Abrupt Terminations in the Treatment of Suicidal and Self-Harming Young People: The Negative in the Therapeutic Relationship

Psychotherapy with suicidal and self-harming young people is complex, as this population group is difficult to engage in treatment and their internal reactions may remain concealed, leading to impulsive suicide attempts or abandonment of treatment. The resulting countertransference reactions of confusion, guilt and shame are most distressing and often cause psychotherapists to avoid treating this population group. Safety concerns increase when self-destructive patients abandon therapy, or their condition worsens despite the therapist's best efforts. The vicissitudes of the adolescent developmental process suggest that, in some cases, withholding information, rejection of the therapist's caring interventions, and abrupt termination of treatment arise from the need for separation and independence and are ego syntonic and therefore suicide protecting. In other cases, the risk for suicide may be increased because of the transference experience of hostile abandonment. A negative therapeutic reaction (NTR) is a disturbing development in the course of psychotherapy that has not been adequately explained in the treatment of suicidal young people. This article is a consideration of whether these negative reactions associated with abrupt, unplanned terminations, in the treatment of self-destructive young people, should appropriately be thought of as an NTR or as a developmental stage in separation.