A psychotherapeutic approach to the suicidal patient.

exposure to the depression of our patients makes us more vulnerable. Where the doctor feels threatened by the patient's depression, and especially if this reaction is an unconscious one, he is likely to try to protect himself by getting rid of the patient. He may do this by putting him on medication, not as an adjunct, but as an alternative to exploration of the problem. Or, if at all alarmed, he is likely to get the patient admitted to hospital. Either nostrum tends to make the doctor feel more secure. The effect on the patient is more equivocal. Retrospectivestudiesof people who have committed suicide show that many of them had had previous courses of anti-depressive or other medication and some were on such medica tion at the time of suicide (is, 4). Many of the successful suicides have been hospitalized frequently in the past and some have committed suicide while in hospital, while on leave, orshortlyafterdischarge(4,II,15).Increasingly, the psychotropic drugs themselves are used in attempted, and sometimes in successful, suicides (8). It would, of course, be absurd to imply that medication is never useful, admission never indicated. Where the patient himself is afraid, or where the suicidal pre occupation is related to frank psychosis, the patient needs outside protection from his self-destructive impulses. In my experience such patients usually welcome admission. Anti depressives or tranquilizers may be useful adjuncts, but in my opinion they are greatly over rated as a means of preventing suicide. The reasons for suicide, as a very real and disturbingproblem in our society,liein the social climate and are outside our province as therapists; but it is important to realize that they affect us just as they do our patients. In 1897 Durkehim (2) p. 323 wrote: †̃¿ If in a given moral environment. . . certain When a patient tells his therapist, directly or indirectly, that he is contemplating suicide, his communication is likely to evoke a strong reaction, although, like the patient's plea, it may, or may not be straightforward. The very fact of his presence shows that the patient has some hope of being dissuaded. It may be that the doctor's skill as an inter viewer has elicited rather more than the patient had intended to confide; but were he quite sure of what he wished to do, the patient would not risk a medical consultation. That is the inference I draw from a well documented study of all suicides in Bristol over a five-year period. Nearly 6o per cent had not consulted a doctor in the preceding four weeks (is) p. 923. The patient may not be aware, however, that he is making a plea, and the doctor may be equally unaware of the nature of his own reaction to it, of the fact that his response may be more anxious than enquiring; more hostile than supportive. These are difficult patients who try one's patience and test one's therapeutic acumen. They can be very demand ing, with a distressing tendency to need emer gency appointments, especially at night or at week-ends. But there are deeper reasons for the doctor's disquiet. Here is a person who feels so strongly that his life is not worth living, and who is so pessimistic about his own ability to alter it, that he is ready to end it by his own hand. To listen attentively to such a person means taking the risk of sharing his experience, his sense of life as empty and meaningless. This is a challenge not only to the doctor's skill as a therapist but to his own sense of values, and his own tendency toward depression. The high suicide rate among doctors (i), and expecially among psychiatrists (5), testifies to the likelihood that we are either more liable than others to such depression or that our