Academic journal article The Psychoanalytical Study of the Child

Integrating the Therapeutic into the Developmental in Treating Disturbed Adolescents

Academic journal article The Psychoanalytical Study of the Child

Integrating the Therapeutic into the Developmental in Treating Disturbed Adolescents

Article excerpt

This clinical study is organized around the treatment of a ¿ate adolescent who feared suiciding impulsively during an immobilizing depression and who proceeded to develop other severe symptoms. Yet he steadfastly refused to take medication and objected to seeing a therapist as well. His reason was an overriding wish to deal with his difficulties himself a feature of his normal developmental imperative to emancipate to a young-adult level of psychological autonomy. Thus, the therapeutic task was to simultaneously hold him in treatment while supporting that normal developmental requisite. Elaborating upon this integration of the psychodynamic and the developmental is the major purpose of this study.

SINCE EPIDEMIOLOGY AND PSYCHOPHARMACOLOGY DISPLACED PSYchoanalytic psychodynamics from the center stage of child and adolescent psychiatry and psychology, clinicians of all professional disciplines have felt under greater pressure to medicate adolescents - even if on an empirical basis. Yet, whether from failure to take prescribed medicine or from nonresponsiveness of their psychopathology to available medications, in the aggregate, at least one-third of adolescents treated for psychiatric conditions do not respond to medicine.1 This paper addresses that sizable minority and many others for whom medications are prescribed but whose purposes would be better served by an intensive psychotherapeutic approach.

This paper is organized around the treatment of a late adolescent. This adolescent feared suiciding impulsively during an immobilizing depression and subsequently proceeded to develop other equally serious symptoms. Yet his unwavering refusal to take medication never seemed to represent an accession to the despair of his depression. Rather, his rationale for wanting neither medication nor therapist reflected his overriding, normal developmental imperative to fend for himself - a crucial feature of his effort to emancipate to a young-adult level of psychological autonomy. Issuing an ultimatum to take medicine would have been inappropriate because it was contrary to this developmental imperative, presumptuous because it was not a sure cure for his symptoms, and fruitless because he would have declined. Refusing to treat him would have been neither professionally responsible, at worst, nor sporting, at best, because none of us has the last word on what makes any treatment effective. So we worked psychotherapeutically - as intensively as he allowed.

This case is presented in detail to: 1) illustrate twelve technical precepts that evolved from his therapy to keep him in treatment against the pressure of his developmental imperative to emancipate - that is, the integration of the psychodynamic and the developmental; 2) illustrate how a distinctive psychodynamic formulation helped to relieve his symptoms; and 3) to present a rationale for intervening in ways that we are not typically inclined to do in conducting psychoanalytically oriented treatment of late adolescents and young adults.

Adolescent Development

Instinctual, intersystemic tension between id and the ego/superego constellation is the most frequently described of the intrapsychic conflicts that are the cornerstone of clinical psychoanalysis. This has particularly been so when discussing adolescents. For the upsurge of drives associated with pubertal development has traditionally been understood to initiate the emancipation process of adolescence. So an instinctual conflict becomes the basis for symptoms that arise when adolescent development goes awry.

However, the clinical significance of inner-systemic, intrapsychic conflicts is also well established. These involve the individual's efforts to reconcile different ego motives that have become mutually incompatible. Bibring's formulation of depression arising "primarily from a tension within the ego itself, from an inner-systemic 'conflict'" (1953, p. 26) is perhaps the best-known example. I have found much adolescent psychopathology better explicated and treated on the basis of inner-systemic conflicts. …

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