https://doi.org/10.4081/ripppo.2024.779
The problem of suicidality, personality disorder, and treatment: an alternative psycho-social perspective
Submitted: April 17, 2024
Accepted: November 12, 2024
Published: December 3, 2024
Accepted: November 12, 2024
Abstract Views: 1082
PDF: 168
HTML: 0
HTML: 0
Publisher's note
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.
Authors
Suicidal behaviour, including both attempted and completed suicides, has been increasing globally, particularly in industrialized nations, making suicidality a significant public health concern. Despite the allocation of increasing resources by US, EU, and UK governmental and mental health bodies, the effectiveness of current strategies for the treatment, management, and prevention of suicide remains in question. This paper reviews evidence from epidemiological studies and national prevention policies, alongside research data from a London-based specialist personality disorder treatment centre and clinical case studies from private psychiatric/psychotherapy practice, to explore an alternative psychosocial approach to addressing suicidality. The dominant psychiatric model, which relies heavily on medication, hospitalization, and often coercive methods of control, may have iatrogenic effects, potentially exacerbating the risk of suicide. In contrast, a psychodynamic and psychosocial approach, focused on understanding the underlying psychological dimensions of suicidality, fostering a trusting therapeutic alliance, addressing both internal and external factors contributing to suicidal behaviour, and promoting open dialogue around suicidal thoughts, has shown promise in reducing suicide risk. The findings presented in this paper argue for a rethinking of traditional psychiatric approaches, advocating for a shift toward more personalized, collaborative, and psychologically informed interventions that can more effectively reduce the risk of suicide.
Barbui, C., Furukawa, T. A., & Cipriani, A. (2008). Effectiveness of paroxetine in the treatment of acute major depression in adults: a systematic re-examination of published and unpublished data from randomized trials. Canadian Medical Association Journal, 178(3), 296-305. doi:10.1503/cmaj.070693.
Burgess, P., Pirkis, J., Jolley, D., Whiteford, H., & Saxena, S. (2004). Do nations' mental health policies, programs and legislation influence their suicide rates? An ecological study of 100 countries. Australian and New Zealand Journal of Psychiatry, 38(11-12), 933-939. doi:10.1080/j.1440-1614.2004.01484.x.
Chang, B. P., Franklin, J. C., Ribeiro, J. D., Fox, K. R., Bentley, K. H., Kleiman, E. M., & Nock, M. K. (2016). Biological risk factors for suicidal behaviors: a meta-analysis. Transl Psychiatry, 6(9), e887. doi:10.1038/tp.2016.165.
Chiesa, M. (1997). A combined inpatient/outpatient programme for severe personality disorders. Therapeutic Communities, 18, 297-309.
Chiesa, M., Cirasola, A., & Fonagy, P. (2017). Four years comparative follow-up evaluation of community-based, step-down, and residential specialist psychodynamic programmes for personality disorders. Clinical Psychology & Psychotherapy, 24(6), 1331-1342. doi:10.1002/cpp.2109.
Chiesa, M., & Fonagy, P. (2000). Cassel personality disorder study: methodology and treatment effects. British Journal of Psychiatry, 176, 485-491.
Chiesa, M., & Fonagy, P. (2002). From the therapeutic community to the community: A preliminary evaluation of a psychosocial outpatient service for severe personality disorders. Therapeutic Communities, 23, 247-259.
Chiesa, M., Fonagy, P., & Gordon, J. (2009). Community-based psychodynamic treatment program for severe personality disorders: Clinical description and naturalistic evaluation. Journal of Psychiatric Practice, 15, 12-24. doi:10.1097/01.pra.0000344915.61706.d4
Chiesa, M., Fonagy, P., Holmes, J., & Drahorad, C. (2004). Residential versus community treatment of personality disorder: A comparative study of three treatment programs. American Journal of Psychiatry, 161, 1463-1470.
Chiesa, M., Sharp, R., & Fonagy, P. (2011). Clinical associations of deliberate self-injury and its impact on the outcome of community-based and long-term inpatient treatment for personality disorder. Psychother Psychosom, 80, 100-109. doi:10.1159/000320975.
Chung, D. T., Ryan, C. J., Hadzi-Pavlovic, D., Singh, S. P., Stanton, C., & Large, M. M. (2017). Suicide Rates After Discharge From Psychiatric Facilities: A Systematic Review and Meta-analysis. JAMA Psychiatry, 74(7), 694-702. doi:10.1001/jamapsychiatry.2017.1044.
Curtin, S. C., Warner, M., & Hedegaard, H. (2016). Increase in Suicide in the United States, 1999-2014. NCHS Data Brief, (241), 1-8. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/27111185
Department of Health & Social Care. (2021). Suicide prevention in England: 5-year cross-sector strategy. London: Department of Health & Social Care. Retrieved from https://www.gov.uk/government/publications/suicide-prevention-strategy-for-england-2023-to-2028/suicide-prevention-in-england-5-year-cross-sector-strategy#contents
Farina, B., Liotti, M., Imperatori, C., Tombolini, L., Gasperini, E., Mallozzi, P., Russo, M., Simoncini Malucelli, G., & Monticelli, F. (2023). Cooperation within the therapeutic relationship improves metacognitive functioning: preliminary findings. Research in psychotherapy (Milano), 26(3), 712. https://doi.org/10.4081/ripppo.2023.712.
Fonagy, P., & Allison, E. (2014). The role of mentalizing and epistemic trust in the therapeutic relationship. Psychotherapy, 51(3), 372-380. doi:10.1037/a0036505.
Franklin, J. C., Ribeiro, J. D., Fox, K. R., Bentley, K. H., Kleiman, E. M., Huang, X., Nock, M. K. (2017). Risk factors for suicidal thoughts and behaviors: A meta-analysis of 50 years of research. Psychological Bulletin, 143(2), 187-232. doi:10.1037/bul0000084.
Griffiths, P., & Leach, G. (1998). Psychosocial nursing: A model learned from experience. In E. Barnes, P. Griffiths, J. Ord, & D. Wells (Eds.), Face to Face with Distress: The Professional Use of Self in Psychosocial Care (pp. 5-41). Oxford: Butterworth Heinemann.
Hagen, J., Knizek, B. L., & Hjelmeland, H. (2018). Former suicidal inpatients' experiences of treatment and care in psychiatric wards in Norway. International Journal of Qualitative Studies on Health and Well-being, 13(1), 1461514. doi:10.1080/17482631.2018.1461514.
Harris, E. C., & Barraclough, B. (1997). Suicide as an outcome for mental disorders. A meta-analysis. The British Journal of Psychiatry, 170, 205-228. doi:10.1192/bjp.170.3.205
Healy, D., & Whitaker, C. (2003). Antidepressants and suicide: risk-benefit conundrums. Journal of Psychiatry and Neuroscience, 28(5), 331-337. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/14517576
Healy, K., & Chamberlain, J. (2005). Suicides associated with admission to an inpatient therapeutic community. Therapeutic Communities, 26, 206 - 214.
Hedegaard, H., Curtin, S. C., & Warner, M. (2018). Suicide Rates in the United States Continue to Increase. NCHS Data Brief, (309), 1-8. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/30312151
Hengartner, M. P., Amendola, S., Kaminski, J. A., Kindler, S., Bschor, T., & Plöderl, M. (2021). Suicide risk with selective serotonin reuptake inhibitors and other new-generation antidepressants in adults: a systematic review and meta-analysis of observational studies. Journal of Epidemiology and Community Health, 75(6), 523-530. doi:10.1136/jech-2020-214611.
Hinshelwood, R. D., & Skogstad, W. (1998). The hospital in the mind: In-patient psychotherapy at the Cassel Hospital. In J. Pestalozzi, S. Frisch, R. D. Hinshelwood, & D. Houzel (Eds.), Psychoanalytic Psychotherapy in Institutional Settings (pp. 59-73). London: Karnac Books.
Hjelmeland, H., Hagen, J., Espeland, K., Nygaard, T. U., & Knizek, B. L. (2018). Guidelines do not prevent suicide. Tidsskr Nor Laegeforen, 138(10). doi:10.4045/tidsskr.18.0349.
Hjorthøj, C. R., Madsen, T., Agerbo, E., & Nordentoft, M. (2014). Risk of suicide according to level of psychiatric treatment: a nationwide nested case–control study. Social Psychiatry and Psychiatric Epidemiology, 49(9), 1357-1365. doi:10.1007/s00127-014-0860-x.
Keller, M. S., Qureshi, N., Mays, A. M., Sarkisian, C. A., & Pevnick, J. M. (2024). Cumulative Update of a Systematic Overview Evaluating Interventions Addressing Polypharmacy. JAMA Network Open, 7(1), e2350963-e2350963. doi:10.1001/jamanetworkopen.2023.50963.
Kochanek, K. D., Murphy, S., Xu, J., & Arias, E. (2017). Mortality in the United States, 2016. NCHS Data Brief, (293), 1-8. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/29319473
Large, M., & Ryan, C. (2014). Disturbing findings about the risk of suicide and psychiatric hospitals. Social Psychiatry and Psychiatric Epidemiology, 49(9), 1353-1355. doi:10.1007/s00127-014-0912-2.
Large, M., Ryan, C., & Nielssen, O. (2011). The validity and utility of risk assessment for inpatient suicide. Australas Psychiatry, 19(6), 507-512. doi:10.3109/10398562.2011.610505.
Large, M., Ryan, C., Walsh, G., Stein-Parbury, J., & Patfield, M. (2014). Nosocomial suicide. Australasian Psychiatry, 22(2), 118-121. doi:10.1177/1039856213511277.
Levy, S. R., Hilsenroth, M. J., Conway, F., & Owen, J. (2022). Patient personality characteristics and therapeutic integration: treating borderline personality and emotionally dysregulated-dysphoric personality features. Research in psychotherapy (Milano), 25(2), 611. https://doi.org/10.4081/ripppo.2022.611.
Madsen, T., Agerbo, E., Mortensen, P. B., & Nordentoft, M. (2012). Predictors of psychiatric inpatient suicide: a national prospective register-based study. Journal of Clinical Psychiatry, 73(2), 144-151. doi:10.4088/JCP.10m06473.
Main, T. (1946). The hospital as a therapeutic institution. Bulletin of the Menninger Clinic, 10, 66-70.
McClelland, H., Cleare, S., & O'Connor, R. C. (2023). Suicide Risk in Personality Disorders: A Systematic Review. Current Psychiatry Reports, 25(9), 405-417. doi:10.1007/s11920-023-01440-w.
Näher, A. F., Rummel-Kluge, C., & Hegerl, U. (2019). Associations of Suicide Rates With Socioeconomic Status and Social Isolation: Findings From Longitudinal Register and Census Data. Frontiers in Psychiatry, 10, 898. doi:10.3389/fpsyt.2019.00898.
National Institute for Health and Clinical Excellence (NICE). (2019). Suicide prevention: Quality standard [QS189], London. Retrieved from https://www.nice.org.uk/guidance/QS189
Office for National Statistics, O. (2023). Suicides in England and Wales: 2022 registrations. ONS website Retrieved from https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/bulletins/suicidesintheunitedkingdom/2022registrations
Paris, J. (2004). Is hospitalization useful for suicidal patients with borderline personality disorder? Journal of Personality Disorders, 18(3), 240-247. doi:10.1521/pedi.18.3.240.35443.
Pirkis, J., & Burgess, P. (1998). Suicide and recency of health care contacts. A systematic review. British Journal of Psychiatry, 173, 462-474. doi:10.1192/bjp.173.6.462.
Rajkumar, A. P., Brinda, E. M., Duba, A. S., Thangadurai, P., & Jacob, K. S. (2013). National suicide rates and mental health system indicators: An ecological study of 191 countries. International Journal of Law and Psychiatry, 36(5), 339-342. doi:https://doi.org/10.1016/j.ijlp.2013.06.004.
Ribeiro, J. D., Franklin, J. C., Fox, K. R., Bentley, K. H., Kleiman, E. M., Chang, B. P., & Nock, M. K. (2016). Self-injurious thoughts and behaviors as risk factors for future suicide ideation, attempts, and death: a meta-analysis of longitudinal studies. Psychological Medicine, 46(2), 225-236. doi:10.1017/S0033291715001804.
Royal College of Psychiatrists. (2021). Suicide prevention for mental health patients. Retrieved from https://www.rcpsych.ac.uk/improving-care/nccmh/quality-improvement-programmes/national-suicide-prevention-programme/suicide-prevention-for-mental-health-patients
Ryan, C., Nielssen, O., Paton, M., & Large, M. (2010). Clinical decisions in psychiatry should not be based on risk assessment. Australasian Psychiatry, 18(5), 398-403. doi:10.3109/10398562.2010.507816.
Schechter, M., Goldblatt, M. J., Ronningstam, E., Herbstman, B., & Maltsberger, J. T. (2016). Postdischarge suicide: A psychodynamic understanding of subjective experience and its importance in suicide prevention. Bulletin of the Menninger Clinic, 80(1), 80-96. doi:10.1521/bumc.2016.80.1.80.
Schechter, M., Ronningstam, E., Herbstman, B., & Goldblatt, M. J. (2019). Psychotherapy with Suicidal Patients: The Integrative Psychodynamic Approach of the Boston Suicide Study Group. Medicina (Kaunas), 55(6). doi:10.3390/medicina55060303.
Schomerus, G., Evans-Lacko, S., Rusch, N., Mojtabai, R., Angermeyer, M. C., & Thornicroft, G. (2015). Collective levels of stigma and national suicide rates in 25 European countries. Epidemiology and Psychiatric Sciences, 24(2), 166-171. doi:10.1017/S2045796014000109.
Shah, A., Bhandarkar, R., & Bhatia, G. (2010). The Relationship Between General Population Suicide Rates and Mental Health Funding, Service Provision and National Policy: a Cross-National Study. International Journal of Social Psychiatry, 56(4), 448-453. doi:10.1177/0020764009342384.
Steeg, S., Kapur, N., Webb, R., Applegate, E., Stewart, S. L., Hawton, K., Cooper, J. (2012). The development of a population-level clinical screening tool for self-harm repetition and suicide: the ReACT Self-Harm Rule. Psychological Medicine, 42(11), 2383-2394. doi:10.1017/S0033291712000347.
Williams, R., Chiesa, M., Moselli, M., Frattini, C., Casini, M., & Fonagy, P. (2023). The relationship between mood disorders, personality disorder and suicidality in adolescence: does general personality disturbance play a significant role in predicting suicidal behavior? Borderline Personal Disorder and Emotion Dysregulation, 10(1), 32. doi:10.1186/s40479-023-00238-9.
Wortzel, H. S., Homaifar, B., Matarazzo, B., & Brenner, L. A. (2014). Therapeutic risk management of the suicidal patient: stratifying risk in terms of severity and temporality. Journal of Psychiatric Practice, 20(1), 63-67. doi:10.1097/01.pra.0000442940.46328.63.
Zalsman, G., Hawton, K., Wasserman, D., van Heeringen, K., Arensman, E., Sarchiapone, M., Zohar, J. (2016). Suicide prevention strategies revisited: 10-year systematic review. Lancet Psychiatry, 3(7), 646-659. doi:10.1016/S2215-0366(16)30030-X.
Zalsman, G., Hawton, K., Wasserman, D., van Heeringen, K., Arensman, E., Sarchiapone, M. European Evidence-Based Suicide Prevention Program Group by the Expert Platform on Mental Health, F. o. D. (2017). Evidence-based national suicide prevention taskforce in Europe: A consensus position paper. European Neuropsychopharmacology, 27(4), 418-421. doi:10.1016/j.euroneuro.2017.01.012.
How to Cite
Chiesa, M. (2024). The problem of suicidality, personality disorder, and treatment: an alternative psycho-social perspective. Research in Psychotherapy: Psychopathology, Process and Outcome, 27(3). https://doi.org/10.4081/ripppo.2024.779
Copyright (c) 2024 the Author(s)
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
PAGEPress has chosen to apply the Creative Commons Attribution NonCommercial 4.0 International License (CC BY-NC 4.0) to all manuscripts to be published.
Similar Articles
- Victoria Klimkowski, Sofia McRae, Alexia Blick, Laurence Beaulieu, J. Reese S. Handley, Anara A. Hopley, Caroline A. Hyde, Devika M. Jain, Sylvia Kolodziejczyk, Josiane Laliberté, Alexa Lévesque, Lara M. Masri, Anya M. Monet, Reagan S. Nediu, Rachel Valihrach, Giorgio Tasca, Models of practice and training in psychotherapy: cross-national perspectives from Italy and Canada , Research in Psychotherapy: Psychopathology, Process and Outcome: Vol. 27 No. 1 (2024)
- Marjolein M. W. Koementas-de Vos, Lucas C. Colleye, Bea Tiemens, Fabiana Engelsbel, Kim de Jong, Cilia L. M. Witteman, M. Annet Nugter, The feasibility, acceptability and effectiveness of a feedback-informed group treatment (FIGT) tool for patients with anxiety or depressive disorders , Research in Psychotherapy: Psychopathology, Process and Outcome: Vol. 25 No. 3 (2022): SPECIAL ISSUE: "Group psychotherapy: between settled benchmarks and new horizons"
- Vittorio Lingiardi, Nancy McWilliams, Laura Muzi, The contribution of Sidney Blatt's two-polarities model to the Psychodynamic Diagnostic Manual , Research in Psychotherapy: Psychopathology, Process and Outcome: Vol. 20 No. 1 (2017)
- Elham Qanbari Alaee, Omid Saed, Sahel Khakpoor, Reza Ahmadi, Mahsa Ali Mohammadi, Majid Yoosefi Afrashteh, Zekrolah Morovati, The efficacy of transdiagnostic cognitive behavioural therapy on reducing negative affect, anxiety sensitivity and improving perceived control in children with emotional disorders - a randomized controlled trial , Research in Psychotherapy: Psychopathology, Process and Outcome: Vol. 25 No. 1 (2022)
- Racheli Miller, Mark J. Hilsenroth, Paul L. Hewitt, Perfectionism and therapeutic alliance: a review of the clinical research , Research in Psychotherapy: Psychopathology, Process and Outcome: Vol. 20 No. 1 (2017)
- Immacolata Zarrella, Luigi Alessandro Russolillo, Giorgio Caviglia, Raffaella Perrella, Continuity and discontinuity between psychopathology of childhood and adulthood: a review on retrospective and prospective studies , Research in Psychotherapy: Psychopathology, Process and Outcome: Vol. 20 No. 2 (2017)
- Johannes Pries, Alexander Niecke, Annekatrin Vetter, Ulrich Schultz-Venrath, More than one way home - Student raters' impressions of interventions and group processes in mentalisation based group psychotherapy and group analytic psychotherapy , Research in Psychotherapy: Psychopathology, Process and Outcome: Vol. 25 No. 3 (2022): SPECIAL ISSUE: "Group psychotherapy: between settled benchmarks and new horizons"
- Olga MarÃa Fernandez, Mariane Krause, Janet Carola Pérez, Therapeutic alliance in the initial phase of psychotherapy with adolescents: different perspectives and their association with therapeutic outcomes , Research in Psychotherapy: Psychopathology, Process and Outcome: Vol. 19 No. 1 (2016): Special issue on Qualitative and Quantitative Research in Child and Adolescent Psychotherapy: part 2
- Maria Pia Casini, Marta Moselli, Alice Wisniewski, Riccardo Williams, The role of suicidal motivations in adolescence: implications for the psychotherapeutic treatment of suicidal risk , Research in Psychotherapy: Psychopathology, Process and Outcome: Vol. 27 No. 3 (2024)
- Sara Silva, Isabel Basto, João Salgado, Carla Cunha, Validation of the client satisfaction questionnaire: a pilot psychometric analysis in Portuguese routine practice , Research in Psychotherapy: Psychopathology, Process and Outcome: Vol. 26 No. 2 (2023)
<< < 1 2 3 4 5 6 7 8 9 10 > >>
You may also start an advanced similarity search for this article.
