Guidelines for Clinicians Working with Gifted, Suicidal Adolescents

Reactions to Death

Undeniably, suicide is an occupational hazard which confronts the psychotherapist who works with self-destructive adolescents. Goldstein and Buongiorno interviewed 20 psychotherapists who had patients commit suicide and reported that the therapists were permanently affected in two ways: first, the experience remained vividly in their minds; second, they tended to no longer minimize suicidal behavior, attempts and gestures.

Giovacchini (1992) further suggests that adolescents can provoke disruptive countertransference reactions, because "the intensity of their neediness and defiance may completely dominate the therapeutic setting and disrupt the orderly course of treatment...Countertransference may destroy the treatment relationship or it may lead to therapeutically beneficial insights."

My reaction to the death of an adolescent, whether by an act of suicide or homicide, is profound self-condemnation. I curse my ignorance, impotence and incompetence any or all of which may have contributed to death.

While painful and humbling, any ex post facto investigation not only purges guilt, but also enables the therapist to devise strategies that may be utilized in other life-threatening crises. Winnicott suggests, "If an analyst is to analyze psychotics or antisocials, he must be able to be so thoroughly aware of the countertransference that he can sort out and study his objective reactions to the patient. These will include hate."

The "adoptive process" in the residential treatment of adolescents has been viewed as the acting out of a rescue fantasy on the part of professionals who have not resolved their adolescent conflicts or who seek to become parental surrogates due to unfulfilled personal needs (Palmer and colleagues).

Shay attributes the need to rescue to an unforgotten, unresolved countertransferential reaction:

 

When we were teens, many of us were concerned with where we stood with our peers...With our newfound sexual yearnings, many of us had the developmentally appropriate wish to...be adored...As we aged, we made peace with these needs as we shaped our identities, found groups to include us, found significant others to love us...The wish to belong, the yearning to be admired, the need to feel loved are frequently revived by our...patients who live these issues passionately every day...To borrow a phrase, "We have met the adolescent, and he is us." If one accepts this notion of an inherent over-identification with our adolescent patients, then the countertransference wish to rescue them is...comprehensible. It is something like the Golden Rule of Countertransference: Rescue others as you would have liked to be rescued yourself.

Certainly, the rescue pattern plays a part in my life. My recurring dream has been described best by J.D. Salinger in The Catcher in the Rye when he wrote about Holden's fantasy preoccupation:

I keep picturing all these little kids playing some game in this big field of rye and all. Thousands of little kids, and nobody's around-nobody big, I mean-except me. And I'm standing on the edge of some crazy cliff. What I have to do. I have to catch everybody if they start to go over the cliff-I mean if they're running and they don't look where they're going. I have to come out from somewhere and catch them. That's all I'd do all day. I'd just be the catcher in the rye and all. I know it's crazy, but that's the only thing I'd really like to be.

For me, the clinical challenge is to prevent the adolescent from falling over the "crazy cliff" that symbolizes destruction and death. I dread thinking about those who committed suicide or were murdered. It has proven beneficial, in retrospect, because I have the courage and resilience to examine what I could have done differently. I have strength to remain involved with those self-destructive, drug-dependent adolescents with whom I struggle to help to survive.

Psychotherapists who do not dream about rescue fantasies need to disqualify themselves from working with gifted, suicidal, drug-dependent adolescents because, without heroic therapeutic intervention, the probability of injury and death is increased significantly with intervention.

 

The Adolescent and Self-Respect

There can be no finer reward than trying to help an adolescent reclaim his or her life by regaining self-respect, a primary psychotherapeutic goal. Bratter and others (1995) describe a therapeutic definition of self-respect which stresses: the concept of choice based on humanistic values that include concern for others and a sense of social responsibility, honesty and the integrity to be assertive. The adolescent needs to behave in a congruent way to achieve immediate to long-term personal-professional goals without depriving others of their rights.

 

Saying Good-Bye

Perhaps one of the most crucial developmental tasks of self-respect is to help the adolescent terminate the bonds of dependency and become autonomous. "Setting free" means free to terminate the treatment relationship with no pressure either to return or to be grateful. Saying good-bye can be liberating, but the adolescent retains the option to correspond or communicate periodically. This can be encouraged provided it primarily satisfies the needs of the adolescent, not those of the therapist.

The termination is similar to all treatment relationships with adolescents. Should the psychotherapist encounter difficulty or feel entitled to continue the relationship, this needs to be resolved because it signals a countertransference problem exists. The adolescent does not owe the psychotherapist anything.