Adolescent Psychoanalysis

The Deconstruction and Construction of Adolescents and Their Analysts

 

Chapter 13

Part 4

 

Many or most of us psycho-analysts, both in the past and the present, have often followed and follow similar social-educational pathways through school,  the large majority of it directed toward ‘left’ brain development.  Most academic/scientific learning is necessarily directed that way.

I am going to focus on the education and other experiences of those students who intend to attend medical school early on in their lives.  For those who wish to become psycho-analytic physicians, graduation from high school, college, medical school, internship, psychiatric residency and psycho-analytic training is the pathway.  (I do realize that these days many psycho-analysts are not physicians or psychiatrists and have had no medical or psychiatric training.  As I said before, I am intentionally focusing on the former group, not the latter.)

(As a side note, without belaboring this point, I wish to focus briefly on the following point since it is relevant to much of what follows. Many of us believe, probably with some correctness, that psycho-analysts without medical training to be fundamentally different in many ways, some good and some not good, than analysts who are not medically trained.  Of course, physician/analysts knowledge of medicine exceeds dramatically that of non-physicians.  That, of course, goes without saying. Elements of medical training and experience, of diagnosing, treating, dealing with death and dying, etc. are both unique and formative. Such experiences fundamentally change many physicians in positive ways that cannot be well described in words nor taught later in life. The experience of these and other similar incidents yield an indelible mark on most physicians. In the proper hands such training and experience can be a great asset in the field of psycho-analysis; in others, unfortunately, such training may be an extreme drawback.  Freud in his  “Five Lectures on Psycho-Analysis” Volume 12 page 10 said “It is not without satisfaction that I have learned that the majority of my audience are not members of the medical profession. You have no need to be afraid that any medical knowledge will be required for following what I have to say.  It is true that we shall go along with the doctors in the first stage of our journey, but we shall soon part company with them and Dr. Breuer, and shall pursue a quite different path.”

If we physician analysts bring to our psycho-analytic patients an awareness of them as an unknown and fundamentally unknowable ‘whole’ human being, to be assessed and understood, not seen by us as a list of theoretical pre-conceptions, we and they are much the better for it.  To grasp physical and physical/psychological symptoms can be of great use.  Contrariwise, if we physicians learn to see our patients, in this instance emphasizing adolescents, as a list of potential diagnoses, as is often the case in medicine, the correct ‘one’ waiting to be found, both we and our patients are far the worse for it.

‘Differential diagnosis’ in medicine means, roughly, a list of the possible causes of a particular symptom or symptoms.  Such a list is extremely important in physical medicine, usually guiding the investigation of symptoms. On the other hand, such a narrowing of possibilities or thinking of our analytic patients analogously as medical problems to be found and ‘cured’ is a crucial mistake, be such a list created by physicians or non-physicians.)

I will use as an excellent example of the education/social experience followed by many of us, a middle school in Brookline, Massachusetts. If one lives in Massachusetts, perhaps Brookline, and wishes to attend Harvard University, the ‘Harvard’ track begins in 7th grade. It is very difficult to be admitted to Harvard in any event, but harder yet if one lives in Massachusetts. To see 7th graders, dressed in coats and ties and carrying briefcases, all in the name of this track, is particularly sobering.  The level of studying and academic achievement expected of these 7-8th grade students is extraordinarily high.  Ordinary social development is often left aside for other children to experience.  These other students are playing basketball, football, Little League and have begun to chase girls (or boys).  Sexuality is beginning to be experienced and seen. These non Harvard-track students will often be dirty from playground dirt and occasionally in trouble with teachers, principals, etc. Many would say they are normal 7-8th graders.

Our hoping to be Harvard bound students, on the other hand, will be as clean at the start of the day as at the end.  The chasing of girls and boys, consciously and unconsciously, will be set aside—too much school work to do. Evenings and weekends are largely unavailable to this group for much of anything but studying or being carted around by parents to various ‘activities’. Meanwhile, the ‘miscreants’ will be playing sports, at the malls, etc.  They will do their work, perhaps successfully, but at times that allow for many other activities.  The splitting off of social experience for our ‘Harvard’ tract students will have well begun. And, per above, many would be medical students will genetically come from and be raised by primarily ‘left’ brain families, usually high achievers.  Studying and academic achievement will receive much more emphasis than other activities.  Letter grades will be much more important.  Group testing results will also achieve much more emphasis.

Many of us have faced the same problems as the young Brookline students, many of us following the ‘Harvard track’ whether Harvard be the goal or some other educational institution. Many of us began our ‘run’ for medical school either in middle school or high school, studying very hard, eschewing ordinary social life in favor of other activities, mostly academic, adding to our academic ‘portfolios’, so that we may matriculate to an excellent college. We often added ‘Extra-curricular’ activities which were usually confined to those that support college admission—–Math club, Science club, etc.

In the good old days, there used to be ‘honors’ classes, which seemed to make at least some sense.  In an ‘Honors’ class, one would be grouped with academically talented and usually extra-motivated students, hopefully to learn more and get an extra grade for their trouble. This ‘extra’ grade was useful in applying for college.  An extra grade would be a grade added on top of a grade.  For example, if one were to get a B, it would be counted as an A. This would increase one’s GPA and broaden the array of colleges to which one might be admitted.

Then came the Advanced Placement class (AP).  This was and is a new and extraordinarily insidious high school academic ‘improvement’ that has sadly continued to develop in high schools to this day.  If one takes and successfully negotiates an ‘AP’ course in high school (available in many subjects), one achieves ‘rewards’.  There are 3: 1) One may actually learn more, an excellent goal;  2) As in ‘honors’ classes,  letter grades are raised by one.  For example, a B becomes an A, an A becomes whatever is above an A and so forth, raising ones high school GPA, sometimes substantially.  The pressure of grade achievement and successfully passing both the AP classes in which one is enrolled and the examinations which follow the completion of these classes is immense; 3) most insidiously, students successfully completing an ‘AP’ class and the associated exams, are excused from taking a similar class in College.  For example, if one takes and passes AP History, one is not required to take the equivalent History class in many colleges.

Many students take a number of AP classes, eliminating the necessity of taking numerous classes in college.  If one thinks about this practice, it is ludicrous.  Firstly, students must study very hard, to the exclusion of other important types of learning in high school. Secondly, there is no reason not to expect that the vast majority of the Professors who teach in Colleges and Universities would not exceed the skills and knowledge and teaching skills of high school teachers? Although this is extreme and impossible, why not have the full complement of AP classes, covering all college courses and eliminate college altogether. Perhaps professors could be eliminated entirely.

One must also recognize that while this academic orgy is continuing, anything that passes for ordinary social maturation and experience is often ignored and usually discarded from the ordinary high school experience.  Adolescence, which nearly everyone agrees is the bedrock upon which so many later developments in life rest, not the least of which is the efflorescence of what will be adult sexuality, is ignored.  Ordinary social interactions between students, boys and girls, athletics, athletic events, etc., for many, simply don’t take place. One cannot study this hard and have time for much else.  No grades are given for ordinary social development.  Perhaps such grades wouldn’t be a bad idea.

At this point, theoretically at least, prospective medical students and many other students, part company.  That is deceptive, however.  I have been discussing only prospective medical students.  There are many other adolescents who follow this same pathway.  Not all AP students by any means are interested in medical school.  The large majority is not.  But, they suffer the same developmental consequences socially.

Then comes the next serious problem for many students for the most part students who are late in adolescence.  College. There are many life functions, independence, love, social interaction, experimentation of whatever type, which should be a large part of college. Once in college, however, for many, the necessity of academic achievement becomes even greater.  If one  wishes to go to medical school or graduate school, especially a ‘good’ one, one must do well or very well academically in college.  It is difficult to quantify what portion of college or high school is responsible for social development (as above) but that portion is undoubtedly very high.  However, to benefit from this aspect of higher education, that of social maturation, students need to be physically and emotionally available.  If the same pattern from Junior High School to High School as outlined above, is followed, these students will be unavailable for anything but academics and suffer the consequences of no real social development.

To complete this particular disaster comes Medical School, Residency, etc.  For us of the old days, less so in current times, the demands on medical students are extraordinary.  There was and is very little time for anything much other than study and active participation in patient care, both in medical school, residency and somewhat in analytic training.  Little time is available except for the rare student who is used to finding his/her way around socially.  They find a way to find extra time, for dates, etc.

This lack of ordinary experiences in our lives leaves many of us grossly unprepared for ordinary life with ordinary social graces. Many outsiders regard practitioners in our field as both ‘weird’ and ‘out of touch’ with reality.  Go to an analytic meeting to gather evidence.  Meet the families of some analysts and be prepared to meet some of the most bizarre families one can imagine.  Often these families seem completely detached, or nearly so, from ordinary social reality. These families, of course, are also most often intellectually superior and highly educated, and, sadly, most often unable to negotiate ordinary life situations.  Choices we make are often bizarre. Unusual and odd theories of child rearing abound.  Ordinary structure is often absent or present in the most bizarre ways.  Theories gained in analytic training and analytic experience are often applied to families as though there were a direct correlation between our psycho-analytic theories and family life.  And so forth.  How much these failures result from the pathway I have described are, of course, unknowable.  In my opinion, the percentage is very high.

Perhaps the biggest problem presented by this pathway is that those who follow it never have the chance to be or to experience being an ordinary adolescent.  We have all encountered children who are said to have never been a child, just skipped ahead.  This is similar, but vastly more important. Not that one needs to jump from a bridge to treat a person who has jumped from a bridge, but to treat an adolescent without ever being one is a virtually impossible task.  The ability to identify with the adolescent is absent.  Ability to compare experiences is absent. Etc. As a consequence, from many analyst’s points of view, adolescents appearance scene is that of a flying saucer complete with spacemen.  ‘It’ is a foreigner.  ‘It’ has values and behaviors never before seen. Freud had very little to say about adolescents.  Neither did Melanie Klein, unless one is to take her theories of early infantile life and transmute them to adolescents.  That is to say, unless their researches and teaching are arbitrarily applied, the practical analysis of adolescents was untouched.  If arbitrarily moved, infancy to adolescence, sadly, make the analysis of an adolescent impossible and usually lead to very early termination.

Some of us treat adolescents largely as ‘symptoms’ that should be expunged.  Analysts of adolescents often seeks to cleanse them of these ‘symptoms,’ some of which are not ‘symptoms’ at all, but which are in fact the building blocks of adulthood. The danger is tempting unless one is aware that during these formative years, valuable parts of emotional and characterological formations, which are extremely important components of ordinary life, develop.

Alternative pathways are not followed by most of us by any means.  Were they, dramatically different personalities amongst us would evolve. Perhaps we can imagine ourselves as adolescents who were socially skilled, socially experienced, sports playing, dating, sexually experimenting, occasionally manipulating, occasionally lying, perhaps drug and alcohol experimenting, etc.  In short, we would have been normal teenagers, who also may have done well in school.

A young Asian girl of my acquaintance who coincidentally attends the same high school attended by me back in the day, has been raised in a very strict fashion by her parents.  She studied and studies very hard, has gotten very good grades, takes piano lessons, attends church many evenings a week, etc.  She was not allowed to see any boys.  She also happens to be very attractive.  Her mother did her best to keep her away from boys, feeling that they would somehow ruin her and keep her from her studies.  This family had moved from China to this country specifically for the sake of their daughter’s education. For a variety of reasons, in spite of the mother’s advice to ‘look up’, the boys ‘got’ her.  She was just too cute to escape unnoticed. She now has three boys who ‘like’ her (innocently), is much happier and her grades, already very good, have gone up considerably. (In her group, she seriously and laughingly explained to me, an A- is an Asian C.)  Because of these recent experiences, she is much less controlled by her parents. And, furthermore, she wants to be a doctor. She has escaped the trap. And, her grades, already ‘Asian’ A’s, improved. If the High School and College experience were confined to what takes place in the classroom, studying, etc., were the sum total of what is ‘learned’ in high school and college, then, of course, the system would be grossly defective.

The Deconstruction and Construction of Adolescents and Their Analysts

 

Chapter 13

Part 3

 

There is yet another crucial issue that must be recognized and addressed.  This issue goes as follows: B analyst, of which I am one, has to be able to ‘switch’ and function as an A analyst, an analyst who can deal appropriately with A material.  By A material I mean material with which many of us are familiar, especially in our work with adult patients. Specifically, adults often bring material specifically lending itself for analysis, such as dreams, specific conflicts and neuroses, depression, anxiety, etc.

One of the great benefits of having created a working, positive relationship with a difficult B adolescent, who usually operates in a B fashion, is that when they ‘switch’, B adolescent, often consciously or unconsciously, and usually abruptly, is working with A material.  By A material, I mean material which is not based on Adolescent/Analyst BB relationship formation, although strongly supported by that relation, but on actual symptoms, such as pain, anxiety, guilt, obsession, depression, etc.

An example is this: a 15 yo extremely B girl, who both required a great deal of trust building and relationship formation. Much of the time she liked to joke, mock, laugh at both herself and me, her parents, her teachers, friends, etc.  She had little or no interest in boys, partially because she reportedly had been raped not long before her analysis began and for other reasons. This joking was not malicious in this girl’s instance, but bore a great deal of humor—characterological, not neurotic.  She had a very appealing and pithy sense of humor.

For the moment, I am ignoring Freud’s admonition, ‘behind every joke ……’ by not being concerned with the meaning behind the joke.  ‘Behind’ means what the joke ‘means’ or ‘represents’ psychologically. Conceptually this means to ‘participate’ in the joke—-to take the joke for what it is, at face value and to talk of the joke material presented by the patient, concretely.  For example, pretend a patient said to me, “Why did the moron tip toe pass the medicine cabinet?”  Taking the riddle for what it is, I might respond laughingly and jokingly, “To not wake up the sleeping pills. What a stupid joke.  I’ve heard it a thousand times and each time I’ve heard it, it seemed stupid. Try to do better next time. Maybe you just think I’m moronically stupid?”

In this example, this lead to participation in her joking. On more than one occasion, she would joke about the stupidity of her mother, particularly if there was a disagreement between them.  Her mother, based on previous material presented by the patient, was not ‘stupid’, whatever ‘stupid’ may mean.  One could discuss this material as we usually do with adults, and try to determine why she ‘hated’ her mother so that we could interpret that meaning to her.

In most circumstances, with adolescents, this is exactly the wrong thing to do. The ‘meaning’ to the adolescent is that her mother is stupid.  As with the ‘joke’, the ‘thing in itself’ of her ‘stupid mother’ is the subject. However, in this instance, she and I investigated the qualities of her mother as provided by the patient, that ‘showed’ mother to be stupid.  The level of that ‘asshole’ mother’s ‘stupidity’ expanded and expanded during that session, helped along by both her and me.

(Collusion was not the basis of this expansion.  As we all know, collusion ends analysis, on the spot, and starts another process, the name of which I don’t know.   At a minimum I would have aligned myself with the daughter against the mother, placing my weight on the side of the daughter and ending her analysis)

The actual interaction in this example and many others was much more like improvisational theater than what we could call traditional psychoanalysis.  The usual goals in improvisational theater are: 1) never disagree and 2) to expand whatever was just said.  For example, if one actor asserted that the President was really horrible, the improvisational theater partner response might be, “yes, and stupid as well”. The response from the original actor might then be, “you’ve got that right.  I don’t think ‘stupid’ adequately describes him.  Worse than stupid.”  And so forth. Anyone who has devoted much time to arguing with an adolescent in treatment about much of anything will understand.

If you’ve done a good job, at some point the patient will bow out of the ‘improvisation’.

“Well, she’s really not that stupid.  You’re exaggerating. We (mother and her) just disagree sometimes.” She said.
(The growing ‘exaggeration’ has passed beyond the adolescent’s point of credulity.) Where we had been united, we were suddenly split. At that point she had aligned herself with her mother and against me.   The pair (mother and daughter) have now become the analyst, and me the misguided, defensive patient, a role which I find both entertaining, and extremely useful in building a constructive relationship.

At this point I reacted to her, not with great seriousness, but by joking, which she really enjoys.
“Now you’ve got me confused.  First you said that she was stupid, now it was only because of a disagreement and now I am exaggerating.  This seems to me to be unfair.  I may be slow, but not that slow.” I responded.

“If I hear you say you’re slow one more time I’m going to throw something at you,” she said laughing.

“Now this is really getting extreme.  First slow, misunderstanding and now a target! What will you throw?” I asked.

“I think you’re twisting things like you usually do.  You need help,” she said laughing.

“I think I’m beyond help.  You’ve said so yourself.  Although I have one asset—twisting things”. I said.

“Yeah.  Now you’ll probably say you think I’m stupid. Go fuck yourself,” she laughed.

“Things are really getting bad now.  You say I call you stupid, you say I’m a target, twist things and now I’m supposed to go fuck myself—however that is done.  All this because you said you’re mother is stupid.” I said.

“Alright, alright, I give.  But I’ll get you someday when you least expect it. You remember things too well.  What you need is some amnesia and a lot less education,” she said.

With this same patient, there were sessions where the essence of the material would change dramatically. For example, this patient came to one session as follows: humor was absent, seriousness was the mood, topics much more dramatic, much crying, anguish, etc. In this instance the material was about her parents, and most particularly her mother. She was anguished that her divorced parents hated each other so much that it made it impossible for her to deal with either one of them. That they were so immature caused great anger in her. How was she supposed to live her life normally

if she really had no real parents?

She told me this dream:

A little girl was walking down a path that she loved and encountered two people, a man and a woman lying on a blanket and kissing each other, openly, in the field that she loved on the right of the road. The little girl became extremely angry and started throwing rocks at the couple, causing them to run away.

Her associations were as follows: She didn’t think she was the girl with the black hair since she had dyed her hair black. The girl in the dream’s hair was blond, although the patient allowed as how she wished that her hair was blond. She didn’t recognize who the little girl was, she said. The path reminded her of a path she had often followed at a park near her mother’s home. She couldn’t recognize the couple although, she added, that her parents often walked along the same path. She was very angry at the couple but didn’t know why. Earlier that day, she said, she was at the mall and hates to see couples walking hand and hand. She said it looked phony. They made her sick, she said. She said that she never threw rocks at anything but trees. She couldn’t imagine herself throwing stones at people and this little girl threw rocks at the couple, who ran off in two directions. She said the stones came very near the woman. She said that the little girl ran off as well, in a different direction, scarred, crying and terrified at what she had done. The patient also said she couldn’t understand the little girl being so upset since she hadn’t hit anyone.

I interpreted that the little girl probably was her and even though she wished her parents would get along so she could talk with them, in this dream at least, she didn’t want to be able to talk with them, but wanted to split them up, perhaps killing her mother. But she felt very guilty about that, in spite of the many times she joked about her.

She reacted to this interpretation with anger at me and at her mother. Yeah, she said, she had often wished her mother dead since she liked her father much more and mother kept him from her, but hadn’t ever told anybody about it. And, she added, that that I reminded her of her father even though she was throwing rocks at him/me, she supposedly wanting to be close to her father/me.

The Deconstruction and Construction of Adolescents and Their Analysts

 

Chapter 13

Part 2

 

Christine is a Type B adolescent. The following notes are of an early session and are divided into sections. Christine illustrates a very complex Type B adolescent. These sessions notes are presented for a variety of reasons, the primary one being to illustrate a Type B adolescent. That she is a Type B adolescent says nothing about the severe difficulties she has. Christine is a scattered, sometimes delusional, funny girl, who is socially experienced, has a history of both a casual sexual life, a large amount of drug use, all wrapped in a very ‘hip’ personality. She also has immense problems with her mother and other relatives. Nevertheless, I apparently formed, early on, a constructive and open relationship with Christine. She does seem to be able to relate to me well and is not self-conscious about discussing herself.

 

 

 

“So what’s up?” I asked.

 

“I had family therapy yesterday and we went to after to go eat and I got to talk to my best friend and my girl friend on the phone”, she said.

 

“Are they the same people?” I asked

 

“No. My best friend’s a guy. His 18^th birthday’s coming up and he’s going to come over on one of my home passes so we can go out. My girlfriend just came back from Provo on Saturday, so I’m going to see her this weekend.” She said.

 

“Is this girlfriend girlfriend or a friend who’s a girl?” I asked.

 

“Girlfriend girlfriend. (pause) I don’t know. I love the house.” She said.

 

“I’m a bit confused. How did we get from girlfriend to house. Anything in particular to account for that?” I asked.

 

“What do you mean?” She asked.

 

“I have an idea, and this will probably sound weird. You love the girlfriend and she is like the house?” I suggested.

 

“I don’t know. I love how it’s so homey and everyone gets along so much. The staff are not rude or stuck up or power hungry. I really like it here, she said.

 

“At XXX residential program the staff were just not too good?” I asked.

 

“Yeah.” She said.

 

“Or power trippers? Or…” I said.

 

“Just bitches all around.” She said.

 

“Did you meet your girlfriend there?” I asked

 

“Yeah. We got in trouble for being in a relationship which is kind of retarded because you’re allowed to have relationships with guys on the guys campus, but girls aren’t allowed to have relationships on the girls campus. We’re not supposed to be in relationships. We got in trouble for it.” She said.

 

“So if you hooked up with some guy, that would be okay?” I asked.

 

“Well, hooked up, I don’t know. But if we’re going out and considered boyfriend and girlfriend, then that’s okay. But if I have a girlfriend, that’s not okay.” She said.

 

 

Silence

 

“You’re my therapist aren’t you? I heard that you’re my therapist. I also heard you’re a doctor. I heard you do it all.” She said.

 

I laughed.

 

“That’s what they said.” She said laughing.

 

“Okay, let’s say I do a lot of things. I also do the windows, …” I joked.

 

She laughed.

 

“Maybe I come across to you like one of the staff you hated at XXX residential program, or something like that, or secret power-tripper?” I said.

 

She laughed.

 

Silence

 

“By the way, last night J  (social worker) called me up, which she pretty much had to. Usually what we do is confidential unless I was convinced you wanted to knock somebody off or off yourself, or get hurt by someone—-then what we talk about is different. However, the reason J called me had to do with you telling her stories of you getting raped at one point or another. What was with that? If you don’t mind my asking?” I asked.

 

“I don’t know. She asked my mom and my mom was like … it’s because some on the guys at school have been touching me and hitting on me, and it freaks me out because I have been raped. It freaks me out and I told my mom about it. I went to the bathroom and when I came back and they were just talking about it. I was like where did this conversation come from? Then J asked if XXX residential program reported it? I said. I don’t know. I told them. I didn’t really talk about it. We had a trauma group and one of the therapists was like you have to share your story with the group. It took me a really long time to do it, but I did. I’ve never shared it with my therapist, my individual therapist because it was the same thing. I didn’t trust him. I didn’t like him at all.” She said.

 

“What kinds of things made you not… I know you gave me examples, but were there any particular things?” I asked.

 

“Just, he didn’t listen. Whenever I told him something. I would tell him something that’s bothering me and he’d be like ‘Okay, that’s interesting.’ You know what I mean? He didn’t listen to me. If staff brings something to him, then he’ll talk about it. We’d have to talk about it. I didn’t like him.” She said.