Chronic suicidal ideations: a risk or a protection.

Chronic suicidal ideations can be consistently present as part of the individual's sense of identity and self-regulation or as a reoccurring pattern to control intense feelings and communicate and relate experiences or intentions. While they can be the precursor to self-harm and suicide attempts, requiring a thorough risk assessment, they can also represent a way to control, avoid, or contain intolerable feelings and experiences. In addition, suicidal ideations can be either deeply internalized and hidden or indirectly or directly conveyed to others. This article focuses on understanding and approaching chronic suicidal ideations that specifically relate to self- and interpersonal characterological functioning, i.e., sense of identity, self-regulation, emotion regulation, and interpersonal intentions. Suicidal ideations must be identified and assessed both in terms of intention, i.e., motivation, plans, and means to harm oneself or end one's life, as well as in terms of function, i.e., related to selfregulatory strategies for counterbalancing or protecting against overwhelming, painful, and frightening external, interpersonal, or internal experiences. Therapeutic strategies and challenges will be discussed, including engaging patients in the therapeutic alliance and building consistency, trust, and reliability.

The Psychoanalytic Study of Suicide, Part I: An Integration of Contemporary Theory and Research.

Psychodynamic psychotherapy has an important role in suicide prevention. The psychoanalytic study of suicide has taught us a great deal about the human experience and the process of suicidality. There is also much to be learned from other fields of study and from empirical research that can be integrated into psychoanalytic therapies. Central to the psychoanalytic approach to suicide has been understanding the patient's internal subjective experience of unbearable emotional or psychic pain and the urgent need for relief. Emotional pain can include intense affects such as shame, humiliation, self-hate, and rage. Factors that can increase vulnerability to suicidal states include problems with early attunement, dissociation and deficits in bodily love and protection, conscious and unconscious fantasy, and certain character traits and dynamics. Empirical research has confirmed many basic psychoanalytic concepts about suicide, including escape from unbearable pain as the primary driver of suicidal behavior, the role of dissociation in increasing risk of bodily attack, and the importance of unconscious processes. Further research into implicit processes and their role in the suicidal process holds potential to improve suicide risk assessment and to enhance psychotherapy by bringing otherwise inaccessible material into the treatment.

The Psychoanalytic Study of Suicide, Part II: An Integration of Theory, Research, and Clinical Practice.

In Part I contemporary psychoanalytic concepts about suicide were synthesized with other theories and empirical research findings. Here the focus is on applying those principles and describing an integrative psychodynamic approach to treatment, one emphasizing the therapeutic alliance, unconscious and implicit processes, exploration of fantasy, and use of the therapeutic relationship as an implicitly interpretive vehicle for change. It is "integrative" because it draws on ideas and techniques described in dialectical behavioral therapy (DBT) and cognitive-behavioral therapy (CBT), as well on developmental and social psychology research. Psychotherapy with suicidal patients is inherently challenging, requiring the therapist to bear intense emotional pain while attending to potentially derailing countertransference pressures. The therapist plays an active role in helping the patient navigate affect storms and counter harsh self-attack, and instilling hope that treatment can lead to meaningful change. The integrative psychodynamic approach offers a pathway to a lessening of harsh self-judgment, greater connection with the body, improvement in continuity of experience, positive changes in narrative identity, emergence of the patient's genuine capacities, and more satisfying interpersonal relationships. These changes promote affect tolerance, improve life satisfaction, and decrease the likelihood of suicidal behavior.

Psychotherapy with Suicidal Patients: The Integrative Psychodynamic Approach of the Boston Suicide Study Group.

Psychotherapy with suicidal patients is inherently challenging. Psychodynamic psychotherapy focuses attention on the patient's internal experience through the creation of a therapeutic space for an open-ended exploration of thoughts, fears, and fantasies as they emerge through interactive dialogue with an empathic therapist. The Boston Suicide Study Group (M.S., M.J.G., E.R., B.H.), has developed an integrative psychodynamic approach to psychotherapy with suicidal patients based on the authors' extensive clinical work with suicidal patients (over 100 years combined). It is fundamentally psychodynamic in nature, with an emphasis on the therapeutic alliance, unconscious and implicit relational processes, and the power of the therapeutic relationship to facilitate change in a long-term exploratory treatment. It is also integrative, however, drawing extensively on ideas and techniques described in Dialectical Behavioral Therapy (DBT), Mentalization Based Treatment (MBT), Cognitive-Behavioral Therapy (CBT), as well on developmental and social psychology research. This is not meant to be a comprehensive review of psychodynamic treatment of suicidal patients, but rather a description of an integrative approach that synthesizes clinical experience and relevant theoretical contributions from the literature that support the authors' reasoning. There are ten key aspects of this integrative psychodynamic treatment: 1. Approach to the patient in crisis; 2, instilling hope; 3. a focus on the patient's internal affective experience; 4. attention to conscious and unconscious beliefs and fantasies; 5. improving affect tolerance; 6. development of narrative identity and modification of "relational scripts"; 7. facilitation of the emergence of the patient's genuine capacities; 8. improving a sense of continuity and coherence; 9 attention to the therapeutic alliance; 10. attention to countertransference. The elements of treatment are overlapping and not meant to be sequential, but each is discussed separately as an essential aspect of the psychotherapeutic work. This integrative psychodynamic approach is a useful method for suicide prevention as it helps to instill hope, provides relational contact and engages the suicidal patient in a process that leads to positive internal change. The benefits of the psychotherapy go beyond crisis intervention, and include the potential for improved affect tolerance, more fulfilling relational experiences, emergence of previously warded off experience of genuine capacities, and a positive change in narrative identity.

John Terry Maltsberger, American Psychoanalyst: Contributions to the Development of Studies of Suicide and Self-attack.

John Terry Maltsberger (1933-2016) was an American psychoanalyst who greatly influenced studies of the suicidal patient, and a suicidologist whose contributions significantly impacted psychoanalysis. Through his devotion to the understanding and treatment of suicidal people he exerted a major influence in both areas. Throughout a long and productive career, Maltsberger focused on an uncomfortable area of the psyche, that sphere that impels the attack on the self. His position in psychoanalysis stands out for his early emphasis on the patient's internal subjective experience and the dynamics of the therapeutic engagement. He had a broad range of knowledge and interests beyond psychoanalysis and was able to integrate perspectives from empirical studies with his empathic understanding of clinical material and a striking ability to make complex and impenetrable intrapsychic processes lucidly understandable.

Suicide as escape from psychotic panic.

Suicides of patients in states of acute persecutory panic may be provoked by a subjective experience of helpless terror threatening imminent annihilation or dismemberment. These patients are literally scared to death and try to run away. They imagine suicide is survivable and desperately attempt to escape from imaginary enemies. These states of terror occur in a wide range of psychotic illnesses and are often associated with command hallucinations and delusions. In this article, the authors consider the subjective experience of persecutory panic and the suicide response as an attempt to flee from danger.

Postdischarge suicide: A psychodynamic understanding of subjective experience and its importance in suicide prevention.

Recent discharge from a psychiatric inpatient facility is associated with a high risk of suicide. There are multiple factors that may contribute to this increase in risk. Psychodynamic considerations about the patient's subjective experience of suicidality, hospitalization, and discharge are often overlooked but are critical to understanding this phenomenon. Qualitative research has begun to provide empirical support for the importance of the psychological aspects of discharge, and the heightened state of vulnerability that patients experience during this time. Review of the literature and careful consideration of clinical experience is helpful in elucidating this experience in a way that can inform effective treatment. This article integrates a psychodynamic understanding of suicidality in the postdischarge period with a review of empirical research and formulates clinical recommendations for suicide prevention.

Measuring mental healthcare quality in the United States: a review of initiatives.

PURPOSE OF REVIEW: This review article aims to present a systematic overview of the current initiatives assessing mental and/or substance use (M/SU) healthcare quality in the United States. RECENT FINDINGS: The study found 36 initiatives incorporating M/SU indicators with efforts from the federal and state government, health plans, nongovernmental and professional organizations. SUMMARY: Although there has been much activity in recent years in the development of M/SU indicators, efforts have lacked coordination, have focused on limited areas of clinical activity, and have not been clearly linked to quality improvement activity. The study recommends that the United States government forms an entity to better coordinate efforts and address these concerns. Clinicians and provider organizations should also increase the use of already developed M/SU indicators to improve quality of care delivered.