Identifying and Reducing Professional Liability When Treating Older Adults, by Jacqueline M. Melonas, RN, MS, JD and Charles D. Cash, JD, LLM, ARM
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.
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.
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.
1. Hendin H, Haas AP, Maltsberger JT, et al. Factors contributing to therapists’ distress after the suicide of a patient. Am J Psychiatry. 2004;161:1442-1446.
2. Tillman JG. When a patient commits suicide: an empirical study of psychoanalytic clinicians. Int J Psychoanal. 2006;87:159-177.
3. Plakun EM,Tillman JT. Responding to the impact of suicide on clinicians. Direct Psychiatry. 2005;25:301- 309.
4. Perry JC, Fowler JC, Bailey A, et al. Improvement and recovery from suicidal and self-destructive phenomena in treatment-refractory disorders. J Nerv Ment Dis. In press.
5. Linehan MM, Armstrong HE, Suarez A, et al. Cognitive- behavioral treatment of chronically parasuicidal borderline patients. Arch Gen Psychiatry. 1991;48: 1060-1064.
6. Clarkin JF, Levy KN, Lenzenweger MF, Kernberg OF. Evaluating three treatments for borderline personality disorder: a multiwave study. Am J Psychiatry. 2007; 164:922-928.
7. Plakun EM. Principles in the psychotherapy of the self-destructive borderline patient. In: Sledge WH, Tasman A, eds. Clinical Challenges in Psychiatry. Washington, DC: American Psychiatric Press; 1993: 129-155.
8. Plakun EM. Principles in the psychotherapy of selfdestructive borderline patients. J Psychother Pract Res. 1994;3:138-148.
9. Plakun EM. Making the alliance and taking the transference in work with suicidal borderline patients. J Psychother Pract Res. 2001;10:4:269-276.
10. Cooperman MC. Defeating processes in psychotherapy. In: Silver AS, ed. Psychoanalysis and Psychosis. Madison, CT: International Universities Press; 1989:339-357.
Evidence Based References
Clarkin JF, Levy KN, Lenzenweger MF, Kernberg OF. Evaluating three treatments for borderline personality disorder: a multiwave study. Am J Psychiatry. 2007; 164:922-928.Perry JC, Fowler JC, Bailey A, et al. Improvement and recovery from suicidal and self-destructive phenomena in treatment-refractory disorders. J Nerv Ment Dis. In press.