Recognizing and responding to a suicide crisis.

Data from therapists who were treating 26 patients when they committed suicide were utilized to identify signs that warned of a suicide crisis. Three factors were identified as markers of the suicide crisis: a precipitating event; one or more intense affective states other than depression; and at least one of three behavioral patterns: speech or actions suggesting suicide, deterioration in social or occupational functioning, and increased substance abuse. Problems in communication between patient and therapist were identified as factors interfering with crisis recognition. Evaluation of the identified affects and behaviors may help therapists recognize a suicide crisis.

Treating the suicidal patient. Basic principles.

Successful psychotherapy with suicidal patients requires an emotionally full, active engagement from the therapist with his patient. Emphasis is on the real relationship, not the transference, and the therapist must be available to the patient as a sturdy, reliable object with whom to identify. The therapist's attitude must be loving, not neutral; the alliance is built upon the therapist's devotion to the patient's growth and the development of the attributes necessary for successful autonomous adult functioning. Patients require emotional containment and support, assistance in modulating painful affect, validation, education, help with reality testing, and kindly limit setting. Countertransference reactions must be expected and kept in check, so that the therapist does not get in the patient's way as he tries to build up the faulty mental structures that got him into trouble in the first place.

Recognizing and responding to a suicide crisis.

Data from therapists who were treating 26 patients when they committed suicide were utilized to identify signs that warned of a suicide crisis. Three factors were identified as markers of the suicide crisis: a precipitating event; one or more intense affective stats other than depression; and at least one of three behavioral patterns: speech or actions suggesting suicide, deterioration in social or occupational functioning, and increased substance abuse. Problems in communication between patient and therapist, often originating in therapeutic anxiety over the patient's possible suicide, were identified as factors interfering with crisis recognition. Evaluation of the identified affects and behaviors may help therapists recognize a suicide crisis.

Therapists' reactions to patients' suicides.

OBJECTIVE: The authors wished to obtain information from therapists about their reactions to the suicides of patients in their care. METHOD: Therapists for 26 patients who committed suicide completed a semistructured questionnaire about their reactions, wrote case narratives, and participated in a workshop to discuss their cases. The therapists discussed what they would do differently, the impact of the death on their treatment of suicidal patients, their interaction with patients' relatives after the suicides, and the reactions of their colleagues and supervisors. RESULTS: Shock, grief, guilt, fear of blame, self-doubt, shame, anger, and betrayal were the major emotional reactions. In 21 out of 26 cases, therapists identified at least one major change they would have made in their patients' treatments; most frequently mentioned were changes in medication, hospitalization of the patients, and consultation with the patients' previous therapists. Nineteen of the therapists saw the patients' relatives after the suicides; in almost all cases the relatives were not critical of them. Some of the therapists were reluctant to accept subsequent suicidal patients into their practices. Although colleagues were supportive, institutional responses and case reviews were rarely helpful, offering either blame or false reassurance that the suicide was inevitable. CONCLUSIONS: Clinicians felt they learned from participating in the project and that it was therapeutic for them. Review of such cases by a disinterested independent group with no institutional ties to the therapists seems desirable.

Pathological narcissism and sudden suicide-related collapse.

Psychiatric inpatient admission of three nondepressed young men who escaped deadly self-injury provided an opportunity to study their character organization. Defects in affect-regulatory functions and evidences of pathological narcissism were identified and explored. Each patient had a specific suicide-risk consultation and a psychotherapy evaluation. Each denied intent to kill himself, and none acknowledged experience of depression or the wish to die. Each also denied his suicidal behavior involved significant risks, and each discounted the importance of obvious, identifiable stressors as triggers for it. The interrelation between pathological narcissism and this particular suicidal behavior is discussed. These observations can assist in the assessment of suicide risk in nondepressed patients.

Culture and ego-ideal in suicide: an adult case.

A case is presented in which the patient's self-expectations, arising from his ego ideal, were violated by a conflict with his wife, who came from a different culture and did not share his marital and family values. When she left him he was devastated, not only by the loss of his family, but by the destruction of his ideal vision of himself as a husband and father. A dangerous suicide attempt followed. The psychodynamic formulation of the case and the treatment that followed from it are discussed.

Calculated risks in the treatment of intractably suicidal patients.

PATIENTS who threaten suicide in all seasons, self-mutilate, and who from time to time make serious suicide attempts tax and challenge clinical workers. Every hospital has its legend about the exploits of such a patient. When these patients die of suicide, a wave of sorrow and guilt follows. Many therapists exclude them from their practices; keeping clinical balance in working with them is difficult. Intractably suicidal patients require much time and great energy from those responsible for their care. They draw forensic attention and excite hospital administrators to action. Much of the anxiety they arouse comes from the question of whether they should be admitted to the hospital and, once they have come into the hospital, from the reciprocal: whether they should go out again. The increasingly litigious climate in the United States makes the treatment of such persons extremely difficult. The purpose of this paper is to review the literature pertinent to the care of such patients, to outline the clinical principles necessary for their management and treatment, and to set forth the conditions that are necessary to minimize legal exposure in the event of suit in the wake of suicide.

Calculated risk taking in the treatment of suicidal patients: ethical and legal problems.

The ethical rationale by which the law permits suicidal patients to be involuntarily confined to institutions, their suicides prevented, and treatment imposed has been much discussed. Economic factors have now made prolonged hospital care almost impossible in the United States. Psychiatrists feel great pressure to discharge suicidal patients from inpatient care. While discharge is therapeutically desirable for some suicidal patients, for others it is not. In the event of postdischarge suicide, the risk of a lawsuit is considerable.