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The occurrence of suicidal fantasies, thoughts, or plans during psychoanalytic treatment brings into focus unresolved dilemmas involving the goals and methods of analytic therapy. Sacred rules such as confidentiality may have to be broken. There will be several alternative treatment choices, all of them potentially bad. In part this article will be concerned with risk management in dangerous situations.
Presented here is an illustration of the dilemma of suicide as it rather frequently presents itself in my consulting practice. A male colleague called me with regard to a patient. This patient is a female attorney in her early 30s, who, had been seeing him for 3 years. She had recently been talking about committing suicide, and he was worried. He suggested the possibility of hospitalization several times, but she would not consider it. In the past there have been periods during which she was depressed and talked about suicide, but never like this, and he was never really worried before. What is different now is that there has been a break in their relationship. She seems remote from him. She won't listen to his suggestions. For example, on occasions in the past she would take appropriate antidepressant drugs when she was depressed, and now she refuses.
I asked what happened? For about 5 weeks, starting 2 months ago, the patient had been involved full-time as lead attorney in an important trial, and had not been able to see him more than two or three times. Her side won the decision in the trial, but afterwards she felt let down, insufficiently rewarded by her firm, neglected by her boyfriend, and by the analyst. She thought seriously of quitting her job, and she turned over most of her files to other attorneys. She talked to the analyst about going away for a long vacation and never coming back. Her suicide plan was unspecified.