New challenges in the clinical work with adolescents
By Enrico DE VITO.
1 Jul, 2007
It is a great honour for me to open the first Regional Conference sponsored by the ISAPP in Eastern Europe. It is very satisfactory indeed that this Conference is to be held in Bucharest, the capital of Romania, a Country with grand cultural traditions and whose deep links with Western Europe and Italy are centuries old.
The ISAPP was founded in 1984, following a proposal by two renowned Members of the IPA, namely Serge Lebovici and Sherman Feinstein, together with other distinguished Colleagues that in Europe and in the United States had focused their work on psychopathology and treatment in adolescence. Philippe Jeammet, Moses Laufer, Alain Bracconier, Francois Ladame and Shelley Doctors were amongst them. Some are here today, like Michael Kalogerakis, former President of the ISAPP for many years, and Daniel Marcelli.
From the time of the foundation, the ISAPP has remained the only international multidisciplinary Association solely devoted to adolescent mental health.
Over time the ISAPP has become a reference in the field of Adolescent Psychiatry and Psychology. The psychodynamic inspiration, which is still the core of our view of normal and pathological development, has been integrated profitably through the years with the contribution of Developmental Psychopathology, Psycho-pharmacology, Epidemiology and Neuroscience.
Since the first Congress held in Paris in 1985, another six International Congresses have been organized by the ISAPP. The latest was held in Rome in 2003 and it was attended by over 1000 professionals coming from 30 different Countries in the world.
Our next International Congress will be held in Montreal from the 4th to the 7th of July 2007 and it will be focused on the transition from Adolescence to Adulthood.
Many other regional Conferences and Symposia were also promoted by the ISAPP in Europe, Asia and South America, in order to increase scientific exchanges on adolescence issues.
In October 2005, the ISAPP sponsored a Conference in London for the first time. It was co-sponsored by the Brent Centre for Young People, founded by Moses and Egle Laufer and directed by them for many years.
I would like to remember Moses Laufer, who passed away last July, someone who informed so deeply our understanding of the clinical work with adolescents, by quoting something he wrote on the occasion of the foundation of the ISAPP:
« After having completed my psychoanalytic training, I started dedicating part of my practice to treating adolescents, in parallel with adults and children. I was constantly faced with patients coming after a sudden breakdown or in an acute crisis. That could manifest itself suicide attempt, anorexia, severe depression, paranoid reaction to people and things and violent raptus.
I was disappointed when I realized that my work with adults and children had not prepared me to deal with what I was seeing then.
My feeling of loneliness increased even more when I also realized that most of the literature and most classification systems concerning adolescence psychopathology were entirely based on a model shaped on the clinic of the adult and the child. There had practically been no attempt to understand the very specific nature of adolescence psychopathology. »
Twenty years after, following the contribution of Moses and Egle Laufer and other Members of our Association amongst others, it can be said that a mayor scientific and cultural shift has taken place. Today there is a general acknowledgment of the specific nature of adolescence psychopathology. The literature in the field has expanded widely since Moses wrote those words; groups focused on adolescencent development and targeting adolescents for psychotherapeutic work have increased in Europe and in the United States; not differently from other Countries such as Japan, Israel, Argentina and Brazil.
It can therefore be said that clinicians and researchers dealing with adolescents can feel less lonely today, even though institutions are still somewhat resistant to create specific Services for adolescents and to provide specific training on adolescence, different from Services and trainings for children on the one hand and adults on the other.
However, in these last years, professionals working with adolescents have been presented and are still presented with new challenges. Changes involving family and society have occurred very rapidly, creating deep unbalance. Young people today are made more vulnerable by new risks and new conflicts that threaten to obstacle, sometimes severely, achievement of the true goal of adolescence, i.e. the development of one's own identity.
Many of the topics concerning these risks and these pathologies will be discussed during the course of this Conference. I shall mention some of these topics:
Destructiveness and violence, problems that have grown more and more their dramatic social relevance. The ISAPP sponsored a high scientific profiled Regional Conference that focused on such themes. It was held in Gottingen, Germany, in 2002 and organized by Annette Streeck Fisher.
Teenage pregnancy, a topic that has become particularly worrying in the United States and in South America, but also in Romania and other Countries of East Europe.
Immigration and emigration that are creating severe problems of integration and a widespread and potentially explosive uneasiness within young people all over the world.
Drug addiction and the so called "new drugs" misuse. Also the severity of this problem is increasing, with more people getting involved at a younger age.
As clinicians, psychosocial workers and researchers confronted with such challenges, our response should be an extra-ordinary commitment to providing our young patients with effective treatment and to planning preventive interventions, rationally informed by the most recent findings in developmental, epidemiological, but also psychopharmacological, genetic and neuroscientific research. In addition to this, we should provide our local and national governments with recommendations increasingly effective and realistic with regards to health policies.
In order to respond appropriately to these challenges, the role of assessment in adolescence - a crucial, difficult and complex one - should be emphasized.
Our psychoanalytic understanding should inform our need to focus on the functioning of the adolescent's personality as a whole, without giving too importance to symptomathology and to diagnostic categories - proceedings typical of nosographic psychiatry.
The assessment should rather look for the meaning of the symptoms, both for the adolescent and for his environment, and it should be strictly linked, from the beginning, to the aim of the psychotherapeutic intervention.
During the latest ISAPP International Congress, held in Rome in 2003, Francois Ladame presented a brilliant synthesis on assessment and diagnosis of mental health disorders in adolescence. He defined adolescence crisis as a "door".
From this door two alternative developmental paths can subsequently depart: either a normal one (towards progression) or a pathological one (towards a developmental arrest or a regression).
The first path relates to adolescents presenting a fluid psychic functioning and owning a "functioning pre-conscious", thus a sufficient capacity of forming relationships. Adolescence crisis here represents an opening towards a progress in development and a good adjustment to the new situation; involving one's body, cognitive functions and conflicts.
The second path rather relates to adolescents continuously invaded by traumatic psychic products. They rely on primitive defenses rigidly, due to a lack of adequate regulatory functions.
The outcome of the crisis, for this group of adolescents, is either a stop in development or regression (most likely, psychotic functioning or psychosis), as mentioned above.
The need to involve the environment (primarily the family, but not exclusively) in the assessment process has been underlined in recent years. Amongst other reasons, it was prompted by the wish to promote multimodal or residential provisions, psychoanalytically oriented, to adolescents that for different reasons may not access traditional psychotherapy.
In addition to that, the various outcomes following adolescence crisis can now be better related to previous developmental paths, thanks to the achievements in the field of developmental psychopathology.
So, the assessment model suggested by Ladame may be integrated with other concepts equally resolving into a Dual Track Model of Development.
Such concepts are connected to research fields that have become increasingly important and widespread during the course of the past twenty years.
They have promoted a deeper understanding of the relationship between internal and external world (especially with regards to the relationships with the parents). They also represent an attempt to integrate the psychoanalytic model with other approaches, such as system theory, infant research, attachment theory and neuroscience.
I will refer to two models in particular. The first one has been suggested by Kerry and Jack Novick (1991, 1998). It originates from the ideas of von Bertalanffy, as applied by Cicchetti and Ragosh to developmental psychopathology.
According to the Novicks, there are two kinds of conflict resolution and self-regulation throughout development that also involve two distinct sets of answers, dependent on the phase challenges. One, the open system, is attuned to reality, characterized by joy, competence and creativity. It is based on positive relationships of mutual respect, developed on the basis of realistic perceptions of oneself and the other. Such relationships are in a fluid communication with experiences coming from either the internal or the external world.
On the contrary, the closed system, avoids reality and is characterized by sado-masochism, omnipotent beliefs and stasi. It is based on distorted perceptions on oneself and the other. It tends to promote repetition and, after adolescence, it tends to become a strict regulatory structure of affects and behaviors.
Both systems develop within parents and child, following the conscious and unconscious representations of them and their interactions.
The Novicks argue that assessment, according to the "two system" model described above, implies a focus on the conditions and the aims underpinning therapeutic alliance, with regards to both the assessment process and a possible psychotherapy later on. Furthermore, it should be related to the adolescent patient, his parents and the therapist himself (who gets to become part of the system).
An optimal development of a therapeutic alliance implies the presence of an open system on the adolescent's, his parents' and the therapist's sides. Such a system involves a certain degree of interest and respect for oneself, for the other and for restoring a process of autonomous development.
In order to build a therapeutic alliance in the context of a closed system, it is important to allow during the course of the assessment enough time to find, within the adolescent and his parents, areas of past and present functioning that suggest the potential for new paths of developement. They should be different from the prevalent defensive mechanisms and negative affects that have characterized mental state and relationships so far, and still do.
The second model I'm referring to, derives from the attachment theory.
As indicated by studies on attachment and empirical research, there are two separate developmental paths, originating from early attachment relationships and the internal representations of such relationships. These paths correspond to secure vs. insecure patterns of attachment and involve a specific organization of the Self.
During adolescence these different developmental paths affect the outcome of the crisis, thus entailing two different solutions (see Table 1).
Those whose attachment is secure/autonomous show a tendency towards resolution and growth while those whose attachment is insecure show a tendency towards onset of developmental arrest and symptomathology.
The symptomathology, therefore:
is due to a vulnerability of the regulatory and adaptative functions of the Self;
is linked with insecure forms of attachment;
is characterized by prevalent defensive modalities.
The attachment relational matrix provides the basis for the development of a "capacity for mentalization", a concept studied by Peter Fonagy. This capacity connects in turn with the relationship between fantasy and reality, with memory functioning, with the construction of language and of autobiographic narratives. The capacity of mentalization seems to protect psychological vulnerability in the face of difficulties in the outside world.
The more traumatizing the environment is, the more the child - and then the adolescent - lacks a capacity for mentalization that would give meaning to behaviours and anticipate them and the more the organization of the Self is going to be damaged, thus entailing wider and deeper shortcomings.
The pathogenesis of borderline personality disorder and conduct disorder lay in such damage and such lack of an "internal mirror".
As in the model suggested by Novicks, two very distinct paths are to be acknowledged here in the course of the assessment.
On the one hand, a child with a secure attachment pattern has developed and can continue developing fluid and flexible relationships with oneself and with the other; on the other hand, those with an insecure attachment show a narrower and sometimes obstructed path, to the extreme of the collapse of those with a "disorganized" pattern of attachment.
In conclusion, trying to integrate these concepts in the assessment process should suggest:
to include more extensively the parents in the assessment process, considering present and past interactions and, in an intergenerational perspective, the way "ghosts" affect behaviours, mental states and narratives;
to establish a "preliminary" therapeutic alliance with the adolescent and his parents, so that all system components can start investing on one's own, and the others' potentials. The aim is the search for solutions different from the stasi;
to shape alternative multimodal intervention, should the assessment underline too limited potentials. Such interventions may implement new factors promoting development (following the establishment of new relationships and new environmental circumstances). They may include residential, psycho-educational and "network" intervention, coherently informed by the psychoanalytic approach;
finally, this view recommends that a specific position and specific interpersonal attitudes are taken up by the psychotherapist, while assessing the adolescent and his parents.
The therapist could be seen as someone promoting a new emotional and cognitive experience, based on those conditions that underpin a secure attachment pattern, such as attunement, limits handling, protest handling, responsiveness, mirroring and so on.
Such therapist should work to establish an identificatory bond and to put his own capacity for mentalization at the disposal of the adolescent and his parents.