Dissociation in suicidal depression: a Reformulated Object-Relations Theory (RORT) perspective

The Interpersonal-Psychological Theory of Suicidal Behavior (IPTS) posits that suicide stems from a motivation to die by suicide, emanating from perceived-burdensomeness and failed belongingness, and a capacity to kill oneself. We propose a bridge between IPTS and dissociation theory/research via a recent reformulation of Melanie Klein’s notion of the depressive position, as comprised of three elements: Demeaning affect, compensatory affect-regulatory maneuvers, and mental representation of self-as-deficient and others as judgmental/punitive and at times seductive. This position is formed in childhood, proceeds to adulthood, and is projected into the future with the hope of finding respite from criticism. This hope is then thwarted by the sufferer’s interpersonal action leading to interpersonal strife. We posit that, in the Basic Level, a trauma-based, dissociative structure is formed, whereby the reformulated depressive position disengages from benign and benevolent mental processes, in turn creating interpersonal havoc. In the Advanced Level, dissociative mechanisms are utilized to assist the now depressed-suicidal position to succeed in its mission: Killing the self. A chilling case illustration of this pattern is presented and discussed. Clinically, we recommend a routine measurement of both dissociation and suicide risk, and appraisal of the psychodynamic connecting dissociation and suicidality.