CASE VIGNETTE
A 29-year-old woman with borderline personality disorder had a history of molestation and a suicide plan to set herself on fire outside the picture window of thehome of her abuser. She often engaged in relatively superficial cutting. When she began psychodynamic psychotherapy, the therapist found the patient’s superficial cutting intolerable, and made prohibition of cutting a condition of the treatment. The therapist failed to recognize that the cutting was an explicit alternative to carrying out her suicide plan. The patient struggled to comply with her therapist’s condition but found herself overwhelmed and ended the treatment within a few months.
Suicide and the therapeutic alliance
The remaining ABT principles are used when suicide is threatened or attempted. The first is differentiating therapy from consulting. ABT is a 4-times-a-week therapy at Riggs, but it has also been used with patients once a week. Therapy sessions are scheduled at predictable times. Such regular sessions help engage the patient and are distinct from sessions scheduled at each meeting, which are conceived of in the therapeutic alliance model as consulting rather than as therapy. The importance of this distinction is seen below.
The next principle is the inclusion of suicidal behavior in the therapeutic contract from the outset. Frank discussion of suicide is an essential part of negotiating the terms of psychodynamic therapy with suicidal patients. It is not possible to conduct outpatient dynamic therapy with a patient who approaches treatment as if it is the therapist’s job to keep him or her alive and the patient’s job to die. Although it is reasonable to ask a patient to take responsibility for staying alive as a condition of therapy, this is by no means a simple request. Clarification of what steps the patient will take (eg, contacting the therapist) if he feels unable to keep the agreement is essential.
Suicide and aggression
Thoughts of suicide that manifest in words or in attempted suicide can be addressed in a manner consistent with the principles that follow. In either case, the therapist offers a contextually appropriate nonpunitive interpretation of the patient’s aggression in the decision to end therapy through suicide. This follows from the terms of the alliance that have transformed suicide to an interpersonal event thathas meaning in the relationship. An attempt or its threat inevitably raises the question of what is happening that leads to the choice of death over therapy. In those instances when the patient attempts suicide, the therapist understands that as the patient’s choice to end therapy.
“Metabolizing” the countertransference
When a patient threatens or attempts suicide, powerful feelings of countertransference (eg, guilt, anxiety, anger) are mobilized. The therapist must therefore find a way to “metabolize” the countertransference. The therapist needs to process and gain perspective on feelings of countertransference rather than responding to the patient out of guilt, fear, or anger. This often requires consultation with colleagues or supervisors and is part of why personal psychotherapy or psychoanalysis is important for therapists who intend to work with difficult patients.
If a patient has attempted suicide, the psychotherapist must respond as compassionately and efficiently as possible to help save the patient’s life. This can be done without immediately trying to understand what happened or venting unresolved countertransference feelings.
Once a patient is stabilized, it is appropriate to interpret in an empathic and nonpunitive way the patient’s aggression in the decision to end the treatment. The next principle assigns responsibility for the preservation of the treatment to the patient. The therapist may note that the regularly scheduled therapy sessions will end because the patient who has attempted suicide has chosen to end therapy by ending the agreement that allows it. On the other hand, the therapist remains willing to meet with the patient in the “consulting” role described above, to discover what led the patient to end therapy. Such consulting may require one or more sessions but is time-limited and distinct from the previous ongoing therapy. Patients may react to this stance by feeling abandoned, but the therapist should particularempathically point out the patient’s part in ending therapy.
