Therapists’ emotional state after sessions in which suicidality is addressed: need for improved management of suicidal tendencies in patients with borderline personality pathology

Suicidality is defined as “the risk of suicide, usually indicated by suicidal ideation or intent, especially as evident in the presence of a well-elaborated suicidal plan” [1]. 50 to 95% of the clinicians report having experienced patients with some form of suicidal ideation or behavior [2‐4]. Moreover, suicidal statements [5] and suicidal ideation [6] were considered as one of the most stressful aspect of the therapeutic work. The current study investigates the impact of suicidality addressed in psychotherapeutic sessions on therapists’ post-session emotional state.

Suicidality plays an important role in Borderline Personality Disorder (BPD). 60 to 70% of patients with BPD commit a suicide attempt at some point in their life and the rate of completed suicide is 50 times higher in patients with BPD than in the general population [7, 8]. Despite the controversy regarding the diagnosis of BPD in underage patients, there is convincing evidence that diagnosing BPD in adolescents is as reliable and valid as in adults [9]. The elimination of the age limit of previous versions for the diagnosis of personality disorders in the International Classification of Diseases 11th revision (ICD-11 [10];) and the consequent possibility of early diagnosis provides the opportunity for effective early intervention [11]. Thus, a chronification and long-lasting impact of the personality disorder could be prevented.

The term countertransference is of great historical importance for therapeutic work since it has heightened therapists’ awareness of their own feelings and has been coined in different ways. In the last decades, it has received more attention since it was acknowledged having great impact on treatment process and outcome [2, 12]. The totalistic view defines countertransference as the total emotional reaction of the psychotherapist to the patient in the treatment situation [13]. The term countertransference is important in that it provides a historical framework for this question, but for the sake of simplicity and conceptual clarification, the following study will refer to “therapist’s emotional response” or the operationalized form of it, “emotional state”.

In association with suicidal patients, the term “countertransference hate” was introduced [14], which can arise in psychotherapists when working with these clients. Its management through full awareness is essential for therapy success, since therapists’ emotional response is assumed to predict patients’ suicide outcome [15]. Moreover, the therapist’s fear of losing a patient to suicide impedes an adequate assessment of the patient’s inner experience, leads to countertransference reactions and thus to alliance ruptures [16, 17]. The fear that a client could commit suicide represents a widespread therapeutic feeling [18] and interferes with their ability to work [19]. Therefore, it is crucial to conduct research on therapists’ emotional states after psychotherapy sessions in which suicidality is an issue.

Scientific evidence about therapist’ countertransference towards suicidal patients is broadly consistent and suggest that it involves negative emotions such as anxiety, anger and higher self-reported distress [3, 5, 6, 14]. Therapist stress is related to increased feelings of anxiety, tension, hopelessness, fear or embarrassment [20]. Others assume a wider spectrum of reactions ranging from hopelessness or sense of failure to the desire to intrusively nurture the patient [21]. A recent systematic review which included ten quantitative studies examined health care professionals’ countertransference toward suicidal patients [22]. Results showed that “suicidal patients elicit disinterest, anxiety, confusion, overwhelming, entrapment, rejection, inadequacy, helplessness or distress – but also engangement and fulfillment – among healthcare professionals, which suggests a specific and mostly adverse suicidal-related countertransference.” (p. 10). Moreover, the authors draw the conclusion that current suicidal ideation seems to be involved in eliciting such countertransference [12, 23], whereas the evidence on current or past suicidal behavior is inconclusive [12, 24‐26]. Nevertheless, it should be stated that study designs, settings, measurement methods of countertransference and suicidality varied widely across the included studies, making any quantitative synthesis of findings difficult.

Since previous research used a between-subject design comparing therapist responses towards suicidal versus towards non-suicidal patients, the question remains whether specific suicidal statements or general personality structure mediated the correlation with therapist response. Moreover, research has mostly focused on therapist traits rather than states such as affect. Therefore, it is important to examine within-therapist variables to further the understanding of therapist factors [27]. The current study meets the need for a prospective study design that can reveal differences between sessions within the patient-therapist dyad. In this way, it can be investigated what influence actual suicidal expressions have on clinicians. Our hypothesis is that suicidality addressed in a psychotherapy session burdens the therapist in terms of more negative emotions and distress measured after the session. The aim of this study is to discover a pattern of therapist’ emotional state after sessions in which suicidality was addressed. This awareness of the emotional state after specific sessions allows for a concrete intervention and prevention to ensure both therapists’ and patients’ mental health.

Some of the method passages are adopted from Zimmermann et al. [28, 29] where the study design has been described in more detail.

The aim of the current study was to investigate therapists' emotional responses toward young female adolescents with borderline pathology talking about their suicidal ideations or about a concrete suicide plan. We hypothesized that therapists’ post-session emotion would differ depending on whether suicidality came up as a topic or not (SS vs NSS). We expected that therapists are more afraid, excited, aroused, uncertain and angry after SS than after NSS. Therapist response was measured by Session Evaluation Questionnaire (SEQ) which had to be filled out by all therapists after each session. Results showed that SS are accompanied by higher therapist arousal. PC1 reflects that SS are associated with higher clinician excitement, anger, fear, arousal and uncertainty than NSS. Moreover, PC2 explained 23% of the variance in the therapist response items predicted by suicidality. This pattern is also characterized by higher arousal and excitement but demonstrates as well satisfaction and definiteness.

Previous research on this topic has especially dealt with therapists’ emotional responses towards “suicidal patients”. For example, a study with suicidal adolescents has shown that due to therapists' countertransference and due to trait-like suicidal ideation, therapists are unwilling to treat those patients at risk for suicide [47]. In patients with BPD it was suggested that the history of suicide attempts was associated with a worse general level of personality organization [48]. In contrast, the current study underlines the importance of significant psychotherapy moments with regard to therapists’ emotional response and shows that specific episodes and sessions affect therapists. Shifting the focus from “difficult patients” to identifying subjectively difficult or even precarious moments in therapy allows clinicians to seek help on a more tangible level.

PC1 reflects therapists’ negative affect and arousal and is to be summarized in the term “distress”. This is consistent with qualitative research [5, 6] and seems highly associated with patients’ suicidal statements since this component explains more than half of the variance in the SEQ data. Distress is to be understood as the “negative stress response, often involving negative affect and physiological reactivity: a type of stress that results from being overwhelmed by demands, losses or perceived threats. It has a detrimental effect by generating physical and psychological maladaptation and posing serious health risks for individuals. This generally is the intended meaning of the word stress” [1]. The concept of distress [49] emphasizes the importance of feeling able to meet the challenge by appropriate coping strategies. Therapists are often confronted with difficult situations in therapy and have a lot of responsibility. To ensure therapists’ mental health, which is the foundation of their work [50], it is important to strengthen therapists’ coping strategies.

In contrast to this, PC2 seems to point towards a positive kind of arousal whereby therapists feel definite and pleased. PC2 shows similarities with the concept of “eustress” and will be referred to as ‘eustress-component’. In the APA Dictionary of Psychology, eustress is understood as a “positive stress response, involving optimal levels of stimulation: a type of stress that results from challenging but attainable and enjoyable […] tasks […]. It has a beneficial effect by generating a sense of fulfillment or achievement and facilitating growth, development, mastery, and high levels of performance” [1]. This state is not a threat but a challenge and leads to positive feelings if the therapist thinks the situation was well managed. The correlation of SS with the eustress-component is of importance for clinical practice: Patient suicidality does not automatically have to be burdening for therapists and they can even feel more pleased and definite after sessions in which suicidality was addressed compared to sessions in which it was not. Addressing suicidality in psychotherapy can be a window of opportunity.

Of course, causality cannot be inferred from this correlation of patient suicidality and therapists’ emotional state after session in which suicidality is addressed. For example, an alternative hypothesis could be stated that therapists’ emotional state during the session has an influence on the patients in whether or not they raise the issue of suicidality. Another variant could be that the mood of the therapists has nothing to do with the session per se and thus represents a finding by chance. Moreover, Krause & Lutz [51] point out that therapist, patient, and context variables cannot be separated and affect each other. In this respect, it can be assumed that therapists respond to patients, but patients also respond to therapists, which makes any conclusive statement impossible. Thus, the therapeutic situation is a result of responsiveness both of the part of the therapist as of the patient.

Two different therapist responses were identified after sessions in which young female patients with BPD or subthreshold BPD talked about their suicidal ideation or about a more concrete suicide plan. Therapists showed an emotional response pattern consisting firstly of arousal and negative affect (“distress”) and secondly of arousal and positive affect (“eustress”). These two types of arousal are distinguished by being angry, uncertain and afraid versus feeling pleased and definite. First of all, this implies that patient suicidality does not always have to be emotionally burdening for therapists and moreover, that clinicians need to feel definite and self-effective which in turn enables the mastery of a challenging situation. If therapists become aware of their “suicidality-countertransference” and their anxiety about patient suicide contained, this can on one hand enable a good therapy process and outcome (including prevent discontinuation of the therapeutic process) and on the other hand lead to clinicians’ well-being. Conducting further research on how therapists’ mental health can be preserved seems necessary in order to ensure appropriate and good care for patients with suicidal tendencies.