Adolescent Psychiatry, V. 24

Annals of the American Society for Adolescent Psychiatry

Aaron H. Esman

• Publisher: Routledge
• Year: 2013
• Topic: Psychology
• eBook ISBN:
  9781134891450
• Subtopic: Clinical Psychology
• Index: Psychology

Launched in 1971, Adolescent Psychiatry 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." 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 24 of The Annals surveys four broad areas of adolescent psychiatry that speak to the challenges and opportunities now before the field. Part I offers three important reassessments of adolescent development; they focus, respectively, on separation-individuation theory, the interpersonal matrix of adolescence, and the psychology of belonging. Part II explores the future of child and adolescent psychiatry in the context of school-based mental health services. Several assessments of ongoing school-based mental health clinics provide the context for reflection on the future of school-based delivery systems. Part III examines forensic issues in adolescent psychiatry and includes an overview of forensic psychiatry for adolescent psychiatrists, an update on juvenile justice, and a review of the issue of competence in adolescents. Finally, Part IV offers a series of current perspectives on psychopharmacology in relation to adolescence. Contributors review the current status of pharmacological treatment of different adolescent populations, including adolescents with behavior disorders, affective disorders, anxiety disorders, pervasive developmental disorders, and psychosis. The volume concludes with a timely examination of the role of psychiatric consultation on an adolescent medical service.

PART I

DEVELOPMENTAL CONSIDERATIONS: ADOLESCENT DEVELOPMENT RECONSIDERED

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SHELLEY DOCTORS AND HARVEY HOROWITZ

At the annual meeting of the American Society for Adolescent Psychiatry (ASAP) in May 1987, Richard C. Marohn presented “A Reexamination of Peter Blos's Concept of Prolonged Adolescence.” After his untimely death, his groundbreaking paper was revised and edited by colleagues Shelley R. Doctors and Robert J. Leider and published in Volume 23 of The Annals.

Dick Marohn, a self psychologist and former president of ASAP, was the first adolescent psychiatrist of stature to question the basic premises of the prevailing theory of adolescent development. He wrote (1998): “If one sees adolescence as ushered in by an increase in libidinal drive (S. Freud, 1905), and the concomitant developmental task as that of the loosening of infantile incestuous object ties (A. Freud, 1958), then the separation-individuation paradigm follows. That view of adolescence (as a recapitulation of separation-individuation) states that continued psychological contact with the ‘infantile objects’ is evidence of immaturity. The self—selfobject paradigm offers an alternative—that, throughout adolescence and adulthood, one retains ties to selfobjects. One never separates, individuates, or becomes psychologically independent. One remains psychologically connected. The contrast between these models is dramatic!” (pp. 14–15).

With this contribution, Marohn joined the intellectual ferment emerging in psychoanalysis, as the relational perspective evolved and differentiated itself from the classical tradition. This process and its tensions continue within the vital and illuminating psychoanalytic dialogue of the past decade. This Special Section, inspired by Dick Marohn and dedicated to his memory, proposes to further his work. The following three invited chapters address the question of a revised, updated psychoanalytic theory of adolescent development. Next year's Annals will present another such section.

REFERENCE

Marohn, R. (1998), A reexamination of Peter Blos's concept of prolonged adolescence. In: Adolescent Psychiatry, Vol. 23, ed. A. Esman. Hillsdale, NJ: The Analytic Press, pp. 3–19.

1 I AM, YOU ARE, AND SO ARE WE: A CURRENT PERSPECTIVE ON ADOLESCENT SEPARATION-INDIVIDUATION THEORY

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MARSHA H. LEVY-WARREN

The topic: what we know from mother—infant research that informs our understanding of the development of a sense of intimacy. The place: a college seminar room filled with bright, articulate upper class students. The discussion goes something like this:

“I think that the attunement between caregivers and infants is a key part of the development of a sense of intimacy.”

“But do you think that each one has to have a sense of self before real attunement is possible? And, if so, when does that kind of sense of self develop?”

“Hold it, though. Is there really a sense of self? Isn't it a dynamic concept? It seems to me that we never really have one sense of self, you know?”

“I think what we all call self changes over time.”

“It seems to me that intimacy requires reciprocity between two people, each of whom has a distinct sense of self—people who really know themselves—so that each can be attuned to the other without mistaking his or her own feelings for the partner's.”

“Is it mistaking feelings or being overly influenced by the other person's point of view that's the problem?”

“That kind of influence seems related to dependency. To be intimate, does each person have to be able to totally rely on the other?”

“Do you think that being close involves being able to lose yourself in someone else?”

Late adolescents, perhaps all adolescents—though their concerns change as they move through the adolescent years—are consumed with how to come to terms with who they are and what they want in life, how to be involved intimately with another person, and how they can come to know their deepest thoughts and feelings about these matters. The psychological theories that describe these processes are varied and often at odds with one another (e.g., S. Freud, 1905; A. Freud, 1958; Blos, 1962; Erikson, 1968; Offer, 1969; Wolf, 1982; Kaplan, 1984; Levy-Warren, 1996; Marohn, 1998). The point of view that I put forth in this paper is that achieving genitality is the primary focus of adolescence, that it embraces all of the outlined concerns, and that it develops by means of the separation and individuation processes of this time.

In 1905, Freud introduced the concept of genitality as the last of the psychosexual stages. In the present paper and elsewhere (Levy-Warren, 1996), I attempt to bring this concept into the framework of modern developmental psychoanalytic theory. As I conceive and describe it, genitality encompasses both the integration of adolescents' mature genitalia and the meaning of the functioning of the genitalia. In the evolution of genitality, adolescents come to accept their changed physiology, and they develop the capacity to derive pleasure from their bodies in having an intimate, satisfying relationship. In order to have such a relationship, people need to be able to see themselves and others accurately; they have to evolve from their childhood understandings of themselves to adolescent conceptions of themselves through the progression of their separation-individuation processes. Blos (1962, 1967) denotes this as a second individuation process.

According to Blos, this individuation is modeled on the separation-individuation process of infancy and early childhood first described by Mahler, Pine, and Bergman (1975). Mahler et al. observed that there is a slowly unfolding intrapsychic process that results in (a) a sense of separateness from, and relation to, a world of reality, particularly with regard to children's own bodies and their primary love objects (i.e., separation), and (b) an awareness of achievements that mark children's assumption of their own individual characteristics (i.e., individuation).

The second individuation theory (Blos, 1962, 1967) has come under attack in recent years (e.g., Schafer, 1973; Galatzer-Levy, 1984; Escoll, 1987; Marohn, 1998). Some argue that the separation-individuation processes of early life do not have applicability to adolescence, that the two phases are too different from each other to be compared (e.g., Furman, 1973; Schafer, 1973). Others believe that the “separation” part of this theory de-emphasizes or even ignores the ongoingness of relations with significant others and the necessity for these relationships to be transformed according to the changing needs of adolescents. They argue that there is no disengagement from significant objects, as they read Blos to be suggesting (e.g., Schafer, 1973; Galatzer-Levy, 1984; Escoll, 1987; Marohn, 1998). It often seems that these critics look at separation as if it means a literal detachment from significant others rather than as the intrapsychic separation that both Mahler et al. (1975) and Blos (1962, 1967) so clearly describe.

I imagine a coloring book with a picture of a group of people. The black outlines of their figures are the lines of separation. They bind the figures and show their physical form (i.e., they show where each figure stops and the next one begins). If we color in the figures, we are demonstrating the individuation process. What is inside our physical boundaries—including everything from how strong we are, to how emotional we are, to what we are interested in, to what we believe in—is all aspects of self that provide us with a sense that we have a vivid understanding of who we are. It is this vivid understanding that we bring to our intimate relationships. Without this understanding, it would be difficult to feel truly close to someone else.

What provides us with a sense of knowing and being known is both a sense of who we are as distinct from others and a sense of who we are as we look deeply into ourselves. Feeling known is a critical component of intimacy. To be known by another, we must know ourselves. It is only then that we can trust that what others claim to know of us feels real.

Adolescents are deeply concerned with their outlines (separation), what colors belong within those outlines (individuation), and how their colored-in figures interrelate (relationships). As they move from early to middle to late adolescence, these concerns unfold. They unfold in order, although one concern does not supplant another. There is a cumulative effect, and one set of concerns interacts with the next. Early adolescents are most deeply concerned with the issues of separation, middle adolescents with individuation, and late adolescents with their relationships to each other. In each subphase, however, there is attention paid to the issues that preoccupy adolescents at other times.

Those who take issue with separation theory point to infancy research as offering evidence that even babies act on their environments in ways that imply that they have their own subjectivity right from the time of their birth—that they, therefore, have no need to differentiate themselves from their caregivers. Critics of separation theory see this as proving that there is no need to formulate a separation process (e.g., Galatzer-Levy, 1984; Stern, 1985; Escoll, 1987; Marohn, 1998). This subjectivity, however, does not obviate the need for individuals to come to terms with their separateness. The alone state that becomes particularly and painfully salient during adolescence is a later elaboration of the early version of separateness that Mahler and her colleagues (1975) described. What this research tells us is that our prior idea about babies being unformed is inaccurate; it does not tell us that we have no need to come to terms with the existential state of aloneness, or separateness, that those of us who work with adolescents see on a daily basis. It also does not remove the need to formulate a way of understanding how that alone state works in tandem with the state of being-in-relation-to-others that is a building block of mature genitality.

In this paper, I take the position that the separation and individuation processes of early childhood must continue in order for the maturation of genitality to take place and that we must understand these processes in the context of adolescent development. What I see is that these processes take place in concert with one another during adolescence, but the valence of the importance of each shifts during the three sub-phases: early, middle, and late adolescence. To restate, then … early adolescence is dominated by separation issues, middle adolescence by individuation issues, and late adolescence by the integration of mature genitality. This paper will define these concepts in the ways that I find most useful for adolescence, discuss and illustrate through clinical examples their changing relevance in the three subphases of this developmental period, and conclude by talking about the necessity for us to be aware of these shifts in our work with adolescent patients.

Early Adolescence

When they become pubertal, children must come to terms with the obvious passage of time and the consequent transformations in relationships inside and outside their homes. Their bodies are no longer childlike, and they both see themselves and are seen as in a different place in life. Some are more ready than others for this different place. Girls enter puberty at the age of 12.5 years (give or take two years), generally two years earlier than boys (Brooks-Gunn and Warren, 1985). Boys, therefore, must contend with female peers who are physically mature before they themselves have begun to develop the relevant changes. As a result, male adolescence often begins (psychologically) before actual physical development takes place. It is not until they are in their midteens that females and males are more on a par in terms of physical, social, and psychological development.

What is singularly important to adolescents in this beginning sub-phase is the shift from seeing themselves as children to seeing themselves as no longer children. Sometimes, this means that they see themselves as adolescents; sometimes, they just see themselves as beyond childhood. Their reactions are mixed. On the one hand, they welcome this shift. They are proud, excited, and filled with the energy of discovery. On the other hand, they feel sad, frightened, and unsure about how they are supposed to be and what it means that their bodies are changing.

In this context, early adolescents have to redefine not only their sense of self (as a nonchild) but also their relationships with their caregivers. Whereas once caregivers seemed larger than life, capable of all things, now they must be brought into sharper focus for adolescents as the normal (or not so normal) people they are. This deidealization process is one component of what is at the core of the tensions that often arise in families at this time. It is not easy for children to see their parents as less than all-powerful. It is not easy for caregivers to sense that the glow of childhood—in which they had the power to comfort by a touch, the power to relieve their children's distress by a smile—is nearly gone from their relationships with their adolescents.

As children move into adolescence, they must alter aspects of their most basic self-awareness—that of their physical self (e.g., Freud, 1923; Greenacre, 1958; Jacobson, 1964; Stern, 1985). The original feelings of cohesiveness, of boundedness, of security, which derive from feeling that they can predictably know and trust the ways that their bodies work—must shift as they see and feel their bodies change. The physical changes initiated by puberty are far more noticeable to the adolescents themselves and result in adolescents' feeling out of touch with this most fundamental sense of self. They seem all of a sudden to have body parts they previously did not have, mood changes and bodily urges that they cannot explain, new spontaneous bodily emissions, and enlargements in parts of their bodies that they never knew would grow. They sweat, they have hair in new places, and they have pimples.

Sometimes adolescents are pleased about these changes; sometimes these are changes that adolescents would gladly reject. But the changes leave adolescents feeling that they have moved, inexorably, out of childhood. They must, therefore, change their most basic mental representations of self, those that derive from images of their physical being. This is a profound transformation, replete with meaning—a transformation that ultimately incorporates changes in how they are being perceived in their social worlds.

When children have the growth spurts that precede and accompany adolescence, they begin to be perceived differently. Often, thos...

Table of contents

• Cover
• Half Title
• Full Title
• Copyright
• CONTENTS
• Editor's Introduction
• PART I. DEVELOPMENTAL CONSIDERATIONS: ADOLESCENT DEVELOPMENT RECONSIDERED
• PART II. SCHOOL-BASED MENTAL HEALTH SERVICES: THE FUTURE OF CHILD AND ADOLESCENT PSYCHIATRY
• PART III. FORENSIC ISSUES IN ADOLESCENT PSYCHIATRY
• PART IV. PSYCHOPHARMACOLOGY IN ADOLESCENCE: CURRENT PERSPECTIVES
• PART V. ISSUES IN ADOLESCENT CONSULTATION-LIAISON
• THE AUTHORS
• CONTENTS OF VOLUMES 1–23
• Author Index
• Subject Index