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Abstract
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OBJECTIVES: Suicidal threats, gestures and overt attempts and suicide are common problems in patients with narcissistic personality disorders and other severe personality disorders. From a psychodynamic perspective, suicidal behaviour is based on both aggression as well as narcissistic self-regulation. Challenges for the clinical treatment of patients with suicidal behaviour and narcissistic disorders are described and discussed from a psychodynamic perspective. Negative self-concept, the ambivalence of suicide and aggression in suicide attempters and other risk factors are discussed.
METHOD: Empirical research findings, classical and newer psychodynamic theories and clinical experiences with psychotherapy for personality disorders are critically discussed.
RESULTS: Psychotherapeutic treatment should follow a suicide attempt. The therapist or psychiatrist must gauge the intensity of the patient's suicidal ideation, the existence of plans, the availability of means, the depth of depression, the extent of social isolation, the amount of alcohol or drug intake, and the degree to which the patient's communications are trustworthy to evaluate the situation. Broadly speaking, suicidal ideation in personality disordered patients has its primary source either in character pathology or affective illness. Different technical approaches apply when suicidality is primarily characterological or primarily affective. Besides the therapist's strong counter-transference reactions, which can include the extreme of hate, typical problems pertaining to his/her attitude and psychotherapeutic process can occur. The focus of the therapy is on the suicidal trigger and the roots of the narcissism. Suicide or the threat of suicide are called on by the patients as solutions to long-standing intrapsychic conflicts. When the patient's aggression, often due to traumatic experiences, is stimulated by current anger, frustration or envy, self-destruction provides a means to cope with the internalised tormentor or destructive schema. In many cases transferences related to the wish for revenge seem the prime motivator of suicidal behaviour. Chronic suicidal behaviour of more severely disturbed narcissistic patients is related to particular treatment difficulties.
CONCLUSIONS: Suicidal behaviour presents therapists treating narcissistic disorders with significant treatment difficulties and risks. Yet, it is precisely the time following a suicide attempt which offers an opportunity to understand patients' narcissistic dynamics and to process them more intensively. Suicidality often necessitates action-oriented interventions and departures from technical neutrality on the therapist's part. Secondary gain from suicidality and learning history should carefully be considered by therapists. It seems possible to integrate both principal psychodynamic models of suicide risk, conflictual aggression problems and their impact on the ego, as well as narcissistic self-economy.
Language: de |