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DROPOUTS WITHOUT DRUGS
DROPOUTS WITHOUT DRUGS A Study of Prolonged Withdrawing Reactions Younger Adolescents
III
Brian]. McConville, M.B. and Lorna C. Boag, M.B. Several authors have commented recently on the interplay between societal; familial, and internal processes in the interesting syndromes of adolescent alienation. For example, N oshpitz (1970) stresses both a decreased internal belief in the "magic of authority" and the relative social affluence of today's adolescents as possible causes of alienation. Similarly, in describing the alienation of youth as reflected in the Hippie movement, Williams (1970) stressed the group's inner need for intimacy and for doing one's own thing, as contrasted with an externally proclaimed need to drop out of a society composed of hypocritical parents and constricting educational and religious systems. Even in the highly visible societal patterns of adolescent drug abuse, various authors (Hekimian and Gershon, 1968; Welpton, 1968; Allen and West, 1968) have commented on associated inner factors of alienation and depression. In terms of etiology, there is considerable interest in whether the striking clinical phenomena of alienation can be linked in some way Dr. McConville is Associate Professor of Psychiatry, and Dr. Boag is Assistant Professor of Psychiatry, at Queen's University, Kingston, Ontario. A briefer version of this paper was presented at the Fall meeting of the Ontario Psychiatric Association, Montebello, Quebec on October 23, 1971. The authors wish to express their appreciation to Dr. George Ashman, Kingston General Hospital, and to Dr. Arjun Purohit and Mr. Allen Elkin of Beechgrove Children's Unit, Kingston Psychiatric Hospital, for their invaluable assistance with this study. Reprints may be requested from Dr. McConville, Director, Beechgrove Children's Unit, Kingston Psychiatric Hospital, Kingston, Ontario.
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to the vicissitudes of the normal separation-individuation process of adolescence. This question is not simple, since a number of writers in a recent symposium (Solnit et al., 1969) have commented on the disparate symptoms seen during the normal separation-individuation process. It is also unclear how the various causative factors of adolescent separation-individuation pathology interact, and how the described "syndromes" compare within themselves. In the 1969 A.P.A. symposium cited above, Settlage described an intense defensive response in adolescents both to the impact of puberty and to the associated pressure toward independence. This was characterized by prolonged regressive retreat into oneself, and away from peers and family. Such regressions could take the form of an extreme preoccupation with the self, with hypochondriasis and somatization reactions. This syndrome seems to imply a complex interplay between societal and intrapsychic factors, and also implies problems in separation-individuation. In this paper, we wish to describe a group of younger adolescents who showed extreme and often chronic withdrawal-alienation responses from many social and educational activities, associated with intense interpersonal anxiety. These patients had minimal direct societal problems, and none was on drugs to any significant degree. Most of these teen-agers came from socioeconomic groups II and III (Hollingshead and Redlich, 1958). Their response to anxiety was not to seek some style of peer or communal living, but to withdraw from peer contact, becoming either chronically anxious or extremely depressed with some suicidal thoughts. Common to all of these adolescents was a feeling of extreme alienation from the world; this was not defined in terms of the fact that society or its value systems had failed them, but rather in terms of a feeling of isolation and of being shut off from a world which they valued and wanted to join. The hypothesized syndrome therefore seems sufficiently different from a stereotype of "culturally alienated youth" to be described, and would seem to bridge the gap further between separation-individuation and alienation problems. After a qualitative description of two representative cases, we shall present a quantitative comparison of the cases, showing the hypothesized syndrome with a comparison group of other adolescent cases seen in clinical practice. On the basis of these quantitative and qualitative descriptions, some observations will be advanced about
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the nature of the syndrome, as well as some speculation about the internal processes attending these rather striking phenomena. REPRESENTATIVE CASES
Case 1: S. C. This well -built and handsome boy originally was referred for individual therapy at the age of 151'2' At that time he had had rather chro n ic symptoms which had started at about age 13 ~ , in which he was overcome by episodes of lassitude and boredom in school, with progressive deterioration of his schoolwork. In particular, he described an interesting oscillation of gross voluntary withdrawal from social contact because of feelings of shyness and awkwardness, with an imposed and entirely alien sensation of being cut off from a world which he valued and wanted to join. His intelligence was high and he had previously done very well in school. He was unable to attribute the falling off in his grades or in his interest to any particular event. He lived alone with his mother; the father had left the family when S. C. was 8, because of in creasing tension between the mother and the father. The boy had been extremely sad at the time, and still missed his father deeply, while continuing to visit him occasionally. Although he felt like quitting school at age 14, his mother had urged him to continue. He felt intense anger at her, which re capitulated the enormous rage he had experienced toward her at the time of the separation, when he felt that the mother had pushed the weaker father out of the home. Initially in therapy, his angry feelings toward the mother were verbalized, and he was able to express some of the rage whi ch he felt toward her. However, this description of rage remained largely at an intellectual level, and his symptoms remained unchanged . Over the
next 12 months he continued in regular psychotherapy, always hopeful that some medication or some explanation would be found for his sudden withdrawal from involvement with the world, yet constantly being disappointed, as when Thioridazine (to decrease impulse strength) and Imipramine (for depression) produced little result. After approximately 12 months, it was explained to him that he had withdrawn from meaningful contact with the world as an erner-
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gency reaction against impulses which had been felt at the beginning of puberty, and toward which he had no particular coping responses. It was therefore suggested to him that as the impulse disturbances of puberty tended to subside, his symptoms would improve, and he would become more affectually and interactionally involved with the world. He greeted this with some hope but without much enthusiasm, since by this time he had withdrawn from high school and was working in a nearby lumber store. He still described feelings of excessive alienation and despair, although on the job he was able to work extremely effectively. Gradually, over the next 12 months, continuing in intermittent psychotherapy, S. C. was able to make the decision to move into a community college which would allow him to take up a career with his available high school credits. For the first 6 months he went into a course in Engineering, following his father's original profession. Later he switched to a course in Town Planning, not only picking a career which had more future, but possibly also symbolizing a greater hope for his own reorganization. He continues to be seen after almost 3 years of therapy, and he has continued in the community college. He has some male friends, and will complete his course, but at times still has feelings of being cut off from the world, although he is able to say that these concerns are much less frequent than before. In this very striking case, a young and personable adolescent who had previously functioned well suddenly became involved in an alienation process from society which did not involve him with the usual feelings of cultural alienation as described for "hippies" and others. He experienced profound depression, withdrawal, and purposelessness, and the therapist was also aware that little effective could be done in therapy other than providing symptomatic relief, along with the use of the relationship as a bulwark to which the patient could cling in his strongest periods of despair. Case 2: K. M.
In contrast to the first chronic and relatively unremitting case, the next example is of a boy who made a rapid initial improvement, but was left with residual alienation symptoms. This boy was first seen at
the age of 16 with symptoms which had started when he was approxi-
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mately 14~. His symptoms were first noted at a time when he was working along with his father in a job situation. His relationship to his father was a very warm, but essentially ambivalent one in which he was very supportive toward his rather passive father, who was dominated by the mother. Although the boy often felt angry at his father, he also felt unable to challenge his father without hurting him. One day he was working with a supervisor in his father's business. This man suddenly became very angry at the boy, and threatened to attack him physically for making an error in a construction job. He felt very angry, but was unable to express his feelings openly. Despite some concern, he felt no other symptoms at the time, but on the next day suddenly began feeling that he was living in two worlds. He existed in one particular and self-contained world which was confined within his own body, and from which he looked out at the rest of the world. The other world was always present, but the patient felt shut off, and at times unable even to focus on the "outside world." His school performance, which had been very adequate, fell off rapidly. Psychological testing was carried out to assist in the diagnostic formulation, and the psychologist reported: Mr. M. is a young man of bright normal intelligence. He appears to be rather shy and to feel somewhat alienated, lonely, and perhaps abused by his peers, although he has a strong need for close relationships. However, he is insecure in his ability to form such relationships, particularly with girls. In general he lacks selfconfidence and is very concerned about his ability to achieve success in life. He would appear to see himself as not being particularly attractive to other people, as well as a rather ineffectual, buffoon-type scapegoat. There are some indications that he has a rather phallic dominating mother who may have considerably overprotected him. There are also indications that he may see his father as not being able to
appropriately handle his mother. He tends to lack respect for authority but is too afraid of his own aggression to challenge authority figures as he would like to, in order to stand up for his rights. He appears to see this as a major stumbling block in being able to become a competent, independent adult. His conception of what might be required to accomplish this seems to be unrealistic and due to wishful thinking that it might not be too difficult. In general he appears constricted emotionally and quite dependent. Beneath this boy's surface appearance of quiet shyness it appears
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that he has a great deal of aggressive feeling and considerable sexual drive. His fear of his aggression, however, appears to cause him to defend against it by reaction formation and withdrawal. He would seem to discharge his aggression mainly in fantasy, since he appears to feel that it would have catastrophic results if let loose. The formal diagnostic impression is that of an obsessive personality disorder with mild schizoid features. Therapeutic recommendations for Mr. M. would be for assertive training, so that he could learn to channel his aggressive and sexual drives to achieve a more satisfying life for himself. In therapy, which spread over 2 years, the assumed nature of this alienation process was explained to him. It was remarked that his feeling of being separate from the world was a defense against being overinvolved with it-especially in an aggressive destructive sense. This feeling had been initiated by the episode in which he had become extremely angry with the supervisor, symbolizing his father. Avoiding anger had been a characterological difficulty with him for some time, as had been a tendency to avoid heterosexual contact. Initially, the tendency which he had noticed for anxiety-producing figures to blur in front of his eyes was explained as being due to his focusing past the aggressive figure, and the therapist demonstrated to him that this was indeed so. He was also reassured that his feelings of looking out from inside his body could be understood, and that this formed part of normal body-image awareness to some degree. This resulted in a considerable decrease in anxiety, although he was still very anxious and awkward in his interactions with me. By my insisting that he should look at me when he expressed his feelings about me (as when he talked about his intolerance that he was not getting better quicker), the patient was not only able to look at me directly but also to express himself more forcefully. As he did so, he noticed that there was a considerable diminution in his feeling that he was cut off from me, and he also started to make rapid social strides with others in assertive social situations. This form of his therapy continued over a 3-month period of weekly sessions, with marked symptomatic improvement. Later in therapy, his school performance improved, and he began to show some heterosexual awareness which led to his taking out a girlfriend for the first time, and having a successful experience. Nevertheless, a large part of his feeling of essential alienation continued, associated with complaints of worthlessness and aimlessness
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in life. He found that although he was able to become more involved with people, any disappointments-especially from the girlfriendmobilized immense rage whi ch he was unable to deal with adequately, and which led to in creased depression. After 4 or 5 months his depression and suicidal thoughts became intense, and he was started on Imipramine in a dose of 150 mgm. daily, with good effect. He became less depressed and more able to function socially; although his first romance did not proceed adequately, he was able to stand the disappointment and find another girlfriend. Despite these changes in his social awareness, the patient was still unable to rid himself of the feeling that his nuclear problems were unchanged. When seen recently, he still felt that he and the rest of the world were different and that the world revolved around him. He constantly asks himself, "Who is Ken?" He is less depressed and his social responses are clearly better, but he still feels uneasy, indecisive, and guarded about what will happen to him. In this case, the therapy for the presenting symptoms was much more directive and successful. Nevertheless, the onset of his symptoms had been sudden, and the prognosis might therefore be assumed to be better. In addition, the central symptom of alienation still remained to a considerable degree.
QUANTIFICATION OF DATA Because of the practical and theoretical interest in this problem, we decided to study the syndrome more systematically. At the end of the initial clinical survey we collected 18 such cases (out of 225 adolescent cases seen over 5 years). As commented, we may have outlined an early alienation syndrome characterized by withdrawal, depression, and general alienation along with sudden lags in school performance and a rather interesting subjective alteration in body awareness ("special alienation"). To investigate further, we compared this series of 18 "alienated adolescents" with a group of 18 other adolescents matched statistically for age, sex, and intelligence. This comparison group was culled from other case histories on file of adolescents who had been referred for a variety of reasons, including acting-out behavior, generally hysterical patterns, drug abuse, and adolescent situational reactions.
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In both groups 8 were males and 10 were females. The average age of the alienated group was 14.9 years (S.D. = 1.40 years) and that of the comparison group 14.2 years (S.D. = 1.07); the group differences with respect to age were not significant (t = 1.639, 34 d.f.), The average IQ of the alienated group was 103.7 (S.D. = 7.1), and that of the comparison group was 103.5 (S.D. = 6.7); the group differences with respect to IQ were not significant (t = 0.085, 34 d.f.). The alienated and comparison groups were therefore similar with respect to age. IQ, and sex. The combined overall symptoms in both groups were then compared. These included suicidal acts and thoughts, sulking, hypochondriacal complaints, general anger, resentment, attacking others verbally, attacking others physically, stealing, drug use, withdrawal, poor school performance, depression, alienation, and altered body image. All the symptoms were first classified on a general 4-point rating from 0 to 3+, with 0 having the general meaning "not present." The 1+ rating of the operational definitions allowed for the presence of some deviance in the sample consonant with that generally found in the peer group, as the overall arbiter of social values in adolescents. A 1+ rating was therefore not "pathological." In a 2+ rating the behavior was seen as being more frequent, occurring at a greater intensity than that seen in the peer group as a whole, although still consonant at times with a deviant subgroup (as in drug abuse). At the 3+ level the behavior became intense, prolonged, and often subjectively distressing or frightening to the patient because of its intensity. Each symptom also had a special operational definition for degrees of intensity, agreed on after discussion between two child psychiatrist raters. Examples of some operational definitions are shown in Table 1. Behavior is largely as described by the patient, since the data from which these operational definitions are derived are taken from the case histories of the patients. In all cases the descriptions refer to presenting symptoms rather than to others which may have developed during the course of therapy. To establish rater reliability a sample of 20 symptom items in 5 patients was rated independently by the two raters; total category agreement was obtained in 85 percent with a. "pathological-nonpathological" (+++,++1+, 0) agreement obtained in 95"percent
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(p < .01 in both cases). Usually, in the computation process only the frequencies in the 2+ and 3+ severity groups were used to estimate pathology; these frequencies were added to form a common "pathological" group. The hypotheses and results for the alienated and the comparison groups were as follows: 1. The alienated group was expected to show more withdrawal, depression, and general alienation than the comparison group. It was also hypothesized that the alienated group studied would show more suicidal thoughts, sulking, hypochondriasis, and resentment than the comparison group, since the alienated group seemed to have difficulties in openly expressing and verbalizing anger. In addition, special (body) alienation and sudden lags in school performance were expected to be more common, from the initial clinical findings. All the symptom variables mentioned above were compared, using the Chi Square test. The results are summarized in Table 2, which shows that the variables found significantly more often in the alienated group are those of suicidal thoughts, withdrawal, general alienation, and sudden drops in school performance. Chronic poor school performance, by comparison, was more common in the control group. It is interesting that depression, resentment, sulking, and hypochondriasis did not reach levels of significance. Similarly, special body alienation.rdid not reach significant levels, although this is probably due to the small number of cases showing this symptom rather than to the equalizing effect of the comparison group. These findings tend to work against a hypothesis of criterion contamination (Gwynne-Jones, 1971), in which the symptoms described for a postulated syndrome reach significance by their greater selection in the experimental versus the control group, causing overlap in the assessment of the independent and dependent variables. 2. The alienated group was expected to have had a longer duration of pretreatment symptoms than the comparison group. The symptom duration time in the alienated group was found to be 1.42 years and in the comparison group 1.56 years. Using the sign test for medians (Ferguson, 1959), we found no significant difference between. the groups (x2 = 0.112, 1 d.f.). 3. The alienated group was expected to spend longer in therapy than the comparison grpup. The mean time in therapy for the alienated group was 1.65 years and for the comparison group, 0.88
TABLE 1 EXAMPLES OF OPERATIONAL DEFINITIONS OF SYMPTOMS
o (No n pathological )
TIONS
+
++
+++ Seve (Pa tho logica l)
n School Sudden areas in ol perfor u s p er ua te.
Symp tom Absent.
Sudden onset of deficit areas in school performance. Achi eves with average or lower 1/ 3 of group.
Sudden ons et of ma rked deficit areas in school pe rform ance. Ach ieves with lower 1/ 3 of gro up.
Sud den onset of d eficit areas in s performance . Fa gra des ob tained sistently.
School Chronic (cognierformance years. No n perfor-
Symp tom Absent.
Chronic d eficit areas in school performan ce, consonant wit h average or lower 1/ 3 of gro u p .
Considerable ch ronic deficit areas in school performance, conso nant wit h lower 1/ 3 of gro up.
Gross ch ron ic ge deficit areas in s perf ormance-fa grades ob ta ined sisten tly.
No feelings of th is.
Occasional feeli ngs of alienation, countera cted by will or by effo rt, e.g., "joining"; usuall y can enjoy being with peop le.
Frequent feelings of a lienation , counter acted wit h difficulty; can still en joy bei ng with people, bu t requires gr eat effort.
Continuous feeli aliena tion that c cou nt eracted; fe pl etel y sh u t off peopl e, alone; s jec tive ly di stress patient.
No feelings of this.
Occasional feeli ngs o f this.
Fr equent feeli n gs of body sepa ra tion from world.
Ver y frequ en t , c tinuou s feelings ical separa tion fr other s," su bjecti tressing to patie
IONS
TABLE
(continued)
+
o (Nonpathological)
++
+++ Seve (Pathological)
escribes wing from
No withdrawal.
Describes some active withdrawing from social contacts, consonant with behavior of peer group members in social situations.
Describes much active withdrawal from social contact, greater than warranted by situation and than noted in peer group.
Describes consta drawal from oth greater than war and than seen in constancy of wit concerns patient
elings of sness, or
No depression.
Occasional feelings of sadness, helplessness, hopelessness, consonant with family or peers.
Frequent feelings of sadness, helplessness, hopelessness, wi th suicidal thoughts seen as possibly solutional.
Very intense fee sadness, hopeless frequent though suicide as wished solutional.
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TABLE 2 COMPARISON OF SYMPTOM VARIABLES IN ALIENATED AND COMPARISON GROUP
VARIABLE
IN ALIEN· ATED GROUP
IN COMPARISON GROUP
(++,+++)
(++,+++)
Withdrawal 18 Sudden Drop in School Performance 13 General Alienation 18 Suicidal Thoughts 12 Poor School Performance (chronic) 3 Hypochondriasis 4 Attacking Others Physically I Drug Use 0 (Special) Body Alienation 5 Sulking 2 Depression 18 4 Sexual Acting Out Suicidal Acts 5 General Anger 9 Resentful 6 Attacking Others Verbally 9 0 Steals (Yates Correction applied
SIGNIFICANCE
x2
(I d.f.)
5
20.3478
P < .001
2 2 4
13.8285 28.8000 7.200
P < .001
8 8 5 4 6 15
3.2727 2.0000 1.8000 2.5313 1.8000 1.4464 1.4545
1
0.9290
I
0.7093 0.4500 1.0286 9 II 0.4500 I .0032 where necessary) 2
II
P p
< .001 < .01
N.S. (p N .S. (p N .S. (p N .S. (p N.S. (p N.S. (p N .S. (p N.S. N.S. N.S. N.S. N.S. N.S.
< .10) < .20) < .20) < .20) < .20) < .30) < .30)
years. Again using the sign test, a significant difference was found between the two populations (x2 = 9.28, 1 d.f., P < .01).
4. The alienated group was expected to have had a longer time of family disorganization than the comparison group. (This term implies a concept of family disagreement, disorientation, or general upset, as described by the patient and as confirmed from other sources. The degree of such disorganization is not estimated, it being felt that this was difficult to do. Estimates of the time of starting' of such family disagreements are probably only approximate, and derived from patients' histories and other sources.) The mean length of family pathology in the alienated group was 3.42 years and in the comparison gTOUp 1.72 years. Again using the sign test for medians, no significant difference was found between the groups (x2 = 1.029, 1 d.f.). 5. The groups were also compared in terms of hypothesized rank
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order correlations between length of therapy and length of pretreatment symptoms, and of family pathology. The results are as follows: (a) In the alienated group the time spent in therapy correlated positively with length of symptoms before treatment (Rho = 0.699, P < .01). However, in the comparison group the time in therapy also correlated positively with length of pretreatment symptoms (Rho = 0.464, P = < .05). (b) In the alienated group there was a positive correlation between length of therapy and length of family pathology (Rho = 0.617, P = < .01), but in the comparison group there was also a positive correlation (Rho = 0.643, P = < .01). In summary, these results indicate that in both groups those who were longest in therapy tended to have symptoms longer and to have family distress patterns for a longer period. This was not different for' the two groups, although duration of symptoms correlated more strongly with length of time in therapy in the alienated group. However, the time in therapy is considerably longer for the alienated group than for the comparison group. This tends to support the hypothesis that the pathological processes found in the alienated group are intrinsically more difficult to reverse than those seen in the comparison group. 6. Since a number of patients in the alienated group had commented both on the absence of fathers and dominance of mothers, absence and nondominance of father and absence and dominance of mother were hypothesized to cause more severe illness, and to be more common in the alienated group. The hypotheses were derived on the following clinical bases. (a) Fathers who were absent (either in terms of excessive pressures of work, or in terms of more severe degrees of absence) could not give the children the support as identification figures or oedipal bulwarks which they needed in early puberty. Hence, their absence might correlate positively with greater frequency in the alienation syndrome. (b) Similarly, it was felt that it was necessary for fathers to be "dominant" in a family, e.g., involved in making decisions. When. this was not so, teen-agers could be more vulnerable to stress-and ' more alienation would result.
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(c) It was also hypothesized that mothers would need to be present in the family for all-round support and that their absence would correlate positively with gTeater alienation illness. (d) It was also felt that mothers should be nondominant with respect to the father, although they could be both supportive and warm in the family constellation. Relative maternal dominance would therefore be expected to correlate positively with greater alienation illness. These four investigative and admittedly naive hypotheses were then investigated in terms of the operational definitions shown in Table 3. It should be noted that the rating scheme relates to perceived parental absence and dominance, as described by the patient in clinical interviews. Parents were interviewed directly in approximately 50 percent of cases. The results are as shown in Table 4. It will be seen that the only factor which varied significantly from the comparison group was that of "absent father." 7. It was therefore felt that there might be a correlation between intensity of the overall syndrome and the absence of the father. Since time in therapy had been found to be a significant overall index of severity of the illness, "absence of father" in the alienated gTOUp was compared with time in therapy using a 2-by-2 table. The Chi Square (with Yates Correction) was 0.2500, and this difference between the groups was not significant. It may be that larger numbers would allow for greater significance, although this is not suggested by inspection of the overall x2 distribution. For further comparison, the boys and girls were compared in terms of high (++,+++) and low (0,+) absent fathers; 7 boys and 10 girls had high absent fathers. The Chi Square distribution is not significantly different between the two groups, going against a hypothesis that boys would be particularly vulnerable to absence of fathers. However, it is of considerable interest that among the boys, only 1 had a very high (+++) absent father, whereas among the girls, 5 had fathers who were very high absent because of death or prolonged separation (x2 = 1.3781 N.S., P = < .30). This suggests that the quality of perceived paternal absence may be quite different for girls than for boys and suggests avenues for further investigation. 8. From clinical observations it was hypothesized that those patients whose anger was directed mostly at their mothers would have
TA B L E 3 R ATING SCHEME FOR ESTIMATING PERCEIVED PARENTAL ABSENCE/DOMINANCE 0
O NS
(No npathological)
+
++
+++ Severi (Pathological )
Father tien t as d ho m e r sup-
No feelings o f th is.
Father described as being occasion all y away from hom e, not th ought of as being around a nd sup po rt ive as often as is need ed .
Fathe r very fr eq uen tl y away from hom e due to work or other social pressures. Absence described as being serious loss.
Father described being a bsen t cont (includes sepa ra t divorce, death) . de scrib es father as ever or never aro
in ant. ondecis ion .
No feelings of this. Father seen as sufficientl y dominant.
Father occasiona ll y seen as nondominant, not different from peer group expe rience of fath er s.
Father often seen as nondomi nant in d ecision making a nd structuring for wife, fam ily.
Fath er described a completely domin non dominant in d making and struc for wife, family.
. Mother tient as d home su p-
N o feelings of th is.
Mother d escribed as being occasionally awa y from home, not a ro u nd and supportive as often as is ne eded.
Mother very freq uen tl y away from home due to work or other social pressu res . Absence de scribed as bei ng a serious loss.
Mother de scribed being ab sent con tin uou sly (includ sep aration , divor d eath). Patient de mother as hardl y never around .
nt. o minan t, n fam ily.
No feelings of this. Mother seen as n on dominant.
Mother occas iona lly seen as dominant, not differcnt from pe er group experience of mo th ers .
Mo ther often seen as domina nt in deci sion making a nd structuring for family.
Mother described bein g complet ely dominant.
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TABLE 4 RELATIVE PARENTAL ABSENCE/DOMINANCE IN ALIENATED OR COMPARISON GROUP IN ALIENATED GROUP
IN COMPARISON GROUP
SYMPTOM
(++,+++)
(++,+++)
(I eLf.)
Fathers Absent Fathers Nondominant Mothers Absent Mothers Dominant
17
7 2 2
12.5000 0.7094 0.2000 1.0836
5 4 8
5
x"
SIGNIFICANCE P
< .001 (N.S.) (N.S.) (N.S.)
more severe (longer time in therapy) illnesses than those who .were mainly angry at their fathers. Ten adolescents described anger directed primarily at the mother, while 7 were more angry at the father. The mean time spent in therapy for the former group was 2.2 years and for the latter group 1.0 years. Because of the uncertain distribution characteristics of "time in therapy," the non parametric
sign test for medians was again used to compare the groups. The results support the hypothesis at the 0.05 level. 9. Finally, in the clinical survey it was remarked that there seemed to be a shorter-lasting syndrome which had a better prognosis, and a longer-lasting syndrome which was more insidious in onset and which lasted a longer period of time. The question was whether this represented two distinct (bimodally distributed) syndromes with distinct etiologies) or a unimodal spectrum of cases. In general, the results seem to favor the notion of a single continuum. For example, the fact that length of time of symptoms correlated with length of time in therapy would suggest this. Another approach was to compare some of the more significant. variables (such as very high alienation (+++) and very high withdrawal (+++) with the length of time in therapy. The results from such investigations show a trend with the alienation figures only. These results do not support the notion of a "two etiology" syndrome, with a severe long-term illness of gTadual onset, and a milder illness of more rapid onset. Fina.lly, a frequency distribution graph of the various 'therapy duration times for the alienated group does not show the two peaks which would be predicted from a two etiology theory, but rather a single curve suggesting a unimodal spectrum of cases.
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The results suggest that there is a fairly well-defined syndrome of severe alienation responses in younger adolescents, not associated with drug use. This syndrome is a variant of the clinical state described by Settlage (Solnit et a1., 1969) and could be seen as one of the group of withdrawing reactions of adolescence described in the DSM II of the American Psychiatric Association (1968). Although the length of symptom onset is not significantly different from that of a heterogeneous comparison group of other clinical cases, the time spent in therapy is significantly longer. The hypothesized syndrome of alienation and withdrawal, along with sudden lags in school performance, was confirmed. However, expected differences from the comparison group in terms of depression or possible depression equivalents such as sulking, resentment, and hypochondriasis were not found. This latter finding could perhaps reflect a high level of depression in any group of adolescents from many causes. Anthony (1970) described moods of joylessness, sorrow, depression, and aggression in the writing's of adolescents, and felt that such moods are encountered so frequently in the course of apparently normal development that they would seem to reflect the difficulties and problems of normal adolescent transition. However, he did differentiate between "normative" reactive depressions and the more severe clinical depressions occurring agairista background of previous mood disturbances in childhood. It seems most likely that the findings of this study merely indicate the frequency and relative nonspecificity of depression and depressive equivalents in a comparison group selected from adolescent patients seen in general clinical practice. Clinically these cases show a spectrum of severity, from very longlasting and rather crippling depression alienation syndromes which have proven very resistant to therapy, to those cases in which early identification and early treatment seem. to give much better results. It could, of course, be argued that cases which are more insidious in onset are by definition going to be seen later than more acute syndromes, and that they may therefore last longer. However, it has seemed that awareness of this particular syndrome has resulted in much earlier identification of the focal problems by the therapist. Such earlier "diagnosis," coupled with more directive therapy focused
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on fostering assertive interactional responses, may have led to more favorable responses to therapy in more recent cases. In terms of an epidemiological profile, the cases are of average intelligence or above, and come from middle- or upper-middle-class parents. They do not seem to show particular reliance on drugs or drug-using subcultures. First children predominate in the alienated series (66 percent), and this could indicate that the process of separation-individuation from the parents at puberty is more difficult for these adolescents. However, 61 percent of the comparison group were also first children. In both the alienated and the comparison group 33 percent were only children. The characteristics of the parents are seemingly heterogeneous. They vary from a group who seem both by history and (in most instances) by direct contact to be cold and ungiving, to another gTOUp who by history and on direct contact seem to be reasonably warm and empathic. However, a common factor in the adolescents' descriptions of the parents is that of intense anger which is unmastered: this was directed toward the father of 7 of the milder cases described; and in 10 more severe cases, the anger was particularly directed toward the mother. In the more severe cases (needing longer therapy) the mother was often seen as chronically cold, powerful, and nongiving. In the less severe cases the anger of the adolescents seemed to be related more particularly to the father, and these adolescents also seemed to be concerned with more overt oedipal difficulties. A surprising finding was the number of "absent father" ratings in the alienated group. Some difference was found in the types of paternal absence in girls versus boys, with girls experiencing more severe absences. However, replication attempts are needed here because the results also suggest that those whose anger is primarily directed at maternal figures have longer and presumably more severe illnesses than those whose anger is mainly directed at the father. In all cases, onset of symptoms seemed to relate to a sudden or relative increase in aggressive-destructive impulses, as well as unmastered sexual impulses in some cases. Sometimes it was possible to see that this instinctual threat was offset by superego effects, in that the alienation and withdrawal from society had a clear association not only with defenses against aggressive destructiveness but also with self-punishment. Overall, the patterns of what might be termed com-
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pensatory alienation seemed to have a defensive purpose, and efforts at change mobilized intense resistance. It therefore follows that therapy has to be extremely direct in terms of both passing on knowledge about the alienation process and of directive patterns designed to reduce anxiety and to modulate instinctual aggression and superego severity. In later cases, approaches have also been used which utilize assertive training and relaxation techniques. Such procedures are seen not as either-or approaches to more formal psychodynamic formulations or insight-relationship approaches, but rather as facilitating these more sophisticated and characterologic approaches, especially in the early stages of therapy. However, if earlier attempts at therapy are not successful, treatment often moves into a longer supportive phase of waiting until the psychobiologic phase of puberty finishes at around 17 or 18. One also deals supportively with the resultant depression-alienation and occasional paranoid tendencies. How can one conceptualize these findings? As Anna Freud (1936) pointed out, impulses are strongly felt in early puberty, and sudden increases in instinct strength may give rise to excessive counter reactions. Erikson (1956) described catastrophic regressions in early puberty, when he wrote of the phenomenon of "identity resistance," in which the beginning of identity changes mobilizes such phenomena as catatonic slowdowns, overwhelming sleepiness, or depersonalization phenomena. Lampl-de Groot (1960) commented that the analysis of adolescents suggests that these patients are involved in relinquishing infantile ties with parental objects, and that there is a certain amount of mourning to be done through this process. At the same time, the adolescent experiences extreme hostility toward his parents, and the mourning processes in terms of loss are colored by intense inward aggression. There does in fact seem to be a consensus in the literature that the phenomena of early puberty are in part caused by a sudden inrush of instinctual drives, which are defended against in various emergency fashions, either by some device such as asceticism, or by some other mode of confining and denying the presence both of impulses and of resultant superego prohibitions. In many cases the defense pattern is that of excessive and prolonged withdrawal-alienation. However, the findings in this paper suggest that it may be possible to extend some further speculations about the nature of the
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responses mobilized by instinctual anxiety, as indicated in the clinical syndrome described. It is, we believe, possible to think of the ego response to instinctual threat in early puberty as having a number of variations. These could include withdrawal responses which begin as quasi-voluntary coping devices, but which become increasingly autonomous and dissociated from conscious processes as withdrawal continues. If this first defense pattern breaks down, or is inadequate, a second and more primitive emergency response of alienation supersedes and results in massive decathexis, especially from the ambivalently regarded parents or substitute love objects.. In extreme cases this can be experienced as a body-image change. Affectual responses in this state are characterized by the sudden irruption of impulses, as in the extreme rage felt by some of these patients at parents or other thwarting love objects. These rages alternate with feelings of intense depression, corresponding to states of internalized aggression and impending loss existing in a general substrate of particular and crippling repression. In the cases discussed, there is some evidence that those adolescents who have more successfully worked through the separation-individuation phase from the mother (along with the anger and mourning associated with this) are better able to cope with the secondary task of working through later manifestations of oedipal concerns. In these shorter-term cases oedipal concerns therefore become more manifest. However, in the longer-lasting cases, when concerns relate often to unmastered anger at the mother, the problems are much less focused and the identity resistance against separation-individuation becomes intense (Berman, 1971). At first glance, the finding that those adolescents who are more concerned with separation-individuation from the mother have longer illnesses contrasts oddly with another finding: that absence of fathers is also an important etiologic factor in the alienated group. However, these findings may be complementary; paternal absence may be seen either as loss of an important identification figure, or as loss of a bulwark against unmodified mother-child responses. The exact function or functions of the father in adolescence cannot be answered from this study, but his importance is clear. In summary, this paper describes an extension of the phenomena already defined by earlier writers as the alienation syndromes of earl y
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puberty. In many cases these form long-term and quite crippling disorders in which the therapist's patience and his own integrity can be severely threatened. Some of these disorders clearly occur in adolescents who have partly completed their separation-individuation and for these the process of therapy may be shorter. Others show more chronic processes, but it is possible that early identification of the basic withdrawal-alienation process, followed by prompt and directive therapy, might avert the patient's passing into a second phase of chronic withdrawal, alienation, and despair when the therapist can do little but "be with" the patient in his lonely and separated vigil. We hope that further studies of this particular syndrome may suggest other case identification and treatment methods which could be helpful in dealing with these complex but fascinating phenomena.
REFERENCES ALLEN, J. R. & WEST, L. J. (1968), Flight from violence: Hippies and the green rebellion. Amer. j. Psychiat., 125:364-370. ANTHONY, E. J. (1970), Two contrasting types of adolescent depression and their treatment. l- Amer. Psychoanal. Assn., 18:841-859. BERMAN, S. (1971), A type of academic failure among male adolescents. This journal, 10:418-443. COMMITTEE ON NOMENCLATURE AND STATISTICS (1968), D.S.M. II, Diagnostic and Statistical Manual of Mental Disorders, 2nd ed. Washington, D.C.: American Psychiatric Association. ERIKSON, E. H. (1956), The problem of ego identity. In: Identity and the Life Cycle [Psychological Issues, Monogr. 1]. New York: International Universities Press, 1959, pp. 133-136. FERGUSON, G. A., (1959), Statistical Analysis in Psychology and Education. New York: McGraw-Hill, pp. 265-267. FREUD, A. (1936), The Ego and the Mechanisms of Defence. New York: International Universities Press, 1966, pp. 152-172. GWYNNE-JONES, H. (1971), Research methodology and child psychiatry. In: Modern Perspectives in Child Psychiatry, ed. J. G. Howells. New York: Brunncrz Mazel, pp. 3-19. HEKIMIAN, L. J. & GERSHON, S. (1968), Characteristics of drug abusers admitted to a psychiatric hospital.]. Amer, Med. Assn., 205:125-130.
HOLLINGSHEAD, A. B. & REDLICH, F. C. (1958), Social Class and Mental Illness. New York: Wiley. LAMPL-DE GROOT, J. (1960), On adolescence. The Psychoanalytic Study of the Child, 15:95-103. New York: International Universities Press. NOSHPITZ, .J. D. (1970), Certain cultural and familial factors contributing to adolescent alienation. This journal, 9:216-223. SOLNIT, A. .J., SETTLAGE, C. F., GOODMAN, S., & BLOS, P. (1969), Youth unrest: a symposium. Amer. [, Psychiat., 125:1145-1159. WELPTON, D. F. (1968), Psychodynamics of chronic lysergic acid diethylamide usc. j. Nero. Ment. Dis., 147:377-385. WILLIAMS, F. S. (1970), Alienation of youth as reflected in the Hippie movement. This journal, 9:251-263_
III
Brian]. McConville, M.B. and Lorna C. Boag, M.B. Several authors have commented recently on the interplay between societal; familial, and internal processes in the interesting syndromes of adolescent alienation. For example, N oshpitz (1970) stresses both a decreased internal belief in the "magic of authority" and the relative social affluence of today's adolescents as possible causes of alienation. Similarly, in describing the alienation of youth as reflected in the Hippie movement, Williams (1970) stressed the group's inner need for intimacy and for doing one's own thing, as contrasted with an externally proclaimed need to drop out of a society composed of hypocritical parents and constricting educational and religious systems. Even in the highly visible societal patterns of adolescent drug abuse, various authors (Hekimian and Gershon, 1968; Welpton, 1968; Allen and West, 1968) have commented on associated inner factors of alienation and depression. In terms of etiology, there is considerable interest in whether the striking clinical phenomena of alienation can be linked in some way Dr. McConville is Associate Professor of Psychiatry, and Dr. Boag is Assistant Professor of Psychiatry, at Queen's University, Kingston, Ontario. A briefer version of this paper was presented at the Fall meeting of the Ontario Psychiatric Association, Montebello, Quebec on October 23, 1971. The authors wish to express their appreciation to Dr. George Ashman, Kingston General Hospital, and to Dr. Arjun Purohit and Mr. Allen Elkin of Beechgrove Children's Unit, Kingston Psychiatric Hospital, for their invaluable assistance with this study. Reprints may be requested from Dr. McConville, Director, Beechgrove Children's Unit, Kingston Psychiatric Hospital, Kingston, Ontario.
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to the vicissitudes of the normal separation-individuation process of adolescence. This question is not simple, since a number of writers in a recent symposium (Solnit et al., 1969) have commented on the disparate symptoms seen during the normal separation-individuation process. It is also unclear how the various causative factors of adolescent separation-individuation pathology interact, and how the described "syndromes" compare within themselves. In the 1969 A.P.A. symposium cited above, Settlage described an intense defensive response in adolescents both to the impact of puberty and to the associated pressure toward independence. This was characterized by prolonged regressive retreat into oneself, and away from peers and family. Such regressions could take the form of an extreme preoccupation with the self, with hypochondriasis and somatization reactions. This syndrome seems to imply a complex interplay between societal and intrapsychic factors, and also implies problems in separation-individuation. In this paper, we wish to describe a group of younger adolescents who showed extreme and often chronic withdrawal-alienation responses from many social and educational activities, associated with intense interpersonal anxiety. These patients had minimal direct societal problems, and none was on drugs to any significant degree. Most of these teen-agers came from socioeconomic groups II and III (Hollingshead and Redlich, 1958). Their response to anxiety was not to seek some style of peer or communal living, but to withdraw from peer contact, becoming either chronically anxious or extremely depressed with some suicidal thoughts. Common to all of these adolescents was a feeling of extreme alienation from the world; this was not defined in terms of the fact that society or its value systems had failed them, but rather in terms of a feeling of isolation and of being shut off from a world which they valued and wanted to join. The hypothesized syndrome therefore seems sufficiently different from a stereotype of "culturally alienated youth" to be described, and would seem to bridge the gap further between separation-individuation and alienation problems. After a qualitative description of two representative cases, we shall present a quantitative comparison of the cases, showing the hypothesized syndrome with a comparison group of other adolescent cases seen in clinical practice. On the basis of these quantitative and qualitative descriptions, some observations will be advanced about
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the nature of the syndrome, as well as some speculation about the internal processes attending these rather striking phenomena. REPRESENTATIVE CASES
Case 1: S. C. This well -built and handsome boy originally was referred for individual therapy at the age of 151'2' At that time he had had rather chro n ic symptoms which had started at about age 13 ~ , in which he was overcome by episodes of lassitude and boredom in school, with progressive deterioration of his schoolwork. In particular, he described an interesting oscillation of gross voluntary withdrawal from social contact because of feelings of shyness and awkwardness, with an imposed and entirely alien sensation of being cut off from a world which he valued and wanted to join. His intelligence was high and he had previously done very well in school. He was unable to attribute the falling off in his grades or in his interest to any particular event. He lived alone with his mother; the father had left the family when S. C. was 8, because of in creasing tension between the mother and the father. The boy had been extremely sad at the time, and still missed his father deeply, while continuing to visit him occasionally. Although he felt like quitting school at age 14, his mother had urged him to continue. He felt intense anger at her, which re capitulated the enormous rage he had experienced toward her at the time of the separation, when he felt that the mother had pushed the weaker father out of the home. Initially in therapy, his angry feelings toward the mother were verbalized, and he was able to express some of the rage whi ch he felt toward her. However, this description of rage remained largely at an intellectual level, and his symptoms remained unchanged . Over the
next 12 months he continued in regular psychotherapy, always hopeful that some medication or some explanation would be found for his sudden withdrawal from involvement with the world, yet constantly being disappointed, as when Thioridazine (to decrease impulse strength) and Imipramine (for depression) produced little result. After approximately 12 months, it was explained to him that he had withdrawn from meaningful contact with the world as an erner-
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gency reaction against impulses which had been felt at the beginning of puberty, and toward which he had no particular coping responses. It was therefore suggested to him that as the impulse disturbances of puberty tended to subside, his symptoms would improve, and he would become more affectually and interactionally involved with the world. He greeted this with some hope but without much enthusiasm, since by this time he had withdrawn from high school and was working in a nearby lumber store. He still described feelings of excessive alienation and despair, although on the job he was able to work extremely effectively. Gradually, over the next 12 months, continuing in intermittent psychotherapy, S. C. was able to make the decision to move into a community college which would allow him to take up a career with his available high school credits. For the first 6 months he went into a course in Engineering, following his father's original profession. Later he switched to a course in Town Planning, not only picking a career which had more future, but possibly also symbolizing a greater hope for his own reorganization. He continues to be seen after almost 3 years of therapy, and he has continued in the community college. He has some male friends, and will complete his course, but at times still has feelings of being cut off from the world, although he is able to say that these concerns are much less frequent than before. In this very striking case, a young and personable adolescent who had previously functioned well suddenly became involved in an alienation process from society which did not involve him with the usual feelings of cultural alienation as described for "hippies" and others. He experienced profound depression, withdrawal, and purposelessness, and the therapist was also aware that little effective could be done in therapy other than providing symptomatic relief, along with the use of the relationship as a bulwark to which the patient could cling in his strongest periods of despair. Case 2: K. M.
In contrast to the first chronic and relatively unremitting case, the next example is of a boy who made a rapid initial improvement, but was left with residual alienation symptoms. This boy was first seen at
the age of 16 with symptoms which had started when he was approxi-
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mately 14~. His symptoms were first noted at a time when he was working along with his father in a job situation. His relationship to his father was a very warm, but essentially ambivalent one in which he was very supportive toward his rather passive father, who was dominated by the mother. Although the boy often felt angry at his father, he also felt unable to challenge his father without hurting him. One day he was working with a supervisor in his father's business. This man suddenly became very angry at the boy, and threatened to attack him physically for making an error in a construction job. He felt very angry, but was unable to express his feelings openly. Despite some concern, he felt no other symptoms at the time, but on the next day suddenly began feeling that he was living in two worlds. He existed in one particular and self-contained world which was confined within his own body, and from which he looked out at the rest of the world. The other world was always present, but the patient felt shut off, and at times unable even to focus on the "outside world." His school performance, which had been very adequate, fell off rapidly. Psychological testing was carried out to assist in the diagnostic formulation, and the psychologist reported: Mr. M. is a young man of bright normal intelligence. He appears to be rather shy and to feel somewhat alienated, lonely, and perhaps abused by his peers, although he has a strong need for close relationships. However, he is insecure in his ability to form such relationships, particularly with girls. In general he lacks selfconfidence and is very concerned about his ability to achieve success in life. He would appear to see himself as not being particularly attractive to other people, as well as a rather ineffectual, buffoon-type scapegoat. There are some indications that he has a rather phallic dominating mother who may have considerably overprotected him. There are also indications that he may see his father as not being able to
appropriately handle his mother. He tends to lack respect for authority but is too afraid of his own aggression to challenge authority figures as he would like to, in order to stand up for his rights. He appears to see this as a major stumbling block in being able to become a competent, independent adult. His conception of what might be required to accomplish this seems to be unrealistic and due to wishful thinking that it might not be too difficult. In general he appears constricted emotionally and quite dependent. Beneath this boy's surface appearance of quiet shyness it appears
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that he has a great deal of aggressive feeling and considerable sexual drive. His fear of his aggression, however, appears to cause him to defend against it by reaction formation and withdrawal. He would seem to discharge his aggression mainly in fantasy, since he appears to feel that it would have catastrophic results if let loose. The formal diagnostic impression is that of an obsessive personality disorder with mild schizoid features. Therapeutic recommendations for Mr. M. would be for assertive training, so that he could learn to channel his aggressive and sexual drives to achieve a more satisfying life for himself. In therapy, which spread over 2 years, the assumed nature of this alienation process was explained to him. It was remarked that his feeling of being separate from the world was a defense against being overinvolved with it-especially in an aggressive destructive sense. This feeling had been initiated by the episode in which he had become extremely angry with the supervisor, symbolizing his father. Avoiding anger had been a characterological difficulty with him for some time, as had been a tendency to avoid heterosexual contact. Initially, the tendency which he had noticed for anxiety-producing figures to blur in front of his eyes was explained as being due to his focusing past the aggressive figure, and the therapist demonstrated to him that this was indeed so. He was also reassured that his feelings of looking out from inside his body could be understood, and that this formed part of normal body-image awareness to some degree. This resulted in a considerable decrease in anxiety, although he was still very anxious and awkward in his interactions with me. By my insisting that he should look at me when he expressed his feelings about me (as when he talked about his intolerance that he was not getting better quicker), the patient was not only able to look at me directly but also to express himself more forcefully. As he did so, he noticed that there was a considerable diminution in his feeling that he was cut off from me, and he also started to make rapid social strides with others in assertive social situations. This form of his therapy continued over a 3-month period of weekly sessions, with marked symptomatic improvement. Later in therapy, his school performance improved, and he began to show some heterosexual awareness which led to his taking out a girlfriend for the first time, and having a successful experience. Nevertheless, a large part of his feeling of essential alienation continued, associated with complaints of worthlessness and aimlessness
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in life. He found that although he was able to become more involved with people, any disappointments-especially from the girlfriendmobilized immense rage whi ch he was unable to deal with adequately, and which led to in creased depression. After 4 or 5 months his depression and suicidal thoughts became intense, and he was started on Imipramine in a dose of 150 mgm. daily, with good effect. He became less depressed and more able to function socially; although his first romance did not proceed adequately, he was able to stand the disappointment and find another girlfriend. Despite these changes in his social awareness, the patient was still unable to rid himself of the feeling that his nuclear problems were unchanged. When seen recently, he still felt that he and the rest of the world were different and that the world revolved around him. He constantly asks himself, "Who is Ken?" He is less depressed and his social responses are clearly better, but he still feels uneasy, indecisive, and guarded about what will happen to him. In this case, the therapy for the presenting symptoms was much more directive and successful. Nevertheless, the onset of his symptoms had been sudden, and the prognosis might therefore be assumed to be better. In addition, the central symptom of alienation still remained to a considerable degree.
QUANTIFICATION OF DATA Because of the practical and theoretical interest in this problem, we decided to study the syndrome more systematically. At the end of the initial clinical survey we collected 18 such cases (out of 225 adolescent cases seen over 5 years). As commented, we may have outlined an early alienation syndrome characterized by withdrawal, depression, and general alienation along with sudden lags in school performance and a rather interesting subjective alteration in body awareness ("special alienation"). To investigate further, we compared this series of 18 "alienated adolescents" with a group of 18 other adolescents matched statistically for age, sex, and intelligence. This comparison group was culled from other case histories on file of adolescents who had been referred for a variety of reasons, including acting-out behavior, generally hysterical patterns, drug abuse, and adolescent situational reactions.
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In both groups 8 were males and 10 were females. The average age of the alienated group was 14.9 years (S.D. = 1.40 years) and that of the comparison group 14.2 years (S.D. = 1.07); the group differences with respect to age were not significant (t = 1.639, 34 d.f.), The average IQ of the alienated group was 103.7 (S.D. = 7.1), and that of the comparison group was 103.5 (S.D. = 6.7); the group differences with respect to IQ were not significant (t = 0.085, 34 d.f.). The alienated and comparison groups were therefore similar with respect to age. IQ, and sex. The combined overall symptoms in both groups were then compared. These included suicidal acts and thoughts, sulking, hypochondriacal complaints, general anger, resentment, attacking others verbally, attacking others physically, stealing, drug use, withdrawal, poor school performance, depression, alienation, and altered body image. All the symptoms were first classified on a general 4-point rating from 0 to 3+, with 0 having the general meaning "not present." The 1+ rating of the operational definitions allowed for the presence of some deviance in the sample consonant with that generally found in the peer group, as the overall arbiter of social values in adolescents. A 1+ rating was therefore not "pathological." In a 2+ rating the behavior was seen as being more frequent, occurring at a greater intensity than that seen in the peer group as a whole, although still consonant at times with a deviant subgroup (as in drug abuse). At the 3+ level the behavior became intense, prolonged, and often subjectively distressing or frightening to the patient because of its intensity. Each symptom also had a special operational definition for degrees of intensity, agreed on after discussion between two child psychiatrist raters. Examples of some operational definitions are shown in Table 1. Behavior is largely as described by the patient, since the data from which these operational definitions are derived are taken from the case histories of the patients. In all cases the descriptions refer to presenting symptoms rather than to others which may have developed during the course of therapy. To establish rater reliability a sample of 20 symptom items in 5 patients was rated independently by the two raters; total category agreement was obtained in 85 percent with a. "pathological-nonpathological" (+++,++1+, 0) agreement obtained in 95"percent
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(p < .01 in both cases). Usually, in the computation process only the frequencies in the 2+ and 3+ severity groups were used to estimate pathology; these frequencies were added to form a common "pathological" group. The hypotheses and results for the alienated and the comparison groups were as follows: 1. The alienated group was expected to show more withdrawal, depression, and general alienation than the comparison group. It was also hypothesized that the alienated group studied would show more suicidal thoughts, sulking, hypochondriasis, and resentment than the comparison group, since the alienated group seemed to have difficulties in openly expressing and verbalizing anger. In addition, special (body) alienation and sudden lags in school performance were expected to be more common, from the initial clinical findings. All the symptom variables mentioned above were compared, using the Chi Square test. The results are summarized in Table 2, which shows that the variables found significantly more often in the alienated group are those of suicidal thoughts, withdrawal, general alienation, and sudden drops in school performance. Chronic poor school performance, by comparison, was more common in the control group. It is interesting that depression, resentment, sulking, and hypochondriasis did not reach levels of significance. Similarly, special body alienation.rdid not reach significant levels, although this is probably due to the small number of cases showing this symptom rather than to the equalizing effect of the comparison group. These findings tend to work against a hypothesis of criterion contamination (Gwynne-Jones, 1971), in which the symptoms described for a postulated syndrome reach significance by their greater selection in the experimental versus the control group, causing overlap in the assessment of the independent and dependent variables. 2. The alienated group was expected to have had a longer duration of pretreatment symptoms than the comparison group. The symptom duration time in the alienated group was found to be 1.42 years and in the comparison group 1.56 years. Using the sign test for medians (Ferguson, 1959), we found no significant difference between. the groups (x2 = 0.112, 1 d.f.). 3. The alienated group was expected to spend longer in therapy than the comparison grpup. The mean time in therapy for the alienated group was 1.65 years and for the comparison group, 0.88
TABLE 1 EXAMPLES OF OPERATIONAL DEFINITIONS OF SYMPTOMS
o (No n pathological )
TIONS
+
++
+++ Seve (Pa tho logica l)
n School Sudden areas in ol perfor u s p er ua te.
Symp tom Absent.
Sudden onset of deficit areas in school performance. Achi eves with average or lower 1/ 3 of group.
Sudden ons et of ma rked deficit areas in school pe rform ance. Ach ieves with lower 1/ 3 of gro up.
Sud den onset of d eficit areas in s performance . Fa gra des ob tained sistently.
School Chronic (cognierformance years. No n perfor-
Symp tom Absent.
Chronic d eficit areas in school performan ce, consonant wit h average or lower 1/ 3 of gro u p .
Considerable ch ronic deficit areas in school performance, conso nant wit h lower 1/ 3 of gro up.
Gross ch ron ic ge deficit areas in s perf ormance-fa grades ob ta ined sisten tly.
No feelings of th is.
Occasional feeli ngs of alienation, countera cted by will or by effo rt, e.g., "joining"; usuall y can enjoy being with peop le.
Frequent feelings of a lienation , counter acted wit h difficulty; can still en joy bei ng with people, bu t requires gr eat effort.
Continuous feeli aliena tion that c cou nt eracted; fe pl etel y sh u t off peopl e, alone; s jec tive ly di stress patient.
No feelings of this.
Occasional feeli ngs o f this.
Fr equent feeli n gs of body sepa ra tion from world.
Ver y frequ en t , c tinuou s feelings ical separa tion fr other s," su bjecti tressing to patie
IONS
TABLE
(continued)
+
o (Nonpathological)
++
+++ Seve (Pathological)
escribes wing from
No withdrawal.
Describes some active withdrawing from social contacts, consonant with behavior of peer group members in social situations.
Describes much active withdrawal from social contact, greater than warranted by situation and than noted in peer group.
Describes consta drawal from oth greater than war and than seen in constancy of wit concerns patient
elings of sness, or
No depression.
Occasional feelings of sadness, helplessness, hopelessness, consonant with family or peers.
Frequent feelings of sadness, helplessness, hopelessness, wi th suicidal thoughts seen as possibly solutional.
Very intense fee sadness, hopeless frequent though suicide as wished solutional.
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TABLE 2 COMPARISON OF SYMPTOM VARIABLES IN ALIENATED AND COMPARISON GROUP
VARIABLE
IN ALIEN· ATED GROUP
IN COMPARISON GROUP
(++,+++)
(++,+++)
Withdrawal 18 Sudden Drop in School Performance 13 General Alienation 18 Suicidal Thoughts 12 Poor School Performance (chronic) 3 Hypochondriasis 4 Attacking Others Physically I Drug Use 0 (Special) Body Alienation 5 Sulking 2 Depression 18 4 Sexual Acting Out Suicidal Acts 5 General Anger 9 Resentful 6 Attacking Others Verbally 9 0 Steals (Yates Correction applied
SIGNIFICANCE
x2
(I d.f.)
5
20.3478
P < .001
2 2 4
13.8285 28.8000 7.200
P < .001
8 8 5 4 6 15
3.2727 2.0000 1.8000 2.5313 1.8000 1.4464 1.4545
1
0.9290
I
0.7093 0.4500 1.0286 9 II 0.4500 I .0032 where necessary) 2
II
P p
< .001 < .01
N.S. (p N .S. (p N .S. (p N .S. (p N.S. (p N.S. (p N .S. (p N.S. N.S. N.S. N.S. N.S. N.S.
< .10) < .20) < .20) < .20) < .20) < .30) < .30)
years. Again using the sign test, a significant difference was found between the two populations (x2 = 9.28, 1 d.f., P < .01).
4. The alienated group was expected to have had a longer time of family disorganization than the comparison group. (This term implies a concept of family disagreement, disorientation, or general upset, as described by the patient and as confirmed from other sources. The degree of such disorganization is not estimated, it being felt that this was difficult to do. Estimates of the time of starting' of such family disagreements are probably only approximate, and derived from patients' histories and other sources.) The mean length of family pathology in the alienated group was 3.42 years and in the comparison gTOUp 1.72 years. Again using the sign test for medians, no significant difference was found between the groups (x2 = 1.029, 1 d.f.). 5. The groups were also compared in terms of hypothesized rank
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order correlations between length of therapy and length of pretreatment symptoms, and of family pathology. The results are as follows: (a) In the alienated group the time spent in therapy correlated positively with length of symptoms before treatment (Rho = 0.699, P < .01). However, in the comparison group the time in therapy also correlated positively with length of pretreatment symptoms (Rho = 0.464, P = < .05). (b) In the alienated group there was a positive correlation between length of therapy and length of family pathology (Rho = 0.617, P = < .01), but in the comparison group there was also a positive correlation (Rho = 0.643, P = < .01). In summary, these results indicate that in both groups those who were longest in therapy tended to have symptoms longer and to have family distress patterns for a longer period. This was not different for' the two groups, although duration of symptoms correlated more strongly with length of time in therapy in the alienated group. However, the time in therapy is considerably longer for the alienated group than for the comparison group. This tends to support the hypothesis that the pathological processes found in the alienated group are intrinsically more difficult to reverse than those seen in the comparison group. 6. Since a number of patients in the alienated group had commented both on the absence of fathers and dominance of mothers, absence and nondominance of father and absence and dominance of mother were hypothesized to cause more severe illness, and to be more common in the alienated group. The hypotheses were derived on the following clinical bases. (a) Fathers who were absent (either in terms of excessive pressures of work, or in terms of more severe degrees of absence) could not give the children the support as identification figures or oedipal bulwarks which they needed in early puberty. Hence, their absence might correlate positively with greater frequency in the alienation syndrome. (b) Similarly, it was felt that it was necessary for fathers to be "dominant" in a family, e.g., involved in making decisions. When. this was not so, teen-agers could be more vulnerable to stress-and ' more alienation would result.
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(c) It was also hypothesized that mothers would need to be present in the family for all-round support and that their absence would correlate positively with gTeater alienation illness. (d) It was also felt that mothers should be nondominant with respect to the father, although they could be both supportive and warm in the family constellation. Relative maternal dominance would therefore be expected to correlate positively with greater alienation illness. These four investigative and admittedly naive hypotheses were then investigated in terms of the operational definitions shown in Table 3. It should be noted that the rating scheme relates to perceived parental absence and dominance, as described by the patient in clinical interviews. Parents were interviewed directly in approximately 50 percent of cases. The results are as shown in Table 4. It will be seen that the only factor which varied significantly from the comparison group was that of "absent father." 7. It was therefore felt that there might be a correlation between intensity of the overall syndrome and the absence of the father. Since time in therapy had been found to be a significant overall index of severity of the illness, "absence of father" in the alienated gTOUp was compared with time in therapy using a 2-by-2 table. The Chi Square (with Yates Correction) was 0.2500, and this difference between the groups was not significant. It may be that larger numbers would allow for greater significance, although this is not suggested by inspection of the overall x2 distribution. For further comparison, the boys and girls were compared in terms of high (++,+++) and low (0,+) absent fathers; 7 boys and 10 girls had high absent fathers. The Chi Square distribution is not significantly different between the two groups, going against a hypothesis that boys would be particularly vulnerable to absence of fathers. However, it is of considerable interest that among the boys, only 1 had a very high (+++) absent father, whereas among the girls, 5 had fathers who were very high absent because of death or prolonged separation (x2 = 1.3781 N.S., P = < .30). This suggests that the quality of perceived paternal absence may be quite different for girls than for boys and suggests avenues for further investigation. 8. From clinical observations it was hypothesized that those patients whose anger was directed mostly at their mothers would have
TA B L E 3 R ATING SCHEME FOR ESTIMATING PERCEIVED PARENTAL ABSENCE/DOMINANCE 0
O NS
(No npathological)
+
++
+++ Severi (Pathological )
Father tien t as d ho m e r sup-
No feelings o f th is.
Father described as being occasion all y away from hom e, not th ought of as being around a nd sup po rt ive as often as is need ed .
Fathe r very fr eq uen tl y away from hom e due to work or other social pressures. Absence described as being serious loss.
Father described being a bsen t cont (includes sepa ra t divorce, death) . de scrib es father as ever or never aro
in ant. ondecis ion .
No feelings of this. Father seen as sufficientl y dominant.
Father occasiona ll y seen as nondominant, not different from peer group expe rience of fath er s.
Father often seen as nondomi nant in d ecision making a nd structuring for wife, fam ily.
Fath er described a completely domin non dominant in d making and struc for wife, family.
. Mother tient as d home su p-
N o feelings of th is.
Mother d escribed as being occasionally awa y from home, not a ro u nd and supportive as often as is ne eded.
Mother very freq uen tl y away from home due to work or other social pressu res . Absence de scribed as bei ng a serious loss.
Mother de scribed being ab sent con tin uou sly (includ sep aration , divor d eath). Patient de mother as hardl y never around .
nt. o minan t, n fam ily.
No feelings of this. Mother seen as n on dominant.
Mother occas iona lly seen as dominant, not differcnt from pe er group experience of mo th ers .
Mo ther often seen as domina nt in deci sion making a nd structuring for family.
Mother described bein g complet ely dominant.
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TABLE 4 RELATIVE PARENTAL ABSENCE/DOMINANCE IN ALIENATED OR COMPARISON GROUP IN ALIENATED GROUP
IN COMPARISON GROUP
SYMPTOM
(++,+++)
(++,+++)
(I eLf.)
Fathers Absent Fathers Nondominant Mothers Absent Mothers Dominant
17
7 2 2
12.5000 0.7094 0.2000 1.0836
5 4 8
5
x"
SIGNIFICANCE P
< .001 (N.S.) (N.S.) (N.S.)
more severe (longer time in therapy) illnesses than those who .were mainly angry at their fathers. Ten adolescents described anger directed primarily at the mother, while 7 were more angry at the father. The mean time spent in therapy for the former group was 2.2 years and for the latter group 1.0 years. Because of the uncertain distribution characteristics of "time in therapy," the non parametric
sign test for medians was again used to compare the groups. The results support the hypothesis at the 0.05 level. 9. Finally, in the clinical survey it was remarked that there seemed to be a shorter-lasting syndrome which had a better prognosis, and a longer-lasting syndrome which was more insidious in onset and which lasted a longer period of time. The question was whether this represented two distinct (bimodally distributed) syndromes with distinct etiologies) or a unimodal spectrum of cases. In general, the results seem to favor the notion of a single continuum. For example, the fact that length of time of symptoms correlated with length of time in therapy would suggest this. Another approach was to compare some of the more significant. variables (such as very high alienation (+++) and very high withdrawal (+++) with the length of time in therapy. The results from such investigations show a trend with the alienation figures only. These results do not support the notion of a "two etiology" syndrome, with a severe long-term illness of gTadual onset, and a milder illness of more rapid onset. Fina.lly, a frequency distribution graph of the various 'therapy duration times for the alienated group does not show the two peaks which would be predicted from a two etiology theory, but rather a single curve suggesting a unimodal spectrum of cases.
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The results suggest that there is a fairly well-defined syndrome of severe alienation responses in younger adolescents, not associated with drug use. This syndrome is a variant of the clinical state described by Settlage (Solnit et a1., 1969) and could be seen as one of the group of withdrawing reactions of adolescence described in the DSM II of the American Psychiatric Association (1968). Although the length of symptom onset is not significantly different from that of a heterogeneous comparison group of other clinical cases, the time spent in therapy is significantly longer. The hypothesized syndrome of alienation and withdrawal, along with sudden lags in school performance, was confirmed. However, expected differences from the comparison group in terms of depression or possible depression equivalents such as sulking, resentment, and hypochondriasis were not found. This latter finding could perhaps reflect a high level of depression in any group of adolescents from many causes. Anthony (1970) described moods of joylessness, sorrow, depression, and aggression in the writing's of adolescents, and felt that such moods are encountered so frequently in the course of apparently normal development that they would seem to reflect the difficulties and problems of normal adolescent transition. However, he did differentiate between "normative" reactive depressions and the more severe clinical depressions occurring agairista background of previous mood disturbances in childhood. It seems most likely that the findings of this study merely indicate the frequency and relative nonspecificity of depression and depressive equivalents in a comparison group selected from adolescent patients seen in general clinical practice. Clinically these cases show a spectrum of severity, from very longlasting and rather crippling depression alienation syndromes which have proven very resistant to therapy, to those cases in which early identification and early treatment seem. to give much better results. It could, of course, be argued that cases which are more insidious in onset are by definition going to be seen later than more acute syndromes, and that they may therefore last longer. However, it has seemed that awareness of this particular syndrome has resulted in much earlier identification of the focal problems by the therapist. Such earlier "diagnosis," coupled with more directive therapy focused
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on fostering assertive interactional responses, may have led to more favorable responses to therapy in more recent cases. In terms of an epidemiological profile, the cases are of average intelligence or above, and come from middle- or upper-middle-class parents. They do not seem to show particular reliance on drugs or drug-using subcultures. First children predominate in the alienated series (66 percent), and this could indicate that the process of separation-individuation from the parents at puberty is more difficult for these adolescents. However, 61 percent of the comparison group were also first children. In both the alienated and the comparison group 33 percent were only children. The characteristics of the parents are seemingly heterogeneous. They vary from a group who seem both by history and (in most instances) by direct contact to be cold and ungiving, to another gTOUp who by history and on direct contact seem to be reasonably warm and empathic. However, a common factor in the adolescents' descriptions of the parents is that of intense anger which is unmastered: this was directed toward the father of 7 of the milder cases described; and in 10 more severe cases, the anger was particularly directed toward the mother. In the more severe cases (needing longer therapy) the mother was often seen as chronically cold, powerful, and nongiving. In the less severe cases the anger of the adolescents seemed to be related more particularly to the father, and these adolescents also seemed to be concerned with more overt oedipal difficulties. A surprising finding was the number of "absent father" ratings in the alienated group. Some difference was found in the types of paternal absence in girls versus boys, with girls experiencing more severe absences. However, replication attempts are needed here because the results also suggest that those whose anger is primarily directed at maternal figures have longer and presumably more severe illnesses than those whose anger is mainly directed at the father. In all cases, onset of symptoms seemed to relate to a sudden or relative increase in aggressive-destructive impulses, as well as unmastered sexual impulses in some cases. Sometimes it was possible to see that this instinctual threat was offset by superego effects, in that the alienation and withdrawal from society had a clear association not only with defenses against aggressive destructiveness but also with self-punishment. Overall, the patterns of what might be termed com-
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pensatory alienation seemed to have a defensive purpose, and efforts at change mobilized intense resistance. It therefore follows that therapy has to be extremely direct in terms of both passing on knowledge about the alienation process and of directive patterns designed to reduce anxiety and to modulate instinctual aggression and superego severity. In later cases, approaches have also been used which utilize assertive training and relaxation techniques. Such procedures are seen not as either-or approaches to more formal psychodynamic formulations or insight-relationship approaches, but rather as facilitating these more sophisticated and characterologic approaches, especially in the early stages of therapy. However, if earlier attempts at therapy are not successful, treatment often moves into a longer supportive phase of waiting until the psychobiologic phase of puberty finishes at around 17 or 18. One also deals supportively with the resultant depression-alienation and occasional paranoid tendencies. How can one conceptualize these findings? As Anna Freud (1936) pointed out, impulses are strongly felt in early puberty, and sudden increases in instinct strength may give rise to excessive counter reactions. Erikson (1956) described catastrophic regressions in early puberty, when he wrote of the phenomenon of "identity resistance," in which the beginning of identity changes mobilizes such phenomena as catatonic slowdowns, overwhelming sleepiness, or depersonalization phenomena. Lampl-de Groot (1960) commented that the analysis of adolescents suggests that these patients are involved in relinquishing infantile ties with parental objects, and that there is a certain amount of mourning to be done through this process. At the same time, the adolescent experiences extreme hostility toward his parents, and the mourning processes in terms of loss are colored by intense inward aggression. There does in fact seem to be a consensus in the literature that the phenomena of early puberty are in part caused by a sudden inrush of instinctual drives, which are defended against in various emergency fashions, either by some device such as asceticism, or by some other mode of confining and denying the presence both of impulses and of resultant superego prohibitions. In many cases the defense pattern is that of excessive and prolonged withdrawal-alienation. However, the findings in this paper suggest that it may be possible to extend some further speculations about the nature of the
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responses mobilized by instinctual anxiety, as indicated in the clinical syndrome described. It is, we believe, possible to think of the ego response to instinctual threat in early puberty as having a number of variations. These could include withdrawal responses which begin as quasi-voluntary coping devices, but which become increasingly autonomous and dissociated from conscious processes as withdrawal continues. If this first defense pattern breaks down, or is inadequate, a second and more primitive emergency response of alienation supersedes and results in massive decathexis, especially from the ambivalently regarded parents or substitute love objects.. In extreme cases this can be experienced as a body-image change. Affectual responses in this state are characterized by the sudden irruption of impulses, as in the extreme rage felt by some of these patients at parents or other thwarting love objects. These rages alternate with feelings of intense depression, corresponding to states of internalized aggression and impending loss existing in a general substrate of particular and crippling repression. In the cases discussed, there is some evidence that those adolescents who have more successfully worked through the separation-individuation phase from the mother (along with the anger and mourning associated with this) are better able to cope with the secondary task of working through later manifestations of oedipal concerns. In these shorter-term cases oedipal concerns therefore become more manifest. However, in the longer-lasting cases, when concerns relate often to unmastered anger at the mother, the problems are much less focused and the identity resistance against separation-individuation becomes intense (Berman, 1971). At first glance, the finding that those adolescents who are more concerned with separation-individuation from the mother have longer illnesses contrasts oddly with another finding: that absence of fathers is also an important etiologic factor in the alienated group. However, these findings may be complementary; paternal absence may be seen either as loss of an important identification figure, or as loss of a bulwark against unmodified mother-child responses. The exact function or functions of the father in adolescence cannot be answered from this study, but his importance is clear. In summary, this paper describes an extension of the phenomena already defined by earlier writers as the alienation syndromes of earl y
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puberty. In many cases these form long-term and quite crippling disorders in which the therapist's patience and his own integrity can be severely threatened. Some of these disorders clearly occur in adolescents who have partly completed their separation-individuation and for these the process of therapy may be shorter. Others show more chronic processes, but it is possible that early identification of the basic withdrawal-alienation process, followed by prompt and directive therapy, might avert the patient's passing into a second phase of chronic withdrawal, alienation, and despair when the therapist can do little but "be with" the patient in his lonely and separated vigil. We hope that further studies of this particular syndrome may suggest other case identification and treatment methods which could be helpful in dealing with these complex but fascinating phenomena.
REFERENCES ALLEN, J. R. & WEST, L. J. (1968), Flight from violence: Hippies and the green rebellion. Amer. j. Psychiat., 125:364-370. ANTHONY, E. J. (1970), Two contrasting types of adolescent depression and their treatment. l- Amer. Psychoanal. Assn., 18:841-859. BERMAN, S. (1971), A type of academic failure among male adolescents. This journal, 10:418-443. COMMITTEE ON NOMENCLATURE AND STATISTICS (1968), D.S.M. II, Diagnostic and Statistical Manual of Mental Disorders, 2nd ed. Washington, D.C.: American Psychiatric Association. ERIKSON, E. H. (1956), The problem of ego identity. In: Identity and the Life Cycle [Psychological Issues, Monogr. 1]. New York: International Universities Press, 1959, pp. 133-136. FERGUSON, G. A., (1959), Statistical Analysis in Psychology and Education. New York: McGraw-Hill, pp. 265-267. FREUD, A. (1936), The Ego and the Mechanisms of Defence. New York: International Universities Press, 1966, pp. 152-172. GWYNNE-JONES, H. (1971), Research methodology and child psychiatry. In: Modern Perspectives in Child Psychiatry, ed. J. G. Howells. New York: Brunncrz Mazel, pp. 3-19. HEKIMIAN, L. J. & GERSHON, S. (1968), Characteristics of drug abusers admitted to a psychiatric hospital.]. Amer, Med. Assn., 205:125-130.
HOLLINGSHEAD, A. B. & REDLICH, F. C. (1958), Social Class and Mental Illness. New York: Wiley. LAMPL-DE GROOT, J. (1960), On adolescence. The Psychoanalytic Study of the Child, 15:95-103. New York: International Universities Press. NOSHPITZ, .J. D. (1970), Certain cultural and familial factors contributing to adolescent alienation. This journal, 9:216-223. SOLNIT, A. .J., SETTLAGE, C. F., GOODMAN, S., & BLOS, P. (1969), Youth unrest: a symposium. Amer. [, Psychiat., 125:1145-1159. WELPTON, D. F. (1968), Psychodynamics of chronic lysergic acid diethylamide usc. j. Nero. Ment. Dis., 147:377-385. WILLIAMS, F. S. (1970), Alienation of youth as reflected in the Hippie movement. This journal, 9:251-263_