Ue 66-90-13 1594 CLS3024436: Psychoanalytic study of the child. WR: (ISSN 0079-7308 / Yale University Press, /) Requested: 2017-03-20 12:10 Not needed after: Pickup at: GW George Washington - Gelman WDD: Web Delivery Citation: Issue: v.33() 1978; Article: The nature of adolescent pathology and the psychoanalytic process / Laufer, Moses; Pages: 307-322 “WRLC Shared Collections Facility - 32882013924249 - - Charged(2016-08-25) “WRLC Shared Collections Facility - 32882013924256 - - Charged(1999-03-04) * WRLC Shared Collections Facility - 32882013924264 - - Charged(2000-05-18)The Nature of Adolescent Pathology and the Psychoanalytic Process MOSES LAUFER, Ph.D. UCH OF OUR UNDERSTANDING OF ADOLESCENCE AND OF ADO- as relied on our insights gained from child pathology. Although this is un: derstandable within the context of the history of the develop- of psychoanalytic thought, there is the danger that we we know about child and adult pathology so that ent’s behavior. The severe limitations of such or of such a view of pathology can be see efforts (to my mind, rather unsuccessful) of va people who work with the seriously disturbed adolescent by Introducing a variety of therapeutic methods and techni and assuming that these innovations or changes will yield the answer to adolescent gy and to the cure of the ill ado- Iescent, The danger is that when these do not work, we say the adoleses escent process do not lend themselves to analytic help, rather than ask ourselves what its that we know and where it is that we are working blind! My understanding of the analytic process in rel to theMoses Laufer is based on some of my views about the co tion that the period of adolescence makes to the person's whole psychological dev as well as on my view about the specific nature of ology. T shalll first si marize these view process in adolescence. Tie DevELoPMENTAL FUNCTION OF ADOLESCENCE The references to F cence often emphasize k lation of one doles. he also wrote pes (what he (p. 234). IF ablishment there described as) the viewed developmenta of a fins inal sexual organizatic , the assumption of organization by the end of adolescence means that the part played by this period of psychological life in the person's future mental health is much more specific than is often assumed. As regards adolescent pathology, I would say categorically that illness in adolescence always ‘contains some abnormality in sexual development and functioning, I shall elabos later, Of course, | do n view that adolescence is a recaj the past deter mines the present and that the past gives emotion and substance to the present. But we blur the im, differences in development and in the und meaning of pathology if we apply Freud's ins and perhaps witho aterial of our adolescent patients. During the period of adolescence, from puberty to aby the age of 21, the usly makes a number of choices which repre: ns to the demands from his sexual body, to the ‘ans of finding acceptable solu- ntificar the conflicts, indecisions, and anxieties are experienced in a wide range of relationships and w many contexts, each of these is echoed via the adolescent's The Nature of Adolescent Pathology 309 o his own sexually mature body. Whether the ad- y the end of adolesc which reflects his t wishes w context of his having physically mature ge! als, and he attempts to find a con ise soluti what is wished for and what can be mise solution which defines the person's sexual identity. 1 would then define the main developmental function of adolescence s being the establishment of a final sexual organization (Laufer, genitals, change in the relationship to the oedipal objects, the change the relationship to contemporaries, the change in the attitude to one’s own body—are part of the main developn Id be viewed in relation to each other rather their own right. in the solution of these s, it s tasks the adolescent’s re wal factor, In my own wor fantasies, feelings, and conflicts involve in some way the per- son’s body, and that the shame or guilt or Pl he feels in relation to it lends his experiences affective meai ing. As a generalization, it may be correct to say that unt lescence the person feels himself and his body to be the exte sion of the mother who first cared for him; in adolescenc when the person has a physically mature body, he normally begins to feel himself to be the owner of his own body (La sequence, the adolescent assum actions and feelings; as actively cent becomes the guardi establishes a sex oles: ly mature bod idemtity by the end of adolescence,310 Moses Laufer solidated picture of himself as a sexual being, which is irrevers. ible—irreversible, that is, without therapeutic intervention, 1e NATURE OF ADOLESCENT PATHOLOGY Having defined will define adoles placing adolescent pathology within a developmental model This means that I do not view the disorders of adolescence as being similar to those of childhood or of adulthood, even though some disorders (e.g., obesity, some of the share a common fantasy whenever the pa- hology presents itself, Rather I consider adolescent pathology to be a breakdown in the process of integrating the physically mature body as part of the representation of oneself. As regards the timing of the breakdown in this developmental process, I believe that it accurs al puberty and has a cumulative effect throughout adolescence, the con- sequences of which will be seen in the adolescent's relationship tributory ingre- oedipal, or preadoles- pathology is that process whose primary or specific function is that of establishing the person’s sexual identity. Whatever may be the specific disorder, the primary nterference in the developmental process (which can be de- fined as adolescent pathology) is in the adolescent's distorted view and relationship to his body, something which is ex pressed via the hatred or shame of, the fury with, the sexual body. U the adult patient escent pat tient experiences his body as the constant representative of that which will overwhelm him with painful or frightening fantasies and affects. He experiences his body as constant proof that he has given in or surrendered passively—and un consciously surrendered it to the mother who first cared for him. The presence of pathology in adolescence always means: therefore, that there isa disturbance in relati the per to his sexual body. Whatever may be the c this breakdown—preoedipal, | The Nature of Adolescent Pathology gin son's sexual life, and that the understanding of this distur- bance is fundamental to the therapeutic task.? THE PSYCHOANALYTIC PROCESS IN ADOLESCENCE In formulating my views, I have relied on my own clinical ex- periences gained in the analyses of a number of adolescents, as well as on the experience gained at the Centre for Research into Adolescent Breakdown where a niynber of seriously dis- turbed adolescents were treated analytically by colleagues as part of a study into mental breakdown in adolescence, and whose treatment I have been able to follow over a period of some years When an adolescent agrees to participate in treatment, he conveys to us that he is unconsciously aware of his being out of touch with part of his internal life; that he feels he does not have the choice to do with his life what he may wish. The real- ity of a physically mature body confronts him with the fact, al- beit also unconsciously, that his fantasies now contain a new dimension, namely, that he is a sexual being and that his past solutions to conflict are now hindering his development; the adolescent may express this either in his symtomatology or in the affect he brings to his sessions. When he talks of his inter- al life, the adolescent patient is constantly telling us that he feels he now has a passive relationship to his body and to a part of his fantasy life which forces itself upon him and, per- haps more importantly, which forces him to behave in ways which are out of his control. When an adolescent patient tells me, for example, that she hates herself because she has to \s which are the jsturbance in the process of indiv of use in delineating specific aspects of an hey may help us make sense of the qui of a core fantasy. But they gin nat is really going wroge Moses Laufer The Nature of Adolescent Pathology overeat, and that she feels like ripping out her insides she can stop masturbating, she may be but affectiv nside her to help her deal w hat ing at the content Is that there is nothing fh the repetitive onslaught from her body. For her, her sexual body is not jemy but is the representative of h T have used the word adolescent's feeling or a the adolescent in touch w he knows ol may take a good deal of time in analysis, but when it happens the adolescent conveys, very often with relief, th wr with his hopelessness, or with his fe control, or with seriously wrong for s this here because I do not w: adolescents, which tempor: of some ver ely to come under the ado- the clue to and the adolescent Tt is the core fantasi the meaning of the adolesce these core fantasies represe ing to terms with his new sex so represent for ab- g to the normality or, in terms of the breakdown at the time of pu- ropa berty, they re] 1g of madness or of being out of sy, have in mind the existence with the implication that there is beyond other as meaning and pow’ ogy of the person. I would say that the core fantasy—the cen- tral masturbatio: niversal phe- nomenon and is itsel athological. Rather, the core fantasy contains the secret to the pathology, and helps to ex- plain the direction ofa person's sexual development and grati- ons; in other word: n’s whole oedi- I consider the piec and the anding of this core fa port adolescent because it is adolescence that this fantasy is confronted by a person w k of techniq nor do T want to describe the ly may have to be introduced i disturbed adolescents. Rather, wh touch with his inter cifically, what is it that enables the ill ing to the pathological s which he has found to conflicts, and especially to find the meaning of the breakdown which took place at the ness? Or more spe- idolescent to add mean mate underst me of puberty and which continues has physically re genitals. Moreover, it is only during ad- to impinge without respite on his present life? jescence that the person will finally we to his fi organi CORE FANTASIES nplies that during adolescence pathological growth is le than we tend to bel Through the var scent may use du is core ication which the ado- ig analysis, we are able to piece together asies. If these core fantasies can be contained mnalysis, then interpretation king through ns by which we and make sense of their meaning. However, when e adolescent's main means of dealing with these core ies, then it may be necessary to place limits on the acting out as a way of keep” ig these core fantasies within the analysis, thereby making # us forms of comm:3M Moses Laufer disregarding the rest of the person's functioning. Of course ot so. But in asking myself what is most important to anding of the adolescent's pathology, to reconstruc. tion, to working through, and ultimately to insight and to cure, I conchide that it is the core fantasy as reexperienced in the transference. It will undoubtedly take a very long time to construct in one’s own mind a patient's core fantasy, but the clues are there in the clinical material, in the whole range of derivatives from the unconscious—repeated daydreams, those object relationships which take on meaning for the patient, the fantasies which accompany the patient's masturbation or other sexual activities, and repetitive forms of behavior which may be understood partially as an undoing of the repression. In my work with the ill adolescent, it is these entries into the un- conscious which enable me, over a period of time, to put together the fantasy which then enables us to understand the motivation, the power of certain kinds of gratifications, and ultimately the pathology. These fantasies will themselves not tell us about the history of their development, nor will the piecing together themselves assure anything but an insight into the unconscious and a meaning to the pathology; but to establish what is this core fantasy is a necessary part of the treatment and a necessary part of the undoing of the illness. ADOLESCENT PATHOLOGY AND ADULT PATIENTS Something about these core fantasies a I part in adolescent pathology may also tell us something about the am- nesia which so many adult patients have for their adolescence or, as may often also be the case, why it is that so many adult patients find it so difficult to participate in the reconstruction of their adolescence (A. Freud, 1958). It is not uncommon for adult patients to have memories of their adolescence which bring with them anxieties or reactions which the patient may feel to be overwhelming and which I, within the treat- ment, felt to be well bey ght have expected. Une consciously, at least some of our adult patients are aware that the clue to their pathology rests in remembering both the af The Nature of Adolescent Pathology fects and the content of their core fantasies, or more specifi ally, the excessive shame and despair and the hopelessness as- sociated with them. Conversely, some adolescents may express their feeling that their sexual bodies are their persecutors. One way of coping with this unending onslaught from their sexual bodies is to give up genital sexuality and give back the nonsexual body to the mother who first cared for it. It is then not difficult to un- derstand that the idea of the sexual body as persecutor may also contain a hint, felt by many ill adolescents, of the mother as the persecutor. TRANSFERENCE AND CORE FANTASIES Icis only within the safety of the transference relationship that the adolescent's pathology and his core fantasies can begin to take on affective meaning, which includes a sense of their his- torical development. Possibly of greater importance, the trans- ference can make emotionally real the fact that ultimately he can find a new way of integrating his sexual body and his ear- ier incestuous wishes into a sexual identity which is of his choice. By understanding the superego strictures and infantile ideals, and by connecting these with his present sexual wishes and fears, patient is enabled to take charge of his sexual body in a way which does not have to contain the re- peated giving of the body to the mother who first cared for it, expressed in the transference by the adolescent's demand for the analyst to participate in his sexual pathology. I have met this repeatedly in the analyses of adolescents, through the ad- escent’s efforts to force the analyst to take charge of the ado- lescent’s actions and fantasies or, more often, expressed via the demand for the analy to seduce the adolescent This may be understood in oedipal terms, but it also s the adolescent's wish to destroy his own sexual body nd to offer back the nonsexual body to the mother. Only this, kind of transference experience enables the adolescent to see that his wishes, which may seem to be g are instead Tegressively organized so as to perpetuate a relationship to the316 Moses Laufer preoedipal parent which, if understood in terms of the adoles cent’s sexual life, contains the destruction by the adolescent of his sexual body. A female patient, aged 19, who had originally come for analysis at 17 because of her obesity, felt that she could not make any decisions without knowing what I thought. She felt forced by me to talk and to confess. She said that unless I did something about her need to masturbate and about her shameful fantasies, she would kill herself. In these shameful fantasies, men were raping other women, and she watched people being raped, or she was the innocentlooking by stander whom nobody would suspect of enjoying these ac- tions. She felt totally hopeless when she began to substitute herself for these women, or when she became the attacker and thought of killing and eating the women. She now felt there was no choice but to kill herself, that is, to kill what she felt t0 be the source of these awful fantasies—her body. Within the transference, she felt that she had disgusted me with her thoughts, and that I now was as worthless as she was because I heard it all and now her thoughts were part of my thoughts. I shall not discuss in detail the many meanings which the analysis of this fantasy disclosed. Instead I stress that transfer ence enabled the patient to understand the meaning of women being attacked; her own pregnancy wishes; her wish to have her mother sexually available; and the meaning of the regressive pull to give up her sexual body and remain the good, admired child. All of this might have been understood in terms of object relations or the narcissistic void, but unless these aspects are linked to the adolescent patient's present seX- ual body and present masturbation fantasies, they do not en- able the adolescent to see the connection with his present life Itis through this kind of understanding that the breakdown which occurred at puberty begins to mean something to the adolescent. Then the analytic process can begin to enable the adolescent to seck a different solution from the original oedi- pal one which is now participating so centrally in his patho ogy. Via the wansference and the analyst's ability to enable the adolescent to understand it both in historical and in present The Nature of Adolescent Pathology 317 day terms, the sexual body, instead of being the persecutor and the source of the pathology, begins to become the vehicle for the satisfaction of wishes which are now chosen by the ado- lescent. The adolescent gradually understands that his break- down at puberty was due to his being overwhelmed by sexual wishes and oedipal fantasies, that it was the emotional core of the trauma which still continually threatens him, and that it was his only means of coping with his sexual body and what that represented for him. At the same time, however, this kind of understanding now offers the adolescent new hope. It ables him not only to understand the past and to place it within the context of the present, but it offers the adolescent the possibility first to undo the repression (and to come into touch with the meaning of his illness) and then to find a new solution to the oedipal resolution and to re-repress this, but now with the ability to feel actively in charge of his sexuality In terms of the establishment of a sexual identity by the end of adolescence, the analytic process has thus created the inter- nal possibility for development to proceed again. John first came for analysis at 16 after he had been asked to leave his school. It was a school with very high standards, and students who did not meet them were asked to leave. Pre- viously, at 13, he had left a note (found by his mother) in which he said he would kill himself because he was not normal and because he was lonely and worthless. In the course of his analysis, which has now been going on for nearly 4 years, he described a fantasy which has been conscious since the age of he would enjoy thinking of girls, or of his mother, who had a pained facial expression. This fantasy stayed with him and, although he felt ashamed at times, he said that he was quite able to live with this secret without feeling threatened or hay- ing to invite too much punishment. Suddenly at puberty, how- ever, he found that he began to have to organize his activities around observing girls or women with pained facial expres- sions. He felt driven to visit sports arenas so that he could ob- serve girls straining themselves and tightening their faces. He became especially alarmed when he felt compelled to hit his Mother, at times so forcefully that he and his family feared318 Moses Laufer that he might seriously harm her. He quite often masturbated before coming to his session, and very gradually began to ac. knowledge how much of his pathology was contained in this fantasy. It took many months before he understood that his excitement in the sessions with me revolved around his telling me things and then his imagining that I had a pained facial expression. He became very frightened when he thought that he might lose control and attack me. When I became ill for a few days and had to sessio ancel some , he could not stop talking of what he had done to me. ad to maintain telephone contact with him because he was frightened that he might have harmed me irreparably. In the sessions following my illness, he said that there were tin when he thought that he actually had attacked me, but that he ould not quite remember the details. Via the transference he began to recall the specific circumstances of his breakdown at puberty when he felt he had lost touch with reality, that is, when he believed that he had actually Killed his mother and had to search the house frantically to find her alive and w Exploring his breakdown at puberty, he began to understand that his present avoidance of girls and his enforced isola that he might want to kill them because of his envy of them; he also understood his hitting of his mother in terms of his sexual longing for his father. Although he was at first frightened by this confrontation, it created for him the hope that there was a way out of his pathological impasse. He realized that his very crazy behavior he needed to keep \ging for me and the anxiety this engendered. For example, he shouted a good deal of the time when he was talking to me, and this helped him feel that he was keeping me away. The analytic process thus enabled him to understand the meaning of his illness in terms of his present and past life Beyond this understanding, however, the analytic process offered him the possibility of finding a different resolution (© The Nature of Adolescent Pathology 319 his oedipal conflict, and thereby a different way of experienc- ing his own sexual body Various THERAPIES AND Ams OF TREATMENT ‘ave emphasized that the period of adolescence has a spe- tine developmental function and that adolescent Pathology has an especial destructive force because I feel that our wor} with ill adolescents becomes diffuse or intellec 7 eaeneee: wusly strengthens the resistance to change when we do not seen) central function as analysts to be the understanding of the illness in terms of abnormal sexual development. It is for this reason that I have expressed my doubts in the introduc, tion to this paper about the use of a whole range of ideas an techniques which, sexuality and view develop- ment and perhaps illness in ways which clinically do not quite add up to what it is that the adolescent patient is experiencing, Tam well aware that many people believe that psychoana- Iytic treatment is contraindicated for the ill adolescent. Among the reasons cited are: the unsuitability of a treatment which expects the adolescent patient to become dependent at a time when independence is needed and wanted; the development process itself in adolescence goes contrary to insight and con tary to “inaction.” My own view goes completely in the other direction. Various therapies may contribute something to pro- gressive development by enabling the adolescent to deal bette with age-appropriate demands and to maintain contact with the outside reality so that real demands may counter the fan- tasied demands. But if these therapies claim or expect to undo pathology, that is, to cure the ill adolescent, then I believe they are mistaken. They may be more than mistaken, in that their view of the function of therapy may produce harm in the life of the adolescent. By this I mean that unless the treatment process confronts the adolescent with the abnormality of Telationship to his sexual body, and unless the treatment creates the possibility of a different solution from the original oedipal one (that is, via the understanding of the core fan-320 Moses Laufer tasies), it confirms the adolescent's fe cially of his sexual body image, is not possible. Help with age- appropriate conflicts may be useful and necessary, but the ad- olescent must not be made to feel this is synonymous the cure of illness. . Conciusion I will comment only briefly on the differences between the an- alytic process in adolescence as compared to the process in childhood and adi mphasizing these dif- ferences would be re of the transference in each period, With the adolescent patient, the incestuous wishes within the transference are ever present, but intensely defended against, not only because of the superego prohibi- ging with himself revolves around his sexual body and its being experienced as a source of pathology. The child does not yet have a sexually mature body capable of physically car- yet experience pa- pathology and mality) are synonymous in- ns his own sexu With the adult, the path solutions which he adopted in adolescence have created a relation to his sexual body whicl more firmly established and less reversible. The incestuous na- ture of the transference and of the wishes may still be present in the adult patient, but the adult, unless he is psychotic or \ess of the unreality of his wish, unreal. This is not so with the he ac- image and thus ytic process in The adolescent must be of his abnormality, lyst as representing the adolescence must go cont able to experience his ow The Nature of Adolescent Pathology hope of having a sexual body which does not contain the ab- ity. We may say that we want to make the abnormal ad- normal. Some analysts do not agree w approach, insofar as they may feel that the ado! choose any sexuality he seeks, but I be offering the sexuality and a different image of the task of the analytic process in ad- norn olescent sexu Some colleagues may not agree with me in other respects. 1 fay give the impression that [am either directly active in my r that I intrude in the patient's privacy, or that 1¢ patient's right to choose the direction of his present and future life. It may be hat the analyst should be passive and allow for the unfolding of the treatment. To my mind, such a role for the analyst is not only fictitious; but even if it were true, it would go cont st in the curing process of the lescent. When I say fictitious, 1 mean that there is no thing as a pas vention is experienced by the active intervention, and that every analyst chooses eithe on to his understanding of the patient's pathology. If 1 apply view of what constitutes the central pathology te adolescent, whose sexta he analyst's function to a terventions, Ttake awa ‘ment of the process of being defined, then it is ive in the patient’s mind and to repres mode of functioning and a direction of development which y to the solutions adopted by the ill adolescent. I di iean by this that the analyst of the adolesc offer himself as an object for identification and unconsciously demand that the adolescent mold himself in the image of the lyst. This could be catastrophic for the future of the ill ad- olescent. Instead, by analyzing the transference and by show- ing the adolescent how his demands inevitably are for the lyst to accept the adolescent's abnormal development and how this contains the adolescent's need to destroy the analyst as well as his own sexual body, the analyst keeps the conflict alive and continues to confront the adolescent with the fact322 Moses Laufer that his solutions are pathological ones. ‘This is the way in which the adolescent can begin to allow for a different out. come, and it is this which can enable the adolescent to risk giv ing up his pathological solutions. These are some of the T have refer to giving the ill adolescent BIBLIOGRAPHY The Psychoanalytic Process in Adult Patients PAUL A. DEWALD, M.D. Ie CONCEPTUAL UNDERSTANDING OF THE PSYCHOANALYTIC process in adult patients has undergone a progressive expan- sion since the earliest formulations proposed by Breuer and re elaboration of the curative fac as moved us further away from an emphasis u single therapeutic element as replaced during the era of the topo- y the conceptualization that the analyst's © the unconscious become conscious. The nce was recognized, but the ana- lyst was to be a passive mirror, reflecting whatever transfer ence distortions the patient chose to project The introduction of the structural theory led to significant expansion of ego and superego analysis, but conceptualiza- tions of the analyst's role still involved interpretation and re- nd in the therapeutic in Was to remain “neutral, aloof, a spectator, and... never a coactor” (Maca p. 535). Sterba (1934, 1940) had described the alliance between patient and analyst, a subject graphic pretat 323