Self-Destruction and Countertransference Reactions in Adolescent Psychotherapy: a Psychoanalytic Case Report

Journal of Psychology & Clinical Psychiatry Self-Destruction and Countertransference Reactions in Adolescent Psychotherapy: A Psychoanalytic Case Report Abstract Case Report Self-destruction behaviors in adolescents constitute a serious mental health problem. Several psychoanalysts and psychodynamic theorists have long attempted Volume 1 Issue 3 - 2014 to understand the desire of self-destruction. Suicidal adolescents often elicit strong George Giannakopoulos*, Kalliopi Triantafyllou and Stylianos countertransference reactions from therapists. These reactions fluctuate from the Christogiorgos throughbelief that of therepresentations therapist should and beemotions the perfect produced object by that the will patient relieve in the sufferinganalyst’s mindteenager facilitates to the openlyfurther hostile understanding stance by theof transferencetherapist. The phenomena. awareness andThe working- present Department of Child Psychiatry, University of Athens Medical School, Greece psychoanalytic case report of a suicidal adolescent tries to illustrate some aspects of *Corresponding author: to the diagnostic access and the treatment of adolescents after a suicide attempt. Department of Child Psychiatry, University of Athens these complex reactions. The psychodynamic approaches can contribute significantly Medical School, Aghia Sophia Children’sGeorge Giannakopoulos, Hospital, Keywords Thivon and Papadiamantopoulou 11527 Athens, Greece, Tel: 0030210747381; Fax: 0030210747381; Email: Adolescence; Countertransference; Psychoanalytic psychotherapy; Suicide attempt [email protected]: June 23, 2014 | Published: July 11, 2014 Introduction Self-destruction behaviors in adolescents constitute a serious mental health problem, with approximately 80% of suicidal when the ego is in so really great danger that it feels unable to thoughts and attempts present in adolescents struggling with a overcomerescue function alone, that it sees before itself was as fulfilleddeserted by by the all mother. protective However, forces psychiatric disorder [1,2]. Depression, substance use, borderline and left to die. Additionally, Fenichel [13] suggested that the personality traits and dissociative symptoms or disorders ego either submits to the protecting aspects of the superego for forgiveness and reconciliation, or the ego expresses rebellious destruction behaviors in empirical studies with adolescents [3,4]. rage against the superego and wishes to destroy it. Inhave fact, been some identified empirically-tested as the major models proximal propose risk factors that although for self- Within a relational context, the aggression toward the self substance use, borderline or dissociative symptoms are used as defenses against painful affects, they eventually facilitate self- that have been lost or have threatened to leave and serves to destruction thoughts or acting out through the enhancement of restorerepresents a threatened an act of relationship retaliatory viaabandonment repentant self-punishmentagainst objects impulsivity, affect dysregulation, splitting of the self and others, [14,15]. Kohut [16] studied the process of collapse of self that numbing of consciousness, depersonalization, and derealization leads to suicide. He wrote that the suicidal patients have not [5]. Several psychoanalysts and psychodynamic theorists have and that leads to a poorly developed sense of self. When others long attempted to understand the desire of self-destruction. adequately satisfied the narcissistic needs during development Freud [6] considered suicide as a form of aggression associated person experiences a deep sense of loss, a threat to its integrity with others and directed toward oneself. He argued that the ego andare frustrated, a deep, unbearable, the result isdisruptive a narcissistic anxiety. injury In throughhis megalomania, which the the suicidal patient believes that suicide is a means to escape from this intense discomfort and a means to control or defeat can kill itself only if it can treat it as an object - when it can direct death. Self-destruction then constitutes a reaction to narcissistic against itself the hostility which is associated with an object and rage, shame or other forms of aversive self-awareness [17]. andwhich the represents ego becomes the the ego’s target original of aggressive reaction wishes. to objects Thus, inFreud the external world. The lost or disappointing object is identified with considered by Freud [7] as a manifestation of the death instinct Object relations theorists regard self-destruction as an linked suicide to sadism redirected toward the self. Sadism was or the instinct of mastery, the desire to dominate and control attempt, in fantasy, to destroy bad internal objects – introjects – or undesirable aspects of the self [18]. Klein [19] argued that been supported by a recent empirical study in a nonclinical [20,21]suicide isclaimed not only that the suicide symbolic involved death of a thefantasy evil object, of destroying but also bad the samplethe object showing [8-10]. that Indeed, sadistic the traits role ofexplained sadism turnedunique inwardvariance has in aspectsmaintenance of the of self the with bonds the with remainder its beloved of the object. self surviving,Also, Winnicott or as suicidality among adolescents [11]. Freud [12] later in his writings a destruction the entire self when the true self is threatened with proposed that the superego fulfills the same protection and Submit Manuscript | http://medcraveonline.com J Psychol Clin Psychiatry 2014, 1(3): 00019 Copyright: Self-Destruction and Countertransference Reactions in Adolescent Psychotherapy: A Psychoanalytic Case 2/5 Report 2014 Giannakopoulos et al. exploitation or annihilation. Suicidal individuals often evidence Case Presentation Treatment of Phoebus, a 14 year old boy, started with a few positive soothing introjects and poorly integrated hostile introjects, and they enact interpersonally and project these frequency of once a week shortly after his hospitalization due pathological internal object relations [22,23]. A common type of incidents at school where he felt that the others (students and to a suicidal attempt by taking pills. He took the pills after some object relationship with these patients, projective identification, teachers) underestimate him and scorn him. He wanted to see the fantasy of ridding oneself of an unwanted part of the self and how the others will react to him if they realize that he feels can be conceptualized as a process involving three phases: first, of putting that part into another person in a controlling way; then terrible. He had previously written a letter to his parents and there is a pressure exerted by means of interpersonal interaction familyhad asked that that there it beis noread danger publicly. to hisImmediately life and health, after taking Phoebus’ the such that the recipient of the projection experiences pressure to drug he was terrified. When the hospital doctors assured the afterthink, beingfeel, and psychologically behave in a manner processed congruent by thewith recipient the projection; [24]. destruction attempt. He felt that it was an extremely successful finally, the projected feelings are reinternalized by the projector, wayspeech to becomebecame famousalmost triumphantat school and when proof talking that he about could the defeat self- Empirical studies that aimed at testing the object-relational attention. In fact, they left him alone during the second night in suicidalview of suicidalbehavior behavior than self-targeted concluded anger, that object-loss maladaptive (i.e. defenses a more death. Both parents say they were not shocked; he did it to attract significant history of past and recent losses) could better explain independent. the hospital on the excuse that they wanted to make him feel or primitiveFrom an object ego representationsfunctioning theoretical [25,26]. perspective, King and Apter [27] described three common themes that occur in year before the suicide attempt. The episode started six months Phoebus had experienced a major depressive episode for a adolescents after a suicide attempt. First, adolescents who have after the death of his maternal grandmother but the symptoms attempted suicide perceive their parents as indifferent to their (mainly the loss of pleasure, weight gain, ideas of worthlessness and decreased concentration) deteriorated in the last quarter adolescents do not have an adequate capability for self-relief before the attempt. physical existence and extremely judgmental. Second, suicidal or tolerance of painful feelings. According to Freud [28], this is Phoebus was tall and overweight. He was the only child of the family and was borne after many traumatic attempts of assisted reproduction. A year before getting pregnant in Phoebus, the indicative of deficient internalized objects that are incapable to a persecutory component through which the inconsolable self is mother miscarried in the 7th month of pregnancy due to a very provide relief. Moreover, the internalized indifferent object has rare complication. While carrying Phoebus, the mother showed of self-care is associated with a tendency to depression. In these extreme anxiety from the 7th month; she feared the baby would experienced as evil and deserving punishment. Third, the lack cases the adolescent is vulnerable to suicidal impulses due to an die so the gynecologist gave her a portable cardiotocograph to extremely strict superego that punishes him for failing to reach his expectations.

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