Is there a psychology behind suicide

The psychodynamics of suicidality

Summary

When people communicate directly or indirectly that they no longer want to live, this is initially to be understood as an interactive event. Therefore, the relationship offer is the central element of every form of treatment, both crisis intervention and psychotherapy of suicidal people. A stable relationship between therapist and client is a prerequisite for constructive therapeutic work. For this to work, it is essential to understand the psychodynamics and the often subtle transference and countertransference phenomena behind suicidality.

In depth psychological theories, suicidality is understood not only as a sign of mental decompensation, but also as a psychological function. This is used when intrapsychic or interpersonal crises no longer seem manageable. Seen in this way, suicidality can have a regulating, sometimes also a stabilizing function. The central conflictual issues of the suicidal person are dealing with aggression, self-esteem regulation and dealing with close relationships. The article presents the most important theories on the psychodynamics of suicidality.

Summary

When people directly or indirectly communicate that they have lost their will to live, this should initially be considered as an interactional event. Therefore, relational support is the central element of all forms of treatment, both in crisis intervention as well as the psychotherapy of suicidal people. A sustainable relationship between the therapist and the client is a prerequisite for constructive therapeutic work. In order for this to be successful, it is essential to understand the psychodynamics and the often subtle phenomena of transference and countertransference behind suicidal tendencies.

In depth psychology theories, suicidal tendency is regarded not only as a sign of emotional decompensation but also as a psychological function. This is then applied when intrapsychic or interpersonal crises seem impossible to deal with in any other way. In this respect, suicidal tendency can have a regulating and sometimes even stabilizing effect. The central conflictual topics of suicidal patients are dealing with aggression, regulating self-worth and handling close relationships. The article depicts the most important theories on the psychodynamics of suicidal tendency.

Preliminary remark

Dealing with suicide from a purely psychiatric, psychological or psychotherapeutic point of view does not do justice to this topic. Philosophical, religious, social and ethical questions point beyond a purely clinical point of view. J. Améry, in his remarkable book “Hand zu sich sein” (1976), radically and uncompromisingly called for the human right to commit suicide and called the act of suicide the ultimate freedom of modern man.

It can be countered by the fact that most people who are suicidal or who have committed suicide experience severe psychosocial stress or mental illness. This relativizes the concept of suicide, because the question arises whether a person who suffers - in whatever form - can be completely free in his will. One speaks of a balance sheet suicide when people come to the subjective assessment that their living conditions have become so hopeless and unworthy that they therefore decide to take their own lives. "The suicide or attempted suicide can then become the ultimate and painful expression of personal freedom without any psychosocial undesirable development or physical illness" (Scobel 1981, p. 101). Ultimately, it cannot be answered whether there is a balance sheet suicide in this, as it were, pure form. Even with many suicides in the context of crises or clearly diagnosed mental illnesses, more or less pronounced balancing elements can be found if the increasing restriction of the perspective of life is anticipated for this reason.

The possibility of thinking about one's own death and actively bringing about one's own death is a reality of human agency. In principle, everyone can therefore develop suicidal thoughts and commit suicidal acts. Suicidal people are desperate, their room for maneuver is narrowed considerably. Many of those affected believe that in this way they can expand their limited scope of action again. Where agonizing hopelessness dominates thinking and feeling, a new perspective and a new path opens up. It therefore often seems impossible to make a definitive decision as to whether a suicide is exclusively the end point of a pathological development or whether it is also a final and painful expression of personal freedom.

As long as the person is alive, there are other ways out. Suicidality is always an interactive event. A sustainable offer of relationships can show such a way out and is therefore essential for any form of treatment, both crisis intervention and psychotherapy of suicidal people. A prerequisite for constructive psychotherapeutic work is that the therapist tries to understand the more or less hidden communication options behind the suicidality, i.e. the psychodynamics and the often subtle transference and countertransference phenomena (Kind 2005).

Causes and motive structure of suicidality

There is no single theory of suicidality. Suicidal behavior is always the result of a complex interplay of neurobiological, psychological and social factors and can only be understood by taking into account the overall personality and the individual psychosocial situation and stress. Therapists must therefore each time anew to explore the meaning of the suicidal fantasies and actions together with the person affected and to derive the correct therapeutic action from them.

It turns out that there are many people who become very seriously suicidal as a result of an acute psychosocial crisis situation, but for whom this remains the only suicidal episode in their life. Crises are triggered by external stressful events such as deaths, separations, diagnoses of illness or sudden job loss. The well-being of those affected worsens and the situation quickly comes to a head. Coping options that are otherwise available are lost. Feelings of despair and hopelessness and various psychological and physical symptoms develop. Self-esteem and identity are in question and the normal level of mental functioning is severely impaired. A suicidal act can then appear to be a last resort. Psychodynamic processes as described below can also be found in crises, but they are limited in time, so they are mostly limited to the acute phase of the crisis. These are situations of high urgency that pose very serious dangers for the person concerned and, if coped with successfully, harbor the chance of maturation and further development (Sonneck et al. 2016; Stein 2009).

In contrast, around 20 to 30% of those who have attempted suicide get repeatedly into suicidal crises. One speaks of chronic suicidality. The risk of suicide for people who have already attempted one or more suicide is forty times higher than that of the general population. About 5–10% die by suicide within 10 years of the first attempt. Very serious psychopathologies are often found in these people. People with affective disorders (depressive and bipolar disorders), with psychoses, borderline and antisocial personality disorders, alcohol, drug and medication abuse and eating disorders are particularly at risk (see Bronisch et al. 2002).

Most knowledge about the psychodynamics of suicidal developments results from dealing with people who have had suicidal ideation or who have survived suicide attempts. There is, of course, little knowledge of what went on in people who actually took their own lives. "To those who committed it, suicide will have appeared to be the last and best of many bad opportunities, and any attempt by the living to explore this borderline can only provide a vague idea and be maddening" (Jamison 2000, p. 75 ). However, in not a few suicides there is also a message to the bereaved. One can say that "the committed suicide not only destroys the dialogue, but also opens it up again, even if the suicide himself can no longer participate" (Küchenhoff 2001, p. 61). A 23-year-old man whose girlfriend hanged herself in his apartment as a result of the separation he initiated is looking for therapeutic help. He seems cool and unaffected in the first interview. The therapist is gripped by a countertransference feeling of horror and horror in his descriptions. Feelings that the client obviously cannot or cannot endure. All too obviously the aspect of terrible vengeance plays a role in this suicide.

Depth psychological theories of suicidality

In depth psychological theories, suicidality is not only understood as a sign of mental decompensation, but also as a psychological function. This is used when intrapsychic or interpersonal crises no longer seem manageable. Seen in this way, suicidality can have a regulating, sometimes also a stabilizing function.

The central conflictual issues of the suicidal person are dealing with aggression, self-esteem regulation and dealing with close relationships. The psychoanalyst Jürgen Kind (2005) sees the relationships of the suicidants and especially their relationship with the therapist as a re-enactment of pathogenic object relationships in early childhood. A comprehensive psychodynamic understanding can only be achieved by merging conflict, self and object relationship psychological suicide theories.

Aspects of suicidality based on aggression theory

Freud formulates the common starting hypothesis of the depth psychological theory in grief and melancholy: "No neurotic feels suicidal intentions who do not turn them back on themselves from a murderous impulse against others" (1917, p. 205). So he postulates a conflict of aggression and interprets the suicidal act as a turn of aggression against oneself. He understands this conflict as a reaction to the subjectively unbearable loss of a real or fantasized object that is emotionally experienced as indispensable. A 25-year-old student with a pronounced narcissistic problem experiences a severe depressive phase with serious suicidal thoughts after an unhappy love. He's thinking very specifically about jumping off a tall building. On the one hand, he thinks he cannot live without this girl, because she is the love of his life, on the other hand, he reports an almost uncontrollable hatred with violent fantasies.

Aspects of suicidality from the theory of narcissism

Such dynamics can be better understood through the concept of the narcissistic crisis (Henseler 1984). It is characteristic of people who are insecure about their own self that they have an unrealistic assessment of their own person with a constant fluctuation between fantasies of size and omnipotence and feelings of inferiority and an unrealistic assessment of objects and interpersonal relationships and therefore keep repeating themselves Show tendencies towards idealization and devaluation. So partners are loved to support and satisfy the self and experienced as part of the self. One speaks of narcissistic object choice. Partners therefore have an extremely important function for self-awareness. They become a “self-object” (Kohut 1976).

Narcissistic crises can not only be triggered by an alleged failure of the loved one. B. also through professional failures or through the limitations and threats of getting older. It is always about considerable hurts that lead to a weakening of the self-esteem. These are mostly a revival of experiences of inferiority, overwhelming threat, catastrophic dependency, and abandonment in the early stages of development. The insults trigger feelings of massive disappointment, powerlessness and intense anger up to hatred, which in turn leads to feelings of guilt and self-punishment tendencies. This goes hand in hand with a dedifferentiation of subject and object. The boundaries between subject and object are blurring. It becomes unclear where the hatred comes from and who it is directed against. The object is saved in this way, at the same time the hatred that was previously directed at the object is now directed against the object in the self, i.e. against one's own person. “Suicide is the psychological murder of an object representation in the subject through suicide” (Götze 2002, p. 118). Since there is an exaggerated idea of ​​the effects of one's own instinctual impulses, anger appears as something threatening and uncontrollable. This necessarily results in strong control over aggressive feelings.

If compensation mechanisms such as denial of reality or self-idealization with corresponding size fantasies are not sufficient to restore the narcissistic system, a deep regression occurs. Suicide becomes a fantasized or acted withdrawal to a harmonious, symbiotic basic state. Subjectively, well-being, warmth and security can be regained and self-esteem can be restored. The anger remains diffuse, is split off and directed against oneself. The objective danger of suicide can no longer be recognized subjectively.

Acts of suicide are therefore very often reactions of self-insecure people to disappointment and insults. The suicidal fantasy helps those affected to actively counter the subjectively experienced feelings of total abandonment and helplessness in order to preserve their self-esteem. This conflict of ambivalence is about both the destruction of the beloved object, which was believed to be lost, as well as the salvation of the object relationship. In this context, one speaks of a “fused suicidality” (Kind 2005, p. 36). This psychological function of suicidality is often reflected in the suicide fantasies of those affected. A 35-year-old client comes for an initial interview due to a separation crisis. She says that she was thinking of "something really terrible". When asked, she reported very serious suicidal thoughts. She has already collected medication. When she is home alone, all she thinks about is killing herself. She says that her 12-year-old son, with whom she has major conflicts, would be better off without her. The thought of “not living any more” is not at all “terrible” for her, but rather comforting. She would then no longer have to endure the inner pain and would finally come to rest. She believes there is another, better, more harmonious world. There she could be reunited with her beloved husband. It turns out that she had lost her husband to suicide two years earlier. It was a complicated grief reaction with a pronounced idealization of the relationship. It later became clear that this had actually been extremely conflictual due to the man's alcoholic illness and considerable financial difficulties before his suicide. As part of the crisis intervention, the grieving process could be revived and the client could allow grief, feelings of guilt, but also anger and an inner separation from the deceased partner, the suicidal constriction dissolved.

Some suicidal clients devalue their therapists because of their narcissistic problems. There is a risk that they will unconsciously act out their resulting unpleasant countertransference feelings such as disappointment and anger by letting the client feel their superiority and dominance. A power struggle then develops in therapy, which prevents at least minimal mutual confirmation and acceptance between the therapist and the client. This combination of devaluation and the lack of a confirmation cycle endangers the therapy to a high degree. Because the dosed and honest communication of positive countertransference feelings has a stabilizing effect on suicidal narcissistic clients. The devaluation makes it much more difficult for therapists to perceive and communicate positive aspects. It is therefore important to be able to “maintain the therapeutic relationship even in moments of aggressiveness” (Schneider-Heine 2017). Even very experienced therapists often have great difficulty dealing with negative, hostile reactions from their patients. Mr K., a 65-year-old client, opened the initial interview by stating that he had a loaded gun at home. He suspected that the therapist could not help him either, so suicide would be his only way out.Feelings of anger, helplessness and powerlessness arose in the therapist and the immediate desire arose to get rid of the client quickly.B. immediately to be instructed as a stationary person. The therapist was able to reflect on these countertransference feelings and avoided acting too hastily. As a result, a very constructive and open conversation was possible.

Object relationship theory aspects of suicidality

In contrast to the previously described regressive withdrawal, the threat to self-limits and autonomy is the central area of ​​conflict for some suicidal clients. Some clients develop suicide fantasies when they see their self-limits and their ego-autonomy endangered. This form of suicidality serves to ward off threatening feelings of dependence, helplessness and loss of control. It is not uncommon for one to experience such a dynamic when accompanying suicidal older people, mostly men. Particularly in old age, the limitation of possibilities and abilities has to be expected more and more. The actual or supposed loss of independence is experienced as a massive offense and calls into question one's own identity. In their phantasy, these clients experience the decision to commit suicide as a completely autonomous act. Jürgen Kind (2005, p. 42) calls this the “anti-fusion” function of suicidality. Such a dynamic was also the trigger for suicidality in Mr. K. On the one hand, he experienced his retirement a few months ago as a major offense. He had a very successful career behind him and had hoped to work in an advisory role for the company after his retirement. However, this was sold to a large investor and no value was placed on his expertise. He developed a severe depressive episode in the course of which he developed physical symptoms that led to pronounced hypochondriac anxiety. Mr. K. was certain that he was seriously ill and that he was dependent on the help of others. He said that he couldn't take it. Then it would be better to decide for yourself and put an end to your life. In his phantasy, this client experienced the idea of ​​suicide as an opportunity to regain control over the threatening situation.

A difficult situation in therapy often arises when clients react to the absence of their therapist with suicidality. It is possible that they regularly react with more or less encrypted suicide threats before going on vacation. Sentences like “You have been away for so long, I don't know if I can do it on my own.” In the countertransference, feelings of helplessness, powerlessness, guilt and anger arise.

Child calls this the countertransference constellation of the “manipulated object” (ibid., P. 127). He speaks of manipulative suicidality and compares the situation to being held hostage. He calls it taking the self hostage. The self is threatened, but the aim is to reach the third, in this case the therapist. Unconsciously, clients tighten or loosen control through the degree of suicidality. They try to bind the supposedly leaving object to themselves or to change it, because they assume that they are not lovable or interesting enough to be able to hold the important person in another way. The clients feel e.g. B. flooded with unbearable fears of loss due to the approaching vacation and develop therefore suicide fantasies. It is crucial for the therapy not to misunderstand the manipulative activities of the patient that serve to secure objects. "If you immerse yourself in the fears of powerlessness and extradition triggered by the impending loss of objects, you will find nothing objectionable in the manipulative behavior and you will no longer speak of a merely demonstrative suicide attempt" (Kind 2011, p. 89). It is precisely through this behavior that the clients provide a key to understanding, because precisely those feelings of powerlessness and anger, which they themselves know only too well from their relationships with their early objects, now come to their therapists - in the sense of a projective identification Unfolding.

Just as it is usually not the aim of a hostage taker to kill his hostage, in this case the aim of suicidality is not to die, but rather to hold or change the other. It is about property security and / or property change (Kind 2005). As a rule, these people had no one in their childhood who would reflect them in an affirmative and empathetic manner. They did not have the experience of being loved and validated in detachment. Instead of building up an inner structure of self-affirmation, a “core self”, a “self-representation of the right to exist” (Kind 2005), by internalizing the external empathic object, they suffer from an identity disorder. They are in a desperate search for themselves and are dependent on and dependent on the external objects. Again and again, and of course also in therapy, they look for an affirmative good counterpart. A 35-year-old client, diagnosed as a borderline personality disorder, repeatedly entangled the therapist in very stressful conflicts about the setting. So she really wanted to see him and meet him in the coffeehouse. To her, only the abandonment of the framework conditions seemed sufficient proof of his interest and his appreciation. Several times she left the therapy session with a hidden threat. She then said: "You know, today I'm going to drive home again". The client lived outside of Vienna, it was known from anamnestical that she had already had an almost fatal car accident and several times she described how she had driven through the traffic light when she was accepting an accident. The therapist was very worried about her after these hours, feeling passed out and helpless, but was also angry.

Being able to reflect on such countertransference feelings, act them out non-destructively, and maintain the relationship is an important corrective experience for the client. The therapist takes on a holding function (Winnicott 1971 ) a. At the same time, however, you should not be exposed to blackmail if possible. H. occasionally, clear limits must be set for self-endangering behavior. So if it is possible to continue to convey constancy, empathic warmth and acceptance while maintaining one's own limits, an understanding of the underlying injuries can be developed and the clients at some point escape the compulsion to re-establish the same offensive relationship constellation over and over again. Then the therapy can come to a constructive end. Interventions on the way are: Clarification of the triggering conditions of negative feelings and the related object relationships, encouragement of the bearing of unpleasant feelings, understanding of the conscious and unconscious goals of the interaction and clarification of how these goals can be achieved without suicidality by changing coping strategies can be.

Failure to maintain the holding function, clients can develop the feeling that all attempts to change or hold the object have been in vain. They give up and withdraw. Child describes this situation as the countertransference constellation of the "abandoned object" (ibid., P. 134). In such situations, it is all the more important to actively approach the client for a while, since they are no longer able to do so themselves due to the extensive detachment of inner object relationships.

Final remark

The essential goals of psychotherapy for suicidal clients can be formulated on the basis of an understanding of these relationship constellations. It requires the projective identifiability of therapists, i. H. one must be prepared to absorb the affects and fantasies induced by clients first and then to develop them further in order to subsequently make them accessible to the therapeutic process in a less destructive form and to make them available to the clients again. Therapists should be emotionally involved and be able to keep the affect appropriate. This attitude corresponds to the principle of containment (Bion 1992). Unbearable, intolerable psychological material, often destructive affects, are absorbed and processed by the therapists. This is only possible if the conversation about the suicide is maintained and it becomes possible to embed the suicide fantasies in a common horizon of understanding (Küchenhoff 2001). The decisive factor here is the common search, which helps the clients to develop a new understanding of themselves. This enables the relationship to be clarified step by step and transforms the storm of affect into a reflexive experience (Schneider-Heine 2017). If the desperate attempt to reach someone else is understood, then it can be possible to hold these people in the crucial moment and to save them from jumping into the void, and this becomes an essential new experience for the suicide, as it is in one touching scene from the novel Riven Rock by TC Boyle is described: The nurse Eddie O'Kane has just saved his psychotic protégé from jumping off a train: “He didn't let Mr. Mac Cormick, who was already covered in blood, already free, die under the rattling wheels, but grabbed him with him the poor and pressed him to her with a force that no power in the world could ever have conquered ”(TC Boyle 2000, p. 546).

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  1. Crisis Intervention Center Vienna, Lazarettgasse 14A, 1090, Vienna, Austria

    Claudius Stein

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Correspondence to Claudius Stein.

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Stein, C. The Psychodynamics of Suicidality. Psychotherapy Forum23, 81-86 (2019). https://doi.org/10.1007/s00729-019-00124-2

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keywords

  • Suicidality
  • Psychodynamics
  • Therapeutic relationship
  • aggression
  • narcissism
  • Object relationship theory

Keywords

  • Suicidal tendency
  • Psychodynamics
  • Relationship between the therapist and the client
  • aggression
  • Narcissism
  • Object relations theory