Kernberg P F
Cornell University Medical College, New York.
Am J Psychother. 1994 Winter;48(1):52-63. doi: 10.1176/appi.psychotherapy.1994.48.1.52.
Acute and chronic styles of suicidal behaviors require different psychotherapeutic approaches--the former needs a supportive-cognitive-focused approach, the latter (chronic or characterological) style needs an expressive insight-oriented psychotherapy with supportive elements to address the adolescent's developmental requirements for structure within the sessions. The psychotherapist needs to be appraised of the epidemiological, dynamic factors as well as the sources of external support the patient can count upon. It is interesting to note that psychodynamic factors alone or psychopathology alone are not sufficient to estimate the ebb and flow of the suicidal risk. A combination of all these factors must be taken into account in estimating suicidal risk at any point in treatment. It is advisable that an independent clinician's consultation be sought during treatment in the case of suicidal attempts as the therapist can easily overestimate or underestimate suicidal risks. Individual treatment requires family intervention from counseling to therapy. Particular problems addressed in the paper are countertransference reactions created by the suicidal behavior in the clinician such as rejection and withdrawal. The psychotherapy should address the resolution of aggressive, envious introjected images, issues of omnipotent control and interpersonal skills deficits. To transform suicidal behavior into reenactment of the aggression within the relationship to the therapist is the main immediate goal. A critical caveat; a patient who lies by commission or omission represents an obstacle for individual therapy on an outpatient basis as he will disguise his suicidal intentions and plans, excluding them from the therapeutic process.
急性和慢性自杀行为方式需要不同的心理治疗方法——前者需要以支持性认知为重点的方法，后者（慢性或性格性）方式需要一种带有支持性元素的表达性洞察导向心理治疗，以满足青少年在治疗过程中对结构的发展需求。心理治疗师需要了解流行病学、动态因素以及患者可依赖的外部支持来源。值得注意的是，仅心理动力学因素或仅精神病理学因素不足以评估自杀风险的起伏。在治疗的任何阶段评估自杀风险时，必须综合考虑所有这些因素。在自杀未遂的情况下，建议在治疗期间寻求独立临床医生的咨询，因为治疗师很容易高估或低估自杀风险。个体治疗需要从咨询到治疗的家庭干预。本文所讨论的特殊问题包括临床医生因自杀行为产生的反移情反应，如拒绝和退缩。心理治疗应致力于解决攻击性、嫉妒性内摄形象、全能控制问题和人际交往技能缺陷。将自杀行为转化为与治疗师关系中攻击性的重演是主要的直接目标。一个关键的警告是；通过主动说谎或隐瞒信息的患者是门诊个体治疗的障碍，因为他会隐瞒自己的自杀意图和计划，将其排除在治疗过程之外。
