The body in adolescence

The Body in AdolescenceThe Body in Adolescence: Psychic Isolation and Physical Symptoms examines the affective experience of psychic isolation as an important and painful element of ado

The Body in Adolescence

The Body in Adolescence: Psychic Isolation and Physical Symptoms examines the

affective experience of psychic isolation as an important and painful element of adolescent development Mary Brady begins by discussing how psychic isolation, combined with the intensity of adolescent processes, can leave adolescents unable

to articulate their experience She then shows how the therapist can understand and help adolescents whose difficulty with articulation and symbolization can leave them vulnerable to breakdown into physical bodily symptoms

This book introduces fresh ideas about adolescent development in the first chapter Subsequent chapters include clinical essays involving adolescent patients presenting with bodily expressions such as anorexia, bulimia, cutting, substance abuse, and suicide attempts Attention is also paid to adolescents’ use of social media in relation to these bodily symptoms—such as their use of online “pro-ana”

or cutting sites Clinicians can feel challenged or even stymied when presented with their adolescent patient’s fresh cut or recent episode of binge drinking Brady uses Bion’s conceptualization of containment and the balance of psychotic versus integrative parts of the personality to examine the emergence of concrete bodily symptoms in adolescence

Throughout, Mary Brady offers ways of understanding and empathically engaging with adolescents This book is essential reading for psychoanalysts and psychotherapists who treat adolescents and other patients with physical symp-toms, as well as other readers with an interest in a psychoanalytic understanding

of these issues

Mary T Brady is a psychoanalyst and clinical psychologist She is in the private

practice of psychoanalysis, psychotherapy, and consultation in San Francisco She

is on the Faculty of the San Francisco Center for Psychoanalysis She is a member

of the International Psychoanalytic Association and the American Psychoanalytic Association She has published widely on adolescence and bodily symptoms In

2010 she won the American Psychoanalytic Association Ralph Roughton Award for her paper, “‘Sometimes We are Prejudiced against Ourselves’: Internalized and External Homophobia in the Treatment of an Adolescent Boy.”

“This book by Mary Brady is a matter of absolute necessity in the literature of Psychoanalysis Presenting her own clinical experience with young people ‘of our times’ – in which the body is taken as the seat of conflict – we can see an experienced and dedicated analyst working sessions with adolescents who suffer from the most frequent presentations of their age: eating disorders, cutting and substance abuse.

With masterful tact, she shows us how clinical work with these developing individuals enlightens us as to the singularity of young people, the dynamics of family groups, as well as the characteristics of a culture which, inundating the senses, aids and abets psychic isolation.”

—Virginia Ungar, M.D., Training and Supervising Analyst,

Buenos Aires Psychoanalytic Association and President Elect

of the International Psychoanalytic Association

“This is a very fine book It enormously extends the range of our understanding of disturbed adolescents The author has great expertise and wisdom, and her beauti-ful clinical stories are also informed by serious scholarship Her identification of the sense of psychic isolation felt at times by even the most ordinary – and ordi-narily sociable – adolescents as a major issue in adolescent psychopathology, is clearly a breakthrough She draws our attention to their attention to their bodies, and her descriptions of her tact and sensitivity with these very touchy wounded young people are a joy to read.”

—Anne Alvarez is a Consultant Child and Adolescent Psychotherapist,

and retired Co-Convener of the Autism Service, Child and Family Department, of the Tavistock Clinic, London

“In this book Mary Brady puts her finger on two crucial areas of adolescent ety, each of which makes the other one worse She finds that loneliness is almost universal; adolescents’ frenetic socialising is often a defence against this The other is their preoccupations with their bodies whose rapid changes fill them with terror Their bodies are the seat of projections of disturbing feelings and unconscious beliefs Her clinical and literary illustrations bring this beautifully

anxi-to life As Bion would have it she has identified the selected facts in the crisis of adolescence.”

—Robin Anderson, Training and Supervising Analyst in Adult and

Child Analysis at the Institute of Psychoanalysis, London;

he was also Consultant Child Psychiatrist at the Tavistock Clinic

where he was Head of the Adolescent Department

The Body in Adolescence

Psychic Isolation and Physical Symptoms

Mary T Brady

by Routledge

2 Park Square, Milton Park, Abingdon, Oxon, OX14 4RN

And by Routledge

711 Third Avenue, New York, NY 10017

Routledge is an imprint of the Taylor & Francis Group, an Informa business

© 2016 Mary T Brady

The right of Mary T Brady to be identified as author of this work has been asserted by her in accordance with sections 77 and 78 of the Copyright, Designs and Patents Act 1988.

All rights reserved No part of this book may be reprinted or reproduced or utilised in any form

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British Library Cataloguing in Publication Data

A catalogue record for this book is available from the British Library

Library of Congress Cataloging in Publication Data

1 “Unjoined persons”: Psychic isolation in adolescence and

2 Invisibility and insubstantiality in an anorexic adolescent:

3 Cutting the silence: Initial, impulsive self-cutting in adolescence 39

4 Substance abuse in an adolescent boy: Waking the object 57

5 “High up on bar stools”: Manic defenses and an oblivious

6 Sexuality unreceived and adolescent suicide 92

7 Pro-anorexia websites through an adolescent development lens 105

Index 115

In writing this book, Mary Brady has made a wonderful contribution to the choanalytic literature of treating adolescents It is an honor for me to comment on some of the notable highlights of her book Her focus on bodily based symptoms

psy-is timely As she notes early on, adolescents now come into treatment much more frequently with problems that manifest in what they are doing to their bodies

We often first meet them when they are starving themselves, cutting themselves, intoxicating themselves, recklessly driving their parents’ cars, or covering their skin with tattoos and piercings

In these situations, parents can seem forlorn, lost, incapacitated, and ested in what lies behind these physically extreme statements about disturbing states of mind Brady’s understanding of how these parental attitudes affect and shape an adolescent’s feelings of containment—or lack thereof—is repeatedly brought to our attention in each case In this book, the combination of her keen intellect, deep empathy, and years of experience in treating adolescents helpfully guides the reader into understanding her patients’ anguish We also learn about the healing that can come when these adolescents have access to such a dedicated and compassionate psychoanalyst, who sees them, listens to them, and is willing to venture where a psyche finds itself lost and stranded

disinter-She comes to her professional life with exceptional credentials Brady is both

an adult and child psychoanalyst Her interest in psychology, and particularly choanalytic psychology, is long-standing She graduated from Holy Cross College

psy-in Worcester, Massachusetts with a major psy-in psychology Brady later attended The Wright Institute in Berkeley, California to complete her doctorate Finally, she graduated from first the adult and then the child programs at the San Francisco Center for Psychoanalysis

She has extensive clinical experience in the treatment of eating disorders, a challenging field that is not for the faint of heart She continues to teach and lec-ture in a variety of psychoanalytic settings, locally, nationally, and internation-ally To have her now write this significant book is a fitting accomplishment that documents what many of us already know: she is a sensitive, wise, and talented clinician

As I read the chapters of Brady’s book, I kept recalling lines from William Butler Yeats’ poem, “The Second Coming.” An Irish poet and Nobel Prize winner, Yeats captures something of the isolation occurring during a turbulent, stormy period He writes: “things fall apart; the centre cannot hold; Mere anarchy is loosed upon the world” (Yeats, 1976: 184) These words reminded me of what adolescents often try to describe when conveying the pain of feeling so alone with everything crumbling about them.

Brady speaks to this sentiment over and over in the case material, as well as

in her discussion of the character Frankie from Carson McCullers’ The Member

of the Wedding This combination of loneliness and spinning in terror—a kind

of anarchy unleashed on an inner world filled with powerful emotions—sets a stage for what Brady describes when adolescents turn to and against their bodies

to communicate how uncontained they feel She articulates the complexities of how internal and external failures of containment can result in disturbing behav-iors of attacking a growing body When the psychic center cannot hold, the body becomes a prime target for expressing unbearable emotions

Normative feelings of isolation in adolescence typically occur during a period

of considerable growth and also loss Parents, teachers, and trusted adults are no longer who they once appeared to be as authorities and protectors A lot of letting go naturally takes place at this time of life, but there can also be confusion about what will replace what is lost Adolescents who are isolated can easily lose their bear-ings around questions such as: who am I at this moment, who can I trust, and who will help me if I need it? Their internal object relationships shift sometimes slowly, sometimes abruptly A wish for a center that holds is not at all uncommon, as Brady shows us in her evocative discussion of Frankie from McCullers’ novel Frankie is both “caught” and “loose,” depicting the multiple occasions of emotional to-and-fro-ing characteristic of adolescent transitions She is not sure where she belongs, and Brady helps us to see that this feeling is almost prototypical of adolescence.When not held either by available internal resources or by caring in the envi-ronment, this feeling can lead to profound alienation Clare’s struggle (Chapter 2)

to feel seen and responded to becomes encased in her anorexia Brady shows

us the paradoxical linkage existing when someone desperately calls attention to herself by physically wanting to disappear Likewise, Marcus’s bleeding knee ( Chapter 3) is a fascinating example of analytic enactment around when an ado-lescent body gets noticed and what this means about who might or might not be paying attention I particularly liked that Brady used André Green’s idea about

applying the etymology of the word “symbol” to analysis In classic Greek bolon), it referred to the joining together of two halves of a clay seal or coin

(sym-that messengers used to recognize one another This notion of putting something together in order to be recognized offers a useful paradigm for analytic encounter

at many levels Marcus was fortunate to have someone to receive his half and to provide him a matching piece that decoded some of the hurt that he was avoiding.What happens when there is no one there to offer the other half of the coin or seal? Adolescents can then turn against their bodies when they feel left alone with

powerful negative emotions This lack of containment often results in dissociated psychic states The cases of Neil (Chapter 4) and Natalia (Chapter 5) show the dissociative pull that adolescents can succumb to, especially when they opt to abuse drugs and alcohol Brady explores what happens internally that could lead

to dissociation overtaking an adolescent mind She raises important therapeutic questions about the holding environment, safety, parental neglectfulness, and use

of supportive treatments for substance abuse Anyone working with adolescents will find her discussion of these topics to be of value

I admire that Brady tackles the inevitable technological modernity that cents bring into our practices Her discussion of the Rutgers webcam spying case (Chapter 6) and of pro-anorexia websites (Chapter 7) shows once again that when new technologies emerge, adolescents will adopt them for better or for worse They frequently revel in the more shadowy aspects of what technology now enables Brady asks, “How do we meet our patients in trying to understand worlds that can seem foreign to us?” (Chapter 7, p 105) This is an excellent question that stretches our imaginations and often our capacities to empathize Hearing about or viewing the anarchy of the Internet, we often may feel that “the center cannot hold.”Reading Brady’s insightful book, I often found myself thinking about initia-tion, which is a topic well researched by the Jungian analyst Joseph Henderson (2005) Initiation is a term that can be usefully applied to the adolescent psyche

adoles-We often hear about fake initiatory acts gone bad, for example in harmful ing by athletic teams and sexual misconduct by fraternities, in both of which the bodies of others are brutally attacked by group members True initiation involves separation, containment, and finally liberation into something meaningful that connects with a community

haz-Puberty invokes a separation from much of what childhood has come to mean Crossing this threshold, there usually follows along this path an experience of ordeals, each of which represents a symbolic death of old ways Overcoming these challenges takes strength, but not just to assert a manic defense or show off in a narcissistic display Rather, it is inner strength to be reborn in a new form This cycle of death and rebirth characterizes many elements of adolescent develop-ment, and it underscores why any attack on the body must be taken very seriously, since it could become lethal

Containment is a necessary ingredient for traversing the initiatory trials that move an adolescent forward into more mature social and psychological capacities Containment implies identification, holding, receiving, and importantly, limits We can see many of these aspects when Catherine (Chapter 1) tries on Brady’s shoes, perhaps sensing someone in whose footsteps she would like to follow Brady’s chapters on adolescent cutting and substance abuse amply demonstrate that ado-lescents need strong adult figures to react against as well as to support them One could consider these extreme behaviors as signifying not only failed containment, but also failed initiation One adolescent boy once told me that the reason he cut himself was to prove that he was not weak—a misconceived ordeal that trapped him in time and did not allow him a way forward

Brady comments on the rite of passage happening in adolescence She shows

us the importance of containment, especially when an adolescent has gotten stuck

by attacking his or her body Therapeutic containment, eloquently described by Brady in many of her analyses, offers the possibility of creating a healing space

so that adolescents can come in from the peripheries of where they feel they have been driven into isolation Brady’s engaging book has given us much to

c ontemplate

Robert Tyminski San Francisco, California References

Henderson, J.L (2005) Thresholds of Initiation Wilmette, IL: Chiron Publications Yeats, W.B (1976) The Collected Poems of W.B Yeats New York, NY: Macmillan.

This book is the result of a protracted labor of love None of us choose our occupations: adolescence and adolescents have taken hold of me for some time Treating adolescents is an undeniably prickly, difficult, and frequently scary endeavor One is richly rewarded however, by the fresh and moving experiences that emerge from the prickles It is a precious analytic responsibility to try to preserve the adolescent process from the incursions of societal pressures or devel-opmental arrest into bodily symptoms

pre-While teaching Adolescent Development to the candidates at the San Francisco Center for Psychoanalysis in 2005, I attended a paper given by Robin Anderson for the Sixteenth Annual Melanie Klein Memorial Lectureship entitled “Adoles-cence and the body ego: The reencountering of primitive mental functioning in adolescent development.” His linking of the physical symptoms of adolescence was formative to me I have subsequently taught courses on “Bodily Based Psy-chopathologies” many times and have written several papers on these issues I am particularly thankful to Robin Anderson for his theoretical depth, his experienced eye, and for his generosity in allowing me to quote from his unpublished paper.Ray Poggi has influenced my clinical thinking over many years and has kindly read several of these chapters During his training in psychoanalysis at the Topeka Institute for Psychoanalysis, he was Director of an in-patient unit at the Menninger Clinic treating young adults and adults Prior to and during his residency he worked

at an adolescent and children’s unit at the Menninger Clinic and also at a unit for adolescent girls at Topeka State Hospital The ethos of the Menninger Clinic involved respect for a team approach for severe disorders Although most of the patients discussed in this book did not need to be hospitalized, readiness to hospital-ize and openness to ancillary care are essential for severe bodily based disturbances Most of the cases in this book involved my collateral work with parents, while some parents have agreed to a referral for parent work with another therapist A minority have been in family therapy It is common that adolescent crises signal a problem

in the family Flexibility to adapt to who needs to be in treatment, and what sort of treatment, is a staple of adolescent work I have been fortunate to benefit from Ray Poggi’s thinking on these issues over many years I hope I convey some fraction of the strength, integrity, and clinical wisdom I have found in him

Another source of generous support for this book has been my colleague Robert Tyminski He and I have taught a weekly consultation group on ‘The Treatment of Adolescents and Young Adults’ for mental health professionals since 2007 Robert Tyminski is a gifted clinician and a creative scholar It is has been a joy to think together about theory and clinical work over many years No less a joy have been the many excellent clinicians who have been members of the group Their com-pany and comradeship has been fortuitous for this work The current group con-sists of Kristen Carey, Kristen Fiorella, Camala Kirchen, Michael Loeffler, Romi Mann, Jeremy Marshman, Elissa Meryl, Dawn Smith, and Jacquie Ward My fond regards to many prior group members as well.

There are three other senior colleagues I would like to thank who have all been very generous with me I have consulted periodically on my child and ado-lescent patients with Virginia Ungar She has a wonderful quality of empathy for even the strangest teens Similarly, I have had the pleasure to consult with Ann Alvarez occasionally and she has read and commented on a couple of the chapters

in this book Her emotional presence with patients, combined with her ability and willingness to say the hard thing when necessary, have been models to aim for Finally, Donald Moss has been a gem I had the good fortune to present an early paper to him at a writing workshop at the San Francisco Center for Psychoanalysis some years ago He discussed the psychological impediments to writing, includ-ing the tendency to write defensively He has read several of the chapters in this book I try to take his advice that it is most interesting to be able to hear the author thinking

Finally, many friends have encouraged my writing Til and Charlie Stewart have been great friends and shared their wisdom as both reader (Til) and writer (Charlie) Cricket Halsey, Cheryl Goodrich, Holly Gordon, Sharon Tyson, Gady Heinic, Margo Chapin, Cathy Witzling and Catherine Mallouh have also been stalwarts Mary Jane Otte’s consultation group, including Elizabeth Biggart, Shela Fisk, Jana Kahn, Ann Martini, and Camilla Von Voorhees kindly read and made helpful suggestions on Chapter Five

In memoriam, I am grateful for having had the opportunity to spend several years in supervision with Joe Afterman while I was a child analytic candidate

He had a wonderfully imaginative and flexible way with children and cents He is a testament to the idea that any real analyst is one of a kind—certainly

adoles-he was

Carey, my husband, has been supportive of my love for both psychoanalysis and for writing about psychoanalysis during the whole of our marriage His matu-rity and capacity to share have been passed along wonderfully to our son, Danny

I have been touched by their enthusiasm for this work

Chapter 1 is based on [2015] ““Unjoined persons”: psychic isolation in

adoles-cence and its relation to bodily symptoms.” Journal of Child Psychotherapy,

41(2), 179–194

Chapter 2 is based on [2011] “Invisibility and insubstantiality in an anorexic

adolescent: Phenomenology and dynamics.” Journal of Child Psychotherapy, 37

(1): 3–15

Chapter 3 is based on [2014] “Cutting the silence: Initial, impulsive self-cutting in

adolescence.” Journal of Child Psychotherapy, 40(3): 287–301.

Chapter 5 is based on [2015] “High up on bar stools: Manic defences and an

obliv-ious object in a late adolescent.” Journal of Child Psychotherapy, 41(1): 52–72.

Chapter 7 is based on [2014] “Pro-anorexia websites through an adolescent

devel-opment lens: Commentary on paper by Tom Wooldridge.” Journal of Infant, Child, and Adolescent Psychotherapy, 13(3): 217–223.

Permissions

novel, The Member of the Wedding (1946), to illustrate adolescent

developmen-tal unrest and the accompanying sense of psychic isolation I will argue that the painful experience of psychic isolation is part of the developmental process of adolescence Bodily changes and psychological separation from parents can con-tribute to states of psychic isolation for adolescents, when all that is new cannot

be easily expressed or even thought Psychic isolation also makes the personality much more vulnerable to breakdown, especially through the projection of mental distress into the body, resulting in somatic symptoms such as eating disorders, cutting, substance abuse, or suicide attempts

My thinking about the experience of psychic isolation crystallized when

read-ing Carson McCullers’ novel, which is set in Alabama durread-ing World War II It is

the story of Frankie, a girl who feels cut off from those younger or older than she

is and unable to articulate the changes within her The Member of the Wedding is

an intensely inward novel Most of the story takes place in Frankie’s kitchen, yet much seems to happen inside her While the experience of psychic isolation is painful for Frankie, her inner world is rich Contemporary adolescents may have too little chance or encouragement to wonder about their inner worlds

Fundamental to this book is the understanding that adolescence is a fulcrum of the body, the psychic, the family and the culture Some elements of contemporary culture seem to exacerbate adolescent loneliness Ungar (2014) comments that adolescents are more alone than ever before She suggests that the accelerated

pace of modern life, the pressure to succeed, as well as the pervasiveness of nology leave adolescents very little room for an inner, intimate space.

tech-The breakdown into somatic symptoms (in relation to feelings that cannot

be contained or symbolized) is particularly frequent in adolescence This book will connect issues surrounding bodily based symptoms, which have previously been discussed separately This grouping is important because of the underlying commonality of developmental themes Cutting oneself versus starving oneself may convey different elements of distress, but both express aspects of develop-mental breakdown when they present in adolescence Paradoxically, while bodily symptoms represent the breakdown of the adolescent’s capacity to bear emotion, they can also engage the reaction of a containing other and potentially a healing process in psychotherapy

Comments on the organization of this book

I intend here a series of largely clinical essays to convey the tendency toward, and meanings of, bodily expressions during this period Eating disorders, cutting, substance abuse, and suicide attempts are the primary bodily symptoms of ado-lescence that are discussed in this book In order to preserve the confidentiality

of patients, I have changed biographical information and other details throughout this book

A host of bodily symptoms emerge in adolescence and express ments in, and failures of, the adolescent process, such as tattooing, piercing, body dysmorphia, promiscuity, and emergencies such as wrecking the family car

develop-An exhaustive review of the somatic expressions that emerge in adolescence is beyond the scope of any one book Neurobiology, as well as issues of access and inexperience, can be factors in these physical symptoms (e.g., with driving or substance use) However, I am discussing these symptoms from a clinical point of view and suggesting there are important developmental factors that underlie them.Chapter 1 will describe a unifying understanding of bodily symptoms in adolescence and the developmental importance of psychic isolation I argue that psychic isolation is part of the developmental process of adolescence Psychic isolation also makes the personality much more vulnerable to breakdown, includ-ing to somatic symptoms

The next four chapters (Chapters 2–5) are each essays centered on patients with bodily based psychopathologies

Chapter 2 will discuss an anorexic adolescent girl Her sense of “invisibility” is understood as resulting from an avoidance of experiences of separation and psychic isolation by overreliance on phantasied merger While phantasied merger avoids anxiety and pain, it interferes with the development of a sense of a visible self.Chapter 3 will focus on initial, impulsive self-cutting in adolescence This sort

of cutting is contrasted with more entrenched, ritualized cutting that can become established if the communication in the initial cutting is not received I will dis-cuss early cutting as potentially symbolic in Green’s (1975) sense of a symbol

being the uniting of two halves That is, cutting has the potential for ing explosive feelings in the object (analyst) who can have (in Green’s terms) a homologous experience to that of the patient This elaboration within the analyst’s feelings allows for the cutting to become truly symbolic of an adolescent’s emo-tional state and not left to be an empty self-destructive action I describe a clinical example in which an incident of self-harm caused distress in the analytic session, but broke the psychic isolation of my patient’s depressive state.

generat-Substance abuse is significant for the adolescents discussed in both Chapters 4 and 5 In both chapters I examine the developmental factors at hand, as well as the underlying object relations

Chapter 4 will focus on a boy in analysis abusing alcohol, marijuana, and other drugs I had initially treated him in latency after his parents’ devastating divorce Both parents were preoccupied after the divorce, and he was left insufficiently supervised and contained Internally he was isolated from healthier parts of himself

as he attempted to distance himself from his sensitivity by hardness (in the form of risk taking and substance abuse) I detail my efforts to interpret these issues and the eventual need for confrontation when he told me of life-threatening experiences Handling these problems required involving his parents, which in this case forced them

to cooperate in ways that made them more real parents This case raises many issues regarding an analytic understanding of setting limits and the use of ancillary care

I believe this work went in the direction of “making a thought thinkable” (facing his parents’ absence from him and from each other and his escalating self- destructiveness) and away from the isolation that eventuates in self-harming symptoms

I discuss four interrelated themes of late adolescence in Chapter 5: birth/death throes, oblivious objects, manic defenses, and the potential for physical symp-toms, sometimes in emergency form These issues are elucidated through the psy-choanalysis of a late adolescent who was bulimic and binge drinking Though her symptoms were severe, elements of her dynamics are seen as characteristic of late adolescence The separation-individuation processes of late adolescence are seen

as a final death throe of childhood and birth throe of adulthood In these death throes, the adolescent can see objects as oblivious The late adolescent can resort

to manic leaps to avoid the subjective experience of psychic isolation that can accompany passages for which she feels unready Such leaps sometimes take the form of physical symptoms, sometimes in crisis form, as late adolescents separate more definitively than in earlier developmental periods

Chapter 6 examines the relationship between psychic isolation and suicidal behavior in young people I will use the example of Tyler Clementi, the gay Rutgers University student who suicided after being spied on by his roommate via webcam during a romantic encounter of his with another man Clementi had felt rejected by his mother after he told his parents he was gay Next, he was surrounded by homophobia in his dorm at Rutgers His mother reported feeling hurt that Tyler had not told her earlier he was gay, but was not able to envision

the psychic isolation involved in his not feeling able to tell his family he was

gay Tyler Clementi went from feeling a sinner within his home and his religious

community to a freak in his new life Psychic isolation that does not meet with any containment, but instead rejection, can be too much to bear The high rate of suicide among gay teens, particularly boys and young men, will be discussed here.

In Chapter 7, I discuss “pro-anorexia” sites: Internet forums that have a lar appeal for adolescents “Pro-ana” sites include chat rooms, images of anorexic bodies, and tips on losing weight and maintaining underweight bodies—so-called

particu-“thinspiration.” Pro-ana sites take an at least partially positive view of eating orders (Wooldridge, 2014) There are similar sites for bulimics (“pro-mia” sites), self- cutters, and for those intrigued with suicide I will suggest that viewing our ado-lescent patients’ use of these sites through adolescent developmental concepts such

dis-as psychic isolation, identity, defiance, and contagion is helpful to our understanding

Adolescent succession processes: intra-psychic,

familial, and cultural

In order for the adolescent to attain adulthood, there must be a shift in the erations Loewald (1979) tells us this involves, in some sense, the murder of the parents The psychological murder of the parents is one crucial aspect, but only one aspect, of the problem of the passage of generations In the arduous process of development, adolescents want to kill their parents and to keep them alive Adults long for a new generation and both provide for it and resent it Likewise, the adolescent separates his need to murder the older generation (to attain adulthood) from his love for his parents In splitting off his aggressive parts, they are less integrated and feel potentially more dangerous The adolescent can retreat into a physical symptom for fear of these tumultuous and conflicting wishes

gen-Could we think of anorexia as an effort to weaken the self in order to evade the desire to succeed mother? In this unconscious scenario, conflicting wishes are projected onto and isolated in the body in order to both express to mother and pro-tect mother from murder Surely, this would be a fraught combination of violence and protection Winnicott’s concept of adolescent “moratorium” comes to mind, as well as his concept of adolescent “doldrums” (Winnicott, 1971) The psychological work of adolescence is too great to be gone through in any efficient manner.The relative absence of contemporary rites of passage for adolescents can leave them to create their own markers of passage These physical markers of passage can range from the frequent acquisition of a tattoo at a time of transition to the development of a bodily symptom to express a developmental crisis

Adolescence in transition

While the experience of loneliness or even freakishness has essential mental aspects, contemporary pressures on adolescents might be lessening their chance to grapple with and elaborate these issues How do contemporary pressures change the problems we meet in adolescents and how does this affect our ways of working with adolescents?

develop-I will refer here to some ideas, which will be further developed in this book

I suggest that adolescents are more frequently presenting with bodily based

pathol-ogies For instance, until the 1990s cutting was usually described in mentally ill

or prison populations in people with diagnoses of serious mental illness (Walsh, 2012) Since the 1990s, cutting has emerged in adolescents who are not seen as seriously functionally impaired When an adolescent is cut off from internal and external containing objects or aspects of the self that could be fallen back on in latency, drastic measures can be reached for Feeling cut off from one’s own or others’ minds can leave chaotic emotions to be played out on the body

The absence of intimate spaces for adolescents also abandons them into more narcissistic formations Much has been written (see, e.g., Mondzrak, 2012) describing a contemporary culture of narcissism Part of this culture of narcissism

is the idealization of youth Consequently, parents may find it harder to parent if they need to deny the loss of their own youth and the transition of generations Generational differences and conflicts can be avoided Generational conflict is crucial in adolescent identity building Adolescents can reach for drastic measures

to define their identities, such as extreme thinness or even anorexia Adolescents seem to be saying, “As long as I’m thin, it doesn’t matter to you if I feel empty emotionally, binge and purge, or starve.”

Adolescents imbibe cultural changes in a most rapid and powerful way, and are the group most intensely affected by rapid cultural changes (Ungar, 2014) Adolescents are the group most affected by the pervasive role of social media.Thus, adolescents are like the birds sent down into mines to signal the presence

of gases Unfortunately, there are sometimes casualties My discussion of the cide of Tyler Clementi in Chapter 6, which was likely spurred by his roommate’s toxic use of social media, is relevant in this regard

sui-The emptiness of cultural values obsessed with external appearances, ticularly for girls, is reflected in pro-anorexia online “thinspiration” images in extreme or even grotesque form These images seem like both an appropriation of cultural values and an accusation of their hollowness

par-Adolescent phenomena and Bionian concepts

Bodily symptoms and narcissistic formations that demonstrate little internal ing space require a greater need to work with projective identification and concepts

think-of container/contained My work is rooted in an object relational model I comment

on Bion’s conceptualizations specifically in this book He did not treat adolescents himself, so his concepts are still being integrated into work with adolescents.Bion’s interrelated concepts of container/contained and the conversion of beta elements to alpha function through maternal reverie are fundamental and clinically relevant to the treatment of contemporary adolescents with physical symptoms The baby expels unbearable anxiety into the mother, whose reverie can transform

it into bearable elements that can be thought about (Bion, 1962: 36) If mother receives her infant’s fears, they are modified in such a way that when they are

re-introjected, they become endurable In adolescence, unmetabolized states (for instance, profound feelings of psychic isolation) can be expressed or evacuated in some chaotic action (for instance, self-harm or binge drinking) Thus, parents and analysts are confronted with unfamiliar and sometimes life-threatening situations They are being asked to metabolize their adolescents’ extreme states The physical symptoms of adolescence are like the desperate cries of an infant seeking a mind that can bear and comprehend them.

What is radical about the concept of container/contained is that it emphasizes the fundamentally interactional nature of human development There is no growth

of an adolescent in analysis without our own growth The development of the adolescent’s own containing capacities involves the internalization of profoundly interactional experiences of container/contained in the analytic relationship.Bion’s development of the concept of container/contained grew out of his combat experience in World War I (Brown, 2012) Bion later described the analyst’s need to be able to think under fire How true this is for analytic work with adolescents—we are often hit with an unmetabolized bodily symptom that requires struggle on our part and struggle with the adolescent

Additional themes

Another underlying theme of the book is the growth of the adolescent’s containing functions through what Ferro calls “narrative derivatives” (Ferro, 1999) Dream space develops in ourselves and in our adolescent patients through the narratives

of music, film, and literature Adolescents can feel deeply uncomfortable with interpretations that focus on their bodily changes Working with narrative deriva-tives allows imaginative elaborations that assist the growth of the mind to handle conflicts While the interpretation of conflict is important, the growth of the capac-ity to handle intense emotions and conflicts and the processes of reverie in the analyst have become increasingly central in contemporary psychoanalysis

An analytic setting for adolescents accepts affective intensity and allows them

to communicate in their own ways As analysts we both accompany adolescents

on their journey and know that we will also be shed Self-harming symptoms must emerge in the session to begin to be known (such as in anorectic indifference to the “food” of the sessions)

At various points throughout this book, boundaries that an analyst must be able

to set to keep an adolescent safe are discussed These measures are necessary for safety, but also to give the adolescent a sense that we are there to be banged up against The complicated necessity for a team approach with some self-harming adolescents, including the use of hospitalization, day treatment, psychopharma-cology, nutritionists, etc., is also, at times, essential (For instance, I discuss the necessity for ancillary, intensive outpatient substance abuse treatment for the adolescent in analysis described in Chapter 4.)

This book will primarily be of use to those with a background in lytic ideas There are other therapeutic approaches to the psyche-soma, such as

psychoana-body psychotherapy (including, but not limited to Reichian therapies and primal therapies) that are offered elsewhere (Heller, 2012; Staunton, 2002; Totton, 2003) Finally, contact with your own adolescent experience would be valuable as you read this book I look forward to readers’ stimulating thoughts and reactions to this work.

References

Bion, W (1962) Learning from Experience London, UK: William Heinemann Medical

Books.

Brown, L.J (2012) Bion’s discovery of alpha function: thinking under fire on the

battlefield and in the consulting room International Journal of Psycho-Analysis,

93: 1191–1214.

Ferro, A (1999) The dialogue: characters and narratives In A Ferro, The Bi-Personal

Field: Experiences in Child Analysis London, UK and New York, NY: Routledge,

112–147.

Green, A (1975) The analyst, symbolization, and absence in the analytic setting (On

changes in analytic practice and analytic experience)—In memory of D.W Winnicott

International Journal of Psycho-Analysis, 56: 1–22.

Heller, M (2012) Body Psychotherapy: History, Concepts, and Methods New York,

NY: W.W Norton.

Loewald, H (1979) The waning of the Oedipus complex In Papers on Psychoanalysis,

New Haven, CT: Yale University Press, 384–404.

McCullers, C (1946) The Member of the Wedding Boston, MA: Houghton Mifflin.

Mondzrak, V (2012) Reflections on psychoanalytic technique with adolescents today:

Pseudo-pseudomaturity International Journal of Psycho-Analysis, 93: 405–422 Staunton, T (Ed.) (2002) Body Psychotherapy East Sussex, UK: Brunner-Routledge Totton, N (2003) Body Psychotherapy: An Introduction Maidenhead, UK: Open

University Press.

Ungar, V (2014) What remains and what has changed in psychoanalysis Unpublished paper given at ‘A Day with Virginia Ungar’, held at the San Francisco Center for Psychoanalysis, November 15, 2014.

Walsh, B (2012) Treating Self-Injury: A Practical Guide New York, NY: Guilford

Press.

Winnicott, D.W (1971) Adolescence: struggling through the doldrums In S.C Feinstein,

P Giovacchini and A Miller (Eds.), Adolescent Psychiatry Vol I New York, NY:

Basic Books.

Wooldridge, T (2014) The enigma of ana: A psychoanalytic exploration of pro-anorexia

Internet forums Journal of Infant, Child and Adolescent Psychotherapy, 13(3):

202–216.

it is particularly prevalent in adolescence for developmental reasons I conceive of psychic isolation in adolescence as an affective state with important developmen-tal underpinnings The affective elements are estrangement and loneliness—and sometimes a feeling of freakishness The developmental underpinnings include shifting (conscious as well as unconscious, internal as well as external) object relations and senses of the self While there could be limitless variations of the experience of psychic isolation in adolescence, there is a common developmental trend I am not referring specifically to teens who are socially isolated, but to an internal state (see Barrett, 2008, who comments that the driven way some adoles-cents socialize can be misconstrued more as evidence that they are not lonely than

as a defense against loneliness)

Transitory or lingering states of psychic isolation are common for adolescents, but also interact with other affective and developmentally related experiences such as rage, rebelliousness, depression, mourning, sexual confusion, spontane-ity, individuating, or identity formation I focus on psychic isolation in this first chapter for two reasons First, I think it has not been sufficiently discussed in psychoanalytic literature Psychic isolation is a frequent theme in literature writ-

ten about adolescents, such as The Member of the Wedding (McCullers, 1946)

or Catcher in the Rye (Salinger, 1951), as well as in literature written for cents, such as the post-apocalyptic City of Ember series (DuPrau, 2003) (which

adoles-was described to me at length by a pubescent boy) Second, psychic isolation can leave the adolescent cut off from others who can contain, relegating his body as the likely receptacle for troubles

Mourning is a fundamental aspect of adolescence (Green, 2013; Wolfenstein, 1966) The adolescent process requires withdrawal from childhood love objects (particularly in relation to authority and to erotic attachment) in order for devel-opment to proceed (Katan, 1951) Unconscious mourning of parental love objects is one element that can contribute to psychic isolation, but so can a feel-ing of strangeness at one’s body changing unbidden One latency age girl told me

that her early adolescent sister had sworn her to secrecy regarding having hair start to grow under one arm, but not yet the other Of course, it is easy to imag-ine that the younger girl was previewing her own impending physical changes Yet, what seemed closer at hand was a sense that it was mysterious to her why her older sister felt so much turmoil about her bodily developments She knew that her sister felt shameful and bizarre, but she could not yet understand what

it meant

When an adolescent is cut off from internal- and external-containing objects or from aspects of the self that could be fallen back on in latency, he or she can take drastic measures Feeling cut off from one’s own or others’ minds can leave chaotic emotions to be played out on the body I will propose here that psychic isolation can make adolescents particularly vulnerable to reliance on somatic symptoms (eating disorders, cutting, substance abuse, suicide attempts, etc.), which will be discussed throughout this book Without an understanding of adolescent states of mind, bodily symptoms can be misunderstood as reflective of greater disturbance than sometimes is the case during the fluctuating mental states of adolescence.Bodily changes and separation processes in adolescence create pressures on the mind that can lead to astonishing new ways of thinking and relating Bion saw separation, or the experience of lack, as the prerequisite for thinking In Bion’s (1967) “theory of thinking,” he says the mind (mental container) is stimulated

to think when it senses the “breast” is no longer available (112) Bion’s ideas are particularly relevant to the psychic separation processes of adolescence, which can cause a pressure or need to think and to develop At the same time, the strains

of separation that cannot be tolerated can also lead to projective identification, sometimes expressed somatically

Although Bion did not himself treat adolescents, several of his izations are helpful in understanding adolescent states (Brady, Tyminski, and Carey, 2012) As is well known, Bion (1962: 36) extends Klein’s understanding

conceptual-of projective identification as a defense to an understanding conceptual-of it as a beginning form of thinking and communication In infantile form, the baby expels unbear-able anxiety into the mother’s mental container, where “maternal reverie” can transform it into bearable elements that can be thought about If mother receives her infant’s fears, they are modified in such a way that when the infant re-introjects them, they become tolerable Translating this into the language of adolescent development: Unmetabolized states (for instance, intense sexual feelings or separation fears) are sometimes expressed or evacuated in some chaotic action (for instance, self-cutting or wrecking the family car) Thus, par-ents or analysts are confronted with new and sometimes life-threatening situa-tions They are being asked to metabolize their adolescents’ intense states and tolerate the knowledge that their child is changing in strange and heretofore unimaginable ways

The physical symptoms of adolescence are like the desperate cries of a baby seeking a mind that can encompass them When an unimaginable experience is shared with someone who has the capacity to comprehend it, beta elements are

transformed by alpha function An aspect of experience is digested (Beta ments are experienced as things in themselves, not as something to observe or think about, propelling projective identification and acting out.) Bion distin-guishes “the class of muscular action” from the realms of thought (1962: 13) For instance, purging could be thought of as a somatic effort to rid the self of beta elements Alpha function develops when an adolescent begins to wonder with an analyst about the motivations in his or her desire to purge.

ele-However, Bion is clear that this process is not just a cognitive reconsideration, but also an emotional experience Through repeated experiences of being under-stood (the translation of beta elements by alpha function through “maternal rev-erie”), he says, “there arises the apparatus for thinking the thoughts” (1962: 92) The child internalizes the experience of the containing function Thus, not only might an adolescent feel understood, but is gradually internalizing a new contain-ing structure1 in relation to his or her emerging adolescent experience

Adolescent states of mind are very much contents seeking a container In the face of profound psychological shifts and identity development, the capacity of the adolescent’s objects to be containing becomes more crucial When intense adolescent experiences are not met by either internal or external processes of con-tainment, they degenerate into “inanimate” (1962, p 14) exchanges, where there

is no reverie and no containment This leaves some adolescents trapped in tive physical symptoms, which threaten chronicity Bion suggests that learning depends on the capacity for the container to remain integrated, but not be rigid This allows the individual to retain his knowledge and yet be receptive of a new idea This is relevant in adolescence Parents and children must somehow retain some sense of who they were to each other, while undergoing sometimes violent throes of a “new idea”—that the child is no longer a child This is a profoundly interactive and experiential process

repeti-In adolescence, previous containing structures of the mind can break down because they cannot sustain all that is new (e.g., new fantasies and experiences of the self related to menarche, first wet dreams, etc.) New structures and senses of the self must be created Yet, adolescents are often not ready to enter the psychic spaces their bodies are propelling them into

The term “break down” is not used here in the psychiatric sense, but with the broader meaning of breakdowns in psychological space, for instance in desperate self-destructive acts that convey a psychotic aspect of the personality When a psy-chotic aspect of the personality is in ascendance, the capacity for development breaks down Of course, there is a spectrum of the extent and persistence of the breakdown The adolescent process in fact requires the re-organization of the personality, as the former organization cannot contain the meanings of new developments, such as menstruation or sexual penetration Anderson and Dartington (1998) contend that the adolescent process requires the “experience of being out of balance” and sug-gest that those adolescents “who have the inner strength and resources to bear to continue the experience of being naturally out of balance, as well as an environment that can support this … can achieve the best adjustment in adult life” (p 3)

When the adolescent mind is overwhelmed and a containing object is not able, the body can receive and express evacuative projective identifications or concretely express evocative forms of projective identification Although a des-perate measure, a physical symptom can stimulate the container/contained to growth by conveying that there is something urgent to be understood.

avail-Latency can be a relatively stable period, even for those who will later develop nificant disturbances in adolescence For instance, in latency the intense sexual and aggressive feelings of the oedipal period become organized in shared peer rhymes and rhythms, beautifully described by Goldings (1974) Here, jump rope rhymes organize shared feelings in a way that can be managed and hidden in plain sight.Anderson (2005: 2–3), influenced by Klein and Bion, describes that in latency, the nonpsychotic or integrative parts of the personality may be in ascendance, “which try

sig-to make order and in which paranoid-schizoid functioning moves sig-toward depressive functioning toward a wholeness, whole objects and cooperating objects, like the two parents.” He sees latency as “an uneasy truce, a compromise between conflicting desires and priorities, which could hold, provided the tensions were not too great.”The pressure of adolescence2 and adolescent developmental crises can lead to psychotic or disintegrative aspects of the personality becoming prevalent, along with reliance on severe splitting, expelling, and disowning “Children who had felt or appeared quite healthy, or at most a little nervous, can suffer quite serious breakdowns as a result of even moderate extra strains,” particularly at the onset of puberty (Klein, 1922: 55) Psychic issues can be expressed in somatic symptoms

at any age (Burloux, 2005); however, the body has a particularly magnetic tionship with the mind in adolescence Bodily based disturbances can be seen as

rela-“an exaggeration and a shift of the balance in the personality, rather than simply a set of aberrant developmental processes” (Anderson, 2005: 2)

Individuals enter adolescence with various internal capacities and tal provisions Stage theories (see for example, Levy-Warren, 1996, for a discus-sion of the subphases of adolescence) describe developmental similarities within

environmen-a penvironmen-articulenvironmen-ar phenvironmen-ase Stenvironmen-age theories cenvironmen-apture certenvironmen-ain elements; cleenvironmen-arly, there environmen-are nificant observable differences between an early adolescent and a late adolescent The Kleinian conceptualization of “positions” and the Bionian conceptualizations

sig-of the ascendance sig-of psychotic or nonpsychotic elements sig-of the personality better capture, however, the fluctuating mental states of adolescence There is a neces-sary tension between developmental and diagnostic generalities on the one hand, and considerations of internal variability, fluctuation and process on the other (see Corbett, 2001, for a discussion of the tension between views that emphasize simi-larity and coherence versus views that emphasize subjectivity and variability)

It could be said that individuals who enter adolescence with depressive, line, psychopathic, or psychotic personality organizations are far less likely to be able to negotiate the adolescent process Alvarez (1992) utilizes such diagnostic terms but emphasizes that models that stress “elements of a protective and devel-opmental type” … [such as] “Notions of immaturity, of weak ego development,

border-of deficit (Kohut), border-of equilibrium (Joseph)” (p 107) could be better descriptors

The object-related concept of positions (Klein, 1975) implies an interactive cess between self and object (both internal and external) For instance, an adoles-cent may project an unmetabolized chaotic emotion, which can be received by the object and potentially re-introjected This could lead to development of the external containing relationship, as well as to the adolescent’s internal containing capacities If the projective identification is not received or if the adolescent is in fact heavily projected into by the object (Williams, 1997) development could not take place or worse, deterioration could ensue Stage theories emphasize hierar-chical reorganization and capture important elements of the adolescent process, but can be misconstrued to deflect attention from the relational Bion emphasized that mothers did much of the mental digesting for the baby Similarly, objects must do much of the digesting for the adolescent.

pro-The adolescent personality is under considerable duress to absorb the meanings

of new sexual and procreative capacities Both early adolescence in general (Blos, 1967; Erikson, 1956), and menstruation in particular (Ritvo, 1976) have been dis-cussed as normative crises Ritvo describes menarche as having all the charac-teristics of a normal developmental crisis that can provide a stimulus or be an obstacle to development—in other words, leading to breakthrough or breakdown

In my clinical experience, the sense of psychic isolation is greatest at early adolescence, but some element can reemerge throughout adolescence Early adolescence has been written about as the most difficult time to initiate therapy ( Fraiberg, 1955) and as the time when there is the heaviest “burden of the unex-pressed” (Harley, 1970)

Gardner (2001) sees the physiological changes of adolescence along with related fantasies as contributing to a sense of bodily estrangement: “the sense of the body

as different, as being an object, something apart and separate from the self” (p 61).She sees this bodily estrangement as a crucial element in self-cutting:

For the person who harms themselves the body is being treated as something other and apart from the self In this way it provides both the target and recep-tacle for unmanageable feelings and uncontrollable instinctual impulses This new relationship to the body is fundamentally one of disconnection, not inte-gration, although the paradox is that only through disconnection can the body become the containing object for the fragile and fragmenting self

Separation from internal and external parental objects leads to a loss of auxiliary ego and superego functions This results in the notable instability in functioning of adolescents—seen in their dizzying shifts from acute sensitivity to insensitivity at rapid intervals The estrangement from objects and from prior experiences of the self is well captured in Carson McCullers’s phrase, “an unjoined person” (1946: 3)

It can be difficult for the analyst of an adolescent to know whether a psychotic state will be a transient upheaval or something far more ominous Eating disor-ders later in life generally have a different feel than they do in adolescence In adolescence, an eating disorder conveys an immediate developmental problem

threatening to shut down the growth of the personality Later in life, eating orders often acquire the sense of an established way of holding the self together.Analysts of adolescents are well aware the transitions into high school and college are periods of risk The onset of puberty (sometimes coinciding with the transition into high school) is a classic time for the onset of eating disorders One patient related that the onset of her eating disorder occurred as she binged on what was left of her Bat Mitzvah cake She was unready for the social, sexual, and academic developments ahead and broke down into an eating disorder The familiarity of day-to-day life, family, and community at least eases the experience

dis-of psychic isolation One anorectic late adolescent told me dis-of her first dream when she went to college: her body was thrown by a bomb blast that her parents and

I might see from far away on television Her containing objects seemed too far away to be of much use in the catastrophe of separation

In the section to follow, I use Carson McCullers’s great 1946 novel, The Member

of the Wedding, to evoke adolescent developmental unrest and psychic isolation I

then give a brief, clinical example of psychic isolation in adolescence Next, I link psychic isolation with vulnerability to the propensity for the breakdown into bodily symptoms in adolescence Next, I give a clinical example in which a physical symp-tom (cutting) is transient (The following chapters will describe patients with more entrenched physical symptoms: anorexia, cutting, substance abuse, and bulimia.) Finally, I consider how the challenge of adolescent development can be weathered

A literary evocation of adolescent psychic isolation

Carson McCullers’s The Member of the Wedding is set in small-town Alabama

Cen-tering on 12-year-old Frankie and the unnamable forces in motion within her, the story takes place over a handful of long, hot summer days, primarily in the kitchen Frankie shares with her family’s African-American cook, Berenice Sadie Brown, and her six-year-old cousin, John Henry Frankie’s mother died giving birth to her Her father remains a shadowy figure around the edges of the story Frankie looks at him “slant-eyed” after he tells her she is now too big to come and sleep in his bed every night.The novel palpably conveys the sense of a girl having outgrown who she has known herself to be and not yet comprehending any way forward for herself Too old now to play with the younger children, she is not yet accepted by the older girls whom she senses have crossed some bridge into sexual understanding that she has not She adopts a new name, “F Jasmine,” in order to leave behind the childish Frankie The kitchen setting seems to capture the inwardness of the changes taking place, while perverse racial inequalities and the catastrophes of World War II lurk in the background In a central scene Frankie/F Jasmine tries to name her uneasy, no-longer-child thoughts to Berenice:

What I’ve been trying to say is this Doesn’t it strike you as strange that

I am I, and you are you? I am F Jasmine Addams And you are Berenice Sadie Brown And we can look at each other, and touch each other, and stay

together year in and year out in the same room Yet always I am I, and you are you And I can’t ever be anything else but me, and you can’t ever be anything else but you Have you ever thought of that? And does it seem to you strange? (114–115)

Berenice responds:

We all of us somehow caught We born this way or that way and we don’t know why But we caught anyhow I born Berenice You born Frankie John Henry born John Henry And maybe we wants to widen and bust free But no matter what we do we still caught Me is me and you is you and he is he … Is that what you was trying to say? (119)

F Jasmine says yes, and goes on:

Sometimes I feel like I want to break something, too I feel like I wish I could just tear down the whole town … Yet at the same time you almost might use the word loose instead of caught Although they are two opposite words I mean you walk around and you see all the people And to me they look loose (120)

In this exchange, the tone between Berenice and Frankie has shifted from previous versations Berenice is now talking to Frankie as an equal who understands something

con-of the complexities con-of life, instead con-of as a child to be protected from them Berenice adds the word “caught” to Frankie’s thoughts—like a good analyst, she seems to understand what Frankie is saying and adds a new shape to it Berenice’s understand-ing of her thoughts seems to allow Frankie to elaborate them She expresses the wish

to “break something,” to “tear down the whole town.” This passage implies Frankie’s urge to break through her feeling of strangeness and isolation physically, consonant with the physical breakthroughs going on in her Able to express her feelings to a con-taining other (someone who can apprehend, share, and tolerate her experience), she finds some way other than being isolated and trapped in physical expressions.This sort of exchange captures what is compelling about treating adolescents There is an urgency to figure things out, to grapple with who we are, what our place and meaning in the universe is The urgency and sense of estrangement are sometimes captured in poignant words (as in the above passage) and sometimes can only find expression by some other drastic means

The adolescent is caught in psychic isolation in many ways—caught in an awareness of things one is not ready for yet Caught in sexuality and gender being more defined and intense, gone is the “uneasy truce” of latency Caught in a body transforming seemingly with a will of its own, caught in inexorable changes with parents, or parental figures such as Berenice Sadie Brown is to Frankie, and caught in the impending challenge to define a role in the larger world The isola-tion is also experienced as being loose One’s own experiences seem strange and impossible to convey One is both caught and loose at the same time While it is

true that people of any age may be caught between the effort to find words or to resort to drastic action, it is particularly true for adolescents.3

A clinical example of psychic isolation in adolescence

Eleanor

“Eleanor,” a 13-year-old whom I had seen in analysis for a year, did not tell me when she started to menstruate When she finally did, she said: “I felt like I was glued on a fence between kid and teenager and that telling you that I started my period would be going over the fence.” She said that then she would be caught in adolescence and not

as free to feel she might be on either side of the fence She also said, “I’m used to love

in my family, not outside of it In the family I can be myself—that love is like I can tie

my shoes or leave them untied Love outside my family, that’s a different kind of love, like a tight love, right there.” The flowing sense of being part of a family as a child felt threatened by her immanent sense of a relationship outside her family

Indeed, Eleanor’s presenting symptom was that she had developed a phobia that she would be kidnapped When I first met her she told me: “In my house I think there are people who watch me when I walk down the hall I think someone’s watching me who wants to kidnap me.” Eleanor’s fantasy of a “kid”-napper con-veyed a beginning conception of a new object who at this point felt more dangerous than exciting Eleanor’s fears caused her waking world to be infiltrated by a night-mare state Her analysis in some ways provided an opportunity for a transitional space where she could be kidnapped and not kidnapped by me, in a way that could

be named and elaborated and was in some ways under her control These issues particularly emerged around increasing the frequency of our meetings Her psychic space for development had broken down into concrete fears of being kidnapped—

an excellent metaphor for being caught and isolated from her younger self and her childhood objects Her prior psychic structures could not contain the mental devel-opments concomitant with the changes in her body and in her wishes Her fear was heard by her concerned parents and eventually allowed a breakthrough of develop-mental experiences that could be contained in her family and in her analysis

I use the term “changes in internal and external object relations” in this chapter, but I do not mean to equate them For instance, there can be a change (such as withdrawal) from actual parents, while internal object relations may be quite intense, such as fears of incestuous contact, fears of murder, etc

Bodily expressions of psychic pain

Some adolescents can only convey the breakthrough of something they not psychically handle through a bodily expression of crisis McCullers (1946) describes Frankie in a state of tension and the attempt to manage it physically:

can-… just at that moment a horn began to play can-… The tune was grieving and low

It was the sad horn of some colored boy, but who he was she did not know

Frankie stood stiff, her head bent and her eyes closed, listening There was something about the tune that brought back to her all of the spring: flowers, the eyes of strangers, rain.

The tune was low and dark and sad Then all at once, as Frankie listened, the horn danced into a wild jazz spangle that zigzagged upward At the end

of the jazz spangle the music rattled thin and far away Then the tune returned

to the first blues song, and it was like the telling of that long season of trouble She stood there on the dark sidewalk and the drawn tightness of her heart made her knees lock and her throat feel stiffened Then without warning, the thing happened that at first Frankie could not believe Just at the time when the tune should be laid, the music finished, the horn broke off … For a moment Frankie could not take it in, she felt so lost

… And the drawn tightness she could no longer stand She felt she must do something wild and sudden that never had been done before She hit herself

on the head with her fist, but that did not help any at all (44)

The music expressed her saddest, wildest emotions and seemed to give Frankie

a sense of something or someone she could be connected to When she loses this consolation, she is trapped in her own separateness again Maybe she hit herself

on the head to try to capture what she is feeling and to express rage at her head for what it cannot yet understand As I imagine what Frankie might be feeling in this moment, I realize that this instance is like many moments with adolescents They present themselves to us with some physical symptom—having banged their head against the wall or cut themselves As analysts we begin to try to imagine with them what compelled them to hurt themselves Sometimes this sort of thinking can be the beginning of becoming freed from self-destructive acts At the same time, I cannot help but think of teens who feel horrified to have these acts thought about Seem-ingly, they would rather leave these acts private and not have them intruded into.One could ask if it is useful to group the bodily symptoms of adolescence together in this way Undoubtedly, there are differences between why one cuts and why one starves oneself There are also meaningful differences among patients with comparatively similar symptomatic presentations Nevertheless,

I have found it useful to conceptualize bodily symptoms as expressing some related developmental issues during adolescence When an adolescent arrives in

an analyst’s office saying he cuts himself, he immediately draws attention to his body Of course confusion about the body is not the only source of the desire to hurt oneself in adolescence The urge to stop overwhelming psychic pain and shift

it into a visible bodily pain or to hurt a parent by hurting oneself are examples of other motivations However, I consider the bodily symptoms of adolescence to be like radioactive markers signaling the body as a source of confusion and distress.4While the extremes of bodily symptoms may appear to us as bizarre,5 it is useful to conceive of them as still on a continuum with the bodily preoccupa-tions of more healthy adolescents (Anderson, 2005) Girls and boys enter adoles-cence with an enormous range of internal capacities or vulnerabilities, as well as with enormous variations in familial or societal containing structures The bodily

self-consciousness endemic to adolescents may seem far from the extreme bodily preoccupation of anorexia, but both are conveying a developmental problem.Many factors contribute to breakdown and the possible propensity for concrete expression through bodily symptoms Aggression, narcissism, and familial or societal chaos or dissolution are all possible factors in adolescent breakdown, as well as many others However, I think of psychic isolation as particularly relevant

to breakdown because it leaves the psyche without internal or external resources

to metabolize the whole range of affects and confusions at hand For instance, intense feelings might be managed if an adolescent has an other who can absorb and understand his intensities or a connectedness to a part of himself that can make sense and order When an adolescent feels isolated from a containing mind, not only can bodily changes seem bizarre, but the now alien-seeming body can be treated as separate and not in need of protection.6

The somatic changes of adolescence spur the mind to metabolize changes, but inevitably there is a lag before the mind can catch up to the body The bodily symptoms that tend to emerge in adolescence are often surrounded in secrecy—picture the ruminative preoccupation of anorexics—and so express isolation and alienation in powerful ways An adolescent’s unconscious sense of helplessness at his or her body changing, seemingly with a will of its own, can lead him or her to try to subordinate the body, such as by restricting in those with eating disorders

On the other hand, somatic symptoms are also a potential communication

by adolescents—their unconscious effort to convey what is wrong, albeit in a difficult-to-decipher manner And of course, as Winnicott tells us, someone hearing the communication is required—the adolescent process can’t take place without a facilitating environment The discovery of self-destructive bodily symptoms in a child can often mobilize parents to seek treatment for their child when they might not have faced troubles presented in a less frightening manner There is an opportu-nity to hear the distress in a physical symptom at adolescence that may prevent the symptom from becoming an established and addictive pattern

Lena

Some adolescents report desperate acts they have undertaken when what they feel

is too big and too fraught “Lena,” age 16, told me of her first incident of self- cutting She had seen her best friend making out with a boy Lena found “gross.” Lena was filled with overwhelming feelings and cut herself Later, she showed her friend her cuts and her friend got her to seek help Associating to “gross” in her first session with me, Lena described her father as “gross, the way he eats, these movements he makes with his mouth.” Soon after, Lena reported her first dream:

“I was yelling at people and then they leave, but in the second part of the dream

I was able to write music and people were interested.” The extreme pain and rage7expressed in her cutting, which might have become ritualized into entrenched self-destructiveness, could here be transformed into meaningful emotional speech and connection A conglomeration of longings and emotions led to the cutting—jealousy, rage, and helplessness She loved the girl and experienced her kissing

this particular boy as a horror The link between this boy and her father seemed

to convey that this scene also evoked unwanted parental sexuality The effort to help an adolescent to begin to get comfortable to express these feelings is crucial.Lena’s cutting could be thought of here as proto-symbolic—intense feelings were cutting Lena up At the point of the cutting she was incapable of translating these feelings into words The intensity of her feelings and her withdrawal from her par-ents precluded thinking and non-bodily representations As she began analysis, she became intrigued with her dreams, helping to translate her feelings to a listening other, although at this early stage in her analysis she would bring me a dream and seem

to leave me to think about it This transition is an example of a beginning use of an other’s mind to contain and represent new experiences and meanings—just as she had not yet been able to represent her emotional experience to her friend in a way other than showing her cuts When Lena was able only to show me her dreams without thinking about them herself, one might think of this as resistance—for instance, as

an inhibition of self-observation arising from conflicts over aggression (Levenson, 2004) It seems to me a problem with the development of internal containment She needed to see someone think about her internal states and dreams to begin to see this

as possible Her ego functioning could grow as she identified with a containing object.Lena was able to begin to dream her experiences and feel they were understood

in her analysis Her self-destructiveness fell away rather rapidly Two years later,

as she was preparing to leave analysis to go to college, she brought me a poem about mourning Lena had found a way of symbolically communicating pain to

me (at first through an other’s words) and was no longer trapped in her body In her final analytic session before leaving for college, she told me she’d had a dream that “a woman named Mary gave me Joseph’s amazing coat of dreams.”

Eleanor, the girl in the first vignette, did not have to resort to bodily harm

to express her upheaval, while Lena did However, Lena’s cutting brought the response of a facilitating and containing environment to bear She could be known

in relation to others, and she increasingly was able to use dreaming, music, and literature to capture her feelings

Weathering development

I’ll return to Frankie to consider some ideas about how development is sometimes weathered As the story begins, she identifies with freaks and calls herself “an unjoined person.” She fits neither with the older or the younger kids Her brother has been off in the military and is returning to marry his sweetheart Frankie sees this couple as a mirage of beauty, adventure, and perfection Suddenly a thought comes to her: “They are the we of me” (McCullers, 1946: 42):

For when the old question came to her—the who she was and what she would

be in the world and why she was standing there that minute—when the old question came to her, she did not feel hurt and unanswered At last she knew just who she was and understood where she was going She loved her brother and the bride and she was a member of the wedding The three of them would

go into the world and they would always be together And finally, after the scared spring and the crazy summer, she was no more afraid (46)

The plan to be a member of the wedding inevitably leads to bitter disappointment, but it creates a temporary transitional space where Frankie can imagine a couple that she is somehow a part of She can imagine entering a wider world without feeling too alone A Kleinian might view this fantasy as a psychotic aspect of the personality (which can coexist with nonpsychotic parts of the personality, includ-ing reality testing) Bion might see the “member of the wedding” fantasy as a dream element—the mind’s effort to dream a solution to an unconscious prob-lem Winnicott might see Frankie as inhabiting a transitional space, where no one should ask whether the fantasy is really possible or not Perhaps, the question of whether such a fantasy is psychotic, dreamlike, or transitional can only be fully ascertained by the breakthrough or breakdown of further growth—or a compli-cated mixture of both When Frankie’s fantasy inevitably breaks down when she

is not invited on the honeymoon, another transition is in store for her Her fantasy allows Frankie to imagine her way into a next world

Dalsimer (1986), in a study of female development, uses The Member of the Wedding to describe a crucial element in the movement from pre-adolescence to

early adolescence in the girl—the finding of a best friend The best friend allows her an experience of a couple and the trying on of different possibilities through identifications and idealizations of the friend Me/not me doesn’t have to be clearly defined in this transitional space

Catherine

This “best friend” development can also be an aspect of treatment “Catherine,”

an early adolescent girl in psychotherapy, relates to me as if I am a knowing older sister She feels that watching me might help her to negotiate things she has not yet figured out Her disinterest in talking about herself in favor of talking about

me has at times been unsettling to me However, like Frankie, I think she needs

to feel a part of something with me—she wants to be a “member of the wedding” with me Catherine structures each session around the repetitive playing of the same game with me—similar to the intimate and repetitive kitchen rituals Frankie shares with Berenice Rituals of sameness and stability are crucial to adolescents

as their bodily and psychic ground shifts beneath them

Within this structure of sameness, some psychic contact with sexuality can be made Before a scheduled time away, Catherine imagined I was going to Paris to buy dresses She regularly asks me if I am married and, if so, what my husband is like At times, we struggle with this, as I try to draw her attention to the internal meanings of these questions Catherine feels shut out by my not telling her about

my husband I struggle with how to let her in in a way that will benefit her, but not yield on my own process regarding what she needs from me

Catherine is very interested in my shoes and has literally tried them on These ways

of relating challenge our ideas about how we treat adolescents Being a child analyst

is useful in this regard In play treatments, we try to let the child’s internal world take the lead, but we are inevitably active in the play My patient and I seem to have differ-ent ideas regarding the treatment—this is an interesting and useful challenge Some patients’ ways of being in analysis or therapy fit our preconceptions more easily My patient is requiring the growth of the container I must adapt to her and be her kind of analyst At the same time, I cannot abdicate from the responsibility of having my own mind in relation to her In any case, her treatment seems to serve as a transitional space where I am and am not her older sister, and we are and are not a couple helping her to feel less alone in facing adolescence Her presenting symptom of bulimia has ceased.

Of course, it could also be possible that Catherine’s sort of identification with

me could hold up development—to prevent her from exploring her own ality However, in this case it began to be clear that her mother, while quite kind, was also quite inhibited Catherine seemed to be using her identification with me (trying on my shoes) as a progressive step in exploring identifications

individu-Conclusion

Psychic isolation is an important aspect of adolescence that can contribute to the propensity for breakdown into somatic symptomatology Heightened sexual and rageful impulses in concert with shifting unconscious object relations and the use

of primitive defense mechanisms leave the adolescent feeling isolated in new and unnamable experiences Psychotic aspects of the personality can come to the fore The adolescent’s sense of strangeness from herself and from her internal objects creates an affective sense of isolation, which is painful to bear The sense of strange-ness can leave adolescents cut off from useful internal or external objects Some-times a period of psychic isolation can allow internal struggle that breaks through

to new ways of experiencing self and others At times the transitional space of an analysis, where these new experiences can be dreamed together, allow adolescents

to feel they are no longer “unjoined persons” but “members of the wedding.”

In the next chapter I will discuss psychic isolation in relation to a more sistent and established bodily symptom than those discussed in this chapter In the next patient, painful experiences of psychic isolation and loneliness were defended against by an effort to be invisible (psychically and physically) and merge with another

per-Notes

1 For example, Bion describes how the “contact barrier” separating conscious from scious gradually develops as alpha elements cohere “The nature of the contact barrier will depend on the nature of the supply of alpha elements and on the manner of their relation- ship to each other” (1962: 17) Thus, the “structure” of the contact barrier is also a dynamic process that depends on the quality of alpha function or other issues such as whether alpha function is disrupted or has not been well developed in regard to particular contents.

2 As is well known, for both boys and girls, physiological adolescence involves tive changes, hormonal changes, and subsequent growth of pubic and other bodily hair

cogni-as well cogni-as overall growth For girls, these changes include brecogni-ast development and the onset of menstruation For boys, testosterone levels increase twentyfold from ages nine to fifteen and result in growth of the testes and penis, the onset of wet dreams, and voice changes.

3 Self-harm is considerably more prevalent in adolescents than adults A statewide vey of self-harm in Massachusetts (2011 Health and Risk Behaviors of Massachusetts Youth) found that 18% reported self-injury (“cutting or burning without wanting to die” [23]) in the prior year One source of comparison with adults is Briere and Gil’s (1998) research, which focused on a random sample of U.S adults Four percent reported “having self-injured at least occasionally” (Walsh, 2006: 41) Walsh also notes that there are “no large nationwide epidemiological studies” of self-harm (2006: 32) The Massachusetts Study (2011) finds an even higher number of high school students—22%—who reported binge drinking, and 7% reported attempting suicide in the past year (2011: 24) Offer’s work (1971) is sometimes cited to indicate that ado- lescence is not as tumultuous as early analysts (e.g., Freud, 1958) described However, Offer’s work shows that, while many adolescents indicate agreement with their par- ents on larger societal issues, myriad rebellions occur on an everyday basis Further, self-report research data are very different from the material of analytic sessions that allow a deeper view into unconscious processes However, we analysts must remem- ber (as Offer points out) that our clinical data are not necessarily representative of the larger population That is, healthier adolescents don’t generally arrive in analysts’ offices—nor may the most disturbed who may be more represented in juvenile justice systems or may have little access to treatment.

4 Campanile (2012) distinguishes actions “on the body” (my focus here) versus “actions

in the body”—hysterical conversion symptoms His description of these hysterical symptoms is fascinating, but I find that actions “on the body” are far more prevalent in adolescence.

5 In work with bulimic adolescents, I was at first shocked to hear of bizarre rituals such

as storing their vomit in jars in their closets Many meanings could be considered

in relation to this symptom Most simply, it may convey that the symptomatic act

of purging—by definition, “an evacuation”—cannot really capture or make meaning since it evacuates the potential for meaning Therefore, the evidence of the symptom must be kept Surely, a vivid example of contents seeking a container.

6 Gardner describes “self-harm” as typically beginning in adolescence and as ized by an adolescent “state of mind” (2001: 59) She cites five states of mind typical

character-in adolescence and also characteristic of self-harmcharacter-ing behavior: the character-intensification of aggressive impulses and processes, narcissism, hypersensitivity and heightened feel- ing, the tendency to action, and the preoccupation with death.

7 Other motivations for cutting have been discussed, such as self-soothing or the effort

to disrupt feelings of emptiness or numbness, sadomasochism (Shaw, 2012), as well

as cutting becoming addictive (Gardner, 2001) Bodily symptoms are often multiply determined (Waelder, 1936), with various motivations being served in the same act.

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