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. …