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Teen Suicide: Practical Interventions for Adolescents in Crisis
10 CEUs Teen Suicide: Practical Interventions for Adolescents in Crisis

Section 23
Development and Purpose of the Death Instinct in Adolescence

CEU Question 23 | CEU Answer Booklet | Table of Contents | Crisis CEU Courses
Psychologist CEs, Counselor CEUs, Social Worker CEUs, MFT CEUs

Every day in hospital emergency rooms, doctors see adolescents who have attempted suicide. The question that doctors may ask these adolescents is, "Why did you want to die?" An immediate connection is thereby Hospital Teen Suicide Practical Interventions counselor CEUmade between suicide on the one hand and the death wish on the other, as though it is obvious that the wish to commit suicide and the wish to die are the same thing.S

The parallel between suicide and death was established as early as Freud in his discussions of the death wish, and also in the work of Klein (1945). Later theoreticians also made a connection between suicide and the death wish, and argued that everyone who attempts suicide suffers from depression. Others suggested a connection between suicide and psychosis. Consequently, for many years it was deemed advisable to place adolescents who attempted suicide in hospital psychiatric wards for observation or treatment. However, recent studies have noted a lack of empirical justification for this approach. For example, Apter et al. (1993) found that psychopathology was low even among youngsters whose suicide attempts had been successful. In other words, suicidal behavior, even when the victim died, had not occurred on the basis of classified psychiatric illness, but rather on the basis of personality disorders.

In many of our conversations and interviews with adolescents, we found that the topic of death is a significant mental preoccupation. Much thought is given to the idea of the end of life, even when self-inflicted, in adolescents having no psychopathology or suicide wish. It thus appears to us that the intuitive, seemingly inseparable connection between the suicidal act and the death wish obscures a far more complex scenario.

We suggest that the suicidal act is an expression of suicidal thoughts, which are far more common than the act itself, which in turn is far more common than completed suicide. This is in contrast to a death wish that may exist but that does not necessarily find a suicidal expression, although its manifestations may be numerous and varied.

Suicidal acts begin to appear in adolescence, together with ego development and the development of abstract thinking (Piaget, 1962), as well as sexual maturation and the formulation of the fourth organizer, with its resolution by taking responsibility over one's mature body and its fertility. These developmental paths lead to attempts by the adolescent to cope with issues surrounding his/her own life and death. Conversely, the death instinct originates with the birth of the human being and is an integral part of development, as has been pointed out by Freud (1926) and Klein (1945).

It is important to note that the wish to die and the wish to commit suicide can appear separately or jointly; in the latter case, they reach their full destructive expression. Accordingly, we will focus on the place of these wishes in normal development and the needs fulfilled by them. We will also attempt to determine the line that differentiates the normal from the abnormal, and how to deal with each of these cases as a result of this demarcation.

The Wish to Commit Suicide
Case example. R., a young woman of 21, has been frequently hospitalized in a closed ward over a period of six years. Since she was 14, R. has attempted suicide repeatedly, but until now this has not resulted in serious injury. It is important to note that R. worked for a while as a paramedic, so that if she wanted to die she is well acquainted with the necessary means for doing so. R. is extremely intelligent, has never been diagnosed as suffering from a major mental illness, but has borderline personality disorder. Despite this, her life revolves around an axis of suicidal behavior. In her own words, she enjoys playing with death and has developed an addiction to the suicidal act. In conversation, she conveys a feeling of overwhelming emptiness and the constant need for mirroring by others.

This patient uses the object in a sadistic way, but does not break it. Winnicott (1958) discusses the self as an unconscious feeling of continuity, which makes it possible, from day to day and from experience to experience, to feel oneself. In this girl, who has a borderline personality disorder, there is disconnection between times, as well as between experiences, and the "oneness" is injured. Therefore, there are disconnections within the experience of the self.

Unlike Bios (1962), who claimed that during adolescence there is anxiety concerning the separation process, Freud (1926) saw adolescence as rebirth. Rakov (1989) and Tyano (1984) also compared it to rebirth or "Renaissance" (i.e., repeating all the stages of development). This comparison is especially interesting when one remembers the colorful and cruel nature of the historical Renaissance. Sexual maturation and fertility which develop at this age necessitate control over oneself through a renewed examination of values and desires. The end of adolescence parallels the genital stage associated by Freud with two goals: loving and working. The development of the ability to love includes the adaptation (cultivation) of the fantasy of the imaginary child described by Freud (1914). The turning outward to the object is dictated by the need for life as a rejection of narcissistic elements. At this stage there is also the resolution of the conflict between ideal ego/superego through the integration of the ideal ego into the superego. This takes place by means of the solution of the inverted complex, which ties the child to same-sex parent. After the act of mourning for the loss of the narcissistic object, and after processing the experience of the ego's loss of a part of itself, heterosexuality receives its domineering status. Subsequently, the ideal of the self expresses itself by anticipation, the realization of which is becoming possible. This integration can be grasped as a meta-psychological expression of the fourth organizer, the conflict around the maturation of the fertile body, and the conscious decision to live, and to bring life, which is related to it. The difficulty of coping with life is especially great during adolescence due to the fact that this is the age at which identity moratorium occurs. The adolescent finds himself/herself in a time bubble in which he/she is not committed to anything except the formulation of the identity that will accompany him/her through life. When the bubble bursts, the adolescent will have to be the possessor of a clear identity and make major life choices regarding a profession and a mate. In other words, commitment. The fear of commitment is tremendous, and at times there is an attempt to defer it by "freezing" time. According to Colarusso (1979), normal child development is directed toward the formulation of two perceptions, or experiences, of time. On the one hand, there is internal or subjective time, which is also called "maternal time." This time has no meaning in the outer world and measures internal changes and experiences only. This conception of time exists from earliest childhood and is regulated by homeostatic mechanisms and feelings of satisfaction and frustration (e.g., satiation as opposed to hunger). On the other hand, there is external or objective time, which is also called "paternal time." This time is regulated by the laws of external reality and the time frames that measure it. Paternal time begins to develop with the formulation of the conception of reality, the determination of the object, and the development of linguistic concepts such as "tomorrow, today, soon, when." Therefore, the conception of reality in childhood is dynamic, and involves a merging of these two times.

In adolescence, paternal time is established by drawing a sharp distinction between the physically and sexually immature past and the mature present. There is the danger of an internal split between the two types of time. With time diffusion, one timekeeping mechanism (paternal time) continues to advance, while the other (maternal time) can be frozen, or can move in different directions, since the reality of time and space do not apply. The process of adjustment to time is painful, and in Colarusso's opinion, expresses a true intrapsychic conflict. On one side, there is the need and desire to get used to time and, on the other, there is an attempt to suspend the associated pain. The greater the pressures to which the adolescent is subjected, or the more sensitive he/she is, the greater the danger of a split between the time frames and the greater the fixation on the conflict. It should be noted that in psychotic patients, and more specifically in melancholic patients, paternal time loses its meaning.

Vincent (1988) describes three developmental positions in adolescence: chaos, narcissistic depression, and renewed cathexis of the object. Tyano (1998) and Vincent (1988) state that the transition between these three positions is liable to involve a great amount of pain, which may result in a crisis. One of the factors that allows one to cope with this pain is the decision to live. In our opinion, during the transition from the first to the second position, every individual unconsciously undergoes the struggle with the question of whether to live or not to live. This struggle thus takes on the status of a normative stage, in which the question is posed and coped with unconsciously, as the adolescent forms an identity. During this process, the adolescent asks himself/herself about the significance of life--brought sharply into focus by a tendency toward philosophical thinking and the preoccupation with abstract questions characteristic of this age. The adolescent, who has previously thought about death in general, realizes for the first time that his/her own life is going to end at some point (Piaget, 1962). This is a new and final stage in the development of one's own death conceptualization.

The fourth organizer usually develops without any disturbances or behavioral manifestations. However, some adolescents, with latent pathology from childhood, may experience certain difficulties, which can have mild, moderate, or severe manifestations according to the degree or nature of the pathology.

The mild manifestations of this organization disorder occur in adolescents who experience pain during the transition from one position to the next. This pain leaves them with emotional scars. In such cases, the question of choosing life ascends more and more into consciousness and the process ceases to be normative. These are the adolescents who suffer from suicidal ideation.

In moderate manifestations, the adolescent may turn to the use of drugs, alcohol, or to what is termed by Nicolas (1980) as Les conduites ordaliques (gambling-on-life behavior), such as driving recklessly. All of these behaviors indicate a preoccupation with the struggle over the question of whether to live or die, or leaving it to fate. These acts, in which an individual may flirt with death, offer a sense of excitement.

Adolescents with severe manifestations turn to suicidal acts which, during adolescence, take on specific significance. These acts express the desire to be "temporarily" absent; in other words, to freeze external time, while carrying on with internal time. This process allows adolescents simultaneously to avoid external pain and to stop the maturation process. As this act of attempting suicide has, dynamically speaking, its pleasure principle (i.e., enjoying victory over death by staying alive), approximately 40% of these adolescents will make additional attempts and become "suicide addicts."

The failure of the fourth organizer process is expressed by the ultimate acting out, which is the decision about suicide that results in death. The suicidal act is carried out, whether its purpose is to soothe the pain or to stop the natural processes (since it will indeed stop growth), or whether its source is an inability to internalize the sexual body. The act is the expression, in a language adolescents create for themselves, of the place in which death and suicide are connected. Even if the death wish itself is not the main motive, it nevertheless exists beneath the surface. The adolescent thus chooses a pathological and destructive solution out of a sense of incapacity and a lack of power to choose life. In these cases, suicide connects with depression, so that suicide becomes the means to express depression.

In many senses, an especially beautiful literary expression of suicide that does not involve the death wish is in The Little Prince. The suicidal act of the Little Prince is performed out of love of life but is caused by him losing his way. The Little Prince is a figure who descended from a star  where everything is innocent and has endless possibilities. Adult rules, expressed in terms of time and space, enter his world of eternal childhood, and the Little Prince can no longer find his place in this world. As a result, he asks the snake to bite him, so that he can return to his star. Without having a particular death wish, but with a perception of prolonged sadness (while watching the sunset), he returns to the place where maternal time reigns.
- Manor, Iris, Vincent, Michel, Tyano, Sam, Adolescence, Summer2004, Vol. 39, Issue 154
The article above contains foundational information. Articles below contain optional updates.

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Personal Reflection Exercise #9
The preceding section contained information about the wish to die and the wish to commit suicide in the adolescent.  Write three case study examples regarding how you might use the content of this section in your practice.

Online Continuing Education QUESTION 23
Although for many years there has been an assumed connection between suicide and psychosis, resulting in the practice of placing adolescents who attempted suicide in hospital psychiatric wards for observation or treatment, what did Manor’s article note about this treatment approach? Record the letter of the correct answer the CEU Answer Booklet.

 
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