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GROUPNESS AND LIFE CYCLE
Adolescence
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Expressions of trauma in the first sessions with the adolescent
by Gianluigi Monniello
INTRODUCTION
My comments, which are psychoanalytically oriented, derive from the first sessions where the focus is on the transactions in the moment that the trauma is expressed itself and begins to occupy space in the mind of the traumatized adolescent in the presence of the therapist.
Following an expression of Freud (1914) about the transference, I suggest that the trauma is not remembered or reconstructed in adolescence, but really discovered and sometimes only propped up by the therapeutic relationship. Helping the adolescent to be interested in his inner world, to think and to reflect on himself are some of the essential aspects of clinical work with adolescents.
In the light of the concept of après-coup (deferred action), according to which the trauma takes place in two phases, the moment in which the trauma emerges and begins to occupy the mind of the adolescent occurs after the actual infantile trauma. The latter is thus intended as the silent presence of an event whose significance cannot be understood due to the state of extreme need (Hilflosigkeit) of the child. The second phase is linked to puberty and cognitive development and propped up by the parental imagos in a normal situation, but by the mind of the therapist in a pathological situation.
Following an image of Bash (1988) about the brain's functioning and the computer, I suggest that when the adolescent must deal with the external world he can only use the software that the parents offered to him.
LITERATURE REVIEW
Briefly remembering Freud (1916-17) who taught us that: the foreign body (trauma) is not a pure external affliction, like an infection, but an internal foreign body; trauma has a deep tie with the memory (the remembering); and that which is traumatic always has to do with that which is desirable.
Here I refer to the pattern of trauma which accentuates the breaking of the protective shield. In this case the anxiety signal is not able to indicate the danger and mobilize adeguate defensive measures to protect the mental apparatus. This pattern has favored the development of a concept of trauma focused essentially on the problem of narcissism and the necessary time needed for the construction of the narcissistic basis of the person. Brette (1988) writes: "The quality of the maternal investment and the set of early mother-child interactions can jeopardize the formation of primal phantasies, which as symbolizing structures offer a representative aim for traumatic stimuli and their quantitative variation; the ego would therefore, be less protected from overly intense regressive tendencies and from a possible breakdown that would cause further damage. I feel it is legitimate to consider this early experience, whose traumatizing effect depends on interactive and intrapsychic experiences, as the potential avant-coup (foreaction) of future traumas." It means, in this case, that there is a failure in the early mother-child relationship, and therefore, a deficient protective shield.
This pattern is very useful in my following clinical illustrations.
First, I would briefly like to underline three concepts that are frequently used in dealing with trauma in adolescence and these are deferred action, or more exactly l'après-coup of French authors (Freud, 1914), traumatic remains (Blos, 1962) and traumaphilic need (Guillaumin, 1985). In analytic work the goal is not to repair but to re-establish the psychic time of the inner world. The time is that of the après-coup (Nachtraglichkeit). It functions in two distinct phases. This conceptualisation considers that an event which was already present wasn't, and that the new significance that arises after, produces sense about what was and that, in its turn, through this same fact transforms itself (Laplanche, 1987). This is the theory of the trauma in two phases.
Blos (1962) says that the task of the adolescence is also to arrive to save what remains of the infantile traumas. He writes: "Trauma is a universal phenomenon of childhood... therefore for the rest of his life the individual will continue to control the trauma... As regards the problem of consolidating the character, at the end of adolescence, we have to insert as part of the total process the problem of trauma... finally any trait of character owes its specific quality on the focusing of a particular trauma or on part of the trauma... the remaining traumas are the strength that push the non integrated experiences in the area of psychic life so that they can be controlled or integrated in the ego".
Guillaumin (1985) hypothesizes that the specificities and difficulties arising in the psychoanalytic treatment of adolescents often recall the existence of a kind of traumaphilic need ("d'une sorte d'appétance ou besoin traumatophilique..."). This tendency expresses an unconscious need of the adolescent to check the border of his bearable exitation. This intrapsychic process could be at the service of the mental development or could escape control of the ego and enter into the dimension of the risk of the autolesionistic consequences.
Then, about the meeting with the adolescent, the reference to the psychoanalytic cure in the therapeutic approach of adolescence is necessarily to be completed by the taking into account of all the intrinsic and extrinsic factors that interplay in the optimalization of the work contrivance. Some characteristics of adolescence (economic system of crisis, topical rehandling of the "new dependency", natural status of transference introjections) contribute to cast a light on the sometimes crucial stake and the dynamic potentiality specific of the encounter with the adolescents. The assessment, which is sometimes instantaneous and reciprocal, cannot easily be dissociated from the identifying process (Donnet, 1983). As regards the first therapeutic approach with the adolescent, two specific techniques are described that consider the dependence conflict to engage the patient in psychotherapy (Barish, 1971). Also the crucial elements of the therapeutic interaction with severely disturbed patients often revolve around the transference-countertransference axis (Giovacchini, 1985).
Then the first session is marked by its dimension of take it or leave it that are at stake for both the adolescent and the therapist (Donnet, 1983; Novelletto, 1985; Gruppo Romano di Studio dell'Adolescenza, 1988). In particular, can this session become an attractive force or sign that makes the traumatized adolescent interested in continuing the therapeutic experience ?
Is it possible that the trauma could be worked through ?
Various scenes pass through the mind of the therapist. He is waiting to know what happened, and which trauma is the origin and the cause of the disturbance. Sometimes the trauma is too evident, sometimes only hypothesized, and othertimes stimulates many hypotheses in the absence of data. All this activates the therapist's mind, and he begins to ask questions. With this, he could also not become involved too much. The wish to explain and interpret the symptoms which caused the pathological effect of the trauma remains a strong motive which is not without risks.
Chan (1991) writes: "It is lucky that the adolescent can utilize the external object, or better still its representations, as a decisive role in its new attitude, in the balancing of cathexis and countercathexis... and to use it in a determined way for his new object choices and for his new identifications."
Finally, in order to circumvent the difficulties and sometimes mortified confrontations, with the severely disturbed adolescent it seems important to open one's mind to the lateral forces which very preciously are brought into play as forms of anaclisis: lateral cathexis, splitting of transference on the setting and lateral transference are, then, useful concepts (Duparc, 1988).
I chose all these concepts because I thought it helped me to take a more satisfying position in my work with these patients.
CLINICAL ILLUSTRATIONS
My clinical descriptions report the first meeting and references to stories in which trauma seems to consist in the failure of any possibility of links and mental representation. Then the main characteristic of these traumatic events seems to be their unrepresentability for the mental apparatus of these adolescents. The traumatic experience happend in early adolescence in the first two cases; in the third case the trauma showed up at the beginning of puberty. I knew about these facts. In all the three cases I noted the positive use of the countertransference to involve the patient immediately to move the therapy forward. The initial impressions described in the three cases are corroborated with data that emerged later in the therapy.
CASE I
When she was 13 Antonella had a car crash with her boy-friend, which caused cranial trauma leading to a coma for two months with left hemiplegia. She was in a specialized hospital for a year. Then she returned home and returned school. She has numerous neurological and neuropsychological residua that need frequent and continous rehabilitation.
Antonella is the only child of a single, teenage (17) mother. For her first years she lived with her maternal grandparents because her mother could not provide sufficient care.
I saw Antonella in consultation when she was 16 because of hetero-and-autoaggressive behavior and progressive isolation.
Antonella is a cute girl, dressed in somewhat childish fashion, with a lively, intense gaze. Upon entering the room her gaze hurriedly swept the room, seeming to look for something to hang on too, as if she feared she would lose her balance. I imagined a child who desperately wants to run and move, but is held back by the uncertainty of her ability to walk, and therefore seeks out visual supports with her gaze.
Antonella sat down only after I tell her to and she says: "I'm here because it is good to talk. I'm not behaving well and I'm not feeling well. Before the accident I was different, happy, good and kind. My mother told me I was in a coma for a long time. It was as if I was dead. I didn't move, I didn't talk. Like in a dream I heard my mother's voice, the doctors and the pain of the injections. They were close to me but I couldn't talk to them. One day I saw my mother go away. I was frightened and tried to call her, shouting with all my strenght and again I could speak. She finds it difficult to talk and I feel the effort she makes to put her thoughts together. When she begins to talk her left leg trembles. She notices and she angrily says: "Look, I continue to tremble, I'm not able to run despite all the exercises I'm doing. I can't bear it and I can't bear not being good at school."
I find myself seeing the slow-motion images of a car accident first seen in a TV film. She stops and begins to cry. I try to confort her, but at the risk of intruding, by saying how painful and confusing it must be to relive the images of the accident. She is silent for several minutes. Then suddenly, and in crescendo, Antonella talks about all the voices in her head from which she cannot escape, and her theories about her accident. "Before, I was always laughing, often went out with my friends who were older then me. We secretly went dancing in the afternoon. I liked meeting boys giving them a date... The boy in the car with me I had met recently. That day we had kissed and touched each other."
She looked at her hand, showed it to me, and said: "Look, it's smaller then the other one. It's the hand that touched him, right there. It became infected, just as I am inside because he trasmitted something bad with his saliva..." In crescendo she continues to describe the "voices," voices of anger that push her to scratch cars, to be aggressive and to hurt herself. Antonella sat down, calmer now, and said: "I can see you are a good person...Since the accident there are many things I can't remember. Could you help me to remember ? I tell her there are many things that we can begin to see together.
DISCUSSION
The central point in this first session with Antonella seems to be when describing the accident in an hallucinatory fashion she entered the trauma. The moments of silence that followed seem to evoke the paralizing anxiety of the sudden violence. It is connected whith the impossibility of expressing her own emotions and thoughts. Perhaps she felt that during her coma, but more likely it indicates a crisis of mental representation, and thus the fragility of her narcissistic foundation, which is attributable to an inadequate early affective dialogue with the mother.
With efforts at recontructing (Robert-Pariset, 1987) directed to protect her from fragmentation and mental breakdown, Antonella tries to fill the silence with a delusion.
In the emotional crisis in which her values and representation of the self were challenged by the demands of the sexual body, Antonella had her first sexual experience just before the traumatic event. In the girl's words, these two elements (sexual fantasies and terror that the event might be repeated) seem inevitably internali del trauma di un adolescente in psicoterapia - di Daniele Biondo (original italian version)
La psicoterapia psicoanalitica nell'adolescenza e la formazione dello psicoterapeuta - di Marco Longo (original italian version)
Inner trauma and outer trauma. A psychoanalytic approach - by Arnaldo Novelletto (translation in english)
Trauma interno e trauma esterno. Un approccio psicoanalitico - di Arnaldo Novelletto (original italian version)
Working through in adolescence - by Arnaldo Novelletto (in course of publication)
BIBLIOGRAPHY
CONFERENCES
Adult Age
independence and responsibility
Old Age
wisdom and decadence
Exitus
the big separation
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