Psychodynamic Psychotherapies - Suicidality

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.

Psychodynamic Psychotherapies Introduction Indications Efficacy

• Evidence for Acute-Phase Efficacy
• Evidence for Continuation- and Maintenance-Phase Efficacy