Adolescent Psychoanalysis

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Adolescent Psychoanalytic Allies

Chapter 4

One absolute key to accomplish the difficult feat of analyzing an adolescent is that the analyst must have an ally in the patient. No ally equals no analysis. This is very difficult but accomplishable with adolescents.  As analysts, we all know that what we can analyze is the material brought to us by our patients. Many of us stray, however, widely from that practice. If one is able to limit his analytic work to investigating that material, chances of successful ally creation, with adolescents at least, escalate dramatically.

For example, in a first visit, a patient brought to me for analysis by his mother, said to me “my mother is a whore”. Such a statement could bring forth a wide variety of responses, depending on one’s theoretical school. If one were, on the other hand, to assume that in ‘truth’ the meaning of this statement needs to be found out. One possible piece of material at hand to examine is to try to find out what ‘whore’ meant to that patient. I said “I’ve certainly heard the word ‘whore’ before. But ?? shrug. “Well not a whore, but she’s really into telling me what to do, all the time. “Telling you?” “yeah. I mean about everything—where I go, what I can do, every-thing”.etc. “here?”. “yeah, I suppose. But at least you’re listening”.

I give this example to illustrate what I mean about forming an alliance. In this very brief interchange a number of things have happened. A dialog started, AND I’m not telling the patient what he means, AND I’m not arguing with the patient AND I’m not colluding with him. An environment of arguing with an adolescent makes ene-mies not allies. Telling him that what he thinks isn’t what he thinks, especially if what we tell him is based upon one our theories, in general, is ruinous.

Another example, this of how not create an ally but an enemy. (please remember that the content I say happened, is hearsay. My comments about that alleged session are my comments. The content of and comments about the second session are directly from my contact with the patient.)

A 14-year-old girl was sent to see a psychologist for ‘analysis’. According to the father, the patient had been caught sniffing ‘white out’ at school. The family also thought that she was not attending school. Moreover, she was rude to her parents. And, her parents were having many marital problems. Because of these factors and others, her father took her to an analyst. However, she didn’t want to go to any therapist, let alone an analyst.

She attended one session. In that session, the first and only session, she entered the consulting room and sat down. The doctor, in his first foray with his patient, told her that he was told by her parents that she was not taking care of herself. He, however was peeling and eating a banana. She told him that he was the one who was not taking care of himself inasmuch as he was eating a banana, which, she said, was full of pesticides. They argued about that, the therapist disagreeing with her assertion. She then told the therapist that she did not want to be there. (at the session) The therapist then said to her, in spite of what she had said, that “she was there because she wanted to be there”. His evidence was that she was still sitting there. She told him that she was only there because her father made her come. He said ‘no, you’re here because you want to be here because you are still here’. She asked ‘does that mean I am free to leave if I wish’? He said ‘yes’, but you’re not going to leave because you want to be here. She said I am not here be-cause I want to be here and walked out. He followed her out into the corridor saying ‘you’re not going to leave, since you don’t want to leave’. He kept saying that as he followed her down the hall to the elevator. And as the elevator door closed, he said, once again, ‘you’re not going to leave because you want to be here’. The closing doors nearly got him in the nose. The 14 year old never returned even though ‘she wanted to be there’.

To not investigate the “ride” of this patient was obviously crucial, and did not happen. The above example, while sadly sophomoric, illustrates that problem. This girl was eminently treatable. This analyst, probably unintentionally created an immediate and unnecessary debate and impasse. He was, if you will, telling the patient what she actually meant, ignoring what she actually said—-a fatal mistake with most adolescents.

This same girl was then brought to see me by her father as a last resort. The patients ‘ride’ at that moment was that she did not wish to be ‘there’ which she stated and as apparently she had stated before with the previous analyst. She said that there was nothing wrong with her. I said “‘Assuming that being the case, nothing wrong with you, why in the world did he bring you? (A question like this usually has a number of virtues. Firstly, and by far of greatest importance, it is a question about exactly what the patient has said. Secondly, it indicates that I was listening openmindedly. Thirdly, such a question does not inspire an argument nor is it argumentative. Fourthly, this question is not artificial, but respectful. I sincerely wanted to know why she was there. Fifth, such a question will almost always lead to the patient explaining their version of events, their ‘ride’. And, finally, such a question virtually always cements one’s relationship with the adolescent, for all of the above reasons.) She said that her father had said, “because we have serious trouble at home”. serious trouble?, I asked. My parents fight and argue all the time and my father is having an affair(s). Affair?. We are always hearing about them at home”. “?” “I don’t know. The stories are sickening. The fact that we even talk about them is more sickening”. Part of ‘serious problems?’ ‘For sure’. Others?. “They say I am always the problem”. Always? She says ‘they say I’m a drug addict, that I never go to school, am failing, etc.” “A real flop, eh?” “No, I sniffed some white out once. I never use drugs or smoke. I also attend school regularly and am getting all A’s”. “confusing” ?Absolutely, if you’re confused, you can imagine how I feel”.

In the second encounter of this adolescent, in this instance with me, I encountered the same or similar pronouncement—“I don’t want to be here”. Differently, however, I did not challenge this pronouncement, but asked about it. I had an ally and a patient, virtually on the spot.

These ideas are extraordinarily important in the analysis of an adolescent, and I wish to pay special attention to them. The statement by the patient is the ‘truth’ of the patient at that point in time. I think it is crucial to understand that idea. By ‘truth’ I don’t mean the actual truth of the content of the statement. In the model that I am discussing, such a truth, at that point in time, is irrelevant.

This first analyst apparently made two serious and treatment ending mistakes. He ignored the initial ‘truth’ altogether, and guessed, somehow, the actual meaning of the content of the statement. As I imagine it, he decided that her initial statement was false, was a pack of lies, or meant to be provocative and, therefore, ignored it. Then, he told the patient what the content of her statement really meant—that she actually wanted to be there which was shown by the presence of her body on a chair

To not investigate the “ride” of this patient was obviously crucial, particularly with adolescents. The above example, while sadly sophomoric, illustrates that problem. This girl was eminently treatable. This Dr. unintentionally created an immediate and unnecessary debate and impsse. He was, if you will, telling the patient what she actually meant which was not what she was saying, a fatal flaw with most ado-lescents even though an accepted analytic technique of most of us analysts with ‘grown-ups.

In the second encounter of this adolescent, in this instance with me, I encountered the same or similar pronouncement—“I don’t want to be here”. Differently, however, I did not challenge this pronouncement, but asked about it. I had an ally and a patient, virtually on the spot.

These ideas are extraordinarily important in the analysis of an adolescent, and I wish to pay special attention to them. The statement by the patient is the ‘truth’ of the patient at that point in time. I think it is crucial to understand that idea. By ‘truth’ I don’t mean the actual truth of the content of the statement. In the model that I am discussing, such a truth, at that point in time, is irrelevant

Traditional interpretations virtually always have the effect of interrupting or perverting the expression of and understanding of the ‘ride’. Further, to adolescents, they sound contrived. They sound theoretical, which they are. Further, and particular importance, is that there are obviously many “rides” in each session, part of each session, about each session, a concept that is often forgotten.

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Functional MRI and Adolescence

Chapter 3

In spite of the above-mentioned seeming drawbacks, many adolescents can be analyzed, Not only can they be, but also they tend to benefit at least as much or more than any age group. Benefits that may occur seem to be twofold: adolescents may be helped with the difficulties that surround nearly all adolescents; Further, analysis may assist in the laying of a sound foundation for the future of an individual adolescent These possible benefits seems to occur in three ways: emotion-ally, intellectually, neurologically.
There is recent functional MRI research that may suggest why this latter point, that of us helping to ‘lay down’ a sound neurological/emotional foundation for the future, may be true, even in Neurological terms.

Jay Giedd, MD, a practicing child and adolescent psychiatrist and Chief of Brain Imaging in the Child Psychiatry Branch at the National Institute of Mental Health is the lead researcher “In a particularly interesting study, wherein Dr. Giedd looked at the brains of 145 normal children by scanning them at two-year intervals. This was work Giedd was only able to do with magnetic resonance imaging, because it re-quires neither harmful dyes nor radiation, making the study of normal children, as opposed to sick ones, ethically tenable. What the researchers have found has shed light on how the brain grows and when it grows. It was thought at one time that the foundation of the brain’s architecture was laid down by the time a child is five or six. Indeed, 95 percent of the structure of the brain has been formed by then. But these researchers have discovered changes in the structure of the brain that appear relatively late in child development suggesting that functional anatomical developments of the prefrontal cortex and cerebellum rather than beginning to decrease, actually increase. Dr. Giedd and his colleagues found that it (pre-frontal cortex and the cerebellum) appears to be growing again just before puberty. The pre-frontal cortex sits just behind the forehead. It is particularly interesting to scientists because it acts as the CEO of the brain, controlling planning, working memory, organization, and modulating mood. As the pre-frontal cortex matures, teenagers can reason better, develop more control over impulses and make judgments better. In fact, this part of the brain has been dubbed “the area of sober second thought.”
“The fact that this area was still growing surprised the scientists. Although they knew that the brain of a baby grew by over-producing synapses, or connections, they had not known that there was a second period of over-production. In a baby, the brain over-produces brain cells (neurons) and connections between brain cells (synapses) and then starts pruning them back around the age of three. The process is much like the pruning of a tree. By cutting back weak branches, others flourish. The second wave of synapse formation described by Giedd showed a spurt of growth in the frontal cortex just before puberty (age 11 in girls, 12 in boys) and then a pruning back in adolescence.
Even though it may seem that having a lot of synapses is a particularly good thing, the brain actually consolidates learning by pruning away synapses and wrapping white matter (myelin) around other connections stabilize and strengthen them. The period of pruning, in which the brain actually loses gray matter, is as important for brain development as is the period of growth. For instance, even though the brain of a teenager between 13 and 18 is maturing, they are losing 1 percent of their gray matter every year.
Dr. Giedd hypothesizes that the growth in gray matter followed by the pruning of connections is a particularly important stage of brain development in which what teens do or do not do can affect them for the rest of their lives. He calls this the “use it or lose it principle,” and tells FRONTLINE, “If a teen is doing music or sports or academics, those are the cells and connections that will be hardwired. If they’re lying on the couch or playing video games or MTV, those are the cells and connections that are going to survive.” )

Adolescents have at least two, or three or more languages. One is much like our ‘adult’ language. This language and it’s words are relatively agreed upon by many adults with respect to meaning and use. Sadly, the study of nearly any ‘adult’ word, in fact, shows that the definition of each word is shrunken. By ‘shrunken’ I mean that amongst the many possible meanings of a word, most of the alternative meanings are discarded. This shrinking is not only related to the words themselves but on the people who use these words and concepts to think and to write and speak. For example, the word ‘depression’ actually has as many meanings as there are people to think/feel them. Of course each individual’s idiosyncratic meaning also changes, making matters even more complicated. But, in our field , for exam-ple, the meaning of ‘depression’ is so shrunken that it’s meaning has long since de-parted. The net result of this ‘shrinking’ is the loss of meaning, the illusion of knowing, and the likely end of curiosity.

This first language is so unnatural to children and adolescents, that they must study hard and long to learn it. It must be learned since so much of our world relies on it—adult speak. Further, we have all met adolescents who seem to have mastered this language early on and use it exclusively—‘the grown up to soon’, ‘missed out on his childhood’ adolescent. Many of us would judge this patient easier to treat, an adolescent who speaks ‘adult speak’ to his analyst who is only able to ‘adult speak’. This is a formidable task, however. Not that it is our province to educate, to ‘teach’ this adolescent to be an actual adolescent is difficult at best. Perhaps that is neurologically impossible.

Then there is adolescent language two, which begins slowly at about age 10-11, peaks around 16-18 and then diminishes to be followed by the growing presence of adolescent language 1, ‘adult speak’. One might hypothesize there is a parallel between ‘adolescent speak and act’ and neurological growth. To wit, the rise and fall of adolescent speak and act seem to parallel the growth of and then pruning of the neurons and synapses of the pre-frontal cortex. Perhaps in adolescence we are seeing what a human being, in our culture at least, looks like with too many neurons and synapses whose wiring is somewhat questionable. And, then, we get a chance to see the other side of this slope—less neurons, less synapses and more hard wiring. Less adolescent and more adult.

Psychoanalysis, by definition, is not a treatment modality. As understood by Freud and Bion, that is the case. Absent memory and desire, there can be no ‘treatment’ as such. Nevertheless, we have all had the experience of patients’ ‘improving’, ‘doing better’ seemingly almost no matter what we do, what theoretical schools we come from, etc.—with the exception of adolescents, where technique matters greatly. If one considers that learning may be the key, learning secondary to understanding, then our work may look ‘curative’ even if that was not the aim.

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Adolescent Speak

Chapter 2

Part 3

With adolescents living and thinking in the present trying to talk with people whose orientation is in the past or predictions of the future, we truly have the often used often meaningless term ‘communication gap’. We truly have ‘gaps’ in our techniques and theories of practice, should we wish to analyze adolescents. We haven’t tried to see what we do wrong with adolescents. We speak and practice as if there are no ‘gaps’ in what we do—an obviously very serious problem since we actually, obviously, do have ‘gaps’. In this instance, the primary gap is between present thinker (adolescents) and analyst thinker. We analysts’ inability to both recognize and bridge this gap—the gap being to have both the analyst and adolescent talk the same language—present and present, must be addressed and hopefully corrected. After all, we are the adults and they are the children. We must be the solver of this problem. We have to be the re-source to solve this problem. Based on my understanding of our theories, we undoubtedly have infinitely more gaps than non-gaps.

The lives of adolescents as well as the rest of us are filled with ‘thorofare’ gaps. Adolescents usually don’t see these but do experience the now. We usually don’t see the ‘gaps’ in our theories either, like our adolescent brethren. We are, however, very good at spotting what we consider the ‘gaps’ in adolescents. Both we and adolescents don’t think ‘gaps’, but for entirely different reasons. They don’t see them because it is not a part of their life view. As I said, we should be able to see ‘gaps’ in our theories. We don’t. According to us there are none, even though that is a very dubious proposition. Should we see them, we would have to accommodate them, possibly having to change our theories and practices—-a seemingly very unwelcome prospect.

There is a term used by skateboarders called “gapped”. The definition in slang dictionaries of “gapped” is a break, unexpected and unseen, in the pathway of a skateboarder, which is suddenly present. The result of the ‘gap’, in this situation at least, is that what happens to one who is “gapped” is entirely unpredictable. Hitting the unpredictable and unknowable gap, may cause one to crash, turn left, turn right, keep going, etc. They may continue as if nothing happened. They may crash horribly, etc. And, they keep right on skate boarding. Most skateboarders, by the way, regardless of the seriousness of their injuries, are usually immediately back skating.

Our theories don’t recognize ‘gaps’ nor encourage their discovery. We have crashed and don’t know it. We will inevitably crash, but most likely won’t know it. How does one crash on something that, according to us, does not exist? The answer is simple—we don’t. Perhaps we could give a lesson to skateboarders, and teach them how what is there really isn’t there. This would be a very hard sell to an injured skateboarder.

To further use the analogy of the skateboarder, we, as analysts, hope to find a magical Thorofare —predictable, knowable, gapless etc. Of course, such a Thoroughfare does not and cannot exist. We just say it does.

The song itself illustrates these concepts. The song is the story of a train, climbing a mountain, arriving at the crest, etc., only to discover that there is another crest, and another and so forth. It is a story of how we analysts see things, supposing that we can see the future—that there is a see-able end in sight which we can see, although that turns out to not be true. Nevertheless, at least the length of the ride can be measured, the speed of the train calculated, etc., but only to the next crest, thought to be the last one. These measurements are “distance”. The distance the train has traveled can be measured. In this song, the ‘ride’ includes all those elements only coincidentally related to distance—Feelings about the train, the train ride, the bridge, the rain, the burned out forest, etc., none of which are a part of distance of the train trip, but all part of the ‘ride’.

The end of this song, “No distance. It’s the Ride” is profoundly correct. ‘Distance’ is a concrete piece of information, for example, the distance traveled by the train. If one carefully thinks about our formulations, they are virtually all “distance”. We declare projective identification to be a thing, and it becomes distance. We know where and what the end is, or at least we think we do. That concept tells us nothing about the ‘ride’ of the patient, unless we decide that Melanie Klein’s theoretical concept actually describes the ride of all of us. Further, for example, “omnipotence” is a distance. We use that word, often directly to the patient. Yet, but for an incredible coincidence, telling a patient that he is ‘omnipotent’ will most likely say nothing about the reality of the patient with the possible exception of being insulting. In psycho-analysis the “ride” is really all that matters. Although we can conjure up all the formulations and theories (distance) that we wish, it is the “ride” of the patient that is all-important. And ‘rides’ are as many as there are people times infinity. Adolescents think and talk about ‘rides’. Distance talk to an adolescent by an analyst ordinarily means the end of treatment. It is one more sign to the adolescent that they are not understood. ‘Distance’ here is theoretical, judgmental. It has nothing to say about the ‘ride’ of the adolescent.

The discussion between analysand and analyst I call ‘a dialog’. The exchange as envisioned by me in psycho-analysis is a ‘dialog’, virtually always illuminates the ‘ride’. The ‘ride’ is the patient’s actual experience of events, thoughts, feelings, etc. The “ride” in our work roughly means the present actual experience of the patient that is attempted to be conveyed moment by moment by the adolescent to the analyst in a session.

The adolescent is attempting to state their experience in life at that moment. In that sense what they say always their ‘truth’. They are telling the ‘ride’ of their life at that moment. The context is now. The recognition by the analyst that there is a “ride” of the patient is crucial. A ‘ride’, for example, is not ‘depression’. The understanding that each ‘ride’ is as different as can be is monumentally important. Grasping this “ride” is the stuff that yields understanding of an adolescent. These concepts are also the ones that enable one to analyze an adolescent.

The ‘ride’ changes by the moment, both in sessions and in life. It is not static. Obviously each or our “rides” in life may superficially appear similar, yet are realistically entirely different, and ever changing. We often consider things to be ‘rides’ even though they in truth are ‘distance’. The ‘Paranoid-Schizoid position’ is an illustration of this problem. Although the concept of ‘Paranoid-Schizoid position’ is an extremely important theoretical contribution to our field by Melanie Klein, never the less, it is ‘distance’. It is a model, static in time. It is often used as though it were a ‘ride’, an actual experience of a patient. There are no experimental equivalents to this construct. There are many parts of another of Ms. Klein’s seminal contributions, ‘the Paranoid-schizoid position’. It, and its parts are often used by analysts. For the most part an adolescent or adult entering analysis, is understood as being arrested at or regressing to this ‘position’. Adolescents who suggest paranoid-schizoid elements are often told directly that these things—envy, projection, evacuation, etc. are true of him-what he ‘really’ means to say. Although some of the defensive mechanisms of this ‘position’ are seen in ordinary life, such as ‘envy’. ‘Envy’ is hardly the same entity from person to person. Would my 16 year old, ‘I want Marry’, benefit or stand for a transference interpretation of ‘his desire to project into his analyst the envy that he feels of me since I am able to get any girl I want and not think only of hair?’ Very likely not. Furthermore, there is no evidence to support such an interpretation. This would be another instance, more than likely, of an unlistened to, attempted to be theory stuffed adolescent who departs treatment.

But for great coincidence, Klein’s theoretical elements, concerning the ‘paranoid-schizoid position, no matter how brilliant they may be as theory, are not the ‘ride’ of any patient, let alone the Mary boy. The Mary Boy sees Mary, her body, and her hair, and she won’t. These elements and associated feelings are his present ‘ride’. Ms. Klein’s formulation is a distance formulation, a model that exists and has existed in its concrete form for many years, and applies to no one’s living life experience, but for extraordinary circumstances or educational efforts. There is a story written by Ms. Klein in her book Envy and Gratitude (which, wherein she writes about the end of an analytic session with a patient of hers. She describes the patient arising and turning to her saying “I have had a good feed”. No one speaks in these terms naturally. Such a statement smacks of education by the analyst of the patient. Discovering ‘Gaps’ in this theory however, is an impossibility. It is not designed for exploration, only recitation. For whatever it’s worth, I have never heard this statement questioned or elaborated on. Ms. Klein certainly didn’t question it, at least to my knowledge. It is the ‘truth’. Patients are ‘well fed’, or not. Period.

Different “rides” should yield different formulations and different applications of these formulations. Per Dr. Wilfred Bion in his book, 2nd Thoughts, Commentary, our ‘formulations’ are only models which must be able to be constantly constructed, discarded, to be replaced by another theory or model, etc”. Models otherwise derived cannot possibly investigate the truth of a patient. These ‘models’ as understood by me are attempts to understand and investigate the ‘ride’ of the patient. To realize the importance of the kind of thinking that goes into this model making with respect to adolescents cannot be overstated. Models must be made which investigate the patient’s ‘ride’. In other words, we are talking to the adolescent about his present and using models of the patient’s associations to further investigate the patients associations.

To imagine that a set of fixed formulations can possibly explain or in fact be related to the truth of any of us is, on the surface, preposterous. In that sense, our usual interpretations aren’t the result of the examination of the ‘ride’ of our patients. Using our ‘distance’ thoughts are sadly incorrect. Jealousy of a girlfriend’s friend will be just that until and if it shows that it has roots in the Oedipal complex. The use by us of our ‘distance’ formulations illuminates no truth of the patient to the patient, but are even more destructive in that we tell patients what isn’t the truth, is the truth.

Unfortunately, our non-truths are supported as truths in many ways. We sound knowledgeable. We have super-abundant amounts of education and experience. Our statements, true or not, are cloaked with the mantel of our authority and position. And so forth. Further, most of us are particularly intelligent, thoughtful, attentive, actively trying to understand our patients no matter what our theoretical bent may be, etc. These qualifications, although admired by many, be they arbitrarily constructed formulations and applications, are usually seen through rapidly by adolescents as negative elements rather than positive. ‘Academic formulations and qualifications’ such as these are often the root of the determination by the adolescents that they are not being listened to, understood and are only being given contrived, theoretical distance interpretations. They often feel, correctly, that what they say is material awaiting the chance to be attached to a theory. So matched, material-theory, adolescents are then told what they ‘really’ meant. Such maneuvers very often lead to the adolescents’ derisive departure from treatment.