The wish to die and the wish to commit suicide in the adolescent: two different matters?

Adolescence, Summer, 2004 by Iris Manor, Michel Vincent, Sam Tyano

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 made 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.

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 Blos (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.