Suicidal Threats and Therapists’ Helplessness

To the Editor: Thomas G. Gutheil, M.D., and Diane Schetky, M.D. (1), provide useful suggestions for the clinical management of time-based and contingent suicidal intentions. The authors recommend that therapists share their feelings of helplessness with patients: “shared helplessness may provide a pathway to empathic connection” (p. 1506). It may reinforce, however, the patients’ sense of control over therapists. For some patients, a time-based and contingent suicidal threat may represent an attempt to dominate therapists. Making therapists feel helpless may allow patients to not only disown this feeling in themselves but to also feel power over the therapists. This defense may be considered equivalent to a mechanism of projective identification. The interpretation of this defense may lead patients to acknowledge their own helplessness, to stop fearing retaliation from therapists, and to better benefit from support.

The authors report that, for some patients, death takes on “the qualities of an object relationship that, paradoxically, permits continued living” (p. 1503). In a similar vein, we have found that the exploration of the meanings of death and suicide in these cases suggests the role of splitting, through which suicide is fantasized about as both a means of getting rid of the bad parts of the self and the object and being reunited with the good object (2). The interpretation of the splitting defense may, without challenging directly this protective relationship, gradually lead to an alleviation of suicidal drive.