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

Bühlmann, Vera; Schlüter-Müller, Susanne; Fürer, Lukas; Steppan, Martin; Birkhölzer, Marc; Schmeck, Klaus; Koenig, Julian; Kaess, Michael; Zimmermann, Ronan (2021). Therapists’ emotional state after sessions in which suicidality is addressed: need for improved management of suicidal tendencies in patients with borderline personality pathology. BMC psychiatry, 21(1), p. 590. BioMed Central 10.1186/s12888-021-03549-9

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Introduction: Patient suicidality is a frequently experienced topic for psychotherapists. Especially adolescents with borderline personality pathology (BPP) often exhibit suicidal tendencies. Previous research which examined therapists' countertransference towards suicidal patients suggested that therapists are negatively affected and distressed by them. We hypothesize that this emotional response of the therapists is related to specific sessions in which suicidality came up as a topic. Accordingly, the objective of this study consists in examining therapists' emotional state on a session level of analysis.

Methods: The sample consisted of N = 21 adolescents (age 13-19 years) with BPD or subthreshold BPD. Therapists' emotional states were measured in n = 418 sessions using the Session Evaluation Questionnaire. Principal component analysis was used to reduce dimensionality of the therapist response. The emotional states were compared depending on whether suicidality has been addressed in the session (SS) or not (NSS).

Results: Two components could be identified. Firstly, therapists were more aroused, excited, afraid, angry and uncertain after SS than after NSS. Secondly, therapists were more aroused, excited, definite and pleased after SS than after NSS.

Discussion: Suicidality does not always have to be a burden for therapists: Both a "distress" and an "eustress" component occur in this context from which the latter is supposed to help clinicians master a difficult situation. Since countertransference feelings are often not fully conscious, it is necessary to do research on therapists' emotional states after sessions in which suicidality is addressed. This is crucial to both prevent the therapeutic process from being endangered and preserve clinicians' mental health. Clinical implications and limitations are discussed.

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