The burden to convince suicidal, alcohol(Drug information on alcohol) and drug-addicted adolescents to return for the next session is a crucial clinical challenge. A simultaneous goal would be to persuade the adolescent to begin not only to trust but also to believe that the credentialed professional possesses the power to force him or her to cease all drug-related activities.
Initially, there can be no therapeutic continuity because self-annihilative adolescents are volatile. It becomes difficult to formulate intermediate or long-term psychotherapeutic goals, other than survival. Treatment difficulties may be further compounded in the case of gifted, self-destructive adolescents exiled by their families for disrespectful and illicit behavior, expelled from high school or college, devastated by the loss of a significant relationship, and/or subjected to legal consequences or assaulted by drug associates.
A Model of Protection
It is important not only to define therapeutic limits but also to enforce them by using an active crisis intervention model that protects the adolescent from harm. A direct crisis-intervention approach assumes suicide can be prevented; otherwise, inpatient treatment must be sought.
Sometimes, at-risk adolescents miss a session to test limits. Sometimes, they arrive intoxicated, creating an immediate treatment crisis that needs to be resolved. The therapist must decide whether to cancel the session or continue. If, however, the therapist decides to continue the meeting, the implicit message can be condonement of confirmed drug abuse.
Issues of Confidentiality
Confidentiality is an important issue. The psychotherapist needs to inform the youth there will be disclosure to third parties when there is a threat of personal harm or violence. Shneidman recommends a kind of "modification of...confidentiality" since the therapist cannot be allied with death. Statements given during the therapy session relating to the patient's overt suicidal (or homicidal) plans are not "a secret between two collusive partners." A written agreement can clearly detail the therapist's policy about confidentiality and disclosure. For instance, my agreement with patients reads:
Our relationship is confidential, protected by the ethics of the American Psychological Association and statutes of Massachusetts. There are, however, three exceptions when I have a moral and legal duty to inform others: when you (1) discuss your intent to harm someone; (2) inform me you consider hurting yourself; and (3) describe a future illicit act. While your interests and welfare are my primary concerns, when believing you want to hurt yourself or others, I will intervene. Please sign signifying you understand the three provisions stated herein. If you cannot agree to this arrangement, then it makes sense for you to work with someone else. If you violate this contact by not discussing your behavior with me before you act, I reserve the right to terminate our relationship.
In my three-and-a-half decades of working with gifted, self-destructive, drug-dependent adolescents, I have not seen them discuss future self-destructive or illegal acts unless they want to be restrained. Their disclosure, therefore, can be interpreted to be a plea for external control. A firm, rational discourse provides reassurance that there will be limit-setting to the healthy part of the adolescent that wants to live.
Robinson believes working with families in an outpatient setting to be "important, particularly when the child's suicidal state is reactive to inappropriate parental behavior" that explicitly suggests disclosing information about self-destructive acts. Parents have the ultimate responsibility to protect their children from self-harm. The psychotherapist who does not attempt to elicit external assistance for self-destructive behavior could be accused of not trying every resource to contain the adolescent's self-destructive behavior. By helping the youth gain the resolve to control and curtail such behavior, the psychotherapist is placed in a position of parental surrogate. Bonding occurs concurrently with therapeutic interventions to limit potentially explosive self-hatred, shame, devastation and rage, because the therapist becomes the "good parent" who protects the adolescent from self-harm.
Sometimes the family of the suicidal adolescent is so dysfunctional it may not be possible to include members as part of the treatment team. Leenas and Lester urge caution involving the family, saying "the system is often inflexible. Denial, secretiveness and especially a lack of communication are seen."
During the course of therapy with suicide-prone adolescents, the therapeutic mandate is to maximize the chances of survival. Any neglect of that task will appear to the patient to be the ultimate irresponsible, noncaring act.
Working with impulsive adolescents who engage in death-defying behavior runs contrary to Szasz's advice "not to show that you are humane, that you care for [the patient]...Your sole responsibility is to analyze him." Wachtel presents a more moderate view of therapeutic neutrality which is designed "to assure that we do not muddy the waters of transference...We are always observing something that occurs in relation to us, and not just to us as screens or phantoms, but to us as...flesh-and-blood human beings sitting in the consultation room."