Dynamic Therapy With Suicidal and Self-Destructive Borderline Patients
Alliance Based Therapy Can Be a Powerful Intervention

There are few more serious problems faced by psychiatrists than the death of a patient by suicide. Suicide is a tragedy for the patient, family members, and friends but also may have a significantly distressing impact on clinicians. Hendin and colleagues1 report that 38% of psychiatrists who have lost a patient to suicide experience severe distress. Therapists’ responses to patient suicide include isolation, guilt, shame, fear of litigation, anger, a sense of betrayal, grief, self-doubt, changes in relationships with colleagues, withdrawal from other patients, and doubts about continuing to work in psychiatry or with suicidal patients. ^1-3 Recognizing the impact ofsuicide on psychiatrists, the American Psychiatric Association Assembly approved an action paper in 2007 naming patient suicide as an occupational hazard for psychiatrists.

We have an obligation to provide optimal treatment for patients who struggle with suicide. Among the patients most likely to be suicidal are those with treatment-refractory mood disorders and comorbid borderline personality disorder, for whom most treatment occurs in outpatient or other unrestrictive settings. There is goo d news for clinicians who treat these challenging patients, however. In a naturalistic, longitudinal, followalong study at the Austen Riggs Center in Stockbridge, Mass, threequarters of previously suicidal and self-destructive treatment-refractory patients with a mean of 6 Axes I and II disorders recovered from suicidal and self-destructive behavior within 7 years.⁴ The overall suicide rate was low. These findings suggest that the psychodynamic psychotherapeutic treatment approach, Alliance Based Therapy (ABT), used at the Riggs Center may be of use for these high risk patients.

ABT is 1 of 3 approaches for treating patients with suicidal and self-destructive behavior. It focuses on the therapeutic alliance with patients as a way to treat suicidal behavior. The other 2 evidence-based approaches for treating suicidal patients are dialectical behavior therapy (DBT) introduced by Linehan and colleagues⁵ and Kernberg’s transference-focused psychotherapy (TFP).⁶ DBT is not psychodynamic, but it is conceptually similar to the psychodynamic approaches of TFP and ABT. The difference is that psychodynamic approaches add interpretation of meaning to therapy. I have been presenting the Riggs ABT approach to working with suicidal and self-destructive borderline patients for more than 15 years in workshops and courses at annual meetings of the American Psychiatric Association and elsewhere, and it has been described in 3 publications.^7-9 Although similar to TFP, it is a distinct psychodynamic treatment.

ABT: A psychodynamic approach to suicidality and self-destructiveness
From a psychodynamic perspective symptoms are viewed as encoded nonverbal communications that have unconscious meaning. This is true of the symptoms of suicidal and selfdestructive behavior. The task of psychodynamic therapists is to break the code and translate the encoded meaning of suicidal and self-destructive behavior into words so a patient can communicate pain, despair, and rage in words rather than action. “Code breaking” makes the unconscious conscious.

Psychodynamic therapists have an obligation to face the meanings and associated feelings that underlie suicidal behavior as they emerge in transference. This often means facing murderous rage because, from a psychodynamic perspective, suicide is a murderous act. What follows is a series of principles (Table) that may help dynamic therapists establish and maintain a therapeutic alliance with suicidal and self-destructive patients with borderline disorder, while using the vicissitudes of the alliance to notice, engage, and put into words the interpersonal meaning of suicide. Suicidal behavior shifts from symptom to interpersonal communication between therapist and patient and can ultimately be brought under the patient’s conscious control—if there is a strong attachment between patient and therapist. This kind of treatment approach is often beneficial but not effective with all patients.

Differentiating lethal and nonlethal behaviors
Differentiating potentially lethal from nonlethal self-destructive behaviors is the starting point for these principles. When we embark on a consensual outpatient psychodynamic psychotherapy, the patient is in charge of the decision to seek treatment, but the therapist is in charge of setting its terms. It is a fundamental given that a patient must stay alive to benefit from treatment. A decision to end life is a decision to end treatment and is always a focus of treatment. Nonlethal self-destructive behaviors (eg, superficial cutting) are not necessarily a focus of treatment unless the patient wants them to be or because of the consequences of such behaviors. Nonlethal self-destructive behavior is not prohibited in the way suicide is. The therapist will undoubtedly be interested in what is communicated through nonlethal self-destructive behavior, but these behaviors can be tolerated. Potentially lethal behaviors are inevitably a focus of treatment because they interrupt treatment and cannot be tolerated.

Nonlethal self-destructive behaviors may have numerous meanings, such as atonement for a sense of evil, replacing emotional pain with physical pain, or as a substitute for an actual suicide. Failure to recognize that nonlethal self-destructive behaviors differ from potentially lethal behaviors can make treatment untenable, as illustrated in the following vignette.