Clinical Commentary XVIII 389

This material reflects very vividly some of the difficulties in working with disturbedadolescents. The disentangling of the infantile from the adolescent, the frighteninglyconcrete nature of the incestuous fantasies (particularly in an adolescent whose sense ofidentity is so easily fragmented) leading to defensive acting-out and distancing.

Joan SchachterMember of the British Psycho-Analytical Society

22 Dyne Road, London NW6 7XE

References

Glasser, M. (1979) Some aspects of the role of aggression in the perversions. In Sexual Deviation (Second Edition) (Ed. I. Rosen). Oxford: Oxford University Press.

Fonagy, P. &Target, M. (1993) Aggression and the psychological self. In International Journal ofPsycho-Analysis 74: 471-85.

Winnicott, D.W. (1956) The anti-social tendency. In Deprivation and Delinquency (Eds. C. Winnicott,R. Shepherd and M. Davis). London: Tavistock Publications, 1984.

Commentary by a Child Psychotherapist

The therapist's account of her work with Paul, aged 16, includes her synoptic view of theproblems and background and detailed notes from three sessions. This gives us privilegedaccess not just to this adolescent boy's way of relating, but to some of the feelings evoked inthe therapist, her countertransference. My clinical commentary looks at both these things sothat, by viewing the psychoanalytic process in detail, we can learn about Paul's internalworld and his very troubled relation to his environment.

As I read the background I found myself asking in places whose account of the historyis it? Whose belief is it also that Paul will end up like his sister who has suffered a severemanic depressive illness, his or his parents'? I thought initially that Paul's own fears andphantasies are not easily distinguishable from those of others. This may simply be becausethis is a brief summary and not that Paul takes on the views of others, or vice versa. I shallreturn to this issue later. Other questions arose for me too. Paul is the youngest by 10 years,so was he a baby or small child when his sister's illness affected her, and did his sister'sillness deeply affect his mother and the family? He now has a breakdown in adolescenceand, like her, comes to the same clinic. Does all this affect not just him, but his mother, towhom he is very close, and the whole environment for his adolescent transition? Is a severestate of flux observable between his perceptions of internal and external reality, now inadolescence as in early infancy? Lastly, what of any effective paternal elements? For, fromwhat little we heard, I thought the father whom he treats with contempt as a tyrant may havebecome a figure in his internal world and in his gang-like tendencies in social relationships.As a preliminary historical hypothesis I was asking, `Did he observe his mother's fragilestate as a baby and equate destructiveness with his own aggression and expressedneediness?'

In therapy we learn how his sense of self has changed for, instead of seeing himself asconfused and stupid, he has a more street-wise attitude. But the sophisticated exterior candisappear into incoherence, and he is a mixed-up learner (dyslexia), a mixed-up

390 British Journal of Psychotherapy (1996) 12(3)

speaker (the stutter), and he sees himself as a `breakdown case' (his fear of going mad). Hecan be worrying, seductive and appealing, with rapid shifts between playfulness andaggression and despair. The therapist is warned by colleagues, `he can lead you in a dance'.I would say, our aim is understanding and one perhaps cannot avoid it, so `let's watch thedance!' For following Joseph (1985, p. 159), `the part that is really needing to be understoodis communicated through the pressures brought to bear on the analyst'.

In the treatment there is evidence of early splitting mechanisms, his therapist is seen asideal, and he keeps away from violent and depressed feelings which would bringambivalence. When the splitting does not work he becomes more disturbed and aggressive.Over the three breaks during the year's therapy there has been an increase of awareness andmore evident depressive pain. What occurs then, however, are self-inflicted burns, threats ofarson and talk of suicide, and separation issues bring thoughts of violence. The transferenceis intense and largely positive but there is often a threat of something negative and violent.The positive elements are evident when he evokes in his therapist a wish to share hisanxieties about moving on, getting to college and so on, but Paul is prone to deep regressionsuch as his recent sleeping in his parents' bed, and he has psychosomatic manifestations dueto his terror of separateness.

Prior to session one Paul saw his therapist in the street, and the impact of this in thesession was apparent before he let his therapist know. He wants direction, about college butabout his own conflicting emotions too, and wonders does she know about `out there'? Hecan use prohibitive or severe guides, the `policeman' and super-ego elements, but whenusing just his own capacity he is very confused, though he spoke with bravado about `notbeing arsed'. He recounts his contact with the `man at the centre'. In reality, he feelspressured there and not understood, the man is supposedly `safe' and has an interest in hisbreakdown, but he is easily and unsatisfactorily put off so that troubling, guilty things abouthis sister are not brought up. His anger with the man erupts in a hostile confrontation withhis therapist, actually lighting a cigarette in the session and saying, `what the fuck, I do whatI want'. Although in a sense he is being an adolescent and just breaking a clinic rule, he isbringing in directly, to the therapist, his threats about fire (the arson) and violence. The `man at the centre' represents a part of him, confusing, infuriating, and his next verbal attackis against the `mad psychologist' and, through projective identification, his psychologist/therapist. Only having unleashed the attack, and evacuated his primitive anxieties, does hecommunicate the fact that has been bothering him all along, seeing his therapist outside. Hedescribes what in his terms she was doing, assuming thereby some control for himself whenunderneath he did not know what she was doing or was like outside. When he thinks he maybe beginning to betray himself in how he is talking, for example, getting embarrassed, thenhe gets his therapist to do something, he gets her to smile. Here and later his humour is anattempt to draw in the therapist, to reduce the focus on and play down the intensity of hisattacks. His curiosity about his therapist is intense, he was very early at the clinic and benton getting someone, the receptionist if not his therapist, to react to him, for example, ingiving him sugar. He wants the therapy to be a secure `home' for him and vehementlyattacks the therapist when he feels it is not.

The therapist's line of interpretation about Paul's anger is to take up that in his eyes shehas broken a rule, being outside the clinic, being a separate person with freedom to

Clinical Commentary XVIII 391

be different. He has not felt he has any such freedom and is intensely envious. The therapistalso interprets his breaking the rule of non-smoking, with the threat this implies. She is lessconfusing to him when she points this out to him and he can see her anew. I think thatsomething at the centre has struck home. Paul is more disturbed but partially aware of somemore real knowledge of his therapist, `you're only bloody human after all'. His tone isaggressive with some humour to tone it down. He's uncomfortable, not relieved, as if it's herwitch-like qualities that can enable his therapist to see his difficulty and despair. He nowmoves in and out of despair, coming back to the wish that his therapist may be useful orgood, rather than the `mad psychologist'. At the end he speaks of not being able to bearseeing his mother and father in the street. I felt he could not bear to experience his therapistas having a separate life or to experience at an infant level the intensity of his dependencyon her. I wondered if the therapist could usefully have made an interpretation during ortowards the end of the session about his intolerance of her separate existence and his terrorthat this meant he is mad. He made a quick exit to stave off his sensing his mad anddelusive dependence on his therapist.

His flight from the two subsequent sessions seem to show his fear of that dependenceand fear too at recognizing certain aspects of truth about himself. He had missed, escaped,being seen face to face by her in the street and had wanted to avoid seeing her face to facein the session, or in the two subsequent sessions. In session two, he knows he has to look athis therapist and himself afresh, but he is in terror of this and switches off his emotionalcapacities for knowledge.

In session three Paul denies the sessions cost him anything so he may as well come asnot come but, in fact, he was well aware of what they were costing him. In his mimicry ofthe posh girls and their mothers, I wondered if his concern about what reception he wouldget from his therapist was as much to do with fear of falsity as his wish for warmth. He seesothers as having something he longs for and he's just 'a boy with dirty knees'. He would likehis therapist to greet him with a `bright shiny face'. But recognition of his longing of whathe wants his therapist to be brings home his sense of `how fragmented he had been feeling'recently, with `lots of different people running round his mind and he did not know whichone he was'.

He tells the disturbing dream about lying in bed with the 9-year-old girl. He is furiousthat his mother minimizes how disturbing the dream is, and minimizes the degree of hislongings and seductiveness. I agreed with the therapist that his reaction to his mother wasmeant as a warning to her. I thought this warning was not to minimize his problems. Thetherapist is now worried that she should go for the content of the dream, but I wondered if itmay be nearer his immediate anxiety to go for his reaction to the dream and his fear of whathis therapist would do with it. When the therapist starts to make links between his materialabout the `posh girls' and their mothers, and thereby moves away from his current intenseanxiety, to work towards a more accurate interpretation of the dream content, manifest andlatent, he explodes. He loses his earlier sense or insight that he is fragmented and insteadprojects into the therapist, ,she just sticks things together', she cannot deal with thefragments, not him. He becomes very hostile and thinks she should know how little he feelsand she is the one who should feel little. I liked the therapist's next interpretations abouthumiliation. But I thought an interpretation about his reacting in terror to his disturbingthoughts, and his fears of disintegration and the processes of projective identification goingon would have been apposite here. This may have enabled him to see something more of

392 British Journal of Psychotherapy (1996) 12(3)

what he earlier described as `lots of different people running around his mind', of therebeing different aspects of himself and his feeling that none of them are really him.

The last interchanges between Paul and his therapist he found valuable. For by histherapist saying he felt misunderstood by her, she is acknowledging that he feels she hasdone something to him, misunderstood him or even confused him. By acknowledging whathe can feel she is redeemed, and he feels he is not to blame totally, a relief from guilt whichmay enable him to go away to think about the session.

In conclusion, overall I would interpret the process of how Paul moves towards insight,is then confused and attacks the therapist, and how communications from the therapist aresometimes experienced by him as her doing something to him, just as his words aresometimes an attempt to do something to her, as centrally moving her away from what iscurrently more worrying for him. His aggression is intense and there seems a severe dangerhe could hurt others or himself. His tendency to violence, in action and verbally, is relatedto fundamental splitting processes, and the enactments aim to control and dominate weakand needy elements. It is important his therapist can be robust and survive, as she says, `being treated as a punchbag', and thereby bring along the process whereby he caninternalize something good and more secure.

Denis FlynnChair of Psychotherapy Dept, Cassel Hospital

Member, Association of Child Psychotherapists57 Lock Road, Ham, Richmond TW10 7LL

Reference

Joseph, B. (1985) Transference: the total situation. In Psychic Equilibrium and Psychic Change (Eds.E. Bott Spillius and M. Feldman). London: Routledge, 1989.

Commentary by a Child Psychotherapist and Psycho-Analyst

I found this clinical material both very interesting and particularly relevant to understandingsome of the difficulties encountered in the treatment of disturbed adolescents. Paul might beseen as representative of many adolescents who desperately need psychotherapeutic help.Despite obvious risks and difficulties, Paul's frequent missed sessions (mainly beforebreaks) and his rather provocative and threatening way of relating, this boy seemed to me tobe capable of valuing and using his therapy.

Paul seems a very vulnerable adolescent who feels trapped in an impossible situation: hewants his therapist to know about his anxieties, to see how fragmented and mad he feels, tosee his anxieties about his sexuality, to tackle his 'fakedness', to see how he cannot bearknowledge of his loving feelings without distorting them in a perverse way, while, at thesame time, whenever his therapist does try to approach this, it is experienced as an attack. Itseems to me that whenever he is confronted with his own psychic reality, he feelsthreatened and attacked by the therapist who is experienced as containing the projections ofhis own `madness'.

It is worth bearing in mind Paul's need to resort to sado-masochistic actions, such asburning himself, suicidal thoughts and possible suicidal attempts, all of which provide