Engagement of affect
Discovering what led the patient to end therapy by choosing death (or to consider doing so when increased suicidal ideation has emerged in therapy) is facilitated by the principle of engagement of affect. Therapist and patient may retreat from honest engagement in the face of suicide, but it is crucial to risk direct and genuine discussion about what really is happening on an affective level. Superficial or textbook explanations (eg, the therapist was going on vacation or the patient’s depression got worse) are often formulations that avoid engagement of affects associated with the emergence of murderous rage and the shift from a side-by-side collaboration to a toe-to-toe battle to the death.
The therapist’s contribution to suicide
The next principle is perhaps the most important: it involves a search for the perceived injury from the therapist that may have precipitated suicidal thoughts or behavior. Here the therapist, not just the patient, is accountable for what has happened between them. Cooperman10 has suggested that suicide attempts may follow empathic failures or narcissistic injuries unwittingly perpetrated by therapists. If the therapist asks, something will often emerge that reveals how the therapist has enraged, humiliated, or otherwise injured the patient and triggered increased suicidal ideation or the suicide attempt. Failure to take a patient’s distress seriously, distraction from a listening stance, or a condescending remark has often been perceived by the patient as a painful abandonment, empathic failure, or narcissistic injury that led to the wish (or decision to act) to “get even” with the therapist by killing the therapist’s patient and destroying the therapy.
This is a difficult but rewarding part of work with suicidal patients, with great potential for learning by both therapist and patient. To do this well, the therapist must genuinely grasp his or her importance to the patient and be willing to look at his own fallibility. This kind of exploration often leads to an “Aha” moment when the patient’s suicidal wish or action suddenly has a context and may make resumption of therapy possible. It is appropriate to apologize for injuring a patient if we have erred. Apology is far more useful than defensively refusing to accept responsibility for the error, as if only patients make mistakes. However, one should avoid premature apology. Patients deserve opportunities to express hurt, anger, or a sense of abandonment to us, while we listen. An apology includes an explicit and difficult-to-refuse request for forgiveness. We do not want to be forgiven before patients have been able to vent their feelings; we do not want to apologize if we have not erred, although we may want to empathize with our patient’s experience.
The final principle may be applied when a patient has unsuccessfully attempted suicide: the provision of an opportunity for repair. In many instances, exploration of the transference meaning of a suicide attempt may allow therapist and patient to learn something new. If the capacity to trust and the credibility of the participants have not been too severely damaged, it may be possible to repair the therapeutic alliance, end the phase of consulting, and resume therapy.
A patient’s apology may be less important than an indication of new awareness of the meaning behind suicide, recognition that the meaning included a choice to end therapy, and that the patient will strive to keep the terms of the alliance and use words rather than action when angered or hurt by the therapist. Meanwhile, the therapist must to be able to put aside any lingering hurt, anger, or mistrust for therapy to resume.
The principles outlined here for ABT with suicidal borderline patients emphasize the patient’s choice and responsibility and make suicide an interpersonal event between therapist and patient that can be explored through the lens of the vicissitudes of their relationship. Suicide is not viewed as simply a symptom of an illness.
The principles are easily misunderstood by the patient who may understand the therapist to be saying “If you attempt suicide, I will quit as your therapist.” In fact, the stance is closer to, “If you attempt suicide, it is inevitably a choice to end our important work. What is going on between us that makes you want to end our work? How have I pushed you to that choice?
ABT will not work with all patients, but it offers a powerful intervention for many. Patients are engaged in a way that views suicidal ideation and behavior as linked to the transference relationship, particularly the negative transference. This gives psychodynamic therapists a way to establish and maintain a viable therapeutic alliance while helping patients take control of suicidal behavior and allow work related to underlying issues to unfold. Until suicide recedes as an issue, however, other interpretive work is not the principal focus of therapy. Before exploring how their life history, conflicts, and unconscious fantasies may affect them, patients must stay alive to come to sessions.