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Resistance in psychotherapy with adolescents
Journal
of .+Idokscence 1984, 7, 1-16
Resistance in psychotherapy with adolescents T. GRAAFSMAX “IT’S
AND
ONLY
M. ANBEEK”’
PUBERTY”
Adults make remarks like this when they find themselves confronted with troublesome behaviour or ideas coming from adolescents.? Furthermore they are remarks which do, in fact, contain a lot of truth. It is undoubtedly correct that the individual is affected by the ups and downs that puberty brings with it. But the remark can also have the intention of cutting short conversation about the adolescent. So the speaker can mean, “Oh, leave it, it’ll blow over” or “that son (or daughter) of mine can do nothing about it, it’s just his (or her) adolescence. Or “I have nothing to reproach myself with”. The tone used indicates the intention, which can be an attempt to shift involvement or responsibility. It can also be an attempt at minimization. In each case, the speaker refuses to accept something about which he is also concerned. That concern may be difficult to bear, although it may have a long history. Thus
a mother seeks help for her x j-year-old son concerning his sleeplessness, intensively aggressive periods and lack of adjustment at school. She has been for help to other organizations which, according to her, interpreted the situation too seriously. In the course of the investigation, however, she relates that she was concerned for a very long time, especially about the bizarre fantasies that her son came out with, as far back as the age of three. Once she asked the advice of a psychologist during a birthday party but kept quiet about various important Incidents. She then let herself wish “it must be the age”. Now once again she had that inclination: wasn’t it a question of a somewhat turbulent adolescence? Not only does the adolescent’s environment sometimes minimize or shift responsibility, it also applies to the adolescent himself. The same youngster that refers to autonomy and his right to self-reliance will hold his parents lAmbulatorium van Het Paedologisch, Instltuut Prim Hendriklaan, 23 1075-AZ Amsterdam, The Netherlands. l*Dr M. A. Anbeek, Stichting Psvchotheek, Eikenplein 3, 1092 CC Amsterdam. tWe consider adolescents as being between the ages of I 2 and 21 years. See De Wit and Van der Veer (1979). 0x40-1971/84.b10001 + 16 So3.oolo
0 1984 The Assoclat~on for
the Psychiatrvz
Study
of Adolescents
T. GRA.4FSiM.4
2
AND M. ANBEEK
responsible for his own shortcomings and failures rather than himself (Freud, 1958). Successes will be self-attributed, while defeats, are belittled or ascribed to others. Normally a therapist faces an adolescent who resists the notion that there might be something wrong in himself and his behaviour is experienced as unpleasant and alarming. The therapist has to deal with the behaviour which the client maintains during his everyday life and resistances form an important part of the work. Often at the beginning of his contact with us, we hear the adolescent talking about the shortcomings of others. A 16-year-old girl talks continually about her parents’ egocentricity, their way of upbringing (“they’ve never taught me how to behave among others of my age”) and then matrimonial disputes. If the therapist asks if she can fit herself in among others of her age without help, he gets a scathing look. “It’s all due to my mother”, she says angrily, refusing to cross over to
self-observation. Now speaking about parents’ shortcomings is undoubtedly linked to a youngster’s wish that parents should be able to prevent disappointments in everyday life. In the adolescent’s reproaching, however, the therapist often has a sense of a resistance. The painful awareness of his own shortcomings and behaviour leads the adolescent to keep attention directed at shortcomings in the outside world. It is striking how long adolescents postpone going to a doctor or psychologist. “Doesn’t it go away of its own accord?” Aren’t there others with far more serious problems? “Am I exaggerating?“These showings are often attempts to dispose of pressing anxieties. A Is-year-old girl comes for a consultation just before the holidays and tells that some six months ago she was subject to fits of depression. At present she is not troubled but she wants contact in case the depression returns. Towards the end of the hour, she says that she is worried about her future. She says she tends to think that perhaps it could well be worse, that others may have far more serious problems. That has been the reason for not seeking help. We make another appointment for after the holidays. In the meantime, during her holiday abroad, she decompensates.
In this example, we see that in a first conversation the manifest complaint is often the most “external” an the least alarming. In the background, “latent” complaints are usually experienced as more internal and more disturbing. Resistances are of considerable significance in psychotherapy with adolescent, and are linked to emotions that threaten to disturb everyday functioning. At the start of treatment, resistance may be marked but also difficult to understand fully. To achieve progress in treatment resistances
RESISTANCE
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must be correctly valued in the attention to resistances met adolescents. In the following discussed and after that, the investigated. We will conclude
ADOLESCEKT
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initial phase. that is why in this article we pay with at the start of psychotherapy with section some forms of presentation will be source and intention of resistances will be with the treatment of resistances.
FORMS
OF RESISTANCE
Before enumerating some forms of resistance characteristic of adolescents let us first define the term. It is behaviour that a person carries out in order to forestall the appearance of an unwelcome impulse, an affect or an action by himself or another. A resistance is a defensive response to sensation that threaten everyday functioning, and the integration of internal and external stimuli. We use the term behaviour, without wanting to associate it with great activity. Indeed, passivity can have a defensive significance. ,4 r6-year-old
boy, under treatment for social isolation and continua1 failure at school, maintains that the latter is to be blamed on the teachers. When he is asked whether he has any remarks about his own achievements or approach, he says: “No, none at all”. After a silence he admits to having trouble accepting that he has greater difficulty in learning than his sister. A little later however-as if this thought has to be retracted-he says that he goes to a “better” school than his sister (something actually untrue). Apparently, the idea of achieving less than
his younger sister threatens his self-respect too much to be acceptable. Presumably self-reflection would produce too much self-criticism, shame and jealousy of his sister. Resistances can arise in many ways. The adolescent in the foregoing example is externalizing: he shifts impressions that actually have reference to himself on to another. Furthermore, he falsifies reality by denying facts. But resistance can also crop up in other forms. An adolescent can keep silent or suppress something. He can forget an appointment, or then again come too late, leave too early or continually check the time. He can get bored or clog the conversation by introducing superficial matters. He can continually voice criticism, pick arguments or attempt to steer the therapist into discussion. He can also keep the therapy apart from the rest of his daily life. Of those forms of resistance, three figure prominently in psychotherapy with adolescents, namely non-attendance, self-justification and acting-out. Non-attendance can be expressed in terms of not coming, arriving too late or forgetting an appointment. Usually the adolescent has then something to repress or deny. Self-justification is evident when the adolescent continually looks for means of accepting his behaviour or feelings. A set-back becomes
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defined as a planned action and a fit of temper justified as a deliberate, angry reprimand of shortcomings in others. One thinks of the moralistic behaviour of the “uncompromising” adolescent (Freud, 1958), in which intensive use is made of rationalizations. Acting out expresses itself especially in impulsive acts by means of which important but threatening feelings can be held at a distance. It means sometimes doing in order not to have to feel and sometimes doing what one actually has difficulty in feeling. * Acting out can help avoid a sense of guilt for example, sexual feelings which evoke and responsibility. Consider, anxiety. In all these cases, the adolescent makes use of externalizations and projections or he identifies with the aggressor. In therapy we often find an internal conflict between conceding to a desire and conceding to a punishing conscience. Two other forms of expressing resistance, that occur less often but are still striking are as follows. First some adolescents say they “feel nothing”. We interpret this as resistance to feelings that are threatening but have to be warded off. One is reminded of depersonalizations. Then we see “ascetic” behaviour, in which the inner life is forcibly isolated, as it were. Second, we sometimes meet adolescents who believe that they have a highly gifted side, even if no factual evidence of this is advanced. Maybe the adolescent is but we are not allowed to see this. In general, however, we suspect defences against feelings and thoughts that conflict with fantasies of greatness. The person concerned sometimes withdraws into these fantasies in disregard of reality and in this way drastically confines his life. Thus there exists a close link between resistances and defence mechanisms and we interpret non-attendance as a resistance in which the adolescent makes use in particular of the defence mechanisms “repression” and “denial”. Defence-mechanisms are the means that a person can employ to raise a resistance against unpleasant, injurious and frightening sensations. [The reader can find a more detailed explanation in Basch (1980, in particular pp. ‘7’-‘73)*1 It is quite normal that a person resists disturbance of his psychic stability. That especially holds for adolescents, who are already under stress in their developmental phase. Adaptation to biological changes and changing social demands is often far from easy. An IS-year-old comes to us complaining of chronic listlessness and feelings of loneliness. After a while, he tells that-he knows and feels nothing, he even wonders what in fact is “feeling”. In his social life, this adolescent is bashful but friendlv as he is with us. LUtimatelv it becomes “For a description of the meanmg of acting-out m the sense of w-enactment, see Blos (1979) and Amrni and Burke (1979).
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to suggest that his adaptability perhaps arises out of fear of rejection. Reluctantly, the client is then able to relate that he has “exceptional fantasies”. The first one he mentions is the fantasy (desire) that a Hitler should come to power here in this country to “really put things in order”. He is afraid that this fantasy (in our opinion not so exceptional) will produce much condemnation. possible
Although non-attendance, self-justification and acting-out strike us forcibly as adolescent forms of resistance, adolescents do use of other forms of resistance. The same goes for the various defence-mechanisms available to them. Some forms of resistance and defence mechanisms are rough and overt, whereas others are more subtle and concealed. Our views correspond here to those of Glover (1955). Concerning the foregoing Sandler and others (1973) remark that there is little sense in trying to arrange a classification of forms of resistance. It is more important to pay attention to their source and intention. That seems to us to be correct; the source and intention of resistances do have a decisive influence on our way of approaching the adolescent.
SOURCE AND INTENTION OF RESISTANCES IN THE INITIAL PHASE OF PSYCHOTHERAPY WITH ADOLESCENTS On entering our institute, adolescents are usually reserved, cautious and curious. Most are very ambivalent about psychotherapy. On the one hand, the unknown is alluring, on the other it is frightening. They know they need help but asking for it is considered a defeat and they fear that the psychotherapist will unearth painful matters. The adolescent shifts about somewhat hesitatingly and seems to wonder: “What shall I say?” “What does he think of me?” “What do they do here exactly?” “Shall I make an appointment or not?” “Does it repay the cost and the trouble?” The adolescent continually determines a position for himself regarding his problems, treatment and therapist. The means that he can call up in this situation
are
However,
these
the
cognitive,
skills
social
can also be used
and
motoric
with
skills
available
the aim of evoking
to
him.
a resistance.
A 16-year-old girl under treatment for potential anorexia nervosa enters in an agitated state and immediately comes out with : “My mother rang, didn’t she? Alright, I’ll tell you the exact story”. After which follows a story about an argument, which she uses to pomt out that the blame lies elsewhere, with her mother. The latter had indeed telephoned, largely with the same intention-of laying the blame for the argument elsewhere. When it is put to the girl that she is apparently afraid that the therapist will blame her for something, she expresses the fear that he will
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side with her mother. She looks fixedly at him and sits upright in her chair. There is a pause. The therapist puts it to her that she is probably critical of her own behaviour but that she also opposes this. He says that she splits off a bit of conscience, as it were, and leaves it with him. Then she relaxes slightly. She does not take up the ideas submitted to her, but changes the subject, with which she once again throws up a resistance against a (further) exploration of her own “share” in the conflict with her mother, possibly from fear of condemnation or rejection.
Just like everyone else, the adolescent also appeals to his “problem solving ability”, to defend himself against painful sensations. And while some adolescents have an intense and rigid use of a few skills others avail themselves of a more broadly and flexibly based arsenal of possibilities. It is time to look at those issues against which adolescents build up resistances. What is the intention? Here we will make a distinction between issues which all those in psychotherapy experience and resistance issues which in our opinion are specific to adolescents. In the first case, we shall speak of a non-specific intention, and in the second case, of a specific intention (in regard to the adolescent phase itself). The non-specific intention concerns the universal resistance of painful feelings. Like anyone else the adolescent is afraid of influences which may render him helpless and ashamed. Furthermore he is afraid of losing ways of thinking and acting which may have brought him misery (e.g. in the form of symptoms) but still let him retain the feeling of an “active mastering of the world”. Another non-specific intention concerns secondary sickness-gains. Naturally, the adolescent builds up a resistance against change, if this reduces the secondary sickness gain. Thus not going to school can have a beneficial side if the adolescent finds it pleasant to be at home with his mother. Giving up studying can have the beneficial side of not yet having to become grown-up. This applies to the initial phase of psychotherapy with adolescents. We often come across the following situation: The adolescent usually expects the therapist to say to him: there’s an awful lot you can’t manage alone. In anticipation, a resistance is thrown up: the adolescent comes up with justifications (the actual situation was unavoidable) and points out shortcomings in the surroundings. During the first minute of his first conversation, an 1%year-old adolescent relates: “I have problems with my mother. Indeed, I don’t live with her anymore. She is always threatening but doesn’t go any further; only false alarms”. Later, after many discussions, it becomes clear how this adolescent himself makes good resolutions, but does not put them into practice and therefore gets into difficulties, at school and financially. Asked the cause, he points to his mother.
*
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The fear of not being self-reliant is not peculiar to adolescents. More specific is the fear of de-individuation. Does the adolescent have to become dependent again, once in therapy? With this, we come to the area of specific intentions of resistances, which is to say, those intentions more strongly tied to the phase. Receiving help is usually interpreted as acknowledging failure and is therefore unacceptable when the demand for recognition and acknowledgement as a separate, autonomous person is so important. The adolescent therefore tends to keep close watch over all occurrences in and around therapy (Harley, 1970). The therapist and the time are observed closely. A discussion about being sent is willingly taken up, just as is a discussion about the use and frequency of the treatment. In our opinion, these facets of the initial situation in psychotherapy with adolescents, although they sometimes create the impression of being less important, nevertheless present significant material that can only be thoroughly investigated after the intention of resistances had been examined in more detail.
A rb-year-old boy comes to our institute after a suicide gesture and immediately takes the initiative, discussing his friends and activities and thereby preventing the therapist from discussing the suicide gesture. That IS what many adolescents do: after a suicide gesture, they endeavour to suppress the event as quickly as possible. There usually exist many feelings of shame and guilt concerning its aggressive side. Although the adolescent usually tends towards belittlement, a suicide attempt is still an indication of a serious problem. Keeping control over the course of the conversation is a good remedy for this. When the therapist airs the suspicion in a later conversation that, despite all his friends, there must be feelings of loneliness, this is rejected. Later it appears that feelings of disappointment about his need to admire and to be admired-precisely those things that the adolescent touched on at the very beginning-are hardly tolerable and often denied. The specific intention of resistance concerns an aspect of adolescence. We already stated earlier that adolescence draws considerably on problemsolving abilities. The adolescents we meet at our institute find themselves in a the cognitive, social and motoric capacities (under “deficiency situation”: which, it is naturally understood, come the defence mechanisms available to an adolescent) are used inadequately or are no longer sufficient. We usually meet with difficulties that in some way are linked to the processes of ripening, regulation, integration or individuation [this classification is derived from Hart de Ruyter. See his “General psychopathology of puberty” for a more detailed explanation (1963, pp. 13z-I~I)] and therefore good to investigate resistances in relation to one or more of these processes. It is striking among 12 and I 3-year-olds, physical and psychic ripening can diverge, and create
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disharmony internally as well as socially. We also frequently see regulation difficulties in the initial phase of adolescence. Impulse control is under great stress and fear of loss of control often leads to extensive resistance to an emotional investment in psychotherapy (Harley, 1970). A number of adolescents report to us with this as the central problem (see the publications of Bartels et al., 1982). A threatened loss of control makes the adolescent apprehensive, and in this connection one thinks of early adolescent hypochondriasis. Integration problems occur more in the middle and final phases of adolescence. Central are the problems of integration of one’s separateness with one’s limitations and one’s possibilities. In the middle phase, the integration of sexual feelings and the sexual role become central.* Resistances are usually related to sexual fantasies that are considered objectionable and the need to defend everyday life, may militate against thoughts of greatness. Here arises the well-known adolescent depression in which narcissistic injuries play an important role. Individuation difficulties seen especially in the second half of adolescence. Emancipation and independence are of crucial importance, and conflicts of loyalty and dependence create problems. Later in adolescence, intimacy becomes more prominent, being both a test of psycho-social and psycho-sexual identity and of the degree to which the adolescent can tolerate being a “separate” person (Novick et al., 1974). The adolescent who comes under treatment in our Institute is usually involved in an internal conflict in one or more of these fields, although the presenting complaints are usually related to depressions, suicidal thoughts, disorders at school or work, psychosomatic difficulties and delinquency, Weiner (1980). The resistances that we meet in the initial phase of treatment have a special bearing on impulse-anxiety, the fear of losing control, fear of the intensity of feelings (see ripening and regulation difficulties) on the assimilation of feelings of responsibility and guilt (see integration difficulties) and on individuation and loyalty conflicts (see individuation difficulties). We think the therapist is right to relate the resistances he encounters with an adolescent client to these issues.
IIVTERVEN’I’IOK The adolescent who has thought about treatment has usually formed an opinion on the seriousness of his complaints. The psychodynamics are self-evidently only fragmentarily realized, but the opinion of the significance *In this respect, compare Bosma and Graafsma (1982) on the central psychosocial developmental task of adolescence and Laufer (1976) on the central psycho-sexual developmental task. However important, it is often very difficult to get adolescents talk about sexual matters. Feelings and fantasies are often repressed or even overtly resisted exactly because the therapist unconsciously is considered as the pre-adolescent parent who denies the adolescent the ownership of his body, including all feelings and fantasies. See in this respect Lamp1 de Groot (1960) and Laufer (1981).
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and seriousness of a problem is certainly present. The adolescent assesses his complaints according to their (ab)normality, the outlook and the trouble that they bring him. These form the most important incentives for seeking help in spite of all resistances. In our opinion, many therapists do not sufficiently appreciate that the presence of resistance (expressed in “non-motivation”) does not necessarily mean that there is no “desire to change”. In other words: the wish to take up normal development (again) is usually implicitly present. This is closely linked to the adolescents’ wish “to belong”. These very adolescents, disengaging from parental ties, feel themselves strongly dependent on social integration and acceptance because they no longer wish to base themselves unthinkingly on the acceptance and approval of their parents, which is no longer “socially” allowed. It is not strange for us to meet adolescents during consulting-hours who display much resistance but ask very directly: “Can you help me?“. A vague answer here is useless. The An therapist will have to say “yes” or “no” or at least offer investigation. answer must be forthcoming to this extremely relevant question, on the anamnestic data, forms of defence and grounds of manifest complaint, transference phenomena. The therapist’s answer to the implicitly or explicitly stated request: “Can of a “working alliance”, an alliance we you help me?” can be the beginning conceive as the joint engagement of therapist and client in therapy. It implies that the adolescent client must to a certain extent, be able to entrust himself and his psychic life to the therapist, to his knowledge and abilities. It implies, * The therapist looks for a link-up also, a willingness for self-observation. with the adolescent’s desire to get rid of painful phenomena, with his wish to make more of life and with his desire to further his own development as well as remove its stagnation. The therapist will try to inspire the adolescent client towards self-observation. Without the support of a working alliance, the adolescent would all too quickly abandon treatment or find it end in deadlock, because of unavoidable resistances. The establishment of a working alliance, however, is luckily not only dependent on the way in which the therapist handles resistances. We shall return to this later. As soon as the therapist has formed an opinion on the structure of a complaint and the source and intention of resistance, he has to question its adequacy. To quote Basch (1980): it is not so much the problem that *One may question whether this capacity or attitude should be present at the outset of therapy, or whether it can be learned during therapy. We think that a base should be laid in the early mother-child relation (see Lampl-de Groot, 1975) in which the mother often functions and has to be available as an ego-extension when the child feels confronted with an overwhelming situation. Very decisive may be the fact that the adolescent has been able to experience the Oedipal situation which leads to ego-attitudes as self-observation and curiosity after insight (see A. Freud, 1965). This background possibly determines the degree in which the adolescent is able and willing to learn from and exchange stews and ideas with the therapist.
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concerns the therapist neither is it that trauma in early life which should be discussed, it is the client’s reaction to that which befell him that must become the treatment’s focal point. For this reason, the therapist has to form an opinion of the adequacy of defence-mechanisms and resistances. We above all ask ourselves whether they are in keeping with the phase of life, whether the adolescent has a limited repetoire of defences or avails himself of a reasonable “arsenal”, whether he can make flexible use of these and, moreover, we speculate as to whether there are detrimental side-effects (cf. Freud, 1965). Speaking in general, the therapist will strive to remove less adequate, less effective and less efficient forms of resistance, substituting where necessary more adequate, more effective and more efficient forms. For this, a number of possibilities are available to him. He can train the adolescent, let him practice other forms of dealing with stress and conflicts. Together with the adolescent, he can investigate and interpret the latter’s resistance patterns to ascertain how far these are adequate and necessary. He can also attempt to influence resistances in a paradoxical fashion. Behaviour therapists make frequent use of training and instruction, as do we at our Institute (see publication of Bartels et al., I 982). They diagnose a resistance and endeavour to teach the adolescent such social skills that less adequate resistances fade into the background, SO to speak. Many therapists for example make use of paradoxical interventions (cf. Marshall, 1962; Evans, 1980; Rohrbaugh et al., 1981). Here for example an adolescent is instructed to keep silent longer than he already does. Use is often made of paradoxes if adolescents are inclined to make resistance the subject of a power struggle with the therapist. A good example of a paradoxical intervention was given by John Evans at the APSA conference in 1980, to a continually provocative adolescent: “Fred, are you going to stop that or do I have to ask you?“. (Evans, 1980). The investigation and discussion of resistances originates above all from psychoanalytic psychotherapy. The therapist makes a functional analysis of them with the client. He puts it to the adolescent that something is being resisted and subsequently how, what and why (compare Gill, 1963 and Greenson, 1967). Plus, continually in the background, the question: how suitable and how necessary is the resistance? Whichever type of intervention the therapist uses, certain demands must always be met. He must be able to carry on a normal conversation. That entails: listening, plus being able to react positively, empathetically and adequately to what the adolescent is saying, also “between the lines”. Both the adolescent and the therapist must feel at ease. The therapist must understand what the adolescent is saying and what he means to say. The latter will often be explained by the therapist, so that the client realizes that he is being
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understood. Furthermore, the therapist must offer the adolescent something (“from his shop”) that holds out the prospect of a better future whether that be advice, investigation of the background and intention of a resistance, training of social or cognitive skills or “incident exploration” (Driessen, ‘973). In our experience, the first resistances to decrease in intensity are, generally speaking, those having what we earlier termed a non-specific intention. We are also inclined to tackle these as quickly as possible. The client himself notices, however, very rapidly that treatment in no way renders one helpless and ashamed. On the contrary, a strong appeal is made to his very activity and introspection. The secondary gain is also very quickly put in order. ,4 16-year-old receiving treatment for sleeplessness requested medication but relates angrily that his mother will put this under her supervision, just as she always interferes everywhere. The therapist, being of the opinion that this adolescent is quite responsible, then asks why he does not discuss this with his mother. The boy hesitates and a moment later breaks into a smile. He says that then maybe she will start making demands, to tidy up his room and so on. The disadvantage of the felt dependence on his mother was the feeling of smallness accompanied by anger and the advantage was the avoidance of boring duties. He did then control his own medication.
This adolescent in essence chose reality, preferring rather more independence and “doing his own thing”. We perceive here a desire to change. The adolescent feels that through this he is more able to cope with the painful side of life. The therapist must track down and link up with such wishes. Here is an opportunity to arrive at a working alliance despite the obstacles formed by resistances. One does not always have to go further into resistances as such. A thirteen-year-old boy came for treatment on account of contactual difficulties and petty theft, but reacted angrily to any discussion of the offence. The resistance, intended above all to avert criticism and condemnation, subsided quickly when the therapist asked if he wanted to break the habit of stealing. The answer is yes, but how? The therapist suggested that they play detective together, listed what was taken, the circumstances and so on, the adolescent actively considered the proposal and a coalition began to unfold. the therapist invited the adolescent to carry out In this example, The aim of the adolescent’s resistance was not (supported) self- o b servation. the fear of criticism and condemnation. difficult to fathom, namely,
However, an attempt was made to reach a working alliance aided by the existence of a desire to change, hidden behind negativity. The feelings of guilt, that play a substantial role in the resistance against treatment, must be
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discussed in detail later on, for the moment, however, other matters are central. Keeping track of times, activities and circumstances is already in itself good training in self-reflection. This is an important gain, especially when it concerns adolescents with weak impulse control and a low level of frustration-tolerance. Training in social and cognitive skills, in which self-reflection and self-control play a large part, can save them from much (self-) destructive behaviour (Bartels et ul., 1982). It is not only the desire for change that keeps the adolescent in treatment but also his transference feelings. We use the term transference here in its broad sense, subscribing to the views of Sandler and others (1975). There exists a close link between a working alliance and transference feelings. A fundamental transference” should be established (Greenacre, 1968) before the adolescent ventures to entrust himself to treatment. It is typical of adolescents that the transference has an idealizing character. We have already explained elsewhere the functional importance of idealizations during the adolescent phase for the furtherance of development [see Graafsma (1980), Bosma and Graafsma (1982) and Wolf, Gedo and Terman (1972)]. The continuation of treatment is generally strongly determined by transference motives. Besides the wish to change, there is also the wish to get something out of the treatment, usually the satisfaction of all needs and the acquisition of greatness. One should keep in mind that both positive and negative transference feelings can keep an adolescent in treatment (see Novick, 1980). An ~&year-old girl in treatment for suicidal thoughts and loneliness soon asked if she could come more often than twice a week. When the therapist went further into this, the girl seemed struck by the therapist’s understanding, plus the absence of denunciation. The therapist asked her if she missed that in her own surroundings and then suggested that
together they investigate whether something could be done about it. The client agreed although somewhat angry at not getting what she originally wanted. The antipathy of this adolescent can be interpreted as a resistance. This resistance can become stronger and build up as soon as it becomes clear that many wishes (transference wishes in this case) are not being honoured. Such circumstances test the strength of the desire to change; the adolescent remains as long as he retains the impression (rationally and/or emotionally) that he can profit from treatment. There must remain the prospect of a “better” future, in which “better” is usually a mixture of more age-appropriate l See in this connection Greenson (1967), Keith (x968), Zetzel (1970), Lampl-de Groot (1975), Gutheil and Havens (1979) and De Bl&ourt (1981). We interpret working alliance here as a “relatively rational, desexualized and deaggressivized transference phenomenon” (Greenson, 1967, p. 172), even though it 1s sometimes tcmporaril!, predominantly specified by unconscious, irrational transference phenomena.
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motives (e.g. becoming freed of loneliness, compulsive actions or hypochondriac complaints) and, in our opinion, those less than adequate (e.g. becoming invulnerable or “managing director of the world”, as one client once told us). The working relationship at the beginning of treatment with an adolescent client is usually limited and delicate, especially when the alliance is based on transference feelings in which the adolescent feels threatened by deindividuation. It is important to establish reasonableness, joint investigation and honesty, though initially tackling transference feelings may have to be held back, for fear of putting the total treatment in danger. Adolescents are easily seduced into transference and when the therapist then appeals to the frustration-tolerance and rational self-observation, the impulse control, adolescent may abandon treatment or even decompensate. Care is also required in investigating above all transference phenomena of a narcissistic, idealizing nature. A therapist who presents himself in a self-debasing manner or to a certain extent refuses to be idealized, runs risks with adolescents. The latter have to renounce many feelings of greatness and are often poorly supported in this by their environment. The nucleus of many adolescent therapies is situated in the re-experience and empathic, supported workingbased on the difficulties of the through of a narcissistic transference, adolescent decentration process. It must be realized that tackling transference feelings must go hand in hand with the furthering of a more “rational” working alliance, although the very presence of transference feelings is the primary reason for the development of a working alliance. As the alliance becomes gradually determined by a joint engagement on a process of change, by observation and by reflection, so can defence with a more phase specific intention be tackled. It also holds that the for example, his therapist must act as “assisting ego”. This includes, investigation together with the adolescent of the use and necessity of resistances. He has to accept that the latter are among the best solutions that an adolescent can find for an internal conflict, and that such a conflict can manifest itself again and evoke anxiety if a resistance suddenly subsides. Strengthening cognitive and social (and sometimes motoric) skills is necessary for the successful removal of less adequate forms of resistance [good examples of this are described by Harley (1970) and by Settlage (r974)l. A thirteen-year-old adolescent reacts with passivity and self-criticism to a situation in the classroom in which he is teased and humiliated. He feels quite disconcerted and relates that in such (anxious) situations he can barely become active. He is very much ashamed and is totally unable to deal with his fear of looking foolish in front of his classmates. Apart from the fact that he reacts as though it is a question of being overwhelmed
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AND M. ANBEEK
(despite the pleasurable teasing situations that can be surmized as part of fantasies related at other times), the therapist first strives towards egostrengthening. He discusses more adequate ways of reacting and now and then makes use of role playing.
The therapist’s functioning as an auxiliary ego means that, later in treatment, frightening conflicts, more closely related to specific adolescent problems, can be more easily investigated. The adolescent is then no longer so afraid of losing impulse control, his fear that “a feeling runs away with you” becomes slighter. Just as the therapist must be careful in handling the client’s transference feelings, this also applies when taking up the source, intention and adequacy of resistances. That requires empathy and neutrality, which is not the same as having no opinion. The therapist must not take sides or maintain illusions. He must be a “Vertreter der Realitat” (Frank1 and Hellman, 1969), who has something to offer to the adolescent. In our opinion, at the start of treatment the investigation of resistances must primarily further the working alliance between the adolescent and therapist, and should lead to self-observation and self-reflection on the part of the adolescent. Then they can observe jointly whether resistances are indeed used too rigidly or injuriously. It is not a matter of making them disappear per se, but of increasing their adequacy (Zetzel, 1954). Whether emphasis should be laid on insight or training is a question of diagnosis. It all requires empathy and neutrality from the therapist’s side and, equally, a thorough knowledge of the developmental dynamics and psychopathology of adolescence.
SUMMARY Resistances are of considerable significance in psychotherapy with adolescents. In this article, that significance is investigated further, because the way in which resistances are valued is very important in treatment. The forms in which it appears and, the source and intention of resistances are discussed. It is proposed that the investigation of resistances should not be aimed primarily at their removal. With thanks to colleague Dr A. Dekker, member of the adolescent Workgroup at the Ambulatorium,
for his stimulating
comments.
REFERENCES Amini, F. (1979). Acting out and its role in the treatment Menninger Clinic, 43, 249-259.
of adolescents.
&dktin
ofthe
RESISTANCE IN PSYCHOTHERAPY WITH ADOLESCESTS
‘5
Bartels, A. A. J., Heiner, H.,. de Kruijff G. and Slott, N. W. (1982). Anzbulante gedragstherapeutische zaardigheidstraining zloor probleemjongeren en gezinnen: Jeugbbescherming en Ondenoek. Basch, M. F. (1980). Doing Psychotherapy. New York. De BICcourt, B., Beenen, F., Gomes-Spanjaard, C., Hommes, H., Verhage-Stins, L. and Verhage, F. (1981). Het samenwerkingsverbond (“working-alliance”) van patient en analyticus. Tijdschnft zoor Psychotherapie, 6, 307-317. BIOS, P. (1979). The Adolescent Passage. New York, pp 254-278. Bosma. H. and Graafsma, T. (1~82). De ontmikkaling ran identiteit in de adolescentie. , Nijmegen. Driessen, ‘4. C. (1973). Flexibiliteit in de ambulante hylpverlening aan jongeren. In Psychologenoperhet kind (deel3), de Wit, J. (Ed.). G roningen: Tjeenk \Villink, pp. 209-225. Evans, J. (1980). Ambivalence and how to turn it to your advantage: adolescence and paradoxial intervention. Journal of ,Jdolescence, 4, 273-285. Frankl, L. and Hellman, I. (1969). Die Ichbeteiligung am therapeutischen Bundnis. In Handbuch der Kinderpsychotherapie, Ibl. I, Biermann, G. (Ed). Rliinchen, pp. 294-302. Freud, A. (1958). Adolescence. The Psychoanalvtic Study of the C’hild, 13, 255-278. Freud, A. (1965). ,Yonnality and Pathologv in Childhood. New York, pp. x77-178. Gill, M. hl. (1963). Topography and systems in psychoanalytic theory. Psychological Issues, monograph no. IO, New York. Glover, E. (1955). The Technique of Psychoanalysis. London. Greenson, R. R. (1967). The Technique and Practice of Psychoanalysis. New York. Graafsma, T. (1980). Individuatie en identiteit in de adolescentie. Kinden.~dolesc-ent, 1, 3-14. Harley, M. (1970). On some problems of technique in the analysis of early adolescents. The Psychoanalytic Study of the Child, 25, 99-121. Hart de Ruyter, Th. (1963). Algemene psychopathologic van de puberteit. In Capita Selecta uit de Kinder-en Jeugdpsychiatrie. Zeist, I 32-171. Keith, C. R. (1968). The therapeutic alliance in child psychotherapy. Journal of the American Academy of Child Psychiatry, 7, 3 1-43. Lampl-de Groot, J. (1960). On Adolescence. The Psychoanal_vtic Study ofthe Child, 15, 95-‘03. Lampi-de Groot, J. (1975). Vicissitudes of narcissism and problems of civilization. The Psychoanalytic Study of the Child, 30, 663-683. Laufer, M. (1976). The central masturbation phantasy, the final sexual organization and adolescence. The Psychoanalytic Stud_v of the Child, 31, 297-316. Laufer, M. (1981). The psychoanalyst and the adolescents’ sexual development. The Psychoanalytic Study of the Child, 36, 181-191. Marshall, R. J. (1972). the treatment of resistances in the psychotherapy of children and adolescents. Psychotherapy, research and practice, 143-148. Meeks, J. E. (1971). The Fragile Affiance. Baltimore. Novick, J. (Ed,) (1974). Becoming a Separate Person in Adolescence. Monograph, no. 5. London: Brent Centre for the Study of Adolescence. Novick, J. (1980). Negative therapeutic motivation and negative therapeutic alliance. The Psychoanalytic Study of the Child, 35, 299321. Rohrbaugh, M., Tennen, H. Press, S. and White, I,. (1981). Compliance, defiance, and therapeutic paradox: guidelines for strategic use of paradoxical interventions. .+nerican Journal of Orthopsychiat?, 3, 454-468.
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Sandier, j., Dare, C. and Holder, A. (1973). The f’atient and the Analyst. London. Sandler, J., Kennedy, H. and Tyson, L. (1975). Discussions on transference. The Psychoanalytic Study of the Child, 30, 409-441. Weiner, I. (1970). Psychological Disturbance in Adolescence. New York. Weiner, I. (1980). Psychopathology in adolescence. In Handbook of Adolescent Psychology. Adelson, J. (Ed.), New York, pp. ~7-471. De Wit, J. and van der Veer, G. (1979). Psychologie van de adolescentie. Nijkerk. Wolf, F., J. Gedo and Terman, D. (1972). On the adolescent process on a transformation of the self. Journal of Youth and Adolescence, 3, 256, 272. Zetzel, E. (1954). Defense mechanisms and the psychoanalytic technique (panel report). Journal of the American Psychoanalytic Association, 2, 3x8-326.
of .+Idokscence 1984, 7, 1-16
Resistance in psychotherapy with adolescents T. GRAAFSMAX “IT’S
AND
ONLY
M. ANBEEK”’
PUBERTY”
Adults make remarks like this when they find themselves confronted with troublesome behaviour or ideas coming from adolescents.? Furthermore they are remarks which do, in fact, contain a lot of truth. It is undoubtedly correct that the individual is affected by the ups and downs that puberty brings with it. But the remark can also have the intention of cutting short conversation about the adolescent. So the speaker can mean, “Oh, leave it, it’ll blow over” or “that son (or daughter) of mine can do nothing about it, it’s just his (or her) adolescence. Or “I have nothing to reproach myself with”. The tone used indicates the intention, which can be an attempt to shift involvement or responsibility. It can also be an attempt at minimization. In each case, the speaker refuses to accept something about which he is also concerned. That concern may be difficult to bear, although it may have a long history. Thus
a mother seeks help for her x j-year-old son concerning his sleeplessness, intensively aggressive periods and lack of adjustment at school. She has been for help to other organizations which, according to her, interpreted the situation too seriously. In the course of the investigation, however, she relates that she was concerned for a very long time, especially about the bizarre fantasies that her son came out with, as far back as the age of three. Once she asked the advice of a psychologist during a birthday party but kept quiet about various important Incidents. She then let herself wish “it must be the age”. Now once again she had that inclination: wasn’t it a question of a somewhat turbulent adolescence? Not only does the adolescent’s environment sometimes minimize or shift responsibility, it also applies to the adolescent himself. The same youngster that refers to autonomy and his right to self-reliance will hold his parents lAmbulatorium van Het Paedologisch, Instltuut Prim Hendriklaan, 23 1075-AZ Amsterdam, The Netherlands. l*Dr M. A. Anbeek, Stichting Psvchotheek, Eikenplein 3, 1092 CC Amsterdam. tWe consider adolescents as being between the ages of I 2 and 21 years. See De Wit and Van der Veer (1979). 0x40-1971/84.b10001 + 16 So3.oolo
0 1984 The Assoclat~on for
the Psychiatrvz
Study
of Adolescents
T. GRA.4FSiM.4
2
AND M. ANBEEK
responsible for his own shortcomings and failures rather than himself (Freud, 1958). Successes will be self-attributed, while defeats, are belittled or ascribed to others. Normally a therapist faces an adolescent who resists the notion that there might be something wrong in himself and his behaviour is experienced as unpleasant and alarming. The therapist has to deal with the behaviour which the client maintains during his everyday life and resistances form an important part of the work. Often at the beginning of his contact with us, we hear the adolescent talking about the shortcomings of others. A 16-year-old girl talks continually about her parents’ egocentricity, their way of upbringing (“they’ve never taught me how to behave among others of my age”) and then matrimonial disputes. If the therapist asks if she can fit herself in among others of her age without help, he gets a scathing look. “It’s all due to my mother”, she says angrily, refusing to cross over to
self-observation. Now speaking about parents’ shortcomings is undoubtedly linked to a youngster’s wish that parents should be able to prevent disappointments in everyday life. In the adolescent’s reproaching, however, the therapist often has a sense of a resistance. The painful awareness of his own shortcomings and behaviour leads the adolescent to keep attention directed at shortcomings in the outside world. It is striking how long adolescents postpone going to a doctor or psychologist. “Doesn’t it go away of its own accord?” Aren’t there others with far more serious problems? “Am I exaggerating?“These showings are often attempts to dispose of pressing anxieties. A Is-year-old girl comes for a consultation just before the holidays and tells that some six months ago she was subject to fits of depression. At present she is not troubled but she wants contact in case the depression returns. Towards the end of the hour, she says that she is worried about her future. She says she tends to think that perhaps it could well be worse, that others may have far more serious problems. That has been the reason for not seeking help. We make another appointment for after the holidays. In the meantime, during her holiday abroad, she decompensates.
In this example, we see that in a first conversation the manifest complaint is often the most “external” an the least alarming. In the background, “latent” complaints are usually experienced as more internal and more disturbing. Resistances are of considerable significance in psychotherapy with adolescent, and are linked to emotions that threaten to disturb everyday functioning. At the start of treatment, resistance may be marked but also difficult to understand fully. To achieve progress in treatment resistances
RESISTANCE
IN PSTCHOTHERAPI-
must be correctly valued in the attention to resistances met adolescents. In the following discussed and after that, the investigated. We will conclude
ADOLESCEKT
WITH ADOLESCENTS
3
initial phase. that is why in this article we pay with at the start of psychotherapy with section some forms of presentation will be source and intention of resistances will be with the treatment of resistances.
FORMS
OF RESISTANCE
Before enumerating some forms of resistance characteristic of adolescents let us first define the term. It is behaviour that a person carries out in order to forestall the appearance of an unwelcome impulse, an affect or an action by himself or another. A resistance is a defensive response to sensation that threaten everyday functioning, and the integration of internal and external stimuli. We use the term behaviour, without wanting to associate it with great activity. Indeed, passivity can have a defensive significance. ,4 r6-year-old
boy, under treatment for social isolation and continua1 failure at school, maintains that the latter is to be blamed on the teachers. When he is asked whether he has any remarks about his own achievements or approach, he says: “No, none at all”. After a silence he admits to having trouble accepting that he has greater difficulty in learning than his sister. A little later however-as if this thought has to be retracted-he says that he goes to a “better” school than his sister (something actually untrue). Apparently, the idea of achieving less than
his younger sister threatens his self-respect too much to be acceptable. Presumably self-reflection would produce too much self-criticism, shame and jealousy of his sister. Resistances can arise in many ways. The adolescent in the foregoing example is externalizing: he shifts impressions that actually have reference to himself on to another. Furthermore, he falsifies reality by denying facts. But resistance can also crop up in other forms. An adolescent can keep silent or suppress something. He can forget an appointment, or then again come too late, leave too early or continually check the time. He can get bored or clog the conversation by introducing superficial matters. He can continually voice criticism, pick arguments or attempt to steer the therapist into discussion. He can also keep the therapy apart from the rest of his daily life. Of those forms of resistance, three figure prominently in psychotherapy with adolescents, namely non-attendance, self-justification and acting-out. Non-attendance can be expressed in terms of not coming, arriving too late or forgetting an appointment. Usually the adolescent has then something to repress or deny. Self-justification is evident when the adolescent continually looks for means of accepting his behaviour or feelings. A set-back becomes
4
T. GRAAFSMA
AND M. ANBEEK
defined as a planned action and a fit of temper justified as a deliberate, angry reprimand of shortcomings in others. One thinks of the moralistic behaviour of the “uncompromising” adolescent (Freud, 1958), in which intensive use is made of rationalizations. Acting out expresses itself especially in impulsive acts by means of which important but threatening feelings can be held at a distance. It means sometimes doing in order not to have to feel and sometimes doing what one actually has difficulty in feeling. * Acting out can help avoid a sense of guilt for example, sexual feelings which evoke and responsibility. Consider, anxiety. In all these cases, the adolescent makes use of externalizations and projections or he identifies with the aggressor. In therapy we often find an internal conflict between conceding to a desire and conceding to a punishing conscience. Two other forms of expressing resistance, that occur less often but are still striking are as follows. First some adolescents say they “feel nothing”. We interpret this as resistance to feelings that are threatening but have to be warded off. One is reminded of depersonalizations. Then we see “ascetic” behaviour, in which the inner life is forcibly isolated, as it were. Second, we sometimes meet adolescents who believe that they have a highly gifted side, even if no factual evidence of this is advanced. Maybe the adolescent is but we are not allowed to see this. In general, however, we suspect defences against feelings and thoughts that conflict with fantasies of greatness. The person concerned sometimes withdraws into these fantasies in disregard of reality and in this way drastically confines his life. Thus there exists a close link between resistances and defence mechanisms and we interpret non-attendance as a resistance in which the adolescent makes use in particular of the defence mechanisms “repression” and “denial”. Defence-mechanisms are the means that a person can employ to raise a resistance against unpleasant, injurious and frightening sensations. [The reader can find a more detailed explanation in Basch (1980, in particular pp. ‘7’-‘73)*1 It is quite normal that a person resists disturbance of his psychic stability. That especially holds for adolescents, who are already under stress in their developmental phase. Adaptation to biological changes and changing social demands is often far from easy. An IS-year-old comes to us complaining of chronic listlessness and feelings of loneliness. After a while, he tells that-he knows and feels nothing, he even wonders what in fact is “feeling”. In his social life, this adolescent is bashful but friendlv as he is with us. LUtimatelv it becomes “For a description of the meanmg of acting-out m the sense of w-enactment, see Blos (1979) and Amrni and Burke (1979).
RESISTANCE
IN PSYCHOTHERAPY
WITH ADOLESCENTS
5
to suggest that his adaptability perhaps arises out of fear of rejection. Reluctantly, the client is then able to relate that he has “exceptional fantasies”. The first one he mentions is the fantasy (desire) that a Hitler should come to power here in this country to “really put things in order”. He is afraid that this fantasy (in our opinion not so exceptional) will produce much condemnation. possible
Although non-attendance, self-justification and acting-out strike us forcibly as adolescent forms of resistance, adolescents do use of other forms of resistance. The same goes for the various defence-mechanisms available to them. Some forms of resistance and defence mechanisms are rough and overt, whereas others are more subtle and concealed. Our views correspond here to those of Glover (1955). Concerning the foregoing Sandler and others (1973) remark that there is little sense in trying to arrange a classification of forms of resistance. It is more important to pay attention to their source and intention. That seems to us to be correct; the source and intention of resistances do have a decisive influence on our way of approaching the adolescent.
SOURCE AND INTENTION OF RESISTANCES IN THE INITIAL PHASE OF PSYCHOTHERAPY WITH ADOLESCENTS On entering our institute, adolescents are usually reserved, cautious and curious. Most are very ambivalent about psychotherapy. On the one hand, the unknown is alluring, on the other it is frightening. They know they need help but asking for it is considered a defeat and they fear that the psychotherapist will unearth painful matters. The adolescent shifts about somewhat hesitatingly and seems to wonder: “What shall I say?” “What does he think of me?” “What do they do here exactly?” “Shall I make an appointment or not?” “Does it repay the cost and the trouble?” The adolescent continually determines a position for himself regarding his problems, treatment and therapist. The means that he can call up in this situation
are
However,
these
the
cognitive,
skills
social
can also be used
and
motoric
with
skills
available
the aim of evoking
to
him.
a resistance.
A 16-year-old girl under treatment for potential anorexia nervosa enters in an agitated state and immediately comes out with : “My mother rang, didn’t she? Alright, I’ll tell you the exact story”. After which follows a story about an argument, which she uses to pomt out that the blame lies elsewhere, with her mother. The latter had indeed telephoned, largely with the same intention-of laying the blame for the argument elsewhere. When it is put to the girl that she is apparently afraid that the therapist will blame her for something, she expresses the fear that he will
6
T. GRAAFSMA
AND M. ANBEEK
side with her mother. She looks fixedly at him and sits upright in her chair. There is a pause. The therapist puts it to her that she is probably critical of her own behaviour but that she also opposes this. He says that she splits off a bit of conscience, as it were, and leaves it with him. Then she relaxes slightly. She does not take up the ideas submitted to her, but changes the subject, with which she once again throws up a resistance against a (further) exploration of her own “share” in the conflict with her mother, possibly from fear of condemnation or rejection.
Just like everyone else, the adolescent also appeals to his “problem solving ability”, to defend himself against painful sensations. And while some adolescents have an intense and rigid use of a few skills others avail themselves of a more broadly and flexibly based arsenal of possibilities. It is time to look at those issues against which adolescents build up resistances. What is the intention? Here we will make a distinction between issues which all those in psychotherapy experience and resistance issues which in our opinion are specific to adolescents. In the first case, we shall speak of a non-specific intention, and in the second case, of a specific intention (in regard to the adolescent phase itself). The non-specific intention concerns the universal resistance of painful feelings. Like anyone else the adolescent is afraid of influences which may render him helpless and ashamed. Furthermore he is afraid of losing ways of thinking and acting which may have brought him misery (e.g. in the form of symptoms) but still let him retain the feeling of an “active mastering of the world”. Another non-specific intention concerns secondary sickness-gains. Naturally, the adolescent builds up a resistance against change, if this reduces the secondary sickness gain. Thus not going to school can have a beneficial side if the adolescent finds it pleasant to be at home with his mother. Giving up studying can have the beneficial side of not yet having to become grown-up. This applies to the initial phase of psychotherapy with adolescents. We often come across the following situation: The adolescent usually expects the therapist to say to him: there’s an awful lot you can’t manage alone. In anticipation, a resistance is thrown up: the adolescent comes up with justifications (the actual situation was unavoidable) and points out shortcomings in the surroundings. During the first minute of his first conversation, an 1%year-old adolescent relates: “I have problems with my mother. Indeed, I don’t live with her anymore. She is always threatening but doesn’t go any further; only false alarms”. Later, after many discussions, it becomes clear how this adolescent himself makes good resolutions, but does not put them into practice and therefore gets into difficulties, at school and financially. Asked the cause, he points to his mother.
*
RESISTANCE
IN PSYCHOTHERAPY
WITH ADOLESCENTS
7
The fear of not being self-reliant is not peculiar to adolescents. More specific is the fear of de-individuation. Does the adolescent have to become dependent again, once in therapy? With this, we come to the area of specific intentions of resistances, which is to say, those intentions more strongly tied to the phase. Receiving help is usually interpreted as acknowledging failure and is therefore unacceptable when the demand for recognition and acknowledgement as a separate, autonomous person is so important. The adolescent therefore tends to keep close watch over all occurrences in and around therapy (Harley, 1970). The therapist and the time are observed closely. A discussion about being sent is willingly taken up, just as is a discussion about the use and frequency of the treatment. In our opinion, these facets of the initial situation in psychotherapy with adolescents, although they sometimes create the impression of being less important, nevertheless present significant material that can only be thoroughly investigated after the intention of resistances had been examined in more detail.
A rb-year-old boy comes to our institute after a suicide gesture and immediately takes the initiative, discussing his friends and activities and thereby preventing the therapist from discussing the suicide gesture. That IS what many adolescents do: after a suicide gesture, they endeavour to suppress the event as quickly as possible. There usually exist many feelings of shame and guilt concerning its aggressive side. Although the adolescent usually tends towards belittlement, a suicide attempt is still an indication of a serious problem. Keeping control over the course of the conversation is a good remedy for this. When the therapist airs the suspicion in a later conversation that, despite all his friends, there must be feelings of loneliness, this is rejected. Later it appears that feelings of disappointment about his need to admire and to be admired-precisely those things that the adolescent touched on at the very beginning-are hardly tolerable and often denied. The specific intention of resistance concerns an aspect of adolescence. We already stated earlier that adolescence draws considerably on problemsolving abilities. The adolescents we meet at our institute find themselves in a the cognitive, social and motoric capacities (under “deficiency situation”: which, it is naturally understood, come the defence mechanisms available to an adolescent) are used inadequately or are no longer sufficient. We usually meet with difficulties that in some way are linked to the processes of ripening, regulation, integration or individuation [this classification is derived from Hart de Ruyter. See his “General psychopathology of puberty” for a more detailed explanation (1963, pp. 13z-I~I)] and therefore good to investigate resistances in relation to one or more of these processes. It is striking among 12 and I 3-year-olds, physical and psychic ripening can diverge, and create
8
T. GRAAFSMA
AND M. ANBEEK
disharmony internally as well as socially. We also frequently see regulation difficulties in the initial phase of adolescence. Impulse control is under great stress and fear of loss of control often leads to extensive resistance to an emotional investment in psychotherapy (Harley, 1970). A number of adolescents report to us with this as the central problem (see the publications of Bartels et al., 1982). A threatened loss of control makes the adolescent apprehensive, and in this connection one thinks of early adolescent hypochondriasis. Integration problems occur more in the middle and final phases of adolescence. Central are the problems of integration of one’s separateness with one’s limitations and one’s possibilities. In the middle phase, the integration of sexual feelings and the sexual role become central.* Resistances are usually related to sexual fantasies that are considered objectionable and the need to defend everyday life, may militate against thoughts of greatness. Here arises the well-known adolescent depression in which narcissistic injuries play an important role. Individuation difficulties seen especially in the second half of adolescence. Emancipation and independence are of crucial importance, and conflicts of loyalty and dependence create problems. Later in adolescence, intimacy becomes more prominent, being both a test of psycho-social and psycho-sexual identity and of the degree to which the adolescent can tolerate being a “separate” person (Novick et al., 1974). The adolescent who comes under treatment in our Institute is usually involved in an internal conflict in one or more of these fields, although the presenting complaints are usually related to depressions, suicidal thoughts, disorders at school or work, psychosomatic difficulties and delinquency, Weiner (1980). The resistances that we meet in the initial phase of treatment have a special bearing on impulse-anxiety, the fear of losing control, fear of the intensity of feelings (see ripening and regulation difficulties) on the assimilation of feelings of responsibility and guilt (see integration difficulties) and on individuation and loyalty conflicts (see individuation difficulties). We think the therapist is right to relate the resistances he encounters with an adolescent client to these issues.
IIVTERVEN’I’IOK The adolescent who has thought about treatment has usually formed an opinion on the seriousness of his complaints. The psychodynamics are self-evidently only fragmentarily realized, but the opinion of the significance *In this respect, compare Bosma and Graafsma (1982) on the central psychosocial developmental task of adolescence and Laufer (1976) on the central psycho-sexual developmental task. However important, it is often very difficult to get adolescents talk about sexual matters. Feelings and fantasies are often repressed or even overtly resisted exactly because the therapist unconsciously is considered as the pre-adolescent parent who denies the adolescent the ownership of his body, including all feelings and fantasies. See in this respect Lamp1 de Groot (1960) and Laufer (1981).
RESISTANCE
IN PSYCHOTHERAPY
WITH
ADOLESCENTS
9
and seriousness of a problem is certainly present. The adolescent assesses his complaints according to their (ab)normality, the outlook and the trouble that they bring him. These form the most important incentives for seeking help in spite of all resistances. In our opinion, many therapists do not sufficiently appreciate that the presence of resistance (expressed in “non-motivation”) does not necessarily mean that there is no “desire to change”. In other words: the wish to take up normal development (again) is usually implicitly present. This is closely linked to the adolescents’ wish “to belong”. These very adolescents, disengaging from parental ties, feel themselves strongly dependent on social integration and acceptance because they no longer wish to base themselves unthinkingly on the acceptance and approval of their parents, which is no longer “socially” allowed. It is not strange for us to meet adolescents during consulting-hours who display much resistance but ask very directly: “Can you help me?“. A vague answer here is useless. The An therapist will have to say “yes” or “no” or at least offer investigation. answer must be forthcoming to this extremely relevant question, on the anamnestic data, forms of defence and grounds of manifest complaint, transference phenomena. The therapist’s answer to the implicitly or explicitly stated request: “Can of a “working alliance”, an alliance we you help me?” can be the beginning conceive as the joint engagement of therapist and client in therapy. It implies that the adolescent client must to a certain extent, be able to entrust himself and his psychic life to the therapist, to his knowledge and abilities. It implies, * The therapist looks for a link-up also, a willingness for self-observation. with the adolescent’s desire to get rid of painful phenomena, with his wish to make more of life and with his desire to further his own development as well as remove its stagnation. The therapist will try to inspire the adolescent client towards self-observation. Without the support of a working alliance, the adolescent would all too quickly abandon treatment or find it end in deadlock, because of unavoidable resistances. The establishment of a working alliance, however, is luckily not only dependent on the way in which the therapist handles resistances. We shall return to this later. As soon as the therapist has formed an opinion on the structure of a complaint and the source and intention of resistance, he has to question its adequacy. To quote Basch (1980): it is not so much the problem that *One may question whether this capacity or attitude should be present at the outset of therapy, or whether it can be learned during therapy. We think that a base should be laid in the early mother-child relation (see Lampl-de Groot, 1975) in which the mother often functions and has to be available as an ego-extension when the child feels confronted with an overwhelming situation. Very decisive may be the fact that the adolescent has been able to experience the Oedipal situation which leads to ego-attitudes as self-observation and curiosity after insight (see A. Freud, 1965). This background possibly determines the degree in which the adolescent is able and willing to learn from and exchange stews and ideas with the therapist.
IO
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AND M. ANBEEK
concerns the therapist neither is it that trauma in early life which should be discussed, it is the client’s reaction to that which befell him that must become the treatment’s focal point. For this reason, the therapist has to form an opinion of the adequacy of defence-mechanisms and resistances. We above all ask ourselves whether they are in keeping with the phase of life, whether the adolescent has a limited repetoire of defences or avails himself of a reasonable “arsenal”, whether he can make flexible use of these and, moreover, we speculate as to whether there are detrimental side-effects (cf. Freud, 1965). Speaking in general, the therapist will strive to remove less adequate, less effective and less efficient forms of resistance, substituting where necessary more adequate, more effective and more efficient forms. For this, a number of possibilities are available to him. He can train the adolescent, let him practice other forms of dealing with stress and conflicts. Together with the adolescent, he can investigate and interpret the latter’s resistance patterns to ascertain how far these are adequate and necessary. He can also attempt to influence resistances in a paradoxical fashion. Behaviour therapists make frequent use of training and instruction, as do we at our Institute (see publication of Bartels et al., I 982). They diagnose a resistance and endeavour to teach the adolescent such social skills that less adequate resistances fade into the background, SO to speak. Many therapists for example make use of paradoxical interventions (cf. Marshall, 1962; Evans, 1980; Rohrbaugh et al., 1981). Here for example an adolescent is instructed to keep silent longer than he already does. Use is often made of paradoxes if adolescents are inclined to make resistance the subject of a power struggle with the therapist. A good example of a paradoxical intervention was given by John Evans at the APSA conference in 1980, to a continually provocative adolescent: “Fred, are you going to stop that or do I have to ask you?“. (Evans, 1980). The investigation and discussion of resistances originates above all from psychoanalytic psychotherapy. The therapist makes a functional analysis of them with the client. He puts it to the adolescent that something is being resisted and subsequently how, what and why (compare Gill, 1963 and Greenson, 1967). Plus, continually in the background, the question: how suitable and how necessary is the resistance? Whichever type of intervention the therapist uses, certain demands must always be met. He must be able to carry on a normal conversation. That entails: listening, plus being able to react positively, empathetically and adequately to what the adolescent is saying, also “between the lines”. Both the adolescent and the therapist must feel at ease. The therapist must understand what the adolescent is saying and what he means to say. The latter will often be explained by the therapist, so that the client realizes that he is being
RESISTANCE
IN PSYCHOTHERAPY
iVITH I-\DOLESCENTS
Ii
understood. Furthermore, the therapist must offer the adolescent something (“from his shop”) that holds out the prospect of a better future whether that be advice, investigation of the background and intention of a resistance, training of social or cognitive skills or “incident exploration” (Driessen, ‘973). In our experience, the first resistances to decrease in intensity are, generally speaking, those having what we earlier termed a non-specific intention. We are also inclined to tackle these as quickly as possible. The client himself notices, however, very rapidly that treatment in no way renders one helpless and ashamed. On the contrary, a strong appeal is made to his very activity and introspection. The secondary gain is also very quickly put in order. ,4 16-year-old receiving treatment for sleeplessness requested medication but relates angrily that his mother will put this under her supervision, just as she always interferes everywhere. The therapist, being of the opinion that this adolescent is quite responsible, then asks why he does not discuss this with his mother. The boy hesitates and a moment later breaks into a smile. He says that then maybe she will start making demands, to tidy up his room and so on. The disadvantage of the felt dependence on his mother was the feeling of smallness accompanied by anger and the advantage was the avoidance of boring duties. He did then control his own medication.
This adolescent in essence chose reality, preferring rather more independence and “doing his own thing”. We perceive here a desire to change. The adolescent feels that through this he is more able to cope with the painful side of life. The therapist must track down and link up with such wishes. Here is an opportunity to arrive at a working alliance despite the obstacles formed by resistances. One does not always have to go further into resistances as such. A thirteen-year-old boy came for treatment on account of contactual difficulties and petty theft, but reacted angrily to any discussion of the offence. The resistance, intended above all to avert criticism and condemnation, subsided quickly when the therapist asked if he wanted to break the habit of stealing. The answer is yes, but how? The therapist suggested that they play detective together, listed what was taken, the circumstances and so on, the adolescent actively considered the proposal and a coalition began to unfold. the therapist invited the adolescent to carry out In this example, The aim of the adolescent’s resistance was not (supported) self- o b servation. the fear of criticism and condemnation. difficult to fathom, namely,
However, an attempt was made to reach a working alliance aided by the existence of a desire to change, hidden behind negativity. The feelings of guilt, that play a substantial role in the resistance against treatment, must be
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discussed in detail later on, for the moment, however, other matters are central. Keeping track of times, activities and circumstances is already in itself good training in self-reflection. This is an important gain, especially when it concerns adolescents with weak impulse control and a low level of frustration-tolerance. Training in social and cognitive skills, in which self-reflection and self-control play a large part, can save them from much (self-) destructive behaviour (Bartels et ul., 1982). It is not only the desire for change that keeps the adolescent in treatment but also his transference feelings. We use the term transference here in its broad sense, subscribing to the views of Sandler and others (1975). There exists a close link between a working alliance and transference feelings. A fundamental transference” should be established (Greenacre, 1968) before the adolescent ventures to entrust himself to treatment. It is typical of adolescents that the transference has an idealizing character. We have already explained elsewhere the functional importance of idealizations during the adolescent phase for the furtherance of development [see Graafsma (1980), Bosma and Graafsma (1982) and Wolf, Gedo and Terman (1972)]. The continuation of treatment is generally strongly determined by transference motives. Besides the wish to change, there is also the wish to get something out of the treatment, usually the satisfaction of all needs and the acquisition of greatness. One should keep in mind that both positive and negative transference feelings can keep an adolescent in treatment (see Novick, 1980). An ~&year-old girl in treatment for suicidal thoughts and loneliness soon asked if she could come more often than twice a week. When the therapist went further into this, the girl seemed struck by the therapist’s understanding, plus the absence of denunciation. The therapist asked her if she missed that in her own surroundings and then suggested that
together they investigate whether something could be done about it. The client agreed although somewhat angry at not getting what she originally wanted. The antipathy of this adolescent can be interpreted as a resistance. This resistance can become stronger and build up as soon as it becomes clear that many wishes (transference wishes in this case) are not being honoured. Such circumstances test the strength of the desire to change; the adolescent remains as long as he retains the impression (rationally and/or emotionally) that he can profit from treatment. There must remain the prospect of a “better” future, in which “better” is usually a mixture of more age-appropriate l See in this connection Greenson (1967), Keith (x968), Zetzel (1970), Lampl-de Groot (1975), Gutheil and Havens (1979) and De Bl&ourt (1981). We interpret working alliance here as a “relatively rational, desexualized and deaggressivized transference phenomenon” (Greenson, 1967, p. 172), even though it 1s sometimes tcmporaril!, predominantly specified by unconscious, irrational transference phenomena.
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motives (e.g. becoming freed of loneliness, compulsive actions or hypochondriac complaints) and, in our opinion, those less than adequate (e.g. becoming invulnerable or “managing director of the world”, as one client once told us). The working relationship at the beginning of treatment with an adolescent client is usually limited and delicate, especially when the alliance is based on transference feelings in which the adolescent feels threatened by deindividuation. It is important to establish reasonableness, joint investigation and honesty, though initially tackling transference feelings may have to be held back, for fear of putting the total treatment in danger. Adolescents are easily seduced into transference and when the therapist then appeals to the frustration-tolerance and rational self-observation, the impulse control, adolescent may abandon treatment or even decompensate. Care is also required in investigating above all transference phenomena of a narcissistic, idealizing nature. A therapist who presents himself in a self-debasing manner or to a certain extent refuses to be idealized, runs risks with adolescents. The latter have to renounce many feelings of greatness and are often poorly supported in this by their environment. The nucleus of many adolescent therapies is situated in the re-experience and empathic, supported workingbased on the difficulties of the through of a narcissistic transference, adolescent decentration process. It must be realized that tackling transference feelings must go hand in hand with the furthering of a more “rational” working alliance, although the very presence of transference feelings is the primary reason for the development of a working alliance. As the alliance becomes gradually determined by a joint engagement on a process of change, by observation and by reflection, so can defence with a more phase specific intention be tackled. It also holds that the for example, his therapist must act as “assisting ego”. This includes, investigation together with the adolescent of the use and necessity of resistances. He has to accept that the latter are among the best solutions that an adolescent can find for an internal conflict, and that such a conflict can manifest itself again and evoke anxiety if a resistance suddenly subsides. Strengthening cognitive and social (and sometimes motoric) skills is necessary for the successful removal of less adequate forms of resistance [good examples of this are described by Harley (1970) and by Settlage (r974)l. A thirteen-year-old adolescent reacts with passivity and self-criticism to a situation in the classroom in which he is teased and humiliated. He feels quite disconcerted and relates that in such (anxious) situations he can barely become active. He is very much ashamed and is totally unable to deal with his fear of looking foolish in front of his classmates. Apart from the fact that he reacts as though it is a question of being overwhelmed
T. GRAAFSMA
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AND M. ANBEEK
(despite the pleasurable teasing situations that can be surmized as part of fantasies related at other times), the therapist first strives towards egostrengthening. He discusses more adequate ways of reacting and now and then makes use of role playing.
The therapist’s functioning as an auxiliary ego means that, later in treatment, frightening conflicts, more closely related to specific adolescent problems, can be more easily investigated. The adolescent is then no longer so afraid of losing impulse control, his fear that “a feeling runs away with you” becomes slighter. Just as the therapist must be careful in handling the client’s transference feelings, this also applies when taking up the source, intention and adequacy of resistances. That requires empathy and neutrality, which is not the same as having no opinion. The therapist must not take sides or maintain illusions. He must be a “Vertreter der Realitat” (Frank1 and Hellman, 1969), who has something to offer to the adolescent. In our opinion, at the start of treatment the investigation of resistances must primarily further the working alliance between the adolescent and therapist, and should lead to self-observation and self-reflection on the part of the adolescent. Then they can observe jointly whether resistances are indeed used too rigidly or injuriously. It is not a matter of making them disappear per se, but of increasing their adequacy (Zetzel, 1954). Whether emphasis should be laid on insight or training is a question of diagnosis. It all requires empathy and neutrality from the therapist’s side and, equally, a thorough knowledge of the developmental dynamics and psychopathology of adolescence.
SUMMARY Resistances are of considerable significance in psychotherapy with adolescents. In this article, that significance is investigated further, because the way in which resistances are valued is very important in treatment. The forms in which it appears and, the source and intention of resistances are discussed. It is proposed that the investigation of resistances should not be aimed primarily at their removal. With thanks to colleague Dr A. Dekker, member of the adolescent Workgroup at the Ambulatorium,
for his stimulating
comments.
REFERENCES Amini, F. (1979). Acting out and its role in the treatment Menninger Clinic, 43, 249-259.
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&dktin
ofthe
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