We have all been adolescents. We have all had to contend with bodies under the siege of inexorable physiological imperatives, whether these were welcome or resisted, and which delivered an adult morphology that we had little choice but to make our peace with. Neuroscience is rapidly teaching us that the changes within the brain are no less physical and no less seismic. If we used to think of adolescent transformation as a mostly linear affair, tadpoles to frogs – breaking out of the egg, gaining limbs, losing a tail – we must now understand that what occurs within the human brain during puberty is a much more complex process which has more in common with the metamorphosis of the caterpillar. A section through a pupating chrysalis reveals not order but apparent physiological chaos, in which all caterpillar (larval) body parts appear disintegrated and no butterfly (adult-imago) parts are revealed. It appears that during human adolescence ‘synaptic pruning’ and the forging of new neurological pathways may be of an analogous order and manifest radical physical alterations in how the brain functions. Perhaps we should not be surprised at the emotional and psychological maelstrom that may ensue, and even less surprised where there has also been a troubled start in life. There is of course a corresponding raft of external, social, changes going on for the adolescent too. Every settled productive adult has had to negotiate a change of role and expectations, take on new responsibilities, steer their own course, become autonomous, work out who they are attracted to and how to be sexually intimate. From a developmental perspective our work with adolescents might almost be understood as a kind of psychoanalytic midwifery: where a complex psychological ‘birth’ seems to be stuck or to be going awry, we may be called in to accompany, intervene, encourage in order to help the young adult be ‘born’, capable of independent, viable and sexual life.
So this issue on a special theme of adolescence opens with three papers which tackle the reality of sexual and erotic transference, and the handling of this, within the psychotherapies of adolescent patients. As each author remarks, the literature on the topic has historically been somewhat slender, and in such a context we make a significant addition with the publication of these articles. Emil Jackson’s is a substantial paper both theoretically and clinically, but its key distinctive feature is the willingness with which he examines his own part in the dynamics generated between himself and the two young women he is treating. Jackson seems to be repeatedly asking himself ‘And what I have done (or not done) here?’ including the difficult question of ‘How might my behaviour be interpreted as sexually provoking?’ Jackson is concerned that we learn to investigate sexuality within the consulting room in a direct yet safe way, and offers his own defensive ‘errors’ and his corrections of these by way of illustration. His paper encourages us to ‘handle the explosive material’ (after Freud) but also cautions us to be fully aware of our timing of interpretations in relation to how firmly the work is established, and to keep a weather eye on the effect of our comments – do they inflame or relieve, help or hinder?
We might assume that the male therapist – young female patient pairings of Jackson’s clinical material are the constellation most likely to present difficulty precisely because of the potential sexual power relationship. This is the one we are most frequently presented with in society. It is with great interest then that we come to our next paper, written by Ian Paton on his work at Open Door, which centres on psychotherapy within a same-sex therapist–patient dyad with a young man who identifies as gay. What comes across with clarity here is how powerful sexualised behaviour in the consulting room can be used defensively to protect the self from the twin terrors of merger or abandonment. The young man both attempts to seduce his therapist with flattering intimacies and to abuse him by expressing intrusive fantasies that leave him unable to gather his thoughts. Paton investigates this material from the perspective of narcissism, drawing on well-established theoretical concepts from Klein, Rosenfeld, Britton and others and with full awareness of the context of the adolescent’s developmental task of individuation as ‘being able to be separate from’, whilst simultaneously alert to his need for and dependency on others. Paton speaks to the psychological struggle this young man demonstrates in making way for the Oedipal third position, and draws our attention to the additional challenges that may be faced by a young person whose sexuality emerges as gay or lesbian.
Fanny Lena’s paper is a worthy companion to these two with reassuringly similar themes. Like Paton’s her (male) patient also has great difficulty in negotiating a distorted Oedipal configuration and his consequent narcissistic vulnerability. Like Jackson, Lena describes her experience of trying to find a helpful middle path between the technical Scylla of addressing the sexual material in a way that could be experienced as exciting by ‘joining in’ and the alternate Charybdis of not addressing it and risking being experienced as rejecting by ‘looking away’. Lena delves more deeply into the infantile roots of narcissistic and Oedipal difficulties, and highlights the fragility of her patient’s link to his internal objects and a lack of containment in early childhood as significant factors in his present difficulties. However Lena draws most particularly on the distinction made by Birksted-Breen between a phallus and penis-as-link state of mind to aid her journey as a therapist with this patient towards a helpful ‘combined state of mind’ in which she can creatively link up with her own thoughts in the service of the psychotherapy. There is a pleasingly concrete cadence to the treatment in which, some nine months in, the patient confesses he has been actually sleeping in a bed with his naked father since he was four and, immediately following such a revelation, moves into his own room.
These papers offer us a springboard to transparency in discussions about sexuality in therapeutic work with adolescents that is long overdue and we encourage readers to consider offering comment or response of general interest that could be published in the next issue. For now we benefit from the candour of Jackson, Paton and Lena, and are also grateful to those young people themselves who have given their consent to share such intimate material from which we can learn and hope to help others in a finer and more informed way.
If these three authors take us into the heat of adolescents thrusting sexuality into the consulting room then Mary Brady’s article shows us quite the opposite response. Here the focus in on young people who are seemingly free of symptomatology and appear to be evading or ‘sleeping through’ a more ordinary developmental turmoil. As the author observes, fairy tales can be a rich source for creative development both in and outside the consulting room and this paper is a highly enjoyable exploration of the Sleeping Beauty tale which is used to illuminate our understanding of what might be taking place for this group of teenagers. The author conceives of the avoidance of turbulence as a common response to adolescence, but one that can also become entrenched, and result in a restriction of emotional growth. These young people, she proposes, are ‘psychically isolated’, cut off from their younger selves but not yet able to see a way towards adulthood, and their therapist may eventually need to wake them from this somnolent state. The article considers a range of issues including the splitting and idealisation fundamental to healthy development in both infancy and adolescence and the difficulties parents of adolescents may experience in integrating their hatred and envy for a new generation with an appreciation for the regeneration they can offer. Of particular interest is Brady’s account of the dilemmas she encounters in her work with a 15-year-old young woman who seems stuck in a prolonged avoidance of the adolescent process. How long should she maintain the role of King and Queen, allowing her patient to sleep? When might her patient be psychologically ready for her to ‘break through’ as Prince and ‘insist on her coming to life’? If we return to the analogy of the therapist-as-midwife, are we here having to consider a breaking of the waters in order to induce labour for a ‘baby’ which is now overdue? The countertransference pressures on the author as she explores these issues make for absorbing reading.
Alexandra de Rementeria’s paper also considers technical issues in working with adolescents: she describes a detailed and in-depth case study covering a two-and-a-half-year period in the treatment of an adolescent girl who has suffered tragic losses, and incurred a serious physical impairment as a result of self harm. The author elucidates the profound and extreme challenges of such work, both psychologically in bearing the unbearable and technically in relation to how to begin to approach her patient’s defences. Her struggle is to try to find a way to engage with a young woman for whom the ordinary developmental tasks of separation and individuation have been obscured by trauma and loss, and whose usual pull is back to grievance and manic over-achievement. De Rementeria draws on Waddell’s ideas about the role of narcissistic defences in adolescence to help her to make sense of her patient’s communications and to give herself a guiding framework. The paper vividly shows how layers of developmental damage, verbal and gradually verbalised elements, all emerge into the treatment relationship. It is particularly illuminating to be able to follow her clinical encounters with her patient in the form of extended session extracts and thus to gain a ‘close-up’ – and very moving – view of how the patient’s increasing awareness of aspects of herself that had previous been hidden (or denied) leads to significant change.
Remaining in the consulting room, Hillel Mirvis’s article, ‘Get me out of this dream!’: making a therapeutic alliance and working in the transference with a psychotic adolescent boy’, takes us into the disordered world of a traumatised adolescent. As the title of the paper suggests, this is very disturbed young man who suffers from hallucinations, a persistent sense that his life is a dream, and who repeatedly claims his therapist does not exist. Using Bion’s bi-partite conceptualisation of the psychotic and non-psychotic parts of the personality, Mirvis carefully conveys the difficulties of understanding and working clinically with such a patient, documenting how he faced frequent and seemly endless challenges before he was able to find some meaning in ‘Ryan’s’ communications. At the heart of the paper is a pivotal moment in the treatment when the therapist expresses concern for his patient after a session. Acknowledging that this takes place ‘outside the therapeutic frame’, the author suggests that it is also an important moment in helping Ryan to feel that his therapist does not only exist in his own mind, raising a very interesting technical question about whether there are times when it might be helpful, even essential, for patients in a psychotic state, to see and speak to their therapist outside the consulting room in order to have a sense of their reality. His account of the treatment exposes, with great sensitivity and honesty, his attempts to get in touch with Ryan’s emotional state; the gradual awakening of his patient’s curiosity about his therapist is a testament to the persistent work that was undertaken.
Our ‘Revisiting’ series – in which a past Journal paper is re-published alongside a newly commissioned commentary – returns in this issue with Shirley Hoxter’s ‘The experience of puberty’ and Jonathan Bradley’s accompanying discussion. First published in the Journal in 1964, this is a paper that takes us back to the fundamentals of the adolescent process and the eruptions of anxiety aroused by pubertal sexual development. As Bradley highlights, Hoxter also conceptualises puberty as a ‘call to war’ waged between adults and adolescents as an externalisation of Oedipal rivalry. His article helpfully locates the piece in the context of the turbulent early 1960s when skirmishes between mods and rockers sparked a national ‘moral panic’ about British youth. But this is no history lesson: the question of teenage violence is as vital an issue now as then and Bradley’s elaboration of Hoxter’s clinical examples – a boy living through a ‘period of intense masturbation’, a girl on the onset of menstruation and a 15 year old with a strong urge to have intercourse with a girl he encounters on a bus – bring these adolescents and their dilemmas vividly to life. We are left not only with a better understanding of the essential conflicts of adolescent sexual development (and the struggle to differentiate between mature and infantile aspects of sexuality) but also with a careful consideration of developments in clinical technique and options for treatment. We hope that Bradley’s article will encourage renewed interest in Hoxter’s important paper – and stimulate further debate both in the pages of the Journal and elsewhere. We would also welcome suggestions about articles for future commentaries and actively encourage you to contact us with your ideas.
The tumultuous nature of clinical work with adolescents is also a feature of this edition’s Clinical Commentary section, in which the case material is that of a 16-year-old girl approaching the end of her therapy. The session invites a range of responses, from Lucy Alexander’s reflections on the ‘pull back to mother’, through Antje Netzer-Stein’s exploration of the impact of ending therapy on the quality of the young woman’s communications, to Cathy Troupp’s discussion of the potential pitfalls of transference interpretation with adolescent patients. All the commentators in their different ways highlight the challenges of working with young people who are oscillating between regressive tendencies and a desire for greater autonomy and independence, and, in their varied reflections, testify to the complexity of the clinical task.
Finally the Research Digest brings together some fascinating abstracts of research on clinical work with adolescents (including the results of the IMPACT trial reported in The Lancet in November 2016 and some of the qualitative articles from the IMPACT-ME (My Experience) research arm). Together with another collection of stimulating book reviews, it adds an additional – and we hope useful – perspective to the wealth of clinical work presented in this edition.
This issue sees the last that Kate Stratton edits. She steps down after a four year tenure as incoming and then senior editor. Kate has been an energetic and meticulous leader, and a lively and supportive member of the committee. She has met the impacts of increased stringency over consent for publication and diminished human resources with creativity and determination. It is Kate who has pioneered our new ‘Revisiting’ series and has been the driving force behind our last two themed issues. We shall miss her companionship and quiet humour and wish her well as she leaves to follow her own professional and academic interests.
Jo Russell
Jo Russell