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

Section 24
Teen Suicide Intervention: Eternity & Annihilation Anxiety

CEU Question 24 | CEU Test | Table of Contents | Crisis CEU Courses
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The Wish to Die
Particularly since the appearance of television in our lives, which routinely discloses the latest traffic accidents, disasters, diseases, wars and terror, death has become a permanent visitor in our living rooms, even if we do not rub shoulders with it in our private lives. Death has become so familiar that it is almost approachable. Unlike suicide, with its frightening suddenness, death is usually experienced as something sad but inevitable. As Camus (1947) has said, "We are all condemned to death, but do not know our hour of execution." At the same time, death has been considered something exalted, as can be seen in the mystification surrounding it. In Mortal Questions, Nagel (1979) asks, in the chapter "Death," whether it is a good or a bad thing. Others see death as a constraint throughout life, influencing everything we do. In general, death is perceived as the final reward--a state of absolute rest. There remains the question of where, deep within us, is the source of the thoughts, impulses, and fantasies surrounding death.

The term "death instinct" first appeared in Freud's (1920) essay "Beyond the Pleasure Principle" and recurred throughout his work. This term remains one of the most frequently discussed to this day. In this context, it is important to understand the development of Freud's thinking. Freud describes the interplay of the life instinct and the death instinct (Eros-Thanatos). It is possible to observe the working of the pure death instinct when it is detached from the life instinct, as, for example, in the case of the melancholic patient in which the superego appears as "a pure culture of the death instinct." According to Freud, suicide is an unresolved problem. How is it possible that an individual can overcome the all-powerful life instinct? Is this a case of disappointed libido or an ego that has become alienated from its own preservation out of its own egoistic motives? Freud suggests that we have no way of answering these questions, other than from the starting point of melancholy and the comparison between it and the effect of mourning. In his essay "On Mourning and Melancholia," Freud (1917) claims that, as opposed to mourning, a process which is a part of growth, melancholy is the unconscious loss of the object which causes reproach. Self reproach is, in fact, an attack against the object. Within every experience of mourning, guilt feelings can be found about what was done and not done, while melancholy is a desperate struggle for survival in the face of annihilation anxiety, and deprives the ego because of the object. In comparison, the ego integrates qualities of the lost object in the mourning process. In fact, the mourning is not for the missing object, but for earlier losses for which it is impossible to mourn, as acknowledging this will cause annihilation. The gap between mourning and melancholy exists because, in mourning, the world becomes empty, whereas, in melancholy, there is an emptying of the self. Accordingly, the decrease in self-esteem differentiates melancholy from mourning. Freud states that at the root of melancholy there is disappointment caused by the beloved object and the undermining or shattering of the relationship with the object. Thus, Freud refers to suicide as the killing of the self, which contains within it the internalized image that the individual actually wishes to destroy. In "The Ego and the Id," Freud (1923) expands on the psychological roots of the death instinct and relates the striving for decomposition and the bursting forth of the death instinct as central expressions of many severe neuroses. Continuing Freud's ideas, and following Klein, Segal (1964) points out that manifestations of the various instincts exist from birth. The mother displays to the infant the whole spectrum, from vitality and eagerness to live, to emptiness, boredom, and inner death. The infant reacts to the mother, as is shown in "The Dead Mother" (Green, 1986), and, through her, experiences these himself/ herself.

With these first perceptions, two possibilities exist for the infant. One is satisfaction of the need, epitomized by the search for the object, love and the expression of the life instinct; the second is the obliteration of the need, in other words the expression of the death instinct. The infant may feel vital and acquires an eagerness to live, as well as sensitivity to different stimuli, from within and from without. Alternatively, the infant may feel empty, a complete vacuum which can never be filled. This perception is total in those babies described by Spitz (1965) as anaclitically depressed.

Freud describes the expressions of the death principle as the compulsive repetition, sadomasochism and murderous wish of the melancholic superego--that same murderous wish which causes suicide. One must stress the importance of aggression, the means by which the organism protects itself against the death instinct, but which also allows aggression to reach expression via its deflection from the psyche onto an object. The death instinct unties the object relations, and the life instinct reties them. Freud (1917) speaks of the silent working of the death instinct, which is constantly involved in the libido and is, thereby, turned outward.

Klein (1945) refers to the death instinct in relation to the development of both anxiety and guilt. In her opinion, both the death instinct and envy have a central characteristic in common, which is an attack on life and its origins. She claims that jealousy is the extreme expression of the death instinct. Early jealousy is covered by the death instinct and there is an intimate connection between them, since the object supplying the need is also perceived as an irritant, requiring removal. At the same time, the object is the creator of the need and is capable of removing the irritation. As a result, hatred and envy are directed toward it. Annihilation allows an expression of the death instinct, but is also a defense against envy, in that it removes the cause of the irritation. Similarly, in Segars (1964) opinion, the defenses against the death instinct create a vicious circle that leads to severe pathologies. As previously mentioned, a later description that differs slightly but is also based on the experience of the death instinct as one of deprivation and emptiness is provided by Green (1986). Green describes the sense of internal emptiness and depression emanating from a patient who was the child of a "dead mother." According to Green's interpretation, the feeling of loss begins with the image of the mourning, "empty" mother, the "dead mother," who is also absent, thus awakening at the core of the infant's existence the feeling of deprivation in the place where her image should have been. Green states that this image binds the infant to a great extent, as an attempt is made to awaken the mother from death. The analyst senses a source of childhood depression, but the patient denies its existence. This depression bursts forth in transference. In addition, Green describes classic neurotic symptoms. Although they are also presented as central, the analyst gets the feeling that their solution will not reconcile the conflict. After attempts at simulated acceptance and agitation fail, the infant turns to mirror identification with the dead mother. The purpose is to achieve ownership over the object, which is impossible because it is not in the infant's jurisdiction, and is accomplished by turning into the object itself, via incorporation (Abraham, 1977) and by achieving narcissistic identification (Freud, 1914). This unconscious identification appears as a foreign body within the ego. Due to its origin in an early part of development, the perception of death extends over a wide range of human existence, in terms of time and norms. The preoccupation with death has its origin in areas defined as normal, and extends into areas of trauma, personality disorders and deprivations. It is important to stress that since the wish to die is the desire "not to exist any more to eternity," it is directly connected to depressive tendencies, which may have already appeared in childhood (seven years old and onwards, if not earlier). In the same way that the infant deprived of love and warmth turns to the wall and withdraws from all human contact (Spitz, 1965), the individual experiencing early frustration is attracted more and more to the embrace of the death experience. Described in literature as a black ocean having no borders, or as a white shining space, the death experience allows the person suffering from early deprivation an illusion of compensation, of an endlessly satisfying wellspring.

Regarding adolescents, the question arises as to whether the preoccupation with death represents, in addition, an exercise in abstract thinking (i.e., a form of experimentation with newly acquired cognitive tools in relation to such a fascinating subject). In light of all this, one might ask if the wish to die is dependent on age. It seems that this wish is, in fact, capable of encompassing all ages, while the amount of yearning after death depends on the degree of early deprivation.

Case example. H., a 13-year-old girl, behaves in her daily life like any teenager. Nevertheless, she suffers constantly from bodily pains, especially in the stomach and head, and has recently developed an eating disorder. However, she "looks after herself' and has suffered no drastic weight loss in the last year; in fact, her weight is quite stable. She has many girlfriends and a normal social life, is a good student, and is an accepted member of her school and community. For the past four years, she has been constantly preoccupied with thoughts about death. There has never been talk of suicide and definitely no suicidal act, and she denies all conscious desire to die. On the other hand, death appears in the poems she writes and also in her dreams. An example of a dream: H. is walking with a group of children when a monster begins chasing them. They run into a house, while on the roofs of other houses there are flashing red lights that H. interprets as the souls of dead children. Two children from the group are killed, so H. is aware that all of them will die. They climb up onto the roof and jump to their death. This dream may be seen as the convergence of depression and paranoia. The narcissistic offense experienced by H. is shown through the pathological conflict of the leading neurosis in the background. The monster may be interpreted as the bad object described by Klein, and as a threatening paternal ghost chasing the living children, as well as the dead children. It is the mixing of the sexual implications of the father for his adolescent (and admiring) daughter and the threat of, as well as the longing for, death accompanying the family, especially the children born after H. It is the interpretation of the fulfillment of sexual drives which implies that death and libido and death instinct are one and the same in that family, as in H.'s subjective universe.

In the course of psychotherapy the central perception is that of depression, although without the components characterizing major depression. There is, rather, an awakening of an experience of great emptiness. The negation experienced by H. is reflected in the emptiness and the perception of "nil," which is in the center all the time: no laughter, no words, no suffering, but also no life.

The wish to die arises with the awakening of life, whereas suicidal tendencies develop ten years later or more, during adolescence. Adolescence is the age in which the wish to die begins to acquire a quality of suicidal expression that becomes possible through puberty. This comes in addition to other expressions that existed beforehand, such as anaclitic depression, thoughts and fears about death. The wish to die and the wish to commit suicide can be conjoined in the final suicidal act, but they are also liable to develop from totally different sources, in time (both paternal and maternal) and in the underground currents that cause them to ripen.

Religion, which records the development of abstract thinking, differentiates between death and suicide. Death is regarded by all religions as an integral part of life. It is another form of existence (see, for example, the descriptions of heaven and hell). Suicide is forbidden by some religions and is considered by others to be an elevated or saintly act. Thus, at the foundation of organized human thought about morality, there is a clear distinction between death and suicide. The explanation for this may lie in the fact that death is a natural phenomenon, whereas suicide is unnatural and is therefore considered an act of defiance against fate. In other words, suicide is considered to be a tragic act which takes control of the life and death "'button" -- the assuming of a God-like role.

The idea of death is liable to be frightening, as it may represent disappearance, dissolution, a total loss of everything one is and everything one was. Nonetheless, the experience of eternity is liable to be no less terrifying. Especially in the eyes of the adolescent, the significance of eternity is that whatever is determined will remain fixed "forever." Specifically, the decisions the adolescent will make at the end of maturation will be fixed, unchanging and eternal. As a result, the choice of life and the eternity it promises is also difficult and frightening.

In the past, adolescence was relatively brief, dictated by the need for survival, which created strict behavioral codes. Those who did not go out to work in the fields were doomed to die of starvation; marriage came early because life expectancy was short and many children died in infancy. As a result, while the adolescent often suffered from a sense of insignificance and helplessness, there was a feeling of reassuring security in knowing life's limits. During the twentieth century, expanded freedom meant fewer of those limits which, in the past, provided a measure of comfort. In addition, the identity development stage of moratorium became extended. As part of the lengthy moratorium, the dilemma surrounding sexual maturation increased. The adolescent is supposed to internalize his/her sexual body (Laufer 1968), and the failure to do so results in arrested development. Complications can lead the adolescent to try to stop the body's development (as in anorexia) by its destruction. The ever-widening gap between biological, hormonal reality and internal, psychological reality magnifies the need to freeze time or to sever relations between its external and internal manifestations; in other words, death is the preferred choice.

The process of mourning surrounding death expresses the distress and ambiguity regarding it. On the one hand, there is loss and anxiety in the face of annihilation, stemming from emptiness and a sense of guilt. On the other hand, mourning is also a protest against death, a sharpening, as Heidegger says, of daily existence in light of it.

Annihilation anxiety is also the fear of following the deceased loved one. In the story of Orpheus and Eurydice, the live groom tries to bring his dead bride back from the underworld. Orpheus is warned that if he attempts it again, he will not be allowed to leave the underworld. Segal (1964) describes a psychic pain involving the expression of the death instinct. In Segal's opinion, this pain stems from the threatened libidinal ego and expresses annihilation anxiety. Similarly, the purpose of the psychic pain involved in mourning may be to remind the individual of the boundary between life and death, and that he/she is still alive. According to Freud (1917), the melancholic patient is incapable of mourning due to the fact that the lost object is incorporated; thus, the patient continues to confront it. It could be said that, according to Freud, the melancholic is an Orpheus who is unable to relinquish his loved one and, as a result, cannot abandon the underworld.

Melancholy is not mourning. It does not entail the pain protecting the individual from the death instinct; it does not involve annihilation anxiety and does not require the suicidal act. Although this act demands the power of the libido and examines the border of life, it finds itself in the realm of death from the beginning. In other words, the wish to die is primal. According to the nirvana principle, it grapples with the wish to live and inflames it, and is created together with it, in the early stages of development, and with the fixation of the first organizers. It is liable to appear and find expression at all ages, and adolescence has no special significance for it. In adolescence, the wish to commit suicide may appear together with the wish to die, and can appear as a metamorphosis of the internalization of the sexual body, rejecting the internal parents, who were in charge up until then, and the need to choose life out of responsibility. It is suggested that in children there are no suicidal thoughts, but there is the wish to die, which searches for expression; conversely, suicide in its clinical and psychological meaning appears only in adolescence.

The experience of death is primal (Klein, 1945); accordingly, the wishes it arouses are also primal and the sensations it arouses are all-embracing and lacking in the individuation that has yet to come into existence. Conversely, suicide is individual, touching on questions that are of importance to the individual, such as "Who am I and do I like what I see?" or, "Am I prepared to live as I am? Suicide is situated in a higher place on the developmental ladder because it defines the existence of death as opposed to life, and the control of the human being over death. As a result, the anxiety expressed by suicide is Anxiety in the face of eternity which, in the adolescent's experience, especially if his/her development is abnormal, is sterile, causing a fear of barrenness and boredom.

It is also possible to define the various wishes by means of basic, key questions that direct a way of thinking. In The Little Prince, the suicidal question is: "Can you return me to my star? This question is based on the desire to freeze time, and conveys a sense of not fitting in anywhere and of being a constant stranger whose language is foreign. The true wish is to preserve a special, individual, consistent identity that does not have to compromise with the reality principle (i.e., the adult world).

The question representing the wish to die is unclear, because the sense of death has its origin in a place where language is primal and the power of speech does not yet exist. A question that possibly represents the death wish is, "Where do the ducks go when the lake freezes over?" (The Catcher in the Rye; Salinger, 1951). When the lake, symbolizing the primal oceanic abyss, is frozen, the ducks have to leave. They have no place in any sense of the word. The death experience is a deep, cold deprivation having no pity or remedy, to the point where the only solution is to disappear. It simply is not clear where to go. As opposed to the suicidal question, which represents a wish to return "home" to preserve omnipotence in the changing continuum of time, the wish related to death is an open question. It cannot express a definite demand, but does the opposite: it expresses despair from an existential position that does not allow survival. It is possible that the gap between the wish to commit suicide and the wish to die stems from this. The act of suicide means seeing a way, and for this reason it enables the adolescent to perform an act. The wish to die goes nowhere beyond the sense of apathy (frozenness) and has "no exit," and for this reason it lacks any practical or verbal expression. There is no act that ends the experience, since the inside is frozen, like the lake outside.

From all this stems the need for different therapy for adolescents. Suicidality in this age group should be treated in accordance with the currents hidden beneath the surface of the act. For the adolescent who presents a conflict connected with the fourth organizer, therapy must deal with the difficulty of coping with sexual maturation together with the need to take responsibility for life. Conversely, for the adolescent who expresses the wish to die, therapy is directed at anaclitic depression. The first deep nonverbal deprivation demands prolonged "resuscitation" of the patient, for whom satisfaction of primal oral needs in the deprivation and emptiness formed around them became predatory. On the other hand, therapy for suicide should focus on the processing of special recurrent distinctions. It cannot be emphasized enough that these states are not necessarily "pure"; on the contrary, they are states in which the conflict that appears on the surface "rides" upon deeper needs and deprivations which involve the wish to die. When the wish to die and the suicidal wish combine, the danger of the fatal act is extremely great. In these situations, we are liable to find ourselves beginning treatment of a patient with a suicidal wish, who seems on the surface to have oedipal conflicts. Nevertheless, we will discover beneath this relatively mature facade a wish to die accompanied by uncontrollable oral drives. In the center, we will find a sense of deprivation which is like a black hole. Consequently, treatment of the suicidal wish, with very ambivalent conflicts at its core dealing with growth and the sense of time, is verbal therapy. Conversely, treatment of the wish to die is dynamic experiential therapy, touching the primal experience lacking speech and a sense of time, and at its core is the need to find a lake that does not freeze, that inner lake which will allow the individual to have faith in growth and development.
- Manor, Iris, Vincent, Michel, Tyano, Sam, Adolescence, Summer2004, Vol. 39, Issue 154

Personal Reflection Exercise #10
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.

Peer-Reviewed Journal Article References:
Fox, K. R., Harris, J. A., Wang, S. B., Millner, A. J., Deming, C. A., & Nock, M. K. (2020). Self-Injurious Thoughts and Behaviors Interview—Revised: Development, reliability, and validity. Psychological Assessment, 32(7), 677–689.

Madjar, N., Sarel-Mahlev, E., & Brunstein Klomek, A. (2020). Depression symptoms as mediator between adolescents' sense of loneliness at school and nonsuicidal self-injury behaviors. Crisis: The Journal of Crisis Intervention and Suicide Prevention. Advance online publication.

Till, B., Wild, T. A., Arendt, F., Scherr, S., & Niederkrotenthaler, T. (2018). Associations of tabloid newspaper use with endorsement of suicide myths, suicide-related knowledge, and stigmatizing attitudes toward suicidal individuals. Crisis: The Journal of Crisis Intervention and Suicide Prevention, 39(6), 428–437.

Online Continuing Education QUESTION 24
According to Manor, when does the wish to die arise and when do suicidal tendencies develop? Record the letter of the correct answer the CEU Test.

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