Adolescents are among the most difficult populations with whom to work therapeutically. Giovacchini (1985) wrote that they possess a "propensity for creating problems within the treatment setting [including]...their reticence about becoming engaged or their inclination to express themselves through action rather than words and feelings."
Only a minuscule number of psychotherapists opt to work with these patients, whose problems may be giftedness, drug-dependence and/or self-destructive tendencies, up to and including suicide. Meeks and Bernet write that "the drama and finality of suicide conspire with the personality traits of suicidal youngsters to make treating the suicidal adolescent one of the psychotherapist's most exacting experiences."
There are two unalterable clinical realities working with suicidal adolescents. Rule One: Some will die of drug overdoses, commit suicide or be murdered. Rule Two: There will be cases when concerned clinicians cannot change Rule One.
Not infrequently, suicides occur in inpatient psychiatric programs having 24-hour surveillance. Maltsberger (1992, 1986) offers a partial explanation of why work with these adolescents cannot always be successful when he concludes that no test exists and no single variable exists to predict suicide. Kernberg urges the psychotherapist to "assess the degree of hopelessness...[that] plays a most important role as a predictor of risk [when the therapist experiences] a sense of pessimism about the treatment and about the patient, and his/her own therapeutic skills."
Samorajczyk writes that alienated youngsters "want to know where the limits are—and that someone gives a damn" to guide them in their search for what is expected of them. When there is fear that the adolescent is out of control and might harm him/herself, most psychotherapists and psychoanalysts, choosing not to become more humanistic, active-directive and pragmatic, will be impotent in providing the limit-setting that suicidal adolescents desperately need.
Since suicidal, drug-dependent adolescents engage in illicit behavior, they trust no one. Initially, the therapist is viewed to be a formidable foe who possesses the power either to force them to terminate pleasurable drug-induced euphoria or to incarcerate them.
While describing working with suicidal adolescents, Jobes contends a negative transference dynamic exists because "the clinician is...seen as a member of the...generation from which the adolescent seeks autonomy, and a teen's associations [with] seeing a 'doctor' or a 'shrink' may have a long history that can be antagonistic to the kind of relationship needed for good treatment."
Until the therapist accepts the mandate to prove personal credibility, alienated adolescents neither will like nor trust the therapist who becomes a target for their unmitigated hostility and sarcasm. To protect themselves from being wounded, such adolescents often project an antagonistic, obnoxious attitude before acquiescing to treatment.
Early Sessions: Limit-Setting
Limit-setting forms the basis of the therapeutic alliance during the first month. Masterson maintains it is "impossible to wait for a relationship to be established before starting to set limits...as early as possible, [which] is the unique means of establishing the therapeutic alliance and...is the very gesture of caring the patient hungers for."
The therapist can have no ambivalence in a life-or-death crisis. Any hesitation can be fatal. Until the adolescent fears intervention by the treatment agent or feels hope for the diminution of pain often caused by impulsive acts, he or she will have no incentive to change. Initially, the clinical challenge is to decrease life-threatening behavior by enforcing compliance, which makes therapy tumultuous.
During the potentially lethal phase of treatment when the adolescent is out of control, the psychotherapist needs to be decisive to decrease the possibility of impulsive, annihilative suicidal acts. Desperate, often heroic limit-setting therapeutic strategies are necessary. The most controversial point in the treatment relationship occurs when the psychotherapist imposes him- or herself as the central figure by determining therapeutic limits.
Understandably, most psychotherapists are uncomfortable with this treatment orientation, but given the special clinical challenges of suicidal adolescents, this is not negotiable during the beginning phase of treatment. It becomes the sine qua non of therapeutic behavior necessary to maximize survival. Schneidman states:
The way to save a suicidal person is to cater to that individual's infantile and realistic idiosyncratic needs. The suicide therapist should, in addition to other roles, act as an existential social worker, a practical person knowledgeable about realistic resources. The therapist needs to work diligently, always giving the suicidal person realistic transfusions of hope, until the perturbation intensity subsides enough to reduce the lethality to a tolerable, life-permitting level.
Maintaining a Presence
Working with self-destructive or suicidal adolescents whose crises occur at times other than appointments can create scheduling problems by necessitating missing sessions with others and disrupting one's personal life. When the therapist vacations, continued communication and continuity are crucial, as Motto points out, "to maintain the psychological sense of 'presence'...to demonstrate...[that] the therapist's concern for the young person is not limited...One of the most common circumstances for suicidal acting out is when the therapist is away...[because] it can so easily stir the fears and feelings of abandonment that generate suicidal impulses."
Unless the therapist is prepared to make personal sacrifices by being accessible, by talking on the phone, scheduling extra sessions and, in extreme cases, visiting the adolescent in the community, this treatment population needs to be avoided. Until the crises abate, accessibility is required on a 24-hour, seven-day-a-week basis.
When anticipating being inaccessible, if possible, the psychotherapist needs to introduce the adolescent to the covering professional and make provisions to be reached by phone either by providing a number or arranging for notification through the answering service should a potential emergency or crisis arise. It needs to be stressed that survival of the adolescent precedes transference-countertransference issues.