Clinical commentary by Amanda Keenan, child and adolescent psychotherapist

Adolescence is, as we know, characterised by a sense of turmoil and upheaval as the unresolved conflicts of childhood and relationships (particularly Oedipal relationships) require working through once again. By mid-adolescence there is a focus on the adolescent finding his or her identity which is different from the childhood self. This period is usually characterised by fluctuating states of mind which shift rapidly between dependency and independency and between the paranoid–schizoid and depressive positions. In contrast to this more ordinary turmoil the therapist introduces us to 16-year-old Alex who we are told has been in psychotherapy for about one year. The rich material reminds us that the way in which the challenges of the adolescent period are negotiated play a vital part in the development of the personality. It is these pressing challenges that Alex appears to be resolutely trying to avoid and defend against. Although we are informed that Alex (along with his family) has chosen not to pursue hormone blockers there is much evidence that his adolescence has indeed been blocked in many different ways.

We learn about Alex’s focus on his intellectual studies – achieving the ‘highest grades’ (despite missing periods of college) and Waddell’s (2002) descriptions of adolescents who over achieve academically as a way of not engaging with adolescent emotional conflict come to mind. There is a danger that the intellectualisation at which Alex is clearly adept will be replayed in the therapeutic encounter. Here I mean that the therapist and Alex can so easily become embroiled in ‘thinking about’ the difficulties rather than truly learning from emotional experience. I think Alex touches on this towards the end of the session when he states that ‘people who research it do not know how it feels’. The descriptions of his fatigue, eating difficulties, food intolerance, OCD symptoms also serve to reinforce the sense that Alex struggles to really take in and digest emotional experience.

As Alex struggles to keep his strong feelings at bay, the name his therapist gives him (which possibly reflects his actual chosen name, which is both a common shortening of a female name and also a male name) and his androgynous appearance also give the impression of a wish for neutrality. His therapist remarks on his pre-pubescent appearance and indeed we encounter some very latency states of mind in the material. Interestingly the therapist remains gender neutral for us too! I would have been interested in this detail to further elucidate the way in which Alex responds to difference and sameness.

From the start, a sense of ambivalence about contact with the therapist emerges. Although the therapist tells us that Alex values his psychotherapy, we also learn of all the sessions Alex has cut and that, in fact, his therapy has been irregular since the Easter break. It is difficult to know whether Alex missing his sessions was a reaction to the separation of the Easter break and intolerable feelings of loss. What is presented instead is a sense of a very busy Alex who scarcely has time to fit the therapist into his packed schedule, as ‘work experience and other events in his calendar’ intrude. One has the impression of a very busy preoccupied internal object. Indeed, later in the session Alex again seems to touch on this when referring to the chronicity of his difficulties with his remarks that his parents appear not to have noticed for as much as a decade.

Although the month’s break in therapy is taken up by his therapist, any feelings about the loss and separation appear to be smoothed away. The only signs of anxiety are Alex’s ‘nervous giggles’. I think that when the therapist draws attention to the evidence and the reality that she or he too has been away, Alex experiences shock and in turn shocks the therapist by asking very directly where they have been. Alex then goes on to talk about who he himself has been with, which perhaps betrays his more underlying concern about who his therapist has been spending time with when she or he has been busy on holiday.

Alex relays that he has been with two friends and his family on holiday. As we are aware, in psychoanalytic thinking friendships with a range of different kinds of other people can represent different aspects of the personality. In Alex’s accounts of the holiday he initially represents his friends as all being of one mind. In the first ‘incident’ we know that Alex’s father has helped him (without being asked) by carrying the umbrella to the beach, but in place of gratitude Alex is outraged that he is to come and collect it from his father. Both his friends are also reportedly shocked and outraged by father’s anger. At this point, the friendship group have more the flavour of a gang-like structure in Alex’s mind, there to support, endorse, defend and dominate, rather than that of a productive group. Another dimension might reflect the sense of a more ordinary adolescent separation in the description of the young people sitting away from the parents and perhaps each group trying to negotiate the distance between them.

Alex is cuttingly dismissive of his parents who reportedly ‘lose it on random things’ and within the way he speaks there is little evidence of any depressive concern or guilt about the impact of his difficulties may be having on them. In the second incident Alex reports that his brother, whilst eating ice-cream, appears to have a reaction to it. Alex recounts the story as if he is the parent talking in an amused way about a child. The therapist is invited to join the group as another ‘witness’ in feeling baffled and shocked by the parental concern towards the brother. However, feelings of competition, rivalry and envy are very close to the surface here. This appears difficult for the therapist to take up, and yet if she or he had raised the possibility of this, such an approach might have provided a way to begin to think with Alex about his feelings of rivalry towards the therapist’s imagined family and friends which she or he has left him for whilst enjoying themself on holiday. Alex’s desire to get the ‘best’ grades can also be thought about as an indication of his desire to be the best, most important pupil, sibling or even parent figure. Could Alex wish to be a better man and husband than he considers his father to be?

Anger and conflict are felt by Alex to be intolerable; he can, we learn, just about manage his mother’s ‘passive aggressive’ anger but nothing more direct. It is clear from the material that any feelings of anger and hostility Alex might have are very much split off and located in others. His feelings of aggression appear as tightly bound as his breasts. The mechanism of this splitting so clearly outlined by Klein (1946) denudes the personality of valuable aspects. Alex recognises that his angry feelings are also turned inwards resulting in attacks on himself and indeed, we see this concretely expressed in the reports of Alex’s self-harm. Laufer’s (1978) work on the body in adolescence draws attention to the adolescent task of taking ownership of the sexually maturing body. We are left to surmise who Alex is attacking in phantasy when he attacks his body.

When speaking of being shouted at Alex tells his therapist that his “inner thoughts take the side of whoever shouts at me”. This seems fascinating and I wonder how much Alex unconsciously provokes others to shout at him in the service of punishing himself. In other words, perhaps there is an aspect of Alex that recognises that his demands to be treated as special are unreasonable and that, in a rather primitive and semi-conscious way, he feels punishment should follow. Alex also acknowledges that he withholds explanations of himself and his behaviour which again reminded me of his eating difficulties. Closing his mouth to certain foods and experiences put me in mind of Williams’ (1997) description of a ‘no entry’ system of defences in which dependency is defended against in ways which often involve refusing to take in potentially enriching experiences.

From the therapist’s observations in the waiting room we see glimpses of the external father/adolescent relationship. There is a distance between them, each looking in different directions. This in contrast to what the therapist notes about mother and Alex sitting closely together and his view that she enjoys driving him around. One wonders here about the quality of the actual external couple relationship as well as Alex’s internalised version of the parental union. In the material Alex hardly refers to his parents as a couple, other than his experience of them both mindlessly not noticing his difficulties. On the second page Alex speaks of his difficulties when confronted by his father or teachers. I think he is drawing attention to the difficulties he experiences with paternal function and boundaries. Later there is a more explicit longing for father’s praise and attention.

We learn that Alex feels his ‘coming out as trans’ has relieved him of the need to explain himself or think about his difficulties. All his difficulties can be concretely located in his gender. There is a real warning to his therapist that when he has been asked to address his problems previously in another therapeutic context, Alex has gone through the motions, dutifully attending but refusing to take anything in. I think the therapist’s interpretation that Alex is saying ‘Don’t challenge me or my problems’ is an accurate one which gets to the heart of Alex’s wish for control and his fears of becoming more in touch with his emotions. Alex’s laughter however again appears to be an attempt to deflect attention away from the therapist’s words.

Alex equates naming ‘being trans’ with another sort of umbrella, the ‘trans umbrella’. This umbrella does not afford protection from the glare of the sun but from the glare of other people’s thoughts and feelings including his own – as he says, it serves to shut people down. In Alex’s mind the trans culture is envisaged as another gang-like structure, albeit one which is ‘on his side’ and helpful in defending him. Although he draws attention to the way in which trans issues have become politicised and how vulnerable institutions such as schools and clinics themselves can be to accusations of intolerance, this can also be thought of in terms of a projection of Alex’s intolerance on a huge scale. It is, in my view, another warning shot to his therapist not to challenge him because the consequences could be very harsh. The therapist talks of the service having to be careful ‘not to tip things over’ but there are also dangers in tip-toeing around Alex’s unexpressed anger and hostility. The therapist takes up Alex’s vulnerability and fragility much more readily than his powerful wish to control. In the transference relationship Alex places his therapist in a very difficult position. Will the therapist be the one who will be blamed and punished or will they have to join exactly with Alex, sharing his views like his friends? There is a marked lack of triangulation in Alex’s thinking, adding to the sense of unresolved Oedipal conflicts.

It comes as somewhat a relief that towards the end of the session Alex does acknowledge some difference of opinion in his peer group. Sam accuses Alex of lying about his symptoms. Only now is there someone in Alex’s mind who questions the way he presents things. However Alex appears quite unable to stay with this thought, dismissing it almost as soon as it comes to mind. The therapist tries to expand on this with Alex but again his response is one of ‘an inflated sense of righteousness’. Puffed up with self-righteousness Alex is nevertheless noted by the therapist to simultaneously look ‘unexpectedly tired and deflated’ at the close of the session. There is a fleeting sense of poignancy when the therapist remembers Alex’s self-harm and late-night worries. He has wasted some of the potential value of his therapy, closed his mouth and mind to some of what might have been offered. Unless Alex is able to really stay with his anxieties in the therapy he risks continuing to find himself alone with his worries late at night.

Notes on contributor

Amanda Keenan is currently Lead for Child and Adolescent Psychotherapy at Leicester, Leicestershire and Rutland NHS Trust. She has worked in various specialist CAMHS services for almost 30 years, initially as an occupational therapist and then training at the Tavistock Clinic in child and adolescent psychotherapy.

Amanda Keenan
Westcotes House
Westcotes Drive
Leicester LE3 0QU
UK
[email protected]
© 2017 Association of Child Psychotherapists
https://doi.org/10.1080/0075417X.2018.1414292