ABSTRACT
In this chapter, the author begins by quoting from an unforgettable self-referral letter received many years ago, from an 18-year-old who was in a suicidally depressed state and seeking help from the our Department. The recommendation to "go home" or to contact local services if feeling suicidal is, in so many cases, entirely irrelevant (despite the tick) because although the young person may have fantasied about, or even specifically planned, suicide before this, the actual act is so often characterized by an insistently, or impulsively mindless and unthinking state. The identification could, alternatively, have been with an internal figure who was simply incapable of keeping them properly in mind in a way that we would regard as sufficiently containing, despite endless well-meaning attempts to manage the pain. The criteria for determining how serious any one of these states of mind may be in relation to risk are obviously very subtle ones and are precisely those that most preoccupy clinicians.
