Adolescent Psychiatry, V. 26

Annals of the American Society for Adolescent Psychiatry

Lois T. Flaherty, Lois T. Flaherty

• Publisher: Routledge
• Year: 2013
• ISBN:
  9781134904891
• Edition: 1
• Topic: Psicologia
• Subtopic: Psicologia dello sviluppo

Volume 26 of The Annals begins with essays that address the challenge of maintaining human connections in a biological century; Philip Katz focuses on the human encounter between therapist and patient whereas Vivian Rakoff emphasizes the continuing identity of the healer throughout history. Papers on adolescent development, which challenge readers to look beyond preconceived ideas, include Robert Galatzer-Levy's examination of adolescence as a social construction expressed in contradictory cultural narratives and Jack Drescher's exploration of the developmental narratives of gay men in order to illuminate the seeming invisibility of gay adolescents.A section dedicated to "Trauma, Violence, and Suicide" explores interventions with special groups of high-risk adolescents, including violent offendors, suicide attempters, and adolescent refugees. A special section on attention deficit/hyperactivity disorder and conduct disorders includes a debate on whether or not conduct disorder is actually a valid diagnosis. The final section of Volume 26 addresses social issues of continuing relevance to adolescent psychiatry: the juvenile death penalty and gays in the military. Reprinted here are the ASAP's position statements on these two issues along with its amici curiae brief in support of the petitioner in the landmark Supreme Court case of Thompson v. Oklahoma.Volume 26 of The Annals tracks the continuing evolution of adolescent psychiatry as it strives to keep pace with therapeutic and social responsibilities which, in the 21st century, have become increasingly intertwined. We have here a typically thoughtful compendium that, in drawing attention to the pressing issues before those who work with adolescents, highlights bith the field's achievements to date and the work that lies before it.

PART I

SCHONFELD AND KEYNOTE ADDRESSES

1

LESSONS MY PATIENTS TAUGHT ME

PHILIP KATZ

I have never forgotten my first psychotherapy case 42 years ago—a 19-year-old histrionic, seductive, extremely attractive girl, a Borscht Belt singer, diagnosed with a hysterical character disorder, a term commonly used at the time. I was about one month into my psychiatric residency and was terrified. My supervisor, a psychoanalyst, said he knew what would help me be comfortable—keeping the door open about four inches. So, I saw her for a year, with the door helpfully open four inches, and learned a lot about attempts by a patient to be manipulative and seductive.

I have done a lot of psychotherapy since then—many hours with many patients. I feel blessed to have worked in a field in which every patient is different, and every hour is different, and in which the results are so gratifying. In preparing this chapter, I have looked back over the years at many of the cases I have treated and at the collection of stratagems, ideas, insights, and knowledge that have accumulated and added to my therapeutic armamentarium. I feel grateful to my professors, who have helped me build that armamentarium—Ed Hornick, Margaret Froelicher, Leo Spiegel, Sandor Rado, Gustavo Lage, and many of my patients.

In this chapter, I focus on the lessons that my patients have taught me, or, perhaps to be more modest, on the lessons that my patients have tried to teach me (I am not sure I have always learned or remembered the lessons taught).

The cases I discuss come from my residency years in the late 1950s and from private and hospital practice since 1962. I started my psychiatric training as a resident at the Brooklyn State Hospital in New York City. Then I went to the University of London Institute of Psychiatry at Maudsley Hospital, London, England. Then it was back to New York for several years at the Albert Einstein College of Medicine at the Bronx Municipal Hospital Center. In 1962, I returned to Winnipeg, Canada, to do private practice and to teach at the University of Manitoba Health Sciences Centre. It was fascinating to see the differences in the children and adolescents of the three cities—London, New York, and Winnipeg—as to culture, behavior, and manifestations of psychopathology.

One of the first stratagems that I learned is that it is often useful to demonstrate the child’s value to his or her parents.

One of the first patients assigned to me in London was a little four-year-old boy named Jimmie. His mother brought him to the clinic and said that, if we didn’t treat him, she would kill him. She had become pregnant with Jimmie when her other child, a girl, was 18. Things were all right at the beginning. When he turned two years old, however, mother found it impossible to tolerate him. He constantly knocked over her piles of newly pressed laundry and made messes, and he was very defiant. She was just not ready for this. She was taken into treatment by a very skilled social worker, and I was assigned to try to rechannel Jimmie’s anger. The first day, we went to my office, and he gingerly inspected the toys and then started to play, very carefully, with the sandbox. After accidently dripping a bit of sand on my shoe, he looked up to see how I reacted. When he saw me smiling at him, he climbed into the sandbox, and we had a Saharan sandstorm. He had a wonderful time. I was quite delighted with it, and I told the social worker about it afterward. She cautioned me that he might have some guilt and anxiety about it. After cleaning up the sandstorm, I decided that, next time, I would take him out to the wet sandpile in the backyard at the clinic. When I came for Jimmie the next session, he didn’t want to go with me. Only when mother said to him, “Go with the doctor,” did he get up, defiantly, and start to walk ahead of me. I told him I had found a nice, wet sandpile we could play in, and I took him out to see it. He stood at the edge of the sandpile, looked at it, climbed in, pulled open his shirt, threw wet sand in, pulled open his pants, threw wet sand in, put wet sand on his hair, rolled in the wet sand, covered himself with it, got up, and said, “I want to see mommy.” As we headed toward the social worker’s office, a trail of wet sand following us, my years of chess playing came to the fore, and I decided to take the offensive. As we walked into the social worker’s office, I boomed, “We had a wonderful time in the sand pile!” The social worker quickly picked up the cue, burst out laughing, and said, “Jimmie, you look terrific!” Mother was stunned. She could only pick up on the social worker’s cue and burst out laughing. At that, Jimmie turned around and gave me a big hug, and off we went, back to the sandpile. He had gotten permission to make a mess at the clinic. Over the next couple of months, we had a great time, with the little hellion getting into all sorts of things and displaying a bright, creative imagination in our play. He was now behaving well at home, but the problem was what still needed to be done so that we could close the case. Mom was a lot happier with Jimmie, but she really had no appreciation of what she had in that little boy. So, the social worker and I decided that we would have a session in which Jimmie and I played with toys in front of mom and the worker. Mom watched in amazement at Jimmie’s display of creativity, fun, warmth, and affection during play. She had had no idea of what was there. This opened the door to a new relationship between her and Jimmie, and we were soon able to close the case.

In addition to learning from Jimmie how important it is to have parental approval of the therapeutic process, I also learned how parents often need to be educated about their children, sometimes demonstrably. Many times, words alone are not enough. And occasionally, the opportunity comes up unexpectedly.

When I started with 12-year-old Arthur, he was a ragingly angry boy who had no use for anyone or anything, especially school. An agency was involved, but he literally stoned the social worker and drove her away from his house. I was lucky that he was very interested in sports—we had a meeting ground that he enjoyed—but for five years we primarily talked sports. He came to sessions consistently, and he let me get him back into school, though he functioned haphazardly there. When he was 17, the battles between him and his parents reached a point at which the parents said they could go on no longer—he had to leave home, and whatever would happen would happen. I decided to take one last stab at the situation and had them come to my house to try to work things out. My den has an alcove in which I see patients, and the parents sat there with me facing them across a coffee table. Arthur took a seat near a stack of books that blocked his view of his parents, and their view of him, but I could see him. As Arthur’s parents launched into their list of grievances about him, he read a newspaper. They were absolutely furious with him. I asked him what his feelings were about all this. He replied that he didn’t care. I asked what his ideas were as to what he would like to do. This led us into a discussion of his plans for the future. Suddenly, he began to expound on his philosophy of life, on what he hoped to achieve, and on what he thought was real and what wasn’t real, and he attacked many of the standards of the adult generation. I looked at the parents and discovered that they were both crying! After a 10-minute exposition, Arthur stopped. The parents were sobbing heavily, and they said to me, “It’s okay, he can stay.” Confused, Arthur looked at me, shrugged, and left. I asked the parents, “What happened?” They said, “He’s got a brain.” I said, “But of course he has a brain—I have been telling you that.” They said, “Those were the first intelligent words we have heard out of him in his whole life. All we ever heard were swear words and abuse. This is worth fighting for.” Two years later, on their wedding anniversary, Arthur threw them a massive, wonderful party for which he himself prepared all the food.

Another lesson is that we are in a key position to educate our patients, and education is extremely important in our work, especially with adolescents. For education of adolescents to occur, we must provide them with the kind of therapeutic environment in which they feel secure that, in telling you their ideas or asking you questions, they will not be embarrassed.

Jerry wasn’t my patient. He was in a residential treatment center where I consulted and where I treated about six boys. Jerry was a 15-year-old Aboriginal (Native American) lad who wanted to be a carpenter, like his grandfather. All the arrangements had been made for him to start a carpentry course. The night before the course was to begin, he told the staff that he was not going to go. All the arguments and discussions got nowhere until one of the staff asked if he would like to talk to me about the situation. He knew several of the patients I was treating and said yes. The staff phoned me, and I went over, picked Jerry up, took him to my office, and asked him what the problem was. He said, “I can’t read a ruler.” I went to my desk, got a ruler, and explained feet, inches, half-inches, quarters, eighths, sixteenths—and the metric side with centimeters, millimeters, and so on. Knowing a bit about Jerry’s history, I then suggested that, at the time when most kids were learning about that stuff in school, his family was coming apart, and his mind was on things other than school. He nodded, thanked me, and went to school the next morning.

I always remember Dennis, a 16-year-old Aboriginal youngster who had grown up in a chaotic family situation in the north woods of Manitoba. Dennis had been quite isolated and received very little schooling. Looking at the sunset from the balcony of my 16th-floor, downtown office, he said very quietly, “Where does the sun go when it sets?” I went and got my flashlight and my Nerf ball and gave him a demonstration.

I have found that many youngsters have some very simple questions but that youngsters in their teens are embarrassed to ask them. One has to provide an atmosphere that tells them that asking questions is safe—that they will not be put down, ridiculed, or looked down on.

A second aspect of our educator role—and the one that we chiefly identify with as psychotherapists—is to use interpretation, education, and confrontation to teach youngsters about themselves, about what makes them tick, and about what makes other people tick. The art of teaching such things without assaulting, offending, embarrassing, or scaring the youngster is integral to our work.

In London, one of my patients, a 12-year-old boy named Marvin, had fairly severe facial tics. They had begun when he was about six, just after his mother had evicted his beloved eldest sister. His sister had been more of a mother to him than his mother was. His contact with his sister after she had been thrown out was infrequent and secret. Mother did not forgive easily. When I first started seeing Marvin, he was almost mute. When he talked, he found it very difficult, and he spoke in very soft tones. I had been told that he liked to draw cartoons, so I took a piece of paper, drew a stick figure, and wrote “Hi” in a balloon above it. Next to my figure, he drew a devil-angel figure and wrote “Who are you?” in his balloon. That was the beginning of several months of mutual cartooning, during which he drew a variety of figures while I stayed with my stick figure. We worked on a number of topics in those comic strips, and they were delightful and richly rewarding. He brought a number of cartoons from home, and we put those up on the walls of my office. They were clever and interesting. Then, one day, he brought a comic book he had drawn. In his book, the Teddy Boys, who in those days in England were a delinquent gang, were fighting the police. The police bombed their food lockers, and the Teddy Boys were starved into submission. Although I had never directly interpreted the cartoons before, this time I couldn’t resist. I told him that the Teddy Boys stood for him and for his anger at his mother for having thrown his sister out, but that he didn’t dare express his anger because he had to depend on his mother to feed and clothe him, so all he could do was make faces at her (the tics). He was enraged. He grabbed a piece of paper and whipped off a cartoon of a creature with a huge nose peering down at a time bomb. He said, “What do you make of this?” I said, “That is me sticking my big nose into your business.” He gathered up all his cartoons, all the strips he could find, took them home, and never brought me another one. He came regularly for sessions, and he continued to talk, but now much more carefully.

After that incident, I remembered Sandor Rado warning us to be very careful about interpreting dreams, stories, poems, and drawings—and that it is often better to use them as guides as to what to discuss than to bind them up in an interpretation. Many patients find that identifying their unconscious processes in their productions is very difficult to accept. My experience with Marvin certainly brought that lesson home. The dream of making the great interpretation, however, entrances us all. Occasionally, one does have one’s moment.

Hugh was 14 when he was referred for suicidal behavior, depression, and school phobia. One day, we were discussing his school phobia, and he talked about how he had always hated school and never wanted to go. I asked when that started, and he said he guessed it was when he was three, when his mother said that she was going to work and that he had a choice—either go to nursery school or stay home alone. He said he had not wanted to stay home alone, so he agreed to go to nursery school, but he has resented and hated school ever since. I asked what about staying home alone was he afraid of. He was thoughtful and then said there were three things he was afraid of—the sound of garbage going down the chute, the sound of a toilet flushing, and the sound of the janitor sweeping up the halls. I gave him a rather genteel interpretation that he felt that he was like waste, in the way that garbage and toilet products and dirt in the halls were, and that he was afraid the same fate awaited him. There wasn’t much response, so I rephrased my interpretation: “It seems as if you were afraid that you would be treated like a little piece of shit.” He went into shock and began to faint. I had to use my medical background to help him get over that. After settling down, he said, “And now I feel like a big piece of shit.” His recognition that his self-image was based on shit enabled us to “reality-test” it and alter it so that he would have a much more positive view of himself.

When I heard Dulit (1995) speak about the similarity between jazz and psychotherapy—that you take a theme and play with it in various ways, in notes or in words—I was reminded of Hugh and that session in which I went from talking about waste to talking, with far more effect, about shit. Many times, I have found that rephrasing an idea again and again eventually results in arriving at a phrasing that is correct for the patient—a phrasing that creates an opening, as in the following example.

When Cynthia was 15, her 16-year-old boyfriend, Timmy, was killed in a car accident on his way to see her. It was very shocking and traumatic to her, and her parents referred her because of the guilt she was feeling about it. She said that, if it wasn’t for her, he would be alive, he wouldn’t have been coming over to see her, he wouldn’t have been in that spot. We worked on that for several months, until she seemed to get over the acute reaction and settle down.

About a year later, there was a knock at the office door, and it was Cynthia in tears. Her new boyfriend had just told her that he was dumping her because she wasn’t alive. He said there was no life to her. We talked about her fear that she was dangerous, that any other boyfriend was at risk because of what had happened to her first boyfriend. She resumed therapy, and we again worked on the guilt, which had caused her discomfort with anything joyful, and a subsequent retreat from emotionality.

Sixteen years later, now in her early 30s, Cynthia phoned me that she was in town and urgently needed to see me. She had been away for almost all the intervening years, had been very successful in her career, and had gotten married about three years earlier. She described her husband as a wonderful man, whom everybody loved, who was just the nicest guy, handsome, wealthy—it seemed to be a dream marriage. The problem was that she was now acutely suicidal. She didn’t know why. It wasn’t so much a feeling of being depressed as it was of being trapped. As we explored her relationship with her husband, it became apparent that, though she described him as being perfect, there was no depth to their relationship. Their sexual life was minimal, and there was very little open affection beyond the rather perfunctory carrying out of duties. They had an active social life, but life at home was empty. I said to her, “You married a corpse.” She held up her hand to stop me from saying anything more and then sat there deep in thought. She said, “He’s Timmy, isn’t he?” I nodded, and she said now she could see it—her husband wasn’t alive, he just went through the motions. Over the next couple of weeks, we worked intensively on her preparing herself to deal with her family and with others who would have great trouble understanding why she was breaking up her marriage. She felt that she absolutely had to do it, or she would certainly commit suicide. Since then, I have heard from her occasionally. She divorced her husband, remarried, and was much happier, and her career continued to bloom. She talked about how the interpretation of marrying a corpse hit it right on the head and opened her eyes to a lot of what was going on.

When offering interpretations, we need to hunt for the precise wording that has a therapeutic impact. There are times, though, when the actions of others have much more impact than our words do.

In London, I was seeing John, a 13-year-old with a severe school phobia. He was the youngest of five children and the product of an accidental pregnancy. He was terrified that, if he went to school, when he came home he would find that the locks had been changed or the family had moved away. His previous therapist had tried hypnotherapy with him without success. I tried conventional therapy and got nowhere. The school dispatched a truant officer, who dragged him to school, but John had such a severe anxiety attack that the truant officer had an anxiety attack and had to go to the hospital! Then, one evening, John’s exasperated mother was riding him particularly hard about why he wouldn’t go to school. He told her that he was afraid that she would move away while he was at school. Mother went into a rage. How dare he think that of her! What kind of mother did he think she was! She was absolutely furious with him, and she swatted him good and hard several times. He went to school the next morning and thereafter with no problems. Mother’s rage about his thinking she would abandon him had convinced him about the security of his home and family far better than anything I could have said. I hesitate to say, in this politically correct era, that her swats may have been more effective than family therapy would have been—but Nathan Ackerman was just developing family therapy at that time. Incidentally, John a...

Table of contents

• Cover
• Half Title
• Title
• Copyright
• Contents
• Editor’s Introduction
• Part I. Schonfeld and Keynote Addresses
• Part II. Developmental Issues
• Part III. Trauma, Violence, and Suicide
• Part IV. Adhd and Conduct Disorders
• Part V. Asap Position Papers
• Author Index
• Subject Index