A response to ‘intensive suicide prevention’

Horgan and Malhi (2018) describe a psychotherapeutic approach to the acutely suicidal outpatient, designated as ‘intensive therapy’. They imply that the psychiatrist should assume responsibility for preventing suicide. We argue that discussion of physician responsibility is incomplete without consideration of patient autonomy. This aspect of clinical judgment is lacking in the cases described, none of which appear to reach the threshold for severely impaired decision-making as connoted by, say, melancholic or psychotic depression. Myriad conscious and unconscious factors may influence self-responsibility in the suicidal patient, including simple intoxication. Rather than enhancing autonomy as part of a therapeutic process, the authors suggest ‘non-fatal oblivion’ as another modification of technique in the face of the threat of ‘irresistible suicidal ideas’. But these are outpatients, so clearly there has been some level of ‘resistance’ to any suicidal impulse.

Clues to the likely contribution of personality factors in their cases include non-responsiveness to multiple trials of antidepressants and unsuccessful psychological interventions attempted by multiple clinicians (in one case 30 psychiatrists). The apparent refractoriness of mood symptoms and threats of self-harm are consistent with emotional dysregulation, a hallmark of the borderline personality—itself derived from developmental trauma and disturbed early attachments. Although the authors apply ‘intensive crisis intervention in acute life-threatening situations’, the notion of acuity is contradicted by one patient who suffered ‘15 years of suicidal depression …’ and by several receiving ‘some months of daily therapy’.

Their cases fail to offer the detail required to understand the meaning of suicidal expressions, such as protest against actual or perceived abandonment, and are unsupportive of any particular direction of management, given that no clear diagnosis, let alone formulation, can be derived. For instance, the dramatic suicidal threats of patient B might be construed as care-eliciting behavior. The authors acknowledge the possibility of ‘non-improvement despite a trial of this modality of treatment’ but fail to consider the likelihood of exacerbation in ‘personality disordered patients craving emotional input …’

From this conceptual confusion, we contend that the authors’ treatment recommendations are misguided, and risk iatrogenic harm—for which the doctor by definition must then assume the responsibility that he or she seemingly seeks. One obvious ‘closure of the circle’ of responsibility arises should a clinician follow their recommendation of ‘nonfatal oblivion’. All the patient in such a state has to do is attempt to descend a flight of stairs, or cross the road, and—‘voila’—non-fatal oblivion becomes fatal, such that the patient achieves the death that he or she ostensibly desires, and the doctor becomes accountable for putting that patient at such obvious risk.

Should the patient survive the ‘oblivion’, they are nevertheless thwarted from gaining the necessary ‘mentalising’ tools for confronting and working through their emotional crises. Therapeutic gains are best achieved by awareness in both clinician and patient, not shared oblivion. Bateman and Fonagy (2016), in setting the framework for therapy with suicidal patients, give a clear message limiting clinical responsibility: ‘I can’t stop you harming yourself or even killing yourself, but I might be able to help you understand what makes you try to do it …’

Horgan and Malhi caricature psychodynamic treatment as ‘the classical highly controlled relationships of advanced psychotherapy’ and ‘the distant therapist traditional model’. A vast literature refutes such ‘straw man’ criticisms of psychotherapy. The authors advocate several boundary relaxations such as contact out of hours and self-disclosure. While we support more active involvement in times of the deepest emotional crisis, we echo the concerns of Adler (1972) of ‘rescuing patients versus helping them’.

The authors’ patients are ‘… spurred on by the knowledge they are intensely cared for by their doctor …’ This fits with the psychoanalytic notion of anaclitic depression, connoting intense dependency. Almost a century ago, Thompson (1930) recognized that ‘… the words of the analyst are often experienced as gifts of love by the depressed person’. McWilliams cautions that despite ‘… the patient’s unconscious belief that the cure of depressive dynamics is unconditional love and total understanding’, this is a dangerously incomplete solution.

Horgan and Malhi fail to adequately consider these dangers, including severe emotional regression. According to McWilliams (2011): ‘Counter-transference with depressive individuals runs the gamut from benign affection to omnipotent rescue fantasies …’ The ‘intensive therapy’ approach may exemplify the latter (McWilliams, 2011).