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

Abstract

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.