a contract so that they will not be hospitalized and prevented from carrying out the act. One study found that in 571 cases of suicide, only 36% of those in psychiatric care communicated suicidal intent. As therapists, we must always remember that certain psychiatric illnesses may be terminal despite our best efforts.