Adolescent Psychiatry, V. 21

Annals of the American Society for Adolescent Psychiatry

Lois T. Flaherty, Harvey Horowitz, Lois T. Flaherty, Harvey Horowitz

• Publisher: Routledge
• Year: 2016
• Print ISBN: 9780367606404
• eBook ISBN: 9781317737445
• Topic: Psychology
• Subtopic: Developmental Psychology
• Index: Psychology

Launched in 1971, Adolescent Psychiatry, in the words of founding coeditors Sherman C. Feinstein, Peter L. Giovacchini, and Arthur A. Miller, promised "to explore adolescence as a process . . . to enter challenging and exciting areas that may have profound effects on our basic concepts." Further, they promised a "series that will provide a forum for the expression of ideas and problems that plague and excite so many of us working in this enigmatic but fascinating field." For over two decades, Adolescent Psychiatry has fulfilled this promise. The repository of a wealth of original studies by preeminent clinicians, developmental researchers, and social scientists specializing in this stage of life, the series has become an essential resource for all mental health practitioners working with youth.

Volume 21 honors the memory of Richard C. Marohn, former editor of Adolescent Psychiatry, and Herman D. Staples, founding member of the American Society for Adolescent Psychiatry. It begins with a section of papers that ranges over important aspects of "Development and Psychopathology." Topics explored by the contributors include: adolescents and authority; adolescents and disaster; adolescent awareness of the past; adolescent daughters of divorce; parent loss; adolescent schizophrenia; and adolescent mood disorders. Sections on "Assessment," "Issues in Psychotherapy," and "Training" round out a balanced survey of the field that is true to the spirit of this distinguished series. Volume 21 will be rewarding reading for child and adolescent therapists and all students of early development.

PART I

DEVELOPMENT
AND
PSYCHOPATHOLOGY

1A HIERARCHICAL MODEL OF ADOLESCENT DEVELOPMENT: IMPLICATIONS FOR PSYCHOTHERAPY

CHARLES M. JAFFE

Psychotherapy with adolescents has long been recognized as particularly challenging because young people come for help with specific problems in adaptation while they are in the midst of rapid developmental change. The rapid fluctuation and the range of behaviors typical of the period can make diagnosis and treatment perplexing (A. Freud, 1958). It may be difficult to understand adolescents because their modes of expression are often action oriented and engender strong responses in those around them. In addition, adolescents are often elusive with therapists, making the ordinary dialogue through which people learn about one another difficult (Katz, 1990).

Following Aichhorn’s (1925) precedent, effective adolescent psychotherapists have flexibly employed a variety of interventions. For many of us, however, the psychoanalytically based developmental theory of adolescence and the practice of adolescent psychotherapy are not congruent. Adolescent therapists have always known that you do whatever works. But, it often seems a stretch to find a theoretical rationale for the wide range of interventions we all make. At the very least, the list of interventions includes giving advice, providing information about sex and educational and vocational opportunities; exploring the possibilities and planning of new ideas and actions; making self-disclosures about our own feelings and life decisions; offering a set of values, and helping the adolescent to develop a realistic acceptance of strengths and limitations. Often, helpful interventions include going to high school plays and graduations and joining patients on wilderness challenges. Occasionally, we might even interpret unconscious conflict.

Descriptions of psychotherapeutic technique with adolescents which use psychoanalytic models have emphasized synthesis over analysis (Gitelson, 1948) or the provision of ego support over the expression of regressive wishes and conflict (Masterson, 1958; Meeks, 1971). Although flexibility and availability are always recommended to adolescent therapists, an integrated rationale for the full range of interventions has been lacking. The result is that many of us feel constricted if we force our understanding into a framework that seems inadequate to describe and treat the problems we encounter, or we feel alienated as we work pragmatically and flexibly but with a sense of operating outside of, or in opposition to, standard practice.

Despite the challenge, every clinician is faced with the task of making sense of patients’ problems in order to form a plan to help, to develop a therapeutic relationship that allows for adequate interventions, and to assess the progress of psychotherapy. In other words, we are always asking, What is wrong and what can I do about it? This task requires a theory to organize what is observed—a psychology of adolescence that can explain expected occurrences in the normal course of development, and that can then be used to understand deviations from the norm and serve as a rational guide to our therapeutic interventions.

I will first review some major psychoanalytic paradigms within which adolescence has previously been conceptualized and then discuss the revisions that have altered these theories. I will then present what I believe to be a broad and useful framework for understanding adolescents that has emerged out of clinical experience, revisions of psychoanalytic theory, and developmental research. Since my purpose here is to present perspectives on the adolescent’s psychological organization, the many social, cultural (Rakoff, 1989; Galatzer-Levy and Cohler, 1993) and biological influences—including organic disorders affecting learning (Silver, 1993), mood (Golombek and Garfinkel, 1983; Cantwell, 1992), and thought (Volkmar, 1994)—are not addressed directly, but are considered from the perspective of their meaning to the psychologically developing individual. Finally, I illustrate how this model influences a theory of psychotherapy of adolescents and provides a rational guide to interventions.

Overview of Adolescence

We are all familiar with the normative spectrum of adolescent behaviors that generally delineate the passage through early, middle, and late adolescence. There are significant alterations in all aspects of life as the child explores new sexual and social behavior, new relationships with family and friends, and new intellectual skills. We generally accept that adolescent development reflects the confluence of physical and cognitive maturation and the expectations of the individual adolescent, the family, and society within an historical context (Blos, 1962; Erikson, 1968; Rakoff, 1989).

The progressive changes in adolescent behavior are understood to be the manifest expression of the developing child’s efforts to master challenges and to manage anxiety. Successful mastery is accomplished through the reorganization of typical patterns of experiencing oneself, others, and the world. The “products” of this reorganization are familiar as the shibboleths of adolescent development: identity, character, mature super-ego and ego-ideal. Autonomy, individuation, and independence derive from these structural changes.

There is general agreement that the transformations of adolescence are influenced by prior development, that reorganization presents the opportunity for new growth through recapitulation of earlier experience in the light of new abilities, and that the transformations are molded by available avenues of expression. The progress toward mastery is monitored by reference to comfort with one’s own body, the quality of relationships (with friends, family, and lovers), educational and later vocational vitality and direction, and the ability to plan flexibly and responsibly view one’s life in the context of a generally optimistic and realistic attitude toward oneself and others. Because the achievement of self-maintenance and satisfying sexual, interpersonal, and vocational functioning is considered by adolescents and adults to be important to a productive and satisfying life, these are usually referred to as “the developmental tasks of adolescence.”

Psychoanalytic Theories of Adolescence

Beyond this generic agreement, there really is no psychoanalytic theory of adolescence. Explanations for the psychological transformations in adolescence have always been based on some general theoretical orientation of mental organization, development, and psychopathology. Each orientation has its own assumptions about the basic motivation for the actions that organize psychological development and functioning (Greenberg and Mitchell, 1983). As a result, psychoanalytic theories of drive, ego, separation-individuation, social interaction, and the development of the self make different contributions to the definition, the process of psychological transformation, and the expected outcome of adolescence.

For example, theories that follow Freud’s emphasis on the biphasic nature of sexual development, with instinctual discharge as the primary motivator for action, view adolescence primarily as the necessary revision of childhood sexuality in response to puberty (Blos, 1962, 1967, 1968, 1979). Independence, identity, intimacy, and realistic productivity reflect the successful reengagement of oedipal and preoedipal conflict so that the mature expression of sexual impulses is assured. Adolescence describes the process through which the child resolves restimulated preoedipal and oedipal conflicts and consolidates a stable character structure through the transformation of instinct, ego, superego, and ego ideal. The outcome of development depends on the child’s ego strength, the strength of the instincts, and the adequacy of the child’s defenses.

Other psychoanalytic theories emphasize the primary motive of object relations. Development and pathology are functions of the vicissitudes of their internal representations, In object relations theory, adolescence is the response to a normative thrust toward autonomy. The adolescent’s task is to achieve autonomy with stable internal self-and object representations, intact reality testing, and secure ego boundaries. Disengagement from primary love objects recapitulates the separation-individuation phase of early childhood (Masterson, 1972). Psychopathology occurs in adolescence because the child is without the requisite internal structures to master the second individuation process.

Yet another theory, self psychology, views self-cohesion as the primary motive for action and development. Self psychology emphasizes the importance of empathic persons who are capable of fostering the selfobject experiences necessary to form and maintain a cohesive self (Kohut, 1971, 1977, 1984). In this view, adolescence is not a reaction to puberty; rather “the essential requirement for its occurrence seems to be the emergence of an inner necessity for new ideals, accompanied by opportunities encountered for such a transformation of the self” (Wolf, Gedo, and Terman, 1972, p. 269; Wolf, 1980, 1982; Kohut, 1972). The adolescent transformation involves a phase-appropriate deidealization of parental standards, resulting in disrupted self-cohesion that the adolescent regulates through selfobject experiences with peers, and culminating in restored self-cohesion through a transformation of the self. Satisfying sexual expression and, indeed, self-assertions in relationships and tasks of all kinds reflect stable selfobject experiences. Pathology occurs if empathic failures in childhood result in the persistence of an archaic idealizing and grandiose self that continues to seek satisfying selfobjects relations (Marohn, 1977).

In summary, each theory emphasizes some aspect of adolescence, and together they provide a sense of the rich adolescent process. Problems arise, however, when one looks more carefully at the individual theories or attempts to integrate them.

Influences of Revisions in Psychoanalytic Theory on Approaches to Adolescence

In the past few years extensive attention has been devoted to clarifying the psychoanalytic theory of motivation and development and to providing a useful theory of therapy. Psychoanalytic theory has been influenced reciprocally by investigations of motivation, theory formation, new discoveries in clinical process and technique, and observational research. These have been usefully applied to understanding and treating adolescents.

For example, Freud’s method of theory formation has been vigorously criticized and his basic assumptions about thought and motivation examined and revised (Peterfreund, 1971; Basch, 1973; G. Klein, 1976; Schafer, 1976). Freud’s assumption that motivation is based on sexual and aggressive instincts that drive a closed system mental apparatus with the aim of tension discharge has been convincingly replaced by the more useful concept of motivation as the search for order mediated by affective communication (Basch, 1976). Motivation and development are more usefully understood to proceed from the fact that the brain integrates information rather than from a need to insure instinctual discharge and to avoid danger. Consistent with this view, child observation studies have demonstrated that infants enter the world as information-processing and organizing individuals very responsive to the environment (Lichtenberg, 1983, 1989; Stern, 1985) and with a propensity for organizing behavior and internal representations in concert with other people (Sameroff and Emde, 1989).

In addition to the motivational theory of instinct, Freud’s assumption that infants’ thinking includes symbols in much the same way that adults use words has been replaced by our knowledge that infants do not think like adults, but go through a progression of cognitive changes involving the increasingly complex use and manipulation of symbols (Piaget and Inhelder, 1969). Freud thought that the fantasies he had recovered through dreams and parapraxes represented the earliest form of thought—the primary process. In fact, he recovered complex symbolic transformations of experience. These revisions of the basic assumptions about human thought and motivation significantly affect any theory of development, defenses, and psychopathology.

The theory of adolescence has also been influenced by discoveries from the clinical process. Observations of transference, counter-transference and necessary alterations in technique have broadened our understanding of factors that affect therapeutic change (Eissler, 1953; Racker, 1968; Tansey and Burke, 1989). For many patients, transference issues seemed directed to the patient-therapist relationship and could not be profitably managed solely by interpretation of defense, resistance, or conflict. For these patients, progress in treatment seemed more connected to the stabilizing effects of the relationship than to insight into repressed wishes. From a theoretical standpoint, this emphasis on the patient-therapist relationship in therapeutic change encouraged clinicians to look for an explanation for these phenomena in that period of life involving the emergence of a self-sufficient individual from the nutritious or deficient soil of the dyadic relationship in infancy. Clinicians were encouraged to view these phenomena as renewed developmental striving and not simply as resistance (Kohut, 1984).

The resulting shift in focus to the subjective experience of the individual striving for wholeness through relationships rather than defending against impulses (Goldberg, 1978) has been especially salutary for understanding adolescents’ need for guidance, for genuine affective responses, and for help in forming a realistic assessment of themselves and others. It gives a theoretical underpinning for the range of interventions necessary for work with adolescent patients.

A Revised Conceptualization of the Adolescent Process

These cumulative revisions have produced an encompassing, rational model of development, pathology, and intervention that is usefully applied to the psychotherapy of adolescents. The model I review here represents an amalgamation. Although the model joins elements born of clinical experience and developmental research, I believe that the grounding of the clinical models in sound developmental principles permits their combination.¹ These common principles include several factors. First, development throughout life relates to the ordering of internal and external stimulation mediated through affective communication. Second, development proceeds in a dialectic between child and caretakers that may be described in terms of feedforward and feedback cycles that include assimilation, accommodation, identification of invariants, and associational learning. Third, the epigenetic principle encompasses development Specifically, increasingly complex organizations of internal models of oneself, the world, and patterns of interaction occur throughout development, each affecting the next. These increasingly complex organizations comprise constellations of affect, cognition, and behavioral integration, subjectively experienced in domains of self. Although organizations seem to appear in some predictable sequence determined by biobehavioral shifts during infancy and early childhood, once in place they co-exist and are transformed throughout life. And, fourth, psychopathology is related to problems integrating affectively meaningful information and the consequences of that behavior on subsequent adaptations.

Integration of Information: Motivation and the Cycle of Competence

The basis for the developmental theory is that motivation is based on the brain’s function of organizing information in the service of adaptation, a process that Basch (1988) refers to ...

Table of contents

• Cover Page
• Title Page
• Copyright Page
• Dedication
• Contents
• In Memoriam: Richard C. Marohn, M.D. (1934-1995)
• In Memoriam: Hennan D. Staples, M.D. (1918-1994)
• Part I Development and Psychopathology
• 1 A Hierarchical Model of Adolescent Development: Implications for Psychotherapy
• 2 The Awareness of the Past in Adolescence
• 3 Adolescence, Authority, and Change
• 4 Adolescents and Disaster
• 5 Breaking up or Breaking Away: The Struggle Around Autonomy and Individuation Among Adolescent Daughters of Divorce
• 6 Parent Loss in Childhood and Adult Psychopathology
• 7 Thought Disorders in Adolescent Schizophrenia: Toward an Integrative Model
• 8 The Family Perceptions of Young Adults with Putative Risk for Schizophrenia
• 9 Adolescent Mood Disorders
• Part II Assessment
• 10 Hearing the S.O.S.: Assessing the Lethality of a Youth in Distress
• 11 Use of Structured Assessment Tools in Clinical Practice
• 12 On the Uses and Misuses of Psychoeducational Evaluations
• Part III Issues in Psychotherapy
• 13 Adolescent Analyzability Reconsidered
• 14 Failures in Everyday Psychotherapy
• 15 Self Psychology Perspectives on Adolescents*
• 16 The Psychotherapeutic Pathway to Adaptive Individuation for Adolescents Confronting Conflict
• Part IV Interventions for Violence and Trauma
• 17 Intervening Against Violence in the Schools
• 18 The Game's the Thing: Play Psychotherapy with a Traumatized Young Adolescent Boy
• Part V Special Section on Training
• 19 Report of the Accreditation Council on Fellowships in Adolescent Psychiatry
• 20 Adolescent Psychiatry Training: Guidelines for Child and Adolescent Psychiatry Residents, General Psychiatry Residents, and Medical Students
• The Authors
• Contents of Volumes 1–20
• Index