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A therapeutic dilemma: symbolic versus literal approach whilst working with adolescent patients, shown with the use of clinical examples

Maria Teresa Aydemir

Jungian Analyst & Clinical Psychologist, IAAP Individual Member, ECECJA Founder-member; private practice, Poland

E-mail : aa

Maria Barbara Lokaj

Jungian Analyst & Clinical Psychologist, IAAP Individual Member, ECECJA Founder-member, PTPA Founder-member; Specialistic Outpatient Family Clinic, private practice, Poland

DOI: 10.15761/CCRR.1000370

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Abstract

The purpose of this paper is to discuss a dilemma often faced by psychotherapists from various therapeutic schools: a choice between a symbolic and literal approach. Authors, Jungian Analysts and Clinical Psychologists with long-term clinical experience, focused in the article on that how this dilemma manifests in analytical psychotherapy of adolescent patients. In order to illustrate this issue, they introduced two clinical examples from their analytical work with adolescents. The article has been prepared based on the material presented by the Authors during the 23rd International Conference on Adolescent Medicine & Child Psychology “Unveiling Novel Therapies and Developmental Strategies to Help Children Grow Better”, organised by Conferenceseries on the 28th - 29th of September 2017, in Berlin. Some of patients' data was changed to ensure confidentiality.

Introduction

A number of our adolescent patients have presented significant emotional deficiencies resulting from the lack of enough parental care and support. In these situations, therapists often become a 'substitute parent'. Our dilemma, as therapists, is how to keep a symbolic and analytical attitude facing these significant deficiencies and needs of our young patients. This dilemma is critical, as the period of adolescence is an especially important and difficult moment in one’s life - a time of a transition from childhood to early adulthood. This time of a transition requires guidance from an adult figure helping them to enter into early adulthood. The question is how far can or should the therapist fulfil this role?

It is a dilemma for an every therapist and councillor who works with children and adolescents. But for us, Analysts, due to the nature of the analytical work, this dilemma is acutely profound. As Jungian Analysts, we work with the unconscious psyche of our patients using metaphors and basing on the paradigm of symbolisation. The analytical work with the unconscious psyche activates patients' contact with symbols and unconscious images. As adolescents have just left their childhood, the time of fairy tails and unconscious images, they now need to put their feet on solid ground in the real world. Paradoxically, the analytical work based on symbolisation can help adolescent patients in this process of grounding. It is because this kind of work confronts our patients with the feeling of frustration. Their frustration in analytical therapy comes from three main sources:

Boundaries connected with limits of the therapeutic frame work (e.g. the length of the therapy sessions - a session finishes at the same time despite the fact that it started later than usually because a patient was late)

The limits in how much work the therapist can do for the patient ( e.g. the therapist can talk with the patient about their problems but doesn't solve their problem for them)

The therapist role is to comment on the patients stories and images by giving interpretations and clarifications instead of giving reassurance which is often craved by the patient (e.g. t).

The title dilemma has been demonstrated through two clinical examples.

Clinical example one: 'Natalie' - “I prefer to die than to be average.”

An adolescent girl, whom I called 'Natalie', was in an individual psychotherapy with me for over 3 years. According to the Polish psychological literature, the time of adolescence is not limited only to the teenage years but it starts earlier and finishes later. The time of adolescence is divided as following:

- Pre-adolescence, puberty: for girls 10-11, for boys 11-12

- Early adolescence: for girls 13-16, for boys 13-17

- Late adolescence: for girls 17-20, for boys 18-22

When applied to the therapy, 'Natalie' was a 17-year old pupil of a private college, having problems with completing the term. Thus, according to the division set out above, she was in her late adolescence. 'Natalie' suffered from low mood, strong anxieties causing the situation that she was even afraid to get up from her bed, and problems with relationships with her peers: she was very lonely having no friends. She also failed high schools and changed schools many times.

'Natalie' was the only child of her parents. She grew up in a well-off family, with high standard of life. Her father, a businessmen, was especially very successful at work. Her mother did not work. 'Natalie' always wears expensive clothes and had a very high expectations regarding her style of life. Her parents bought her a car. 'Natalie' felt a strong anger toward her parents but she was also seeking emotional reassurance from them. When 'Natalie' was at out, her mother phoned her several times a day. 'Natalie's' mother was always over-caring and allowed her daughter for almost everything. 'Natalie's father was usually absent, being involved very much in his business. The Patient described the situation at her parents' home so: her father was lying on the sofa, 'Natalie' was sitting nearby and her mother was running around them and catering to their every need. 'Natalie' grew up with the impression that her father was very lazy and helpless, so she felt contempt for her father. He also felt contempt for her mother because her over-caring attitude and was on the opinion that her mother was stupid.

When 'Natalie' was a child, her father used to tell her that only educated people could have a chance to become rich and only rich people could have any meaning and be respected in the society. When 'Natalie' was 12 years old, her father used to give her physics books for 15 year olds. 'Natalie' could not fulfil her father's orders to complete the exercises from the book. Then her father sneered at her. 'Natalie' felt stupid and helpless and hated her father. When 'Natalie', as a child, asked her father a question, her father used to give her a very complicated answer which 'Natalie' was not able to understand and felt hopeless again.

The first year of therapy, was a time of struggling with boundaries. 'Natalie' was fighting with her teachers in the college by not delivering her projects on time and with me by being late to her sessions. She perceived a clock on the wall in my consulting room as his oppressor and me as an oppressive male figure who expected from her things which were impossible to do. I contained 'Natalie's' anger and her attacks on boundaries. My role was to be patient but assertive at the same time. It was like being with a 3 years old toddler who was testing his limits. In the 2nd year, 'Natalie' started to cooperate with me and changed her attitude to her school: she changed her college that time from a private for a public high school (in Poland, the level of public colleges and universities is usually much higher than the level of private high schools, so it costed her more effort to learn in a public school than in a private one). First time in her life, 'Natalie' completed the year without repeating any exam. She also increased her social circle, starting seeing regularly three new peer-friends.

At the time when 'Natalie' was doing practically nothing, lying in her bed with her head covered with a blanket, she developed grandiose fantasies that she would soon become a millionaire who would open her own fashion house and become famous. In the third year of her therapy, when 'Natalie' has already started to verify her real capabilities, she became very disappointed and frustrated. She started to develop a negative transference, blaming me for taking her addictive fantasies and emotional 'drugs' away from her.

'Natalie' could not accept the fact that she was not the best student in her class and however hard she worked, she was unable to fulfil her own expectations. She started developing strong feelings of hatred and contempt towards herself and to have suicidal thoughts. She felt a huge rage to the world and herself that she was not such an outstanding person as she expects herself to be. In the attacks of rage, 'Natalie' shouted and kicked doors in her flat and throws objects. She also tried to kill a dog with her speeding car and felt satisfaction and triumph when the animal was escaping in panic.

'Natalie' often repeated: “I prefer to die than to be average.” and: “ If I had to work in a supermarket, I would kill myself." To show me that she was serious about that, 'Natalie' described the situation when she was sitting on the outside windowsill of her apartment on the eighth floor.

When 'Natalie' has changed her life situation in a positive way and overcame her anxieties, she started feeling worse. This is an example of a negative therapeutic reaction. Realised that she is not so great as she saw herself in her fantasies, she started to punish me for this. She became sarcastic and arrogant towards me, rejecting and denigrating all my interpretations. She repeated that everything what I said was useless for her. She wanted to leave her therapy but felt she was in the trap. Once, she said: “You took my leg and now I can't go away”. As the 'leg' , she understood her faith in her grandiose fantasies which were a sense of her life since her childhood. In the transference, she reacted and perversed the situation from her childhood: 'Natalie' played the role of her humiliating father and I was playing the role of humiliated child – 'Natalie'. The Patient demanded concrete answers for her questions and simple 'prescriptions' how to solve her problems, refusing to even start to struggle with my interpretations. She repeated with an ironic voice: “I know all this but how does this help me?”

The problem in this situation as a therapist, was to find a middle ground where I was not doing everything for 'Natalie' like her over-caring mother but at the same time was not like her father, giving his daughter tasks too difficult for her to achieve and making her feel hopeless.

In the counter-transference, firstly, I found myself trying to fulfil 'Natalie's' expectations, running around her with a plate of soup, like her mother did. I tried to simplified my interpretations, as 'Natalie' complained that she could not understand anything and that my interpretations were “too abstractive” for her. I was also considering to give her some kinds of 'advice' and even gave her comments how she could subtly modify her behaviour regarding her social relationships, as she used to complain all the time that she did not know how to keep long-term relationships with her peers. But, despite all my efforts, the Patient was still disappointed and denigrated my attempts to help her. So, I realised that I was doing all this only to avoid to feel helpless as a therapist.

Then, I started to offer my Patient more challenges during our sessions. I gave her comments and interpretations which required her effort to digest them. But I realised, that I started to feel impatient and developed strong irritation toward 'Natalie' – in the counter-transference, I became somehow her cruel father. So, I started to push myself to develop empathy for 'Natalie'. In order to help both of us – 'Natalie' and me – to get out of the trap of the vicious circle of humiliation and retaliatory triumph, I suggested her to limit the time of her therapy. I have suggested the following framework: we will work together during next 6 months, and then we will decide whether we are able to continue our work. If not – I will find 'Natalie' another therapist. The Patient agreed for this idea and was grateful to me because she stopped feeling imprisoned by me. She hated me but in the same time she was afraid to stay without any therapy and didn't know where to find help. I also started to offer 'Natalie' some kinds of explanation of her intrapsychic situation based on simple images. 'Natalie' found this way of working helpful for her.

Thinking about 'Natalie's' therapeutic process, I am still having doubts how much she really was not able to symbolize and understand my interpretations and how much she just manipulated refusing to chew the interpretations by herself, imitating her 'lazy' father lying on the sofa and expecting me to feed her with a spoon...

Clinical example two: 'Andrew' - “Only I'm keeping myself warm.”

My patient is a 15 year old boy whom I will refer to as Andrew. He started analysis with me 3 years ago. His history, is a story of early and hard abandonment.

He is an adopted child. When he was only a few months old she was left by her biological parents. At the age of 9 months he was adopted by her current parents.

Andrew's parents divorced when he was 8 years old. Both parents had new relationships, but not stable and long-term ones. Now, her father has a child from one of his more recent relationship. In the past, his father abused drugs and alcohol. The father's addiction to drugs and alcohol were the main reasons for the divorce. Since the divorce, the father has finished rehabilitation for addictions. Andrew's mother has been under psychiatric care for many years- having taken tablets because of depression. Her mood is very changeable and is easily put into a bad mood.

Mother is very critical with Andrew. Some coldness between them is visible and they have difficult story together including physical violence (they fought with each other). The difficulties in their relationship was a reason to send Andrew to psychological and psychiatric treatment when he was 12.

Andrew has decided that he wants to leave home when he is 18 because of the cold relationship with his mother. He said: “ I wonder if she realises that I will not have any contact with her when I will be an adult?”

Father seems more responsive for Andrew needs. When I asked him for help to find a new school for Andrew - father responded actively. He seems more engaging and caring. Andrew has learning difficulty and failed secondary school. He started a new school. Mother was very disappointed because of his failure and called him stupid.

Andrew brought to his analysis problems with obsessive thoughts about possible abandonment by his girlfriend. These thoughts are very exhausting for him. Andrew often can’t sleep and he is very anxious at night. He is also anxious about relationships with his peers and imagines rejection from them. This anxiety is very visible in how he behaves in his new school.

Andrew presented himself to me as someone surprisingly mature and without illusions. It has been very difficult and bitter for him realising that he will not get longed get affection and support from his mother. His attitude towards his parents is a mixture of anger and disappointment but on the other hand his respect and care is visible. My impression was that despite his whole difficult history, he was sometimes more mature than his parents, more caring and understanding for them than they are for him.

Andrew said once: “Only I'm keeping myself warm”. It was in context of absence of his father in his everyday life and the moodiness and anger of his mother. This short, moving sentence shows briefly the core of his relationship with his actual parents but maybe it also echoes his early abandonment by his biological parents. For me, this statement was incredibly sad, insightfully showing me his loneliness.

This quote from D.Winnicot seems to fit very well for Andrew:

“While growing process in adolescence is in progress, responsibility must be taken by parental figures. If parent-figures abdicate, then adolescents must make a jump to a false maturity and lose their greatest asset: freedom to have ideas and act on impulse”. (Winnicot, 1970, p.176)

During his analysis, Andrew said a few times “ I can only rely on you and I trust you'”. He really cared about our relationship, in a way that other adolescents do not care. I believe and hope that I gave him good enough container but I tried not to exclude his parents. My impression was that his parents were busy with their lives and simply gave him under my 'psychological care'.

Andrew needs more psychological ‘holding’ than just one session per week but has no money for additional sessions. He initiated to send me text messages and I allowed him to do this. He used this privilege just times of crisis- the exchange of messages between us were just in order to calm him down. These text conversations were only short exchanges as he did not abuse this form of contact but he has a feeling that I am somewhere and accessible. From analytic point of view, it is questionable because of boundaries and limits set.

Andrew brought something very symbolic to his analysis. He got a tattoo on his back, it was a tattoo of an eagle's wings. Wings are a very vivid symbol for his survival and strength, remind him that he will get through difficult moments in his life, reminding him about his own strength.

I believe that that my role is to help Andrew to grow, step by step, a symbolic attitude. In the face of a lack of good enough adult support, I wanted to provide him something what is missing, something which helps him to go through this difficult period of him. I hope this is not too much and not too little. I invited his parents to cooperate with me but I believe that help in becoming an adult is still needed for him in face of parental deficiency [1-6].

Conclusions

Usually in the transference, the Analyst is a kind of parent for the patient. It is particularly true whilst working with adolescent patients. When the parents are not supportive or sometimes even destructive, then adolescents’ longing for a good parent becomes very strong. There is an unconscious pressure on the Analyst to do more, to go further, to be as a foster parent. It is visible in the Analyst’s countertransference feelings. This pressure is much stronger than in the analysis of adults. This is what was experienced by a Therapist in her relationship with Andrew.

What is important for an adolescent, is to grow and develop a symbolic attitude. The symbolic attitude can be enriched through playing, imagination and creating new ideas. When an adolescent has to control the family dynamics and focus on their parents’ problems, then there is no space for them to freely play and imagine. Andrew seems to be too adult, too literal, even his relationship with his girlfriend seems to be too serious, it’s rather more like a marriage than an adolescent relationship.

Winnicot said: “Child may suddenly need to become responsible because (for instance) of the break-up of a family (...) such a child must be prematurely old and must lose spontaneity and play and carefree creative impulse. This is false maturity.” (Winnicot, ibidem p.171)

Tattooed wings could be a creative impulse. They reminded Andrew the strength of his survival, his identity, his individuality. Because of his painful story, it is difficult for Andrew to have inside of his image of something good so he wanted this image very close: on his skin.

And what about Natalie who bullies her therapist by the blackmail that she will kill herself or somebody else if she doesn't become a genius millionaire? Grandiose self and narcissistic vulnerability is a central feature of adolescence. Adolescents usually have an ideal which helps them to transit into adulthood. But Natalie has been fixed on her omnipotent sense of self and refuses to see her shortcomings, demanding affirmation for her illusory power. An adolescent is a young person who is developing into an adult. So how to help Natalie to develop an adult self-esteem when she fully identifies with her unrealistic fantasies?

Her grandiose fantasies are typical rather for a 7-year old girl than for a late adolescent. Should Natalie be told this despite her feeling of humiliation? Is the literal solution of the limited time of therapy enough for Natalie or should she be rather confronted with her aggression towards her therapist and, in the transference, towards her parents? Isn't Natalie's therapist just escaping from her patient's rage by giving her explanations instead of more difficult interpretations? Should she be even more flexible in her efforts to literally support Natalie or should she frustrate her more to encourage her to grow up?

The capacity to symbolise is achieved not only by playing but also by experiencing frustration caused by the situations that parents are not always accessible and not always fulfil their child's needs. In both our cases, there is a danger that therapists identifying with good parental figures and unconsciously competing with the patients' 'bad' parents, may slow down their patients' development by offering them too literal support.

It is also questionable whether a corrective experience of having a good parental figure in the person of a therapist is enough for our patients to go into adulthood and whether it will replace the exploration of their inner world. There is a question how much we can analyse our patients' relationships with both their real and intrapsychic parents in the situation when adolescents are still fully dependent on their parents emotionally and as well as financially and their parents pay for the therapy.

Because of their difficult history both patients have a problem with normal, adolescent, creative playing with thoughts and ideas. If they have ideas for their future, these ideas are rigid, fix and difficult to any shift. Also their anger to their parents it is not only adolescent rebellion against authority. Most adolescents need a confrontation with authority, it is normal phenomena. But their anger (or even rage) is much more powerful and connected with very difficult story with their parents from the past.

Both our patients needs to rely on a real person (analyst) but at the same time analytical work should open a symbolic space where they found symbols which help them to rely on themselves.

With this and the questions asked above, we would like to open a floor for discussion regarding this crucial therapeutic dilemma.

References

  1. Carpy DV (1989) Tolerating the Counter-transference: A Mutative Process.Int J Psycho Anal70: 287-294
  2. Jung CG (1929) Problems of modern psychotherapy. In Collected Work 16.
  3. Peters R (1991)The therapist’s expectations of the transference.J AnalytPsychol36: 77-92. [Crossref]
  4. Wiener J (2009)The therapeutic Relationship. Texas A&M University Press. CollegeStation.
  5. Winnicott DW (1984) Ego Distortion in Terms of True and False Self. In: Winnicott DW (Ed.), The Maturational Processes and the Facilitating Environment,The Insyitute of Psycho-analysis Karnac Books, 140-153.
  6. Winnicott DW (1966) Playing and Reality. New York: Routledge.

Editorial Information

Editor-in-Chief

Andy Goren
University of Rome "G.Marconi"

Article Type

Case Review

Publication history

Received date: November 07, 2017
Accepted date: November 27, 2017
Published date: November 30, 2017

Copyright

©2017 Aydemir MT.This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Citation

Aydemir MT, LokajMB (2017) A therapeutic dilemma: symbolic versus literal approach whilst working with adolescent patients, shown with the use of clinical examples. Clin Case Rep Rev 3: doi: 10.15761/CCRR.1000370

Corresponding author

Maria Teresa Aydemir

Jungian Analyst & Clinical Psychologist, IAAP Individual Member, ECECJA Founder-member; private practice, Poland

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