Department of Psychiatry, Harvard Medical School, Boston, MA; Mass General Brigham McLean Hospital, Belmont, MA; Boston Psychoanalytic Society and Institute, Newton, MA; Boston Suicide Study Group, Cambridge, MA, United States.

Department of Psychiatry, Harvard Medical School, Boston, MA; Boston Psychoanalytic Society and Institute, Newton, MA; Boston Suicide Study Group, Cambridge, MA; Mass General Brigham Salem Hospital, MA, United States.

Department of Psychiatry, Harvard Medical School, Boston, MA; Mass General Brigham McLean Hospital, Belmont, MA; Boston Psychoanalytic Society and Institute, Newton, MA; Boston Suicide Study Group, Cambridge, MA, United States.

Department of Psychiatry, Harvard Medical School, Boston, MA; Mass General Brigham McLean Hospital, Belmont, MA; Boston Psychoanalytic Society and Institute, Newton, MA; Boston Suicide Study Group, Cambridge, MA, United States.

Chronic suicidal ideations can be consistently present as part of the individual’s sense of identity and self-regulation or as a reoccurring pattern to control intense feelings and communicate and relate experiences or intentions. While they can be the precursor to self-harm and suicide attempts, requiring a thorough risk assessment, they can also represent a way to control, avoid, or contain intolerable feelings and experiences. In addition, suicidal ideations can be either deeply internalized and hidden or indirectly or directly conveyed to others. This article focuses on understanding and approaching chronic suicidal ideations that specifically relate to self- and interpersonal characterological functioning, i.e., sense of identity, self-regulation, emotion regulation, and interpersonal intentions. Suicidal ideations must be identified and assessed both in terms of intention, i.e., motivation, plans, and means to harm oneself or end one’s life, as well as in terms of function, i.e., related to selfregulatory strategies for counterbalancing or protecting against overwhelming, painful, and frightening external, interpersonal, or internal experiences. Therapeutic strategies and challenges will be discussed, including engaging patients in the therapeutic alliance and building consistency, trust, and reliability.

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