Death anxiety and existential concerns among patients experiencing chronic or recurrent suicidal ideation in Interpersonal Reconstructive Therapy

ABSTRACT

Objectives

Through detailed analysis of case examples, this work seeks to provide valuable insights for clinicians wishing to explore suicidality with their patients in ways that are informed both by existential and attachment-based perspectives.

Design

Specific case studies are used to explore and illustrate areas of intersection around the topic of suicidality using Interpersonal Reconstructive Therapy (IRT) theory and Terror Management Theory (TMT) lenses together.

Results

Intersecting themes focus on meaning-making, attachment, and how these together inform how patients experiencing chronic suicidal ideation appear to overcome the evolutionary desire to survive. In this view, suicidality can be seen as a maladaptive attempt at adaptation, miscued by learning about perceived safety and threat signals derived from close attachment relationships.

Conclusion

Implications for theory, research and practice are discussed.

KEY POINTS

What is already known about this topic:

1. In Interpersonal Reconstructive Therapy (IRT), patterns linked to suicidality can often be seen as reflecting lessons learned about self and others in the context of close attachment relationships, and these lessons are summarized for individual using a reliable case formulation method.

2. Maladaptive behaviour that is motivated by desires to receive love, protection, or approval from problematic internalized attachment figures is termed a “gift of love” (GOL).

3. Work with the GOL is a major focus in IRT and typically involves gaining sufficient awareness of related patterns, their origins, and their functions in the present. The awareness allows greater choice about changing problematic behaviour, including suicidality.

What this topic adds:

1. Clinical case examples from IRT work, supplemented by extant research data, highlight how existential and relational themes are involved in the change process with suicidal patients having complex presentations and prior non-response to treatment.

2. Case illustrations demonstrate how suicide, when present as a GOL, can override normative fears of death as part of a maladaptive attempt to solve problems that are themselves rooted in relationships and relational patterns.

3. Also demonstrated is how will and existential choice are involved in relinquishing the GOL, and related desires for death, by differentiating oneself from the rules and values of internalized loved ones.

KEYWORDS:

• Terror management theory
• interpersonal reconstructive therapy
• suicide
• attachment
• case formulation

Disclosure statement

No potential conflict of interest was reported by the author(s).

Data availability statement

Due to the nature of this research, participants of this study did not agree for their data to be shared publicly, so supporting data is not available.

Notes

1. All case examples have been de-identified through use of pseudonyms as well as omission or alteration of contextual and demographic material that might identify them or others in their narratives. However, the SASB-defined interpersonal patterns enacted with self and others, as well as the general nature of the familial and cultural contexts in which specific events occurred, are authentic to the original interviews and sessions, and are recognizable by the patients who made these contributions even though others would not know it was them. Each patient granted formal written consent for educational and research use of their clinical materials under condition of these protections to their confidentiality.