Problems in psychotherapy with suicidal patients

Article

Problems in Psychotherapy With Suicidal Patients
Herbert Hendin, M.D. Ann Pollinger Haas, Ph.D. John T. Maltsberger, M.D. Bethany Koestner, B.S. Katalin Szanto, M.D.
Objective: The authors studied recurrent problems in psychotherapy with suicidal patients by examining the cases of patients who died by suicide while receiving openended psychotherapy and medication. Method: Therapists for 36 patients who died by suicide while in treatment filled out clinical, medication, and psychological questionnaires and wrote detailed case narratives. They then presented their cases at an all-day workshop, and critical problems were identified in the cases. Results: Six recurrent problem areas were identified: poor communication with another therapist involved in the case, permitting patients or relatives to control the therapy, avoidance of issues related to sexuality, ineffective or coercive actions resulting from the therapist’s anxieties about a patient’s potential suicide, not recognizing the meaning of the patient’s communications, and untreated or undertreated symptoms. Conclusions: The se cas es illumin ate common problems therapists face in working with suicidal patients and highlight an unmet need for education of psychiatrists and other mental health professionals who work with this population. (Am J Psychiatry 2006; 163:67–72)

onsiderable evidence points to the complexity of the psychotherapeutic treatment of suicidal patients (1–4). A number of structured protocols have been developed to treat suicidality, including cognitive behavior problemsolving therapy (5–8), dialectical behavior therapy (1, 9, 10), time-limited interpersonal psychotherapy (11), and brief psychodynamic psychotherapy (12). Although some evidence exists for the efficacy of such protocols for selected patient groups, in our experience of supervising, consulting with, and studying clinicians who treat suicidal patients, we have found that most clinicians employ a relatively