Clinical Work With Adolescents

Judith Marks Mishne

• Publisher: Free Press
• Year: 2010
• Print ISBN: 9780029212608
• eBook ISBN: 9781451602418
• Topic: Social Sciences
• Subtopic: Social Science Research & Methodology
• Index: Social Sciences

In this welcome follow-up and companion to her highly acclaimed Clinical Work with Children, Judith Mishne provides a comprehensive overview of the fundamentals of adolescent psychotherapy. Drawing on her own extensive experience and the work of other professionals, she offers a cogent analysis of the psychological disorders afflicting teens today and explores the range of dynamic treatment interventions available in clinical work with teenagers and their families.

With an emphasis on the need for flexible, individualized planning for young patients, Clinical Work with Adolescents succinctly shows how clinicians can develop and follow a course of treatment in a variety of settings, from private outpatient therapy to residential programs. In addition, it outlines the various stages within the therapeutic process itself, analyzing the therapeutic alliance, transference and countertransference, the phenomena of resistance, typical defenses, “working through,” and, finally, the termination of treatment.

A comprehensive and thorough integration of theory and practice, Clinical Work with Adolescents is essential for both novice and experienced practitioners—as well as students—in understanding and successfully helping teenagers to cope with the difficult transition to adulthood.

PART I

An Overview of Adolescence

Child and Adolescent Therapy: A Historical Perspective

The advent of child psychoanalysis may be dated to 1909, when Sigmund Freud published his report of the psychoanalytic treatment of Little Hans, who was treated for a phobia by his father under Dr. Freud’s guidance. Dr. Freud, however, did not focus on adolescence beyond his references to the transformation of puberty in “Three Essays on Sexuality” (1905). Following these publications, it was some time before children or adolescents were treated directly.

In the late 1920s Anna Freud was trying to convert a psychoanalytic interest in childhood as it is recalled by adults into a concern with childhood itself. Under her leadership, the new profession of child analysis was born. In her seminal paper on adolescence (1958), Miss Freud delineated adolescence as a unique and specific period of late childhood, characterized by normative upheaval and turmoil. Miss Freud was assisted in her pioneering explorations of adolescence by Aich horn, who studied and treated aggressive and delinquent adolescent youth.

Shortly before the publication of Miss Freud’s paper, Erikson (1950) made an enormous contribution to our understanding of the experiences of adolescence as the time of life that promotes the sense of personal identity. He articulated his formulation of the major conflict of adolescence, namely, “identity versus identity diffusion.” Piaget (1969), in his studies of cognition, delineated the adolescent stage as the time when the capacity for abstract thought, the highest level of intellectual development, is achieved and gives its special quality to the human mind. Blos, in the early 1960s, also made major contributions in investigating and describing the unique stressors and developmental tasks of the teen years.

Keniston (1971) observed that while puberty as a biological state had been recognized, adolescence, as we understand it today, was only discovered in the nineteenth and twentieth centuries. Not only has adolescence been acknowledged, but additionally, contemporary society has begun to support this phase of development by providing educational, economic, institutional, and familial resources for teenagers. This has allowed for the greater possibility of continued psychological growth during the ages 13 through 18. Educational possibilities, recognition and acceptance of the moratorium, and a positive image of post-childhood are now almost universal.

This more realistic appreciation of adolescence relates to social and economic realities. “Increasing industrialization has freed postpuberal youngsters from the requirements of farm and factory labor. The rising standards of economic productivity make the adolescent, especially the uneducated adolescent, a burden on the labor market. Growing affluence enables families and society as a whole to support economically unproductive adolescents in school” (Slaff, 1981, p. 8).

Recently there have been challenges to Anna Freud’s view of the normal, expected, necessary turmoil and upheaval of adolescence.* While the debate continues about the length and nature of the adolescent. stage, there is agreement on the special needs of this age group. There has been growing recognition, in outpatient and inpatient programs, since the postwar “baby boom” that enormous increases in demand for services for this age group have occurred and that these patients are often difficult to treat. Methods that are effective with children and adults do not suffice with teenagers.

Special separate inpatient and outpatient services for adolescents have been established. The American Society for Adolescent Psychiatry was developed in 1967, “with aims of providing a national forum for adolescent psychiatry, initiating efforts and cooperating with other organizations on behalf of adolescents, and facilitating communication and cooperation among constituent societies” (Slaff, 1981, p. 13). The professional journal Adolescent Psychiatry published its first volume in 1971. Issues of particular concern for adolescents, such as college mental health, drug abuse, and delinquency, were recognized as requiring advocacy and improved consultation and treatment resources. Specialization in treatment of adolescents has taken place in other nations, much as it has in the United States. The first international meetings on adolescent psychiatry took place in Jerusalem and in Edinburgh during 1976.

The adolescent psychiatry movement has invited members of allied professions to cooperate in joint clinical work, research, and program development. Genuine sharing, collaboration, and mutual support is crucial in effective work with this population, who frequently require the team approach—the coordinated efforts of psychoanalysts, social workers, psychiatrists, psychologists, nurses, educators, and on occasion, lawyers, child care staff, recreation personnel, and speech, art, music, and drama therapists.

Adolescents have a propensity for creating problems within the treatment setting because of their reticence about becoming engaged or their inclination to express themselves through action rather than words and feelings. Our responses to the various impasses adolescents typically produce, interestingly enough, have become our most valuable asset in giving us technical guidance to deal with what at first seems to be impossible situations. True, some impasses may, in fact, be difficult: but if we make a frank and non-anxious examination of our feelings, many may prove to be resolvable [Giovacchini, 1985, p. 447].

This text aims to provide a clear and comrehensive presentation of the fundamentals of clinical assessment and treatment of adolescents for use by graduate students and practitioners in the above disciplines. The literature that discusses clinical work with adolescents is dominated by the writing of child psychiatrists and child analysts. It requires that students and practitioners from various professions translate the material for use in their own nonmedical and nonanalytic practices. Proficiency in work with adolescents is a clinical skill only gradually acquired. Nevertheless, early in their training, social work and psychology graduate students, medical residents, nurses, and art, drama, dance, and speech therapists are expected to treat adolescents. Indeed, some settings demand instant expertise in direct work with teenagers and their parents. Enhancement of clinical proficiency, via translation of psychiatric and psychoanalytic principles into more broadly based practice, is the goal of this text.

Specialization in adolescent and/or child therapy can only begin during one’s formal professional education. Because of the special dimensions of this field—the unclear communications from adolescents, their particular reticences, resistances, rebelliousness, and propensity for action rather than words and sharing of feelings—work with this population is a specialty, requiring lengthy, ongoing training, experience, and supervision.

Ultimately, to be able to do intensive psychotherapy with adolescents, any aspiring therapist, regardless of discipline, will need some personal treatment. This is necessary in order for the practitioner to develop a therapeutic, objective, emphatic response that embodies the necessary self-awareness and self-observation, and that controls against regression and acting out through, and/or with, adolescent patients. We may or may not have encountered, struggled with, or lived through the identical pain and stresses that our clients experience. But as adolescents, we once all engaged in the same developmental struggles for autonomy, separation, and individuation; we also suffered the same fears of narcissistic injury and failure that our teenage patients are currently experiencing. We once encountered with alarm, anxiety, and excitement our first love, erotic arousal, and sexual and emotional intimacy. Thus, clinical work with adolescents strikes continuous responsive chords in all therapists in a unique, stressful, and universal manner.

* See pp. 9-11.

Adolescence Defined and Described

In “Three Essays on Sexuality” (S. Freud, 1905), puberty was described as the time of life when the bodily changes occur which give infantile sexual life its final form. During puberty there is subordination of the erotogenic zones to the primacy of the genital zone. Orality and anality have waned, and the child’s focus and bodily cathexis are fixed on the phallic genitalia while the mental and emotional life is centered on the loved and forbidden oedipal incestuous objects. New sexual aims and the seeking of new sexual objects outside the family are noted as the main events of puberty.

Anna Freud explained that the newly developed notion of the existence of an infantile sex life lowered the significance of adolescence. “Before the publication of the ‘Three Essays,’ adolescence had derived major significance from its role as the beginning of sex life in the individual; after the discovery of an infantile sex life, the status of adolescence was reduced to that of a period of final transformation, a transition and bridge between the diffuse infantile and the genitally centered adult sexuality” (A. Freud, 1958, p. 256). In 1922 Jones published a paper that examined the correlation between infancy and adolescence, and noted the recapitulation during adolescence of what had been significant developmental steps during the first five years of life. Jones stated “that adolescence recapitulates infancy, and that the precise way in which a given person will pass through the necessary stages of development in adolescence is to a very great extent determined by the form of his infantile development” (p. 399).

Anna Freud cited Bernfeld as the next prominent observer researcher examining the adolescent stage of life. Bernfeld described a particular kind of male adolescent phenomenon, the so-called protracted adolescent phase that produces artistic, literary, scientific, and philosophic creation. His conclusions arose out of his clinical work with teenagers in which diaries and poetry were shared. Artistic and creative productions were assumed to be the outcome of inner psychological frustrations and external environmental pressures; neurotic, sensitive youth employed sublimation to deal with conflicts through creativity.

Aichhorn studied the adolescent stage of life through examination of asocial and criminal development in youth who demonstrated faulty superego development and delinquent and rebellious behavior. His seminal, world-renowned text Wayward Youth (1935) was a pioneer step in employing psychoanalytic theory in an effort to understand the young offender.

Anna Freud examined the struggles of the ego to master tensions and pressures created by the drives in “The Ego and The Id at Puberty” and “Instinctual Anxiety During Puberty,” which became chapters in The Ego and the Mechanisms of Defense (1936). She concluded that conflictual process led to character formation and, in some cases, pathological outcomes and the formation of neurotic symptoms. The battle between ego and id during the oedipal stage ends at the beginning of latency and breaks out again at puberty. She stated: “I made the point that, more than any other time of life, adolescence with its typical conflicts provides the analyst with instructive pictures of the interplay and sequence of internal danger, anxiety, defense activity, transitory or permanent symptom formation and mental breakdown” (1958, p. 258).

Following World War II, more publications attempted to define and describe the stage of life known as adolescence. Nevertheless, this increased focus did not improve clinical skill in direct work with adolescent patients. In the 1950s, Miss Freud concluded that adolescence remained, as it had been before, a stepchild in psychoanalytic theory. Problems of engaging and sustaining teenagers in treatment remained formidable, and so material was sought through less than satisfactory avenues, e.g., via the memories and reconstruction of adolescence by adult patients. While facts and events were recalled,

what we fail to recover, as a rule, is the atmosphere in which the adolescent lives, his anxieties, the height of elation or depth of despair, the quickly rising enthusiasms, the utter hopelessness, the burning—or at other times sterile—intellectual and philosophical preoccupations, the yearning for freedom, the sense of loneliness, the feeling of oppression by the parents, the impotent rages or active hates directed against the adult world, the erotic crushes, whether homosexually or heterosexually directed—the suicidal fantasies, etc. These are elusive mood swings, difficult to reverse which, unlike the affective states of infancy and early childhood, seem disinclined to re-emerge and be relived in connection with the person of the analyst [1958, p. 260].

Repeated treatment obstacles in work with adolescent patients caused Miss Freud to conclude that analytic technique was inadequate to deal with the young patients, all of whom demonstrated rapid shifts of emotional position, revolt, and abrupt and undesired termination of therapy. The obstacles in treatment caused her to conclude that these patients had a lower threshold for frustration, a preference for action rather than verbalization of feelings, and new weaknesses and immaturities of ego structure. She likened this time of life to that of a mourning state, a period of slow and painful recuperation from an unhappy love affair. Because of the narcissistic withdrawal, adolescents have little if any libido energy available with which to explore their past, or relate to the present. The detachment from the parents causes intense and all-absorbing mental suffering.

Repeated clinical observations compelled Miss Freud to conclude that the adolescent upset is inevitable, desired, and “no more than the external indications that inner adjustments are in progress” (p. 264). Balance between id and ego forces must shift to accommodate the accelerated pubescent drive activity. Some degree of adolescent upset is predictable; upset is especially intense when the incestuous oedipal and pre-oedipal fixations to the parents have been exceptionally strong. Delineating between normality and pathology is problematic.

As described above, adolescence constitutes by definition an interruption of peaceful growth which resembles in appearance a variety of other emotional upsets and structural upheavals. The adolescent manifestations come close to symptom formation of the neurotic, psychotic or dissocial order, and merge almost imperceptibly into borderline states, initial, frustrated or fully fledged forms of almost all the mental illnesses [p. 267].

Miss Freud concluded that normal adolescence is, by its nature, a disruption of peaceful growth, and that any steady equilibrium during the adolescent process is in itself abnormal. The basic disharmony is the norm!

I take it that it is normal for an adolescent to behave for a considerable length of time in an inconsistent and unpredictable manner; to fight his impulses and to accept them; to ward them off successfully and to be over run by them; to love his parents and to hate them; to revolt against them and to be dependent on them; to be deeply ashamed to acknowledge his mother before others and, unexpectedly, to desire heart-to-heart talks with her; to thrive on imitation of and identification with others, while searching unceasingly for his own identity; to be more idealistic, artistic, generous, and unselfish than he will ever be again, but also the opposite, self-centered, egoistic, calculating. Such fluctuations between extreme opposites would be deemed highly abnormal at any other time of life [p. 275].

In concert with Miss Freud’s formulations, her colleagues continued to view adolescence from an ego psychological perspective, as a moratorium (Erikson, 1950); a normative crisis (Erikson, 1956); and a period of mourning and depression (Laufer, 1966) during which the young person makes a final emotional separation from parents and bids farewell to childhood. As Jones (1922) viewed adolescence as a recapitulation of the early infantile-toddlerhood development, Blos (1962) called it a second edition of childhood. Drawing on the lifelong work and studies of Margaret Mahler, Blos (1968) developed the view of adolescence as a “second individuation” process. However,

This process should not be thought of as replica of the first separation individuation … Separation-individuation occurs once and only once during the first 3 years of life: it refers to the infant’s gradual recognition and acceptance of the boundaries between his own self and those of the mother” [L. J. Kaplan, 1984, p. 94].

L. J. Kaplan (1984] emphasized the difference between the original separation-individuation of infancy and that during adolescence: “Adolescent individuation … involves the reconciliation of genitality with morality” (p. 95). Kaplan cautioned about mistaken notions of adolescence as a recapitulation of the past. Adolescence revises the infantile past and the early narcissism is transformed from love of oneself to love of the species. Much as Kohut (1966) discussed transformation of narcissism; Kaplan described the transformations of adolescent narcissism into an “adult capacity for moral dignity, cultural aspiration and ethical ideals” (p. 20).

In contrast to this longstanding traditional view on the inevitability, in fact, the desirability of turbulence during adolescence, a number of researchers recently have suggested that the extreme upset of adolescence is not universal and that the personality upheaval of this phase of life can be reflected primarily in manageable nondebilitating rebellion and depression. Such current research studies have proposed that normal teenagers experience little, if any, of the inner upheaval or acting out behavior ascribed to them in the classic literature (Douvan and Adelson, 1966). This more recent perspective suggests that rebellion occurs over minor matters and that adolescents continue to share with parents a core of stable values. The findings of Offer (1967), and his initial colleagues (Offer, Sabshin, Marcus 1965), pointed to rebellious behavior solely during early adolescence and then only over minor matters such as dress, household chores, music and curfew. No delinquent acts or great emotional upheaval were evident. Transient feelings of anxiety, depression, guilt, and shame were observed but no debilitating forms of anxiety or depression were noted. These studies reveal that adolescents normatively maintain psychic equilibrium while struggling with developmental tasks, remain able to demonstrate successful social and family adjustment, evidence only mild forms of depression and anxiety, and have only minor disagreements with authority figures. The findings of Rutter et al. (1976) on rural youth ages 14 and 15 substantially agreed ...

Table of contents

• cover Page
• Title Page
• Dedication
• Contents
• Acknowledgments
• PART I An Overview of Adolescence
• PART II Assessment
• PART III Adolescent Pathology
• PART IV Adolescent Sexual Behavior
• PART V Selecting a Treatment Plan
• PART VI The Treatment Process
• Index