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 the representations therapist should and be emotions the perfect produced object by that the will patient relieve in the suffering analyst’s mindteenager facilitates to the openly further hostile understanding stance by the of transferencetherapist. The phenomena. awareness and The 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 via abandonment repentant self-punishment against 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 be is 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 recipientthe 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 representations functioning 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. Through feelings of depression, the adolescent easily evades situations where he feels inadequate and this thetake lower home end which of the she normal used constantly. weight range In theuntil early the ageyears of 6of and his evasion reinforces the feeling of failure by directing aggressive helife, often Phoebus vomited presented when heeating did notdifficulties want to and eat anywas more.consistently Entering at impulses towards him. puberty, he started eating more than normal, became overweight Suicidal adolescents often elicit strong countertransference and his parents were trying to control his eating. According to Phoebus, his mother loved him very much and reactions from therapists. These reactions fluctuate from the relieve the suffering teenager to the openly hostile stance isolated childhood with absolute dependence on the mother and belief that the therapist should be the perfect object that will accepted him, while his father rejected him. He described a rather representations and emotions produced by the patient in the by the therapist. The awareness and working-through of analyst’s mind facilitates further understanding of transference ofmaternal 1 year, grandmother.he used to sleep He inhad his extreme parents’ difficulty room alternating to establish with a phenomena [29,30]. Apart from facilitating the understanding onefirm or friendship the other relationship parent. with any of his peers. From the age of transference, another component of countertransference conceals aspects of transference. These two components are His father, 55, assumed he had the role of the evil one in the integrated [25] into a single psychic activity, which is set out by family, he was hard and absolute, but he felt that his wife did not the analyst as a response to his or her transference movements. allow him to impose any limits in the upbringing of the child. His Thus, every therapeutic situation is addressed and functions within the transference-countertransference space that is vengeful, horribly demanding, assertive and loud at home. father described Phoebus as immature, competitive and jealous, the therapeutic situation operate on any occasion. The following everything. She admitted she was very submissive towards the The mother, 50, satisfied all of Phoebus’ favors and he told her psychoanalyticcreated. Within this case framework, report of the a suicidal particular adolescent characteristics tries toof illustrate some aspects of these complex reactions. child because there were all these difficulties in child-bearing. Often she hugged, kissed and caressed him as a little kid.

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Giannakopoulos G, Triantafyllou K, Christogiorgos S (2014) Self-Destruction and Countertransference Reactions in Adolescent Psychotherapy: A Psychoanalytic Case Report. J Psychol Clin Psychiatry 1(3): 00019. DOI: 10.15406/jpcpy.2014.01.00019 Copyright: Self-Destruction and Countertransference Reactions in Adolescent Psychotherapy: A Psychoanalytic Case 3/5 Report  2014 Giannakopoulos et al.

Countertransference reactions during treatment therapist, a guilt that stemmed from the assault of Phoebus onto

his internal and external objects. Phoebus’The first mental introductory strength and meeting some characteristics with Phoebus of his caused physical the in maintaining the setting of the therapy. It was apparent to therapist to feel some degree of dislike. The therapist doubted The therapist gradually began to understand his difficulty adolescent or for his life and was defending himself against the therapist that he had been feeling a lack of caring for the withappearance this adolescent caused himwhile to he think was ofanxious a probable lest Phoebus chromosomal repeat such feelings by being generous with his time that no one could andisease. attempt. He felt Along somewhat with the skeptical information as to whether he received he could from work the assessment of the child psychiatry team during the hospitalization desertionaccuse him from of indifference. an internalized The indifferent unspoken, destructiveshared feeling mother was that it was Phoebus’ painful or frightening fantasies of attack or about a quite disturbed teenager, who often moved between omnipotentphase, the therapist manic mental was forming states and a first feelings hypothesis of helplessness in his mind and his mother for his delays, since she was so overprotective of who killed her babies. In the external world, Phoebus blamed hopelessness.

himher childout of – her after sight the and several never traumatic allow him attempts to come toof sessions assisted onreproduction his own for and fear miscarriages that he might – that get shehurt. would For the never therapist, allow During the therapy sessions, the impressions of dislike and one hand, was eager to get help from the therapist, on the other, one important step in integration of the feeling of indifference unjustified reservation were changed. It seemed that Phoebus, on was the ability to understand his experience of guilt and his defenses against his feelings of indifference, rather than trying to tempestuoushe was terrified for by long the periods, prospect cut of offdependence from emotions on therapy and with as he a sensehoped ofto live urgency. an “independent” If the therapist life. Initially, attempted he was to say very something talkative, psychological processing was the therapist’s feeling that he could about what Phoebus thought or felt, Phoebus interrupted havedeny feelingsor project of theseguilt orfeelings. indifference A necessary without prerequisite being damaged for this by them. The therapist at this point chose to interpret Phoebus fear countertransference, the therapist felt that both should be very of his own indifference toward an unmotherable, unwanted and him and continued to talk about his numerous problems. In these would become unbearable and the end would be again as from inside. In this way, the therapy attempted to digest the bad.careful On because,other occasions, if they had the therapistfeelings or was talked forced about to feel them, as a then, very hopeless self and his fear of being abolished, attacked or deserted the interaction between the therapist and the adolescent. projection and make it available for re-internalization through situations:strict judge forwho example, did not allow in one him instance to speak he spontaneously, could not say but the obliged him to anxiously find decent words to describe difficult scheduled vacation. There was discussion about death replete withThe deep situation feelings was of abandonment also difficult and in sessionsloss. The before therapist’s the therapist witnessed Phoebus’ struggle against an extremely strict concern about Phoebus’s condition during vacation and the sadisticword “bashing” superego referring to which to a Phoebus fight incident surrendered with a classmate. and to which The rationalizations that he made about the need for rest and the anxiety was that the treatment made him want and demand aversion to Phoebus who, in turn, counter transferred the feeling morePhoebus and identified externalize neglecting his aggression his needs openly. and impulses. If he wanted Phoebus’ and constraints that reality imposes, probably concealed a kind of

of disappointment and anxiety about reuniting with the rejecting As with the suicide attempt, Phoebus conveyed to the therapist demanded more, then, he would attack himself even harder. therapistClearly, - object. on the countertransference level, the therapist faced the message that each session came too late, that the therapist could not do anything for him because he was not next to Phoebus externalserious challenges. stimuli into The psychic therapist’s elements function and functioning was influenced according either day came, the problems had already been solved somehow or tothrough the role weakening that is of assigned the symbolizing to them capability each time), (transforming or through when the latter really needed him and when, finally, the session hampering the capability to understand the child’s function therapist to reveal an effort by Phoebus to approach the therapist of phantasy. The impact on the symbolizing capability was whohad beenshould forgotten. have been Although, more available, at first nevertheless level, this seemed the therapist to the felt that Phoebus said this to indicate that he was disappointed the present situation during the sessions. The therapist showed by the therapist, causing the therapist guilt. The same thing expressed mainly in the therapist’s altered ability to think within happened when the therapist tried to maintain the sessions’ time ability to integrate the urges that came from the patient. In schedule since Phoebus often failed to come on the agreed time, otherirrelevant words, emotional the therapist reactions was due presented to a temporarily with a disordered weakened blamed his mother for the delays and requested that their session capacity to contain. The therapist was struggling with the game be extended. The therapist was ambivalent especially after a long delay and felt he had to give him some minutes; otherwise the therapist would be very strict and indifferent. In retrospect, the of identifications with the child and the phantasized parents and therapist thought that the guilt he had to carry was probably the there was always the risk of his being overwhelmed and losing ofhis these capacity countertransference to understand object-relationships feelings played a vital and catalytictransference role phenomena. The therapist’s supervision in the working-through result of the projective identification of Phoebus’ guilt on to the Citation:

at the countertransference level. Devaluation of parents and psychoanalysis—offered the space for reprocessing and authority, another characteristic of adolescence, also arises containingin this case. these The reactions supervision—like related to the the therapist’s adolescent’s individual psychic in the therapeutic relationship. Defying the therapist’s ability and utterances is very common and understandable; however, this does not negate the challenge to the therapist. The game of Three years after the start of treatment (which is still difficulties. control regarding limit-setting is endless at all levels. ongoing), Phoebus managed to some extent to discover a sense of energy, positive aggression that allowed him to feel stronger and being expressed in damaging or potentially catastrophic manner towardsCountertransference, the teenager. The when therapist, not recognized, who has the creates megalomaniac the risk of action.less terrified However, of the he consequences remained vulnerable of his anger. to loss, Also, disappointment he improved expectation to be able to offer to the teenager the corrective his ability to think more about himself rather than to jump into emotional experiences that he never received as a child, will emotionally in the relationship with his parents: on one hand, he wasand experiencing criticism. He the had full particular availability difficulty of his mother to place that himselfoffered empathic therapy or when the patient devours this acceptance him pleasure along with anxiety, fear and guilt in a very tight, andbe disappointed requires more when and more the patient time and does energy not acceptfrom the this therapist. kind of overprotective relationship and, on the other hand, he was facing Possible consequences of a not recognized countertransference (either positive or negative) is the aggressiveness towards the patient. the absolute rejection by his father who left him helpless, under constantDiscussion judgment, and in despair. moves to which therapists may resort when they feel negative In the case of a suicidal adolescent presented here, the central Maltsberger and Buie [22] identified five different defensive themes that dominated the treatment over time were- that can manifest itself as a feeling of boredom or fatigue. The a. A narcissistic vulnerability, an insecure sense of self and a secondcountertransference is the shift in feelings. countertransference The first is the hatredrepulsion towards of hatred the self, so the therapist masochistically discredits himself and reduced self-esteem. This reduced self-esteem triggered feels inadequate. The third type of defensive move is reaction heightened sensitivity to losses and rejections that led to depressive feelings, anxiety and anger in response to any formation. Here, the therapist occupies himself excessively with the care of the patient and he experiences intense anxiety and a sense of urgency to help the patient. The fourth defense b. narcissisticAnger, accusations injury. and envy directed towards others and often led to discontinuation of his interpersonal relationships, confusion about who is to blame and patient his own intense aggressive feelings. Here, the therapist is projection. In this case, the therapist projects on to the ultimately anger towards himself followed by depressive feelings. attempt, even when the data do not support that there is a overemphasizes the likelihood that the patient commit a suicide c. Experiences of guilt and shame. Emotions and desires that he experienced as bad or wrong, feeling that his love thissignificant occurs risk. through The last the type discrediting of defense of is the distortion patient asand helpless denial for others could not outweigh his aggressiveness towards orof untreatable.reality that In certifies this case, counter the therapist transference may be hostility. experiencing Often them. Often he resorted to self-criticism and a negative perception of self. patient. Here, often the treatment is terminated prematurely or indifference, pity or anger; nevertheless, he lacks empathy for the d. Idealized and devaluated expectations for himself and the patient is referred elsewhere. others. Abrupt transitions between the two states often Given that the technique of interpretation is not always led to frustration, anger towards self and others. available in such situations, the main goal is to use these counter e. Defensive means against painful feelings, especially transference responses in the service of the adolescent’s psychotherapy by understanding the adolescent’s internal world and the splitting that did not allow his energy and reality, resistance, and experience, as well as the intensity and aggressionthe projection to be that integrated led to a into recurring the development sense of a hostile of his nature of external experiences within the family. Psychoanalytic personality.

psychotherapy, apart from enhancing interpersonal skills and adolescent’s support networks, should focus on improving the Regarding adolescent psychoanalytic psychotherapy, it is losses, modifying less adaptive defenses, and containing the preconditions for the emergence of intense countertransference quality of object relations, working through actual and fantasized reactions.noteworthy Emotions that developmental and transference characteristics movements create alternate specific rapidly even during the same session; thus, the therapist projective identification of primitive introjects. is invited to go from one extreme to the other in order to to the diagnostic access and the treatment of adolescents after emotionally contain the adolescent. Acting out—a characteristic The psychodynamic approaches can contribute significantly of the adolescent developmental stage—manifests naturally and developmental factors in understanding suicidal patients in the therapeutic relationship and challenges the therapist [5,11,26].a suicide attempt Exploring [3]. the Research transfer supports and processing the role of of dynamic counter

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