In addition to these strategies and techniques, some particular tactics apply when this treatment is performed with patients presenting characterologically anchored suicidal tendencies. First is the preliminary development of a treatment contract that includes common features for all patients, such as agreeing on meeting times, financial arrangements, protocol for vacations and cancellations, potential involvement of third parties, and so on. Patients receive instructions to communicate their thoughts, feelings, and perceptions freely in the therapy hours, and therapists clarify their own responsibility for sharing with patients information that may help them increase their knowledge of self. To these, general features must be added for suicidal patients: specific arrangements that delimit clearly the responsibilities of patient and therapist in the management of the suicidal behavior (Yeomans, Selzer, & Clarkin, 1992). The treatment contract must include the setting up of conditions that ensure the patient's survival. To this end, patient and therapist must reach an understanding about the management of whatever suicidal behavior may emerge.
The treatment contract establishes conditions that protect both life and the treatment frame, practically limiting the therapeutic contacts to the treatment hours, thus permitting the therapist to maintain an interpretive, technically neutral stance. Concretely, patients are encouraged to communicate all suicidal fantasies, desires, and intentions in the therapy hours and to commit themselves to refraining from any action on these desires between the hours. The understanding is that, should patients consider themselves incapable of controlling the suicidal behavior, they would go to an emergency service of a psychiatric hospital to be examined and, if necessary, be hospitalized until considered safe by the hospital staff for continuing treatment as an outpatient.
Patients' responsibilities consist of either controlling their suicidal behavior and reserving its discussion to the treatment hours or, if unable to do that, to assume the responsibility themselves to be evaluated at an emergency service. Patients are discouraged from attempting to contact the therapist outside the treatment hours to avoid secondary gain of the symptom and to maintain the therapeutic communications in the context of the sessions themselves.
Often patients' suicidal threats, expressed to family members or other persons, may promote powerful secondary gain that feeds into the suicidal symptomatology. The therapist may have to meet with the entire family to explain the treatment arrangements and to explicitly liberate them from responsibility for the patient's survival. It needs to be stressed that should the therapist be concerned about the patient's reliability as protector of his or her own survival between the sessions, it is preferable to hospitalize the patient until a definite diagnosis is achieved and the patient's capacity for responsible participation in the treatment is reliably assessed.
In practice, the fact that the suicidal behavior of these patients cannot be predicted and is either impulsive or responds to the kind of cold planning discussed previously should provide the therapist with certainty that this unpredictable suicidal behavior cannot be controlled by any external measures, not even hospi-talization. Only patients' cooperation and the elimination of secondary gain can prevent the suicide of patients whose suicidal tendencies are anchored in their character structure.
To perform the treatment effectively, therapists must assure themselves of their own security (physical, legal, and psychological) by explaining to the families the rationale for making patients responsible for their own safety. It must be very clear to patients and to the relatives why long-term hospitalization does not seem indicated under the circumstances and why outpatient treatment is recommended, despite the ongoing, uncontrollable risk for suicidal behavior. Therapists also need to spell out these arrangements in writing for their own legal protection. It is essential that therapists achieve a therapeutic frame and conditions for the treatment that permit them to remain calm under conditions of explicit or implicit suicidal threats from patients or pressures from patients' family members.
A further specific tactical measure and an absolutely essential aspect of this treatment approach is that therapists must interpret the transference implications of the treatment conditions for suicide control from the very start of the treatment. Thus, the therapist interprets, as far as possible based on total knowledge of the patient's present personality structure and history, the potential meaning that the patient may be giving to the therapist's intervention—as an act of invasive control, hostile dominance, or an arbitrary restriction. The therapist then attempts to link this interpretation with the more general transference interpretations that may be warranted. An essential tactic of this treatment approach is the combination of structuring the treatment, setting limits on the patient's suicidal behavior, and immediate interpretation of the transference implications of this limit-setting until such transference implications can be fully explored and resolved.
The underlying theoretical assumption is that, regardless of the particular psychodynamic issues activated in each case, a common feature of chronic suicidal or parasuicidal behavior is an implicit activation in the patient's mind of an object representation of a sadistic, murderous quality and the complementary activation of a victim representation of that object representation—a defeated, mistreated, threatened self-representation. The relationship between these two representations (self and object) is marked by intense hatred and is revealed in a relationship of the patient with his or her own body. Chronic suicidal and parasuicidal behavior reflect a somatization of an intrapsychic conflict: The limit-setting as part of the structure of the treatment arrangements and the interpretative approach to the corresponding implications for the therapeutic relationship transform such a som-atized, internalized object relation into a transference-activated, internalized object relation that permits the suicidal conflict to be approached directly.
The patient temptation for suicidal behavior is thus transformed into a potentially hateful relation between one aspect of the patient's self and one aspect of his or her projected object representation that is attributed to the therapist. This transformation may dramatically eliminate long-standing suicidal behavior from the beginning of treatment; and while the transference rapidly shifts into a dom-inantly negative one, the containment, interpretive working through, and gradual resolution of that primitive transference may resolve suicidal behavior in the early stages of the patient's psychotherapeutic treatment.
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