The wish to die and the wish to commit suicide in the adolescent: two different matters?

Manor, Iris ; Vincent, Michel ; Tyano, Sam 等

Every day in hospital emergency rooms, doctors see adolescents who have attempted suicide. The question that doctors may ask these adolescents is, "Why did you want to die?" An immediate connection is thereby made between suicide on the one hand and the death wish on the other, as though it is obvious that the wish to commit suicide and the wish to die are the same thing.

The parallel between suicide and death was established as early as Freud in his discussions of the death wish, and also in the work of Klein (1945). Later theoreticians also made a connection between suicide and the death wish, and argued that everyone who attempts suicide suffers from depression. Others suggested a connection between suicide and psychosis. Consequently, for many years it was deemed advisable to place adolescents who attempted suicide in hospital psychiatric wards for observation or treatment. However, recent studies have noted a lack of empirical justification for this approach. For example, Apter et al. (1993) found that psychopathology was low even among youngsters whose suicide attempts had been successful. In other words, suicidal behavior, even when the victim died, had not occurred on the basis of classified psychiatric illness, but rather on the basis of personality disorders.

In many of our conversations and interviews with adolescents, we found that the topic of death is a significant mental preoccupation. Much thought is given to the idea of the end of life, even when self-inflicted, in adolescents having no psychopathology or suicide wish. It thus appears to us that the intuitive, seemingly inseparable connection between the suicidal act and the death wish obscures a far more complex scenario.

We suggest that the suicidal act is an expression of suicidal thoughts, which are far more common than the act itself, which in turn is far more common than completed suicide. This is in contrast to a death wish that may exist but that does not necessarily find a suicidal expression, although its manifestations may be numerous and varied.

Suicidal acts begin to appear in adolescence, together with ego development and the development of abstract thinking (Piaget, 1962), as well as sexual maturation and the formulation of the fourth organizer, with its resolution by taking responsibility over one's mature body and its fertility. These developmental paths lead to attempts by the adolescent to cope with issues surrounding his/her own life and death. Conversely, the death instinct originates with the birth of the human being and is an integral part of development, as has been pointed out by Freud (1926) and Klein (1945).

It is important to note that the wish to die and the wish to commit suicide can appear separately or jointly; in the latter case, they reach their full destructive expression. Accordingly, we will focus on the place of these wishes in normal development and the needs fulfilled by them. We will also attempt to determine the line that differentiates the normal from the abnormal, and how to deal with each of these cases as a result of this demarcation.

THE WISH TO COMMIT SUICIDE

Case example. R., a young woman of 21, has been frequently hospitalized in a closed ward over a period of six years. Since she was 14, R. has attempted suicide repeatedly, but until now this has not resulted in serious injury. It is important to note that R. worked for a while as a paramedic, so that if she wanted to die she is well acquainted with the necessary means for doing so. R. is extremely intelligent, has never been diagnosed as suffering from a major mental illness, but has borderline personality disorder. Despite this, her life revolves around an axis of suicidal behavior. In her own words, she enjoys playing with death and has developed an addiction to the suicidal act. In conversation, she conveys a feeling of overwhelming emptiness and the constant need for mirroring by others.

This patient uses the object in a sadistic way, but does not break it. Winnicott (1958) discusses the self as an unconscious feeling of continuity, which makes it possible, from day to day and from experience to experience, to feel oneself. In this girl, who has a borderline personality disorder, there is disconnection between times, as well as between experiences, and the "oneness" is injured. Therefore, there are disconnections within the experience of the self.

Unlike Blos (1962), who claimed that during adolescence there is anxiety concerning the separation process, Freud (1926) saw adolescence as rebirth. Rakov (1989) and Tyano (1984) also compared it to rebirth or "Renaissance" (i.e., repeating all the stages of development). This comparison is especially interesting when one remembers the colorful and cruel nature of the historical Renaissance. Sexual maturation and fertility which develop at this age necessitate control over oneself through a renewed examination of values and desires. The end of adolescence parallels the genital stage associated by Freud with two goals: loving and working. The development of the ability to love includes the adaptation (cultivation) of the fantasy of the imaginary child described by Freud (1914). The turning outward to the object is dictated by the need for life as a rejection of narcissistic elements. At this stage there is also the resolution of the conflict between ideal ego/superego through the integration of the ideal ego into the superego. This takes place by means of the solution of the inverted complex, which ties the child to same-sex parent. After the act of mourning for the loss of the narcissistic object, and after processing the experience of the ego's loss of a part of itself, heterosexuality receives its domineering status. Subsequently, the ideal of the self expresses itself by anticipation, the realization of which is becoming possible. This integration can be grasped as a meta-psychological expression of the fourth organizer, the conflict around the maturation of the fertile body, and the conscious decision to live, and to bring life, which is related to it. The difficulty of coping with life is especially great during adolescence due to the fact that this is the age at which identity moratorium occurs. The adolescent finds himself/herself in a time bubble in which he/she is not committed to anything except the formulation of the identity that will accompany him/her through life. When the bubble bursts, the adolescent will have to be the possessor of a clear identity and make major life choices regarding a profession and a mate. In other words, commitment. The fear of commitment is tremendous, and at times there is an attempt to defer it by "freezing" time. According to Colarusso (1979), normal child development is directed toward the formulation of two perceptions, or experiences, of time. On the one hand, there is internal or subjective time, which is also called "maternal time." This time has no meaning in the outer world and measures internal changes and experiences only. This conception of time exists from earliest childhood and is regulated by homeostatic mechanisms and feelings of satisfaction and frustration (e.g., satiation as opposed to hunger). On the other hand, there is external or objective time, which is also called "paternal time." This time is regulated by the laws of external reality and the time frames that measure it. Paternal time begins to develop with the formulation of the conception of reality, the determination of the object, and the development of linguistic concepts such as "tomorrow, today, soon, when." Therefore, the conception of reality in childhood is dynamic, and involves a merging of these two times.

In adolescence, paternal time is established by drawing a sharp distinction between the physically and sexually immature past and the mature present. There is the danger of an internal split between the two types of time. With time diffusion, one timekeeping mechanism (paternal time) continues to advance, while the other (maternal time) can be frozen, or can move in different directions, since the reality of time and space do not apply. The process of adjustment to time is painful, and in Colarusso's opinion, expresses a true intrapsychic conflict. On one side, there is the need and desire to get used to time and, on the other, there is an attempt to suspend the associated pain. The greater the pressures to which the adolescent is subjected, or the more sensitive he/she is, the greater the danger of a split between the time frames and the greater the fixation on the conflict. It should be noted that in psychotic patients, and more specifically in melancholic patients, paternal time loses its meaning.

Vincent (1988) describes three developmental positions in adolescence: chaos, narcissistic depression, and renewed cathexis of the object. Tyano (1998) and Vincent (1988) state that the transition between these three positions is liable to involve a great amount of pain, which may result in a crisis. One of the factors that allows one to cope with this pain is the decision to live. In our opinion, during the transition from the first to the second position, every individual unconsciously undergoes the struggle with the question of whether to live or not to live. This struggle thus takes on the status of a normative stage, in which the question is posed and coped with unconsciously, as the adolescent forms an identity. During this process, the adolescent asks himself/herself about the significance of life--brought sharply into focus by a tendency toward philosophical thinking and the preoccupation with abstract questions characteristic of this age. The adolescent, who has previously thought about death in general, realizes for the first time that his/her own life is going to end at some point (Piaget, 1962). This is a new and final stage in the development of one's own death conceptualization.

The fourth organizer usually develops without any disturbances or behavioral manifestations. However, some adolescents, with latent pathology from childhood, may experience certain difficulties, which can have mild, moderate, or severe manifestations according to the degree or nature of the pathology.

The mild manifestations of this organization disorder occur in adolescents who experience pain during the transition from one position to the next. This pain leaves them with emotional scars. In such cases, the question of choosing life ascends more and more into consciousness and the process ceases to be normative. These are the adolescents who suffer from suicidal ideation.

In moderate manifestations, the adolescent may turn to the use of drugs, alcohol, or to what is termed by Nicolas (1980) as les conduites ordaliques (gambling-on-life behavior), such as driving recklessly. All of these behaviors indicate a preoccupation with the struggle over the question of whether to live or die, or leaving it to fate. These acts, in which an individual may flirt with death, offer a sense of excitement.

Adolescents with severe manifestations turn to suicidal acts which, during adolescence, take on specific significance. These acts express the desire to be "temporarily" absent; in other words, to freeze external time, while carrying on with internal time. This process allows adolescents simultaneously to avoid external pain and to stop the maturation process. As this act of attempting suicide has, dynamically speaking, its pleasure principle (i.e., enjoying victory over death by staying alive), approximately 40% of these adolescents will make additional attempts and become "suicide addicts."

The failure of the fourth organizer process is expressed by the ultimate acting out, which is the decision about suicide that results in death. The suicidal act is carried out, whether its purpose is to soothe the pain or to stop the natural processes (since it will indeed stop growth), or whether its source is an inability to internalize the sexual body. The act is the expression, in a language adolescents create for themselves, of the place in which death and suicide are connected. Even if the death wish itself is not the main motive, it nevertheless exists beneath the surface. The adolescent thus chooses a pathological and destructive solution out of a sense of incapacity and a lack of power to choose life. In these cases, suicide connects with depression, so that suicide becomes the means to express depression.

In many senses, an especially beautiful literary expression of suicide that does not involve the death wish is in The Little Prince. The suicidal act of the Little Prince is performed out of love of life but is caused by him losing his way. The Little Prince is a figure who descended from a star where everything is innocent and has endless possibilities. Adult rules, expressed in terms of time and space, enter his world of eternal childhood, and the Little Prince can no longer find his place in this world. As a result, he asks the snake to bite him, so that he can return to his star. Without having a particular death wish, but with a perception of prolonged sadness (while watching the sunset), he returns to the place where maternal time reigns.

THE WISH TO DIE

Particularly since the appearance of television in our lives, which routinely discloses the latest traffic accidents, disasters, diseases, wars and terror, death has become a permanent visitor in our living rooms, even if we do not rub shoulders with it in our private lives. Death has become so familiar that it is almost approachable. Unlike suicide, with its frightening suddenness, death is usually experienced as something sad but inevitable. As Camus (1947) has said, "We are all condemned to death, but do not know our hour of execution." At the same time, death has been considered something exalted, as can be seen in the mystification surrounding it. In Mortal Questions, Nagel (1979) asks, in the chapter "Death," whether it is a good or a bad thing. Others see death as a constraint throughout life, influencing everything we do. In general, death is perceived as the final reward--a state of absolute rest. There remains the question of where, deep within us, is the source of the thoughts, impulses, and fantasies surrounding death.

The term "death instinct" first appeared in Freud's (1920) essay "Beyond the Pleasure Principle" and recurred throughout his work. This term remains one of the most frequently discussed to this day. In this context, it is important to understand the development of Freud's thinking. Freud describes the interplay of the life instinct and the death instinct (Eros-Thanatos). It is possible to observe the working of the pure death instinct when it is detached from the life instinct, as, for example, in the case of the melancholic patient in which the superego appears as "a pure culture of the death instinct." According to Freud, suicide is an unresolved problem. How is it possible that an individual can overcome the all-powerful life instinct? Is this a case of disappointed libido or an ego that has become alienated from its own preservation out of its own egoistic motives? Freud suggests that we have no way of answering these questions, other than from the starting point of melancholy and the comparison between it and the effect of mourning. In his essay "On Mourning and Melancholia," Freud (1917) claims that, as opposed to mourning, a process which is a part of growth, melancholy is the unconscious loss of the object which causes reproach. Self reproach is, in fact, an attack against the object. Within every experience of mourning, guilt feelings can be found about what was done and not done, while melancholy is a desperate struggle for survival in the face of annihilation anxiety, and deprives the ego because of the object. In comparison, the ego integrates qualities of the lost object in the mourning process. In fact, the mourning is not for the missing object, but for earlier losses for which it is impossible to mourn, as acknowledging this will cause annihilation. The gap between mourning and melancholy exists because, in mourning, the world becomes empty, whereas, in melancholy, there is an emptying of the self. Accordingly, the decrease in self-esteem differentiates melancholy from mourning. Freud states that at the root of melancholy there is disappointment caused by the beloved object and the undermining or shattering of the relationship with the object. Thus, Freud refers to suicide as the killing of the self, which contains within it the internalized image that the individual actually wishes to destroy. In 'The Ego and the Id," Freud (1923) expands on the psychological roots of the death instinct and relates the striving for decomposition and the bursting forth of the death instinct as central expressions of many severe neuroses. Continuing Freud's ideas, and following Klein, Segal (1964) points out that manifestations of the various instincts exist from birth. The mother displays to the infant the whole spectrum, from vitality and eagerness to live, to emptiness, boredom, and inner death. The infant reacts to the mother, as is shown in "The Dead Mother" (Green, 1986), and, through her, experiences these himself/ herself.

With these first perceptions, two possibilities exist for the infant. One is satisfaction of the need, epitomized by the search for the object, love and the expression of the life instinct; the second is the obliteration of the need, in other words the expression of the death instinct. The infant may feel vital and acquires an eagerness to live, as well as sensitivity to different stimuli, from within and from without. Alternatively, the infant may feel empty, a complete vacuum which can never be filled. This perception is total in those babies described by Spitz (1965) as anaclitically depressed.

Freud describes the expressions of the death principle as the compulsive repetition, sadomasochism and murderous wish of the melancholic superego--that same murderous wish which causes suicide. One must stress the importance of aggression, the means by which the organism protects itself against the death instinct, but which also allows aggression to reach expression via its deflection from the psyche onto an object. The death instinct unties the object relations, and the life instinct reties them. Freud (1917) speaks of the silent working of the death instinct, which is constantly involved in the libido and is, thereby, turned outward.

Klein (1945) refers to the death instinct in relation to the development of both Anxiety and guilt. In her opinion, both the death instinct and envy have a central characteristic in common, which is an attack on life and its origins. She claims that jealousy is the extreme expression of the death instinct. Early jealousy is covered by the death instinct and there is an intimate connection between them, since the object supplying the need is also perceived as an irritant, requiring removal. At the same time, the object is the creator of the need and is capable of removing the irritation. As a result, hatred and envy are directed toward it. Annihilation allows an expression of the death instinct, but is also a defense against envy, in that it removes the cause of the irritation. Similarly, in Segal's (1964) opinion, the defenses against the death instinct create a vicious circle that leads to severe pathologies. As previously mentioned, a later description that differs slightly but is also based on the experience of the death instinct as one of deprivation and emptiness is provided by Green (1986). Green describes the sense of internal emptiness and depression emanating from a patient who was the child of a "dead mother." According to Green's interpretation, the feeling of loss begins with the image of the mourning, "empty" mother, the "dead mother," who is also absent, thus awakening at the core of the infant's existence the feeling of deprivation in the place where her image should have been. Green states that this image binds the infant to a great extent, as an attempt is made to awaken the mother from death. The analyst senses a source of childhood depression, but the patient denies its existence. This depression bursts forth in transference. In addition, Green describes classic neurotic symptoms. Although they are also presented as central, the analyst gets the feeling that their solution will not reconcile the conflict. After attempts at simulated acceptance and agitation fail, the infant turns to mirror identification with the dead mother. The purpose is to achieve ownership over the object, which is impossible because it is not in the infant's jurisdiction, and is accomplished by turning into the object itself, via incorporation (Abraham, 1977) and by achieving narcissistic identification (Freud, 1914). This unconscious identification appears as a foreign body within the ego. Due to its origin in an early part of development, the perception of death extends over a wide range of human existence, in terms of time and norms. The preoccupation with death has its origin in areas defined as normal, and extends into areas of trauma, personality disorders and deprivations. It is important to stress that since the wish to die is the desire "not to exist any more to eternity," it is directly connected to depressive tendencies, which may have already appeared in childhood (seven years old and onwards, if not earlier). In the same way that the infant deprived of love and warmth turns to the wall and withdraws from all human contact (Spitz, 1965), the individual experiencing early frustration is attracted more and more to the embrace of the death experience. Described in literature as a black ocean having no borders, or as a white shining space, the death experience allows the person suffering from early deprivation an illusion of compensation, of an endlessly satisfying wellspring.

Regarding adolescents, the question arises as to whether the preoccupation with death represents, in addition, an exercise in abstract thinking (i.e., a form of experimentation with newly acquired cognitive tools in relation to such a fascinating subject). In light of all this, one might ask if the wish to die is dependent on age. It seems that this wish is, in fact, capable of encompassing all ages, while the Amount of yearning after death depends on the degree of early deprivation.

Case example. H., a 13-year-old girl, behaves in her dally life like any teenager. Nevertheless, she suffers constantly from bodily pains, especially in the stomach and head, and has recently developed an eating disorder. However, she "looks after herself' and has suffered no drastic weight loss in the last year; in fact, her weight is quite stable. She has many girlfriends and a normal social life, is a good student, and is an accepted member of her school and community. For the past four years, she has been constantly preoccupied with thoughts about death. There has never been talk of suicide and definitely no suicidal act, and she denies all conscious desire to die. On the other hand, death appears in the poems she writes and also in her dreams. An example of a dream: H. is walking with a group of children when a monster begins chasing them. They run into a house, while on the roofs of other houses there are flashing red lights that H. interprets as the souls of dead children. Two children from the group are killed, so H. is aware that all of them will die. They climb up onto the roof and jump to their death. This dream may be seen as the convergence of depression and paranoia. The narcissistic offense experienced by H. is shown through the pathological conflict of the leading neurosis in the background. The monster may be interpreted as the bad object described by Klein, and as a threatening paternal ghost chasing the living children, as well as the dead children. It is the mixing of the sexual implications of the father for his adolescent (and admiring) daughter and the threat of, as well as the longing for, death accompanying the family, especially the children born after H. It is the interpretation of the fulfillment of sexual drives which implies that death and libido and death instinct are one and the same in that family, as in H.'s subjective universe.

In the course of psychotherapy the central perception is that of depression, although without the components characterizing major depression. There is, rather, an awakening of an experience of great emptiness. The negation experienced by H. is reflected in the emptiness and the perception of "nil," which is in the center all the time: no laughter, no words, no suffering, but also no life.

DISCUSSION

The wish to die arises with the awakening of life, whereas suicidal tendencies develop ten years later or more, during adolescence. Adolescence is the age in which the wish to die begins to acquire a quality of suicidal expression that becomes possible through puberty. This comes in addition to other expressions that existed beforehand, such as anaclitic depression, thoughts and fears about death. The wish to die and the wish to commit suicide can be conjoined in the final suicidal act, but they are also liable to develop from totally different sources, in time (both paternal and maternal) and in the underground currents that cause them to ripen.

Religion, which records the development of abstract thinking, differentiates between death and suicide. Death is regarded by all religions as an integral part of life. It is another form of existence (see, for example, the descriptions of heaven and hell). Suicide is forbidden by some religions and is considered by others to be an elevated or saintly act. Thus, at the foundation of organized human thought about morality, there is a clear distinction between death and suicide. The explanation for this may lie in the fact that death is a natural phenomenon, whereas suicide is unnatural and is therefore considered an act of defiance against fate. In other words, suicide is considered to be a tragic act which takes control of the life and death "button"--the assuming of a God-like role.

The idea of death is liable to be frightening, as it may represent disappearance, dissolution, a total loss of everything one is and everything one was. Nonetheless, the experience of eternity is liable to be no less terrifying. Especially in the eyes of the adolescent, the significance of eternity is that whatever is determined will remain fixed "forever." Specifically, the decisions the adolescent will make at the end of maturation will be fixed, unchanging and eternal. As a result, the choice of life and the eternity it promises is also difficult and frightening.

In the past, adolescence was relatively brief, dictated by the need for survival, which created strict behavioral codes. Those who did not go out to work in the fields were doomed to die of starvation; marriage came early because life expectancy was short and many children died in infancy. As a result, while the adolescent often suffered from a sense of insignificance and helplessness, there was a feeling of reassuring security in knowing life's limits. During the twentieth century, expanded freedom meant fewer of those limits which, in the past, provided a measure of comfort. In addition, the identity development stage of moratorium became extended. As part of the lengthy moratorium, the dilemma surrounding sexual maturation increased. The adolescent is supposed to internalize his/her sexual body (Laufer 1968), and the failure to do so results in arrested development. Complications can lead the adolescent to try to stop the body's development (as in anorexia) by its destruction. The ever-widening gap between biological, hormonal reality and internal, psychological reality magnifies the need to freeze time or to sever relations between its external and internal manifestations; in other words, death is the preferred choice.

The process of mourning surrounding death expresses the distress and ambiguity regarding it. On the one hand, there is loss and anxiety in the face of annihilation, stemming from emptiness and a sense of guilt. On the other hand, mourning is also a protest against death, a sharpening, as Heidegger says, of daily existence in light of it.

Annihilation anxiety is also the fear of following the deceased loved one. In the story of Orpheus and Eurydice, the live groom tries to bring his dead bride back from the underworld. Orpheus is warned that if he attempts it again, he will not be allowed to leave the underworld. Segal (1964) describes a psychic pain involving the expression of the death instinct. In Segal's opinion, this pain stems from the threatened libidinal ego and expresses annihilation anxiety. Similarly, the purpose of the psychic pain involved in mourning may be to remind the individual of the boundary between life and death, and that he/she is still alive. According to Freud (1917), the melancholic patient is incapable of mourning due to the fact that the lost object is incorporated; thus, the patient continues to confront it. It could be said that, according to Freud, the melancholic is an Orpheus who is unable to relinquish his loved one and, as a result, cannot abandon the underworld.

Melancholy is not mourning. It does not entail the pain protecting the individual from the death instinct; it does not involve annihilation anxiety and does not require the suicidal act. Although this act demands the power of the libido and examines the border of life, it finds itself in the realm of death from the beginning. In other words, the wish to die is primal. According to the nirvana principle, it grapples with the wish to live and inflames it, and is created together with it, in the early stages of development, and with the fixation of the first organizers. It is liable to appear and find expression at all ages, and adolescence has no special significance for it. In adolescence, the wish to commit suicide may appear together with the wish to die, and can appear as a metamorphosis of the internalization of the sexual body, rejecting the internal parents, who were in charge up until then, and the need to choose life out of responsibility. It is suggested that in children there are no suicidal thoughts, but there is the wish to die, which searches for expression; conversely, suicide in its clinical and psychological meaning appears only in adolescence.

The experience of death is primal (Klein, 1945); accordingly, the wishes it arouses are also primal and the sensations it arouses are all-embracing and lacking in the individuation that has yet to come into existence. Conversely, suicide is individual, touching on questions that are of importance to the individual, such as "Who am I and do I like what I see?" or, "Am I prepared to live as I am?" Suicide is situated in a higher place on the developmental ladder because it defines the existence of death as opposed to life, and the control of the human being over death. As a result, the Anxiety expressed by suicide is Anxiety in the face of eternity which, in the adolescent's experience, especially if his/her development is abnormal, is sterile, causing a fear of barrenness and boredom.

It is also possible to define the various wishes by means of basic, key questions that direct a way of thinking. In The Little Prince, the suicidal question is: "Can you return me to my star?" This question is based on the desire to freeze time, and conveys a sense of not fitting in anywhere and of being a constant stranger whose language is foreign. The true wish is to preserve a special, individual, consistent identity that does not have to compromise with the reality principle (i.e., the adult world).

The question representing the wish to die is unclear, because the sense of death has its origin in a place where language is primal and the power of speech does not yet exist. A question that possibly represents the death wish is, Where do the ducks go when the lake freezes over?" (The Catcher in the Rye; Salinger, 1951). When the lake, symbolizing the primal oceanic abyss, is frozen, the ducks have to leave. They have no place in any sense of the word. The death experience is a deep, cold deprivation having no pity or remedy, to the point where the only solution is to disappear. It simply is not clear where to go. As opposed to the suicidal question, which represents a wish to return "home" to preserve omnipotence in the changing continuum of time, the wish related to death is an open question. It cannot express a definite demand, but does the opposite: it expresses despair from an existential position that does not allow survival. It is possible that the gap between the wish to commit suicide and the wish to die stems from this. The act of suicide means seeing a way, and for this reason it enables the adolescent to perform an act. The wish to die goes nowhere beyond the sense of apathy (frozenness) and has "no exit," and for this reason it lacks any practical or verbal expression. There is no act that ends the experience, since the inside is frozen' like the lake outside.

From all this stems the need for different therapy for adolescents. Suicidality in this age group should be treated in accordance with the currents hidden beneath the surface of the act. For the adolescent who presents a conflict connected with the fourth organizer, therapy must deal with the difficulty of coping with sexual maturation together with the need to take responsibility for life. Conversely, for the adolescent who expresses the wish to die, therapy is directed at anaclitic depression. The first deep nonverbal deprivation demands prolonged "resuscitation" of the patient, for whom satisfaction of primal oral needs in the deprivation and emptiness formed around them became predatory. On the other hand, therapy for suicide should focus on the processing of special recurrent distinctions. It cannot be emphasized enough that these states are not necessarily "pure"; on the contrary, they are states in which the conflict that appears on the surface "rides" upon deeper needs and deprivations which involve the wish to die. When the wish to die and the suicidal wish combine, the danger of the fatal act is extremely great. In these situations, we are liable to find ourselves beginning treatment of a patient with a suicidal wish, who seems on the surface to have oedipal conflicts. Nevertheless, we will discover beneath this relatively mature facade a wish to die accompanied by uncontrollable oral drives. In the center, we will fred a sense of deprivation which is like a black hole. Consequently, treatment of the suicidal wish, with very ambivalent conflicts at its core dealing with growth and the sense of time, is verbal therapy. Conversely, treatment of the wish to die is dynamic experiential therapy, touching the primal experience lacking speech and a sense of time, and at its core is the need to find a lake that does not freeze, that inner lake which will allow the individual to have faith in growth and development.

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