(Brent Adolescent Centre S) Moses Laufer - Adolescent Breakdown and Beyond-Karnac Books (1997)

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ADOLESCENT B R E A K D O W N
A N D BEYOND
Also from the Brent Adolescent Centre/Centre for Research
into Adolescent Breakdown:
The Suicidal Adolescent, edited by Moses Laufer
Also by Moses Laufer (with M . Egl6 Laufer):
Adolescence and Developmental Breakdown
ADOLESCENT. BREAKDOWN
AND BEYOND
EDITED BY
Moses Laufer
for the Brent Adolescent Centre/
Centre for Research into Adolescent Breakdown
Anthony Bateman Debbie Bandler Bellman

Gabrielle Crockatt Maxim de Sauma
Domenico di Ceglie Sara Flanders
Maurice H. Friedman Christopher Gibson
Kevin Healy M. Egle Laufer
Kamil Mehra Joan Schachter
Nicholas Temple Peter Wilson
London
KARNAC BOOKS
First published in 1997 by
H . Karnac (Books) Ltd,
118 Finchley Road,
London N W 3 5HT
Copyright © 1997 by the Brent Adolescent Centre

Arrangement Preface, chapters 1 & 6 copyright © 1997 by Moses Laufer
Chapter 2 copyright © 1997 by Kamil Mehra
Chapter 3 copyright © 1997 by M. Egle* Laufer
Chapter 4 copyright © 1997 by Maurice H . Friedman & M . Egl6 Laufer
Chapter 5 copyright © 1997 by Peter Wilson
Chapter 6 Discussion copyright © 1997 by Nicholas Temple
Chapter 7.1 copyright © 1997 by Debbie Bandler Bellman
Chapter 7.2 copyright © 1997 by Sara Flanders
Chapter 7 Discussion copyright © 1997 by Kevin Healy
Chapter 8 copyright © 1997 by Anthony Bateman
Chapter 8 Discussion copyright © 1997 by Domenico di Ceglie
Chapter 9 copyright © 1997 by Gabrielle Crockatt, Maxim de Sauma,
Christopher Gibson, Joan Schachter, & Peter Wilson
The rights of the editor and the contributors to be identified as the authors of
this work have been asserted in accordance with §§ 77 and 78 of the Copy
right Design and Patents Act 1988.
All rights reserved. N o part of this publication may be reproduced, stored in

a retrieval system, or transmitted in any form or by any means, electronic,
mechanical, photocopying, recording, or otherwise, without the prior written
permission of the publisher.
British Library Cataloguing in Publication Data
A C L P . record for this book is available from the British Library
ISBN 978 1 85575 149 1
Edited, designed, and produced by Communication Crafts
10987654321
Printed in Great Britain by BPC Wheatons Ltd, Exeter

CONTENTS
LIST OF CONTRIBUTORS
INTRODUCTION
PART O N E
The adolescent
and developmental breakdown
CHAPTER ONE
Developmental breakdown in adolescence:
problems of understanding and helping
Moses Laufer
CHAPTER TWO
Interferences in the move from adolescence
to adulthood: the development of the male
Kamil Mehra
Vi CONTENTS
CHAPTER THREE
Interferences in the move from adolescence
to adulthood: the development of the female 27
M. Egle Laufer
CHAPTER FOUR
Problems in working with adolescents 39
Maurice H. Friedman & M. Egle Laufer
CHAPTER FIVE
The problem of helping
in relation to developmental breakdown
in adolescence 57
Peter Wilson
PART TWO
Proceedings of conference on
"Adolescent breakdown and beyond"
CHAPTER SIX
Defining breakdown 75
Moses Laufer
Discussion 87
Nicholas Temple
CHAPTER SEVEN
Working with adolescent breakdown 93
1. Pre-therapy 93
Debbie Bandler Bellman
2. Therapy 103
Sara Flanders
Discussion 113
Kevin Healy
CHAPTER EIGHT
Later consequences of adolescent breakdown
Anthony Bateman
Discussion
Domenico di Ceglie
CHAPTER NINE
Responding to mental breakdown
in adolescence
Panel discussion
BIBLIOGRAPHY
INDEX
LIST OF CONTRIBUTORS
ANTHONY BATEMAN, MA, MRC Psych; Psychoanalyst; Consultant

Psychotherapist and Clinical Director of Mental Health Services,
Haringey Healthcare N H S Trust, London.
D E B B I E B A N D L E R B E L L M A N , BA; Child & Adolescent Psychother

apist; Former Staff, Brent Adolescent Centre/Centre for Research
into Adolescent Breakdown, London.
G A B R T E L L E C R O C K A T T , MA; Consultant Child Psychotherapist,

North West London Mental Health Trust, London.
M A X I M D E S A U M A , MD; Psychoanalyst; Brent Adolescent Centre/

Centre for Research into Adolescent Breakdown, London (Staff to
May 1996; Director from May 1996).
D O M E N I C O D I C E G L I E , MRC Psych; Consultant Child & Adolescent

Psychiatrist, Adolescent Department, Tavistock Clinic; Chair,
Gender Identity Development Unit, Portman Clinic, London.
S A R A F L A N D E R S , PhD; Psychoanalyst; Staff, Brent Adolescent

Centre/Centre for Research into Adolescent Breakdown, London.
ix
X LIST OF CONTRIBUTORS
MAURICE H. F R I E D M A N , MB, ChB, DPM; Psychoanalyst; Former

Staff, Brent Adolescent Centre/Centre for Research into Adoles
cent Breakdown, London.
C H R I S T O P H E R G I B S O N , BEd; Psychoanalyst; Staff, Brent Adolescent

KEVIN H E A L Y , DPM, MRC Psych; Consultant Psychotherapist,

Cassel Hospital.
M. E G L £ L A U F E R , B S C (Hons); Psychoanalyst; Staff, Brent Adolescent

Centre/Centre for Research into Adolescent Breakdown, London
(Staff to May 1996; Consultant Psychoanalyst and Trustee from
May 1996).
M O S E S L A U F E R , PhD; Psychoanalyst; Brent Adolescent Centre/

Centre for Research into Adolescent Breakdown (Director to May
1996; Consultant Psychoanalyst and Trustee from May 1996).
KAMIL MEHRA, PhD; Psychoanalyst; Former Staff, Brent Adolescent

JOAN SCHACHTER, MB, ChB, MRC Psych; Psychoanalyst; Consultant

Psychotherapist, Parkside Clinic; Former Staff, Brent Adolescent
N I C H O L A S T E M P L E , MB, ChB; FRC Psych; Psychoanalyst; Consultant

Psychotherapist and Chairman, Tavistock Clinic, London.
P E T E R W I L S O N , BA; Child Psychotherapist; Director, Young Minds;

Former Staff, Brent Adolescent Centre/Centre for Research into
Adolescent Breakdown; Trustee, Brent Adolescent Centre/Centre
for Research into Adolescent Breakdown, London.
INTRODUCTION
T
his monograph includes chapters addressing the theme
of adolescence and developmental breakdown, together
with the proceedings of a conference on "Adolescent
Breakdown and Beyond", held in October 1995 in London.
Acute mental breakdown in adolescence can have profound
consequences for the whole present and future life of the person.
However, it often goes unnoticed or ignored, in the silent hope
that the person will "grow out of it". But this is a hope that is
unrealistic. From our work with adolescents who have experi
enced a breakdown, it is clear that they are in urgent need of
psychological help. To "wait and see" can mean that a vital or last
chance to help has been lost.
The guilt and the fear about breakdown that is present in the
lives of many young people and in their parents often stand in
the way of acknowledging the urgency of appropriate help.
The Brent Adolescent Centre is a preventive mental health
service, which is supported by public funds and by private Trusts
xi
Xii INTRODUCTION
and Charities. The Centre for Research into Adolescent Break

down aims to study adolescent mental health problems and ways
of preventing mental disorder among young people.
Brent Adolescent Centre/
Centre for Research into Adolescent Breakdown
Johnston House
51 Winchester Avenue
London NW6 7TT
TEL.: 0171 328 0918
Editor's note
For the sake of simplicity, we have used the masculine pronoun
where adolescents in general are discussed.
PART ONE
THE A D O L E S C E N T
A N D DEVELOPMENTAL
BREAKDOWN
CHAPTER ONE
Developmental breakdown
in adolescence: problems
of understanding and helping
Moses Laufer
" | developmental breakdown" represents a concern that

I 1 remains central to our work at the Brent Adolescent
^ ^ Centre. And this concern, which must certainly be
shared by anybody who works with the troubled adolescent, can
be summarized as follows: how do we know when to be worried,
and when is help urgent? Implied in this is that there are adoles
cents who may be troubled but about whom we need not be
especially concerned, whereas there is a group of adolescents
whose troubles represent signs of a serious disorder or, at least, of
the likelihood of severe mental disturbance in the near-present or
in the future. It is this latter group on whom I would like to con
centrate, because they are the ones whose emotional lives—and
often actual lives—are seriously at risk, and who must not be left
with the unreal hope that they will grow out of it. Our experience
shows that these adolescents do not "grow out of it" but remain
emotionally damaged at the least and actually develop towards
mental illness at the worst, if they are left on their own. With help
at the right time, we think that some of these adolescents can be
helped greatly, often with the possibility of reversing the move
towards the firm establishment of severe disorder.
3
4 MOSES LAUFER
I would like to begin with an observation that ultimately

brought me to the idea of "developmental breakdown" and has,
over a period of years, made me dissatisfied with the often-used
explanations or classifications when describing certain serious
signs of mental disturbance among adolescents. Some time ago a
very simple fact impressed me, a fact that I had obviously known
about for many years but one that I—as many others—preferred to
deny and avoid understanding. It was this: it seemed that the
reported incidence of suicide or attempted suicide increased rap
idly in adolescence and, linked to this observation, it seemed also
that the conscious decision to kill oneself did not exist as a "social
problem" before adolescence. From this, and from our shared ex
perience at our Centre, I realized that the same observation or
question could be asked about so many adolescents: why the sud
den signs of mental illness, which are diagnosed as schizophrenia;
why anorexia in adolescence, and not at all the same incidence in
childhood; why drug addiction in the adolescent, or promiscuity,
or severe depression, or signs of sexual abnormality, or the vio
lence that is not the result of a social norm but is given impetus by
the private "voices" or by the need to keep out of consciousness
the feeling of being abnormal—and the list can certainly be ex
tended. But by saying that the list can be extended, I do not mean
that we should include every form of stress in every crisis, with
the likely result that we do not then differentiate between normal
stress and signs of developmental breakdown. I will come back to
this when talking about criteria that can help us judge when to be
worried.
It was the observations to which I referred a moment ago that
made me think that there are not only new stresses following
physical sexual maturity but that it may well be that the period
which we call adolescence is a time of special vulnerability to
breakdown. When I talk of the period of adolescence, I have in
mind the time from puberty to about the age of 2 1 . I begin with
puberty because it is the time when the person not only has a
physically mature body but is able either to impregnate or become
pregnant—a fact that must always be kept in the forefront of our
thinking when trying to make any sense of behaviour, thoughts,
wishes, fears, or hopes of the adolescent. I date the end of adoles
PROBLEMS OF UNDERSTANDING AND HELPING 5
cence to about the age of 21 simply because it seems that it is

at about this time that the person has established "predictable
ways" of dealing with anxiety, and it is these predictable ways
that convey that one's ideals, or conscience, or ways of finding
pleasure, are now more fixed than they were either in childhood
or at puberty, together with the assumption that major changes in
these areas will no longer take place.
It is during adolescence that one's past begins to catch up with
one, so to say. What I mean is that psychological life, however
much we may want to divide it into periods such as infancy, child
hood, adolescence, adulthood, middle age, old age, is a continuous
process, but with each period having its own special characteris
tics and, I would say, each having its own special contribution to
psychological life and development. And the special contribution
of adolescence can be summarized as follows: that this is the time
during which a mental picture of the person himself, with a specific and
fixed sexual identity, will be established.
By this I mean that this is the time during which the person
will seek an answer through relationships, through various social
and sexual experiences, through various educational and work
efforts, to what it is that is acceptable to his conscience and ideals,
and what it is that must at all costs to his mental functioning be
rejected or, at least, kept away from being satisfied. I am implying
by this statement that by the end of adolescence the specific sexual
identity is always a compromise between what we might want
and what our conscience allows us to live with.
In adolescence, the earlier values, the earlier ways of finding
pleasure and of feeling cared for and loved, the earlier ways of
feeling male or female, are put under a different and new kind of
stress because of the presence of a sexually mature body. In most
instances—that is, in development that is proceeding more or less
normally—the adolescent may still experience stress, but he will
finally find acceptable ways of answering his conscience and his
ideals, and in this his past is experienced as an ally in the effort
and the wish to proceed to adult sexual and social life.
I talked of one's past catching up with one, and this may give
the impression that I am saying that all present behaviour is deter
mined by the past, and that one only has to hold on tight until
6 MOSES LAUFER
adolescence is over and then one can get on with one's life as an
adult. Many people certainly take this view, expressed in such
phrases as "he will learn as he gets older" or "if we can just help
him through his adolescence, then he'll be all right". I take a differ
ent view; although I accept the authority of the past, I think that
there are some critical events within ourselves during adolescence
that make a difference not only to present and future life, but to
present and future mental health, including that of illness and
breakdown.
I will use my own words to describe a process that Freud
considered of primary importance in understanding something
about adolescence. It seems that it is during adolescence that
certain creations of the mind (Freud talked of them as fantasies)
become interwoven with past experience, and it is the combination
of the past with the more immediate fantasies of adolescence that
ultimately establishes the pathologies (he referred to the neuroses)
that we see later in life. If this is so, it means then that what we learn
from our adolescent clients or patients or those in our care must be
taken very seriously, because the experiences of adolescence may
shape our future emotional lives considerably, including our rela
tionships to people, our pleasures and our disappointments, and
our relationship to ourselves as people whom we like or hate. But,
more immediately, it also means that the period of adolescence
brings about changes in mental life that make the person much
more vulnerable to the self-hatred and despair that we see in our
work every day.
* **
How is it possible, then, to define the difference between the stress,
or despair, or hopelessness that may be part of normal
development, and similar reactions that are signs of "developmen
tal breakdown"? I should say that, when I refer to "developmental
breakdown", I have in mind the breakdown of a process of devel
opment; I do not mean to convey something akin to "nervous
breakdown", which conjures up a picture of a collapse of the
nerves or sinews and which, as a phrase, has its roots in the early
psychiatric assumptions of mental disorder with the idea of tension
felt in the nerves or, at worst, where damage to or disintegration of
the nerves was believed to be a primary contributing factor to
mental disorder, with little status being given to the role of psycho
logical conflict, regression, fantasy, and so on.
In development that is proceeding normally, a number of
characteristics may be evident:
1. The adolescent ultimately knows that he has ways of feeling

valued and admired without having to remain totally depend
ent on his parents.
2. However much he may feel guilty or ashamed of some of his
private thoughts and feelings coming from his body, he can still
enjoy the pleasure from these thoughts and feelings, and he can
seek relationships that in part enable him to remain in touch
with these feelings from his own body.
3. Even though there are times when he may have thoughts that
not only shame but worry him (because of their connection to
ideas of abnormality), he is also aware that these thoughts will
not ultimately overwhelm him—in other words, he knows (not
consciously, of course) that he does not have to remain tied to
these thoughts or wishes, but he can have other sources of
pleasure that enable him to want to move on to adulthood.
4. However much despair or hopelessness he may feel, he is also
aware that he can rely on admiration from his own conscience
to help him restore a feeling of self-respect.
5. I would like to add another, which is critical because it takes
into account the view held by the adolescent about himself as a
man or woman, husband or wife, father or mother: that in spite
of the feelings of emptiness and the anxiety experienced in the
process of giving up or becoming less dependent on the parents
of one's childhood, there is sufficient inner love for oneself
carried on from childhood to enable one to look forward to the
future, and it is a future that perpetuates that which is felt to
be good in oneself and good in the parents of one's past. I am
implying that, without being conscious of it, the adolescent can
normally look forward to the future as a time when he can make
amends for his own hatreds or his own disappointments, a time
when he can have the inner freedom to allow himself to forgive
the parents of the past who inevitably had had to let him down
in some way.
8 MOSES LAUFER
But there are those adolescents who experience something

quite different, and for whom the period of adolescence is prima
rily a time of torment. They may seek a whole range of ways to
change this feeling, varying from changes in appearance to chang
ing the feelings that live within themselves, but inevitably with the
awareness that they are unable to leave this torment behind. And,
from the point of view of assessing what is going on, we need to
be aware that these adolescents can only go as far as finding res
pite from themselves, but with their development being seriously
distorted. I have in mind those adolescents who are unable to feel
that they have the means within themselves to restore their self
respect, or to undo the harm that they believe their thoughts and
feeling do to themselves and to others, or who are never free of the
thoughts and feelings that convince them of their abnormality, or
who may feel convinced that people hate them and who will then
try to destroy or harm those who are experienced as being respon
sible for this persecution. Ultimately, the war that is experienced
by the adolescent is one that always includes the sexually mature
body as one of the central enemies or at least as one of the main
sources of the feelings of abnormality, or of madness, or of worth
lessness. These are the adolescents who, no matter what they do,
are left with the feeling that the creations of their minds haunt
them; in other words, it seems to them that however much they try
to feel that the sources of pain or hatred are outside themselves,
they are ultimately faced with the feeling that their bodies are the
source of their abnormality or their hatred, and that there is little
they can do about this except to capitulate to this enemy. For some
of these adolescents, it is as if everything was good enough, or
even perfect, until puberty, or until they felt forced to give up the
perfect world of their childhood, and it is their adult sexual bodies
that force them to have the mad thoughts or wishes or feelings that
make them behave in ways that result in shame or self-hatred and
force them to lose control of their actions.
For these adolescents, relationships to other people are dis
appointing and frightening, because they have to end in hatred of
themselves or of the other person; masturbation, or the thoughts
accompanying masturbation, cannot be enjoyed because the nor
mal guilt is instead experienced as a confirmation that they are
abnormal or dirty; closeness to one's teacher or adviser cannot be a
valued relationship because of uncontrollable jealousy or because

of the doubt they have of the teacher's or adviser's motives, and
these jealousies and doubts are then woven into their suspicions
and accusations; parents cannot be felt to be interested in them,
but are felt instead to be false and prying; and so on.
At the time of experiencing these feelings, the adolescent is, of
course, not aware that he is reacting to his own mental distortions.
At that moment his experiences are real, he does not doubt, and he
remains convinced that he cannot trust, that he must not feel love,
or that he must never capitulate to his body because if he does, it
will take over his life and it will make him irreversibly mad and
abnormal. And from the point of view of his development, there is
at best a stalemate; more probably, the self-hatred and the fear of
abnormality come to be woven into the image of himself as a
sexual being, and the distortions are echoed in the person's rela
tionships, in the attitude to himself as a person who does not have
the right to experience pleasure, and who is never able to get away
from the conviction that the torment that he feels is of his own
making and is his due. But in all this the adolescent feels that he
cannot reverse this process, that he is overpowered by something from
within himself over which he no longer has control His mind and body
are his enemy.
I would like to describe two adolescents whom I have been
trying to help, and in whom I think a breakdown took place fol
lowing puberty.
The first I heard of "Muriel" was when she telephoned our

Centre to say that she wanted to talk to somebody. She had left
school two years earlier when aged 16, and she had had eleven
jobs since then. She had thought of getting some O-levels with
the hope that she might then get a nice job. But she attempted
suicide just before her O-level exams and never returned to
school to sit them. She was convinced that her parents felt that
she was weak and a coward, but when I met the parents, they
had been very shocked at Muriel's decision to kill herself and
remained very frightened that this might happen again.
From the moment I heard of her suicide attempt, I could
feel sure that she had experienced a breakdown at the time of
10 MOSES LAUFER
the a t t e m p t ( a n d v e r y p r o b a b l y before), a n d I w o r k e d w i t h
this a s s u m p t i o n , e v e n t h o u g h s h e a s s u r e d m e m a n y t i m e s that
e v e r y t h i n g w a s q u i t e w e l l n o w , that s h e h a d forgotten about
the p a s t , a n d that h e r m a i n p r o b l e m w a s f i n d i n g w o r k a n d
d o i n g s o m e t h i n g interesting. B u t as w e t a l k e d , h e r r e c o l l e c
t i o n s a l t e r e d ; the i d e a l i z a t i o n of h e r p a s t p r o v e d to b e v e r y
fragile a n d c o n s i s t e d of m u c h self-hatred, d i s a p p o i n t m e n t , a n d
a l o n g - s t a n d i n g belief that s o m e t h i n g w a s w r o n g w i t h h e r . I
w i l l s u m m a r i z e w h a t s h e a n d I w e r e able to l e a r n a n d m a k e
s o m e s e n s e of, a n d w h a t it w a s that c o n v i n c e d m e , a n d h e r ,
that s h e h a d e x p e r i e n c e d a s e r i o u s c h a n g e w i t h i n h e r s e l f at
a b o u t the t i m e of p u b e r t y , c u l m i n a t i n g i n h e r s u i c i d e attempt.
M u r i e l first h a d s e x u a l i n t e r c o u r s e w h e n a g e d 13; at the t i m e ,

s h e felt r e l i e v e d that s h e c o u l d feel n o r m a l , or at least n o t
a b n o r m a l . S h e k e p t this a secret f r o m h e r f a m i l y a n d h e r
f r i e n d s . S h e s o o n b e g a n to r e a l i z e that s h e h a d to h a v e i n t e r
c o u r s e w i t h different b o y s , o t h e r w i s e s h e w o u l d feel they h a t e d
h e r or t h e y m i g h t see t h r o u g h h e r facade. S h e h a d felt v e r y
a l o n e at that t i m e , a n d s h e h o p e d that a close r e l a t i o n s h i p to a
b o y w o u l d take this terrible feeling a w a y . B u t it d i d n o t d o this.
S h e c o n n e c t e d this l o n e l i n e s s to the d e a t h of h e r d o g , w h o h a d
d i e d w h e n s h e w a s a g e d 8. F r o m 8 to 13 s h e h a d n o t t h o u g h t too
m u c h a b o u t the d o g , b u t t h e n s u d d e n l y s h e felt r e m o r s e , b l a m
i n g h e r s e l f for n o t t a k i n g g o o d e n o u g h care of h i m , f e e l i n g that
s h e w o u l d l i k e to see h i m a g a i n a n d a p o l o g i z e to h i m for h a v
i n g forgotten h i m , a n d getting to the p o i n t of h a v i n g to s t a n d
o u t s i d e the d o o r of the v e t to w h o m h e r d o g h a d b e e n t a k e n . A t
the t i m e , h e r p a r e n t s b e l i e v e d that this w a s a s i g n of M u r i e l ' s
w a r m h e a r t e d n e s s a n d w a s " j u s t c h i l d i s h " i n a n y case; w h a t
t h e y m i s s e d , of c o u r s e , w a s that this w a s n o t the m o u r n i n g
that f o l l o w s the l o s s of s o m e b o d y w h o m o n e l o v e s , b u t the
first o b v i o u s s i g n of a b l a m i n g a n d s e l f - h a t r e d that c o u l d b e
c o n s i d e r e d m e l a n c h o l i c i n q u a l i t y . H e r s u i c i d e a t t e m p t before
h e r O - l e v e l s w a s not, b y a n y m e a n s , a s u d d e n d e c i s i o n to k i l l
herself; i n s t e a d , it w a s clear that s o o n after p u b e r t y h e r self
h a t r e d , r e s i d i n g i n h e r attitude to h e r b o d y , b e c a m e i n t e n s e a n d
c a r r i e d the s e e d s of a n a c t i o n that w o u l d k i l l w h a t s h e h a t e d .
From this, we could also begin to make some sense of her

eleven jobs and her need to move from one to the next. She
remembered that, at one time, she had been frightened because
she felt too attracted to another girl, and had been very jealous
if this girl would talk to other people at school. At first, she just
hated this girl for making her feel this way, but then she be
came frightened that she might be abnormal in some way. She
got some relief from this worry by remembering that her inter
course was quite nice, but of course missing the fact that she
felt compelled to have intercourse well before she felt that her
sexual body was really her own (and since then never feeling
able to trust herself to be alone with her own body). But she
also found that as soon as she became friendly with girls at her
various jobs, she became anxious and somehow found a reason
either to leave or to be dismissed.
I will come back to Muriel, but I want now to describe another

adolescent, "Paul", who was aged 17 when I first met him a couple
of years ago.
Paul had come on the advice of his mother, who had been
worried that Paul might well end up either badly beaten up or
in borstal if something was not done to help him. My success in
helping him was limited, but I want instead to concentrate here
on what was going on in him and how his own inner life
affected his development and distorted his life.
The first sign of trouble was when, at school, Paul became
involved in fights, which then developed into his being recog
nized as someone to be reckoned with. He loved knowing that
people were frightened of him. One day he hit a male teacher,
and this ultimately resulted in his suspension. After the sus
pension, he hung around outside the school, and once he
threatened this teacher again for picking on him. Paul was
convinced that he responded only to provocation, and he felt
blamed for things that were being done to him. As far as he
was concerned, he beat people up and hit the teacher only
because they teased him or hinted at his worthlessness.
12 MOSES LAUFER
Paul's father had left home when Paul was aged 9, and he had
never seen his father again. When Paul's mother became very
ill and was in hospital, Paul had to be taken care of by neigh
bours. Secretly he used to cry before going to sleep, feeling
sure that his mother would die. He found himself wandering
and getting lost, and, to his astonishment, he and I could con
vincingly see that his wandering was his dreamlike way of
looking for and feeling convinced that he would find his father,
something that inevitably ended in disappointment. He started
boxing when aged about 14, and he became quite a well
known amateur boxer. Once, following a boxing match, he told
me that, when in the ring, he wanted to kill his opponent; he
then realized through our talking that the hatred he felt for his
father was forcing him now to try to mutilate or to kill this
enemy in the ring. And what had happened at the time when
he had hit the teacher was that he had thought that the teacher
was being too nice to one of the other boys, and he felt sure at
the time that the teacher might be a homosexual. This distor
tion hid Paul's disappointment and his feeling that the teacher
no longer cared for him—a teacher of whom Paul had become
very fond and whom he had valued for his fairness.
But it was Paul's own wish for a close relationship to a man,
and his own fear that he might himself be abnormal in some
way, that culminated in the attack on the teacher, making him
feel that he was destroying the person who might be respon
sible for his own feelings of being abnormal. The breakdown
had taken place, I think, well before the trouble blew up at
school—the early signs could already be seen in Paul's use of
fighting and beating up people, often to the point that he felt he
could kill the person. The homosexual fear was intense, and
Paul was able to go on convincing himself that he was fine. But
he could never have a girlfriend because he was sure that he
might hurt or kill her if she made him jealous—that is, if she
chose a better man than himself. These rationalizations hid his
feeling that there was something wrong with him, that he had
inherited a terrible temper and some kind of madness from his
father, and that the only safe future he had was to be a boxer.
His distortions were of such a magnitude that every experience
was coloured by them; I believed at the time that Paul was

trying to keep under control a paranoid idea of being laughed
at, being made abnormal by other people's wishes, and being
molested by boys and men at the school from which he was
suspended.
* **
Neither Muriel's nor Paul's case is as uncommon as it may sound.

Very many adolescents have the ability to fool themselves and
others without intending actually to do so. Both Muriel and Paul
might have been considered to be adolescents who were not
very different from the many others around them—especially
Paul, who lived in an area where violence and fighting were fairly
common. But to view certain behaviour and certain directions of
development as signs of breakdown during adolescence adds a
dimension to our understanding that enables us to free ourselves
from the usual psychiatric and psychological classifications that
were intended initially for adults and have not taken into account
the contribution of adolescence to psychological life. Muriel could,
I suppose, be classified as "hysterical personality" and Paul might
be considered as showing "early signs of paranoia" or as a psycho
pathic personality. Such classification might perhaps be correct
but would, nonetheless, ultimately be very harmful for Muriel and
Paul and theoretically show a total disregard for what we are
beginning to know about adolescence and the need to look differ
ently at the meaning of behaviour in adolescence compared to the
same behaviour in adulthood. The harm would be contained in
the assessment we make of behaviour, in the view we take of the
function of adolescence and therefore of our role as people who
can contribute critically to the present and future life of the person,
and in our attitude about the reversibility or irreversibility of
certain forms of mental disturbance.
It is for this reason that I chose to describe Muriel and Paul. A
suicide attempt in adolescence is, in my view, always a sign of a
serious breakdown, requiring immediate help and psychological
treatment. I say this because I think it requires a special quality of
distortion of one's feelings about oneself, and about one's body,
and about one's parents who are now a part of oneself, to choose
14 MOSES LAUFER
consciously to carry out an act that will either destroy one's body or
will be felt as destroying someone who is now part of oneself. It
also implies a hopelessness about the possibility of changing any
thing and a giving-up of any idea of pleasure in the future. For
Muriel, it required a temporary break with reality—that is, an
acute psychotic episode—to enable her to carry out the action that
endangered her life. Without help, we can be certain that this self
hatred, this feeling of worthlessness, this fury with her body
would never just go away. It might subside and remain dormant,
but I would predict that it would show up again either during her
later adolescence or certainly during her adult life in a relationship
with a man or when she became a mother. The severe danger
would reappear, but with much more severe and, I think, irrevers
ible consequences.
I can talk similarly about Paul. I referred to the early signs of
trouble when he started to beat people up, and finally when he hit
the teacher. For him, there was nothing good left inside him, and
he felt compelled to acquire certain characteristics that would keep
out of his consciousness his fears about being abnormal. The anger
that he showed towards his boxing opponents emphasized the
extent of his hatred, and of the way in which this hatred distorted
all his relationships. For him, having a sexual body meant simply
that he had to show his destructive power while at the same time
being able to keep himself from acknowledging how frightened he
was that he might be abnormal.
# *#
From what I have said about the contribution made by the period
of adolescence to a person's future life, it follows, I think, that
signs of developmental breakdown are our signal that something
must be done now and urgently for the adolescent. There is still
a vast group of people who view the period of adolescence as
being the moratorium between childhood and adulthood, with the
belief that whatever happens during adolescence can be corrected
or undone by patience, support, or simply by letting things lie
quietly. The loser, I think, must always be the adolescent who is in
trouble. Clearly, my own view is that the period of adolescence is
a critical time in one's mental development. For those unfortunate
enough to experience breakdown, it may be the time for a second

chance rather than for giving up.
And when I talk of "adolescent breakdown", it is not intended
simply as another phrase to describe something in a person's life.
My intention has been, instead, to show that the result or the
outcome of earlier development and of its distortions becomes
fixed only by the end of adolescence; breakdown is often allowed
to pass without too much notice or concern, with the result that in
adulthood the person will be faced with severe distortions of his
life, at best, and often with mental illness, at worst. The idea of a
"breakdown" of a process implies also that, at the time of the
breakdown—that is, before the results are fixed as part of one's
sexual identity—there is the possibility of reversibility. And those
of us who work with adults will, I think, confirm that many of
them need not have reached the point of despair or illness at
which they are, and that the difference in their lives could well
have come in their adolescence if they had been taken seriously,
and if their behaviour or despair had not been dismissed as a
passing phase.
CHAPTER TWO
Interferences in the move

from adolescence to adulthood:
the development of the male
Kamil Mehra
W hile it is generally accepted that the ground-plan of

adult personality is laid down in infancy and child
hood, it is not sufficiently recognized that its final
shape will depend on the experiences of adolescence. The chal
lenge of physical development, especially the demands of mature
sexuality and the push to become free of dependence on parents
during adolescence, places the individual in a critical situation,
when he can either move forward or cling to infantile modes of
functioning. We do not fully understand the smooth transition
from adolescence to adulthood, but our work with disturbed in
dividuals helps us to recognize some of the factors that interfere
with this process. Before giving examples of disturbed individuals,
I would like to spell out some of the special features of adolescent
development.
Compared to the earlier phases, the adolescent phase is char
acterized by certain crucial tasks, the solution of which will
determine the individual's move into normal adulthood. The tasks
are:
1. A change in one's image of oneself, including the changes in the

17
18 KAMIL MEHRA
b o d y , e s p e c i a l l y the m a t u r e s e x u a l o r g a n s a n d t h e i r c a p a c i t y to
function i n a n adult manner.
2, A l e s s e n i n g of e m o t i o n a l d e p e n d e n c e o n o n e ' s p a r e n t s , a n d a
realistic a p p r e c i a t i o n of their s t r e n g t h s a n d w e a k n e s s e s . T h e
d e t a c h m e n t f r o m the p a r e n t a l i m a g e s frees the p e r s o n to f o r m
l o v i n g r e l a t i o n s h i p s o u t s i d e the f a m i l y , a n d the i n t e r i o r i z a t i o n
of s e l e c t i v e a s p e c t s of their c h a r a c t e r e n r i c h e s h i s p e r s o n a l i t y .
3. A g i v i n g u p of u n r e a l i s t i c a m b i t i o n s a n d i d e a l s that the i n d i
v i d u a l feels h e o u g h t to a c h i e v e d u r i n g a d o l e s c e n c e or i n the
f u t u r e . W i t h the g i v i n g u p of u n a t t a i n a b l e a m b i t i o n s , t h e r e is
a greater a c c e p t a n c e of w h a t h e c a n a n d c a n n o t d o , a n d t h i s
m a k e s it p o s s i b l e for h i m to c o m m i t h i m s e l f to the t a s k at h a n d ,
w h e t h e r this is s t u d y i n g or l e a r n i n g a trade. M o r e o v e r , the
s u c c e s s e s a n d f a i l u r e s i n these v e n t u r e s a r e p e r c e i v e d r e a l i s t
i c a l l y , a n d their effect o n h i s feelings a b o u t h i m s e l f i s n o t as
s t r o n g as it w a s i n the past.
T h e s e x u a l d e v e l o p m e n t of the m a l e d u r i n g a d o l e s c e n c e s p a n s
a p e r i o d of s e v e r a l y e a r s , d u r i n g w h i c h there are significant
c h a n g e s i n the p h y s i c a l a n d e m o t i o n a l a r e a s . F u r t h e r m o r e , the
r e a c t i o n of a d o l e s c e n t s to these c h a n g e s i s n o t a l w a y s a p o s i t i v e
o n e , a n d s o m e are quite c o n f u s e d a n d b e w i l d e r e d b y t h e m . T h e
r e s p o n s e of e m o t i o n a l l y h e a l t h y b o y s , for e x a m p l e , to e m i s s i o n s , i s
o n e of p l e a s u r e t i n g e d w i t h s o m e a p p r e h e n s i o n , w h e r e a s that of
e m o t i o n a l l y d i s t u r b e d a d o l e s c e n t s i s o n e of s h a m e a n d a n x i e t y .
T h e latter p e r c e i v e t h e m as d i r t y ; they try d e s p e r a t e l y to s u p p r e s s
their s e x u a l e x c i t e m e n t a n d w i s h t h e y w e r e free of t h e m . H o w
e v e r , t h e y are n o t s u c c e s s f u l i n c o n t r o l l i n g the e x c i t e m e n t , t h e y feel
g u i l t y , a n d as t h e y g r o w u p they t h i n k of s e x u a l a c t i v i t y as d a m a g
i n g to t h e m s e l v e s or to others.
W i t h the m a t u r a t i o n of the b o d y , there i s a n i n t e n s i f i c a t i o n of
i m a g i n a t i v e life a n d a p r o l i f e r a t i o n of s e x u a l fantasies. I n i t i a l l y the
objects of the s e x u a l fantasies are p a r e n t s , teachers, or f r i e n d s , a n d
the a d o l e s c e n t feels h o r r i f i e d at h a v i n g s u c h t h o u g h t s a b o u t t h e m .
H e feels g u i l t y a b o u t h i s d e s i r e s a n d afraid that if h i s p a r e n t s k n e w
of t h e m , t h e y w o u l d reject h i m . A n a d d i t i o n a l c o m p l i c a t i n g factor
i n the e x p e r i e n c e of s e x u a l fantasies i s that t h e y a r e n o t a l w a y s of
a heterosexual nature; some boys have frank h o m o s e x u a l w i s h e s ,
THE DEVELOPMENT OF THE MALE 1 9
which they see as grossly abnormal. In most cases the homosexual

thoughts are transitory, but there are some boys who continue to
be tormented by them, and they feel guilty and ashamed. Inciden
tally, they are the ones who need most help, but are too afraid to
ask for it. They keep their thoughts to themselves, and it is only
by recognizing disturbances in the non-sexual areas such as a drop
in academic performance, moodiness, preoccupation with physical
illness, withdrawal from the company of others, unprovoked out
bursts of temper, and so on that one can guess at the underlying
disturbance.
When the individual is able to accept the changes in the body
and has succeeded in exchanging the target of his sexual desires
from the parents to people outside the family, he is capable of
forming loving attachments. His sexual life is no longer dominated
by doubts about his ability to function sexually, or about how he
compares with other young men of his age; he now wishes, in
stead, to attain sexual satisfaction with a partner. Sexual activity
now serves a dual purpose: first, as an affirmation of one's sta
tus—physical and psychological—as a male and, second, as a way
of relating to the opposite sex. Instead of being preoccupied with
his own wishes, he cares for his partner and her needs. There is a
significant change in his feelings; in the past, the emphasis had
been on excitement and activity; now there is a wish for tender
ness and closeness. This shift, I think, encourages him to see
himself as a potential husband and a father.
A necessary condition for being able to form mature relation
ships is an alteration of the image of one's parents during
adolescence. For example, the young male has to renounce his
attachment to his mother and to modify the image of the father
from one who prohibits all sexual activity to one who gives him
permission to be like him. The change of the image of the parents,
furthermore, leads to a modification of the young man's ideals and
values. Thus far, his ideals have been based either on a total accept
ance of the parents' values, or they have been shaped by feelings of
rivalry or competition with them; now they are accepted only if
they are useful to him.
The process of detachment from the parents is not an easy one,
either for the adolescent or his parents. The parents experience the
adolescent's challenge of their authority as perverse behaviour;
20 KAMIL MEHRA
they see him as selfish and uncaring, and then often worry about
the final outcome of his development. Moreover, the shift in his
attitude from admiration to denigration of them is seen as a failure
in their way of bringing him up. Although the adolescent is com
pelled to reject all that the parents stand for, he feels pained by it.
An additional source of pain is the giving up of the protectiveness
and dependence that he has experienced so far. However, all
young people have to go through this process of detachment, some
noisily, others silently, but at the end they feel much closer to their
families.
In the above I have given a description of some of the major
tasks of adolescence and suggested that, when they are success
fully fulfilled, they lead to a move into adulthood. I shall now give
some examples of young adults who did not make a successful
transition and describe some of the factors that were responsible
for their failure.
"Bob", a 26-year-old civil servant, came to the Centre with the

complaint of a tenseness in the abdomen that had existed for
several years. He had been thoroughly investigated at different
hospitals and was found to be free of any organic illness. The
doctors had tried to reassure him and had given advice that he
should forget about his illness and take part in sport, social
activities, and so on. However, he could not act on their advice
and spent most of his spare time either brooding about his
illness or poring over medical texts. Bob was good at his job,
but he had turned down opportunities for promotion as he felt
the additional responsibility would make his illness worse. He
had tried to mix with young men and women of his own age,
but he gave it up because he could not eat with them. He had
restricted his diet to a few items of food and was afraid to try
new foods, as he felt ill after eating them. From his description
of his current life, it appeared that he was totally preoccupied
with his illness. Although he talked only about the distressing
feelings in his stomach, I had a strong impression that he per
ceived his body as damaged and decaying, and that he had to
hide it from others.
Bob could not remember a great deal about his childhood, but
THE DEVELOPMENT OF THE MALE 21
he did describe feeling upset when he moved home at the age

of 1 2 . He was especially unhappy about losing friends, and
since then he had remained a solitary, person. After finishing
school, he joined a university, where he spent three years
studying for a degree. At the university he was extremely shy;
he did not take part in the social or cultural activities but spent
most of his spare time either studying or reading novels and
poetry. As he matured sexually, he turned to his body for com
fort and indulged in anal and genital masturbation. Since he
was completely isolated from others, he could not compare his
experiences with that of other young men, and he felt that by
indulging in masturbation he had damaged himself perma
nently. By experimenting with special diets, Yoga, and strenu
ous physical exercises, he tried to repair the damage, but these
activities did not help him. With the belief that he was dam
aged, he moved into adulthood as someone who would be
shunned by others. The ideas about illness provided not only a
justification for his withdrawal, but also a mode—albeit an
immature one—of loving himself.
As Bob refused the offer of psychotherapy, it is not possible to
understand the specific factors that were responsible for his
illness. It should be said however that, had his shy manner at
school and at the university been recognized as a sign of
emotional disturbance and had he been offered psychological
help, his illness would not have crystallized into an obsessional
neurosis in adulthood.
The above is one of many adolescents who come to the Centre

because of their fears of being physically damaged (I am reminded
of several who, feeling that there is something wrong with their
bodies, have asked for plastic surgery), or impotent, or homo
sexual. Their histories invariably show that emerging sexuality,
which can be a self-enhancing experience during adolescence, was
experienced as damaging and resulted in physical illness during
adulthood.
These adolescents are suffering from organized symptoms or
specific complaints. There are others, however, who want help
with depressed moods, acute states of anxiety, generalized irrita
22 KAMIL MEHRA
bility, dissatisfaction with work, or an inability to make satisfac

tory relationships. While listening to their stories, one often finds
that during their adolescence they suffered from shocks they could
not withstand. The difficulty in mastering the traumas not only
made the adolescent phase a disturbed period, but also distorted
their future development.
"Charles", a young engineer aged 23, was seen in an agitated

state, wanting to kill himself because he could not control his
wish to be embraced and cuddled by his 50-year-old married
aunt. At every opportunity he would rush to her house and sit
with her for hours. Understandably, his behaviour aroused the
uncle's jealousy, and he prohibited the nephew from coming to
his house. Since then, the young man had felt restless all the
time; he could not concentrate at his job or relax during his free
time. Being on his own, especially at night, was a problem, and
he spent long hours roaming the streets. Sometimes he suffered
from wild attacks of fury, when he wanted to destroy the
machinery at his place of work or to smash a car and kill
himself. He had no friends; he quarrelled with his colleagues at
work and avoided women because he thought that they were
mean and cunning.
Charles's mother had died when he was under 2 years of age,
and he lived with an aunt for some months until his father re
married. The step-mother was a kind, loving person, and she
looked after him well, but he could remember that even as a
small child he had been jealous of her relationship with the
father. When he reached the age of 12 or 13, he became ob
sessed with thoughts of the parents' sexual activities, and he
masturbated compulsively. He felt intensely guilty about mas
turbation and had suicidal and murderous wishes. The inten
sity of his sexual activities decreased after some time, but they
left a permanent imprint on his character: he started to become
suspicious of people, he often quarrelled at home and at
school, and he started to do badly in his studies.
At 17, Charles chose to attend a technical college away from
home, where, after an initial period of missing his family, he
settled down. Although he made some friends and took part in
the cultural activities at the college, he was often in trouble

with the teachers. Moreover, he had occasional worrying
thoughts that his father might die. The trouble-free period did
not last for long, however, and during the first year of his
stay at the college his father died of a sudden heart attack.
Although he became depressed, he continued to work hard at
studies. A feeling of responsibility for the widowed step
mother and her young children spurred him on to complete his
studies successfully. During the last year of his stay at college
he had isolated himself from the company of friends and spent
most of his time by himself. The withdrawal from the company
of others served the function of enabling him not to be re
minded of his family, but this manoeuvre failed when he took
a job in a town where his aunt and uncle were living. Their
affectionate interest—especially that of the aunt, who recog
nized his wish to be loved—instead of helping him, resulted in
his breakdown.
Charles was in therapy for over two years, during which we
were able to understand the effect of his parents' death on his
personality. For a long time I had to help him separate the idea
of losing one's parents from the fantasy of having killed them,
and to help him understand that his suicidal wishes were an
expression of a fantasy of joining them. Furthermore, his infan
tile wishes were, in part, understood as a flight away from
mature sexual urges, which he experienced as dangerous and
destructive. At the end of therapy he could tolerate his de
pressed moods: he started to make friends and could imagine
being married and having a family in the future.
* **
A different case, with a more severe disturbance, and whose
improvement has been a slow one, is that of "Dan", a young
man aged 25 years, whom I have been seeing, off and on, for
over five years. A bright student, he won a scholarship to a
famous university, and his teachers thought that he would be
come a brilliant scholar. Their expectations, however, were not
fulfilled. Dan became depressed during his second year at uni
versity. With some help from me, he managed to finish his
24 KAMIL MEHRA
studies, but since leaving the university he has drifted from

one unskilled job to another. He has no close relationships and
spends most of his free time getting either drunk or stoned. For
some years he was totally disorientated and suffered from
hallucinations and delusions. Although his present mental con
dition is not as bad as it had been, it is quite apparent that,
hidden behind a superficial facade of reasonableness, there are
mad thoughts that he keeps to himself.
Dan can remember very little about his childhood, but he has
some memory of his mother's protracted mental illness, which
ended in her suicide when he was 12, The suicide of his mother
has devastated his mental life completely: he often sees her
around, and at times he is not sure whether he is not his own
mother. The death of his mother has coloured his relationship
with girls to such an extent that he spurns their friendly ges
tures and is afraid that if they started to like him they would,
like his mother, kill themselves. Furthermore, in order to avoid
having any feelings about them, he thinks that he is a homo
sexual. Dan is too ashamed to admit that he has disappointed
his father by not becoming a scholar. However, his unsettled
mode of life and frequent changes of jobs are his way of pun
ishing himself for not meeting his parents' expectations.
Bob, Charles, and Dan would, in terms of their age and physi
cal development, be considered as adults. In their psychological
development, however, they are similar to the disturbed adoles
cents we see daily in our work at the Centre. In contrast to a
feeling of stability and autonomy, their lives are dominated by
forces over which they have no control. Moreover, their emotional
involvement is mainly with significant figures from the past, and
there is a total lack of satisfactory relationships in the present.
Instead of being proud of their bodies and minds, they perceive
them as dirty and damaged, and they experience sexual impulses
as damaging and destructive. With so little love or care for them
selves, it is too much to expect them to be loving and caring
towards others. And, instead of sharing the pleasures of emotional
exchange with other people, they are locked in their private
worlds, desperately but ineffectively trying to cope with their mad

thoughts.
Although in the case studies above I have placed special impor
tance on events in adolescence, I do not mean to imply that those in
childhood were not significant. The fact that these people could not
cope with the stresses of the adolescent phase shows that they
arrived at this stage with damaged personalities. What I have tried
to show is that the revival of traumas of the past, or fresh ones
during adolescence, occurred during a critical phase of their devel
opment. The control and integration of newly awakened sexual
and aggressive desires is a difficult process in every adolescent.
This task was made more difficult for these young men, however,
because of the shocks they suffered during this phase of their de
velopment. The disturbing events gave a special colouring to their
attitudes: sex was experienced by the civil servant, for example, as
bad and damaging, by the engineer as destructive to people he
loved, and by the student as a fulfilment of his incestuous wishes.
Aggressive wishes, too, were experienced as frightening because,
while every adolescent may at times wish that his parents were
dead, in these cases it actually happened. The actual loss of the
parent during this period was a significant factor in their view of
themselves and of others.
* **
To sum up, in this chapter I have tried to describe some of the
special tasks of adolescence and to show that, when the individual
is successful in fulfilling them, he moves into adulthood. By way
of contrast, I have described cases where the disturbances during
adolescence interfered with this move.
CHAPTER THREE
Interferences in the move

from adolescence to adulthood:
the development of the female
M . Egle Laufer
I n this chapter I try to show how the emotional experiences a

girl goes through in her adolescence can be related to her men
tal health or ill-health in adulthood. Thus, I do not want to
focus especially on the actual problems or disturbances of adoles
cence that we encounter in the course of our work with them, but
on the implications these may have for the sort of adulthood that
person is likely to experience. Because, when we are faced with
having to make decisions about whether or not we should inter
vene in a young person's life, or whether we should at least be
concerned about an adolescent, one of our criteria must be the sort
of adulthood, normal or abnormal, that we think this person is
moving towards. (We also thought it would help us to be more
specific in our thinking if we talked separately about the male
and female adolescent; in the literature, it always seems as if,
when adolescents in general are talked about, the comments are
more applicable to the male.) I will limit myself therefore to those
emotional problems that appear to be specific to women in their
adulthood and then try to relate these back to their adolescence.
27
28 M . EGL£ LAUFER
This also means that I will have to omit referring to many aspects
of adolescent development, not because I do not think that they
are important, but because they do not seem specifically related to
those problems of adulthood that I am considering here.
After approaching the problem in this way, I realized that such
an approach is not such a limitation after all, since it does take one
straight to the basic meaning of adolescence for the young person.
Children arrive at puberty with the main outline of their personal
ity development already well established. This, of course, includes
their feelings about males and females—usually based on what
they feel about their mother's and father's roles. From a psycho
logical point of view, the effect of puberty is to present them with
the further task of relating these feelings to themselves in that they
now have to see themselves not just as children, but as male or
female persons on the way to becoming independent adult men
or women. Freud, at first, went so far as to say that basically, up
to puberty, all children develop similarly. However, further work
with ill adult men and women led him to reformulate this and to
say that already in childhood there is a psychological difference in
development between boys and girls—because even the child has
to take into account the significance to itself of possessing either
a male or a female body. But from our work with children and
adolescents we have also learnt that with the advent of puberty
the conscious awareness of possessing either a male or a female
body takes on a much more real meaning for the person. The little
girl, as long as she is as good as boys at doing things, can continue
to feel as if she really is a boy, and thus she is able to avoid the
conscious awareness of the significance of having a body that is
different and female. But in time, menstruation and her devel
oping breasts mean that she no longer has any choice but to be
aware of being female and of what this makes her feel about her
self. Some girls react to their puberty with such great anxiety and
horror that they already show signs of breakdown in their psycho
logical development at this stage—I describe this in greater detail
further on. And we can assume that any psychological disturbance
that we see during adolescence must in part be a reflection of what
is happening in that girl's mind, in the effort to change her child
hood image of herself to that of now being an adult woman in a
physical sense. In psychological terms, we can say that being an
THE DEVELOPMENT OF THE FEMALE 29
adult woman means possessing a body that is now equal to her

mother's in its capacity to be loved and to experience the active
wish to be penetrated by a man, and to give birth to children of her
own. We can then say that normal, psychologically healthy adult
hood has been reached by a woman when she has been successful
in this task and thus feels psychologically as well as physically
ready to deal with these two new events in her life as an adult—a
sexual relationship with a man within a stable and loving relation
ship and the bearing and mothering of her own child.
I stressed the fact that an important implication of possessing
an adult sexual body is that it is making the girl an equal of her
mother. This fact is of special importance in determining whether
the girl is able to accept her new image of herself or whether she
feels anxious or guilty and as if she is being forced by her body
into accepting her femaleness. The reality of being in the position
to compete with one's own mother in being attractive to men, or of
being able to bear children, may make a girl feel frightened that
she is making her mother jealous of her, or make her feel as if she
is taking a vital power away from, and thereby destroying, her
mother. Although I shall come back to this, I would like to men
tion as an example something we have all come across—the girl
who has accidentally become pregnant and expresses her fear that,
if she were to tell her mother, this would certainly "kill" her.
As well as having to deal with guilt that arises from feeling that
she is competing with her mother, there is another problem related
to her mother that can interfere with the girl's move into adult
hood. Most girls do not wish to become like their own mother in
some particular respect. However, some may hate their mothers
altogether and feel very afraid that when they become women,
they might become like their mother. Girls who, for instance, as
children, were badly treated or left by their mother, are terrified by
the thought that they could become bad mothers themselves. The
fear of being like one's own mother—or, alternatively, of experi
encing a fate similar to hers—can be a serious hindrance to
wanting to move on to becoming an adult oneself, and also to being
able to make decisions about getting married or having children,
which imply taking on the status of wife or mother.
The following example of adult disturbance is of a woman
during whose adolescence these psychological tasks had not been
30 M. EGlt. LAUFER
successfully accomplished and who then, as an adult, reacted to

the physical event of giving birth with intense feelings of anxiety
and depression.
A few days after her baby was born, "Flo" started to behave in
a very disturbed way. It became clear that she was terrified by
thoughts of actually attacking and harming her baby. These
thoughts frightened her so much that she had to ask people to
prevent her being able to do so, by taking the baby away from
her and removing anything that she felt could be used by her
as a weapon. Thus, she became unable to care for the baby
because even to change its nappy was frightening for her.
Gradually she became very depressed and felt she should kill
herself so that someone better able to care for the baby could
look after it.
This is an extreme example of what is called post-natal depression,

but it is also something many women suffer from after childbirth,
though in a less extreme form. This woman had felt very happy at
being pregnant and had been looking forward to the baby. How
ever, the actual birth had brought back to her mind all the horror
and anxiety she felt about having a female body and made her
feel that she was unprepared for the task of caring for her child,
since she felt as if she were still an angry uncontrolled child her
self.
When I learned more about Flo's adolescence, I could see

that there had already then been indications that the changes
that should have been taking place were not occurring. She
was the only girl in a family of boys, and as a child she had
always been very anxious to be as much like her brothers as
possible—competing with them both in sport and academ
ically. She felt that if she failed to be as strong and clever
as they were, she would not be loved by her parents. During
her adolescence she appeared to be doing well. She continued
to be successful at sport and did well academically. However,
although she had friends, she had no boyfriends. As an older
adolescent she did become very attracted to a young man, but
when the relationship started to become a physical one she
became intensely anxious and broke it off. At the time she felt
that her anxiety was related to a gynaecological symptom, and
she was not aware of the connection between that worry about
her body and the feelings she had about her boyfriend that had
led to her breaking off the relationship. Her mental breakdown
occurred after her marriage as an adult, when she had her first
baby.
So far, I have mentioned the sort of childhood this woman had,

which had made the adolescent move into seeing herself as having
a female body so difficult for her. But we know that psychological
ill-health is not the result of any one cause; usually we find that a
whole set of circumstances and experiences have added up to
gether to create the inability to progress in development.
In the case of Flo, a number of experiences during her adoles

cence had added to the difficulties she had brought with her
from childhood. She had begun to menstruate at an unusually
early age. This had frightened her very much and made her
feel that there must be something wrong with her body. The
period of early adolescence, in which her body was develop
ing, had therefore been a time of great anxiety for her. Not only
did she have to become aware of herself as a woman, but there
was also the anxiety that she was abnormal. In her first phys
ical relationship with a man this anxiety had been revived and
intensified her gynaecological symptom to a point where she
had felt unable to deal with it and had broken off the relation
ship.
Also, Flo's father had died suddenly when she was aged 16,
and her mother had become very depressed and dependent on
her for support. This event, occurring at this particular time
in her life, had added significantly to the difficulties she had in
her move towards adulthood, since the normal guilt and the
anxiety that are always felt by a girl about competing with her
mother were now so intensified because of the mother's de
pression that she could only experience a sexual relationship to
a man as a source of anxiety and guilt, and thus as something
to be avoided.
32 M. EGLE LAUFER
I chose this example to show how certain events, if they

happen to occur during adolescence, can seriously influence and
potentially hinder that person's normal development to adult
hood. Here I have shown in what way the death of a father may
influence a girl's development, depending on her earlier experi
ences. But other events can also potentially be equally harmful to
the successful outcome of the developmental tasks for a girl—such
events as becoming pregnant, having an abortion, having a homo
sexual relationship, being the victim of a rape or seduction by a
much older man (or even by a father or near relative), the death
of a parent or sibling, the birth of a sibling, alcoholism or mental
illness in a parent, and so on. All those external events may poten
tially be harmful to the development of the new adult female
identity for a girl, and they may affect her ability eventually to
view herself as a person who can safely feel identified with her
own mother and be in control of her own sexual body without
having to feel anxious, ashamed, or guilty about it. I am not, of
course, implying that external events on their own create the diffi
culty, but they can help or hinder development in a person who is
already vulnerable.
It is extremely important that the long-term effects of such
events occurring in an adolescent's life are taken seriously and not
minimized simply because the immediate problem has been dealt
with successfully—as might be the case, for instance, with an un
wanted pregnancy, once an abortion had been arranged. Taking
the example of a girl becoming pregnant, for example, if this
occurs before she is fully able to feel that she no longer needs her
mother as a source of approval and support and if she is fright
ened of the effect of her pregnancy on her mother, then she is not
able to see the pregnancy as something that affects her herself and
her own future life. She experiences it as something that just hap
pened to her—that is, she "fell" pregnant—with the implication
that she has just failed to be in control of her own body. Having an
abortion confirms this view of herself, while the actual birth of a
baby can just feel as something else that she has to allow to happen
to her. Thus the normal function that childbirth can fulfil—that of
reassuring a woman that she is normal and capable of actively
producing a normal baby—must fail in such a situation. The girl's
ability to relate to the baby can then, in turn, be coloured by this
same attitude of helplessness and passivity, which, of course, we

often see expressed as a fear that she is unable to look after her
child adequately and needs the constant support of the social
agencies to help her to do so. Thus every further experience that
would normally go towards increasing the confidence that an
adult woman has in herself, can, for the adolescent girl, result in
the reverse effect and go on to confirm in adulthood an image of
herself as sexually uncontrolled and incapable. In other cases the
girl may have wanted the pregnancy. In those cases we would
have to be careful to assess whether the interference in develop
ment is related to the girl's inability to see herself as a person who
can hope in adulthood to have a stable relationship with a man.
You may often see this in girls who have been brought up without
a father to whom they can relate. The decision to have a baby can
then represent their hopelessness of the future and the belief that
the only stable relationship that they are able to achieve is that of a
mother and child via having their own baby.
Homosexual experiences in early adolescence can, for some
girls, be a necessary step in helping them feel that they can also
like their own bodies. Mutual exploration of each other's body
may be the only way of dealing with their fears and of feeling
alone with their own newly mature body. However, such an expe
rience can also become an interference in the ability later to move
on to feeling safe in physical relationships with boys, because the
pleasure that the girl experienced with another girl, instead of
helping her feel more secure within herself, can make her feel that
her body is abnormal and only capable of relationships with
women. This is, specifically, the case of a homosexual experience
in early adolescence; a homosexual relationship in late adoles
cence, on the other hand, can no longer be regarded in the same
way as a step towards normal development with only the poten
tial to interfere with development. Instead, I see it as an indication
of a breakdown in normal development already having taken
place. This is because, by the time a girl has reached late adoles
cence, the choice of a girl with whom to have a relationship is a
sign that she has given in to her fear of being abnormal and can
no longer see herself as capable of moving towards normal adult
hood. Thus, it represents a turning back to the relative safety of
another woman's body—as if turning back to her mother—and not
34 M. EGL£ LAUFER
a step forward on the way to heterosexuality, as it is for the

younger girl.
Sexual experiences with boys in early adolescence can also be a
sign of trouble for the future. It is often the first sign of an inability
to form stable relations with men. It is normal for the young ado
lescent girl to think of the actual act of intercourse with some fear
and anxiety. She sees the physical act of penetration by the male as
an attack on her and fears that, in order to have a close relation
ship to a man, she must accept such an attack passively. However,
for some girls, their fear, instead of making them avoid sexual
relationships until they have dealt with them realistically, can also
compel them to plunge into sexual activity actively at a time when
they are not yet able to master their fears. The actual experience of
intercourse, instead of helping them to feel reassured, is then often
felt by them as a real confirmation of their fears. These are the
girls who may then tend to become promiscuous throughout their
adolescence and, in adulthood, are left feeling guilty and ashamed
and thus vulnerable to expecting to be rejected and unwanted by a
man.
I cannot go in detail into all the other events and experiences
that I listed as potentially interfering with development to normal
adulthood, but I hope I have said enough to show how careful we
have to be in our assessment of the effects such experiences may
have, not only on the present life but also on the future life of a
person.
For some girls, the advent of puberty itself can be the source of
the greatest difficulty. Menstruation is experienced as the need to
see themselves as women who possess female sexual organs and
not those of a man. But we know that there are some women
who still suffer as adults from a constant sense of inferiority and
depression that is quite unrelated to any reality but is a reflection
of the view they have of themselves as a woman. Clinically, we
might find such states described as women suffering from frigidity
or the inability to make stable sexual relationships, but contained
in these descriptions is a constant sense of inferiority about being a
woman.
We must, then, ask what can prevent a gradual change taking
place in a girl during adolescence which would lead to the normal
feeling of being able to value herself as a woman in adulthood.
Many adolescent girls react to the changes in their bodies at the

time of puberty with conscious feelings of disgust and dislike.
Some, indeed, as I mentioned earlier, may show signs of mental
breakdown at this point in their lives.
I saw a young woman who had become unable to continue to

go to school when she first started to menstruate. She had
become convinced that everyone would be able to see that she
was menstruating and that, when some girls laughed at her,
they were secretly laughing at her because she was menstruat
ing. She became so disturbed that she had to spend some time
in a mental hospital at that time. When I saw her, aged 19, she
was a desperately lonely young woman, dressed completely
like a boy and living a vagabond life to prove herself as tough
and strong as a male.
Thus, here we can see the extreme result when the period of ado
lescence fails totally in its function to allow for the gradual change
to take place from the not uncommon preadolescent attitude of
thinking of women's genitals as something funny and disgusting
to one of liking herself. For this girl, when she began to menstru
ate, as well as thinking that grown-up women were funny, had
had to feel that she herself would now be laughed at. And thus her
only way of being able to relate to the world outside her family as
an adult was first by hiding herself and staying at home and then
by hiding any signs of her own femininity.
In other cases we might see the reaction to the maturing body
being expressed by desperate attempts to feel in control and to
stop its growth. This we can see in those girls who start to diet
compulsively. Their conscious feelings about their sexually matur
ing body and being female may be more concerned with the
obvious outward signs such as breast development and getting
fat, and they react with anger at their bodies, which they see as
responsible for shaming them in this way. This anger may then be
expressed in an implacable determination to show that they can
control their bodies' development via dieting, which can become
so severe that they starve themselves. This can not only interfere
with psychological development but also lead to physiological
changes that result in the girl ceasing to menstruate normally. We
36 M. EGLE LAUFER
describe this condition clinically as anorexia, but in this context

this condition can be viewed as a complete breakdown in the girl's
ability to like, and therefore to take care of and feed, her own
body. Unless adequate help is provided, such a breakdown must
lead to an adult life that is influenced by an inability of the person
to like her own body and a tendency towards self-destructive
actions.
However, even in those girls who show no obvious sign of
breakdown in development having occurred, as in anorexia, we
may still see the signs in their later adult lives of the unsuccessful
completion of this task of adolescence. These are the women who
have to continue to struggle with their jealous and competitive
feelings towards men in such a way that it affects their ability to
be successful at work or to have a non-competitive and close rela
tionship with men. They feel constantly threatened by feeling
unworthy to be appreciated or loved and may eventually fall ill of
a depressive illness. If we understand also how these adult distur
bances are related to a lack of the necessary psychological changes
having taken place during adolescence, we can also become more
careful to look for indications of actual interferences in the psy
chological development having occurred at that time. I described
those women whose lives remain a constant struggle against their
feelings of depression, and the relationship of this to their feelings
about being a woman. But there are also those women who con
tinue to regard themselves as dependent children needing to be
looked after, even after they have become adult and are married. I
am referring here to the many women who suffer from the inability
to leave their homes without being accompanied by an "adult"—
usually their husbands.
One aspect of this very crippling disturbance can again be
regarded as a result of a failure, during adolescence, of the girl
to come to feel that she is able to trust herself to be in control of
her fantasies and her own sexually mature body. For the child, the
problem is one of having to learn to be in control of its own bodily
needs of urinating and defecating; to a lesser degree, one can add
that of feeding oneself, keeping clean, and so on. With the arrival
of puberty, there are new needs—the adult sexual wishes that now
have to be satisfied and controlled—but here the adolescent girl
can no longer turn to her mother for help, as she could as a child.
In fact, at this time what we can observe is how girls may turn
against their mothers, rejecting all emotional closeness and insist
ing on keeping their lives and their bodies secret from her. It is
as if they are too afraid of their old childish wish to turn to the
mother as their source of support and can now only see her as a
danger to be avoided. Such an attitude to her mother may enable a
girl to get through adolescence and feel independent enough even
to get married and have children, but the change this should also
represent in her feelings about herself may be more apparent than
real. Unconsciously, unless someone is there to support her and
thus control her body, she may still not feel safe in situations
where she thinks she must control it herself. For such women, it
becomes impossible to leave their homes on their own because of
the unconscious fear of what they feel they might do. For some it
may be the unconscious fear of meeting "strange men", as if they
were afraid that they would be unable to control their sexual
wishes towards them; with others it may be experienced more as
the old childish fear of losing control over the bladder and thus of
shaming themselves. The only way open to them to feel safe is to
deny their independent adult status and their adult sexual feelings
and to see themselves as if they still had a child's body, which
would then need to be protected by an adult. This disturbance—
agoraphobia—is crippling because it affects a woman's life com
pletely, even if it is not called a breakdown and does not require
hospitalization. This example, of avoiding an external situation
that is felt as potentially dangerous, again represents an extreme
case of an attitude that can be present in a less extreme form in
many women and affect their ability to feel mentally healthy and
free to do what they want to—many women are hindered in their
lives by having to live with fears or phobias that prevent them
doing what they would like.
Finally, I would like to come back to the view of normal,
healthy adult functioning: this can be defined as the ability to be in
charge of her own sexually mature body without anxiety or shame
or guilt, to care for and protect her own body, to feel that she is
potentially capable of caring for a dependent child, and to be con
fident that she can receive and give satisfaction in a stable sexual
relationship with a man.
CHAPTER FOUR
Problems in working
with adolescents
Maurice H. Friedman & M. Egle Laufer
I n this chapter we discuss some of the problems that arise in

situations where we not only observe the adolescents or listen
to them, but where we also have to become actively involved
with them on a day-to-day basis. We are basing our remarks on
the sort of contact with which we ourselves are familiar—that is,
interviewing young people or being involved with them in a treat
ment situation. But what we are saying can also be applied to
other fields of work—such as teaching, probation or social work,
or youth work—because, although the sorts of problems that arise
in work with adolescents may differ according to the specific role
we play in their lives, the adolescent's reactions to adults who are
involved in his life remain the same and are determined by what is
going on in his mind.
The three main areas in which changes must take place in the
adolescent's life are:
1. in his relationship with his parents;

2. in his relationship to his contemporaries;
3. in his attitude to his sexually maturing body.
39
40 MAURICE H. FRIEDMAN & M. ECLE LAUFER
Of these three, it is mainly the first area—the need to change his

relationship with his parents—in which we become actively in
volved, because for the adolescent we, as helping adults, can come
to represent the parents themselves. It could be, for example, that
we represent authority for him, and the struggle to change the
relationship will then be directed actively against us. Or, again,
we may be seen by the adolescent as allies in the struggle to free
himself from his emotional attachment to his parents. In either case
we are always in danger not only of being seen by the adolescent
in this role, but of being manoeuvred into actually playing it. We
can all think of situations where we have been forced by the behav
iour of the adolescent to become punitive and authoritarian with
out really feeling that this is the role we want to be in, and where it
feels as if the adolescent is constantly fighting us. Conversely, we
can all think of instances where an adolescent will tell us, or imply
by his behaviour, how wonderful we are and where he compares
us to his parents, who, he says, don't understand the needs of the
young people of today (as we do) and who are, therefore, useless,
old-fashioned, or bigoted. This latter role, when it is assigned to us,
feels a much more attractive one to be in than the authoritarian
one, and we can enjoy it to the point of forgetting that the adoles
cent's need is to learn to deal with his actual parents, whether
good or bad, and with his anger and disappointment with them—
and that we cannot be the substitute good parent the adolescent
wants us to be.
But, even if we cannot fulfil the role the adolescent wishes us to
play, we can still have a very important role in the adolescent's
life. And it is because we are in a position to fulfil some very
important needs of the adolescent during his development that it
is essential to have some understanding of what is going on in his
mind. For example, the adolescent who appears to see us in such
an idealized sort of way may really be gaining some strength
from this point of view in his attempt to become a different sort
of person himself. He may, for instance, be like one boy seen at
the Centre, who was worried that he would become tyrannical
towards his girl-friend in the same way as his own father had been
towards his mother. But this boy had a very good relationship to a
teacher whom he admired enormously and whom he gave as an
PROBLEMS IN WORKING WITH ADOLESCENTS 41
example of the sort of person he himself would like to become.

One could see how this admiration of the teacher helped the boy
to feel that he could be a different sort of person from his father. It
is very important, if we are in a situation like this teacher, to be
able to understand that the intensity of the boy's admiration and
idealization is related to the struggle going on inside him because
of his fear of becoming like the father. If we ourselves, along with
the adolescent, subscribe to the image of being thus idealized, then
we will also make the adolescent feel the impossibility of becom
ing a similar sort of person himself.
We would like to come back to the adolescent who puts us into
an authoritarian role of having to nag, reproach, or even punish
him for not working at school. Such an adolescent may, in fact, be
very worried at the realization that he is unable to get himself to
do the work, and humiliated about his inability to become more
independent and about his continued childish need to have some
one there to act as the angry parent. Here we may find that if we fit
too readily into this punitive role allocated to us, the adolescent
can use it to confirm his belief that he is unable to function as an
independent and more grown-up person. There is obviously dan
ger in such a situation—in any situation, for that matter, where the
adolescent feels that we are allowing ourselves to fulfil a role that
is determined solely by him.
One must not forget, however, that there are also times when,
even though we may feel as if the adolescent's difficult or annoy
ing behaviour is meant to provoke us, this may in fact not be the
case at all. He may be concerned with some other anxieties of his
own, and his behaviour may have very little to do with us at that
moment—because, as mentioned earlier, there are other important
areas of the adolescent's life that give rise to stress.
For example, we were discussing with a group of teachers a

boy who appeared to be doing all he could to disrupt the class
and make it impossible for the teacher to teach anything, either
to him or to the rest of the class. The teacher felt very upset
about this, but also puzzled and hurt. This boy, "John", had
been a very enthusiastic pupil and had done well up to then.
The teacher had felt proud of him. In the past, John himself
42 MAURICE H. FRIEDMAN & M. EGLE LAUFER
also had shown his gratitude and appreciation to the teacher

because he felt he had been helped to pass his exams. How
ever, after passing the exams, John had obtained a job and was
now back on a day-release course. He now appeared to be
totally changed: the teacher felt as if suddenly he had been
rejected and was being attacked as being useless and not hav
ing his former value to the boy. On discussing it with us, we
felt that it might not be the teacher or the college John was fed
up with; there might be other problems.
The following week, the teacher told the group that he had
talked to John and had learned that he was having a hard time
at work because the foreman was a bully who seemed to enjoy
frightening the new apprentices. One could then understand
John's behaviour at college as having more to do with his feel
ings at work than any real attack on the teacher. John felt bewil
dered and frightened at suddenly being in a situation where he
had to be careful to control his temper and not answer back for
fear of what the foreman could do to him; the feeling of having
to tolerate this situation passively had made him very tense and
anxious. It was this anxiety that was showing itself at college in
his seemingly provocative behaviour.
This sounds like the common story of the weak man who allows
himself to be bullied at work and goes home and strikes his wife;
but in John's case it could easily have appeared as if he was just
reacting to the teacher and showing him that, now that he was an
adult, he could not be bothered to learn any more.
* **
We now continue with a more detailed description of how the
mind of an adolescent functions in his efforts to change the rela
tionship to the parents. The processes we are about to describe
are, of course, part of normal development, but we also want to
indicate at what point one should begin to suspect that normal
development is not taking place.
The conflict that exists within any adolescent between strivings
towards adulthood on the one hand and the opposite wish to re
main a child on the other accounts for many of the fluctuating and
contradictory phases of behaviour through which the adolescent

passes. These can change with bewildering rapidity, causing dis
tress, perplexity, and anger in those who are trying to help him,
whether they be parents, teachers, probation officers, or therapists.
But we hope to show that, in fact, this behaviour is related to the
developmental process in a way that is logical and, to some extent,
predictable.
We know that, on entering adolescence, the individual has to
cope not only with the stress of physical sexual development, but
also with intense revived childhood feelings, particularly towards
the parents, and ones which seem more appropriate to a 6-year
old. These revived feelings are an inevitable part of the adolescent
process. They occur as unconscious processes, and, indeed, the ado
lescent suffers from the confusion that must result when strong
trends pulling him back to childhood occur, paradoxically, at the
moment when consciously he is looking forward to adulthood. This
revived childhood relationship to the parents must be dealt with
and resolved by the adolescent if he is to progress toward adult
hood. It is the manner in which this particular task is tackled that
will determine how the adolescent behaves towards us in our role
as helpers. Exactly how the emotional dependence is broken is
determined by mental processes that we can learn to recognize
even though they are quite unconscious as far as the adolescent is
concerned.
The first process in the adolescent's attempts to free himself
emotionally from his parents consists of an abrupt withdrawal
of emotional feelings from the parents and a displacement onto
people in the environment outside the home. This is one of the
normal processes already referred to. If the process is not too exag
gerated, we get a relatively healthy picture of an adolescent who
gets on well with his teacher and with other adults, including
neighbours, but who at home presents the picture of complete
indifference to his parents. This is often the type of adolescent who
is accused by the parents of being merely a boarder in his own
home; thus, in this particular case, it is the parents who feel re
jected and who may ask, "Where did I go wrong?" Nor does it
help matters much for them to note that their sullen, morose son or
daughter gets on famously with the people next-door. Or it may be
the teacher who is idealized; although the teacher may find this
44 MAURICE H. FRIEDMAN & M. EGL£ LAUFER
enjoyable in some ways, he will often also feel it as a strain, be

cause the pupil's devotion is of a demanding (that is, infantile)
nature. The adolescent has, in fact, displaced his childish depend
ence from the parents onto the teacher.
The process by which emotion is withdrawn from parents and
transferred onto others may take a more exaggerated form: the
object of the adolescent's attention may still remain people who
unconsciously represent parents, and yet they will appear to have
been selected because these people may have characteristics that
are quite opposite to those of the parents. The usual picture here is
of the adolescent associating with adults who are to some extent
undesirable to the parents and whose standards are adopted un
hesitatingly. If this reaction is taken to an extreme and the chosen
adults are undesirable from a realistic social viewpoint, the danger
of delinquency looms. In these extreme cases any relationship to an
adult with a reasonable code of behaviour is avoided, the teacher is
dismissed with the same lack of regard as the parents, and it is the
probation officer whose expertise will in all likelihood be needed.
But it must be emphasized that these adolescents are not primarily
delinquent—that is, delinquency is not part of their character struc
ture; their childhood history usually gives no evidence of delin
quent activity prior to adolescence, and there is often abundant
evidence that they have had a well-functioning conscience. What
has brought them into trouble with the law arises out of the task
they are engaged in—that is, of breaking the childhood tie to the
parents. The game is given away by their choice of such obviously
unsuitable people; it indicates that they have not yet been able to
change their emotional dependency on their parents, in spite of all
the sound and fury. This type of adolescent is in great danger, and
it is often difficult for us to know how to be useful, because the
individual is totally unaware of the inner struggle in which he is
engaged. If, as a consequence of delinquent activity, he is forced to
have some sort of relationship with a probation officer, this could
then become a means of helping him. In fact, the probation officer
is often the only worker who is in a position to help an adolescent
in this particular category.
This applies to those adolescents who are trying to detach
themselves emotionally from their parents. Other adolescents re
main very much tied to their parents: they attempt to break the
childhood tie, not by turning to others, but by a reversal of their

former feelings towards the parents. Quite dramatically, loving,
obedient children become hostile, disobedient ones; the parent
who was formerly admired is now derided and contradicted. The
adolescent may dwell under the illusion that he has emancipated
himself from the family, but it is clear that his emotional life re
mains very much tied to the home. Where this type of reaction
remains relatively mild, one gets the picture of the adolescent who
is difficult at home. But with a more intense reaction, the picture
emerges of an angry, unhappy, guilt-ridden young person, con
tinually in opposition to his family but also quite unable to free
himself from the family circle or to make much use of any other
adult in his environment. These adolescents are quite aware of
their suffering and, though unable to use other adults normally,
will often appeal for help from adults. This appeal is a search for
allies against his parents, and the unsuspecting adult may be led to
believe that the adolescent's parents are cold and unsympathetic,
which may in fact not be true at all. In a case we discussed at the
Centre recently, the adolescent's reversed feelings caused him to
experience his parents as if they were like that. Because this type
of adolescent is so extremely difficult at home and yet presents no
problems outside the home, the situation is often ripe for misun
derstandings to arise between parents and other adults.
At this point we would like to emphasize that the two pro
cesses described so far—namely, the displacement of feelings from
the parents onto other adults and the reversal of feelings towards
the parents—are not mutually exclusive; mild to moderate degrees
of both can be observed in any normal adolescent. It is where an
excessive and exaggerated use of these processes occurs that the
possibility of ill-health arises.
So far we have found a useful place in the adolescent's life for
teacher, neighbour, probation officer, and therapist. It would ap
pear that parents are relatively powerless to do anything actively
helpful; yet, in fact, they have the most important task as well as
the most difficult one: that of just being around in the expectable
way; being quietly supportive without getting caught up in prov
ocations, and maintaining their personal standards in spite of
the temptation to come down to the child's level. This is certainly
a great deal to ask, and yet every parent of an adolescent must
46 MAURICE H. FRIEDMAN & M. EGLE LAUFER
respond as best he can. What can be damaging, however, is when

parents, under the misguided assumption that they really are
unloved, unwanted, or considered unnecessary, react to these feel
ings and wash their hands of their adolescent son or daughter.
A third process that we can learn to recognize in the adoles
cent's attempt to break the emotional dependency on the parents
(and which always indicates the development of serious ill-health)
is the process whereby emotional interest, having been withdrawn
from the parents, is not reinvested in other adults or contempor
aries, but remains vested in the person of the adolescent. In other
words, there is an emotional withdrawal from the environment;
the picture, then, is of an adolescent who, although appearing to
give no cause for concern is, in fact, detached from his environ
ment. He often shows excessive preoccupation with himself and
his body: it is as if all his emotional interest is now in himself, his
bodily functioning, the shape and size of his body parts; often
there are anxieties about what is going on inside the body or the
mind as well. It is, of course, normal for the adolescent to be con
cerned about his body, but here we are describing an exaggerated
form of concern and one that is substituted for all other interests in
his life. This may often be the initial phase of a psychotic illness,
but in any case the early detection of such a state is of vital impor
tance. The adolescent who is in the process of withdrawing from
the environment may often be spotted at school (where his behav
iour seems very odd compared with others), rather than at home,
where very gradual processes may go on undetected.
"Lloyd", an intelligent 17-year-old West Indian boy seen at the

Centre, initially angered his teacher because he took no interest
in his lessons, came to the class very late, and left when he felt
like it. Homework was not done, and punishment had no
effect. The teacher had an interview with the parents, but this
was unproductive because they felt that their boy was very
good and no trouble at home. The issue of colour discrimina
tion was raised, and matters became complicated and ob
scured. Fortunately the teacher had made one observation that
did not fit in with the picture of a disobedient, provocative
boy—he had observed that the boy had no friends, spoke to no
one, and was, in fact, totally isolated. In this case the teacher
had to be the one to arrange contact with the Centre, in the face
of parental opposition. In this he was aided by the GP. The boy
was then assessed as being severely withdrawn (his main pre
occupation seemed to be with the functioning of his heart), and
the possibility of a schizophrenic process was thought likely.
So, at present, he attends for treatment. His teacher is still
faced with the very difficult task of coping with him in an
ordinary class. If treatment helps this boy, there is no doubt
that the teacher's contribution will have been enormous, be
cause we know how important it is to try to keep the with
drawing individual in touch with his environment. Thus, for
instance, removal from class and the provision of a home tutor
might have been the easiest step to take, but this solution
would have been very detrimental to the boy.
* **
So far we have been describing unconscious modes of mental func
tioning that are used to cope with the adolescent upheaval, and we
have shown how the resulting picture can vary enormously, from
normal behaviour to severe mental ill-health. We have also tried to
indicate in what ways those adults working with the adolescent
can help him. But there is another group of adolescents who mani
fest a picture quite different from those so far described; these are
the so-called "good" adolescents who, at 15 or 16, remain exactly
the same as they were at 8 or 9. They are loving, considerate sons
and daughters, who continue to accept, unquestioningly, the pa
rental dictates. Now, because of their adolescence, we know that
there must be a considerable degree of inner unrest, and the lack
of external evidence should alert us to signs of trouble, because the
price they may be paying for the temporarily peaceful lives they
lead could be a crippling of the maturational processes and a de
velopmental arrest.
A 17-year-old girl, "Angela", who was encouraged to come to

the Centre by her teacher, presented such a picture. It had been
noted that she was excessively over-conscientious about her
work, and she worried quite unnecessarily about doing badly.
She had severe examination anxiety and had, in fact, reached
the point where her work had begun to suffer. She was clearly
48 M A U R I C E H . F R I E D M A N & M. EGLE LAUFER
a very unhappy model pupil, and on the teacher's advice the

parents brought her to the Centre.
At the interview the impression she gave was of an agitated,
depressed girl who firmly maintained that she had no worries.
She was willing to admit that she had not slept well for over a
year and that she worried about her work, but she did not
consider these as problems needing specialized help. She was
profuse in her admiration for her mother, and we quote from
notes made at the time: "Angela told me that she worshipped
her mother, and thought she was the most wonderful person
alive; she went on to say that she worried excessively about her
mother's health; she simply did not know what she would do if
her mother died. During this recital, she would occasionally
burst into tears, and this in itself alarmed her, because she
could think of no reason to feel sad."
The parents were subsequently interviewed, and the following
picture was revealed: the mother talked of the extent to which
she adored her daughter and how close they were, but she
could not see that her daughter was in any trouble or in need
of help; she said that she and Angela were very much alike; as
a girl she, too, had been rather over-anxious, and she herself
had got over it. Angela's father took a very different view of
the situation and he, in common with the teacher and the staff
member at the Centre, felt that treatment was vital. But the
mother and Angela remained unconvinced and rejected the
offer of help. This unsatisfactory outcome was disappointing
because the teacher had been particularly perceptive in detect
ing Angela's unhappiness. However, it should be emphasized
that this type of adolescent is well worth detecting, as therapy
is the only way to enable progressive development to take
place.
In discussing these various types of adolescent reactions, it

should be noted that the very nature of the adolescent state means
that the individual's relationships to people are unpredictable, in
consistent, and fickle, as compared with the reasonable stability
of relationships that are possible to the mature adult. Thus, for
P R O B L E M S IN W O R K I N G W I T H A D O L E S C E N T S 49
instance, a therapist treating an adolescent (and this is true in any

other field of working with adolescents) must not expect the sort
of cooperation that would be taken for granted with adults. Ado
lescents may enter treatment, not with the true aim of gaining
insight, but in order to spite their parents, and they may remain in
treatment and apparently be good patients because they develop a
"crush/ on the therapist rather than because of a real desire for
7
change. They are likely to miss sessions because something more

attractive offers itself that day, or they may miss sessions for no
observable reason at all. In one treatment session they may be
extremely cooperative and work hard at achieving insight, and
the very next session may be one of relative silence. In all this, the
therapist has continually to remind himself that in some area of
his mental life the patient suffers a great deal, and much of his
difficult behaviour towards the therapist is meant to ward off
examination of the area of suffering. This takes time and much
patience for the therapist to hold the situation and gradually lead
the adolescent towards an examination of his problems.
In the same way, the teacher has to put up with the same type
of inconsistent behaviour in class; a pupil may produce excellent
work one day and deplorable work the next; behaviour in class
may show similar fluctuations; the attitude to the teacher may be,
in turn, respectful, idealizing, adoring, indifferent, derisive, or
hostile. The teacher who can survive is the one who is perceptive
enough to spot the irrational nature of the variations in behaviour
and who will, therefore, not feel too upset or disappointed when
his prize pupil lets him down. For one must also remember that,
however smoothly the process of achieving emotional independ
ence is proceeding, there is still a constant simultaneous pull back
towards more childish forms of behaviour, which results in all
these variations.
***
We would now like to go on to examine the feelings and the prob
lems that arise from our own reactions to the adolescent, and also
to show how we can make ourselves less vulnerable in our work
if we are able to understand and recognize our own feelings and
reactions as well as those of the adolescent.
50 M A U R I C E H. F R I E D M A N & M. EGLE LAUFER
The first problem we would like to discuss is that raised by the

adolescent who comes to us and, in telling us of his problems,
produces in us a feeling that we have to do something at once
about his problem. Such a feeling can also be due to the adoles
cent's own sense of urgency, which then finds its echo in our own
reaction. For the adolescent it is normal to feel the tension aroused
by any stress as unbearable and to feel that something active must
be done at once in order to relieve his tension. (We at the Centre
took this factor in the adolescent's life into account by the manner
in which we have set up the Centre—that is, that we function as a
walk-in centre where people are not kept waiting for an appoint
ment.) But our anxiety to do something about a crisis we are
presented with may in fact be due to being made to feel by the
adolescent that his tension is unbearable, and not because there
is any action that we can usefully undertake. It is therefore impor
tant to share with the adolescent his feeling of urgency about the
crisis, while at the same time being careful not to feel rushed into
taking action. It is only once we can understand the real cause that
has brought about the present crisis that we can judge the value of
any action.
"Gina", a 17-year-old girl, came to the Centre saying that she

had been sent to us by her doctor. She had gone to him com
plaining of stomach pains. She said that she had been missing
many days at work and was afraid that she would be sacked.
She had gone to the doctor hoping he would tell her to stay
away from work and that he would do something for her. He
had, however, said that he could find no physical cause and
suggested that she should come to see us. When she was seen,
Gina's anxiety had reached panic proportions. She talked of
hating her work and feeling very depressed; she said it had no
prospects, and she wished she had stayed on at school to do
A-levels. She wanted us to arrange for her to leave work at
once and to find her a school where she could study. The feel
ing she gave the interviewer was that he must do something at
once to help her. However, on going into detail, it turned out
that Gina had already been very depressed in the summer and,
at that time, had insisted that she would feel better if she
were allowed to leave school and go to work. Her parents had
agreed to her demand because they were concerned about her

and hoped that if she left school she would feel happier. This
piece of information made the person seeing her feel that he
should be cautious before rushing into another decision. On
further thought, it could be seen that there was no real urgency
in the matter. The problem was not a new one and needed
much more time to sort out in detail. The next time the girl was
seen, the picture had changed completely. She liked her work,
there were reasonable prospects, and she had been thinking of
going to evening classes to get her A-levels.
Here, the demand of the adolescent that we must do something

at once to make her feel better could have led us to decide on an
action that might have been quite detrimental in the long run. But
by showing her our concern for her distress at the time of her
panic, we were able to help her until we could see the nature of the
problem more clearly. This had to do with her relationships to
the girls with whom she worked. She had formed an intense rela
tionship to one of the girls there, and she had become unbearably
jealous whenever this girl talked to anyone else. This same prob
lem had already occurred while she was at school and had been
her original reason for wanting to leave. It could then be seen that
the same problem would have arisen again wherever she went.
We could then begin to discuss with her how she could be helped,
and eventually treatment was arranged.
We can also react to this type of demand because it makes us
feel very powerful. The adolescent likes to see us as powerful
people who can alleviate his distress in an almost magical way.
This is again an example of the way in which earlier childish
dependent feelings are revived in adolescence and transferred
onto adults outside the home. But again the danger exists that we
ourselves come to feel as if we have to confirm this wish of the
adolescent by acting in a powerful manner.
As well as being able to make us feel very powerful, the ado
lescent can also make us feel very helpless. One of the most
difficult tasks of working with adolescents may, in fact, be the
times when one has to acknowledge one's own helplessness. For
example, we see young people at the Centre sometimes who we
know are very disturbed and will probably grow into very dis
52 M A U R I C E H. F R I E D M A N & M. ECL.£ LAUFER
turbed adults. But we may still have to decide that there is nothing
very much that we, as psychotherapists, can do to help them.
We have in mind, for instance, "Hal", a young man who came

to the Centre complaining of feeling that he was unable to
make relationships, with either boys or girls, that really meant
anything to him. He wondered if anything could be done about
this. He was clearly very depressed and even had suicidal
ideas at times, and he urgently needed some form of help. But
in discussing the details of the past history and present circum
stances of this boy, we realized that psychotherapy as a form of
help could not hope to change anything basically in him at this
point, however much we felt we wanted to help him. He was
someone who had been so severely deprived during childhood
that he would only be able to view therapy as a means of
obtaining from adults the love and attention for which he still
craved. From a therapeutic point of view, treatment would fail.
We had to accept that this type of help was not the appropriate
one for Hal. Had we put this boy into treatment, a situation
would have developed where the boy's real needs would
not have been met, nor would the therapist's aims have been
accomplished, and rather than giving him any relief this could
have resulted in an increase in the boy's suffering through this
new disappointment. From his point of view, Hal's need was
for some sort of parent-substitute rather than for a therapist.
But it was a mistake we could easily have made because there
was a wish to help. Offering treatment would have been a way
of rationalizing our own feelings of pity for this boy and the
feeling he provoked of making us wish to rescue him.
We would like to contrast this example (where we were realis

tically helpless, however sorry we felt for him) with another
example, where the adolescent also made us feel helpless, but in a
very different way.
"Jill"/ a 19-year-old girl, came to the Centre but she did not
want to give her name when she made the appointment. She
came asking if we could help her find hostel accommodation
because she felt that all her troubles came from living at
home. If she could get away and live in a hostel, all would be
well. Jill gave an account of a very disturbed and demanding
mother, who, she said, did not allow her to lead her own life
and made her ill through the sort of demands she made on her.
From her account it did seem as if her mother suffered from
hypochondriacal complaints that reduced the whole family,
particularly the daughter, to having to care for her continu
ously. The daughter herself was now in danger of becoming a
disturbed person. It seemed that it would be very desirable for
her to leave home. However, when we went into Jill's history in
greater detail, it turned out that a whole list of professional
people had already tried to help this girl, and every attempt
had ended in failure. She then said that she had not wanted to
give her name because she felt she was "known" in the neigh
bourhood. It became clear that she felt very anxious about all
the workers whom she believed she had previously antago
nized, and who, she now felt, wanted nothing more to do with
her.
When we contacted some of these people, this turned out to be
quite true. This girl really was frustrating to work with. And
we could also see how she had managed to get herself rejected
each time. When we tried to find her hostel accommodation,
every time we thought we had found something suitable, a
new objection emerged which made that particular hostel un
suitable: she could not share a room; she could not live too near
home; she could not live in a house with a dog; and so on.
After a time, the person seeing Jill at the Centre said at a meet
ing of the staff that he felt that nothing could be done for this
girl, that the situation was hopeless. Other people at the meet
ing could then point out how angry the girl had made him by
making him feel helpless and, therefore, making him want
to get rid of her—just as all the other workers had done up to
then. Only then could one see what must have been the pattern
throughout this girl's life. It was part of this girl's disturbance
to make people feel as hopeless about her as she felt about
herself. And then one could begin to recognize the girl's real
54 M A U R I C E H. F R I E D M A N & M. EGI_£ LAUFER
suffering and the depression behind her complaints about all

the people who had let her down, without having to feel angry
with her for her implied accusations. In fact, we did arrange
treatment for this girl. She was helped a great deal, and she is
now working and living away from home. Of course she is still
very vulnerable. But we could easily have given her up as
hopeless.
Another time when we can feel both helpless and worried is

when the adolescent is behaving dangerously in the environment
and yet we are unable to control him. Our anxiety may result in
feeling angry with the adolescent. In therapy we are often in this
situation. However, we do find that it can be very helpful to tell
the adolescent that we know that, however worried we may be
about their dangerous behaviour, we are not able to do anything
to stop it. This confrontation with reality can often help the adoles
cent to see the danger for himself and yet still leave him with the
feeling that we are concerned for him.
The final problem we wish to discuss arises from the fact
of the adolescent's sexual maturity. The feelings this arouses in
adults working with adolescents also have to be recognized and
acknowledged. The gap in ages between adolescent and worker
may be fairly narrow, and the adolescent's sexual feelings and
interest may be directed towards the adult worker. The adult him
self may find himself sexually attracted to the adolescent. This
becomes a problem only if it is not recognized as a real possibility,
as, for example, if the adult continues to handle the adolescent
physically as if he still sees him or her as a child and denies that
this may also be experienced as sexually stimulating by the adoles
cent. But at the same time we must not be afraid of recognizing the
reality of the adolescent's real wish to attract us. It is only if we
show that we respect the adolescent as a sexually mature person
that we can also reassure him that we can still keep the emotional
distance that he needs if we are to be able to help him. Some
disturbed adolescents, especially girls, may use their bodies in a
provocative way to try to attract the attention of the adult whose
love they crave. Very depressed girls, for instance, sometimes be
have in this seemingly seductive manner, dressing provocatively
and flirting with the teacher or youth worker or with boys. It may
be these girls' only way of showing their need and wish to be

loved, but their real fear is that they can only feel wanted if they
make their bodies available. By reacting to their flirtatious behav
iour, we can easily miss how it hides a very sad and suffering
person who may be very worried about herself. Similar problems
may exist when listening to an adolescent telling of his sexual
activity. If we become involved through the interest and curiosity
and envy that it arouses in us, we can easily miss that the adoles
cent himself may not be as happy about it as we think he should
be. He may be much more worried than he can admit and feel
very let down if we have no understanding of his anxiety.
The same dangers can exist if we become involved with the
adolescent's social activities or try to become the adolescent's
friend in other ways. We may, for instance, be in sympathy with
some of their social or political aims, but if we become actively
involved with them, we are no longer able to keep our emotional
distance, and hence we become unable to help them in our proper
role. Our participation in these activities, or our offers of friend
ship, may be seen more as an expression of our need to be liked by
the adolescent and will be taken as a proof of our weakness in
carrying out our own role.
These examples now make it possible for us to generalize and
to say that, in order to be less vulnerable to our own feelings, we
have to be able to acknowledge them and to keep in mind con
stantly the aim of the work we are doing. Any intervention or
reaction must be within the strict limits set by our specific roles.
This applies to any trained person working with adolescents. We
will always be under pressure from the adolescent to become
totally involved with them—to love them, allow ourselves to be
involved with them, hate them, reject them, or punish them. It is
up to us to remind ourselves constantly—and the adolescent as
well—that we are there to help them, teach them, support them
when in trouble, or whatever our particular role in their life may
be, but that we cannot fulfil all their other needs.
* **
In discussing the problems arising from work with adolescents,
we have shown some of the processes at work in the mind of the
adolescent which go towards determining how he will react to the
56 M A U R I C E H . F R I E D M A N & M. EGL£ LAUFER
worker. We have also tried to show how, if we learn to understand

these particular processes, much of the adolescent's behaviour
makes sense. We have discussed how the feelings that the adoles
cent can arouse in the worker can become a hindrance in one's
work, but that if we can recognize and understand our own feel
ings as well as those of the adolescent, we can be much more
effective (and less vulnerable) in our roles.
CHAPTER FIVE
The problem of helping

in relation to developmental
breakdown in adolescence
Peter Wilson
I recently met with some teachers working in a special unit

for disruptive pupils. We were trying to think of ways of help
ing one particular 15-year-old boy, who was causing concern.
This boy, whom I shall call Eddie, had been suspended from his
secondary school because of his violent behaviour. He had beaten
up a number of boys, and things had come to a head when he had
attacked the Deputy Head. His attendance at school had been
erratic, and his academic achievements were well below his poten
tial.
Eddie's background was suitably appalling. His mother was a
drug addict and had been involved in various criminal activities.
His father had left his mother when Eddie was a small child; Eddie
had no contact with him. He had one brother, who was living in a
children's home. His mother had had numerous men friends and
was also a member of a lesbian group. It is probable that Eddie
had witnessed all manner of adult sexual and violent activities.
His early childhood had been unsettled, and he had been placed
in and out of care. At the time of the discussion, he was living in
57
58 PETER WILSON
a children's home; his mother was in prison, following a burglary

in which he and his brother were also involved.
In the unit, Eddie had made a good start. He had involved
himself in group activities and had generally been seen as a coop
erative and competent member of the unit. In discussion, some of
the staff were ready to come to his defence and support and even
admired his capacity to function so well. Unease was expressed,
however, about his increasing tendency to isolate himself and to
lose interest in the life of the group. There was an additional dis
quiet about his violence—in particular, about a recent attack he
had made on another boy, which seemed quite unpremeditated
and characterized by a disturbing quality of vindictiveness.
As we sought to understand the situation better, it became clear
how important it was for Eddie to maintain a sense of control over
what he did and how he related to others. It was also noticeable
that he needed to preserve a certain kind of sophisticated self
sufficiency; although he was often seen as quite charming and
engaging, his relationships tended to be superficial and short
lived. He liked to keep himself to himself—distant and competitive
for control with boys, and off-hand and slightly denigrating to
girls. A further important feature that stood out was the way in
which he seemed to make an implicit demand that others admire
him and comply with his wishes. We noticed that, whenever this
demand was not met, whether it be in some argument with the
other boys or a disagreement with the teacher, he tended to with
draw and linger over whatever the altercation in a grudging and
surly way. The boy whom Eddie had beaten up had apparently
done no more than interrupt a story that Eddie had been telling.
What had been ominous was the intensity of Eddie's fury and the
extent to which he wanted to prolong the fight. It should be added,
however, that following the incident Eddie had put himself out to
be cooperative with the boy.
One of the teachers commented on his own increasing appre
hension and disappointment in relation to Eddie. The teacher had
initially responded to Eddie's charm, being chummy, going along
with Eddie on his terms. Following Eddie's continuing violence
and increasing disinclination to involve himself in work and
activities, the teacher had become disaffected with this approach.
HELPING AND DEVELOPMENTAL BREAKDOWN 59
In consequence, he had decided to take a less accommodating

attitude and had set himself in a more uncompromising role as
teacher, taking a firmer stand about the boy's behaviour and
work. Eddie clearly did not like this: he was noticeably surly in
his manner and the teacher became worried that he might be the
cause of Eddie's increasing lack of involvement.
At the end of the meeting we were left with some fairly funda
mental questions. What was the matter with this boy? Why did he
break out every so often in such a violent and vindictive manner?
How concerned should we be with his tendency to isolate him
self? Should the teacher maintain his policy of firmness in the belief
that only in this way could he make use of what was a fairly
positive relationship, to teach Eddie that if he were to get on in
this world, he would have to come to terms with other people's
expectations and differences? Or should every endeavour be
made to provide this boy with experiences in which he could
achieve and assume some sense of control, drawing upon himself
the approval and admiration that he seemed to need? Should the
teacher's attitude, in effect, be less challenging and more affirm
ative? Or, again, should a policy be adopted whereby a combina
tion of these approaches be tried—organized by some kind of more
detailed behavioural analysis, if need be? Finally, should someone,
in the unit or elsewhere, be asked to see Eddie individually and to
address himself to Eddie's concerns and worries about himself, his
mother, and his relationships in general? If that kind of psycho
therapeutic help were offered to the boy, would he accept it—and,
anyway, where would it be found?
There were no clear answers at the end of this meeting; nor am
I about to reveal them here. My purpose in sharing this discussion
is simply to highlight some of the issues that arise when faced with
an adolescent whose behaviour becomes increasingly problematic
and whose general mood and level of relatedness suggests a dis
turbance of some sort that requires attention. There was no doubt
at all that the educational provisions within this particular disrup
tive unit were of considerable value to Eddie. He clearly felt less
threatened in a small group setting, and he was able to respond
positively to the more individual attention of the teachers and the
controls set by them. He attended the unit every day, his learning
60 PETER WILSON
improved, and to some extent he seemed more settled. The fact

remained, however, that his violence continued to erupt and
threaten, and his ability to sustain relationships remained im
paired.
It could be said that the teachers had done their job. They
had provided him with a satisfying educational experience and
had enabled him to get along more adequately. They themselves,
however, were not content with their intervention. Their concern
extended beyond the immediate: they were left with doubts about
this boy's future capacity to hold down a job without entering into
violent confrontations with the boss or with workmates and to deal
with the demands and frustrations of family life. They were, in
other words, seeing the limitations of their efforts as educational
ists in preparing this boy for future life. They shared a general
disquiet that no matter what approach they adopted in their every
day handling of Eddie, they would fall short of reaching the core of
his difficulties. As one of the teachers put it: "There is something
wrong inside."
This, I felt, was not a conclusion of despair but, rather, an
important and constructive recognition of the magnitude of this
boy's disturbance. The teachers were honest enough to face the
limits of their intervention and to be clear about the extent of the
aims that they had set for their own work. They chose not to deny
the severity of this boy's suffering—no matter how concealed it
might seem or how offensively the boy might at times present
himself. With this important recognition, they were thus able to
adapt their approach to Eddie in a slightly more understanding
and appropriate way—and they were ready to look beyond what
they themselves could provide for some extra kind of help that
could address itself to the more fundamental difficulties in Eddie.
Theirs was a position of honesty and humility, which I believe all of
us, no matter how elevated our status might be or how committed
we might be to our method of working, should aspire to if we are
genuinely to seek to improve our ways of helping adolescents in
difficulty.
The question remained: what further help could be provided
for Eddie? What would be the optimum intervention in relation to
something wrong inside? Before any satisfactory answer could be
found, it seemed necessary to understand what exactly needed to

be helped. Some attempt at a formulation of what lay beneath his
disturbing behaviour was required in order to ascertain what sort
of help he needed.
What I would like to offer, then, at this point, is some construc
tion to the picture presented, based on the information given, and
some further knowledge of the history, and drawn from a psycho
analytic understanding of the adolescent process.
To begin with, I saw Eddie's adolescence as already under
mined by the adverse circumstances of his childhood. Eddie
entered adolescence with considerable unresolved and conflictual
emotions and with coping mechanisms that, though effective in
childhood, proved inadequate to deal with the pressures and tasks
of adolescence. In brief, Eddie's childhood had been characterized
by recurrent disappointment and fear. He had not lacked affection
from his mother; but he had been subjected to unpredictable
mothering, alternating between sheer abandonment and probably
over-stimulating intimacy. His loving impulses and infantile
yearnings had met with repeated frustration, leaving him with
intense hostilities that had had to be held in or cut off. He had been
overly exposed to adult sexuality, which must have been experi
enced by him, as a child, as dangerous and frightening. Addition
ally his perception of sexual roles had been confusing—with men
seen as frightening and women as alternately attacking and seduc
tive and excluding of men.
Somehow as a child he had managed to survive and cope with
these experiences. The advent of puberty, however, had an unset
tling effect. The intensification of his sexual and aggressive feelings
at that time activated and reawakened feelings of love and hate, in
particular towards his mother and more generally towards other
caring adults. These feelings were experienced, as by all young
adolescents, as potentially overwhelming. At some level, he found
himself feeling helpless, bad, and frightened, especially by the
intensity of his fury and by the threat of loss of control. His view
of himself as a man was uncomfortably based on new and intense
body sensations and bewildering sexual fantasies, and fashioned
around confusing images of what men and women did. Faced with
the confusion of these new pubertal developments and addition
62 PETER WILSON
ally with the growing awareness of his own separateness (exacer

bated by the fact of his being in care, with tenuous contact with his
family), there was a part of him that sought to regain some past
experience of being cared for and protected. This conflicted, how
ever, with another part of him that had learnt to be mistrustful of
dependency and frightened by the feelings that it evoked. To avoid
this, he attempted to fall back, as he had no doubt done earlier,
on a kind of reliance on himself, a determined self-sufficiency in
which feelings of any sort were denied and pushed out of con
sciousness. His observed endeavour to establish a position of
control over himself and over others, through implicitly demand
ing their admiration and complicity, represented an attempt to
regain a sense of omnipotent power and safety in which he could
feel invulnerable as well as to safeguard against the arousal of
sexual and aggressive feelings.
If this account seems complicated, it is meant to be. It is given
as an attempt to understand the nature of this boy's underlying
internal experience and to draw attention to the complexity of the
adolescent process. It highlights the pervasive influence of child
hood experience, the impact of puberty on the quality and mixture
of sexual and aggressive feelings, and the internal attempts to
maintain equilibrium and achieve integrity. For Eddie, the adoles
cent experience was particularly confusing and overwhelming.
His solutions to finding a way forward were not proving effective.
The threat to him of closeness led him to withdraw and to hold on
to a level of self-control that was impossible to sustain, leading to
outbursts of violence. These outbursts, in my view, contained a
powerful sexual element, drawn from sadistic excitements and
fantasies aroused and uncontained within his earlier maternal
environment and subsequently beyond his control in adolescence.
It is in this sense that I would describe him as being in a state of
adolescent breakdown. His violent breakthroughs were specific
instances of his defensive breakdowns. His retreat into self-insula
tion constituted a serious interference in the normal adolescent
momentum towards experimentation and involvement. He could
not be described as an adolescent who was developing confidence
in his freedom to use his body or express his feelings in relation to
others.
If this viewpoint of Eddie's adolescent disturbance is in some

measure accurate, then the meaning of what would constitute the
most appropriate help becomes clearer. What was primarily in
need of attention was Eddie's internal situation of deadlock and
disequilibrium. If this could be reached in some way and dealt
with, then significant progress could be made in healing the break
that was causing interference in Eddie's development towards a
satisfying and successful adulthood. Ultimately, the efficacy of
help has to be measured with reference to this developmental
point of view.
This, of course, may seem an impossible—almost Utopian—
position to take. It will be argued that there are simply not enough
resources to engage with adolescent problems at this level; and
that, in any case, there are innumerable resistances on the part of
adolescent, parent, and adult alike to permit such a focus. Never
theless we should think of our helping intervention in reference to
how far we are acknowledging and attempting to respond to the
extent of this kind of breakdown in adolescence. It may well be
that some of our efforts will fall far short of this ideal. It is not my
intention to devalue or dismiss the wide range of activities that
take place in the broad endeavour to help adolescents. The per
spective on the general task of helping, as I have tried to make
clear, however, should not be abandoned. Just as the teachers in
the disruptive unit had evaluated the value and the limits of their
work, so should we all be prepared to consider the gains and the
limitations of our own interventions.
Returning to the perplexing problem of how to help Eddie, it
would seem that if we were to follow the line of argument I have
been putting forward and attempt to relate as relevantly as pos
sible to the core of Eddie's adolescent breakdown, we would first
have to consider the possibility of offering him psychoanalysis. For
the moment I am not concerned with the feasibility of this possi
bility but, rather, with its theoretical relevance. It is my belief that
psychoanalysis would constitute the most comprehensive and in
tensive endeavour to enable Eddie to reach back to past experience
and to give him the opportunity of re-experiencing it, understand
ing it, and finding alternative solutions and adaptations to the
painful and conflictual feelings he had harboured within him—
64 PETER WILSON
with a view to negotiating his adolescence more adequately and

finding a pathway towards a more confident sense of himself as an
adult.
I will briefly explain what I mean by psychoanalysis, so as
to dispel some of the myth and confusion that surrounds this
activity. What would happen is that Eddie would see a psychoana
lyst four or five times a week, talking and reflecting on his current
and past life and developing an increasingly close and dependent
relationship with the analyst. The very dependency and closeness
of the relationship would evoke strong feelings that up to this
point, I believe, he had effectively blocked out of his mind; and it
would lead him gradually to perceive and experience the analyst
in a variety of ways, coloured largely by his earlier experiences of
caring people upon whom he had depended in his childhood—not
least, his mother. The analyst would come to be experienced as the
loving or depriving, attacking or seductive mother that he had
known as a child; or possibly, at times, as the indifferent or men
acing father. The point is that what would be recreated in the
analytic situation would be a close replication of Eddie's child
hood experience. In this way the origin of Eddie's current adoles
cent feelings could be explored and the intensity of his passionate
hatreds and yearnings could actually be felt and understood with
reference to his difficulties and avoidances in his ongoing life.
The analytic, therapeutic contribution in relation to all of this
would be first of all to provide containment and, in some measure,
gratification of this boy's unfulfilled need to be held and cared for.
The analyst would also exist to survive the boy's demands and
hatreds, and to help him gradually to go over and understand
what he was frightened of and how he was contriving to protect
himself from his own violence or from what he anticipated as
hostile and overwhelming from other people. The ultimate aim
would be to help Eddie know himself better and to be less bewil
dered and thrown by the intensity of his feelings. This analytic
work would be in the interests of equipping Eddie with a surer
sense of control over himself and a better integration of the diverse
feelings that had earlier led him to avoid close relationships.
This, needless to say, would be no easy task—either for Eddie
or for the analyst. The question is whether or not this model of
HELPiNG AND DEVELOPMENTAL BREAKDOWN 65
approach—a model originally developed in relation to the adult—

could be adequately and appropriately applied to Eddie's ado
lescent personality. How far would his cultural background and
general level of psychological sophistication ever permit him to
entertain the idea of such an experience? More importantly, how
far would he be prepared to let himself go in order to achieve the
degree of closeness and dependency necessary in the analytic rela
tionship? As I have described, the frightened part of Eddie that
sought to be cared for and to find refuge from the confusion and
anxiety of his early adolescent/pubertal experience conflicted
strongly with his mistrust and fear of any kind of dependency or
exposure of vulnerability. For him, this would constitute a major
objection to analysis. It would be an objection specific to his own
defended personality and of general significance with respect to
his early adolescent status.
Most adolescents of his age would struggle and fight against
the analyst in one way or another and in effect say: "You'll never
get the measure of me." The analyst would inevitably represent
a threat to the adolescent's develop mentally active striving for
autonomy and independence. Moreover, the revival of past feel
ings for the parents, intensified and currently experienced in the
present, would add to the overall strain of the analytic experience;
essentially, it would run counter to the more progressive trends
within the adolescent, which urge him to leave the past behind
and find new experiences beyond the realm of the family. The
danger could be that the adolescent's understandable resistances
to the reactivation of powerful childhood feelings disrupt and
obscure the whole helping purpose of the analysis.
In Eddie's case, it is not unlikely either that he would simply
not be able to tolerate the exposure of his feelings activated within
the inherent dependency of the analytic relationship, and so break
off the analysis prematurely, or that he would come under the
influence of such intense feelings of hatred and persecution in
relation to the analyst that he would lose sight of the analyst as a
helping person. I can only guess at what might emerge in Eddie's
analysis if it were ever to get under way. I would imagine, how
ever, taking into account the circumstances that we know of his
childhood, that at some point he would begin to experience the
66 PETER WILSON
analyst as humiliating, menacing, and potentially neglectful, and

his own feelings would be dominated by rage and the wish to
attack and destroy. In this situation, the analytic interpretations
would probably be heard not as clarifying or facilitating, but,
rather, as denigrating and as attacks on his self-esteem and sense
of control. There would then arise intense unease over the ques
tion of whether Eddie could contain his violence and control the
impulse to act out and attack the analyst.
I do not believe I have let myself become too melodramatic in
drawing this possible course of events. Psychoanalysis might be
the most relevant form of help in relation to Eddie's difficulties,
but it would equally be most difficult and treacherous. In view of
the difficulties I have outlined—his questionable motivation, his
fear of dependency as an individual and as a young adolescent,
his precarious capacity to tolerate painful feelings or control his
impulses—we might well decide to abandon the whole idea of
psychoanalysis. Instead, we might still seek to attempt to relate to
him on an individual basis while respecting the underlying anxi
ety and suffering with which we believed he was having to cope.
Our aim, however, would be less ambitious, and we would seek to
modify our approach to take account of his need to retain some
degree of distance and self-composure.
This second approach would be through individual psycho
therapy—his being seen once or perhaps twice a week. Tensions
such as those I described that might disrupt psychoanalysis would,
of course, also threaten to complicate this less intensive experience.
These tensions would not, however, be exacerbated by the insist
ence of the analysis. They would be recognized, but they would not
be allowed by the psychotherapist to develop to the same extent. It
is not possible here to give an account of the variety of therapeutic
strategies that might be adopted in individual psychotherapy. The
range of approaches is wide, approximating at one end of the
spectrum an analytic stance that is close to the one I described with
an exploratory and interpretative emphasis and, towards the other
end of the spectrum, a more active approach, with the psychothera
pist offering himself as a source of support and identification and
contributing additional elements of clarification, encouragement,
and so forth.
Whichever approach is taken, the most important feature is

that the therapeutic attitude takes account of the adolescent's (par
ticularly the young adolescent's) need for privacy and his inherent
difficulty in acknowledging his new and diffusely experienced
feelings and in comprehending the tensions within himself and the
state of his emerging self. Clearly, this less intensive form of psy
chotherapy would set a limit to the thoroughness of the work
being carried out. Nevertheless, returning to the case of Eddie, I
believe that he would be better able to tolerate this level of rela
tionship and be prepared to cooperate with it and make use of it,
both as a valuable support and as a source of insight. I think he
could be helped slowly to acknowledge something of the feelings
with which he was coping, to see more clearly the ways he handles
himself in relation to others, and hopefully to reach a position
of anticipating those moments of uncontrolled fury that lead him
into trouble and bring such shame upon himself. In an analysis, an
attempt would be made to take him through, experientially, the
source of his pain and fear; in psychotherapy, on the other hand,
he might hopefully be enabled to see his vulnerability better and
to keep it in its place, as it were.
Let me quote one adolescent who, after a brief course of psy
chotherapy, reflected on the discovery and understanding he had
reached in talking for the first time about his strong and confusing
feelings in relation to himself, his parents, and his presenting psy
chosomatic complaint. He said simply, "I know those feelings are
still there, but I know now how they work! I know what they are
and can accept them a bit better. I can see them coming—and I can
do something about them now. My body doesn't have to protest
against them so much."
Up to this point I have only considered the possibilities of
individual help for Eddie. This is primarily because of my concern
that attention be paid to the adolescent in his own right, with his
own private struggles and dilemmas. I am aware, of course, of the
contribution of family and group therapies and, indeed, of behav
iour therapy, but I cannot give adequate consideration to their
role and function in the field of helping adolescents. Suffice it to
say that I see their value primarily in terms of engaging the ado
lescent, alerting families and others to their contribution to the
68 PETER WILSON
adolescent's difficulties, clarifying interactions, and setting some

kind of order to the management of crises and difficulties pre
sented by adolescents in their family and school lives. I do not see
them as engaging with the process of internal adolescent break
down, which I consider to be the ultimate criterion for helping.
This is not intended as a devaluation of their contribution, but,
rather, as an indication and recognition of the limits of their range.
Eddie could undoubtedly benefit from group work—as indeed
was shown in some of the work carried out in the disruptive unit.
Insofar as he, as a young adolescent, was learning from peer group
experience, group work as therapy could mobilize this and enable
him to gain an understanding of himself in identification with
and in response to the feelings expressed by others. Eddie's style
was, however, to keep himself to himself, to hide his vulnerabili
ties, and to cope by insisting in subtle ways on preserving an air of
control, of superiority. There would, I think, be an inevitable limit
to how far he would allow the group experience to touch him
beyond that defensive position.
With regard to family therapy, I do not think that many family
therapists would regard Eddie's case as a suitable one for their
approach, if for no other reason than that he does not have a
cohesive and functioning family. However, there is no doubt that
the response of the family to the adolescent's—in particular the
young adolescent's—emerging sexuality and strength and his de
velopmental task of establishing autonomy is of considerable im
portance. In many respects, the impact of the adolescent on other
members of the family can be equated to the impact of puberty on
the adolescent himself. Strong unresolved feelings, wishes, and
attitudes in relation to sexuality, aggression, and separateness are
invariably aroused in the parents of adolescents, and their often
unconscious counter-response can constitute a formidable external
force—facilitating, distorting, or opposing the adolescent's move
towards growth and independence. The complexity of the young
adolescent's internal life is matched by the subtleties of collusive
and coercive arrangements between him and his family.
With this fully recognized, it is clear that help for the adoles
cent should include help for his family. This often gains additional
urgency in view of the quality of the crisis that many adolescent
problems create, such as attempted suicide, persistent non-attend
ance at school, worrying withdrawal and depression, refusal to

eat, violent behaviour, and so on. There often arises a certain kind
of imperative on helping professionals to find ways of unlocking
an impasse in a family or of facilitating some pathway by means of
which family and adolescent can live more agreeably with each
other, at least for the time being.
It is in this context that I see the value of family therapy—or
perhaps, more accurately, the value of recognizing the significance
of family interactions. Whatever theoretical standpoint is taken
and or whatever technique is used, there is often an important
therapeutic task in intervening on behalf of the adolescent to create
more favourable conditions within the family to allow for the ado
lescent's independence and creativity. In those cases in which I
have achieved some degree of successful family intervention, the
single most important therapeutic achievement has been in work
ing towards enabling the parents to take ownership of their own
anxieties about sexuality, anger, or loneliness, and to contain their
own unresolved resentment and guilt about their destructiveness.
This has invariably had the effect of relieving the adolescents of
their parents' difficulties and of enabling the parents either to be
more straight in their dealings with their adolescents or to be more
tolerant of their adolescents' differences.
Having said this, however, I am left with a fundamental
doubt—not unlike the teacher whom I mentioned earlier in this
chapter—as to how far I have reached the internalized disturbance
within the adolescent himself—a disturbance built not only on
current altercations and confusions within the family but on past
experiences that have established deep impressions within the
child, which in adolescence have been reactivated and continue to
exist separately from his ongoing actual life. I am forced to admit
that in thinking about my family interviews, the adolescent him
self has too often been left out; he has hidden himself, too ashamed
or afraid of his sexual and hostile feelings in relation to his parents,
or afraid of what his parents' responses might be if he were to
express his views. Thus, although I may find, if I am lucky, that in
having some effect on the family process I have facilitated some
greater freedom for more adequate functioning on the part of
the adolescent and within the family, I am left concerned about the
foundations of the adolescent breakdown and the persistence of
70 PETER WILSON
this in future life. It is in this respect that I would have to evaluate

the effectiveness of the help I had given the adolescent himself.
Returning to Eddie, if an attempt were made to hold a series of
family interviews with a view to re-establishing contact between
mother, brother, and Eddie, there might be some value in enabling
each member of the family to recognize feelings engendered in
each other and to gain some empathy or awareness of each other's
difficulties. This might have a reassuring effect on Eddie in help
ing him deal with his sense of abandonment, but, I think, such an
attempt would clearly also have its limitations. Eddie's long
standing ambivalence towards his mother and brother I would see
now as internalized and not'open to change through improving
family communications. I would suspect, too, that in family inter
views he would keep to himself certain feelings that he might
think would offend or distress his mother.
* **
In conclusion, what I think I have been conducting is a kind of
diagnostic conference with myself. I have taken Eddie as a not
untypical, disturbing adolescent problem. I have listed his present
ing difficulties; I have noted the ways in which he had been helped,
I have looked at and attempted to formulate the underlying distur
bance and then considered some of the possible ways of helping
him. I am aware, of course, that I have not given due consideration
to all the possible ways of helping Eddie; I have not mentioned, for
example, chemotherapy or behaviour therapy. I do not know how
effective such approaches might be in this case. However, I would
see their attempts at either suppressing anxiety or changing overt
behaviour as relating to the crisis rather than as engaging with
Eddie's intrinsic problem. The point that I have tried to make is
that, if we are to offer substantial help to an adolescent like Eddie,
we have to recognize first the extent of the internal breakdown
in his adolescent development. If this can be acknowledged, then
we are at the beginning of measuring the relevance and the effec
tiveness of our methods of helping. A central dilemma revolves
around the problem of the urgency of dealing with adolescent
crises and the issue of looking beyond the crisis, towards a way of
engaging with the underlying cause of the problem. A major diffi
culty, it seems to me, for the helper in this field is in facing and
understanding the extent of the adolescent problem; in acknowl

edging and learning from the limits of our knowledge and in
terventions; and in taking the risk of sharing the anxiety of the
disturbed adolescent.
It has to be accepted that whatever we do at this point in
Eddie's development, there will be a limit to how far we can re
verse the damage that has already been done in his life. Our
knowledge is simply not ajd^quate at present to understand fully
the nature of his disturbance or how best to help him. What is
important, however, is to> guard against the feeling that there
is nothing we can do, or tideny his disturbance and pretend that
he will somehow grow out of it, or to hope that a better environ
ment somewhere will make all the difference. As far as Eddie is
concerned, my recommendation at this point would be actively to
support the staff of the disruptive unit he attends and to offer
individual psychotherapy, with a view to helping both Eddie and
the psychotherapist to understand his problems better.
PART TWO
PROCEEDINGS OF CONFERENCE
O N "ADOLESCENT B R E A K D O W N
A N D BEYOND"
CHAPTER SIX
Defining breakdown
Moses Laufer
T
he concern with adolescent breakdown, the central theme
of this book, must certainly be shared by anybody who has
contact with the troubled adolescent. Those of us who
work with the adolescent—whether at school, at a youth club, in
the doctor's surgery, or in an institution—are certainly aware of
how vital our relationship to the adolescent may be. But, in spite of
this, we are also prone to finding ways of explaining away the
presence of serious signs of existing or impending trouble, with
the hope that the adolescent will grow out of it, or with the belief
that it might be more constructive to let things be rather than to
create a crisis. At the same time, we all know that mental break
down, and certainly mental illness, is a dreadful human tragedy
that frightens all of us. But our present knowledge of the mind
does enable us to say that many severe mental disorders and
breakdowns can be prevented if we act early enough and if that
Chair: D R C . DONOVAN
75
76 MOSES LAUFER
action is based on the belief that mental breakdown does not come
from out of the blue, but that it has a very specific meaning in the
person's life.
At the same time, it is becoming clearer that the period of
adolescence—that is, the time from the age of about 13 to 20 or
21—may be a last chance to stand in the way of crippling mental
disorder. And it is in this context that I want to define and discuss
"adolescent breakdown"—the process that results in the adoles
cent's development to adulthood being distorted by a mental
break with the world, that is, mental creations taking over from
what is actually going on in the real world.
We know, from observation and from our own experience in
growing up, that the period of adolescence is, at best, stressful and
at times frightening. The physical maturity of the body means that
the male adolescent can father a child and the female adolescent
can grow a child in her body. This essential fact must never be
denied, however much the adolescent may try to believe that he is
only a big child or that his behaviour or mood has nothing to do
with what is going on within himself but is due instead to external
stresses that will soon go away. So when an adolescent tells us that
she hit her mother because her mother insulted her, we should
listen carefully to what this is about; we must not hear the adoles
cent's explanations as being sufficient to define what it was that
enabled this adolescent to attack the parent physically, however
sympathetic we may feel towards the adolescent and the provoca
tion coming from a parent.
Nor should we try to find acceptable explanations for why a 13
or 14-year-old girl becomes pregnant, and for us to believe that her
loneliness or her fear of losing the young man whom she desper
ately wants, or the choice of pregnancy rather than suicide, should
be heard as an explanation of what is going on in the mental world
of the adolescent. We may want to find logical reasons for the
behaviour of those adolescents who hate themselves, or who feel
alone and worthless, or who want to die rather than live a lonely
and sad life, but we must think further and consider certain behav
iour as a signal of the presence of severe disorder, both now and in
the future. It might be appropriate to add here that mental break
down never (at least in my experience) comes from out of the blue;
DEFINING BREAKDOWN 77
it always has a history in the mental life of that adolescent, visually

heralded by warning signs—even if we do not notice them.
"Breakdown" in adolescence has a very specific meaning, and
one that must always be taken seriously. It means that the adoles
cent who attempts suicide, or chooses to rely on drugs to change
his mental life, or feels compelled to attack people physically, or
threatens and beats up people at school, has lost touch with his
own mental life and is responding to creations from his own mind
(which also contain a hatred of himself and his own body). There
is an enormous pressure from people at work or at school or
among friends to accept certain behaviour as the norm, but this is
a norm that contains the seeds of the adolescent's self-destruction.
It is also a sign of the adolescent's despair and internal aloneness,
often with the accompanying feelings of being sexually abnormal
or a sexual and social failure.
Many adolescents convey this, whether or not they are con
scious of their despair and their aloneness. When they come to us
for help, or when they are able to show their despair, it is essential
that we take this seriously and that we do not dismiss their efforts
to communicate with us as an excuse, a fiddle, a way of fooling,
or a sign of their delinquency. Often it is a desperate plea for
help.
* **
But having said this, it still leaves unaddressed the vital question
of how it is possible to define the difference between the stress, or
despair, or hopelessness that are part of normal development on
the one hand, and similar reactions that are signs of "breakdown"
on the other. When I refer to "breakdown"—as defined in chapter
one—I have in mind the breakdown of a process of development, not
something akin to a "nervous breakdown", which conjures up a
picture of a collapse of the nerves and which, as a phrase, has its
roots in the early psychiatric assumptions of mental disorder, with
the idea of tension felt in the nerves or, at worst, where damage to
or disintegration of the nerves was believed to be a primary con
tributing factor to mental disorder, with little, if any, status being
given to the role of psychological conflict or to the part played by
the mental creations or fantasies of the person.
78 MOSES LAUFER
In development that is proceeding normally, a number of char

acteristics that enable the adolescent to feel mentally not alone may
be evident:
1. The adolescent may feel that he has ways of being valued and
admired without having to remain totally dependent on his
parents.
2. Even though he may feel guilty or ashamed of some of his
private thoughts and of feelings coming from his body, he can
still enjoy the pleasure from these thoughts and feelings, and he
can seek relationships that help him to remain in touch with
these feelings.
3. Even though there are times when he may have thoughts that
shame him and worry him (because of their connection to ideas
of abnormality and because of his awareness that some of these
thoughts appear during masturbation), he is also aware (not
consciously, of course) that these thoughts will not ultimately
overwhelm him.
4. However much despair or hopelessness he may feel, he is also
aware that he can rely on admiration from his own conscience
to help him restore a feeling of self-respect.
5. Finally, I would like to add another characteristic—one that is
critical because it takes into account the view held by the ado
lescent about himself as a man or woman, husband or wife,
father or mother—that in spite of the feelings of emptiness and
the anxiety experienced in the process of becoming less depend
ent on the parents of one's childhood, there is sufficient inner
love for oneself carried on from childhood to enable one to look
forward to thefuture—and to a future that perpetuates that which
is felt to be good in oneself and good in the parents of one's past.
It means that, without being conscious of it, the adolescent who
is developing normally can look forward to the future as a time
when he can make amends for his own private hatreds and his
own disappointments, and a time when he can have the inner
freedom to allow himself to forgive the parents of the past who
inevitably had had to let him down in some way.
* **
But there are those adolescents who experience something quite

different, and for whom the period of adolescence is primarily a
time of private torment. It is these adolescents who "break down"
and who soon feel and know that they are unable to leave this
torment behind. And for those of us who may be in a special
position of helping these adolescents at a critical time in their
lives, we must not forget that these adolescents can only go as far as
finding respite from themselves, but with their development being
seriously distorted. They feel unable to restore their self-respect
and are never free of thoughts and feelings that convince them
of their abnormality. Ultimately, the war experienced by the ado
lescent always includes the sexually mature body as one of the
primary enemies or as one of the main sources of the feelings of
abnormality, or of madness, or of worthlessness. No matter what
they do, these adolescents are haunted by self-denigration or a
feeling of being abnormal and often feel convinced that the
creations of their minds are true. They may feel convinced that
people hate them, and they will then try to destroy or harm those
who are experienced as being responsible for this persecution.
The adolescent is, of course, not aware that he is reacting to his
own mental creations. At that moment of despair or worthlessness
he believes his experiences to be real, he does not doubt, and he
remains convinced that he is surrounded by enemies, by critics,
and by those who will mock him. He feels that he must not capitu
late to his body because if he does, it will take over his life and
make him irreversibly mad, abnormal, and hated by those around
him. But in all this the adolescent feels that he cannot reverse this p
cess, that he is being overpowered by an enemy that resides within
over which he no longer has control His mind and his body are now
enemy.
He may not be in touch with the extent of his vulnerability to
self-attack, to suicide, to severe depression, to attacking others
who, he feels, are mocking him, and to a range of other behaviours
whose primary function is to silence the enemy who is with him
day and night. These adolescents are in urgent need of help, and
we, as those who try to offer such help, have a critical contribution
to make to them.
So it is obvious that when I refer to "adolescent breakdown", I
have something very specific in mind: a breakdown in develop
80 MOSES LAUFER
ment, which results in the rejection by the adolescent of his sexual

body. The result is that one's genitals are ignored or disowned or,
worse still, the feeling that the genitals are different from what one
wanted them to be. It is a breakdown in the process of integrating
the mature body image into the mental picture of oneself.
The breakdown in development takes place at puberty, and its
timing is tied directly to the adolescent's reaction to the sexual
maturation of his body. The consequences of this breakdown will
vary enormously—from withdrawal and isolation, to the wish
not to go on living, to the belief that destroying one's physically
mature body will answer the problems, or to the move to a break
with the world and a consequent psychotic organization.
This must never be considered to be a transitory crisis; it must,
instead, be understood as a serious outcome of the adolescent's
response to the body that he hates or wants to be rid of.
* *#
I would like to tell you something about two adolescents whom I

came to know at our Centre, and in whom, I think, a breakdown
took place following puberty.
The first I heard of "Molly" was when she came into the Centre
late one afternoon, having been advised by one of her teachers
to come along to us. Molly had begun to miss days at school—
something unusual for her—and her class teacher, who had
asked Molly whether she could help, was confronted with a
crying girl who said that she was worried about her mother
and did not really want to leave her alone at home. Although
the teacher had known of our Centre, she was rightly very
cautious in suggesting that Molly come to us. Instead, she
offered to meet with Molly one afternoon after school, with the
hope of helping. But when she learned from Molly that she did
not really want to go on living, she encouraged her to come to
us and even offered to come along with her, if this would help.
Molly said that she would be able to get to the Centre on her
own, but when she talked to me about this a short time later,
it was clear that the teacher's concern and readiness to help,
without being intrusive, meant a great deal to Molly and was
of critical help in enabling her to get to the Centre.
Molly started telling me that she nearly did not come to the
Centre, because she felt I might talk to the teacher about her
and she did not want anybody to know why she had thought
of killing herself. She had been worried about her mother, who
had often talked of being fed up with life, but the reason for
her missing days at school was, she felt, not because of her
mother. She had been a very close friend of another girl attend
ing the same school. They had behaved "like sisters", meaning
that they were very committed to each other. Molly, who was
now aged 15, suddenly felt abandoned when her friend be
came somewhat distant after she met a boy and now wanted
to spend her time with him rather than with Molly. Molly not
only felt alone and abandoned, but she had never told anyone
that she loved this friend; she had recently begun to have
"secret" thoughts of loving this friend and of not really want
ing any other person to be close to her. She suddenly felt that
there was no purpose in going on living if this friend did not
need her any longer. But she became very frightened when, in
the kitchen at home, she found herself holding a knife and
wondering whether she should stab herself through her heart,
and for a fleeting moment thinking that the love for her friend
was in her heart, so she could kill this love and perhaps kill her
friend as well by stabbing herself.
This early intervention by her teacher in enabling Molly to
come to the Centre was critical. She felt very grateful to this
teacher for not asking too many questions and not being made
to feel that she would have to talk about things that frightened
and shamed her, but at the same time she felt cared for and
valued by her teacher for taking such an interest in her "with
out me having to tell her my secrets". I myself feel that this
initial contact of Molly's with her teacher, and the teacher's
careful and discreet way of responding to Molly, helped to
save her emotional life and perhaps also her actual life. Follow
ing my initial contact with Molly, we were able to meet regu
larly over a period of nearly three months, after which she
agreed to accept my suggestion that she should have regular
help with a member of the Centre's treatment staff.
The crisis is far from over for Molly, but a process has begun
82 MOSES LAUFER
where she is not only no longer alone with this need to want to
kill or damage herself or to revenge herself on this special
friend who chose to love a boy, but where she can begin to
make sense of the meaning of her love for her friend and of her
own readiness to what she described as "giving over" her life
to her best friend.
***
The situation was quite different with "Jim", a 19-year-old
young man who was already in much more serious trouble
mentally when he first came to the Centre. Jim's parents had
separated when he was aged 7, and he was now living with his
mother and stepfather. His father lived in another city, and Jim
talked with him on the telephone each week but had in fact not
seen his father for over a year. The present fury from Jim was
concentrated on the stepfather, whom Jim described as a bully
because he teased and denigrated Jim; Jim was too frightened
to tell him to "shut up".
According to Jim, the crisis in his life had become acute about
eight months earlier, when he suddenly found himself unable
to leave his house. He gave up his job as a helper in a large
food shop, having previously withdrawn from college because
he could not be near people and could not tell anyone about
this; as he said, "I couldn't tell anybody because I didn't know
myself what was going on. I only knew that I felt better staying
in the house". Although his stepfather mocked and teased him,
his mother had not yet "given up" on him and had pleaded
with him to do something about himself. With Jim's agreement
his mother telephoned the family doctor, who spoke to Jim on
the telephone and encouraged him to come to his surgery.
After seeing Jim at his surgery, the family doctor telephoned
the Centre (without Jim's prior agreement) and spoke of his
concern and his uncertainty about what to do. It was clear from
what the doctor said that Jim was in serious trouble, and the
doctor was encouraged to get Jim to come to us, but also to tell
him that he had contacted us because of his wish to help.
The interviewer who saw Jim was very concerned by what he
heard and saw. Jim could barely speak, and he cried when he
talked of his parents and the feeling that he had lost his father.
Although this made him very sad, his worry was now more
to do with his feeling of helplessness in doing anything about
his fears. He had no friends, he could barely .talk to people, and
he cried silently during the night. He felt unable to use a bus
or the underground and had to walk everywhere. But when
he walked, he was frightened that he might be attacked or
laughed at, and he then had to run down the street. Often
when coming to the Centre he would arrive covered in sweat,
breathless, and feeling that he made himself "look like a stupid
idiot". One day, when he arrived at the Centre with bruises on
his face, he told the interviewer of having been beaten up by
some "idiots". Later, however, came a vague clue that there
was much more to Jim's story. It was when Jim broke down
and cried that the interviewer enabled Jim to say that the
bruises on his face were inflicted by himself—and that he "had
to" beat himself up every night before going to sleep.
This feeling of being compelled to do certain things to one's own
body always has to be taken as a sign of serious inner trouble.
This was certainly the case with Jim. His breakdown was con
tained in his need to use his body to live out fantasies of self
destruction, whilst at the same time obtaining a sexual pleasure
that was both shameful and secret. Nobody must know of this
behaviour, no other person was to be involved, and the sexual
pleasure was in the self-beating and in the secret self-humilia
tion over which Jim did not have any control.
The interviewer and those of the Centre staff who regularly
discussed Jim were now convinced that, due to the urgency of
the situation, the safest course would be for Jim to agree to
hospital admission. This was discussed with Jim, and although
he cried uncontrollably when this was suggested, he could
leave the interview by thanking the interviewer and saying that
he now felt that he could again think of living. With Jim's
permission, his mother, stepfather, and father were each seen at
the Centre, and plans for his hospital admission were agreed. I
should add that Jim was present at each of these meetings.
84 MOSES LAUFER
Treatment for him will be very difficult and very painful, but
we and he felt that it was the last chance to save his mental life
and to protect his chance for a more normal future.
* #*
In the course of the above, I have used the phrase "a last chance to
stand in the way of crippling mental disorder". Although I have
discussed the meaning of this phrase through the examples of
Molly and Jim, I would like to elaborate further why we place such
importance on what is contained in this statement.
We know that mental disorder, breakdown, and mental illness
contain the individual's past and what he has been able to make of
it. Our knowledge about the human mind no longer allows us to
accept that mental breakdown just happens. Instead, we know that
it has a very particular meaning for the individual in question.
And we are also beginning to know more about the specific con
tribution that the period of adolescence can make to the person's
life—in both constructive and destructive ways. We know that the
presence of a physically mature body makes certain emotional
demands that are critical for both health and illness. In either
health or illness, adolescence is the period when one's relationship
to oneself and to the outside world becomes fixed and irreversible
and when the development to mental health or mental illness
takes on a more fixed and predictable character with the presence
of a mature sexual body, as represented in the cases of Molly and
Jim.
I have also tried to point out the urgency, in terms of the
person's present and future life, of taking the early signs of "break
down" seriously and creating a special chance for the adolescent
to curb a pathology that, if left untouched, will certainly damage
or destroy his emotional life. There are very many adolescents
"out there" who are bewildered, frightened, and ashamed, but
who nevertheless are able to respond to help that talks to their
internal world and to their suffering.
The sense of urgency that is often present silently in our work
with the troubled adolescent arises from our knowledge that
breakdown during this period, if left free to take its own course,
can destroy the person's emotional future, with the result that
adult life becomes, at best, a compromise, which has as its purpose

fighting the unknown enemy housed in one's mind, who may
ultimately destroy one's adult life. Adolescent breakdown does
not stand still at the end of adolescence; it goes on to encompass
the person's private internal world, his social relationships, his
work, his sexual life, and his relationship to the world around him.
At best, the price is a damaged or distorted relationship to oneself
and to one's contemporaries, but often the tragic consequence of
adolescent breakdown that goes untreated is an established
mental illness, which inevitably includes a break in one's relation
ship with the world.
* **
I have talked about the adolescent, his history, and his develop
ment to mental health or breakdown or illness. But I have said
nothing yet about one other vital factor that is seldom if ever
discussed seriously—and this is the relationship that we, as those
who work with the adolescent, have to our own adolescent years.
Adolescent mental health and illness and the meaning of ado
lescent breakdown can only ring true if we, as those working with
the adolescent, are able to bring alive our own histories, our own
pains and disappointments, our own fears of madness or of sexual
abnormality, and our own ways of dealing with such problems
and the meaning of the answers we found to these problems in our
own mental development. If we are unable to use what we have
learned to help us make sense of our own adolescent lives, then
some of the things I have talked about will remain, at best, an
intellectual exercise that may not carry with it the belief that it
really has something essential to contribute to the adolescents with
whom we work.
I say this because, unless we are in touch with the meaning of
our own adolescent years and with the meaning of the answers or
the compromises we have found in dealing with those years, our
work with the troubled or the ill adolescent will lose its meaning
and will, instead, result in compromises and in minimizing the
extent of the danger that may be present in the life of the adoles
cent whom we are trying to help, where the phrase "he will grow
out of it" becomes an excuse for our own compromises and our
86 MOSES LAUFER
own disappointments. In this way, our own blind spots about our
own lives can have serious consequences on our work with the
troubled adolescent. If we do not or cannot take seriously what
the troubled or ill adolescent is trying to tell us, then we may be
missing a chance to help with a beginning or an existing break
with the world. Many adolescents seek help because they are
frightened and because they know that they have lost control of
their thoughts and actions, and that the creations of their minds
are destroying their relationships and their ability to feel that they
are in charge of their lives. If we miss the presence of serious
disorder in the life of the adolescent either because the adolescent
cannot tell us or because we must not allow ourselves to hear what
the adolescent is saying, then we will have lost a chance that may
not present itself again.
Discussion
Nicholas Temple
I want first to acknowledge the optimism and hope that is con

tained in the struggle against adolescent disturbance, because I
think that in our society there is a tendency to give up or take a
cynical or feeble view of this sort of disturbance—and Dr Laufer
has referred to this in some of his comments—that is, how we try
to find ways to avoid facing the struggle with adolescent dis
turbance. I would also like to say that we ought to put this in the
context of the whole developmental notion of human life. Fre
quently one regrets sadly, when seeing a patient in the middle
years or old age, that an opportunity in adolescence for such a
struggle of work Dr Laufer has described has been lost or has
failed. Sometimes the adolescent, at that stage in his life, has run
away from the opportunity for help, or it may have been avoided
or denied, or the circumstances prevented it from being given. I
think that this often leads to life-long difficulties that result in a
kind of compromise—a limited or restricted sort of life. I would
like to emphasize this as an important element, perhaps nmning
alongside the risk of major mental illness.
88 NICHOLAS TEMPLE
I think that there is a very important area of discussion to be

had with Dr Laufer about the actual struggle with serious mental
illness. This is another area of controversy because, as we know,
the present services for serious mental illness are very poor and
getting worse, partly because of the lack of any philosophy of
struggle of the kind that Dr Laufer describes. I very much welcome
the developmental context and the lifelong developmental needs
to be linked to that of the adolescent.
I would be interested to take up a discussion with Dr Laufer
about the extent to which the adolescent's relationship to his body
is one particular area of struggle with internal figures. He has
underlined the importance of the notion of the distortion of in
ternal figures, who may occupy the adolescent's mind completely
and identify his body as the bad thing. In my own experience,
this often seems to be a form of developmental crisis in which
the inevitable process of physical sexual and mental development
causes a conflict with internal compromises that go back a long
way. I refer also to narcissistic compromises made with internal
figures, derived from the child's experience of an object that sees
the child as partly an extension of the self—in other words, parents
having difficulty in actually seeing a child as being separate. I
think this relates to comments Dr Laufer made about how this can
be avoided. There is sometimes a wish to stamp out the true sepa
rateness of the adolescent and even the growing separateness of
the child. So often, in my own experience, one has a preface or a
warning when one looks closely at the development in the second
year of life as to what is going to happen in adolescence in a
particular family setting.
The whole nature of the family environment is vitally impor
tant in understanding this interplay and in throwing light on the
nature of what the internal world is and what the internal objects
may be. I think that the critical point that Dr Laufer has made—
and it is a great rallying call to everybody here—is the importance
of the intervention, and the importance of struggling with the real
difficulties. This implies that the role of the intervening person is a
vital part of the overall scene and not just that of a chance observer
in a terrible struggle.
Here I want to comment upon my observations, perhaps at a
distance, of the importance of the Brent Adolescent Centre in rep
resenting that much more widely in society. I feel that the nature
of this idea of a third object struggling with the internal conflict
and how it is acted out does sometimes need institutional support
and recognition, and I think that this is what the Centre has a great
record in doing. One has to contrast that with a collapsing service
for adolescents. We can blame those collapsing services partly on
society, but we also have to acknowledge that they are sometimes
due to the failure of the conceptionalization of the internal world
in adolescent services. Dr Laufer has made important allusions to
the importance of one's own introspection, one's own personal
therapy and capacity to understand oneself, and one's experience,
particularly as an adolescent. Of course, it always brings sadness
when you think of your struggles. It certainly does to me. Also, I
think one has not spelt it out—the capacity to continue self-analy
sis with reference to one's past is so important in maintaining
this—but I would like to underline how that containment in one's
own mind has links to the capacity to work as an object in this
difficult situation. The institution is vital in maintaining that—not
only conceptionalizing it, but also representing it concretely by
something that does survive and work, and this is not emphasized
enough as a very important inspiration—an ability to maintain
this position.
I agree very much with the notion of the long history of the
breakdown. The way it is constructed and represented contains a
great deal of meaning. From my own work with the delinquent
adolescent, a crime or a delinquent act often contains in condensed
form so much of the past and so much of the essential conflict with
something of a persecutory fight with a particular object, with a
particular distorted object. Also, in family work in that context,
one sees the relationship between that internal persecutory conflict
and the actual family situation. Obviously it is distorted, but it is
there to be understood and even extends to serious mental illness,
which psychiatrists may classify as being biological in origin. I
think the question of how we know whether this is a serious situa
tion that has to be taken note of depends very much upon one's
own capacity to tune in, through the countertransference, to the
state of mind of the adolescent—although one always has to have
a respect for one's capacity to get it wrong or be led astray and to
make a terrible mistake.
90 NICHOLAS TEMPLE
Clearly Dr Laufer has described and touched upon the ways

the adolescent avoids this internal conflict or denies it. So much of
adolescent culture contains the idea that one can omnipotently
avoid the conflict and therefore not work it out—through drugs,
crime, a kind of narcissism about adolescence that implies that one
does not have to adapt to adult life, the counter-culture, the denial
of the need for adult adjustment. I think it is important to empha
size how often peculiar compromises arising from adolescence
then go on for the rest of life.
Sometimes it is interesting to see, in the analysis of an older
patient, how such a sort of compromise comes apart or has come
apart in later life. I am very struck by the tendency of decades to
present an echo of adolescence. My thought about this is that there
is a crisis at the ages of 30/40/50, and these crises seem to echo the
failure of the adolescent resolution and the compromise that has
been arrived at. The common one seems to be an early adult struc
ture that has been formed and then collapses at around the age of
30, often because it is based on certain omnipotent solutions to the
conflicts we are discussing. I think it is very interesting that this is
an age at which so many people seek help.
I wanted to make a few comments about the patients described
by Dr Laufer. It does seem that the common theme to both the
patients is that there was thoughtful help accessible, not neces
sarily in the family, but certainly, in the case of Molly, with the
teacher. There was someone who could immediately link up. I
wondered whether the existence of the Centre itself in the mind of
the teacher might be a very important help in responding in that
way, because it was clear that the teacher had a capacity to listen
and contain something and link up with the Centre in a way that
was helpful for Molly.
Equally, in the situation with Jim, which was perhaps much
more worrying at that time, there was a thoughtful, helpful re
sponse from the GP, which also seemed to be connected with his
own relationship to the Centre. So often, as Dr Laufer has pointed
out, one turns away, or a standard treatment is offered which
contains no capacity to interact with the adolescent's internal
world. It has to be said that this work is very difficult.
The reason that adolescent services collapse is all too often
because it is very difficult to sustain contact with the disturbance.
It does call forth anxieties that often lead to an avoidance or to a

fear of failing the adolescent because of the difficulty of containing
such conflict.
I think it would be very interesting to explore more fully the
nature of the common forms of internal world with which we are
struggling, and to what extent the interaction between a persecu
tory internal world and sexual development can be understood.
CHAPTER SEVEN
Working with
adolescent breakdown
1. Pre-therapy
Debbie Bandler Bellman
A
number of years ago, when working at a children's
treatment centre in London, I was asked to see Mary,
who was then almost 1 2 . She was attending boarding
school outside London, and her mother felt she was unhappy. Mrs
T, an anxious, highly troubled Spanish woman, wondered if Mary
should return home and receive help or stay at boarding-school.
However, she also felt that she would not be able to cope if Mary
lived at home.
After seeing Mary, I felt she was a girl with many problems but
also strengths. It seemed clear she needed help, and I felt worried
about the course her disturbance could take in adolescence. There
were signs that aspects of her development could break down, and
I was concerned she could become suicidal. Mary herself, how
ever, was adamant she wanted to stay at boarding-school and did
not want to receive help there. This, together with her mother's
wishes and disturbance, made me conclude that boarding-school
was the best option at that time. I felt anxious about this recom
mendation and offered her the chance to see me during school
Chair: DR L . CAPARROTTA
93
94 DEBBIE BANDLER BELLMAN
holidays. My hope was that, should Mary become increasingly

depressed, she would not feel alone with it, and we could then
think together about how to proceed.
For the following six and a half years we met in the school
holidays, for a total of approximately thirty-two sessions. She
also wrote letters to me. During this time Mary changed from a
troubled pre-adolescent to a suicidal and bulimic adolescent. I
often felt witness to a process I could not help alter, and at times
I wondered what I was attempting to do in my sporadic contact
with her. Increasingly, as a sort of life-line, I offered her the possi
bility of future therapy—that is, when she was despairing I would
talk about how I felt her hope would come from fully understand
ing why she felt the way she did.
Mary remained at boarding-school until she had completed
her A-levels. She then returned to London and accepted a referral
to the Brent Centre, where she was reassessed and offered therapy.
This is described by Dr Flanders in the second part of this chapter.
Here, I focus mainly on my concerns at the assessment stage and,
subsequently, on my longer-term contact with her. It is also impor
tant to present some details of Mary's background and her
mother's involvement with the children's centre.
Before I saw Mary, her mother had met several times with
another therapist, Miss M, to give a social history. Mrs T gave the
impression of being highly anxious and depressed, and she was
often unable to follow through on her thoughts. She would veer off
into tangents and free associations, frequently of a morbid nature.
It was difficult to glean any true picture of Mary, as Mrs T seemed
largely unable to differentiate her own anxieties from her daugh
ter's. She was full of contradictions, describing Mary alternately as
"always happy" and "always depressed". Mrs T denied any diffi
culties in their relationship, but she said she feared that they
would kill each other if Mary lived at home.
Mrs T had divorced Mary's father, Mr N, when Mary was 2
years old. The mother had already met Mary's stepfather, and
they married when Mary was 7. According to Mrs T, Mary had not
seen her father since she was 4. Mary reportedly never got on with
her stepfather, and it was he who instigated the idea of boarding
school, which Mary attended from the age of 10. Mrs T said that
Mary had grown unhappy at school, having been "ill-treated" by a
WORKING WITH ADOLESCENT BREAKDOWN 95
housemistress. Mr T had tried to intervene, but this had misfired,

with "people turning against" Mary afterwards. Mary had one
brother, age 21 at the time of referral, who was not living at home.
When I met her, Mary was huddled up against her mother,
looking like an unhappy waif. A very anxious face peered at me,
and her body was enveloped in a large dark coat that seemed at
once to cuddle and hide her. She easily disentangled herself to
come with me, but her mother needed encouragement to stay
behind. Mary sat upright on the edge of her seat, hands folded
primly in her lap, looking down with an anxious but essentially
bland expression. She had not wanted to come and was at first
reluctant to say anything, but she gradually became more forth
coming. At times she would light up and grow quite passionate,
giving the impression that there was a very lively side to her—a
side that would quickly disappear, both as if I was not supposed to
see it and as if it perhaps caused too much conflict for her. By the
end of the two assessment sessions I felt that although there was
much I did not know about her, I knew enough to feel worried.
In many ways Mary was positive about boarding-school. She
was interested in her studies, and she liked activities such as
swimming. The main difficulties were in her relationships. She felt
that most of her peers disliked her, and that this must be her fault.
She got along better with younger children, although at times they
found her too bossy. At this point it looked as if Mary had a good
capacity to think about herself and her behaviour. However, when
she gave examples of things the other girls did that made her
conclude she was disliked, she came across as easily wounded and
quick to withdraw, while maintaining a vigilance towards the
behaviour of others that had a slightly paranoid flavour. What had
looked like a good capacity for insight now seemed like a ten
dency to berate herself and to assume that she must be unlikeable.
Mary's difficulties with her peers seemed linked with conflicts
over her developing body and sexuality. She was scornful of the
other girls, describing them as "silly" and "giggly". The giggliness
clearly pertained to boys and sex—subjects that she acknowledged
she felt distinctly uncomfortable with, hence her preference for
younger children. She said she did not like boys—only her father
and her brother. She agreed she felt uneasy about the changes in
her body and any sexual thoughts of her own. I felt concerned by
the apparent absence of any pleasure in her pubertal development

and by how she was distancing herself from her peers.
It became clear that Mary was intensely preoccupied with
her relationship to her mother—a relationship characterized by
longings, guilt, anger, and secrecy. She felt it must be her fault that
she was sent to boarding-school. She had been "disobedient" when
younger, and this must have caused her mother and stepfather to
want to get rid of her. It must be that there was something very bad
about her. I was struck by Mary's repeated emphasis on things
being her fault and on her "badness", both of which pointed to a
rather persecuting sense of guilt and low self-esteem. She felt par
ticularly bad about her anger towards her mother for sending her
away to school. She had not forgiven her mother and wanted to
punish her. She frequently felt homesick, but she then did not like
it once she was at home. She felt confused by her contradictory
feelings but stressed that she had stopped telling her mother about
her homesickness as she wanted to stay at school and feared her
mother and stepfather would intervene again, and perhaps pre
cipitously withdraw her.
Mary emphasized that she in fact told her mother very little
about anything any more. She felt that her mother's reactions were
different from many of the other mothers' and could be injurious
to her. Her biggest "secret" was that she was in contact with her
father. She feared her mother would be furious and stop this, were
she to know. I found it difficult to evaluate Mary's secretiveness
fully. On the one hand, it indicated her strength in that she was
trying to separate herself from her mother and was trying to pro
tect herself from her mother's over-anxious and destructive
intrusiveness. On the other hand, there was a guardedness to her
overall presentation that suggested that her need to be secretive
could now be an integral part of herself, a part that could interfere
in all her relationships. I found it equally difficult to evaluate
Mary's firm wish to remain at school. To what extent was this a
healthy wish to lead her own life, and to what extent was it driven
by a fear that she could not survive physically were she to live
with her mother?
Had Mary been living at home, I would undoubtedly have
tried to work with her towards regular treatment. There seemed
a chance that, without help, she might be able to maintain her
academic interests and achievements, but I was worried that she

would not be able to negotiate adolescence on her own. How
would she react when she was more fully into adolescence and
thus more fully faced with internal and external pressures to come
to terms with her sexual development and her relationship to her
mother? Would she be able to extricate herself from her relation
ship to her mother, or would she feel trapped within herself?
Would she be able to find ways of bolstering her low self-esteem
and lessening her guilt, or would they tip over into acute self
hatred and suicidal despair? I felt it unlikely that she would find
the resources in herself to manage. Her vision of the future was of
leaving school, returning to live with her mother, earning enough
money to buy her own house, living self-sufficiently on her own,
then looking after her mother in her mother's old age. It was as if,
not yet 12, her future was already determined—as if at some level
she were aware that she would not be able to lead an independent
life as a sexual woman.
Mary was, however, not living at home. Equally, although she
could acknowledge some of her difficulties, she was far from being
able to feel them as problems she needed help with. Could one
recommend that she return home against her wishes and seek
therapy? Could one also ask Mary to live with a mother who said
she feared that she and her daughter would kill each other if they
lived together, to return to a home where there were no trusted
males who could act as buffers between mother and daughter? My
colleagues and I concluded we could not make this recommenda
tion. Neither could we send Mary away while feeling so worried
about her development. I shared with Mary both my concern about
her and my respect for her wish to remain at boarding-school,
and I discussed with her the possibility of seeing a therapist near
her school if this could be arranged. Mary was horrified at this
suggestion but accepted with relief my subsequent offer to meet
her during her holidays.
Mary's mother's reaction to the recommendation was also one
of relief. Although the mother's need for help was palpable, she
did not wish for it. It was left that she could talk to Miss M, whom
she knew from the assessment, about Mary as she needed.
Over the years, Mrs T's contact with Miss M revealed a much
greater degree of disturbance than had first been apparent. She
was prone to extreme anxiety and paranoid thoughts and to out

breaks of possessive rage that could give way to violence. As far as
we know, her physical violence was never directed at Mary,
though her rages often were. Attempts were made to refer the
mother for help for herself, but she was too frightened to pursue
them.
There was, however, some genuine concern on the part of the
mother for Mary's well-being. It was this that enabled her to allow
Mary to talk to me, though she could not at first bear the idea of
being left out from our discussions, and would ring Miss M, de
manding to know exactly what was said. The importance of Mary
having a space to herself was consistently stressed. I think that the
work done in this area must have been crucial in helping Mrs T to
allow Mary to seek therapy later on.
Mrs T initially took charge of Mary's contact with me, making
the appointments through Miss M and accompanying Mary to the
children's centre. Mary came willingly, but she often betrayed a
certain relief when she left, as if she felt she had managed to
escape without giving too much away. In the early months I felt
quite concerned and at times uncertain about the nature of our
contact. We touched on a number of issues, but we could not, of
course, go deeply into anything. I think we both regarded our
meetings as a mixture of chat and check-up, although the "chat"
on my part consisted of attempting to understand her. However,
as her disturbance progressed and the seriousness of her difficul
ties fully emerged, my work with Mary became a prolonged prep
aration for psychotherapy, while I attempted to hold her through
the crises that increased as she grew older.
The first real crisis came when Mary was Y2}A, almost a year
after I had met her. Mrs T had rung the children's centre over the
summer holidays to ask for advice about a new school for Mary.
Why she wanted Mary to change schools was not clear, but it
seemed linked in some bizarre way to the divorce she was getting
from her husband, Mr T. It was as if she had to divorce Mary from
her school at the same time. Mrs T was urged to take time to think,
not to act impulsively. She subsequently "forgot" Mary's appoint
ment with me at the beginning of term, then rang in a panic to
rearrange it. Mary had written a note, saying she wanted to end
her life. She had also drawn a picture of a girl who had hanged,
shot, and stabbed herself. "By the way", Mrs T added, Mary
would be starting at a new boarding-school in a couple of weeks.
The change in Mary from the relatively cheerful girl I had seen
a month earlier was striking. She was unable to hide her misery
and despair, and she spoke about her confusion and anger to
wards her mother for taking her away from the school she liked.
Although she admitted to having felt suicidal—she saw death as
a rest—she insisted she would never do it. She wanted me not to
take her suicidal wishes seriously, but I let her know that I did,
I took up not only her despair, but also the hatred towards her
mother and wishes for revenge contained in her wish to die. As
she grew able to think, she confessed to having frequently com
plained to her mother about school. By the end of the session I felt
that there was no immediate suicidal danger, but her precarious
balance could easily be tipped again. As previously, Mary did not
want to speak to anyone at school about her feelings. I now felt
that it was important for her to be able to take charge of her
contact with me, so that she was not reliant on her mother and so
as to begin to take her need for help more seriously. She agreed,
and she subsequently wrote to make her own appointments and,
much later, wrote letters about her inner state. She also began
coming to the children's centre on her own.
Mary's letters were always beautifully written and polite. It
was not, however, easy to arrange appointments with her. She
might be home for a week and, as far as I could tell, have very little
to do, but she would offer me only one or two times when she
could see me. This was the case even when she was at her most
suicidal. In the sessions we could do no more than acknowledge
her need to see me on her own terms and her fear of showing her
dependency.
Although in some ways Mary settled in at her new school,
any upset with friends would spark off her suicidal feelings. She
rarely told me about these feelings spontaneously, but she would
respond to my questions and comments. We spent much time
talking about her relationship to her mother, which deteriorated as
her adolescence progressed. Mary could no longer refrain from
screaming at her mother when she was at home, and each time
she did, she would feel suicidal afterwards. When at school, she
would telephone her mother whenever upset, leaving her mother
1 00 DEBBIE BANDLER BELLMAN
in a highly anxious state. She did not like my attempts to explore

her need to phone her mother, her need to perpetuate the sort of
cat-and-mouse game in which the two of them engaged. Gradu
ally, however, she could speak about how she was frequently
beset by fantasies of revenge towards her mother, and she would
then have to ring her mother to check that she was all right.
Mary became aware that, while she was preoccupied with her
mother, her peers at school were becoming increasingly preoccu
pied with boys. There were dances with a neighbouring boys'
school, and she always felt shy and inadequate. Her father and her
brother were still the only males with whom she felt comfortable.
She could not bear to talk about this, as any discussion led into
how she felt "different" from the other girls. This quickly became
a fear that, if she were "different", she must be like her mother. If
she were like her mother, then she must be "abnormal". Her fear
of being like her mother made it extremely difficult for her to think
about or even acknowledge that any of her own feelings or
thoughts might make her feel "abnormal".
Mary's fear that she was "different", like her mother, and "not
normal" also made it very hard for her truly to think of herself as
having problems she needed help with. It was all right to see me. I
was far away from school in London, and she only saw me occa
sionally at her request. She thus did not really have to make a
commitment to getting help. But increasingly I tried to explore
with her the fear of owning her problems and to show her the
many ways in which she was in trouble within herself. I let her
know that I felt it would be crucial for her to seek treatment when
she felt in a position to do this.
From the age of 16 Mary's suicidal feelings took on a new
intensity, and her symptomatology increased. The prospect of O
levels and then A-levels confronted her in a new here-and-now
way with the question of what she would do once she had finished
school. Equally, a trip to Spain with her mother at age 16, where
she met many new people, faced her with the extreme social and
sexual anxieties from which she had to some extent been shielded
in her school environment. Ultimately, she could not avoid the fact
that she was emerging from her adolescence beset by numerous
problems, tied to her mother, and unable to plan for her future.
Following her holiday in Spain, where she met a boy and had
intercourse, Mary began writing me suicidal letters. Her initial
feeling that she must be "normal" because she had a boyfriend
gave way to a fear that he would discover that "something" was
very wrong with her—a fear driven by her own feeling that she
was abnormal. The prospect of a visit from her boyfriend would
make her want to kill herself.
When she was 17V£, Mary wrote that she had a terrible secret,
one that would surely make me hate her. She wanted to die, she
was sure there was no hope for her. She had come across a maga
zine article on bulimia, and she realized that this was what she
had had for almost eighteen months, since meeting her boyfriend.
She had to tell me, she could not bear to be alone any more with
her "secret". I responded that I was glad she had told me, that I
could understand her despair, but that I thought there was hope,
that understanding her feelings could help, and that I hoped she
would stay alive in order to seek therapy.
Mary's suicidal letters always made me feel very anxious and
faced me with my helplessness in the situation. I had to be careful
to make it clear that it was her responsibility to stay alive; I could
only be there to help if she was alive. When, after a particularly
suicidal letter, she would make it difficult to arrange an appoint
ment and then clam up in my presence, I would also feel
infuriated and teased. But the fact that there was someone to
whom she could write, if not talk to freely, helped her regain some
feeling of being cared for.
Mary's last year at school was perhaps the most difficult. Her
boyfriend left her, she was studying for her A-levels, and her
mother was pressurizing her to go to university. I felt that she
might make a suicide attempt at any time. I talked to her about
leaving school early and getting regular help, but she felt she
would then surely kill herself, as she would feel that all these years
of study had been wasted. She also felt that she would kill herself
if she succumbed to the pressure to attend university. She could
not stand the idea of giving in to her mother. At her request, I
saw her and her mother together, in order to help her mother see
the importance of Mary making her own decisions, and to see the
seriousness of Mary's inner state.
Mary somehow managed to get through that year. She did well
at her A-levels and subsequently moved back to her mother's
home. We had met more frequently than usual, spending much
time on the issue of therapy and what it meant for her to say
good-bye to me. Mary had known for a long time that she would
not be able to have me as her therapist. I no longer worked at
the children's centre but had continued to meet with her there. I
had made it clear that I would not continue to see her once she
returned to London, as I felt the possibility of intermittent contact
with me could stand in the way of her seeking the help she
needed. At the same time, I let her know that I would always be
happy to hear how she was doing.
In some ways, the knowledge that she could not maintain her
infrequent contact with me, although causing her much anger,
sadness, distress, and feelings of rejection, helped Mary to make
the commitment to therapy. More importantly, as she had felt
increasingly out-of-control and desperate, she had come to feel
that therapy was her only hope. She had gained some inkling of
what therapy would be like through the way we had discussed
things and at least knew intellectually that therapy did not come
with any guarantees and could not provide a magic cure, just as I
had not been able to provide one. But I felt that there was a grow
ing idealization of therapy, to which I had perhaps unwittingly
contributed out of my own feelings of helplessness, and that this
could only be fully dealt with once she was in treatment.
There were no vacancies at that time for treatment for a girl of
her age at the children's centre, and so I suggested she go to the
Brent Centre. At our last meeting, Mary was tearful, anxious, sui
cidal, and grateful. She left clutching the piece of paper on which I
had written the address and telephone number of the Brent Centre.
Looking back, I think my contact with Mary had helped her to
feel less alone and had helped her retrieve hope when she lost it. It
could not change the course of her disturbance, but it had helped
her to own her difficulties and to feel that there might be a future
where she could be less burdened by them. For me, however, it
was extremely difficult to watch her disturbance unfold and to be
left wondering what different route her adolescence might have
taken had it been possible to offer her the help she needed when I
first met her.
2, Therapy
Sara Flanders
I n my first encounters with Mary at the Brent Adolescent

Centre I was above all struck by the artful reverence of her
presence. Piety and gratitude marked her posture in the con
sulting room, suggesting a prayerful devotion to the once-weekly
treatment on which she had embarked. This composed gratitude
hid, even from herself, her disappointment at getting something
much less exalted and more difficult than she had hoped for. My
efforts to discover and articulate her inner state—including any
sense of unease she might have with me and any disappointments
with what she had been offered (I knew she had known of more
intensive treatment and expressed a rare wish for it)—were
pushed away. Having been clung to as salvation, the therapy
needed to be kept preciously free from any worry or doubt and
purified of anything Mary thought was not "normal". Mary's con
ception of normality was a very limited, emotionally thin state of
perfection.
Chair; D R C . BRONSTEIN
103
104 SARA FLANDERS
My experience of all this purity was of a palpable deadness,

as Mary heroically struggled with silences she found difficult,
putting her calm and polite versions of how well she was doing
thanks to being in therapy: passing a driving test or enduring a job
interview, even getting a first Saturday job. I struggled to stay
engaged, responsive, sometimes even awake. I have vivid memo
ries of holding onto chair arms in an effort not to fall asleep. At the
same time, Mary was reporting achievements that were not negli
gible. She was using the fact of at last starting therapy to take real
steps in her real life. But gradually I came to realize how danger
ous I was to this .process. My interest in engaging with her emo
tional life and my observations, which were different to her own,
were experienced by her as a threat. If she had not already thought
of my interpretation, she had failed. She was full of terror about
the possibility of not pleasing me, not keeping me happy by mir
roring me. She did not want me lifting the lid on the emotional life
that she experienced as such a threat. Gradually we came together
to understand the various paths that led Mary to the unconscious
conviction that feelings were poison.
Within the treatment room, a puzzling gesture, which dis
turbed this unnatural calm, gave a clue. Every once in a while
Mary looked as if she was stifling a yawn or even holding back
and swallowing regurgitated food. This non-verbal response to
what I construed were concretely experienced interpretations
almost disappeared in the central period of her treatment and was
related to the symptom she brought, the other side of this reverent
politeness. Outside the consulting-room, in moments when she
was emotionally provoked, she binged and vomited quite vio
lently. She was seriously bulimic. In the modus vivendi she had
reached at the age of 18, living as she now did with the mother by
whom she felt rejected at 10, the awakening of any strong feeling
was experienced as a danger, one that could be met by deadening
herself or, failing that, by gratifying a wish to binge wildly and
then vomit out the material that then stood for bad feeling. Such
an understanding took a long time to come and a longer time to be
used. Much of what I had to say initially converted rather quickly
to bad food and was got rid of.
Her reliance on vomiting she dated from her meeting the boy
on holiday with her mother and her precarious entry into sexual
WORKING WITH ADOLESCENT BREAKDOWN 1 05
life. She began vomiting when she could not, she claimed, say
"no" to the food offered by the fiance's mother, food she thought
would make her fat and undesirable and make her body hateful.
Bingeing came later, when the boyfriend stayed with her and her
mother in England. When both he and her mother were asleep, she
crept to the kitchen and binged on whatever she could find. By the
time she disclosed the pattern to me, soon after beginning psycho
therapy, bingeing and vomiting had become her way of regulating
her emotional tension. She could let herself go on bingeing, attack
the food in a frenzy, with the knowledge that it could then be got
rid of—she could make that happen, she was, after all, in control.
Bingeing and vomiting represented in fact a livelier, less passive
solution to feeling states that filled her otherwise with suicidal
despair, a despair that opened up with appalling frequency in
Mary's internal life, whenever she found herself not fulfilling her
notion of normality.
Suicide, which she contemplated, as far as I could tell, when
ever her equilibrium was disturbed, would put an end to the
torment of having living responses to the world: wishes, desires,
fears, and hatreds, everything she could see only as the barrier to
her acceptability. Her paradoxical problem, then, was that in order
to have a place in the world, to be alive, she had to be nearly dead.
In adolescence, with her body betraying her into life, into sexual
adulthood, into being a woman, perhaps like her madly jealous
mother, Mary was presented with a nigh-insoluble problem. She
brought to the emotionally demanding crisis of adolescence the
hope that her first relationship at the age of 16 might put an end to
feeling unwanted, and—I only exaggerate a little here to make my
point—an end of feeling.
The paralysed stuckness of Mary's presence constituted her
solution to the fact of the developmental process, the fact of sexual
development, the realities of separation from childhood, with
which she was silently at war. One of the tasks of therapy would
be to help her out of the stuckness, which, in spite of her determ
ination to get therapy, she was very terrified of leaving: better the
familiar despair of being locked in a maternal prison than con
fronting the void of abandonment. She could just conceive a better
possibility, which she expressed in the opaque language of "join
ing in". She wanted to be able to "join in", to feel no different to
106 SARA FLANDERS
anyone else, because if she had a specific experience that belonged

to her, she was in danger of being got rid of. Perhaps I labour the
point, which is that Mary transformed this familiar adolescent de
sire into something painfully rigid and paralysing. "Fitting in"
collapsed for Mary as soon as she felt the tension of any difference
in her view and another's. Dialogue, the basis of psychotherapy,
was distinctly problematic, a source of painful and dreaded ten
sion. I believe she longed to be as neutralized and homogenized as
her language. She responded to my hypotheses with the strange
swallowing action, half-gagging on the stuff.
Therapy
Gradually, we came to understand some of the quality of feeling

with which she struggled; I gained enough insight—a shred or
two more than she intended—and little by little I was allowed to
give some back to her. I learned something of the history of her
own violent feelings and the corresponding timidity, or, as she put
it much later, the "silence" she "wrapped herself in" to cover it up,
even stifle it. I made do, in the beginning, with the revelations that
came in asides, when she would report a scrap of spontaneous
experience, pretty much by mistake disclosing to me a glimmer of
what she held on to so tightly: for example, the crumbling apart or
violent rage with which she responded to her car being beeped at,
revealing her susceptibility to being made to feel she had no right
to occupy her place or space. An association to this experience in
the first six months of therapy gave the clue to her psychological
situation. Her place in therapy—confused with her place as she
had taken it up at home with her mother, and in which she was
terrified of being suffocated—was the place once taken by the
stepfather, the uncomfortable place she had re-taken since leaving
boarding-school to live at home. Her compelling possessive and
jealous attachment to her mother was suffused with the abnormal
ity she dreaded.
The experience that gathered meaning over the years, after
first appearing in our discourse as, unusually, an association to the
car that had beeped at her, was of Mary locked in the bathroom on
WORKING WITH ADOLESCENT BREAKDOWN 1 07
her mother's and stepfather's honeymoon, and being made to get

out of the bath; just as when the car beeped at her, she had been
disturbed, exposed, and humiliated. This was an ordinary experi
ence in an extraordinary context, as many emotional experiences
were for Mary. This had been an unusual sort of honeymoon, and,
with what was once described as "belle indifference", she described
the part she had played: she did not vacate her mother's bed. At
the age of 11, after a year in boarding-school, she would not leave
her mother's bed on her mother's honeymoon. This information
she disclosed quite guilelessly, though acknowledging that it had
made some impact on the stepfather, who divorced her mother,
according to Mary's history, quite soon after the honeymoon, cit
ing this incident in his complaint.
Inadvertently, she disclosed the extreme splitting in her think
ing, which was needed to blind her to the power of her unrelin
quished incestuous attachment and which contributed so much
to her experience of being susceptible to banishment, not belong
ing—an abnormal creature in the ordinary world. The determined
confusion of her safe, protected place—the bath, the consulting
room—with the incestuous place in her mother's bed, describes the
knot that she had firmly tied in her mind after leaving boarding
school, and which she brought with her to the psychotherapy, with
the hope, I think, of rescuing her normality by adding it onto the
incestuous situation, not by giving it up. Realization of the power
ful and now angry sexualized attachment to the mother, played out
in the frenzied bingeing, foreclosed her development. Its disclosure
was central to whatever developmental steps she was able to take.
You can well imagine how difficult this was to look at. To her great
credit, Mary did not flee, although she flinched from realizing the
nature of her clinging.
On thinking
Gradually, Mary was able to think about it. However, we needed

to develop in the therapy some space for thinking, and that took
some time. It took time for the food for thought I offered to be
considered; it took time for Mary to survive the depression she
108 SARA FLANDERS
was left with if she experienced me spoiling an ideal. At first, she

responded to much of what I said as if to bad food, which she was
preparing to vomit out. I offered therefore little of what I could be
certain she experienced as impingement. I assumed the quiet she
forced on me and herself had to do with her anxiety of having
thoughts, and gradually I became aware of very mad thoughts,
forced into her—a craziness, much of which was actually articu
lated in her mother. Given so much anxiety about what I might
say, it was very brave of her to endure the situation, which she
might not have done without the idealizations that made it so
difficult to bring the therapy alive. The imperatives of adolescent
development, the hopefulness associated with it, did not die.
The terror of being overwhelmed has specific relevance to
the adolescent, who has experienced in the physical changes of
puberty the concrete reality of inner transformation, which, when
the maternal object, the primary object, is so disturbed, becomes a
fantasy of being malignantly taken over. Mary's presence was, I
believe, the product of having to defend herself very powerfully
from intrusion, having very much indigestible emotionality forced
into her all her life. On the other hand, she had not much experi
ence of learning, little by little, to bear the burden of her own
emotional life, which gradually becomes loosened from the in
cestuous ties. Much of her character had formed itself around the
unpredictable volatility of a mother who would not be able to
empathize with her because she would be too overwhelmed her
self. She needed to push these projections away, and I believe she
was inclined to anticipate my interventions in the same light. In
the first year of treatment, the eating habit she stuck to at home
was to eat half and leave half of what her mother served. Not only
was this a way of keeping control over what she took in and what
conceivably could take her over, it also, concretely, imposed an
order—even a boundary—of what is inside and what is out.
Although the sessions she was offered did have about them the
quantifiably gratifying potential of food, therefore dangerously
evoking the greed of which Mary was so ashamed, she was also
hungry for the experience of having her thoughts taken in and
added to and given back to her, rendered bearable. I believe
therapy actually did give her space fit to think in, so that after a
year she eagerly accepted a second therapy session. Occasionally
she showed a glimmer of curiosity about what I was thinking. My

mind became something she could rely on, although not always in
the way she wanted it; I was not under her control, and I was not
paranoid and intrusively projecting into her. Here one can see the
developing awareness and use for the mind of the other, along
with the mind of the self, which becomes the key to attending to
gradually more bearable emotional life.
Several simultaneous developments took place in this second
year of treatment, when Mary began to come twice weekly. She
began openly to seek out her real father—a man who proved
to be quite disappointing to her but who was certainly someone to
whom she could speak about, among other things, his perspective
on his marriage to her mother. A place for a father in her mind, in
her thinking, was reinforced by her therapy, by my paternal func
tion, as the one who gave her the space to gain a perspective
on her inner life and her difference from her mother and to realize
a heretofore frightening sense of separateness, a miserably con
ceived individuality. Once or twice she hazarded a comparison
between some thought I had offered and something from her
mother—more room for thought. A young man came to live for a
short time in the home, and there was a pleasant possibility of all
three being together—an experience that seemed miraculous to
Mary. Of course, this threesome did not contain the painful reality,
the true asymmetry of the oedipal situation. The lodger was in
timate with neither Mary nor her mother. It was social, it was
playful, it was bearably competitive, nobody was painfully left out.
A level of experience between withdrawal and violent contact—a
necessary and helpful stepping-stone—was established.
Her own mother began to see—and it seemed, to tease her with
signs of—her ex-husband. This continued throughout the therapy
and was useful inasmuch as Mary was able to bring the passionate
and enraged jealousy to her sessions and to think about it. It be
came an important source of information, exposing her mother's
difficulty in helping Mary to face the still hot issues of the oedipal
situation and, indeed, her capacity to inflame them. She teased her
with the experience of being left out. Madly, she assured her
daughter she saw her ex-husband only to wreak "revenge", pun
ishing him for having made Mary's life so difficult, referring to the
incident at boarding-school, now almost ten years ago, when he
110 SARA FLANDERS
intervened with a house mistress, ostensibly on her behalf. In fact,

though Mary's elderly mother actually needed the physical help
offered by this man, not to mention whatever pleasure and con
cern he could offer, I think this teasing provocation of her
daughter, the furtive leaving of traces of the continued involve
ment with the hated ex-husband, was her revenge on Mary and
her therapy, and perhaps also a reflection of her feeling about
being left out herself.
These developments at home coincided with Mary's deeper
commitment to her treatment. Once Mary had begun coming
twice weekly, her mother did ring the Centre, with distraught
complaints about Mary's smoking. She contacted me, and she did
seek to penetrate the boundaries that it was so necessary to pre
serve. These were, however, not devastating attacks. In fact, given
her own mental struggles, she behaved with heroic restraint.
Enough took place to confirm that Mary's disturbance was not
simply the product of her own intra-psychic difficulty, and it be
came an important feature of her therapy to differentiate her own
mental processes from what she observed in her mother's and
which she leaned upon when it suited her.
The fragile capacity to separate, to think, to have a sexual life, to
hazard a safe experiment with living occurred in the second year of
treatment. Mary went on holiday with a friend and established a
sexual relationship with another foreign boy, this time not from her
mother's country. It was short-lived but was, as far as I could tell,
good enough and sexually more truly arousing and satisfying than
her experience with her first boyfriend, her "ex". Crucially, this
holiday is one she took while I was still working. She had a week of
therapy to return to, during whichtimeI had not changed. Without
fear of punishment, she could tell me she had had the "best experi
ence of my life". This temporary strengthening was quickly un
done by my holiday break, my seeking my own pleasure. Her
sense of worth was not sustained. Her capacity for pleasure ebbed
away, and her sense of well-being and reflective capacity disap
peared down the holes created by the absent containment. Sepa
rated from me, in her mind psychologically abandoned, she then
resorted to bingeing and vomiting—her omnipotent solution to the
overwhelming anxiety associated with feelings of abandonment
and helplessness.
This rhythm would continue through the last eighteen months

of her treatment. She always responded more strongly to the action
—the beginnings and endings—than to my words. I would inter
pret to her what I could get hold of: both her anxiety in relation to
me and what I threatened in my presence, particularly the pro
jected intolerance of her separateness, her capacity for joy. I was
pretty relentless on her terror of abandonment and possessive rage,
the downside of our separateness. She developed. She grew bolder
with me, more curious, she would disagree, became guardedly
more emotional in my presence, more thoughtful. She had access to
a less primitive internal object some of the time. She gained promo
tion at work, she made friends, one of whom she could fall out with
and repair damages, and she got a boyfriend who lived locally,
again from the country of her parents' origins. She managed to
enjoy a sexual relationship, where pleasure was enough the rule
that she noticed its absence. She required her boyfriend to take an
Aids test until he agreed to use a condom, not without appropriate
hesitancy and embarrassment and therefore with some real cour
age. She even managed to put up with her mother's ex-husband
and to give up the need to control her mother's sexual life omnip
otently.
She recognized and mourned the reality of her father's in
ability to help her find the symbolically significant separate place
to live. She turned to him, and he let her down, as he had
when she was small. Her father, recalling his own slashed tyres,
was too frightened to have Mary stay with him, even temporarily,
when the battles at home became heated. His failure, based on his
dread of real violence, underscored the problem of her mother's
psychotic functioning—another painful reality to recognize and
mourn.
There were considerable stretches without bingeing, and Mary
could see that these stretches always occurred when she was able
to remain emotionally alive and in communication with me, with
her boyfriend, with herself. I believe that from her in-touchness
she was able to tell me, with real tears, as we approached the end
of treatment that she still was, as she put it, "not right". On the one
hand, this was a reproach for my not turning her into the chatty
foreign girl of her adolescent idealization. On the other, it came
from a genuine awareness of the limitations in her ability to en
112 SARA FLANDERS
dure closeness. More than two days a week with her boyfriend
threatened her with panic. It was her awareness of this limit to her
capacity for intimacy that was the stepping-stone to the considera
tion of further treatment—treatment that she could consider as a
young, economically viable adult.
I believe that she did actively make use of the fact of an ending:
her emotional and real achievements accelerated as the reality
moved closer. So, however, did its undoing. Her mother also got
some professional help, which seemed to help her attend to her
own difficulties. But she and Mary colluded to undermine this
effort to separate by buying a new house together—one for which
Mary would pay the mortgage with the greater part of her salary.
Together, the two formed a last-ditch assault on the achievements
of separation. Mary finally acknowledged my interpretations, but
she held on to her bondage, disclosing her intention eventually to
become the master of this house, to become the one, finally, to tell
her mother to go. Before the last day of treatment, in a temper, she
did indeed tell her mother she would have to go. This would be
a reversal of her adolescent experience and of the fact that her
therapy was ending, and it was she who would have to leave. She
would make a last, angry stand against reality, and against the
conditions of her psychotherapy.
This triumph did not last. A part of Mary knew this was a false
solution, and she became too frantic to wait for the processing of a
referral for more intensive treatment. Instead, and arguably more
appropriately, she negotiated, within the following year, private
psychotherapy, with which I trust she is continuing a process of
development opened up in the psychotherapy she received as an
adolescent.
Discussion
Kevin Healy
I am in charge of the Adolescent Unit at the Cassel Hospital, a

National Health Service hospital that works as a psychothera
peutic community providing treatment for families, adults, and
adolescents, who come to live together, to have a living experience
alongside each other. This is the important part, the part that links
with this chapter—the opportunity to think about that living expe
rience, to explore, and to have that third space to make sense of
the intensity of feelings that arise within relationships. We end up
with individuals who are very stuck in their lives in terms of their
development, their relationships within families or with peers, or
their careers and who are very desperate and will often have made
very serious attempts on their lives, either through overdosing or
through increasingly violent behaviour, such as hanging or
stabbing. They will often be full of loathing and self-hatred, with
resultant attacks on their bodies—cutting, burning, bingeing, vom
iting—all representing a degree of hate—self-hate—that could be
so hard to live with at times. What is therapeutic about a place
like an adolescent in-patient unit is that people can be kept alive
within the possibility of hope. We have heard about this in both
114 KEVIN HEALY
parts of this chapter—hope that something may change, hope that

an individual may be involved in taking the steps that will make
change possible.
There are two main factors that apply, certainly to the in
patient side, but also to any therapy that can promote change. One
is the taking-on of responsibility by the individuals themselves to
try to look after themselves and what they do with their lives, to
keep themselves safe enough. For in-patients, there is the need to
get involved in living in the in-patients unit and in the day-to-day
work of the hospital, taking on jobs, preparing meals, linking with
times away at the weekend. All of that is very important—the
actual milieu experience, the living experience, through having
space to think about, talk about, and understand. That space is
provided informally with other patients in the hospital, with nurs
ing staff and in therapy—whether individual therapy or group
therapy, or in the therapy provided by the group as a whole.
Alongside that, as the second factor, we do have some space to
work with families to make sense, where appropriate, of what the
individual tries to carry around inside himself.
I am saying this, aware that an in-patient unit, particularly in
the current climate, would not be a first choice for anyone who
needs treatment. The current approach is that the adolescent,
where possible, should be helped within the context of his own
life, his continuing schooling, his continuing friendships, home
bases, family. I think that the work of a service such as the Brent
Adolescent Centre is essential in being able to provide that sort of
approach. The emphasis in an in-patient setting is to deal with
problems where it is not possible to continue with a more standard
approach.
A place like the Cassel Hospital is a referral service where
professionals involved on an out-patient basis will have done
considerable work with the individual prior to his referral, and
this may tie in with the point raised earlier about milieu therapy.
It might be effective. It is an intensive resource, an expensive
resource, and not a resource for first choice—it is one to be consid
ered when other approaches have broken down.
In relation to Mary, no formal family approach had been pos
sible, but it could be argued that there might have been benefits in
I
WORKING WITH ADOLESCENT BREAKDOWN 1 1 5
trying to engage with Mary, her mother, her stepfather, father, and
brother.
I was left very curious about her brother as an individual,
who was but wasn't around in what we heard about in this case
study. I wondered about how he had managed to get through his
adolescence, and I thought that there might have been things that
Mary can learn from how he managed things. However, I know
that there are probably many very good and important reasons
why engaging in this formal way was not possible with all of
Mary's family. There was, nevertheless, obviously a lot of work
done with Mary and her mother. Over the years, the mother had
made contact with the various centres working with Mary, and
much work needed to be done with her in order to make the
continuing work with Mary possible. The father seemed to be ab
sent in Mary's life, and this was one of the painful things Mary had
to come to realize. But that, perhaps, was provided by boarding
school or by contact with Mrs Bellman and Dr Flanders.
I was left with lots of thoughts about the work with Mary—
what came up in it, what did not come up in it, and how all this
can be condensed into such a short space. But what impressed me
most, and what continues to impress me, is the experience that
both workers had and what they provided to Mary in getting
alongside her at times of suicidal despair—which is so painful and
so difficult. I think the important thing is that both workers heard
what it was like for Mary—her suicidal feelings and her sense of
badness.
CHAPTER EIGHT
Later consequences
of adolescent breakdown
Anthony Bateman
A
dolescence is an inevitable developmental continuation
of the latency period. After the dramas of the oedipal
phase—a time when a child is negotiating his relation
ship with both mother and father—"latency" provides respite, a
period in which psychosexual development and emotional matu
ration continue in a much more muted vein and in which the
acquisition of cognitive and motor skills, and the capacity to go
beyond the family into a world of peer relationships, is the pre
dominant developmental task. With adolescence, there is a return
to earlier dramas, which are re-worked within the context of a
developing sexual body.
Just as the ways in which attachment and loss are handled
and felt when a child is primarily attached to one parent will affect
the oedipal stage, so, too, will a child's oedipal and latency ex
periences equip him for good or ill during the turbulence of
adolescence. Each phase is a continuation of the past and offers
Chair: M R P. WILSON
117
118 ANTHONY BATEMAN
opportunities for new beginnings. The adolescent faces the twin

tasks of separation from his family of origin and preparation for
the intimacies within the family he generates—putting the devel
opmental trajectory of the first two decades into reverse by moving
from loss to bonding. Two central issues here are identity (Erikson,
1968) and the body (Laufer & Laufer, 1984). Sexual identity begins to
be established fully in adolescence. There is intense preoccupation
with appearance and change in body image, an exploration of
the balance between intimacy and individuality, a grappling with
fears of merging on the one hand and isolation on the other.
Adolescents are individuals of action as they struggle to under
stand and renegotiate their relationship with the world in the con
text of their developing social and sexual powers and frailties.
They are wary of adults, although desperate for new figures with
whom to identify. Their internal world is in a state of confusion:
internal conflicts tend to be externalized, impulses are difficult to
control, and feelings are dangerous to express. Phantasies can only
be partially sublimated, and impulsivity, bewildering sexual feel
ings, and outbursts of anger and emotion result. The adolescent no
longer relies on the parent to regulate and modulate his bodily
affective states; he has to undertake this task for himself. The anor
exic who does not know when he is hungry or when he has had
enough is struggling with this issue. At the same time, he has to
learn how to entrust the other with his anger and sexuality, with
out feeling that others will be destructive or rejecting. He has to
know who he is so as to make choices and begin to create a world
of his own. In place of parents come ideas, systems, role models,
fashions, aspirations. Their purpose is to contain and define the self
whose lineaments are beginning to solidify. A negative identity
built around protest and a preoccupation with what one is not, or a
conformism based on compliance with parental aspirations, may
equally conceal an inner sense of emptiness and lack of connection.
Recognition of such developmental problems offers an oppor
tunity to intervene, helping the adolescent back onto a creative
trajectory and preventing an inexorable, self-feeding decline into
turmoil and conflict. Help may also represent an adolescent's
worst fear of being odd or abnormal; however, it can also offer a
"moratorium" or "Spielraum" (Erikson, 1968) within which adap
tation can occur.
LATER C O N S E Q U E N C E S 1 1 9
"David" was a pleasant 19-year-old, presenting with panic

attacks that had temporarily crippled him, making him unable
to leave the house alone or study effectively for his exams. His
movements were tentative, as though he did not quite inhabit
his adult body; his hair and voice were slightly soft and child
like. A middle child, he had a successful older brother and a
much-adored younger sister. The family was supportive, but
tense. David's father, a builder, suffered from severe asthma,
which had kept him off work for long periods. The family was
in financial difficulties, and there was pressure on David to
leave school and earn his living. David was very close to his
mother, sympathizing with her worries about his father's
health, but he resented her pushing and domineering manner,
and he envied her more straightforward relationship with
his sister, feelings he expressed by sulky withdrawal. During
his sessions David was polite but wary, communicating a sense
of helplessness and a passive wish that I should instruct him
how to live without his fears. He felt guilty about following his
own interests rather than helping in the home, where he felt he
was needed. At times he felt his life was empty and meaning
less. He had a girlfriend, of whom his parents did not entirely
approve, with whom he slept, but did not make love.
Discussion focused on the possible connection between his pre
senting anxiety and remnants of earlier fears of breaking the
bond with his mother if he made a sexual relationship with his
girlfriend, and of triumphing over his damaged father if he
was successful in his exams and achieved sexual potency. This
was linked with his cautious and deferential attitude towards
me. David was at first outraged at this "ridiculous" suggestion,
insisting that he and his father were the best of friends, but he
then admitted that he did resent the way he felt that his father
favoured his elder brother. This open conflict with me seemed
to shift things. By the end of David's treatment, he was feeling
better, and he had been to two school dances, he had made
love enjoyably with his girlfriend, and his exams had gone
reasonably well.
In the case of David, difficulties were recognized, reflected upon,

and sensitively handled. But many adolescents try to avoid accept
1 20 ANTHONY BATEMAN
ance of profoundly disturbing feelings within themselves. It is ter

rifying for adolescents to realize that their actions are a result of
inner experiences rather than the fault of others, to accept internal
conflict, to have to tolerate impulses without acting on them, and
to recognize that their struggle for autonomy is hindered as much
by internal conflict as by external authority figures. Their prob
lems are covered over by defensive operations such as excessive
intellectualization and rationalization, denial, identification with
sub-groups, escape through travel around the world, excessive
conformity, and so on. As a result, others—especially parents and
teachers—may be equally tempted to turn a blind eye to difficul
ties, hoping that time will heal, and age will bring about a quieter
maturity. Many carers other than parents—for example, teach
ers—may be involved with adolescents for a relatively short
period of time and so simply ride out the storm. But distressed
and distressing adolescents tend to grow into unhappy, dejected,
and desolate adults, their problems unrecognized, their conflicts
intact, their self-development curtailed, and their potential
stunted. It is this group that I discuss here.
For these adolescents, their parents or carers, their teachers,
and their friends unwittingly turn a blind eye. Problems are simply
"not noticed" or put down to growing up. I think this is an uncon
scious collusion arising out of a complex emotional interaction in
which all parties—that is, the adolescent, his friends, and his
carers—are rendered powerless. Thus, the inability to recognize
adolescent breakdown may be a function of the breakdown itself.
The unconscious task of the adolescent in the midst of a breakdown
is to ensure that it goes unrecognized. Similarly, the needs of his
parents may be such that they are unable to confront problems
constructively. For the adolescent, recognition of difficulty and
conflict brings acceptance of developmental failure, feelings of
humiliation, and experience of internal collapse. Yet avoidance
of recognition means that the possibility of help is sacrificed to
private turmoil, underlying rage at not being understood, acute
sensitivity to rejection, anti-authoritarian attitudes, external blame,
and despair.
How can I justify such a statement? I shall describe a 37-year
old patient whose treatment revealed that her relationships since
LATER C O N S E Q U E N C E S 121
early adolescence had been mummified and entombed, rigidly

controlled, and despotically ruled through threat and fear. But the
fear was not solely in the patient—it was her mother who was then
blind to all the problems.
Jane is a 37-year-old woman. She had a successful career until

the age of 34. At that time, she had taken some time out to do
some research; when she was on the point of returning to work,
her colleagues informed her they did not want her back. Bewil
dered, she accepted their decision, cleared her desk, and never
returned to any form of work. She experienced the rejection as
a crushing personal blow that confirmed a lifelong expectation.
It substantiated her terror of never being able to do anything
well. Her pre-existing view of herself was of someone who was
a fake, who was always on the edge of being found out, and
who struggled to cover over her inferiority. She had now been
unmasked. Until this point, her life had been a question of
surviving, of making it through, of not getting caught out. Now
it had come to an end. In a similar vein, she felt that there was
nothing attractive about her. She believed her closest friend, a
man, only visited her because she had conned him. She was
anxious that her false presentation of someone intelligent and
lively would be found out and he would reject her in the same
way as her work colleagues had done.
Jane came from a middle-class background, the third child and
only daughter of professional parents who were both success
ful. Her father was a powerful, dominating man, bombastic,
incisively intelligent, and critical. Hard on his children, he had
little time for their problems or difficulties, which, he believed,
should be ignored. He himself had struggled as a child with
a physical deformity. Never giving in to the limitations this
imposed, he excelled at sport for the disabled and achieved
highly academically, gaining a double first at Oxford. He ex
pected his children to do the same: to overcome adversity
without a whimper and to develop a self-sufficiency that could
only arise out of neglect. "Pull yourself together, gal ' was his
7
phrase when faced with childhood emotional expression. His

return from work each day was awaited with dread by the
whole family. He drank excessively, often not returning home

until late evening. Jane remembers lying awake in bed listen
ing for his key in the latch, fearful that he would come up to
her bedroom and start shouting at her after an altercation with
her mother.
Her mother, a successful writer, was quiet and long-suffering,
always complaining that her only support came from Jane.
Jane reported at the beginning of her treatment that her rela
tionship with her mother was close and intimate. Ever since
early childhood she had felt that she was her mother's favour
ite. They spent many hours with each other whilst her siblings
played together. Thus Jane described her relationship with her
mother as the best friendship she had ever had. However, as
her sessions progressed, it became clear that there was another
side to their relationship. The evidence for this emerged
through her relationship with me—the transference relation
ship in which her patterns of relating to others became mani
fest in the therapy.
Let me give you an example: Jane asked to change the time of
a session because of commitments with some friends. When
offered another time, she at first accepted, relieved that her
request had been granted. But as the session progressed, she
became convinced that I resented her request, which she now
saw as a demand to which I had reluctantly acquiesced. She
then asked whether I was sure the change in time was conven
ient; if not, she would try to come at her normal time. By the
end of the session Jane had decided that I must not want her to
change her time, and so she insisted on coming at her normal
time. As a result, she missed the official function she was sup
posed to attend with her friends. She felt it was impossible to
miss the session itself as she believed I would be so angry with
her that I would not allow her to return to her treatment.
I suggested that if she asked for something for herself, she felt
guilty, believing she would be enviously attacked by me as she
would have taken something from me. This led her to talk
about how during meal-times she had had to allow her elder
brothers to help themselves to food first. After finishing their
LATER C O N S E Q U E N C E S 1 23
portion, they often complained that she still had food on her
plate, for Jane was a slow eater. Her mother would say: "You
don't mind giving them some more, do you, Jane?" If she re
fused, complaining that things were unfair, her brothers would
threaten her with retaliation. Further association suggested
similar elements in her relationship to her mother. If Jane
argued, complained or refused to do something, her mother
would say that everyone was against her, nobody supported
her, and she would rather die than carry on struggling alone.
Jane would try to reassure her mother that she loved her and, in
doing so, capitulate to her mother's demand.
Childhood became a constant need to care for mother, to pro
tect her from her bombastic husband, to look after her rather
than be looked after. Failure of protection led to guilt, which
itself led to desperate attempts at reparation. Any effort on the
part of Jane to have a life of her own with school friends and
others was seen by her mother as a betrayal and abandonment.
For example, if Jane arranged to go out to visit a friend during
her adolescence, her mother would say that she was not sure
she would be there when Jane returned—a veiled threat of
suicide. Jane's needs became secondary; yet, like her father, she
found strength in academic achievement and eventually went
to Oxford. However, this was experienced not as an achieve
ment, but more as a fulfilment of a family expectations. Both
her brothers had been to Oxford, so gaining entrance was
anticipated.
Whilst attending university, she felt compelled to return home
every weekend to see whether her mother was surviving. Her
siblings refused to visit except for occasional family gatherings,
leaving Jane feeling solely responsible for her mother. She con
sidered her brothers to be cruel and neglectful.
Reflecting with me about some of her late-adolescent activity,
Jane was able to understand that her life had become an exten
sion of her mother's. She herself lived little life of her own. No
clear separation had developed between her and her mother.
She blamed her mother for this, citing many examples of how
her mother had spoiled all her attempts to form an independent
24 ANTHONY BATEMAN
life of her own. A particularly pertinent example was her 21st

birthday. The day before her party, she received a telegram
from her mother, saying that the party should be postponed
because a car accident had left her with severe facial bruising,
and she did not wish to be seen in public. Jane was needed to
look after her. In a moment of clarity Jane refused to postpone
the party and went ahead without her mother. Nevertheless,
her mother's absence cast a shadow over her birthday.
In summary, therefore, Jane was brought up in an intellectually
stimulating environment but one that was devoid of close emo
tional contact. The contact that took place was based primarily
on threats and criticism from her father and guilt induced by
her mother. As a result, Jane became adept at monitoring her
mother's needs and avoiding her father's rage. The needs of
others were placed first. Not surprisingly, after university Jane
became a care worker in a school for handicapped children,
excelling in her ability to understand and to anticipate the
children's needs. However, acceding to family pressure, she
trained for a profession, excelling in her exam results. On quali
fying, she found a job with a prestigious firm.
Returning now to Jane's request to change the time of her
session, this occurred again but with a menacing outcome. It
was impossible to arrange an alternative time. Initially Jane
deferred, the way she had in the past. She said she would come
at her normal time; she would miss her commitment. She felt
unable to cancel the session. However, later her stance changed
dramatically, Jane became convinced that I would not change
her time because I wished to be cruel to her. She angrily
accused me of looking after my own needs and ignoring hers.
She likened this to my taking a holiday break. Since people
enjoy their holidays, partly because of taking a break from
work, I must enjoy not seeing her, as she was my work. She was
convinced that I hated her. She told me she was not coming to
her sessions any more. However she did attend the next day
and reported that she had cut her wrists that morning. This
surprised me, although in retrospect it should not have done.
She told me that she had not cut her wrists for twenty years and
accused me of reawakening earlier conflicts. When I asked her
about this, she told me that when she began attending uni
versity, she began cutting her wrists, abdomen, and thighs
on a regular basis. This was done secretly at times of personal
distress. She found it relieved her tension and enabled her to
continue concentrating on her work. I suggested that my inabil
ity to change the time of her session had left her feeling that she
had to fulfil my requirements, just as she had always surren
dered to her mother. This had left her feeling angry, just as she
had done when she felt compelled to return home every week
end to gratify her mother's needs.
In reply Jane was very clear that she had been born to look after
her mother. Her definition as a person came through her role as
a daughter. If her mother died, this defining role would be
gone, and so she, too, would have to die. The rest of her life she
considered as a cloud, ephemeral and insubstantial, dispersed
by a breath of wind, much as her job had been—there one day
and yet gone the next, her name forgotten without a murmur.
Now her life had become defined by her treatment. However,
just as her role as a daughter had been conflictual, so, too, was
her role as a patient. Maintaining a role as daughter or patient
gave her a feeling of self, that she was of substance, but it also
left her trapped, unable to move towards independence and
reverse the developmental trajectory of childhood, unable to
ask for something for herself. She was sacrificing her life for
her mother's and mine, failing to break free and to develop her
own sense of self. On the one hand, her wrist-cutting allowed
her to concentrate on her therapeutic work, unencumbered in
her mind by her cruel attacks on her mother (and on me in
the transference), and yet, on the other, it left her feeling de
pendent, needy, small, and without a clearly defined sense of
self.
The first time Jane had asked for a session change, she was
offered a time that was convenient to her. She accepted, but
then she found that her fears of retaliation were so great that
it was better to sacrifice her own needs to mine. This led us to
discover some of her unconscious masochistic trends in which
she gave herself to the phantasied needs of others. The second
time the change of session was requested, no mutually conven
ient time was available. But by this time Jane had done further
work in her treatment, and the underlying paranoid rage
emerged. She was determined not to succumb to what she felt
was my cruelty. The only way she could deal with the struggle
was in the physical domain—a pathological compromise that
had worked during her adolescence.
Jane had never told anyone about her wrist-cutting. It had been
her secret, relished at times of emotional difficulty, protected
from discovery. It was hers. It was something that her mother
did not know about. Gradually Jane felt able to talk more
openly about her adolescence. She had discovered a second
method of ensuring that her inner emotional struggle was
calmed. After eating, she would make herself sick. This symp
tom had now returned and accompanied the wrist-cutting. It
was clear from what she said that during adolescence she had
suffered from bulimia, taking laxatives, inducing vomiting,
and exercising excessively. For a number of years, she would
binge in order to induce vomiting, which was pleasurable, ex
citing, and relieved tension.
In this single case history I am trying to illustrate a more general

point. How is it that a wrist-cutting, bulimic, excessively exercis
ing, dependent adolescent's problems were not recognized? First,
she excelled academically, thereby minimizing the risk of discov
ery from her teachers and lecturers. Poor academic performance,
troubled behaviour, and non-attendance are more likely to attract
the concern of tutors and others than are good exam results, in
tellectual rigour, and participation. Second, Jane was an emotional
protector, a prop to her mother's narcissistic needs. Any attempt
by Jane to break free led to guilt and was met by veiled threats
and accusations of cruelty and abandonment. Third, Jane had to
appease her underlying rage, which lay not far beneath the sur
face, like a dormant and unpredictable volcano. Finally, Jane's
father was unable to intervene and act as an avenue along which
she might find some freedom. His neglect of emotional issues left
her abandoned to her identifications with her oppressed and vic
timized mother. I think this final constellation may be important in
ensuring that adolescent breakdown goes unrecognized.
The female adolescent struggling with differentiation from her

maternal identifications needs the help either of her father or
of some other secure figure. Sometimes this is done through a
phantasied father, especially if there has been a breakdown in the
parental relationship. I have seen a number of individuals, whose
father was absent for one reason or another, who clearly identified
with a phantasied ideal built up within themselves. In Jane's fam
ily her father was unavailable to her, dismissive of her worries,
frightening, and critical. She took refuge in a "marriage" to her
mother. Elsewhere I have talked about the need for a third object
to intervene in such a relationship (Bateman, 1995). No interven
tion was made in this patient until the age of 37, and as a result
Jane was left to struggle with her quest for independence, feeling
alone and isolated. Although some of her father's absence resulted
from her father's own character, I think other factors were at work
(this time, the evidence came through my countertransference).
(Broadly speaking, the term "countertransference" now applies to
those thoughts and feelings experienced by the analyst that are
relevant to the patient's internal world and may be used by the
analyst to understand the meaning of his patient's communica
tions to help rather than hinder treatment—namely, "patient
derived countertransference", in contrast to the earlier notion of
" analyst-derived countertransference".)
You may have noted that I have placed a great emphasis on
Jane's mother, and I could be considered to be falling into the
fallacy of seeing everything as her mother's fault. I assure you that
this is not the case, although there is no doubt that I lost sight of her
father for a substantial period of her treatment.
By the fourth year of her treatment, Jane had stopped cutting

herself, and her bulimic symptoms had subsided. However,
she continued to exercise extremely hard, almost to the point
of damaging her body. At this time, I began to realize that my
general feeling towards her had changed. During our earlier
struggles about changing session times, I offered some flexibil
ity. Now I did not. I was stricter, more certain of my analytic
position. I thought that this was due, in part, to an escalation
in Jane's demands to move times, arrange holidays at different
dates, and be kinder to her. But it dawned on me that over a
period of months I had lost a firm, yet fair, father in myself. I

had given Jane more leeway than is normal within my style of
working. On a few occasions I had seen her for an extra session
on a Saturday. Consciously, this had arisen out of anxiety about
her difficulty in managing over the weekend when she was
cutting herself. It was only later that the unconscious process
became clearer. Unconsciously, there was a reversal in roles,
through which I had become Jane and she had become her
mother. Thus I felt she could not manage at weekends in the
same way as she had felt her mother could not manage. She and
I had become bound up in the same way as Jane and her mother
had been. I needed to find a father in myself to intervene.
Having done so, I was able to contain my worry and become
firmer about the boundaries of the treatment. I think it is pos
sible that during adolescence this process had prevented others
from realizing that Jane was in trouble and obstructed effective
intervention. Her emotional intertwining with her mother had
led to an ablation of her father within herself, which, in turn,
had allowed everyone else to be shut out.
To summarize: the form and content of Jane's adolescent
breakdown ensured that it was not recognized. This left her alone
and isolated, struggling to break away from her mother, to form
her own identity, to develop a life of her own, to accept loss, and to
move to a bonding with others outside her immediate family. This
she singularly failed to do. She was not married, and she had been
unable to form stable and fulfilling sexual relationships. This was,
in part, a result of her mother's selfish needs as well as father's
inability to face conflict and emotional pain. However, it also arose
out of her own sacrifice to her mother. In this process, her father
became absent within her mind and was unavailable to intervene.
This developmental process became represented in the treatment.
Just as Jane had done, so I lost sight of a father who maintained
boundaries. Her constant demands on me to change things were,
in effect, an attempt to wake me up, to be clear about my position
as an analyst. Only then could she begin to be clear about herself,
without fear that she would either become overly dependent
or need to lock herself away, fearful that I might invade her bed
room, overstep a boundary.
Would it have made a difference if Jane's troubles had been

recognized during adolescence? I think so. Treatment would have
allowed her to work on her psychological conflicts when they
were raw. I mentioned that ideas, systems, role models, fashions,
and aspirations replace parents as an adolescent moves towards
independence. Their purpose is to contain and to define a new self.
But they have a further purpose. It is to re-find our parents afresh,
reworked within ourselves against a background of separation.
Only when this task is complete is it possible to move towards the
development of one's own family. To wait until 37 to begin this
process is to commit oneself to twenty years of pain. That alone
behoves all those who work with adolescents to keep a watchful
eye—paradoxically, especially on those who may appear to be
doing well.
130 DOMENICO DI CEGLIE
Discussion
Domenico di Ceglie
This case study raises important issues for those working with
adolescents. It emphasizes a developmental perspective and poses
a challenge to professionals and families to recognize adolescent
difficulties early enough.
I want to discuss the complex problems involved and the
implications for the services for adolescents. In this chapter, Dr
Bateman implicitly describes three groups of teenagers with psy
chological problems.
The first group is illustrated by the case of David. Here is a
young man who presents symptoms that you will recognize as
interfering with his development and achievement of autonomy.
He has panic attacks. David can symbolize to some degree the
conflict in his inner world, like Freud's case of Little Hans. He can
accept the dependency and the need for help.
The second group consists of teenagers who are in distress, but
the worry is located in the adults who are in contact with them,
not in the adolescents themselves.
The third group is illustrated by the case of Jane. Jane's prob
lem seems to have escaped detection in adolescence and, I would
add, in her childhood. Dr Bateman has given us a very vivid illus

tration of the interactions occurring during her treatment. He
asks why she was not helped in adolescence; I would add, why not
even earlier, in childhood. Jane belongs, in my view, to a group
of patients whose symptoms are part of a psychic organization
aiming at maintaining a psychological equilibrium, however pre
carious this is. This organization helps individuals to survive trau
matic experiences. Jane's father had an alcohol problem. For these
patients, any threat to this organization is perceived by them as
potentially leading to collapse or catastrophe. I think of patients
who feel as if they have built a bridge over the precipices; their
traumatic experiences are like a precipice to them, and the bridge
is the organization they have built. Once this bridge has been built,
then all sorts of other traffic goes over it, which makes it difficult
for it to be changed or shifted.
People belonging to this group usually come to therapy much
later in life—often, as in the case of Jane, following a life event that
has threatened the equilibrium. In her case, it was the loss of a job,
or as the result of some external pressures from teachers or parents
during adolescence. Sometimes these people will face temporary
depressive episodes, but by and large they are very difficult to
motivate to come to therapy. So if they do come, they come under
pressure: "I come because my parents want me to come" or "my
teachers say I should attend". There is very limited recognition of
their problems. What they want in large measure is that an equi
librium should be established, rather than change. They tend to
resist interpretations or attitudes that threaten their psychological
organization. One finds this with anorexia or bulimia.
In Jane's case, the analyst had to be exactly like her. If she
changed the time, then the analyst had to wish to change the time
too and totally conform to Jane—as if in some sense she was ex
pecting that if she said, "Well, I want to change the time", the
analyst would answer, "Well, I want to change the time too". What
Jane expected was to hear an echo of her own voice. The trouble
started when she realized that this could not be so. She seemed to
have little experience of emotional containment. What she had
probably had in early childhood was a mirroring experience: that if
she screamed, what she got back was a scream, or she heard her
own scream because her mother could not respond. So there was
132 DOMENICO Dl CEGLIE
no sense that her scream could be contained or understood and

related to. In cases like this, compromise and negotiation are not
possible. I think the apparent absence of a third object, to which Dr
Bateman referred, was necessary in the first phase of her treatment,
as it allowed Jane to reproduce with the therapist the emotional
relationship with her mother.
Dr Bateman shows clearly at what point he could change gear
in her treatment and respond differently to her demands—for ex
ample, by being firmer. But if this had happened too early, it
would have had disastrous consequences. Jane would probably
have disappeared.
Another aspect that is connected to the lack of introjection of a
parental containing function in early childhood is the resulting
impaired capacity for symbol formation. Under pressure, a patient
like Jane resorts to concrete thinking and possibly temporary
psychotic episodes.
Dr Bateman has given us a very clear example of the acting out
that occurred during therapy. Once I saw an adolescent suffering
from bulimia, like Jane, who would cut her wrists superficially
on a few occasions. The last time she did it, she cut herself very
severely, severing an artery. She then told me that she cut herself
so deeply that she thought she was cutting her mother's body—a
temporary psychotic experience, which she had never had before.
In the case of Jane, one might speculate that the concrete attacks on
her body were also the expression of hostility to a female body that
stood in the way of her identification with a male figure filling the
space left by her absent father, who did not support or help her
mother. A negative constellation emerges here. Dr Bateman men
tions a "marriage" to her mother—as if in some way Jane had
displaced her father and concretely taken his place.
What are the implications of these observations for services
dealing with this group of teenagers?
1. With teenagers of this group, who is there who could put

pressure on them to contact a service? Coming into contact with
the service, the problems with engaging them in therapeutic
work are enormous and require great skill.
2. Acting out in the course of therapy is also frequent, as we have
seen in the case of Jane.
3. The therapist has to tolerate absences, often following some

shift or progress in therapy, and to tolerate working with a
precarious therapeutic alliance for a long time. These are the
kind of patients one is always worried about. "Will they come
next time" or "will they appear after a holiday"? Sometimes
they disappear, and one has to work very hard to get them back
into treatment. To work with these adolescents has to be long
term, as Dr Bateman illustrated with Jane. Sometimes these
patients show little progress externally for quite some time.
CHAPTER NINE
Responding to mental breakdown

in adolescence
Panel discussion
T he following is the text of a panel discussion held at

the end of the conference. The discussion was chaired by
PETER WILSON of Young Minds, and the members of the panel
were DR JOAN SCHACHTER, DR MAXIM DE. SAUMA, MRS GABRIELLE
CROCKATT, and M R CHRISTOPHER GIBSON.
PETER WILSON: We have heard a great deal about working with

adolescents during breakdown and seeing it in later life. The
key issue today is, "How do we respond to mental break
down?"
D R JOAN SCHACHTER: It is very difficult to make a brief comment.
But there has been a lot of talk about maintaining boundaries,
and I think there are many sorts of boundaries that we need to
think about. One that we think about quite a lot from within
the clinic setting is the boundary between specialist services
and community services, and particularly thinking about how
one can enable the adolescents and young adults who don't
come to treatment services to be able to come.
D R MAXIM DE SAUMA: What I think is important, first, is the hope
135
136 PANEL DISCUSSION
that some adolescents have when they are lucky enough to

have treatment. They can be helped. It was not too obvious
twenty years ago. When I started work as a psychiatrist, it was
not so obvious as it is now for many people who work with
adolescents. Even now there are services, agencies, parents,
teachers, etcetera, who really don't know about those things.
The second issue is detection. That is where teachers, parents,
and various agencies should be contacted.
M R S GABRIELLE CROCKATT: In the Children and Family Department
at Parkside Clinic, we have an overlap with the adult depart
ments, so that we think about adolescents and young people.
I think I will be the third person to say something about the
links between services and the way we all work together to help
young people. The particular link that I would like to empha
size is the importance of identifying young people who are in
trouble and linking them in with mental health services. The
point I wanted to make is something to do with the contribution
towards the mental well-being of young people that other serv
ices make: that young people who are in education get very
well helped as far as their self-respect goes from having a good
teacher. I think the same would be true of all the services that
young people are involved in. It is the contribution that we all
make towards mental health.
M R CHRISTOPHER GIBSON: Before working at the Brent Adolescent
Centre, I was a teacher and later a headteacher in schools for
emotionally disturbed children and adolescents. It used to be
called "maladjusted". The word that struck me early on today
was "amateur", because from my experience being prepared to
put effort and time into working with disturbed adolescents,
to tolerate the frustrations and anxiety that you have to carry, to
try to set boundaries, has nothing amateur about it. It is very
professional What concerns me is to be able to make an offering
to anyone who works with disturbed adolescents—an offering
to develop each person's thinking about what they are doing,
because it is through thinking that movement and change can
occur.
FLOOR: There are not many school counsellors around, but maybe
there are year heads or pastoral senior team management mem
RESPONDING TO MENTAL BREAKDOWN 137
bers who would have a new world opened up to them if they
heard some of the things said here today about what happens.
FLOOR: It seems to me that the first statement that did concern a
broader aspect of health education that does go on in some
schools is that some places have lots of it and some places have
none at all. Can I link that to something Dr Bateman said that
was ringing in my ears and that Peter Wilson picked up on,
about adolescent breakdown being—and perhaps having to
be—unrecognized. There is an interesting connection here, I
think, with broader issues that have been discussed today—
there is the tremendous pressure on adolescents to conform.
The pressure to conform seems to be greater today than before.
That breakdown should go unrecognized is even more power
ful, especially where there is a lack of services to meet the
needs of adolescents. Their actual problems to be recognized
are equally great. I would identify myself entirely with Dr
Laufer's optimism and Dr Bateman's positive approach to his
work. It seems to me that these are very powerful, institutional,
societal, social, economical, and political issues, which are very
important.
FLOOR: Something that is of a particular interest to me and has
been referred to occasionally today is that—looking around
this room, for example—there is a significant number of men.
I work as a college counsellor, with a very noticeable minority
of men on my client list. I think one of the things that we are
trying to deal with in any area of provision, particularly under
any of the present circumstances of reducing funding, is that
we are often very frightened of opening the floodgates. I would
ask the Panel's comments on the problem.
PETER WILSON: There are a few important points about the insti
tutional forces towards conformity generally and societal atti
tudes about gender and expectations about gender and how far
men are free to make use of these services or are expected or
allowed to.
M R S CROCKATT:It is true of our services that men use the service
much less than women do. I think it is something we have to
keep working at. Certainly one of the ways we have worked at
it is to go out into schools and youth schemes and to talk about

the walk-in clinics, where people can just come in and have free
counselling services, and we have really tried to normalize the
idea about coming to that clinic—that it is not about madness,
it is about the ordinary problems young people have—and we
try to make it seem like a normal thing to do. I cannot say it has
turned the tide in the number of young men who have come,
but I think we have to continue trying.
FLOOR: When we are talking about groups that don't get identi
fied, one of the groups that I have come across in society are
refugee children, many of whom have the most tremendously
traumatic experiences. It seems that the staff sometimes don't
recognize the large number of refugee children they have in the
school. This certainly happened in one of the large comprehen
sive schools that I know of. Equally, they are terrified of open
ing this can of worms, and usually it is the teacher who teaches
a special language or a special subject who is left to deal with
these children's distress and who needs support.
D R DE SAUMA: I would like to comment about what the student
counsellor said about conferences. I think our conference was
advertised in many of the schools in London and also to GPs.
Unfortunately, we do not have many GPs here, but one-quarter
of the people attending this conference deal with educational
institutes. But one big problem we have is the funding, the
financial constraints—that people receive the information but
can't do anything about it. There are funds for schools and
other agencies, so it is important to go into schools, as we are
doing now, because this is a long-term endeavour.
M R GIBSON: I would like to add to Dr de Sauma's point about
conferences and parents and other groups. The presentations
here illustrate that, since we are in a position to find out a good
deal about adolescents and disturbance in adolescence, there is
an onus on us for the relevant information about breakdown
and analytic psychotherapy to be made available as widely as
possible. I think that is sometimes a neglected area and is left in
books that sit on shelves. We have a duty to inform the commu
nity about what we have found out. I know of the difficulties
from my own experiences, when I was a teacher of emotionally
disturbed children: I had ten maladjusted adolescents taking

me apart from 9.00 a.m. to 4.00 p.m., and thereafter I might
have the opportunity to pick up a book. I think the idea of
having some way of bringing information to people is some
thing very important and absolutely essential. The actual avail
ability of psychoanalytic work to the vast majority of
adolescents is minimal. There are 58 million people in this
country—10 million adolescents. We have a lot of work to do.
Where funding is very important is that what comes out of
the money being spent is not just the treatment of particular
adolescents, but research that can be used to help and inform
10 million.
FLOOR: I would like to come back to something that Dr Temple
stressed earlier—that there is the anxiety of the people who
have to deal with adolescents. That also contributes to keeping
people away from conferences. It is not enough to think that
you can spoon-feed information without helping people to
face their anxieties or being made to listen to what they are
hearing. For most of us this means: "What am I going to do? I
am hearing about these dreadful problems, and what is going
to happen if I don't pick it up in time? It makes me feel even
worse and more responsible." So there is a limit to the idea of
just giving information. I think that we should be more aware
that people who work with adolescents in schools, hostels, hos
pitals, feel terribly isolated and alone. To go to a conference
once a year is not enough. It needs to be recognized that anyone
working with adolescents needs to have some support group. It
should be built into their work, so that they can meet with each
other, in a way that they can help each other to contain their
anxiety. That is necessary in order to recognize what they are
dealing with. I think that is the point that Dr Temple was mak
ing.
FLOOR: Is there a challenge that could be issued to Brent Adoles
cent Centre on this subject? Because when we talk, we do so
very broadly about 10 million adolescents, and my heart sinks.
But here we have a Centre that survives through difficulties
and is an inspiration to us and an inspiration to many people,
because it is actually not just about books and writing. It is also
about where one can refer people to, where they can go. There
is, as I understand it, a place where it is possible to engage in
teaching and training at appropriate levels. But we probably
have failed to consider the different levels of support and train
ing that can be offered to people.
My experience over many years in adolescent units and spe
cial units for disturbed children is that one of the things that is
missing is training that is derived from a psychoanalytic model
at appropriate levels. That is what people need. I think that is
something about which one could challenge the Brent Ado
lescent Centre, as to whether that is possible. Certainly it is a
concern and issue at the Tavistock Clinic that we have not pro
vided broad-enough training that can reach those who need
it. I think that is one of the reasons why so many adolescent
services and centres have collapsed or closed. They haven't
sufficient levels of training appropriate to nurses and others
who are working in those areas. We haven't provided an edu
cational system that is broad enough for that. That is something
we need to think about. It cannot cover for 10 million people,
but it is a way in which something can start that answers the
problem. There does seem to be an enormous gap between the
teacher on the ground and the people who have had the oppor
tunity of doing specialist training.
FLOOR: I work with parents and also with schools. My question is
whether members of the panel could make some comments
about how a parent or teacher or youth worker can cope with a
dilemma of both keeping order and safety and control with
these youngsters, family, school group, or whatever, and yet
be able to offer this containment and understanding and even
therapeutic process. I think people tend to go to one extreme or
the other, and neither is successful unless you are somehow able
to keep both. Obviously, a one-to-one clinic situation is different
from the classroom or the youth group situation, but perhaps
you are able to give tips, from your experiences, that are rele
vant.
PETER WILSON: You're the second person who has wanted tips.
PANEL: T O some degree it seems that you have answered your own
question in terms of trying to maintain a balance between the
extremes one can be pushed into. We cannot usefully offer you

tips just like that. But what we can do is set up and maintain
dialogue out of which can come some useful ideas about ways
of working in particular settings.
M R GIBSON: In relation to earlier points raised by Dr Temple: there
is a way to respond to this issue. I take the point raised by Mrs
Laufer and Dr Temple that the way forward, in addition to
information, is to have support for workers in the field, to en
able people to think about what they are doing and to contain
their anxiety, to contain the anxiety that is projected into
them—into us—each day. I am sure you have all had the expe
rience of going home and finding yourself going on and on
about a particular adolescent, to the exasperation of the family.
One way we used, in schools, of helping ourselves with this
problem in trying to maintain a reasonable balance between
the task of education and other tasks was to have a meeting
after work each day. Now, that involved extra work for every
one, but it meant that for a small group it was possible to think
about what happened during the day. In the absence of having
a therapist in the school, this was a part-solution that went on
for many years and helped everyone to think about what they
were doing. There is no instant solution in these circumstances,
but it can be very helpful if you can work out some suitable
support meeting.
In answer to the challenge faced by the Brent Adolescent
Centre, I think at the moment they are responding to it—the
need for further development with the wider community. We
have started, for example, to run a course specifically aimed at
teachers, to understand more of the classroom dynamics and to
think about problems with adolescents.
FLOOR: I want to come back for a moment to a question Mrs Laufer
raised and Dr Temple responded to. It is a reference to what Dr
Temple raised earlier about the issue of services for adolescents
succeeding and sustaining themselves. He was intimating that
in the public sector there has been a feeling of finding it very
difficult to survive and develop in recent years, and pointing to
the inspiring example of the Brent Adolescent Centre in actu
ally having done this, and suggesting that this was due to the
degree of attention paid within the organization to the nature

of the demands that working with the troubled adolescents
makes on those who are doing the work. I think this needs to
be looked at further. The suggestions about training courses are
obviously correct, but I think the actual practice of the centres
that succeed in maintaining themselves—often against the dif
ficulty of financing and other problems—needs to be thought
about. I don't know the arrangements at the Brent Adolescent
Centre, but one assumes that, apart from the experience and
quality of the analytic training of those who work there, the
internal arrangements for discussion of work and those areas
and the quality of the institutional dynamics assist very much
in managing the specific intense anxiety that working with
adolescents occasions.
Certainly with our own organization at Open Door—
another organization that has survived and developed over the
years, with very clear convictions about the kind of frame
works for treatment that are most helpful—the way in which
we have organized our work for our staff within the organiza
tion and the attention we have paid to those relationships have
been the basis of dealing with young people's anxieties and
helped them to move rather than being overwhelmed by them.
This is a very important issue, and we can't avoid the profes
sional responsibility for the quality of how that is done, and
whether these kinds of organizations both survive and are able
to spread their ideas more widely, in the way the Brent Adoles
cent Centre has regularly been able to do.
FLOOR: One of the themes today has been about the accessibility of
services. I think there is a lot of work and thinking to be done
about that, which includes a flexibility in the range of services.
I think that the accessibility of services in the minds of other
professionals arises out of the existence of personal links.
I wanted to come back to Dr Donovan's point about opening
the floodgates and say that GPs might have more purchasing
power in the future and would be able to say, "We need more
adolescent services".
MRS CROCKATT: I wanted to say about networking, that there are
more services around than one realizes, but often each service
i
RESPONDING TO MENTAL BREAKDOWN 1 43
is working away on its own and not connecting enough with

the other ones. I think intensive networking on your own patch
can often reveal a lot more in terms of discussion and sugges
tions.
DR DE SAUMA: I would like to go back to a particular adolescent. I
was minking of Mary, the girl who was seen by Mrs Bellman
and later by Dr Flanders. It was a very moving account. It is a
good demonstration of how adolescents can be helped when
there is someone there to help them and to understand and
even, in Mary's case, to save her life.
FLOOR: The prevalency rate for problems among adolescents is
about twenty percent, which is about two million. That is a
figure that the Mental Health Foundation has made public for
some time. It is widely quoted that two million young people
under the age of 16—including children as well—have sig
nificant mental health problems that require some kind of
additional help. That is an awful lot of people. There are many
ways of reacting, and we have had a variety of suggestions
here of the different parts to be played in responding to the
various kinds of distress and disturbances that young people
have.
I have been coming to Brent Adolescent Centre conferences
for many years, and I have always been very impressed and
excited by them. I think one of the key things is that they do
raise awareness of the importance of the work, of the severity
of the work with many of the adolescents, and of what it
takes—as Dr Healy discussed—in really getting alongside and
working intensely with adolescents and knowing what these
human beings, who are young and at a very critical point in
their lives, are going through.
The danger of what we are left with is that we can't possibly
do that for two million, and there is a major shortfall between
the actual provision and the demand and need that is out there.
I think Dr Bateman's point about so many young people
having significant problems that are unrecognized just adds
to that two million by, I should imagine, another million or
two. The problem is enormous, and I think that those of you
who work in schools and in the difficult areas would say that
twenty per cent is an underestimation—probably more like

sixty per cent in your classrooms have problems.
I think there are key points about paying serious attention
to the internal life of young people, to what they bring into
adolescence from their childhood, to the quality of parenting.
This is a whole other area—really to help parents to parent
their own children for the sake of a better life, a better life
in their childhood and a better life in their adolescence and in
later years.
PETER WILSON: There can be no doubt that the subject of adolescent
breakdown is of crucial concern, not only to adolescents
themselves, but to all those who care about them. What is at
stake is both the creativity of a young human being and the
construction of a future adult life. When things go wrong in
adolescence, learning becomes curtailed, curiosity constricted,
pleasures prohibited, friends avoided, assertions distorted;
there is, in effect, a disruption of growth, an interference in the
normal continuities of progressive development. Implicit in the
concept of breakdown is a failure to sustain these continuities—
that something has broken down within the individual that
should ordinarily enable him to cope with the pressures and
strains of living.
There is, of course, much in the adolescent experience that
is inherently stressful. All young people, whatever their cir
cumstances, and in differing degrees, live with a wide range of
developmental anxieties—of losing childhood dependency;
of feeling alienated and alone; of facing demands and the
challenges of exams; of coping with feelings of inadequacy; of
sorting out the questions and the possibilities of sexuality;
of dealing with the fear of losing control. None of these anxi
eties, moreover, is made any the easier in the social and cultural
context of our times. Young people now live in a climate of
unprecedented change, dealing with major economic and
moral uncertainties and growing up within the insecurities of
their families and communities. The predicament of the mod
ern adolescent is not a comfortable one. Typical development
anxieties—of adjusting to the impact of puberty and establish
ing separation and individuation—are compounded by the ten
RESPONDING T O MENTAL B R E A K D O W N 145
sions and demands of contemporary life: the pressures of media

imagery, the shifts in gender role and expectations all add com
plexity to notions of normality and social adaptation. Financial
and employment factors, too, contribute to a prolongation of
dependency among many adolescents and their families.
There is thus a great deal on young people's minds—and it
is a measure of their mental health how well they deal with
these many kinds of anxieties. The majority manage well
enough—they have sufficient inner resource and supportive
backup (both within their present families and from their past
experiences) to take on the challenge of their development and
face the world with both a sense of fun and serious purpose.
But there is a significant minority who do not fare so well—
who find the impact of their experiences overwhelming and
who see the prospects of growth as daunting—even impermis
sible. Within them, there is, in effect, a collapse of their capacity
to defend adequately against fears and intense feelings—and it
is this that constitutes their adolescent breakdown.
The presentations have provided an invaluable insight into
the nature of adolescent breakdown and raise major issues
about detecting and responding to its various manifestations.
In the cases that are described, the overriding picture is of
young people terrified by the forces of their own bodies and the
fantasies that accompany them, and equally afraid of breaking
away and/or (paradoxically) of not being able to break away
from parental ties. The adult state does not excite them; rather
it presents them with the awesome prospect of responsibility
for one's actions (both bodily and mentally) and of loneliness
and isolation. These are young people who, in one way or
another, cannot disentangle themselves, within their minds,
from their dependencies upon their parents. Invariably, they
have been held back by the complications of their family cir
cumstances and of the vulnerabilities of their parents, them
selves struggling with their own questions about sexuality and
individuality.
The ways in which adolescents give expression to their
breakdowns vary a great deal. Some become withdrawn, so
cially isolated, refusing to go to school or work; others develop
eating problems or take refuge in solvent abuse. Still others

become more outgoing, more defiant and violent. And many
harbour suicidal thoughts and act in a suicidal way. Through
out the experience of adolescent breakdown is the risk—more
extreme in some than others—of self-destructiveness in its
many forms. The key developmental issue for many is not only
how to live, but, indeed, whether to live: it is about how to give
expression to potentiality and how to establish dignity and self
worth.
The detection of adolescent breakdown in some adolescents
is not too difficult—their symptomatology gives a clear signal
of distress and internal difficulty. With others, however, the
task is not so straightforward, for the extent of breakdown is
often concealed and all too easily overlooked. There are many
adolescents, for example, who though in difficulty, do not seek
help—or if they do—or it is presented to them—they strongly
resist it. Despite their despair or the violence of their predica
ment, they set obstacles to receiving help. Some feel unworthy
or filled with disillusion, mistrust, and resentment of the adult
world. Often they make others feel as deficient, useless, and
rejected as they feel themselves, seeking to evade acknowl
edgement of their own disturbing feelings, conveying a mis
leading impression to the outside world. As Anthony Bateman
has made clear, they can easily invite from others a collusive
"blind eye" to their difficulties: "The unconscious task of the
adolescent in the midst of a breakdown is to ensure that it goes
unrecognized."
It is testimony to the value of such discussion and debate
that its contributors steadfastly refuse to be pushed away. In
their assessments, they sustain a strong and caring scrutiny of
the internal world of the adolescent. In their therapy, they offer
a readiness to engage with the underlying forces of the break
down and an opportunity to think and gain through greater
understanding.
BIBLIOGRAPHY
Aichhorn, A. (1925). Wayward Youth, London: Imago Publishing, 1951.

Bateman, A. (1995). The treatment of borderline patients in a day
hospital setting. Psychoanalytic Psychotherapy, 9 (1): 3-16.
Bios, P. (1962). On Adolescence. New York: Free Press of Glencoe.
Bios, P. (1977). When and how does adolescence end: structural crite
ria for adolescent closure. Adolescent Psychiatry, 5: 5-17.
Chasseguet-Smirgel, J. (1981). Loss of reality in perversions—with
special reference to fetishism. Journal of the American Psychoanalyti
cal Association, 29,511-534.
Deutsch, H. (1944). The Psychology of Women, Vol 1. New York: Grune
& Stratton.
Deutsch, H. (1945). The Psychology of Women, Vol 2. New York: Grune
& Stratton.
Deutsch, H. (1968). Selected Problems ofAdolescence. New York: Interna
tional Universities Press.
Erikson, E. (1959). Identity and the Life Cycle (Psychological Issues:
Monograph No. 1). New York: International Universities Press.
Erikson, E. (1968). Identity: Use and Crisis. London: Faber & Faber.
147
148 BIBLIOGRAPHY
Esman, A. H. (Ed.) (1975). The Psychology of Adolescence: Essential Read

ings. New York: International Universities Press.
Freud, A. (1958). Adolescence. Psychoanalytic Study of the Child, 13:
255-278.
Freud, A. (1965). Normality and Pathology in Childhood. New York:
International Universities Press. [Reprinted London: Karnac
Books, 1989.]
Freud, S. (1905d). Three Essays on the Theory of Sexuality. S.E. 7.
Freud, S. (1910g). Contributions to a discussion on suicide. S.E. 11 (pp.
231-232).
Freud, S. (1917e [1915]). Mourning and melancholia. S.E. 14 (pp. 239
258).
Freud, S. (1924e). The loss of reality in neurosis and psychosis. S.E. 19
(pp. 183-187).
Friedman, M., Glasser, M., Laufer, E., Laufer, M., & Wohl, M. (1972).
Attempted suicide and self-mutilation in adolescence: some obser
vations from a psychoanalytic research project. International Jour
nal of Psycho-Analysis, 53:179-183.
Glasser, M. (1985). The weak spot—some observations on male sexual
ity. International Journal of Psycho-Analysis, 66:405-414.
Hale, R., & Campbell, D. (1991). Suicidal acts. In: J. Holmes (Ed.),
Textbook of Psychotherapy in Psychiatric Practice (pp. 287-306). Edin
burgh: Churchill Livingstone.
Hall, G. S. (1916). Adolescence (2 vols.). New York: Appleton.
Jacobson, E. (1964).T/ie Self and the Object World. New York: Interna
tional Universities Press.
Jacobson, E. (1971). Depression. New York: International Universities
Press.
Laufer, M., & Laufer, M. E. (1984). Adolescence and Developmental Break
down. New Haven, CT: Yale University Press. [Reprinted London:
Karnac Books, 1995.]
Laufer, M. (Ed.) (1995). The Suicidal Adolescent. London: Karnac Books;
New York: International Universities Press.
Mead, M. (1949). Male and Female. New York: Morrow.
Sands, D. E. (1956). The psychoses of adolescence. In: A. H. Esman
(Ed.), The Psychology of Adolescence (pp. 402-413). New York: Inter
national Universities Press, 1975.
Schilder, P. (1935). The Image and Appearance of the Human Body. New
York: International Universities Press, 1950.
BIBLIOGRAPHY 149
Stengel, E. (1964). Suicide and Attempted Suicide. Harmondsworth,

Middlesex: Penguin.
Winnicott, D. W. (1958). The capacity to be alone. International Journal
of Psycho-Analysis, 39: 416-420. [Also in: The Maturational Processes
and the Facilitating Environment (pp. 29-36). London: Hogarth Press
and the Institute of Psychoanalysis, 1965. Reprinted London:
Karnac Books, 1990.]
Winnicott, D. W. (1964). The Child, the Family and the Outside World.
Harmondsworth, Middlesex: Penguin.
INDEX
abnormality, fear of, 4, 7, 9, 21, 77, 78, examination, 47

79,118 of girls at puberty, 28,30
effect of, 33 [see also case studies (Flo)]
and homosexual thoughts, 19, 33 "predictable ways" of dealing with,
masturbation as source of, 8 after adolescence, 5
sexually mature body as source of, 4, as reaction to sexual development,
8 18
therapist's own, 85 [see also case studies (David, Gina)]
[see also case studies (Flo, Mary, appearance, preoccupation with, in
Muriel, Paul)] adolescence, 118
abortion in adolescence, effect of, 32 attachment, 19
adolescent phase: abnormal, to mother: see case studies
characteristics of, 17 (Mary)
defining role of, 5 and loss, in oedipal stage, 117
for females, 27-37 to parents, of adolescent, 40
for males, 17-25
despair in, seriousness of, 77 Bateman, A., be, 117-133,137,143,146,
[see also despair] 147
developmental breakdown in behavioural analysis, 59
(passim) behaviour therapy, 70
problems in, recognizing, 17,19, 21, Bellman, D. B., ix, 93-102,115,143
136,143 bingeing: see bulimia
adolescents, working with, problems of, Bios, P., 147
39-56 body:
aggression, 25, 68 physically mature, in adolescence,
[see also case studies (Eddie); 80, 84, 118
violence] and fear of abnormality, 4, 8
agoraphobia, 36-37 bulimia as hate of body, 36
Aichhorn, A., 147 image, change in, in adolescence, 118
alcoholism, in parent, effect of, 32 sexually mature, 4
ambitions, unrealistic, in adolescence, attitude towards, 35, 39
18 problems arising from: see case
ambivalence, towards family, 70 studies (Mary)
analytic interpretations, 66 rejection of, in adolescence, 80
anorexia, 4,118,131 breakdown:
as hate of body, 36 definition, 75-86
anxiety, 30, 78,108, 110, 111 developmental (passim):
in adolescence: adolescent's lack of recognition of,
acute states of, 21, 65 131
normal, 7 as classification, 4
caused by sexual relationship, 31, 34 importance of, 3-15, 77
about competing with mother: see later consequences of, 117-133,
case studies (Flo) 144
151
152 INDEX
breakdown (continued) parental, 132

developmental (continued) control:
vs. nervous breakdown, 6,77 bulimia as: see case studies (Mary)
vs. normal stress, despair, fear of loss of, 37
hopelessness, 4,6 [see also case studies (Eddie)]
recognizing, 60, 70,118,119,120, feeling of loss of, in adolescence, 8, 9,
126, 128,129, 130, 137,146 18, 22, 24, 25, 30, 32, 35, 36, 37,
response to, 135 79, 86,118
seriousness of, 3,13,14,15, 32, 80, [see also case studies (Jim)]
84, 120 of mother's sexual life: see case
working with, 93-102,103-115 studies (Mary)
mental breakdown in, consequences need for: see case studies (Eddie)
of, passim rigid, of relationships: see case
Brent Adolescent Centre, ix, x, xi, 3,4,9, studies (Jane)
20, 21, 24, 40, 45-53, 80-83, countertransference, 127
88-90, 94,102,103,110, 114, as assessment tool, 89
136,139,140, 141,143 crime: see delinquency
Bronstein, C , 103 Crockatt, G., ix, 135,136,137, 142
bulimia: see case studies (Jane, Mary)
delinquency, 44, 77, 89, 90
Campbell, D., 148 [see also case studies (Eddie)]
Caparrotta, L., 93 delusions: see case studies (Dan)
case studies: denial, 120
"Angela", 47 depression:
"Bob", 20-21, 24, 25 in adolescence, 4, 21, 69, 79,131
"Charles", 22-23, 24, 25 and seductive behaviour, 54
"Dan", 23-24, 24,25 [see also case studies (Angela,
"David", 119,130 Charles, Dan, Gina, Hal, Jill,
"Eddie", 57-71 Mary)]
"Flo", 30-32 adult, 36
"Gina", 50-51 [see also case studies (Flo)]
"Hal", 52 mother's: see case studies (Flo, Mary)
"Jane", 121-133 post-natal, 30
"Jill", 52,53 de Sauma, Maxim, x, 135,138,143
"Jim", 82-84, 90 despair, 6, 77, 79, 94,105,120
"John", 41-42 [see also case studies (Mary)]
"Lloyd", 46-47 in adolescence, seriousness of, 77
"Mary", 93-102,103-115,143 normal, vs. developmental
"Molly", 80-S2, 84, 90 breakdown, 6, 7, 77, 78
"Muriel", 9-11,13,14 suicidal: see case studies (Mary)
"Paul", 11-13,14 detachment:
Cassel Hospital, x, 113,114 from mother, 19
Chasseguet-Smirgel, J., 147 from parents, 19, 20
chemotherapy, 70 Deutsch, H., 147
childbirth, normal function of, 32 development, normal, characteristics of,
childhood feelings, revival of in 7,78
adolescence, 43 developmental breakdown: see
community services vs. specialized breakdown, developmental
services, 135 di Ceglie, D., ix, 130-133
conformity, pressure for, 137 dieting, compulsive, 35-37
containment, 64, 89,110,140 doctor, role of: see case studies (Jim)
emotional, 131 Donovan, C , 75
INDEX 153
drug addiction: hallucinations: see case studies (Dan)

in adolescence, 4, 77,90 Haringey Healthcare NHS Trust, be
mother's: see case studies (Eddie), 57 Healy, K., x, 113-115,143
Holmes, J., 148
Erikson, E., 118,147 homosexual experience:
Esman, A. H., 147 in adolescence, effect of, 32,33
in later adolescence, and
family: development, 33
environment, importance of, 88 homosexuality, 21
impasse, 69 fear of, 12,18
interactions, significance of, 69 flight to: see case studies (Dan)
and internal persecutory conflict, 89 mother's: see case studies (Eddie)
therapy, 67, 68-70 hopelessness, 14
fantasies of adolescence, 4, 8, 9, 79 normal, vs. developmental
and neuroses, 6 breakdown, 6, 7, 77, 78
father: and pregnancy in adolescence, 33
death of, effect of, 31, 32 hysterical personality, 13
fear of becoming like, 40
lack of: identity, in adolescence, 118
effect of on girl, 33 impotence, fear of, 21
[see also case studies (Eddie, impregnate, ability to, relevance of, 4,
Mary)] 76
mature relationship to, 19 incarceration, mother's: see case studies
powerful, dominating: see case (Eddie)
studies (Jane) incestuous attachment: see case studies
search for: see case studies (Paul) (Mary)
seduction by, effect of, 32 individuality, vs. intimacy, 118
feelings, fear of: see case studies (Mary) individuation, 144
females, development of, 27-37 intellectualization, 120
Flanders, S., ix, 94,103-113,115,143 internal conflict:
Freud, A., 148 of adolescents, 120
Freud, S., 6,130,148 omnipotent avoidance of, 90
on development of boys vs. that of internal figures, narcissistic
girls, 28 compromises with, 88
Friedman, M. H., be, 39-56,148 internal life, affected by adolescent
friends, as objects of sexual fantasies, 18 breakdown, 85
frigidity, 34 internal object, family environment clue
to, 88
Gibson, C , x, 135,136,138,141 internal persecutory conflict, and family
Glasser, M., 148 situation, 89
group therapy, 67, 68 internal world:
guilt, xi, 8,18,19, 22, 29, 31, 32, 34, 37, conceptionalization of, failure of, 89
45, 69,123 confusion and conflict in, 118
induced by mother: see case studies effect of family on, 68
(Jane) persecutory, and sexual
sense of: development, 91
normal, 78 reaching, 90, 111
about relationship with mother: through countertransference, 127
see case studies (Mary) interpretations, regurgitation of: see case
studies (Mary)
Hale, R., 148
Hall, G. S., 148 Jacobson, E., 148
154 INDEX
jealousy, effect of on normal sexually mature girl, as equal of, 29

relationships, 9 mothering, unpredictable: see case
studies (Eddie)
latency period, 117
adolescence, continuation of, 117 nervous breakdown, vs. developmental
experience during, effects of, 117 breakdown, 6, 77
Laufer, M , x, xi-xii, 3-15, 75-86, 87, 88, networking, 142
89, 90, 118,137,141,148 neurosis, 6
Laufer, M E., x, 27-37, 39-56,118,148 obsessional, 21
"Little Hans", 130 North West London Mental Health
Trust, ix
madness:
fear of, 8,9, 25, 79,138 oedipal phase, 117
[see also case studies (Dan, Paul)] oedipal situation: see case studies
therapist's own, 85 (Mary)
[see also case studies (Mary); mental Open Door, 142
illness]
male, development of, 17-25 paranoia, 13
masochism: see case studies (Jane) adolescent's: see case studies Qane,
masturbation, 78 Mary, Paul)
and fear of being abnormal, 8 mother's: see case studies (Mary)
[see also case studies (Bob, Charles)] parent(s), 19
maternal identifications, differentiation alcoholism of, effect of, 32
from, problems with: see case attitude of, towards adolescent, 69
studies (Jane) attitude towards, in adolescence, 9,
maturation, emotional, 117 13,18
Mead, M., 148 maturing of, 17,19
Mehra, K., x, 17-25 [see also case studies (Muriel)]
melancholia: see case studies (Muriel) death of, effect of, 32
menstruation: [see also case studies (Charles)]
affected by extreme diets, 35 detachment from, in adolescence, 19,
as cause of anxiety, 28, 34, 35 20, 40-56, 78
[see also case studies (Flo)] exaggerated, 44
mental disorder, xii, 6, 7, 75, 76, 77, 84 and withdrawal from environ
signs of, 76 ment, 46
mental distortions, in adolescence, 4, 6, inability of to see child as separate,
8, 9, 79 88
Mental Health Foundation, 143 mental illness of, effect of, 32
mental illness, 4,24, 75, 84, 87, 88, 89 as objects of sexual fantasies, 18, 69
in parent, effect of, 32 relationship with, maturing of, 7
result of adolescent breakdown, 84 sexual activities of, obsession with:
roots of in adolescence, 3,15 see case studies (Charles)
services for, 88 Parkside Clinic, x, 136
mother: phobias, 37
attachment to: physically mature body, significance of,
of female: see case studies (Mary, 80, 84
Jane) [see also body]
of male, 19 Portman Clinic, ix
girl's fear of becoming like, 29 pregnancy, 4, 76
hatred of: see case studies (Mary) in adolescence:
rejection of, 37 effect of, 32, 33, 76
[see also case studies (Eddie)] and relation to mother, 29, 32
INDEX 155
privacy, adolescent's need for, 67 intensity of feelings within, 113

probation officer, 45 mother-daughter, 94
role of, 39,43,44 [see also case studies Qane, Mary)]
promiscuity, in adolescence, 4 with parents, importance of, 39,42
effect of, 34 parental, breakdown in, 127
psychiatric classifications, not peer, during latency period, 117
applicable in adolescence, 13 rigidly controlled: see case studies
psychoanalysis, 63, 64, 66 (Jane)]
psychological classifications, not sexual:
applicable in adolescence, 13 as cause of anxiety, 31
psychopathic personality, 13 early, 34
psychosexual development, 117 stable and loving, 29, 37
psychosis, 14 [see also case studies (Muriel)]
psychotherapy, 21, 66, 67, 71,98,105, with teacher, importance of, 59,40
106,107,112 transference: see case studies (Jane)
with adolescent, difficulties of, 49 resistance:
analytic, 138 of adolescent:
individual, 66 to psychoanalysis, 65
ineffectual: see case studies (Hal) to psychotherapeutic help, 63
psychotic illness, 46 revenge, wish for: see case studies
puberty, 80,108,144 (Mary)
as beginning of adolescence, 4, 28
as time of change, 8,9,28 Sands, D. E., 148
relevance of, 4, 28, 34, 35, 36,68 Schachter, J., x, 135
[see also case studies (Eddie, Schilder, P., 148
Muriel)] schizophrenia, 47
in adolescence, 4
rape, effect of, 32 seduction, by older man, effect of, 32
rationalization, 120 self-attack, 79
refugee children, problems of, 138 self-beating: see case studies (Jim)
regression, 7 self-cutting, 113,132
relationship(s), 29, 31, 64, 84, 86, 88, 96, [see also case studies (Jane)]
110, 111, 117, 127, 128, 132 self-destruction, fantasies of: see case
ability to form, 6, 7,18,19 studies (Jim)
during adolescence, volatility of, 48 self-destructiveness, in adolescence, 146
adult, affected by adolescent self-esteem, low: see case studies
breakdown, 85 (Eddie, Mary)
analytic, 64 self-hatred, 6,10,14, 77,113
closeness and dependency in, 65 in adolescence, 9
with contemporaries, 39, 58 sexually mature body as source of, 8
homosexual: [see also case studies (Mary, Muriel)]
as cause of anxiety, 33 self-insulation: see case studies (Eddie)
effect of, 32 separateness, awareness of: see case
identity through, 5 studies (Eddie)
inability to form, 8, 9,12,14, 22, 24, separation:
34, 36 from family, during adolescence, 118
and pregnancy in adolescence, 33 and individuation, 144
[see also: case studies (Dan, Hal, sexual abnormality, 4
Mary)] sexual activity, purposes of, 19
inability to sustain: see case studies sexual body, development of, 117
(Eddie) [see also body]
inappropriate, 44 sexual experiences, early, 34
156 INDEX
sexual identity, established in good, importance of, 40,136

adolescence, 118 xrole of, 39, 45, 80
sexuality, adult, overexposure of child [see also case studies (Angela,
to: see case studies (Eddie) Eddie, Lloyd, Molly)]
sexually mature body: see body Temple, N., x, 87-91,139,141
sexual maturity, 17,18, 21, 37, 79 therapy: see psychotherapy
in adolescence: torment, in adolescence, 8, 79
problems arising from, 54
relevance of, 4, 5, 8, 54, 76 urgency, need for, in treating
of female, relevance of, 29 adolescents, xi, 3,14, 68, 70, 75,
inability to face, 36 79, 84
of male, relevance of, 18
sibling, birth or death of, effect of, 32 violence, 109, 113
silence, as cover-up for violence: see in adolescence, 4
case studies (Mary) [see also case studies (Eddie, Paul)]
Simple Minds, 135 father's dread of: see case studies
social worker, role of, 39 (Mary)
specialist services, vs. community mother's: see case studies (Mary)
services, 135 silence as cover-up for: see case
"Spielraum", 118 studies (Mary)
Stengel, E., 149 [see also aggression]
stuckness, paralysed: see case studies vomiting:
(Mary) as attack on body, 113
suicide: bulimic: see case studies (Mary, Jane)
in adolescence, 4, 79,105
attempted, 4,13, 68, 77,101 walk-in clinics, 50,138
vs. pregnancy, 76 Wilson, P., x, 57-71,117,135,137,140,
[see also case studies (Muriel)] 144
mother's: Winnicott, D. W, 149
threat of, 123 withdrawal:
[see also case studies (Dan, of emotions:
Muriel)] from environment, 46 [see also case
wish for: see case studies (Charles) studies (Eddie)]
from parents, 43,44,46
Tavistock Clinic, ix, x, 140 at puberty, 80,145
teacher, 41,48, 80, 81 as symptom, 19, 69
attitude towards, of adolescent, 9, vs. violent contact: see case studies
49 (Mary)
aggressive: see case studies (Eddie, [see also case studies (Bob, Charles,
Paul) David)]
idealization of, 43 Wohl, M., 148
inability to have supportive worthlessness, feeling of, 8,14, 79
relationship with, 8,44 [see also case studies (Paul); self
need for support of, 138,139,140, hatred]
141
as object of sexual fantasies, 18 Young Minds, x, 135
relationship with, 41-42 youth worker, role of, 39
Adolescent Breakdown and Beyond
Edited by Moses Laufer
C o n t r i b u t o r s : A n t h o n y Bateman, Debbie B a n d l e r B e l l m a n ,
G a b r i e l l e C r o c k a t t , M a x i m de Sauma, D o m e n i c o d i Ceglie,
Sara Flanders, M a u r i c e H . F r i e d m a n , C h r i s t o p h e r G i b s o n ,
K e v i n H e a l y , M . Egle Laufer, Moses Laufer, K a m i l M e h r a ,
Joan Schachter, N i c h o l a s T e m p l e , Peter W i l s o n
"For many years, Moses Laufer and his colleagues at the Brent
Adolescent Centre/Centre for Research into Adolescent Breakdown
have made important contributions to our understanding of the
assessment and treatment of psychiatric disorder i n adolescence. This
new monograph underscores, w i t h rich clinical documentation, the
urgency of these tasks and the value of a psychoanalytic developmental
perspective i n pursuing them. It w i l l be of value to all professionals
w h o w o r k w i t h young people, and should be essential reading for
those concerned w i t h public policy as well."
Aaron H. Esrnan, M . D . Professor of Clinical Psychiatry (Emeritus)
Cornell University Medical College Editor, Adolescent Psychiatry
This is the second monograph published by Karnac Books on behalf

of the Brent Adolescent Centre/Centre for Research into Adolescent
Breakdown. D r a w i n g on the Centre's unique pool of expertise i n the
field, it contains papers giving up-to-date psychodynamic perspectives
on adolescent breakdown by leading clinical experts. These cover a
range of topics, such as the differing developments i n male and female
adolescents, and the particular problems of psychotherapeutic
intervention w i t h them. It also includes the proceedings of a conference
on the subject held i n October 1995. Here the issues of adolescent
breakdown are discussed i n the wider context which workers i n the
caring professions must consider. Overall, the book provides a concise,
contemporary overview of a topic whose importance is increasingly
being recognised both inside and outside the psychotherapeutic
community.
Karnac Books, Cover Design by

58, Gloucester Road, Malcolm Smith
London SW7 4QY ISBN 1 85575 149 6

(Brent Adolescent Centre S) Moses Laufer - Adolescent Breakdown and Beyond-Karnac Books (1997)

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1

Anthony Bateman Debbie Bandler Bellman

Copyright © 1997 by the Brent Adolescent Centre

All rights reserved. N o part of this publication may be reproduced, stored in

British Library Cataloguing in Publication Data

A C L P . record for this book is available from the British Library

ISBN 978 1 85575 149 1

Edited, designed, and produced by Communication Crafts

Printed in Great Britain by BPC Wheatons Ltd, Exeter

ANTHONY BATEMAN, MA, MRC Psych; Psychoanalyst; Consultant

D E B B I E B A N D L E R B E L L M A N , BA; Child & Adolescent Psychother­

G A B R T E L L E C R O C K A T T , MA; Consultant Child Psychotherapist,

M A X I M D E S A U M A , MD; Psychoanalyst; Brent Adolescent Centre/

D O M E N I C O D I C E G L I E , MRC Psych; Consultant Child & Adolescent

S A R A F L A N D E R S , PhD; Psychoanalyst; Staff, Brent Adolescent

MAURICE H. F R I E D M A N , MB, ChB, DPM; Psychoanalyst; Former

C H R I S T O P H E R G I B S O N , BEd; Psychoanalyst; Staff, Brent Adolescent

KEVIN H E A L Y , DPM, MRC Psych; Consultant Psychotherapist,

M. E G L £ L A U F E R , B S C (Hons); Psychoanalyst; Staff, Brent Adolescent

M O S E S L A U F E R , PhD; Psychoanalyst; Brent Adolescent Centre/

KAMIL MEHRA, PhD; Psychoanalyst; Former Staff, Brent Adolescent

JOAN SCHACHTER, MB, ChB, MRC Psych; Psychoanalyst; Consultant

N I C H O L A S T E M P L E , MB, ChB; FRC Psych; Psychoanalyst; Consultant

P E T E R W I L S O N , BA; Child Psychotherapist; Director, Young Minds;

and Charities. The Centre for Research into Adolescent Break­

" | developmental breakdown" represents a concern that

I would like to begin with an observation that ultimately

cence to about the age of 21 simply because it seems that it is

1. The adolescent ultimately knows that he has ways of feeling

But there are those adolescents who experience something

valued relationship because of uncontrollable jealousy or because

The first I heard of "Muriel" was when she telephoned our

M u r i e l first h a d s e x u a l i n t e r c o u r s e w h e n a g e d 13; at the t i m e ,

From this, we could also begin to make some sense of her

I will come back to Muriel, but I want now to describe another

was coloured by them; I believed at the time that Paul was

Neither Muriel's nor Paul's case is as uncommon as it may sound.

enough to experience breakdown, it may be the time for a second

Interferences in the move

W hile it is generally accepted that the ground-plan of

1. A change in one's image of oneself, including the changes in the

which they see as grossly abnormal. In most cases the homosexual

"Bob", a 26-year-old civil servant, came to the Centre with the

he did describe feeling upset when he moved home at the age

The above is one of many adolescents who come to the Centre

bility, dissatisfaction with work, or an inability to make satisfac­

"Charles", a young engineer aged 23, was seen in an agitated

the cultural activities at the college, he was often in trouble

studies, but since leaving the university he has drifted from

worlds, desperately but ineffectively trying to cope with their mad

Interferences in the move

I n this chapter I try to show how the emotional experiences a

adult woman means possessing a body that is now equal to her

successfully accomplished and who then, as an adult, reacted to

This is an extreme example of what is called post-natal depression,

When I learned more about Flo's adolescence, I could see

So far, I have mentioned the sort of childhood this woman had,

In the case of Flo, a number of experiences during her adoles­

I chose this example to show how certain events, if they

same attitude of helplessness and passivity, which, of course, we

a step forward on the way to heterosexuality, as it is for the

Many adolescent girls react to the changes in their bodies at the

I saw a young woman who had become unable to continue to

D E B B I E B A N D L E R B E L L M A N , BA; Child & Adolescent Psychother

and Charities. The Centre for Research into Adolescent Break

bility, dissatisfaction with work, or an inability to make satisfac

In the case of Flo, a number of experiences during her adoles

enjoyable in some ways, he will often also feel it as a strain, be

We would like to contrast this example (where we were realis

ally with the growing awareness of his own separateness (exacer

understanding the extent of the adolescent problem; in acknowl

In development that is proceeding normally, a number of char

I want first to acknowledge the optimism and hope that is con

was prone to extreme anxiety and paranoid thoughts and to out