Archives of Suicide Research, 10:323337, 2006

Copyright # International Academy for Suicide Research

ISSN: 1381-1118 print/1543-6136 online
DOI: 10.1080/13811110600790918

Assessing and Engaging

Suicidal Teenagers in
Psychoanalytic
Psychotherapy: A Case
Consultation
Stephen Briggs, John T. Maltsberger, Mark J. Goldblatt,
Reinhard Linder, and Georg Fiedler
Assessing and engaging suicidal adolescents in psychoanalytic psychotherapy is filled
with complexity and stress, but offers a potential for lasting suicide prevention. This
study provides a detailed account of the initial psychotherapy sessions with a suicidal
teenager, drawing extensively on the comprehensive notes taken by the therapist. Four
discussants were invited to provide their perspectives as to how they would assess the
main factors in the case and from this to provide a brief commentary for their own
perspectives. This study concludes with a discussion of the differences and commonalities between the various contributions.
Keywords adolescent, psychoanalytic psychotherapy, suicide, therapeutic relationship

the paper aims to show what really happens

in psychoanalytic sessions with a suicidal
adolescent and to provide some detailed,
descriptive material from these sessions
on which discussants have been asked to
comment.
Four discussants (two of whom would
collaborate to provide a joint commentary)
were invited to provide their perspectives
as to how they would assess the main factors in the case and from this to suggest
either (a) the different options available to
the therapist in working with the case,
including issues arising either in the management of the case (the structure=setting)
or in the emerging dynamics of the
therapeutic relationship (transference=
counter- transference), and (b) to offer

The aim of this paper is to discuss the complex processes involved in engaging suicidal
adolescents in psychoanalytic psychotherapy, and through it to explore the
potential of this approach for prevention.
The process of engagement involves establishing a therapeutic alliance and assessing
the nature of disturbance and risks. It is
of considerable clinical importance currently to assess the merits of different
approaches to psychotherapy, and this
study provides a detailed account of how
psychoanalytic psychotherapists approach
work with a suicidal teenager. Through
providing a detailed account of the initial
psychotherapy sessions with a suicidal teenager, drawing extensively on the detailed
notes the therapist took of these sessions,

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Engaging Suicidal Teenagers in Psychotherapy

some thoughts about how they would proceed with the treatment of the case, in the
context of their own work settings. The
discussants chose to focus on the following
themes: fear of self-disintegration, the role
of aggression and hostility and the essential
framework conditions for working with
highly ambivalent suicidal patients.
METHOD
Working Psychotherapeutically with
AdolescentsStephen Briggs

The approach I take to working with

a suicidal adolescent is to think firstly
about the impact of adolescence. Adolescence is a period of upheaval in terms
of physical, emotional and sexual development. Working with adolescents requires
adaptation of psychoanalytic technique to
take into account the unevenness, intensities, and diversities of adolescent development, and the ways that adolescents think
about themselves, communicate and relate
to others (Briggs, 2002). Making emotional
contact with the adolescent and understanding the defences against such contact
is central. The therapist must also take
into account the patients projection of
intense feelings; accept them, and attempt
to make sense of them, returning them in
modified or detoxified formacting, in
other words, as a container for intense
emotional experiences (Bion, 1962).
Beneath the adolescents often ambiguous
communications lies a struggle between
attempting to engage with the tasks of
development and defensively retreating
from the pains development incurs. The
therapist has to assess how the adolescent
feels about facing developmental tasks,
and to note, in particular, defensiveness
characterized by precocious maturity, on
the one hand, and reluctance to leave
childhood dependencies on the other
hand (Waddell, 1998).

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Suicidal adolescent patients convey a

powerful emotional experience. The therapist may become involved in the suicidal
dynamics through being stirred up by the
anxiety of the adolescents suicidality. In
contrast, some suicidal adolescents can play
down, understate or deny suicidal thoughts
and feelings, and in these cases the therapist has to attend to the possibility of missing or underrating suicidal communications
(Wright et al., 2005). Therefore, it can be
emotionally taxing to find ways of engaging
and sustaining suicidal adolescents in
therapy, whilst, at the same time, making
assessments about possible risks, especially
of further suicidal behavior, which could
generate anxiety in the therapist. The
interplay between these factors will be
illustrated by the following case example.
The Case1

Annabel, age 15, was referred for

psychotherapy by a psychiatrist, Dr T.
She had taken two separate overdoses of
paracetamol within fourteen days. Both
overdoses of 1520 tablets were on the
borderline of presenting a threat to life.
She was admitted to a hospital on both
occasions. At that time Annabel had started
to cut herself repeatedly, though not, at this
stage, deeply. Dr T. assessed her as at risk
of further suicide attempts, and was particularly concerned that Annabel had not
asked for help, and was unable to provide
an account of the reasons for her self harm,
saying only that she had felt unhappy and
that she was imitating a school friend.
Annabel has an older brother who is 19
and he has recently started living away
1

The case discussed formed part of a research project, Object relations and suicide in adolescence,
funded by the Tavistock Institute of Medical Psychology. Ethical approval was given by the Tavistock
and Portman NHS Trust Research Ethics Committee. All names and some other details have been
changed to preserve anonymity and confidentiality.

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from home. Her mother has arthritis, causing her considerable pain over the past two
years. Annabel has nursed her mother.
Additionally, she often complains of pain
in her back and hands. Despite this apparent identification with mother, Annabel
stated that she and her mother are not
alike: mother is quiet and reserved,
Annabel is dramatic and emotional. Father
attended only a family meeting the day after
Annabels second overdose, and then
refused to participate further.
Annabel has done fairly well academically and socially. She has had a number
of boyfriends but recently became distressed about the ending of a relationship
with a boy with whom she had her first
sexual experience. Annabel said there was
no link between leaving her boyfriend and
her overdose.
Assessment and Treatment

The assessment process in the

Tavistock Clinics Adolescent Department
usually consists of four weekly meetings.
Adolescents are referred, or, often, refer
themselves, to the Clinic without necessarily having an informed understanding of
the psychotherapeutic process. These
assessment sessions enable the therapist
to get a sense of how the adolescent
responds to the therapeutic structure
(weekly sessions at a regular time), allowing
the adolescent an opportunity to appraise
what therapy will be like (Anderson &
Dartington, 1998). Patients are asked to
complete a self report questionnaire, the
Youth Self Report Form (Achenbach,
1991) before the first appointment. For
adolescents like Annabel who are under
16 at the time of referral, parental consent
is required for treatment. For Annabel,
beginning therapy meant transferring from
one clinician to another, and entering a new
institution. A second psychotherapist met
with Annabels mother but her father
refused to attend any of these sessions.

First Assessment Session

When the therapist met Annabel for

the first time she was struck by how
nervous and fragile Annabel seemed.
Physically, Annabel seemed to be tying
herself in knots, she:
. . . ducked and twisted her head in a
strange manner, but smiled and said
hello in a whisper, still ducking and
twisting. She followed me from the
waiting room to the consulting room
very slowly. I slowed down and wondered if we were ever going to make
it to the room. I could hear her twisting the bangles on her wrist and I
imagined her whole body contorting.
Once in the room she gave the
impression of tying herself in knots
as her arms cross and uncross. I
asked her if she would like to tell
me something about herself and I
noticed that I have softened my
voiceI felt that any loudness could
send her scurrying out of the room.
There was a long silence while she
wriggled and twisted and played with
a hair band which she wound around
and around her fingers. I asked, perhaps she could tell me something
about her family or her school or
her life. In a voice that shook slightly,
but with a smile she said, well shes
got a mother and father and a
brother. Schools fine, her lifes
OK. She gave a nervous laugh and
stopped speaking. Her hands started
their dance again. I wondered for a
moment if she was mocking me, but
on reflection perhaps its all so
unbearable here that its all she can
manage. It was as if she had a big sign
saying dont probe or Ill shatter.
It is interesting that the first impressions of Annabel are that she is extremely
fragile. The therapist finds herself softening

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her voice, feeling that Annabel might take

flight, or, alternatively, that she might shatter. On the other hand a contrary theme
emerges when Annabel provides only minimal information in response to the therapists request to tell her something about
herself. This is experienced by the therapist
as having a somewhat mocking quality.
Annabels anxiety is palpable and is seen
vividly in her nervous, contorted body
movements. The therapist has a sense that
this anxiety is so great that it is almost
unbearable for her to be here. Furthermore, the therapist noticed that starting
psychotherapy might be making Annabel
very anxiousas is often the case for adolescentsand she attended to this anxiety,
by naming it and explaining the structure of
the assessment: there will be four assessment meetings at weekly intervals. The
therapist also added that she will be able
to continue to see Annabel after the assessment, if that is what they decide. Following
this, Annabel is more forthcoming; she
relaxes a little and provides information
about herself.
She talked about her psychiatrist,
Dr T., who referred her here, ending
with and then she left. The therapist
wondered aloud that it might seem
difficult to build another relationship
after getting attached to Dr T. who
then left. In response, Annabel tilted
her hand to indicate this was not
entirely true. The therapist felt she
cant risk admitting to an attachment
without negating it. Annabel said
she had not agreed to see another
doctor after Dr T. She asked if someone would be seeing her mother, so
she could report back to her mother
on this. The therapist said that a colleague would indeed be contacting
her parents.
Annabel continued to be more forthcoming and talked about the difficult, tense

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and unhappy relationships in her family.

She volunteered the thought that it was
good her brother was no longer at home
as she has his room now. She described
her fathers grumpy moods, and his hostility towards her and her friends.
Hes always going on about all my
friends (both male and female) being
stupid, ugly short-arses or bitches. He
calls me stupid bitch a lot too,
especially when I dont get a perfect
grade at school, just average. Mum
is laid back, too laid back and Ive just
started to see why dad gets so angry
with her. Dad just winds me and
mum up all the time. . . .
Annabel says she can talk to her
mother, but not her father. She adds that
she rarely tells her mother how shes feeling. Annabel says her mother, will just witter on, like Im doing now, sort of
inconsequential babble. She then says that
family holidays are really awful now that
her brother does not come, and the spotlight is on her, which she finds very
uncomfortable.
Life in this family is difficult. Annabel
experiences her parents to be unresponsive,
hostile and difficult to talk to. She also
downplays her attachments. She says she
is pleased her brother is not there now,
but later she feels his absence makes it
more difficult for her, as she is now in
the spotlight. Being left without her
brother to dilute the impact of being
with these parents seems unbearable for
Annabel. Towards the end of this first
session, Annabel begins to reveal that her
mother is concerned about her:
Annabel says that her mother has
started to worry about her, since last
year and I asked if Annabel could
say what had made her mother worry.
Now Annabel finally told me about
her suicide attempts. This has been

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hovering in the air since the beginning of our session and it is quite a
relief that she is able to bring it into
the session herself. She talked of
them being a random thing she
did. One morning before school she
just decided to take 20 paracetamolsfor no particular reason. She
went to school and told one of her
friends that she felt sick. I feel sick
too said the friend No, no, said
Annabel, Ive taken an overdose.
Oh I did that too, said the friend,
youll be all right, I was. And she
walked off. Was she listening to me
at all, I dont think so? I point out
that Annabel is relating this to me
as something quite comic not as
something so literally deadly serious.
Her response was to give a little laugh
and I found myself thinking of the
expression, I could have died
laughing.
Annabels defensive trivializing was
noted by the therapist. This is accompanied
by a profound lack of interest in her suicide
attempt. Annabel said she still has no idea
what made her do it. Perhaps it was
because her friends took overdoses and
perhaps this was why she had started cutting too. She dismissed any attempt the
therapist made to indicate the importance
of underlying meaning and emotional states
and stuck rigidly to her story of her suicidality being merely a kind of copying.
As she continued, Annabel provided
considerable detail about the second suicide attempt. She revealed that her suicidal
behavior expressed her wish to be noticed
and loved.
She remembered waking up in a ward
and her dad was holding her, saying
he loved her. This was the first time
he had ever expressed warmth and
caring. The warmth didnt last long
and shortly he was back to his rude

ways. She made friends with everyone

on the ward, played games and cards
with them all day, which was really
nice. She enjoyed that, it was a good
experience. The therapist said that it
seemed as if she was describing a
gap year in a foreign country. Annabel said funny you should say that,
because my brother Tom is away
for a gap year.
Her brother Tom expresses caring for
her, but it also has a hostile undertone.
Annabel added that when she got
back home, Tom had a big box of
chocolates for her because he
thought shed overdosed through
being upset that father called her a
fat bitch and made remarks such as
it was impossible to move around
the kitchen when she was in there.
Tom had told father he would make
her become anorexic and he wanted
to show he thought she wasnt fat
by giving her chocolates.
Thus the gift might be a way of ensuring father has new ammunition for further
hostile attacks in the future. Annabel
requested a different time, right at the
end of the session.
At the end of the session Annabel
asked for a different time because this
time interfered with her going to parties. The therapist felt annoyed by
thismother had insisted on therapy
times being outside school hours
hence the 5pm appointment. She tells
Annabel she cant change the time at
this point and Annabel reluctantly
agreed to come at the same time next
week.
One way of understanding why the
therapist was annoyed by this exchange is
that a parental authority is invoked to say

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do your homework before you go to the

party. It is an adolescent conflict, and
for this moment the therapist is nudged
into a position where she is rigidly holding
on to a boundary. This kind of emotional
pressure is often experienced in work with
adolescents, leaving the therapist in undesirable positions like this.
The first
assessment session is typical of a first meeting with a fragile adolescent, where precarious adolescent development is taking place
in the face of considerable adversity. There
is a great conflict, which surfaces in this
session, about relating thoughts and feelings to an adult, who is feared to be persecutory, and potentially harmful, rather
than thoughtful, empathic and helpful.
The problems in Annabels development
emerge in the session in an initial picture
of a family where there are no good
objects, where relationships are experienced as predominantly hostile, and where
hurting and being hurt is part of the way
the family members interact. It is in this
context that Annabels suicidality must be
understood. Her inability to think about
the reasons for her suicidal behavior
appears to form part of a defensive constellation in which emotionally important issues
are dismissed, derogated and mocked. This
mirrors her description of her parents
they either witter on or are abusive
towards her. Thus not thinking about emotionality, and development, is both an
experience she has had, and one which
she has internalized.
On the other hand, it is Annabels
intense anxiety which is uppermost in this
first session, and although it is quite an
ordeal, she does come for her appointment,
and manage to stay. She has had some therapy before, with Dr T., and this probably
helps her cope with the session. She does
become more forthcoming and in fact
reveals quite a lot about herself. She shows
glimpses of her wish to be loved and the

Summary of the First Assessment Session.

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meaning of the suicide attempt as aiming

to show her parents they have failed to love
her enoughor failed to love only her.
After the first meeting, the assessmentwhich must be provisional at this
stagewas that Annabel could well be at
risk of further suicidal behavior and self
harm. The underlying conflict in which suicidal behavior aims to express the feeling
of not being loved has been recognized as
a suicidal dynamic (Campbell & Hale,
1991). Annabels inability to recognize
and reflect on her suicidal motives, the
intensity of her anxiety, presence of hostility and the mocking, downplaying and
denigrating aspects are also factors associated with suicidality in adolescence. Future
sessions would aim to elaborate and more
clearly identify the strength of these trends
and the risks they posed.
In the second and third
sessions Annabel showed fluctuations in
the balance between the different aspects
of her which had been identified in the first
session. In the second session she seemed
from the beginning, to be less anxious
and more mocking, even triumphant. She
teased the therapist about whether she
was allowed to ask her questions, disparaged Dr T. (calling her that psychiatrist
thingy woman) and began to ask some
seemingly strange questions. Annabel said
she wanted to know if you have to be good
at sciences to be a sports instructor, which
the therapist commented on as referring to
her father. Annabel then asked Can a goldfish change color? and then said that her
pet goldfish died and father replaced it with
another, which she thought was a slightly
different color. Without stopping to think
about what this might mean, she asked if
you put a matchstick in a mouse will it
explode.
In this mocking, tricky way Annabel
does draw attention to the fact that she
has some idea that change, separation and
loss mean something to her. The loss of

Subsequent Sessions.

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an attachment figureDr T.leads to her

disparagement or denigration of that person. She is aware of her experience of
changing therapist, preoccupied with death
and communicates about explosive murderousness. Fathers intervention with the
goldfish promotes substitution rather than
mourning, an omnipotent defense against
the pains of the experiences of loss. When
the therapist tries to discuss the reasons for
her suicide attempt, Annabel responds with
increased sarcasm and mocking hostility.
Annabel said she told Dr T. who
wrote it down, so there is no need
to discuss itshe caught her breath
and looked at the therapist and said
You mean she didnt write it down?
What did it say then, what? Can you
remember? She winked and the
therapist said it would be helpful if
Annabel told her in her own words.
Annabel then talked about her
mother as nice but fuzzy and incompetent, and hopeless. Dr T. is also
described as nice (the therapist had
earlier commented that Annabel
seemed to want to turn her therapy
into a cosy chat).
The therapist feels herself under attack
from Annabels resistance, and her mocking questions when she stands for taking
the reasons for the suicide attempt seriously. The therapist has to work hard
within herself, and in what she takes up
with Annabel not to be pulled into either
one of two extreme positions, which are
denigrated positions in Annabels eyes.
There is pressure on the therapist to be
nice, cosy and fuzzylike mother essentiallyor rigid, mocking and punitive, like
father. For Annabel, fathers have an authority which must be attacked, but nice
mothers are incompetent. Annabel did
not return for her third session for 4 weeks.
After each missed session, the therapist
wrote to Annabel to confirm the time of

the next session and each week her mother

phoned on Annabels behalf to say Annabel would not be coming. On each
occasion a plausible reason for not attending was given. When Annabel does return
to the clinic she shows a wish to engage
further in her therapy. As there is clearly
considerable need, the therapist offers her
open ended once weekly psychotherapy.
The therapist asks Annabel to think about
it and let her know what she wishes to do
in the next session, the following week.
In the fourth and concluding assessment
session Annabel said that she accepted
the offer of therapy and the therapist confirmed that therapy would start immediately after the impending break for the
Christmas holiday.
Annabel seemed relieved to have the
plan for her therapy settled, but she
covered this with a sarcastic joke.
The therapist commented on this,
and wondered aloud if Annabel was
protecting herself through keeping
people out. Can she divert the therapist and brush away her difficulties
with a joke? Annabelwithout sarcasm or other avoiding tacticssaid
she is like her dad who pretends
everything is all right, he hates admitting its not. He tells her that shes
OKhe doesnt ask her, he tells
her. The therapist said that Annabel
is relieved that she, the therapist is
not conned into pretending everything is OK but this makes it a bit
frightening for her. Like father she
would prefer not to have to think
about these difficult things. Annabel
added that she did get herself to these
sessionsI came, I got myself
hereand the therapist acknowledged this is true. Annabel adds it is
only her mother who wants her to
come, because she wants Annabel to
be happy.

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There is development in the discussion

here, with Annabel joining in with the therapists comments and interjecting an idea
of a benign maternal object who wants
her to be happy, just as she asserts her
efforts to face difficult things, unlike her
father. The therapist is able then to
acknowledge the truth of Annabels statement. This is followed by Annabel briefly
entrusting the therapist with her vulnerability, by talking about being hurt by her
ex-boyfriend:
Annabel said she felt she opened
herself up to him, only for him to
betray her. She described a recent
meeting with him and her mouth
drooped, revealing a glimpse of sadness about missing him. Quickly she
gathered herself up and made a joking, mocking comment about a teacher at school. Annabel said that
her passion is art but her art teacher
was leaving. She pulled a mock sad
face. The therapist said that she felt
Annabel was telling her something
that is making her feel sad but she
turns it into a pantomimic clown sadness. The therapist wonders aloud if
Annabel has noticed this. She said
yes, she did, but she hoped others
had not noticed.
DISCUSSION
Case Discussion: Fears of SelfDisintegration in a Suicidal
AdolescentJohn T. Maltsberger

Annabel, struggling against intense

affect, feels in danger of flying out of control and explodingthis frightened child
presents herself for the Tavistock assessment with a stony barrier of denial
intended to keep her assessor out, but also,
herself held together inside against great
disruptive pressure. My discussion of
this case will focus on developing some

330

thoughts on how this defensive barrier pervades the initial sessions and provides a
focus for thinking about treatment. My
responses to this situation would shape
my subsequent maneuvers in trying to
inaugurate a treatment.
Through transparencies and cracks in
Annabels barrier I would tentatively infer
that the moving away of her brother had
left Annabel even more intensely and painfully positioned between her ill mother
from whom she was not well differentiated,
and her frightening father. She shows signs
of having been distressed by the loss of her
previous psychiatrist, Dr. T., and by the
impending departure of her art teacher at
school. This young patient, badly in need
of narcissistic supplies from outside herself
in order to preserve her self-integrity,
seems on the verge of self-fragmentation,
or disintegration of her self-representation
(Sandler & Rosenblatt, 1962; Stolorow,
1975).
Recalling how her father replaced a
dead goldfish with another of a slightly different color, she asks, Can a goldfish
change color? and then quickly adds, If
you put a matchstick in a mouse will it
explode? The first remark seems to imply
instability in self and object representations. Annabel speaks of herself in the third
person, as though she tries to distance
herself from an intolerable inner selfexperience by objectifying herself and
speaking of herself as though she was
someone else. Her second remark, expressing a fantasy of bursting, suggests the
danger of an explosive loss of self-integrity
under intolerable affective pressure
(Glover, 1938). Penetration by a match of
course suggests the tension is flamingly
sexual, but the tension must also be raging
and intensely anxious. We now have
empirical evidence that intense, intolerable
affective tension is central to many suicides, and that intense affective overload
accompanies
self-break-up
(Hendin,
Maltsberger, Haas et al., 2004; Maltsberger,

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2004). Suggestions that there are dissociative symptomsfor example the way
Annabel refers to herself in the third persondescribed in the protocol give further
evidence that Annabel is near break-up; she
is fending off unbearable anxiety by splitting off some of her mental experience,
which leaves her feeling de-realized and
depersonalized.
Developmentally Annabel is striving to
separate herself from her parents and to
move forward into adulthood, but the intensity of her ambivalence toward both parents
is making this impossible. Novick (1984) has
described a suicide sequence in adolescents, wherein his young patients would
make tentative forays into their first heterosexual attachments, only to fail, whereupon
they regress and fall back upon their parents.
Flooded with intolerable feelings and burdened often with conscious incestuous fantasy, their egos regress also, so that suicide
or psychosis is threatened. That Annabel is
in this precarious place is suggested by the
fact that she has recently opened herself
up to a boy only to be betrayed.
She comes to see a psychotherapist as
she is beginning to withdraw from others,
defending herself from the threat of closeness with a mocking devaluation of everyone. Desperately in need of a trustworthy
attachment to someone else, Annabel challenges the therapist to find the right
distancenot too far away, but not too
close either. She presents a formidable
challenge. The challenge would be easier
to answer if the mother can pull herself
together, with treatment herself. She might
then become Annabels ally in a very
difficult adolescent negotiation.
Case Discussion: The Role of Hostility in
the Assessment of a Suicidal Adolescent
Mark J. Goldblatt

Annabel is a very disturbed teenager,

who has been struggling with suicidal
feelings for at least one year. She is now

referred for specialized care probably as a

result of several precipitants which include
her therapist (Dr T.) terminating treatment
after 10 months; sex with her boyfriend for
the first time, coupled with the relationship
recently ending; evidence of increased talk
of self-hatred and repeated self-cutting.
By noting how aggression and hostility
are dealt with in this family, and the connection to Annabels self-destructiveness,
the therapist may help the patient to find
mechanisms to deal with rage and hostility
without resorting to self-destructiveness.
There are several instances where
aggressive impulses and hostility are
described, beginning with Annabels increase in self-hatred and cutting prior to this
evaluation. In the first session, Annabel
was noted to be nervous and fragile. It
was as if she had a sign that said: Dont
probe or Ill shatter. She seemed to convey
to the evaluator that she was not able to tolerate any hostility whatsoever. Similar to
those who show these kinds of responses
to trauma, Annabel conveys a sense that
she is familiar with hostility and expects
further aggression, which she would then
find overwhelming. We might even consider her nervous motor contortions as a
manifestation of her fear of aggression.
The source of her fragility is also suggested in the interview. Although Annabel
denied that she was like her mother, whom
she viewed as too passive, she seems to
identify with certain aspects of her mother,
including her mothers back pain, and irritation at father. Mother suffers from severe
arthritis and needed Annabel to nurse her
over the course of the past two years. The
ambivalence that she feels towards her
mother ( having loving feelings for her,
and also rage at her for her passivity and
physical deterioration, right at the point
where Annabel is herself developing into a
young woman) complicates their relationship with a repression of any overt hostile
wishes. However, some of the hostility
then appears in her sarcasm and mocking

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discourse. She appears to be fearful of her

own unbearable feelings of rage, and transforms them into verbal attacks and selfdestructive behaviors.
In addition to her own unmanageable
rage, Annabel also has to deal with her
fathers hostility, which is overt, and directed at her and sometimes at her mother. He
is seen as hot tempered and unapproachable, except for a short time soon after
her suicide attempt. Interestingly, her
brother Tom is described without apparent
hostility. He demonstrates his caring by
giving Annabel a box of chocolates.
By the end of the first session Annabel
has settled down enough (perhaps feeling
she is not going to be attacked by the therapist) to tell of the suicide attempt, and even
assert herself enough to ask for a change in
time for the second session.
In the second session the therapist
notes that Annabel is less anxious and
more mocking. In this session she seems
to be distancing herself from her original
therapist, and trying to form identification
with her new therapist. She teases the
therapist about whether she can ask
her questions. The therapist interprets
Annabels question about being good at
science, to refer to her father. Annabels
associations go to the dead goldfish that
is replaced with one of a different color.
Her next thought is if you put a matchstick in a mouse it will explode. We
might hear this sequence as Annabel
reacting to what she perceives as a hostile
reply from the therapist, in response to
her own efforts to reach out for help.
Her thoughts go to the exploding mouse,
symbolic of her own uncontrollable rage.
When the therapist tries to restart the
discussion about Annabels suicide
attempt, Annabel becomes even more
sarcastic and hostile. Her associations are
to her mother (and by implication, the
new therapist), as nice, but fuzzy and
incompetent. She implies that there has
been failed empathic response, and her

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narcissistic response is to distance herself,

and attack the attacker.
Interestingly, Annabel is unable to
return for the third session for nearly one
month, further evidence that she deals with
narcissistic injuries with rage and withdrawal. And expressions of rage, albeit in
a defended manner, scare her so that she
is unable to face her therapist until the
intense feelings have calmed down.
In the fourth session Annabel confirms
these hypotheses about the rage in the family, and how it is processed. She refers to
sarcasm in the family, as a way of denying
anything is wrong. This made the therapist
wonder whether this was her way of protecting herself. Annabel admits to her
identification with her father who uses sarcasm as a form of protection. She also
stresses her separation from father, where
she was able to face her feelings and attend
to the difficult sessions. Through this interchange the therapist helps the patient gain
some understanding of her feelings and
her style of engagement that enables her
survival in her family. Through this
empathic therapeutic exchange, Annabel
is able to acknowledge her sadness at the
loss of the art teacher, (who is identified
with the former therapist), and begin the
process of grieving for her loss. The new
therapist is then able to draw the issue to
the current relationship, and the wishes
for safety. Implied in this session is that
through an empathic connection the therapist will be able to help Annabel to mourn
her losses, and find new ways to deal with
narcissistic injuries and aggressive attacks.
From this case presentation we are able
to dissect out a mode of interaction
between the patient and her family in
which Annabel experiences the aggression
expressed towards her as suicide inviting.
Without the moderating influences of the
caring brother, Tom, or the support of
her terminating psychiatrist, her risk of suicide increased. In the transference, she
revealed her fear of hostility directed

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S. Briggs et al.

towards her, as well as an inability to deal

with her own destructive impulses. The
patient seems unaware of her murderous
wishes towards those who aggressively
attack her. She experiences the hatred and
hostility as blaming, and rejecting, leaving
her with little sustaining resources, and
causing her to withdraw as a way to deal
with overwhelming affects. This withdrawal may ultimately lead to suicide as
her resources are depleted. Annabel is
unable to explain why she has been trying
to hurt herself because her inner life has
become so impoverished, that she feels
empty and unaware of her unbearable
feelings.
The task of therapy is to help this
patient to deal with her unbearable feelings.
Similarly to the work that was started in
these four sessions, the therapist uses an
empathic connection to help the patient
become aware of her thoughts and feelings.
This would involve clarifications of
the hostility that she experiences, and
her own responses of withdrawal and=or
aggression to attack others in retaliation.
Therapy should therefore focus on building
an alliance that would help Annabel to feel
safe enough to deal with her own
aggression, and come to terms with the
issues of rage and loss that have defined
her so far.
Case Discussion: Considerations about the
Setting: Essential Framework Conditions for
Working with Suicidal Teenagers
Reinhard Lindner and Georg Fiedler

The intention of this contribution is to

develop some thoughts arising from this
case about the similarities and differences
of working psychoanalytically with suicidal
adults and adolescents. From this we will
also make some comments on the essential framework conditions required to
provide psychodynamic psychotherapy for
suicidal adolescents such as Annabel. This
discussion draws on our experiences of

psychoanalytic psychotherapy mainly with

suicidal adults.
The case presentation shows the start
of psychotherapy for a 15-year-old girl suffering significant suicidality, identity and
self-worth problems, accompanied by a
massive denial of her own inner state in a
pronounced adolescent conflict of ambivalence. This arises from a conflict of attachment desires and anxieties, and she runs the
risk of losing all self-regard in a close
relationship. This conflict situation is
ubiquitous; it is based on an autonomyindependence conflict, a central human
conflict which accompanies us throughout
our lives. The appearance of this conflict
in Annabels case however, also bears
specific features of her age, as well as
indications of an individual pathology.
Both adolescent and adult age groups
are characterized by a high level of ambivalence which is a central aspect of suicidality. Additionally, suicidal adolescents and
adults are often also very distrustful. In
their suicidal experiences and behaviors
they often isolate themselves from other
people, but, on the other hand, it is also
possible that their attachments become
especially intensive when they are suicidal,
due to the fact that their feelings
within relationships and for people who
are important to them become extremely
intense. At the very beginning of treatment
fears of being rejected, overwhelmed or
patronized are often reproduced, but at
the same time there are also high expectations for exclusivity, tacit understanding
and intimacy. There are significant differences between suicidal adolescents and suicidal adults. In adolescents, the current and
primary reference persons are mostly identical, whereas with adults, the early relationship experiences that mark our inner world
are generally repeated with someone other
than the primary objects. There are also
specifics in the inner world of suicidal adolescents which especially characterize the
start of a therapeutic relationship. This

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Engaging Suicidal Teenagers in Psychotherapy

was also the case with Annabel, who was

readily prepared to re-actualize with the
therapist the separation difficulties from
the parental objects, her sexual identity,
insecurity and the specific role of a changing body as a projection and acting-out
area for sexual fantasies, feelings and
desires which were frequently experienced
as abnormal. Annabel is fearful of being
caught in a relationship similar to the
parent-child relationship, where she would
be at the mercy of regression and disintegration anxieties. Annabels denigration of
both therapeutic relationships indicates a
typical transference situation where adolescents neither can be, nor want to be
understood, because being understood
prompts threatening feelings of being
preyed upon. The result of this in the setting is that the adolescent constantly tests
the framework conditions and the therapists loyalty, for example, by arriving late,
missing sessions and wanting to terminate
treatment: at the same time, there is
extreme sensitivity regarding any changes
to the setting by the therapist. Suicidal boys
appear to have a particular problem with
the start of a therapeutic relationship, with
noticeably fewer attempting to enter treatment, perhaps because it is a stronger
attack on their already fragile male identity
than is the case with girls. In countertransference, a therapist working with
suicidal adolescents must have, a liking
for the incomplete (Berger, 1999, p. 62)
and must listen to the echo of his own adolescence in his feelings during treatment.
From this discussion, we suggest that
the essential framework conditions are vital
for work with suicidal adolescents and that
these are different from the ones described
in the case. Based on the thought that
suicidal peopleboth adolescents and
adultsoften live in highly ambivalent
relationships, dominated by actual insults,
separations and loss, the emphasis of our
work in the early phase of psychotherapy
is not on the assessment of the psychic

334

disturbance but on the start of the

therapeutic relationship. As a result, the
diagnostic focus is placed on the developing relationship between patient and
therapist, and it is the quality of this
relationship, as well as the mostly spontaneous details about the patients life,
his=her psychopathologic state and suicidality biography which lead to assessment
and understanding.
In our experience, psychotherapy
should begin immediately, in principle,
and only in cases where the therapeutic
relationship does not appear to be strong
enough are patients passed on to another
treatment. Low-level access to treatment
is a condition for psychotherapy, for both
adolescents and adults. Long waiting
periods are intolerable in an acute suicidal
crisis. When comparing treatment for
adolescents and adults, it is important that
relatives play a different part in the former.
Apart from legal necessities for adolescents, it is a fact that the parentsdespite
all ambivalencestill have a vital function
and the adolescent has not yet separated
from the parents in his everyday life. It is
necessary here to find a differentiated
balance between the adolescents wish to
exclude the parents from the contents of
the treatment, and the parents need for
information and assistance. Not so with
adults: the psychotherapist does not generally require any other information than that
which he receives from the patient during
the sessions. He does not intrude upon
the patients real life by making contact
with real reference persons.
In contrast to working methods at the
Tavistock Clinics Adolescent Department,
our practice employs a somewhat lowerlevel access: there are as a rule, no explicit
assessment sessions before the decision is
made to begin psychotherapy by both the
patient and the therapist. The therapist
relationship begins immediately. This
enables a real establishment of the therapeutic relationship, and not merely a trial,

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S. Briggs et al.

and to deal directly with the relationship

disturbance which frequently has a direct
connection to the suicidality. To use
Freuds words: that the actualization of
pathological transference relationships (that
reflect suicidal modes of relating to important others), especially in the very beginning of psychotherapy is the direct way to
strike the enemy ( Freud, 1914). But
there are also suicidal adults who are
initially offered a few talks because the
offer of psychotherapy causes such fear
of losing control, of manipulation and of
being swallowed by the feared and powerful apparatus of psychiatry that they would
never accept it. Perhaps, therefore, by
explicitly maintaining assessment sessions,
there is an implicit perception of a specific
relationship offer to the highly ambivalent
adolescent, whose fear of an ensnaring
and engulfing therapeutic relationship is
calmed at the prospect of trial therapy.
CONCLUSIONS
All Authors

The aim of this case consultation is to

explore, in depth, using a single example,
how establishing therapeutic work with a
suicidal adolescent takes place from a
psychoanalytical perspective. We describe
the process of the beginning of an adolescents therapy following suicidal behavior,
and illustrate the complexities of the therapeutic relationship as well as how the
adolescents patterns of inner relatedness
emerge. This is evident in what Annabel
reveals about herself and in the emerging transference relationship. Although
Annabel found it difficult to think and talk
about her suicidal behavior, ultimately she
is able to convey to the therapist some of
the important elements in her development, and in her relationships.
The discussants each chose a different
focus, forming three key themes in this

case. The first discussant identified that

the suicidal conflict may be thought of as
emerging from the impact of intense affective tension and overload that threatens
self-representation and self integrity. The
second discussant showed that Annabels
fear of hostility and aggression, in others
and in herself, leaves her feeling fragile
while defending against the narcissistic
injuries that she experiences in relationships. The third contribution focused on
the setting, and considered the importance
of the frame in psychotherapy with suicidal
adolescents. These patients are inevitably
caught up in their ambivalence and repeatedly test the therapeutic frame.
These different approaches reflect
some of the differences in the various
psychoanalytic schools of thought. The
case is presented from the perspective of
British Object Relations in the Kleinian tradition, with an emphasis on elucidating and
naming deep anxieties, whether positive
or negative (Daniel, 1991). The contributions of the discussants flow from the
somewhat different approach, in North
American and German psychoanalysis
respectively.2 Such differences lead to an
emphasis on divergent aspects in a suicidal
individual, which in this case leads to an
increased awareness of important factors
in the treatment of suicidal teenagers.
How is the therapeutic alliance established and maintained? In particular, how
does the therapist deal with hostility on
the one hand, and affective overload, on
the other? How does the psychotherapist
manage the setting and the frame? How
much flexibility is appropriate in response
to the specific vulnerabilities of suicidal
2

The self psychology approach in North America

(Kohut, 1977) has recently made links with Kleinian
thinking (Maltsberger, 2004). In Germany, the
approach in this case relies on the first scene, perhaps the most important post war contribution to
psychoanalysis from Germany (Argelander, 1970;
Kluwer, 2001; Lorenzer, 1973).

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Engaging Suicidal Teenagers in Psychotherapy

teenagers like Annabel? Should therapy be

offered from the outset, or should an
assessment phase, such as that described
here, be used in order to permit the teenager to opt in to a therapeutic relationship? One key thought arising from this
case consultation is that through active
comparison of psychotherapeutic practices
important knowledge is to be gained about
what is effective for the treatment of our
patients.
The contributors all note that Annabel
is in considerable developmental difficulty
and poses a serious risk for suicide. All
three contributions also focus attention
on understanding the complexities of the
patients relationships, in her interpersonal
world and in the therapeutic setting.
There is agreement, in other words, that
understanding the transference countertransference configurations underpins
psychoanalytic work. Treatment of suicidal
adolescents like Annabel follows the therapists efforts to understand the meaning of
relatedness to the patient. The therapist
tries to maintain a position that is both
close enough to understand the patients
emotional communications, and also removed enough to allow the patient enough
space to not feel intruded upon. The search
for this impossible position, a task which
the therapist undertakes within herself
and with the patient, is the hallmark of
the therapeutic relationship with patients
like these. The therapist aims to find and
maintain a position that is not too far
away, but not too close either. Making
emotional contact with the patient is somewhat precarious. She tests the framework
conditions, through missing sessions, for
example, and through the ways she defends
in the sessions from being overwhelmed by
her emotions and her fear of the hostility
of others. In working with this kind of fragility, the task of the therapist is to strive to
find and hold on to a position from which
she can be close enough to be engaged and
distant enough to be able to observe and

336

make sense of these ways of relating

without the patient feeling intruded or
assaulted. This is intense and demanding
work, and is reflected in the case and the
discussion.
Finally, we return to the therapists
reports of her own experiences and
Annabels subsequent treatment over the
course of one year. The feelings of precariousness persisted throughout the therapy.
During this time, the therapist felt that
she was only slowly getting to know what
is behind the facade. Annabel was able to
recognize her wish to be cared for in the
therapy, but, due to her ambivalence, she
had great difficulty in expressing this need.
The therapist was always walking on a
tightrope of recognizing the need for closeness, and not intruding by acknowledging
Annabels neediness. For example: The
therapist commented; at the end of one
year that Annabel has a habit of showing
me, usually at the end of the session a
hidden part of her that needs care and
attention. For example, she wears shoes
that leak and often sits through the whole
session with soaking wet feet. I am only
allowed to see this when it is too late.
However, more recently she has begun to
give me glimpses earlier in the session of
how neglected she feels. Importantly, there
were no further suicide attempts, during
the psychotherapy that lasted a year
altogether, and Annabel gradually stopped
her self-harm through cutting.
AUTHOR NOTE

Stephen Briggs, Tavistock Clinic, London,

UK.
John T. Maltsberger, Harvard Medical
School, Mclean Hospital, Boston, MA,
USA.
Mark J. Goldblatt, Harvard Medical
School, McLean Hospital, Belmont, MA,
USA.
Reinhard Lindner & Georg Fiedler
Centre for Therapy and Studies of Suicidal

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S. Briggs et al.

Behaviour, University Hospital Hamburg

Eppendorf, Hamburg, Germany.
Correspondence concerning this article
should be addressed to Stephen Briggs,
Adolescent Department, Tavistock Clinic,
London, NW3 5BA. E-mail: sbriggs@
tavi-port.nhs.uk
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