[Treatment and prevention for suicidal patients with severe personality disorders].

Suicide is a complex behavior of multiple, inter-related factors. The author, in this paper, discusses several issues of the psychodynamic psychotherapy for chronic suicidal patients with severe personality disorders. With regard to psychotherapy for them, the author firstly points out the treatment difficulties that stem from the training system both of psychiatry and psychotherapy where students are not systemically trained with treatment of suicidal behavior. Secondly he discusses psychodynamic evaluation, therapeutic attitude, treatment setting, counter-transference, and grief work. In terms of psychodynamic evaluation, it is suggested that a therapist needs to recognize self-maintaining function, unconscious fantasy of re-union with great pleasure, internal object relations that lead to self-destructiveness, resentment toward self, capacity for loving good aspects of personality, specific sensitiveness to certain object loss, disorganization of self representation, and ego regression. With regard to, the attitude of, the therapist and the treatment setting, the author stresses that psychotherapy should be conducted in a highly structured treatment setting with the attitude of the therapist such as active intervention, honesty (openness), awareness of treatability, and conviction. Countertransferences frequently develop based on the feelings that the therapist experiences narcissistic injury with regard to his/her own ego ideal in the psychotherapy process, in which he/she develops the various defense mechanism against the increasing aggression of his/her own. A therapist needs to be aware of the patient's dependency, make frequent interpretations of patient's destructiveness, and make effective use of the consultation at the time when he/she places himself/herself at the impasse of treatment. Finally, the author emphasizes the grief work for both therapist and family in the case when the patient unfortunately has committed suicide and open communications among therapist, other staff involved and family members should be strongly recommended. These works not only help persons concerned to work through their mourning work, but also prevent the transmission of suicides over generations.